We report a case of a 23-year-old male, known case of Down’s syndrome, who presented to our Emergency Department with a complaint of severe headache for three days. It was accompanied by nausea, vomiting, and confusion. There was no history of trauma, seizures, loss of consciousness, change in vision, or relevant signs of virus infection. He was not on any regular medications. His medical background included surgical closure of ventricular septal defects in his childhood. There was no past medical or family history of coagulopathies.\nOn examination, his Glasgow coma score was 14, with normal vital signs. On neurological examination, the patient was confused, with dense right-sided hemiparesis. Liver function test, prothrombin time, partial thromboplastin time, and international normalized ratio were all within normal range. The brain CT scan revealed left-sided subacute SDH with a 12 mm midline shift and uncal herniation ().\nThe patient underwent emergent left-sided craniotomy and SDH evacuation. The blood evacuated was a mixture of dark stained blood and clots. Post-surgery, the patient’s consciousness level returned to normal, and he regained full power in all limbs. His post-operative CT scan showed optimal evacuation of the left-sided hematoma. There was also a new finding of a small right-sided SDH in the parietal region with no significant mass effect (). The CT scans review showed hyperdense areas in the transverse and sigmoid sinus; this raised suspicion of thrombosis. Magnetic resonance venography (MRV) confirmed the diagnosis of CVST in the right transverse and sigmoid sinuses with loss of flow signal ().\nClinically, the patient made an excellent post-operative recovery. After the diagnosis of CVST, we obtained neurology opinion and considered it risky to commence therapeutic anticoagulation in the early post-operative phase. He was started on a prophylactic dose of low molecular heparin. The patient was discharged home one week after surgery. Subsequently, he was readmitted electively two weeks later and was commenced on Apixaban. He was followed up regularly in outpatients and was asymptomatic.\nThe patient re-presented three months later complaining of a headache and recurrent vomiting, with normal consciousness levels. His repeat brain CT showed recollection of hematoma in the left subdural space (). An updated MRV revealed an interval shrinkage of the thrombus in the right sigmoid venous sinus; however, the reduced flow was seen through the sinus. The medical decision was to stop the anticoagulation, and the patient underwent reopening of the left-sided craniotomy and evacuation of the recurrent SDH. He recovered well after surgery, and we elected not to restart anticoagulation and follow-him clinically.\nThe patient remains clinically well. Interval MRI and MRV scans at six months show complete resolution of the SDH, with residual partial thrombosis of the right sigmoid sinus; however, the sinus is patent, and the venous flow is restored ().
A 60-year-old male experienced one month of escalating bifrontal headaches refractory to analgesics and antibiotics prescribed for presumed sinusitis. The headaches increased during sneezing, bending over, or bedrest and improved when he was sitting or standing. There was no history of trauma. His prior medical history was notable for hypertension and hyperlipidemia. There was no family history of coagulopathy or thrombophilia. He was married, employed, used 0.5 packs of tobacco (7.5 packs/years), consumed alcohol socially, and did not use any illicit drugs. His vital signs were notable for sinus bradycardia with a heart rate of 39 and elevated BP of 184/86 mmHg. He had no other significant findings on physical examination; detailed neurologic examination was unremarkable. Routine admission laboratory studies were within normal limits. Coagulation studies including platelet function assays were normal.\nNoncontrasted head CT demonstrated a 19 mm left isodense SDH with 10 mm of midline shift []. The collection was more prominent in the frontal region. A CT angiogram was obtained prior to surgery, and no source of bleeding was identified. He underwent a mini-craniotomy; and repeat CT imaging after the procedure [] demonstrated excellent hematoma evacuation and brain reexpansion.\nA scheduled follow up head CT obtained on postoperative day 27 was notable for recurrent SDH with a frontal predilection \n[]. The appearance and location were similar to the initial presentation. He was readmitted to the hospital and underwent SDH drainage via burr hole. On subsequent imaging with MRI, MR angiography, and MR venography, a filling defect was visible in the distal left transverse sinus and no flow was observed in the distal left sigmoid sinus or internal jugular vein. These findings were confirmed on CT venography.\nPatient underwent cerebral angiography on postoperative day 7 after SDH evacuation []. Left carotid injection was notable for a prominent left vein of Labbe with delayed wash-out, a filling defect in the left transverse sinus, and retrograde flow in the left transverse sinus with subsequent drainage into the right transverse sinus. Transvenous catheterization confirmed retrograde drainage of the left transverse sinus and venous stasis in the left vein of Labbe. Manometric readings in the left sigmoid sinus and both transverse sinuses were elevated (18-25 mmHg range). Thrombectomy with the Penumbra device and venoplasty with 7 × 20 mm balloon were performed; 10 mg of systemic abciximab was administered. Follow up venography demonstrated improved flow in the left vein of Labbe, restored normal direction of flow in the sinuses with normalized pressure (11 mmHg) in the left transverse sinus. Daily aspirin (325 mg) was initiated on the day of this intervention; patient was discharged home without neurologic deficits. A follow-up CT venogram at 6 weeks demonstrated patent venous sinuses and no recurrence of his SDH. His 3 month clinical outcome was excellent (modified Rankin score 0).