Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding: implications for treatment

Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding is an uncommon event rarely described in the literature. We report here a case and summarize the problems in the management of this patient.

A 48-year-old female suffered from two episodes of severe headache and vomiting 7 days before and on the day of admission. She was deeply somnolent with mild paresis of her right leg. Computed tomography (CT) scans revealed diffuse basal subarachnoid bleeding and a left parietal subcortical hemorrhagic area. A cerebral angiogram demonstrated an anterior communicating artery aneurysm. The angiographic late venous phase showed nonopacification of the cortical veins on the hemorrhagic area compatible with cerebral vein thrombosis. She underwent successful aneurysm clipping combined with moderate systemic anticoagulation. After 7 days of gradual clinical improvement she presented acute bilateral cerebral herniation signs and died 48 hours later. CT scan showed a generalized brain swelling. Postmortem examination confirmed the correct occlusion of the ruptured aneurysm sac and the presence of a postthrombotic subcortical left parietal hemorrhage as well as a complete obstruction of the superior sagittal sinus extended into both transverse sinus.

The fatal outcome with the documented extended thrombosis, despite careful anticoagulation therapy, indicates the necessity of closely meshed follow-up studies examining the sinus patency in such complicated cases with associated pathology.