Subarachnoid hemorrhage as the initial presentation of dural sinus thrombosis

Abstract

Cerebral venous thrombosis (CVT) can be difficult to diagnose because of its wide spectrum of clinical manifestations. Its diagnosis may be further complicated when patients initially present with acute subarachnoid hemorrhage (SAH). We report on four patients with SAH revealing a CVT and discuss the role of imaging for diagnostic and pretherapeutic workup. In three women and one man presenting with severe headaches, images initially suggested SAH with no associated parenchymal bleeding. In all patients, SAH involved the sulci of the convexity and spared the basal cisterns. Digital subtracted angiography showed occlusion of intracranial venous sinuses but did not reveal any other cause of SAH. All patients improved with anticoagulant therapy. Risk factors for CVT and SAH, namely, head trauma and oral contraception, were identified in two patients. These cases highlight the fact SAH may reveal a CVT, which should be considered in the diagnostic workup of SAH, especially when the basal cisterns are not involved.

Fig 1.

Case 1. A–B, FLAIR images (9800/152/2300/1) showing hyperintensities sparing the basal cisterns and involving the sulci of the right convexity, compatible with an acute subarachnoid hemorrhage. C, T1-weighted spin echo image (480/9/1) revealing signal changes within the superior sagittal sinus (arrow).

Fig 2.

Case 2. A, E, Plain CT scan showing a bihemispheric subarachnoid hemorrhage, predominating in the left insular sulci. B, F, FLAIR images (9800/152/2300/1) showing hyperintensities within the subarachnoid spaces. C, FLAIR images (9800/152/2300/1) showing absence of signal changes in the basal cisterns and revealing a hyperintensity within the left transverse sinus (arrow). G, T2-weighted image (7000/86.3/2) in the frontal plane confirming the presence of a hypersignal within the left transverse and superior sagittal sinuses (arrows), raising the suspicion of sinus thrombosis. D, H, Venous phase of the digitized subtracted angiogram (A–P views) of the left carotid (D) and the left vertebral (H) arteries confirming the occlusion of the left transverse and superior sagittal sinuses. The right transverse sinus is not seen medially but fills laterally from venous collaterals and drains into the right sigmoid sinus.