A 77-year-old male with a recent syncope-related fall and closed head injury presented with gradually worsening isolated right upper extremity monoparesis. The fall occurred 1 month before presentation. On examination, the patient demonstrated 4/5 strength in his right upper extremity, with no additional neurologic deficits. Noncontrast head CT demonstrated bilateral mixed density convexity subdural hematomas [22 mm on the left and 14 mm on the right; and ]. The patient underwent a left craniotomy for evacuation of the larger hematoma, in conjunction with bilateral MMA embolization as primary treatment for the right convexity subdural hematoma in addition to limiting potential recurrence along the left convexity. Intraprocedural digital subtraction angiogram revealed two Cognard Grade III DAVFs, one arising from the parietal branch of the right MMA draining into an occipital cortical vein, and the second arising from the temporal branch of the left MMA draining into the vein of Labbe [-]. Given the presence of cortical venous reflux and associated risk of future intracranial hemorrhage, treatment of the fistulae was indicated. This was approached in two staged procedures. Following an uncomplicated left MMA embolization (frontoparietal branch), the incidental findings were discussed with the patient and he underwent a second stage embolization for the DAVF on a later date. During the second stage, a more prolonged infusion of liquid embolic was employed to ensure penetration into the recipient cortical venous outflow, resulting in nonopacification of the aforementioned fistulae. The postoperative course was complicated by seizures which resolved with uptitration in antiepileptic medications. At 6-month follow-up, there was complete resolution of the patient’s presenting symptoms and surveillance CT demonstrated no residual SDH.
A 68-year-old woman with polycythemia vera experienced a global, nonpositional headache for one day. She subsequently became comatose. On emergent evaluation she exhibited decorticate posturing. Her Glasgow coma score was 6. There was no preceding history of trauma, infection, or dehydration. She was not on anticoagulants or antiplatelet agents. Her polycythemia vera had been managed with therapeutic phlebotomy and hydroxyurea (500 mg daily). She had no prior history of thromboembolic events. Noncontrasted head CT showed extensive left 20 mm acute SDH with 16 mm of midline shift []. She underwent emergent craniotomy and hematoma evacuation. On careful inspection of the exposed brain, a prominent and engorged cortical vein observed. No other vascular abnormalities or potential bleeding sources were identified. CT venography and MR venography detected partial superior sagittal sinus thrombosis, which leads to the empty delta sign (the intraluminal thrombus prevents central filling of the sinus; ). She was managed conservatively with hydroxyurea, hydration, and aspirin. Laboratory analyses were notable for normal coagulation panel, normal platelet function assays, hematocrit of 45.9, negative thrombophilia evaluation (protein S, protein C, antithrombin III, anticardiolipin antibody, homocysteine, lupus anticoagulant, beta-2 glycoprotein antibodies, Factor V Leiden mutation, prothrombin gene mutation). Analysis of DNA extracted from her blood revealed the presence of the V617F mutation within the JAK2 gene. Her 3-month outcome was poor (modified Rankin score 4).