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Neurology India, Vol. 55, No. 4, October-December, 2007, pp. 438-439 Neuroimage Subdural hematoma, subarachnoid hemorrhage and intracerebral parenchymal hemorrhage secondary to cerebral sinovenous thrombosis: A rare combination Thomas Mathew, G. R. K. Sarma, Vikram Kamath, A. K. Roy Department of Neurology, St.John’s Medical College Hospital, Bangalore - 560 034, India Date of Acceptance: 05-Feb-2007 Code Number: ni07140 Cortical vein thrombosis (CVT) is increasingly recognized as a distinctive cause of cerebrovascular disease in the young. The easy availability of imaging techniques like magnetic resonance imaging (MRI) and venography (MRV) has led to better awareness among the neurologists. The clinical picture is extremely variable and presentation is often misleading. Isolated subarachnoid hemorrhage (SAH) and subdural hemorrhage (SDH) can be an uncommon presentation of CVT. We report a case of CVT with hemorrhages in three brain compartments - subdural, subarachnoid and parenchymal. Occurrence of both intracranial bleeding and thrombosis makes the management of such a patient challenging. A 40-year-old man presented with headache and vomiting of two weeks duration and weakness of the left upper and lower limb since five days. He was addicted to alcohol for the past 20 years and had last consumed alcohol 10 days prior to admission. On examination he was in altered sensorium, not responding to verbal stimuli and had a dense left hemiplegia. Routine blood investigations including renal and liver function tests, prothrombin time, bleeding and clotting times were normal. The MRI of the brain showed right parietal parenchymal hemorrhage, bilateral subdural hematoma and left parietal localized subarachnoid hemorrhage [Figure 1]. The sagittal sinus and bilateral transverse sinus were hyperintense on T1W, T2W and FLAIR images, suggestive of thrombus in the subacute stage. Magnetic resonance venogram (MRV) showed total absence of filling in the sagittal and bilateral transverse sinuses, confirming the diagnosis of cortical sinius thrombosis [Figure 2]. Workup for antiphospholipid antibodies, lupus anticoagulant and vasculitis was negative. Serum homocysteine levels were normal. The patient was treated with heparin, antiepileptic agents, antiedema measures and multivitamin supplementation. His sensorium improved significantly after two days of treatment. Oral anticoagulation was instituted. Following two weeks of treatment, patient had recovered totally in sensorium but the left hemiplegia persisted. On follow-up, after one month, patient had fully improved with no deficits. Discussion Cortical sinovenous thrombosis occurs in both males and females, but is more common in women in the postpartum period, especially in developing countries like India. [1] The common etiologies include prothrombotic states, infections, drugs and inflammatory diseases like lupus, Behcet′s etc. Alcoholism is an important risk factor commonly observed in male CVT patients. Neuroimaging usually shows hemorrhagic infarcts with hyperintense sinuses suggestive of thrombosis of the sinuses. Isolated cortical vein thrombosis usually presents as a parenchymal bleed or with raised intracranial tension, but can rarely present as subarachnoid hemorrhage. [2] Circumscribed subarachnoid hemorrhages along the cortical convexity are rare and have only been described in singular case reports so far. Subarachnoid hemorrhage due to CVT is a low-pressure, localized, cortical surface bleed which lacks the characteristics of a basal subarachnoid hemorrhage. Typical signs of basal SAH, such as nuchal rigidity, thunderclap-headache or alteration of sensorium are rare. [3] There is only a single case report of intra-parenchymal hemorrhage and subdural hematoma secondary to CVT. [4] To the best of our knowledge, no case of subdural, subarachnoid and parenchymal bleed occurring together in a patient with CVT has been reported. The multicompartmental intracranial bleed most probably results from the rupture of bridging veins, secondary to high back pressure, arising from the blockage of venous drainage into the thrombosed cerebral venous sinuses. Management of such a patient is difficult because of the simultaneous presence of both thrombosis and bleeding. A high index of suspicion is needed for early recognition of this condition, instituting appropriate therapy and avoiding unnecessary interventions. Though subarachnoid and subdural hemorrhages are rare in CVT, one should consider this diagnosis when both occur together in the same patient.References
Copyright 2007 - Neurology India The following images related to this document are available:Photo images[ni07140f1.jpg] [ni07140f2.jpg] |
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