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 40-year-old female presented to an emergency in altered sensorium with right hemiplegia with a history of a severe headache and multiple episodes of vomiting 1 day prior to admission. She was on oral contraceptives for last 2 years. Her Glasgow Coma Scale at admission was E1M3V1 and left pupil was dilated and not reacting to light. Computed tomography (CT) of head revealed venous infarct in left temporo-occipito-parietal region with linear area of hemorrhage within it with large left fronto-temporo-parietal acute subdural hematoma with midline shift of 9 mm toward right side with subfalcine herniation with descending transtentorial herniation with sub-arachnoid hemorrhage in the left parietal and occipital sulci with diffuse cerebral edema [].\nCT venography revealed thrombosis in superior sagittal sinus extending to adjacent cortical veins []. She was immediately taken for surgery, and a left fronto-temporo-parietal decompressive craniectomy was performed with the evacuation of acute subdural hematoma and lax duroplasty. However, she continued to deteriorate in the postoperative period and died on the first postoperative day.