Unusual Presentation of Cerebral Venous Sinus Thrombosis with Non-Aneurysmal Subarachnoid Hemorrhage, Intracerebral Hemorrhage and Pulmonary Thromboembolism in a 33-Year-Old Woman

We present a 66-year-old male presenting with sudden onset of headache. Medical decompression was done and neuroimaging of plain cranial CT angiogram (CTA) and CT venogram (CTV) showed components of subarachnoid hemorrhage, intracerebral hemorrhage and hyperdense appearance of the superior sagittal sinus and proximal left transverse sinus. The following were done to look for etiologic factors: 1. fungal swab to determine the cause of the intracerebral hemorrhage secondary to venous thrombosis as the patient presented with a chronic history of sinusitis, 2. coagulopathy workup to look for a hypercoagulable state, and 3. workup for systemic disease of autoimmune in etiology. Anticoagulation was safely initiated within several days given the regression of the intracerebral hemorrhage along with stable findings of subarachnoid hemorrhage. Here we report cerebral venous sinus thrombosis rarely presenting as acute subarachnoid hemorrhage and intracerebral hemorrhage. Keywords: Cerebral venous thrombosis, superior sagittal sinus thrombosis, subarachnoid hemorrhage, intracerebral hemorrhage

Preeclampsia and Cerebrovascular Disease.

To the Editor: Sir, the study by Canhao and colleagues made the important point that the most frequent cause of death in patients with cerebral venous thrombosis (CVT) is transtentorial herniation and that these patients may potentially have benefited from decompressive hemicraniectomy.1 We would like to corroborate this argument by providing evidence for a rise in intracranial pressure (ICP) preceding brain herniation and death in a patient with CVT. A 29-year-old pregnant woman who presented with confusion and vomiting was admitted to a district general hospital. A right-sided weakness developed within 2 days. A CT brain scan showed a left temporal hemorrhage without mass effect. Her Glasgow Coma Scale score dropped to 8/15; she was intubated and transferred to the neurocritical care …

Patient: Female, 44Final Diagnosis: Subarachnoid hemorrhageSymptoms: Sudden severe onset of headache • decreased level of consciousness • right-sided weakness over a period of 1 weekMedication: —Clinical Procedure: MRISpecialty: NeurologyObjective:Rare co-existance of disease or pathologyBackground:Subarachnoid hemorrhage is rarely the first presentation of cerebral venous sinus thrombosis. This case study emphasizes the presentation of perimesencephalic subarachnoid hemorrhage due to cerebral venous sinus thrombosis and the importance of neurovascular imaging for reliable diagnosis of nonaneurysmal perimesencephalic subarachnoid hemorrhage due to cerebral venous sinus thrombosis.Case Report:We describe a case of cerebral venous sinus thrombosis manifesting initially as subarachnoid hemorrhage. Non-contrast computed tomography showed evidence of subarachnoid hemorrhage involving the prepontine and suprasellar cisterns. Cerebral convexities were totally spared while parenchymal microbleeding was observed in the midbrain. The diagnosis was confirmed by magnetic resonance arteriography and venography. Treatment included low molecular weight heparin and warfarin therapy to restore the international normalization ratio of the patient to 2.5, followed by oral warfarin therapy for 3 months.Conclusions:Cerebral venous sinus thrombosis manifesting initially as subarachnoid hemorrhage is rare. Subarachnoid hemorrhage caused by cerebral venous sinus thrombosis has been reported previously to be confined to the cerebral convexities, sparing the basal cistern. However, this is not always the case where the radiological confirmation suggests the occurrence of nonaneurysmal perimesencephalic subarachnoid hemorrhage.

Sirs: In a clinical setting, isolated thunderclap headache is commonly assumed to be benign in origin once subarachnoid haemorrhage (SAH) has been excluded [1]. However, cerebral venous sinus thrombosis (CVST) is an infrequent, alternative cause of sudden-onset headache and is not conclusively excluded by normal conventional CT and LP. CVST is also a recognised rare cause of SAH. Here, we report a case of CVST presenting with thunderclap headache and complicated by delayed SAH. A previously well 53-year-old woman presented with spontaneous, sudden-onset occipital headache as her sole symptom. Neurological examination including fundoscopy was normal, with no evidence of meningism. Acute head CT and subsequent LP performed 16 hours after onset were unremarkable (opening pressure 19 cm, CSF acellular with no bilirubin detectable on spectrophotometry). The headache resolved completely within 24 hours and the patient was discharged with a diagnosis of primary thunderclap headache. The following day, she represented with sudden-onset headache at rest accompanied by mild neck stiffness. Her symptoms resolved before a further suddenonset headache occurred two days later. Examination remained normal throughout. Repeat, unenhanced head CT demonstrated a small, high left frontal SAH along the cranial convexity without involvement of the basal cisterns (Fig. 1a). CT angiography detected no arterial aneurysm, but its venous phase showed changes suggestive of superior sagittal sinus thrombosis, which was confirmed on MR venography (Fig. 1b). Screening for secondary causes of thrombosis was negative. She was initially treated with intravenous unfractionated heparin to allow rapid reversal in case of rebleeding, before being warfarinised under cover from low molecular weight heparin. She remained well at follow-up six months later. Repeat MR angiography showed resolution of the superior sagittal sinus thrombosis, with no other vascular or brain parenchymal abnormalities. Thunderclap headache is an unusual presentation of CVST, perhaps seen in fewer than 20 % of cases [2]. Rarely, there may be no concomitant findings to suggest the presence of a CVST, such as focal neurological signs, seizures or features of raised intracranial pressure. Most patients with CVST have a raised opening pressure and abnormal CSF constituents, but absence of these features does not conclusively rule out the diagnosis. In a previous series of 38 cases, nine patients had both opening pressure and CSF constituents measured, and in one of them all parameters were normal [3]. SAH is a very rare complication of cerebral venous thrombosis, with only 30 cases reported to date. It has been suggested that venous intraparenchymal haemorrhages may rupture into the subarachnoid space, thus causing sudden-onset headache in CVST [2, 4]. However, we hypothesise that our patient’s first headache was caused by the CVST, as there was no evidence of SAH on initial brain CT and bilirubin was not detectable in the CSF. The second or third episode of headache may have been caused by SAH. LETTER TO THE EDITORS

The main objectives of the present study are to assess the incidence of cerebral venous thrombosis (CVT) presenting as isolated subarachnoid hemorrhage (SAH) and to determine the occurrence of cortical venous thrombosis (CoVT). Among 332 patients with CVT, investigated with the same CT and MR standardized protocol, 33 (10 %) presented with SAH, associated in 11 cases with hemorrhagic infarct or intracerebral hemorrhage. This study is based on 22 cases of CVT presenting as SAH in the absence of hemorrhagic brain lesion. Diagnosis of sinus thrombosis was established on T2* and magnetic resonance venography and that of CoVT on T2* sequence. Diagnostic of SAH was based on fluid-attenuated inversion recovery (FLAIR) sequence. CVT involved lateral sinus in 18 patients, superior sagittal sinus in 16, and straight sinus in 1. Cortical veins were involved in all patients, in continuity with dural sinus thrombosis when present. SAH was circumscribed to few sulci in all cases and mainly localized at the convexity (21 cases). CoVT implied different areas on the same side in four patients and was bilateral in seven. There was no perimesencephalic or basal cisterns hemorrhage. Cortical swelling was present in 12 cases, associated with localized edema. All patients except one had a favorable outcome. This report shows that the incidence of CVT presenting as isolated SAH is evaluated to 6.4 % and that SAH is, in all cases, in the vicinity of CoVT and when dural thrombosis is present in continuity with it.

Cerebral venous thrombosis presenting with subarachnoid hemorrhage (SAH) is very rare. We report a case of cerebral venous sinus thrombosis as an initial manifestation of SAH. A 14-year-old boy was admitted with progressive headache, nausea, vomiting, diplopia, and gait disturbance. Cerebral computed tomography scan showed a widely SAH in the basal cisterns, bilateral sylvian fissures, and anterior interhemispheric fissure. Cerebral angiography was performed to detect any aneurysm in intracranial vasculature as a cause of SAH; however, the totally thrombosed superior sagittal sinus, galenic vein, and straight sinus were the sole abnormal findings.

Subarachnoid and intra-cerebral hemorrhage in young adults: Rare and underdiagnosed

Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease with a wide spectrum of clinical manifestations. The aim of this study is to assess the presence of subarachnoid hemorrhage (SAH) in the context of CVST and to present its epidemiological, clinical and radiological/laboratory aspects. Between October 2012 and October 2019, 43 patients with CVST were reviewed. Eleven (25.58%) cases presented SAH. A quarter of the patients evaluated with CVST had SAH. There were 9 women (81.82%) and 2 men, with a mean age at presentation of 37.7years (range 28-49). The most common risk factor was the use of oral contraceptives and the most prevalent symptom was headache. Both sinuses, the superior sagittal sinus and the transverse sinus, were the most affected. There was no isolated involvement of the cortical vein. The SAH was limited to some sulci of cerebral convexity in 8 cases (72.73%). In one case, the location of SAH was in the cerebellum and in two cases in the Sylvian fissure. In two cases, there was an evolution to venous infarction; and in three cases, intraparenchymal hemorrhage was present. Seven patients (63.64%) improved considerably with anticoagulation after 6months of treatment. This series found that 25.58% of patients with CVST had SAH. It is the highest incidence described in the literature so far. Findings of SAH located in the cerebral convexities, without affecting the base cisterns, should always lead to the suspicion of CVST.

BACKGROUND: Cerebral venous thrombosis is a multifactorial and difficult-to-diagnose disease, complicated by venous stroke, intracerebral hemorrhage, progressive cerebral edema, dislocation syndrome, and even death. The broad variability of clinical symptoms and lack of pathognomonic manifestations complicate timely diagnosis of cerebral venous thrombosis. AIM: To identify significant risk factors for cerebral venous thrombosis and to evaluate the dynamics of neuroimaging findings at 1, 3, and 6 months after cerebral venous thrombosis onset in young and middle-aged patients with a history of COVID-19, comparing outcomes between those treated with direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs). METHODS: Young and middle-aged patients with a history of novel coronavirus infection (COVID-19) were examined and divided into two groups depending on the presence or absence of cerebral venous thrombosis. The main risk factors, structural features of the major arteries and cerebral venous sinuses, as well as the course of cerebral venous and sinus thrombosis during anticoagulant therapy (with direct oral anticoagulants and vitamin K antagonists) at 1, 3, and 6 months after the development of cerebral venous thrombosis were analyzed. RESULTS: We examined 120 young and middle-aged patients with COVID-19 divided into 2 groups: Group I – 70 patients who developed cerebral venous thrombosis during COVID-19 – 21 (30%) men and 49 (70%) women; Group II – 50 patients who had COVID-19 without cerebral venous thrombosis development – 27 (54%) men and 23 (46%) women. The main risk factor for developing cerebral venous thrombosis among women in the first group (with cerebral venous thrombosis during COVID-19) compared to the second group (patients who had COVID-19 without developing cerebral venous thrombosis) was the use of combined oral contraceptives: 22.9% and 4.0%, respectively (р = 0.001). Among group I patients, 32 (45.7%) cases of cerebral venous thrombosis were accompanied by the development of venous stroke: ischemic in 13 (18.6%) patients, hemorrhagic in 7 (10%), mixed (ischemic stroke with hemorrhagic infiltration) in 12 (17.1%) patients. In a comparative analysis of the variants of the structure of the cerebral arteries (absence of the posterior communicating arteries, pathological tortuosity of the internal carotid artery [ICA], trifurcation of the ICA, open arterial circle of Willis) and venous sinuses (presence of hypo-/aplasia), no statistically significant difference was detected. The analysis of the course of cerebral venous thrombosis during treatment with vitamin K antagonists (warfarin) and direct oral anticoagulants in 53 patients with cerebral venous thrombosis (age 41 ± 12 years) at 1,3, and 6 months after the development of cerebral venous thrombosis onset showed that with anticoagulants, recanalization was observed in 44 (83%) patients: complete – in 21 patients (47.7%), partial – in 23 (52.3%). Recanalization was absent in 9 (17.0%) cases. No recurrent cerebral venous thrombosis cases were observed among the study patients. CONCLUSION: Verification of cerebral venous thrombosis in the context of COVID-19 necessitates a detailed examination of risk factors, patient history, assessment of clinical manifestations, and comprehensive implementation of laboratory and instrumental, as well as neuroimaging diagnostic methods. Timely verification and immediate initiation of anticoagulant therapy ensure a relatively favorable prognosis for the disease course.

SUPERIOR SAGITTAL SINUS THROMBOSIS PRESENTING AS DETERIORATING RESIDUAL WEAKNESS

Sensitivity Of Computed Tomography For Subarachnoid Hemorrhage

In the presence of Subarachnoid Haemorrhage (SAH), diagnosis of underlying Cerebral Venous Thrombosis (CVT) is challenging as there is no difference in clinical presentation and therapeutically it is important because CVT need to be treated with anticoagulant unlike SAH. This article is about a 50-year-old male presenting with headache, right hemiparesis, and recurrent seizures. The Computed Tomography (CT) head was suggestive of SAH in right posterior parietal region. But Magnetic Resonance Imaging (MRI) venogram showed cerebral venous sinus thrombosis. Hence, he was treated with anticoagulants. The patient showed significant clinical improvement. SAH secondary to underlying CVT is relatively rare entity. After reviewing medical literature of such cases, 42 case reports and case series forming 95 cases of SAH secondary to CVT were found.

Cerebral venous thrombosis presenting with subarachnoid hemorrhage: Case report and review

Postcesarean Subarachnoid Hemorrhage as the Initial Presentation of Cerebral Venous Thrombosis