Cerebral venous sinus thrombosis complicated by subdural hematomas: Case series and literature review

A case of convexity non-aneurysmal subarachnoid hemorrhage caused by cerebral sinus thrombosis

BACKGROUND

Convexity subarachnoid hemorrhage (cSAH) is an uncommon presentation of subarachnoid bleeding, referring to bleeding more localized to the convexities of the brain. The diagnosis of cerebral venous sinus thrombosis (CVST) can be difficult especially when patients initially present with cSAH. The authors present a case and then discuss the pathophysiology and management.

CASE PRESENTATION

A 56-year-old woman with a previous history of hypertension and ischemic heart disease presented to the emergency department after experiencing it. Two seizures following a severe headache. The patient's history was negative for recent illnesses, head trauma, history of migraines, smoking, alcohol consumption, or intravenous drug use. The patient was diagnosed with CVST based on magnetic resonance venography (MRV). Genetic studies further identified homozygous mutations in the Prothrombin and MTHFR genes. Anticoagulant therapy was initiated with 60 mg of Enoxaparin twice daily and subsequently transitioned to Warfarin after 48 h continued for 3 months, and then replaced by rivaroxaban.

CONCLUSIONS

This study highlights the importance of considering CVST as a cause of SAH, emphasizes the role of advanced imaging in diagnosis, and demonstrates a successful treatment approach using both traditional and direct oral anticoagulants. The insights provided in this article can contribute to improving the management of patients with CVST-related SAH.

Unmasking hidden risks: cerebral venous sinus thrombosis and spontaneous subdural hematoma in women on oral contraceptives - insights from a case report and systematic literature review

BACKGROUND AND OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare but critical condition, particularly in young women, often linked to oral contraceptive use. It can lead to complications like subdural hematoma (SH), which are challenging to diagnose and manage. We report the case of a 39-year-old woman who presented with severe headaches and neurological symptoms, leading to a diagnosis of chronic SH and CVT, associated with long-term oral contraceptive use. This case is unique as it documents the first known instance of chronic SH associated with CVT induced by oral contraceptives. Our objective was to explore this association using the Bradford Hill criteria and to review the diagnostic and therapeutic challenges of CVT and SH in this population.

METHODS

We conducted a systematic literature review adhering to PRISMA guidelines, focusing on SH cases linked to CVT in women using oral contraceptives.

RESULTS

Including our case, four cases of SH associated with CVT secondary to oral contraceptive use were identified. Common symptoms included severe headache and neurological deficits. All patients received anticoagulation therapy, with surgical intervention required in severe cases. Prognosis was generally favorable with appropriate management.

CONCLUSION

This case emphasizes the importance of considering CVT in women presenting with spontaneous SH, particularly those on oral contraceptives. Early diagnosis, careful clinical and radiological monitoring, and timely surgical intervention are crucial for optimal outcomes.

Cerebral Venous Sinus Thrombosis Associated Subdural Hematoma: A Case Series on Clinical Presentation and Management

Diagnosis and treatment of cerebral venous sinus thrombosis (CVT) associated with subdural hematoma (SDH) is challenging with an increased risk of rebleeding on using anticoagulation. There are no guidelines at present due to its rare presentation. In this report we describe three patients who presented with non-traumatic SDH and CVT over the last 3 years. Clinical assessment, investigations including neuroimaging, and management were reviewed both at time of admission and follow-up. These patients presented with varied CVT syndromes -isolated raised intracranial pressure (ICP), focal and diffuse encephalopathy. Neuroimaging helped in diagnosing CVT and SDH. Cases 1 and 3 had SDH alone, while case 2 had SDH along with intraparenchymal hemorrhage. Management of these patients was tailored individually as per mechanism of CVT. Case 1 was clinically stable, however, she had rebleeding after starting anticoagulation, requiring its discontinuation. Cases 2 and 3 underwent immediate neurosurgical intervention in view of deteriorated sensorium. Although CVT manifesting as SDH is rare, clinicians should have a high index of suspicion to accurately diagnose and manage these challenging cases. The decision regarding use of anticoagulation and apt time for neurosurgical intervention needs to be individualized depending on patients condition and response to treatment.

Acute Subdural Hematoma: A Rare Manifestation of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) usually presents with headaches, seizures, and signs and symptoms of raised intracranial pressure (ICP). Risk factors for CVST commonly include hypercoagulable states such as pregnancy and the peripartum period, dehydration, vitamin B12 deficiency, hyper-homocysteinemia, coagulation factor deficiency, antiphospholipid antibody disease, oral contraceptive pill intake, etc. CVST with venous hemorrhagic infarction is commonly reported, but only a few cases have been reported in the literature of CVST presenting as SDH. Here, we present a case of a 28-year-old female who presented with an acute onset of severe headache, vomiting, and bilateral papilledema on fundus examination. She had a prior history of oral contraceptive pill intake. An MRI brain venogram suggested CVST involving the superior sagittal sinus, right transverse, and a few cortical vein thromboses with subdural hematoma (SDH) in the frontal-parieto-temporo-occipital region on the right side. The patient was treated with anticoagulants and antiepileptics and had significant improvement in symptoms with the resolving SDH on subsequent scans.

Imaging Approach to Venous Sinus Thrombosis

Cerebral venous thrombosis (CVT) is a rare cerebrovascular disease caused by an occlusion of the cerebral venous sinuses or cortical veins. It has a favorable prognosis if diagnosed and treated early. CVT can be difficult to diagnose on clinical grounds, and imaging plays a key role. We discuss clinical features and provide an overview of current neuroimaging methods and findings in CTV.

Decompressive surgery in cerebral venous thrombosis: A systematic review and meta-analysis

OBJECTIVE

The efficacy of decompressive surgery (DS) in cerebral venous thrombosis (CVT) patients has been reported in several case reports and case series. We aimed at determining the association of DS compared with medical management and timing of surgery with functional outcome and mortality. We also aimed at determining the prevalence of DS in CVT patients.

METHODS

The literature search was conducted till 7 November 2022 in PubMed, Google Scholar, EMBASE and Cochrane Library databases. Risk of bias was examined using Joanna Briggs Institute scale for case series and case reports. Association of DS compared with medical management and timing of surgery with functional outcome and mortality was determined using odds ratio (OR) and 95% confidence interval (CI). Pooled prevalence of DS in CVT patients with 95%CI was calculated. Heterogeneity was explored using outlier, meta-regression, sensitivity and subgroup analyses.

RESULTS

Fifty-one studies consisting of 483 CVT cases with DS were included. The OR of poor outcome with surgery was 0.03; (95%CI: 0.00-0.22) and of mortality with surgery was 0.25; (95%CI: 0.02-2.60) versus that with medical management. Surgery done ≤48 h of admission was significantly associated with less mortality (OR: 0.26; 95%CI: 0.10-0.69). Pooled prevalence of DS in CVT was 12% (95%CI: 8%-17%; I²  = 91%). Revised pooled prevalence after removing outliers was 10% (95%CI: 7%-13%; I²  = 73%).

CONCLUSIONS

Surgery ≤48 h of admission might decrease mortality in CVT patients and may result in improved functional outcome. Further prospective studies with appropriate control arms are required to confirm its efficacy over medical management.

Cerebral venous sinus thrombosis with an acute subdural hematoma treated with endovascular intervention: A case report

We report two cases of endovascular intervention for management of cerebral venous sinus thrombosis complicated by an acute intracranial hemorrhage during treatment with therapeutic anticoagulation. The first patient developed an acute subdural hematoma with progressive enlargement and was subsequently managed with venous sinus thrombectomy. The second patient developed an intraparenchymal and subdural hematoma and was treated with middle meningeal embolization. Anticoagulation is the primary treatment for cerebral venous sinus thrombosis but also contraindicated in an acute intracranial hemorrhage. In these cases, after endovascular intervention both patients resumed therapeutic anticoagulation without further hematoma expansion or additional invasive interventions. Both patients made an excellent neurological recovery and returned to their baseline functional independent status. Given the need for anticoagulation, endovascular intervention in the form of thrombectomy or middle meningeal artery embolization may be a viable adjuvant to anticoagulation in select patients.

Pitfalls in the diagnosis of subdural hemorrhage - Mimics and uncommon causes

PURPOSE

Subdural hemorrhage (SDH), the accumulation of blood between the dura and arachnoid mater, is one of the most commonly encountered traumatic findings in emergency radiology setting. The purpose of this essay is to review the pitfalls in the diagnosis of SDH including a) mimics on CT imaging and b) etiology other than accidental trauma. We describe several entities that closely mimic SDH on non-contrast CT scans. A knowledge of these mimics is essential in the emergency setting since overdiagnosis of SDH can lead to unnecessary hospital admissions, potentially invasive procedures, or even delay in necessary treatment. The mimics of SDH on non-contrast head CT include: PATHOLOGIC ENTITIES IATROGENIC MIMICS ANATOMIC/PHYSIOLOGIC MIMICS ARTIFACTUAL MIMICSWe also briefly review non-accidental and non-traumatic causes of SDH. Although, the most common cause of SDH is accidental trauma, other routinely encountered causes of SDH include coagulopathy, non-accidental trauma, cranial surgery, vascular malformations etc. CONCLUSION: Clinicians dealing with SDH in the emergency setting should consider SDH mimics and less common etiologies of SDH in order to facilitate appropriate patient management.

Acute subdural haemorrhage complicating cerebral venous thrombosis in a patient with protein C deficiency

Cerebral venous thrombosis (CVT) directly causing subdural haemorrhage (SDH) is a rare entity. We present a case of an 18-year-old female patient who presented with severe occipital headache. Neuroimaging showed acute SDH and CVT. She was eventually discovered to have underlying protein C deficiency. She was treated with anticoagulation and made an uneventful recovery. We aim to highlight the epidemiology, risk factors and aetiopathogenesis of CVT. We have included a literature review of previously described 13 case studies/reports describing SDH associated with CVT and a brief discussion of the dilemmas associated with management.

Cerebral Venous Sinus Thrombosis Manifesting as a Recurrent Spontaneous Subdural Hematoma: A Case Report

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Cerebral sinus venous thrombosis is a rare cause for a subdural hematoma and should be considered in the differential diagnosis of such cases.

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Neuroradiological imaging has a valuable role in diagnosing and follow-up of patients.

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Management of subdural hematoma secondary to venous sinus thrombosis could be challenging due to the controversy in using anticoagulation medications.

Background

Diagnosing cerebral sinus venous thrombosis (CSVT) manifested as a spontaneous subdural hematoma (SDH) is challenging due to variability of its clinical features. The neuroradiological investigation is crucial to confirm the diagnosis. The management of SDH secondary to CVST is controversial and not well established.

Case description

We present a case of an adult man with Down’s syndrome who underwent a left-sided craniotomy and evacuation of spontaneous subdural hematoma. Post-surgery magnetic resonance venography (MRV) revealed venous sinus thrombosis in the right transverse sinus with loss of flow signal. He was started on Apixaban two weeks post-surgery. Three months later, the patient re-presented with recurrence of the SDH. His anticoagulation was discontinued, and he underwent craniotomy reopening and evacuation of the recurrent hematoma. The patient returned to his baseline following this procedure. The patient was followed up in the out-patient clinic regularly. Interval brain MRI and MRV performed at six months showed further resolution of the thrombosis of the right sigmoid sinus with restoration of the venous flow.

Conclusion

The management of SDH complicating CVST remains controversial due to the rarity of its presentation and the hazards associated with the use of anticoagulation.

Mechanical Thrombectomy with Intraoperative Local Thrombolysis Versus Mechanical Thrombectomy with Continuous Thrombolysis for Treatment of Cerebral Venous Sinus Thrombosis: A Systematic Review of 82 Cases

OBJECTIVE

The first-line treatment of cerebral venous sinus thrombosis (CVST) is systemic anticoagulation. However, patients with severe or a clinically worsening condition might benefit from mechanical thrombectomy (MT) combined with intraoperative thrombolysis (IOT) or MT with continuous thrombolytic infusion (CTI). The present study compared the efficacy and safety of these 2 endovascular therapeutic methods by performing a systematic review of the literature.

METHODS

The present systematic review was conducted to identify all cases of CVST treated with MT+IOT or MT+CTI/MT+IOT+CTI reported in PubMed and Ovid. The recanalization rates, outcomes, operation-related complications, sequelae, and postoperative hemorrhage rates were evaluated.

RESULTS

A total of 28 studies, including 82 patients, met the inclusion criteria. Alone, MT+IOT was performed in 42 patients (51%), and MT+CTI/MT+IOT+CTI was performed in 40 patients (49%). Overall, outcomes data were available for 69 patients, of whom 57 (82%) had had a good outcome and 12 (18%) had had a poor outcome or had died. Recanalization data were available for 68 patients. Of these patients, 28 (41%) had had complete recanalization, 40 (59%) had had partial, and no patient had had no recanalization. Operation-related complications occurred in 5 patients (6%), and 3 patients (4%) developed postoperative intracerebral hemorrhage. However, no significant differences were found in the recanalization rate or prognosis between the MT+IOT and MT+CTI/MT+IOT+CTI groups.

CONCLUSIONS

The results from our review suggest that MT with local thrombolysis is relatively safe, with no significant differences in efficacy and safety between MT+IOT alone and MT+CTI/MT+IOT+CTI. However, randomized controlled studies are required to provide a definitive answer on its use for CVST.

Stent retriever thrombectomy combined with local thrombolytic therapy for cerebral venous sinus thrombosis: A case report

The present study reports the effect of successful treatment of cerebral venous sinus thrombosis (CVST) with stent retriever thrombectomy combined with local thrombolytic therapy. Medical records of 29 patients were retrospectively analyzed following a diagnosis of CVST with magnetic resonance venography (MRV) or digital subtraction angiography (DSA). Systemic anticoagulation was the initial treatment in all patients following admission. In group A, stent retriever thrombectomy combined with local thrombolytic therapy was performed on 14 patients who met the criteria of endovascular therapy. Stent-assisted angioplasty was also performed when patients presented with venous sinus stenosis. A total of 15 patients in group B received systemic anticoagulant treatment. Subsequently, warfarin was administered orally for 3 to 12 months as a continuous anticoagulant therapy. International normalized ratio was monitored when patients were receiving anticoagulant therapy. Additionally, clinical presentation, decision to escalate therapy, recanalization, Glasgow Coma Scale, modified Rankin Scale (mRS) and the clinical outcome was assessed. A total of 14 patients (9 female patients, 5 male patients), with ages ranging from 17 to 57 years, met the criteria of endovascular therapy. The clinical symptoms of 12 patients had improved after receiving endovascular therapy and only 2 patients suffered from intracranial hemorrhage following the procedure. Complete recanalization of venous sinus was exhibited in 10/14 (71.4%) patients in group A when compared with 1/15 (6.7%) patients in group B. mRS were improved in the 12-month follow-up in groups A and B when compared with that at admission. In the present study, patients with acute CVST treated with stent retriever thrombectomy combined with local thrombolytic therapy had a favorable outcome. To conclude, the present study provides a treatment option in treating CVST, particularly for patients that present with evident cortical venous outflow stasis or deteriorate neurology, despite appropriate anticoagulant therapy.

Imaging features of myeloproliferative neoplasms

Myeloproliferative neoplasms (MPNs) are a heterogeneous group of haematological disorders including polycythaemia vera (PV), essential thrombocythaemia (ET), primary myelofibrosis (PMF), and chronic myeloid leukaemia (CML). These disorders show large overlap in genetic and clinical presentations, and can have many different imaging manifestations. Unusual thromboses, embolic events throughout the systemic or pulmonary vasculature, or osseous findings can often be clues to the underlying disease. There is limited literature about the imaging features of these disorders, and this may result in under-diagnosis. Multiple treatments are available for symptom control, and the development of multiple new pharmacological inhibitors has significantly improved morbidity and prognosis. Knowledge of these conditions may enable the radiologist to suggest an MPN as a possible underlying cause for certain imaging findings, particularly unexplained splanchnic venous thrombosis, i.e. in the absence of chronic liver disease or pancreatitis. The aim of the present review is to outline using examples the different categories of MPN and illustrate the variety of radiological findings associated with these diseases.

Acute subdural hematoma secondary to cerebral venous sinus thrombosis: Case report and review of literature

Cerebral venous sinus thrombosis is a rare type of stroke primarily affecting young women. Diagnosis is generally delayed or overlooked due to a wide spectrum of clinical symptoms. Subdural hematoma secondary to cerebral venous sinus thrombosis is very rare. We report a case of 40-year-old female with cerebral venous sinus thrombosis who presented to us with an acute subdural hematoma and subarachnoid hemorrhage besides venous infarct. Management of such patients is complicated due to the rarity of the condition and contraindication for the use of anticoagulation. We conducted a thorough literature search through PubMed and could find only nine cases of spontaneous subdural hematoma secondary to cerebral venous sinus thrombosis.

Alternate theories of causation in abusive head trauma: what the science tells us

When cases of suspected abusive head trauma are adjudicated in courts of law, several alternative theories of causation are frequently presented. This paper reviews common theories and examines their scientific basis.