This 67-year-old male man has had a progressively worsening pain on the left cranium over 2 weeks that intractable to some analgesics. There was no recent head trauma or other medical disease in his history. On admission, the general physical and neurologic investigations were not remarkable. Routine laboratory evaluations including coagulation profiles and platelet function were within normal limits.\nBrain computed tomography (CT) scans revealed an isodense left-sided CSDH with marked cerebral shifting (). There was no evidence of source of this hemorrhage with temporal predilection on the CT angiogram. On magnetic resonance (MR) image subsequently obtained, the abnormal intensity within the subarachnoid space and the brain parenchyma was not visible. The patency without steno-occlusion in both transverse and sigmoid sinuses was clearly delineated on T2-weighted sequences (). This patient has received a trephination and SDH drainage, after that he was sent home with resolution of headache. Approximately 2 weeks later, however, he developed an excruciating pain in the temporal and parietal regions with recurrence of subdural collection. The site and density of hematoma was similar to the first presentation (). He was immediately returned for subdural irrigation and decompression through the prior burr-holes. The patient's clinical course was not eventful, but he complained of a mild headache again. Follow-up CT scanned just prior to discharge was strikingly for the newly-formed thin hematoma at the operative site (). Another evacuation of this subacute subdural clot was not deemed to be necessary.\nAt this time, an active intervention was sought for this patient who had an intractably recurring CSDH. On the 7th day after the second surgery, angiography was performed to rule out an occult vascular lesion. A flow-guided type microcatheter (Prowler 10™, Cordis Neurovascular, Miami Lakes, FL, USA) was positioned in the main trunk of the MMA for selective angiography. The frontal and parietal branch of the MMA was appeared normally, and the abnormal membrane staining on the affected side was not detected. A left external carotid angiogram disclosed a dural AVF between the petrosquamosal branch of the MMA and the transverse-sigmoid sinus without retrograde cortical venous draining. The AV shunt had no connection to the internal carotid artery and its branches. It was suggested that the bleeding from the draining venous system of the dural AVF led to refractory CSDH. The microcatheter was introduced into the petrosquamosal branch of the MMA, thereafter polyvinyl alcohol particles ranging 150 to 250 µm were distally injected (). After trans-arterial obliteration of the feeder and fistula, the AV shunt disappeared. The recurrent hematoma of this patient did not increase, and his complaints of headache gradually subsided. The brain CT at one year following the embolization therapy revealed complete regression of the subdural hematomas ().
A 58-year-old right-handed postmenopausal woman presented to the emergency with progressively increasing holocephalic headache for 3 days. She did not have fever, nausea, and vomiting. The headache gradually worsened in severity and on the day of presentation, she developed a generalized tonic clonic seizure. Apart from the history of well-controlled diabetes mellitus, she did not have significant past medical, personal, and family history. She had not received any vaccines in the recent past. On examination, she was ill-looking, but her vital signs were stable. She had Wernicke's aphasia. She did not have disc edema; cranial nerve examination was normal, and she did not have any focal deficits.\nAn urgent CT scan of the head without contrast showed left temporal hematoma with surrounding vasogenic edema (Figure ). Hemorrhagic picture was noted in the insular cistern (Figure ), left fronto-temporal subdural space (Figure ), the perimesencephalic, ambient and suprasellar cisterns (Figures and ), and the sulci of the left temporo-parietal lobes (Figures and ). There was a subtle dense clot sign in the left transverse sinus (Figure ). She was diagnosed as having left transverse sinus thrombosis leading to left temporal hematoma, SAH and SDH. She was treated with low molecular weight heparin, levetiracetam, and 3% hypertonic saline. The magnetic resonance venography (MRV) done the following day confirmed the presence of left transverse sinus thrombosis (Figure ). CT angiography of the brain did not reveal any vascular malformations. Her complete blood counts, coagulation profiles, routine blood chemistry, and C-reactive protein were within normal limits. Antinuclear antibody and SARS-CoV-2 RNA polymerase chain reaction tests were negative. She underwent CT scan of neck, chest, abdomen and pelvis, mammogram, stool occult blood, carcinoembryonic antigen, CA-125, and Ca 19–9 tests, all of which were non-contributory to any occult malignancy. Thrombophilia screening was not done at this acute stage. We decided to get those done after the completion of anticoagulant treatment. She showed good clinical improvement over the course of the next few days. A repeat CT scan of the head done on day seven, revealed decreasing edema and stable hematoma volume with no new bleeding. The cause of her CVST was deemed undermined at this stage and she was discharged home on dabigatran 150 mg twice daily, as she could not get PT/INR done reliably due to the current lockdown imposed by the government. She has been doing well on follow up.