We report a case of a 23-year-old male, known case of Down’s syndrome, who presented to our Emergency Department with a complaint of severe headache for three days. It was accompanied by nausea, vomiting, and confusion. There was no history of trauma, seizures, loss of consciousness, change in vision, or relevant signs of virus infection. He was not on any regular medications. His medical background included surgical closure of ventricular septal defects in his childhood. There was no past medical or family history of coagulopathies.\nOn examination, his Glasgow coma score was 14, with normal vital signs. On neurological examination, the patient was confused, with dense right-sided hemiparesis. Liver function test, prothrombin time, partial thromboplastin time, and international normalized ratio were all within normal range. The brain CT scan revealed left-sided subacute SDH with a 12 mm midline shift and uncal herniation ().\nThe patient underwent emergent left-sided craniotomy and SDH evacuation. The blood evacuated was a mixture of dark stained blood and clots. Post-surgery, the patient’s consciousness level returned to normal, and he regained full power in all limbs. His post-operative CT scan showed optimal evacuation of the left-sided hematoma. There was also a new finding of a small right-sided SDH in the parietal region with no significant mass effect (). The CT scans review showed hyperdense areas in the transverse and sigmoid sinus; this raised suspicion of thrombosis. Magnetic resonance venography (MRV) confirmed the diagnosis of CVST in the right transverse and sigmoid sinuses with loss of flow signal ().\nClinically, the patient made an excellent post-operative recovery. After the diagnosis of CVST, we obtained neurology opinion and considered it risky to commence therapeutic anticoagulation in the early post-operative phase. He was started on a prophylactic dose of low molecular heparin. The patient was discharged home one week after surgery. Subsequently, he was readmitted electively two weeks later and was commenced on Apixaban. He was followed up regularly in outpatients and was asymptomatic.\nThe patient re-presented three months later complaining of a headache and recurrent vomiting, with normal consciousness levels. His repeat brain CT showed recollection of hematoma in the left subdural space (). An updated MRV revealed an interval shrinkage of the thrombus in the right sigmoid venous sinus; however, the reduced flow was seen through the sinus. The medical decision was to stop the anticoagulation, and the patient underwent reopening of the left-sided craniotomy and evacuation of the recurrent SDH. He recovered well after surgery, and we elected not to restart anticoagulation and follow-him clinically.\nThe patient remains clinically well. Interval MRI and MRV scans at six months show complete resolution of the SDH, with residual partial thrombosis of the right sigmoid sinus; however, the sinus is patent, and the venous flow is restored ().
A 25-year-old primigravida with a history of pre-eclampsia was brought to the emergency department with sudden onset of severe headache. The headache started two days after delivery. It was followed by confusion and loss of consciousness over a few hours. On initial evaluation, the patient was confused with a Glasgow Coma Scale (GCS) of 12/15, blood pressure of 130/90 mmHg, pulse rate of 82 beats/min, respiratory rate of 30/min, temperature 98°C, and oxygen saturation of 97 mmHg at room temperature. On physical examination, bilateral equivocal planters were noted with no other significant findings, and bilateral papillary edema on fundoscopy was seen. The rest of the review system was unremarkable. She underwent an urgent MRI with magnetic resonance venography (MRV) of the brain, which showed right transverse sinus thrombosis with an element of SAH (Figure ).\nCoagulation profile, including thrombin time (TT), prothrombin time (PT), partial thromboplastin time (PTT), antithrombin III, fibrinogen, proteins C and S, antiphospholipid antibody titers, and homocysteine levels, were normal. She was started on a half dosage of low molecular weight heparin (LMWH) (60 mg subcutaneously once a day) with regular monitoring of her blood pressure and GCS. Her GCS started improving; therefore, she was continued on a half dose of LMWH for 10 days, and brain MRI was repeated after 10 days, which showed the gradual resolution of SAH (Figure ). The quantity of LMWH was doubled, and warfarin was started after a full dose of LMWH. After improving her GCS and achievement of international normalized ratio (INR) of two to three, she was discharged with the advice of regular INR monitoring and follow-up to the outpatient department. On follow-up at six weeks, MRI with MRV was repeated, which showed thrombosis had resolved, although a mild filling defect was noted. She was kept on anticoagulants for one year, and on further follow-up at six months, she was doing well.