Hemorrhage and thrombosis hand in hand.

A 30-year-old man presented with headache of 5 days’ duration and altered sensorium of 3 days’ duration. He had multiple episodes of generalized tonic-clonic seizures in the last 3 days. He had no history of fever or trauma. His neurological examination was unremarkable, but he had bilateral papilledema on fundoscopy. Non-contrast CT (Figure 1) and MRI (Figure 2) showed subarachnoid hemorrhage with cerebral sinovenous thrombosis. Cerebral sinovenous thrombosis (CSVT) is an unusual cause of stroke in young adults (1%–2%). It presents with varied and nonspecific clinical signs and symptoms. Common manifestations are headache, seizures and focal neurological signs. Subarachnoid hemorrhage (SAH) is a rare initial presentation of CSVT.1–4 The plausible cause of the SAH in CSVT is increased vascular permeability, extravasation of blood in the subarachnoid space, localized venous hypertension and rupture of hemorrhagic venous infarction.1,2 SAH seen in CSVT is mainly localized at the cerebral convexity and spares the basal cistern and skull base.1,2 Imaging modalities for CSVT are CT and MRI, but rarely, angiography when CT and MRI findings are nonspecific. SAH seen in CSVT is of venous origin, so it is important to make an early diagnosis of CSVT as the management of SAH seen in CSVT is different from SAH of arterial origin.

Figure 1

Non-contrast axial CT sections showing hyperdensities in the superior sagittal, straight, transverse and sigmoid sinuses (white arrows) suggestive of thrombosis. Subarachnoid hemorrhage (black arrows) is seen in left sylvian fissure and along the left cerebral convexity.

Figure 2

Axial T2-weighted (A) and coronal FLAIR (B) images showing hyperintense signal in the superior sagittal sinus (white arrows) and subarachnoid hemorrhage (black arrows) in the sylvian fissure.