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Cerebral Venous Sinus Thrombosis Manifesting as a Recurrent Spontaneous Subdural Hematoma: A Case Report
Reem Alharshan1, Hammad U Qureshi2, Abdullah AlHada2
1King Abdulaziz Hospital, Al Ahsaa, Saudi Arabia.
Insights
Diagnosing cerebral sinus venous thrombosis (CSVT) presenting as subdural hematoma (SDH) is difficult. This case highlights challenges in managing recurrent SDH secondary to CSVT, even with anticoagulation.
Area of Science:
- Neurology
- Radiology
Background:
- Cerebral sinus venous thrombosis (CSVT) presenting as spontaneous subdural hematoma (SDH) poses diagnostic challenges due to varied clinical presentations.
- Neuroradiological imaging is essential for confirming CSVT diagnosis.
- Management strategies for SDH secondary to CSVT are not well-established and remain controversial.
Observation:
- A case of an adult male with Down's syndrome presenting with spontaneous SDH is described.
- Initial management involved craniotomy and hematoma evacuation, followed by anticoagulation with Apixaban.
- The patient experienced recurrent SDH three months later, necessitating discontinuation of anticoagulation and repeat surgical intervention.
Findings:
- Post-operative MRV confirmed CSVT in the right transverse sinus.
- Recurrence of SDH occurred despite anticoagulation, leading to its cessation.
- Follow-up imaging at six months demonstrated resolution of thrombosis in the right sigmoid sinus with restored venous flow.
Implications:
- The management of SDH complicating CSVT is complex and controversial.
- Anticoagulation for CSVT with SDH carries potential risks, as evidenced by the recurrent hematoma.
- This case underscores the need for careful consideration of treatment strategies in rare presentations of CSVT.
Background:
Diagnosing cerebral sinus venous thrombosis (CSVT) manifested as a spontaneous subdural hematoma (SDH) is challenging due to variability of its clinical features. The neuroradiological investigation is crucial to confirm the diagnosis. The management of SDH secondary to CVST is controversial and not well established.
Case Description:
We present a case of an adult man with Down's syndrome who underwent a left-sided craniotomy and evacuation of spontaneous subdural hematoma. Post-surgery magnetic resonance venography (MRV) revealed venous sinus thrombosis in the right transverse sinus with loss of flow signal. He was started on Apixaban two weeks post-surgery. Three months later, the patient re-presented with recurrence of the SDH. His anticoagulation was discontinued, and he underwent craniotomy reopening and evacuation of the recurrent hematoma. The patient returned to his baseline following this procedure. The patient was followed up in the out-patient clinic regularly. Interval brain MRI and MRV performed at six months showed further resolution of the thrombosis of the right sigmoid sinus with restoration of the venous flow.
Conclusion:
The management of SDH complicating CVST remains controversial due to the rarity of its presentation and the hazards associated with the use of anticoagulation.
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