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.
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).