Summary: A 42-year-old female with no significant past medical history presented to the emergency department (ED) with altered sensorium. Her spouse reported confusion and left-sided hemiparesis. Examination revealed right gaze deviation and left hemiplegia. Brain CT imaging showed an acute intraparenchymal hematoma in the right frontal lobe, with hemorrhage along the right cerebral convexity and a resultant leftward midline shift. Due to the hemorrhage pattern involving multiple arterial regions, a CT brain venogram was performed, revealing multiple cerebral sinus thromboses. She was also found to have diabetic ketoacidosis (DKA). Anticoagulation was initiated, and she was treated for DKA and admitted to the high-dependency unit for monitoring. During her stay, a repeat CT brain scan was performed following a drop in GCS, which showed stable hemorrhage but a new infarct in the right occipital and frontal lobes. She subsequently underwent cerebral venous sinus thrombectomy. Thrombotic and autoimmune screenings were normal. She recovered with residual left-sided hemiparesis and was referred to a rehabilitation hospital and discharged with lifelong anticoagulation. Managing CVST with venous hemorrhage presents challenges, as anticoagulation may exacerbate the hemorrhage. This patient’s initial plain CT brain hemorrhagic findings were not initially recognized as a possible CVST by the neurosurgeon, and after reviewing the CT images by the ED physician, further discussion with the radiologist was done, and a CT venogram was performed. Although plain CT brain scans are widely used, ED physicians must recognize findings suggestive of CVST. While CVST is treated with anticoagulation, endovascular thrombectomy may be a viable option for selected patients in centers equipped with this capability.
Liew et al. (Sun,) studied this question.