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 59-year-old male with a recent fall and closed head injury presented with progressively worsening headaches. The fall occurred 9 days before presentation. On examination, no neurologic deficits were found. Noncontrast head CT demonstrated a 5 mm left convexity CSDH []. He underwent burr hole evacuation and was discharged on the subsequent day. He presented again on postoperative day 6 with recurrence of his headaches. Noncontrast head CT demonstrated recurrence of the left convexity subdural hematoma []. He subsequently underwent a left craniotomy for evacuation. He was discharged on postoperative day 2 with no postprocedural complications. At 1-month follow-up, he continued to complain of severe headaches. Surveillance CT demonstrated a new 27 mm right convexity mixed density subdural hematoma [ and ]. He subsequently underwent right MMA embolization as primary treatment. Intraprocedural digital subtraction angiogram revealed a Cognard Grade III cribriform plate DAVF supplied by the right ophthalmic artery draining into a right frontal cortical vein [ and ]. The right MMA temporoparietal and frontal branches were embolized with n-BCA glue. Follow-up was arranged to treat the DAVF at a later date and he was discharged the following day. The patient was subsequently lost to follow-up, but presented to the emergency department 4 months later with diplopia and a right abducens nerve palsy. Noncontrast head CT demonstrated significant reduction in size of the previously embolized right convexity subdural hematoma. He was admitted and underwent attempted endovascular treatment of the DAVF. Catheterization of the arterial and venous sides of the fistula achieved suboptimal positioning for liquid embolic embolization and so he underwent a right craniotomy for surgical ligation of the fistula. The patient experienced no postprocedural complications. At 2-week follow-up, there was complete resolution of his presenting symptoms and surveillance CT demonstrated no residual SDH.