Cerebral venous sinus thrombosis with nontraumatic subdural hematoma.

Dear Editor,

A 60-year-old-patient reported to our hospital with complaints of acute onset of weakness over right side limbs for 2 days and complex partial seizure for 1 day. He was a known diabetic and hypertensive under irregular medication with no history of recent trauma. He had grade-III power in right side limbs, right side extensor plantar reflex, and bilateral papilledema. Noncontrast computed tomography (NCCT) scan of head shows thin isodense (subacute) subdural hematoma (SDH) over left frontal lobe convexity [Figure 1]. Contrast-enhanced magnetic resonance imaging (MRI) of brain shows T1W iso to hyperintense, T2W hypointense thin collection over left frontal lobe convexity and occluding thrombus in right transverse, sigmoid sinus and part of superior sagittal sinus. The patient was treated with antidiabetic, antihypertensive drugs and low molecular weight heparin, followed by oral warfarin with maintenance of the prothrombin time, international normalized ratio (prothrombin time INR) at 2:1. The patient recovered well on treatment.

Figure 1

Non-contrast computed tomography of head (a and b) shows thin subacute subdural hematoma over left frontal lobe convexity which is iso to hyperintense in T1W(d) and hypointense in T2W(e) image. Contrast-enhanced magnetic resonance image of head shows thrombus(arrow mark) of sagittal sinus(c) and right sigmoid sinus(f)

Cerebral venous sinus thrombosis (CVST) accounts 1%−2% of strokes in adult.[1] Trauma, infection, pregnancy, hormonal therapy, surgery, hypercoagulable disorders, connective tissue disease, malignancy, dehydration, tumor, diabetes mellitus, and nephrotic syndrome are common etiological factors.[2] The SDH is possibly due to rupture of bridging veins resulted from high backpressure by the obstructed thrombosed vein.[3] While NCCT scan of head is ideal for evaluation of intracranial hemorrhage, MRI with magnetic resonance venography is the investigation of choice for CVST. Small SDH with CVST can be managed conservatively by anticoagulants.