Treatment of cerebral venous sinus thrombosis with subdural hematoma and subarachnoid hemorrhage.

Dear Editor,

A 58-years-old male presented with severe headache and giddiness for 3 days without vomiting, convulsions, or unconsciousness. Central nervous system examination-conscious, disoriented, restless, moving all four limbs with normal pupils, and bilateral presence of Babinski reflex. Rest of the examination was normal. His magnetic resonance imaging revealed superior sagittal sinus thrombosis with bilateral parietal hemorrhagic infarcts with peripheral edema formation, mild subarachnoid hemorrhage (SAH) in the left parieto-occipital region, and subdural hematoma (SDH) along the right frontoparietal convexity of the skull without midline shift [Figures 1 and 2]. He was treated with mannitol, low-molecular-weight heparin (and later oral anticoagulants), and proton pump inhibitors. Uncomplicated course in hospital and improved after 15 days without any residual neurodeficit.

Figure 1

MRI of Brain- Axial view

Figure 2

MRI of Brain- Coronal view

Cerebral venous sinus thrombosis (CVST), though an uncommon cause of stroke, usually presents with either manifestation of raised intracranial pressure or with venous infarct (which may turn hemorrhagic). CVST rarely manifests with SDH or SAH. In the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT), none of the patients (n = 624) presented or were reported to have SDH or SAH.[1] Another study of an inpatient neurosurgery database identified only three patients of CVST with SDH over a 6 years period.[2] SAH as a manifestation of CVST is equally rare.[3] The bleeding manifestations of CVST are due to the rupture of bridging veins secondary to back pressure changes in the venous channels proximal to the thrombosed cerebral venous sinuses. The management of CVST with SDH and SAH is controversial and not well established. We propose an algorithm for the management of these patients [Figure 3]. Although there have been a handful of reports from India, this case is presented to re-emphasize this association between intracranial thrombotic and hemorrhagic manifestations.

Figure 3

Management algorithm of cerebral venous sinus thrombosis with subdural hematoma and subarachnoid hemorrhage

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