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.
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).