Beyond Aneurysms, Subarachnoid Hemorrhage Unraveling Dural Venous Sinus Thrombosis: A Rare Case Report

Beyond Aneurysms, Subarachnoid Hemorrhage Unraveling Dural Venous Sinus Thrombosis: A Rare Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Beyond Aneurysms, Subarachnoid Hemorrhage Unraveling Dural Venous Sinus Thrombosis: A Rare Case Report Muhammad osama, Abdullah Abdullah, Mohammad Noman, Hafsa Khan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5394133/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Dural venous sinus thrombosis (DVST) can be challenging for clinicians, especially when presenting with subarachnoid hemorrhage (SAH)-like symptoms. DVST presents with headache, vision loss, paralysis and seizures. Case presentation: We report a case of a 22-year-old male with left-sided weakness, severe headache and loss of consciousness. Examination revealed left-sided weakness and optic disc blurring. Lumbar puncture showed numerous RBCs. MRI brain with Magnetic Resonance Venography (MRV) revealed “left transverse and sigmoid venous sinus thrombosis and minimal subarachnoid hemorrhage.” A diagnosis of SAH secondary to DVST was made. The patient was treated with Apixaban, resulting in resolution of DVST and SAH. Conclusion This case highlights the need for early recognition of DVST in SAH patients lacking aneurysmal components or basal cistern involvement and its management with anticoagulation if hemodynamically stable. Dural venous sinus thrombosis Subarachnoid hemorrhage Lumber puncture MRI with MRV Direct oral anticoagulant Figures Figure 1 Background Sometimes the diagnosis of Dural Venous Sinus Thrombosis (DVST) becomes challenging, and is even more difficult when the patient initially presents with signs and symptoms of subarachnoid hemorrhage (SAH) 1 . DVST presents in various ways including severe headache, visual symptoms such as blurry vision, any of the manifestations of stroke such as paralysis of the face and limbs unilaterally, and seizures 2 . SAH is often caused by vascular abnormalities especially aneurysm in 85% of cases and generally DVST is not taken into consideration in the workup of SAH. Surprisingly, there are very limited reports on patients who exhibit radiological signs of subarachnoid hemorrhage (SAH) in conjunction with deep venous sinus thrombosis (DVST) 3 . SAH in these instances can be attributed to multiple rationales including an elevation in venous pressure within the draining venous tributaries 4 . The purpose of this case report is to understand a unique way in which DVST can manifest, such as SAH in our case. Case Presentation A 22-year-old male with no co-morbidities and laborer by profession was brought to the emergency department with left-sided weakness and severe headache accompanied by loss of consciousness and an episode of vomiting for four days. The patient was in his usual state of health when he suddenly developed a severe holocranial headache and subsequently, there was weakness on the left side of his body. On arrival, his blood pressure was 100/60 in both arms, pulse rate of 81 beats per minute (bpm), Oxygen saturation of 98% at room air, and temperature of 98 . On examination, the patient was oriented to time, place and person with a GCS score of 15/15. He was photophobic and all the signs of meningeal irritation neck stiffness, kerning, Brudzinski, and jolt accentuation test were positive. Fundoscopy showed slight blurring of optic discs bilaterally but his pupillary reflexes and ocular movements were normal and symmetrical. Power in the right upper and lower limbs was normal while on the left side, it was 4/5 in the upper limb and 3/5 in the lower one, though plantar were down-going bilaterally. Reflexes in the left upper limb were brisk but there was no clonus in either limb. Cardiac auscultation revealed normal S 1 and S 2 with no added sounds or carotid bruit. The rest of the examination was unremarkable with abdominal examination revealing no visceromegaly or renal bruit. MRI brain with MRV was ordered which showed “left transverse and sigmoid venous sinus thrombosis and minimal subarachnoid hemorrhage along left sylvian cistern and along the convexities of the left temporoparietal region” (Figure 01) . Subsequently, a lumbar puncture was done which shows numerous RBCs. Ultrasound abdomen and pelvis was done to rule out polycystic kidney disease as a potential cause of subarachnoid hemorrhage due to weak cerebral vasculature and the study revealed normal kidneys and other viscera. The patient was started on Tab Nimodipine and other supportive measures. Serological tests were ordered to know if there was any underlying defective coagulation problem. Coagulation profile results were normal (Table 01) . Table 01: Lab investigations of the patient. S.NO Entity of Investigation Results Normal Range 1 TLC 24.8×10 3 /ul 4-11×10 3 /ul 2 DLC Neutrophils 89.5% 40-75% 3 Lymphocytes 4.9% 20-45% Monocytes 5.4% 2-10% Hemoglobin 14.8g/dl 11.5-17.5 Platelets 339/ul 150-450/ul 5 Blood urea 23.2mg/dl 10-50mg/dl 6 Creatinine 0.98mg/dl 0.3-0.9mg/dl 7 Coagulation profile APTT 32seconds 30seconds PT 14seconds 12seconds INR 1 1 TT 13 12-19 sec Protein C 85 65-135 IU/dl Protein S 94 60-150% Fibrinogen 240 200-400mg/dl Anti-thrombin III 94 80-130% Homocysteine 8 <15mcmol/l His electrocardiogram was normal as well. Three weeks on the initial medications the patient showed very little clinical improvement with bouts of severe headache. Tab Apixaban 5mg BID was subsequently added to his treatment regimen along with Tab Escitalopram 10mg. One week later, the patient showed significant improvement in his overall condition with almost complete resolution of signs and symptoms of meningeal irritation and episodes of headaches. His limb weakness resolved and he was able to ambulate without assistance. CT-Scan Brain showed “A normal study with the resolution of thrombosis and the subarachnoid hemorrhage”. The patient was discharged with a follow-up scheduled in six weeks; she was doing well. Discussion DVST presents a tricky situation even to experienced clinicians when it presents unusually like SAH. DVST can present in multiple ways including severe headache, visual symptoms such as blurry vision, any of the manifestations of stroke such as paralysis of the face and limbs, and seizures 2 . SAH is caused by a ruptured aneurysm in 85% of cases 5 and by non-aneurysmal peri mesencephalic hemorrhage in 10%; the rest of 5% is related to multiple uncommon causes such as Dural arteriovenous fistula, arterial dissection, and cocaine abuse 3 . The exact mechanism of SAH in the setting of DVST is unknown. It may be caused by the leak of venous parenchymal hemorrhagic infarcts into the subarachnoid space 4 . Hypertension may cause tear of the enlarged, delicate walled subarachnoid cortical veins that do not contain smooth muscle fibers. DVST can cause a confined inflammatory response and can also cause SAH, resulting in enhanced endothelial permeability 3 . Rupture of delicate walled cortical veins secondary to venous hypertension with DVST may also lead to SAH 4 . Dilatation of the cortical veins as a result of DVST, may tear and leak blood into the subarachnoid space and lead to SAH 6 . Neuroimaging modalities include Computed Tomography (CT)/ Computed Tomography Venography (CTV), Magnetic Resonance Imaging (MRI)/ Magnetic Resonance Venography (MRV), and Cerebral Angiography 7 . Whenever there is SAH involving convexity plus there is sparing of the basal cistern, it is advisable to proceed with specialized vascular imaging of the intracranial arteries as well as the dural sinuses 8 . Digital subtraction angiography (DSA) continues to be considered the preeminent imaging modality in current practice to look for cerebral artery aneurysms. However, being an invasive procedure with potential complications DSA is therefore usually not the first-line imaging test except perhaps in patients with acute SAH 9 . Conventional imaging modalities such as computed tomography (CT) or magnetic resonance (MR) angiography targeting the arterial structures of the circle of Willis are insufficient for visualizing the distal arteries and the venous system concurrently within a single imaging session, therefore they may miss it 10 . Systematic consideration of DVST in the diagnostic workup of SAH involving cerebral convexities is necessary, 11 otherwise there is a high probability of the condition going undetected when these noninvasive angiographic techniques are used 12 . The management strategy for DVST primarily comprises general supportive interventions, anticoagulant therapy, and endovascular thrombolysis 7 . The safety of heparin in the treatment of dural venous sinus thrombosis has been established in a randomized controlled trial involving 20 patients 13 , another study showed promising results with a combination of low molecular heparin and oral anticoagulation in 60 patients, although the results were non-significant statistically 14 . Currently, direct oral anticoagulants (DOACs) are also used for anticoagulation in the management of DVST. Several studies have demonstrated that DOACs, in comparison to warfarin, exhibited comparable clinical and radiographic outcomes as well as safety profiles 15,16 . In our case, we also used DOACs (apixaban) with the patient showing significant improvement. Although multiple studies also showed no significant benefit of anticoagulation in patients with DVST 13 . The recuperation rate of individuals diagnosed with DVST was found to be 80% with different durations of several weeks or months needed to return to a state of normalcy 17 . Seizures and occurrences of new thrombotic events were noted as the predominant complications during the subsequent monitoring period 18 . Conclusion The presentation of DVST is highly variable. The physicians should keep a high suspicion of DVST if a patient presents with SAH but has no aneurysmal component or basal cistern involvement on imaging, in addition, if blood is found in the cerebral convexities, this further supports this possibility. In these cases, it is recommended to provide immediate treatment with anticoagulation, depending on the patient's hemostatic stability. Abbreviations DVST: Dural venous sinus thrombosis SAH: Subarachnoid hemorrhage. DOACs: Direct oral anticoagulants. MRV: Magnetic resonance venography. MRA: Magnetic resonance arteriography. CT scan: Computed tomographic scan. DSA: Digital subtraction angiography Declarations E thics Approval: Not applicable Consent for publication: Informed consent was obtained before collecting data, explaining the publication of neuroimaging and medical history without revealing the patient's identity. Availability of data and material: The data is available upon the request of editor-in-chief of the journal. Competing Interests: The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article. Funding: No funding Acknowledgment: Not applicable References Oppenheim C, Domigo V, Gauvrit JY, Lamy C, Mackowiak-Cordoliani MA, Pruvo JP, et all. Subarachnoid hemorrhage as the initial presentation of dural sinus thrombosis.AJNR Am J Neuroradiol. 2005 Mar;26(3):614-617. PMID: 15760875; PMCID: PMC7976499. Silvis S, Aguiar de Sousa D, Ferro J, Coutinho J (2017). "Cerebral venous thrombosis".Nat Rev Neurol. 13 (9): 555–565. doi:10.1038/nrneurol.2017.104. PMID 28820187. S2CID 54526187. Cuvinciuc V, Viguier A, Calviere L, Raposo N, Larrue V, Cognard C, et all. Isolated acute nontraumatic cortical subarachnoid hemorrhage. AJNR Am J Neuroradiol. 2010 Sep;31(8):1355-1362. doi: 10.3174/ajnr.A1986. Epub 2010 Jan 21. PMID: 20093311; PMCID: PMC7966116. Pradhan S, Yadav R, Diwakar H, Phadke RV. Subarachnoid hemorrhage following chronic dural venous sinus thrombosis. Angiology. 2007 Aug-Sep;58(4):498-501. doi: 10.1177/0003319706291117. PMID: 17875965. Hostettler IC, Sebök M, Ambler G, Muroi C, Prömmel P, Neidert MC, et all. Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score. Neurosurgery. 2020 Dec 15;88(1):96-105. doi: 10.1093/neuros/nyaa316. PMID: 32779716. de Bruijn SF, Budde M, Teunisse S, de Haan RJ, Stam J. Long-term outcome of cognition and functional health after cerebral venous sinus thrombosis. Neurology. 2000 Apr 25;54(8):1687-9. doi: 10.1212/wnl.54.8.1687. PMID: 10762517. Chaurasia D, Yadav B, Dhungana K. Dural Venous Sinus Thrombosis: A Case Report. JNMA J Nepal Med Assoc. 2021 Dec 11;59(244):1316-1319. doi: 10.31729/jnma.7170. PMID: 35199774; PMCID: PMC9200019. Lin JH, Kwan SY, Wu D. Cerebral venous thrombosis initially presenting with acute subarachnoid hemorrhage. J Chin Med Assoc. 2006 Jun;69(6):282-5. doi: 10.1016/S1726-4901(09)70258-8. PMID: 16863016. Expert Panel on Neurologic Imaging: Salmela MB, Mortazavi S, Jagadeesan BD, Broderick DF, Burns J, Deshmukh TK, Harvey HB, Hoang J, Hunt CH, Kennedy TA, Khalessi AA, Mack W, Patel ND, Perlmutter JS, Policeni B, Schroeder JW, Setzen G, Whitehead MT, Cornelius RS, Corey AS. ACR Appropriateness Criteria® Cerebrovascular Disease. J Am Coll Radiol. 2017 May;14(5S): S34-S61. doi: 10.1016/j.jacr.2017.01.051. PMID: 28473091. Wang YF, Fuh JL, Lirng JF, Chang FC, Wang SJ. Spontaneous intracranial hypotension with isolated cortical vein thrombosis and subarachnoid haemorrhage. Cephalalgia. 2007 Dec;27(12):1413-7. doi: 10.1111/j.1468-2982.2007.01437.x. Epub 2007 Sep 19. PMID: 17888012. Spitzer C, Mull M, Rohde V, Kosinski CM. Non-traumatic cortical subarachnoid haemorrhage: diagnostic work-up and aetiological background. Neuroradiology. 2005 Jul;47(7):525-31. doi: 10.1007/s00234-005-1384-6. Epub 2005 Jun 22. PMID: 15971064. Sharma S, Sharma N, Yeolekar ME. Acute subarachnoid hemorrhage as initial presentation of dural sinus thrombosis. J Neurosci Rural Pract. 2010 Jan;1(1):23-5. doi: 10.4103/0976-3147.63097. PMID: 21799614; PMCID: PMC3137828. Einhäupl KM, Villringer A, Meister W, Mehraein S, Garner C, Pellkofer M, Haberl RL, Pfister HW, Schmiedek P. Heparin treatment in sinus venous thrombosis. Lancet. 1991 Sep 7;338(8767):597-600. doi: 10.1016/0140-6736(91)90607-q. Erratum in: Lancet 1991 Oct 12;338(8772):958. PMID: 1679154.. de Bruijn SF, Stam J. Randomized, placebo-controlled trial of anticoagulant treatment with low-molecular-weight heparin for cerebral sinus thrombosis. Stroke. 1999 Mar;30(3):484-8. doi: 10.1161/01.str.30.3.484. PMID: 10066840. Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, et all. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke. 2022 Mar;53(3):728-738. doi: 10.1161/STROKEAHA.121.037541. Epub 2022 Feb 10. PMID: 35143325. Bose G, Graveline J, Yogendrakumar V, Shorr R, Fergusson DA, Le Gal G, et all. Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review. BMJ Open. 2021 Feb 16;11(2):e040212. doi: 10.1136/bmjopen-2020-040212. PMID: 33593766; PMCID: PMC7888326. Moll S, Waldron B. Cerebral and sinus vein thrombosis. Circulation. 2014 Aug 19;130(8):e68-70. doi: 10.1161/CIRCULATIONAHA.113.008018. PMID: 25135131. Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F; ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004 Mar;35(3):664-70. doi: 10.1161/01.STR.0000117571.76197.26. Epub 2004 Feb 19. PMID: 14976332. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5394133","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":376558744,"identity":"4976b43b-95d9-41cb-b682-2f27c968f9f1","order_by":0,"name":"Muhammad osama","email":"","orcid":"","institution":"Khyber Medical College","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"osama","suffix":""},{"id":376558745,"identity":"0fa5cd3a-9b8c-49e1-a277-310cdc9ad943","order_by":1,"name":"Abdullah Abdullah","email":"","orcid":"","institution":"Khyber Teaching 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09:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5394133/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5394133/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71561245,"identity":"3ab551c0-1c7f-4b09-93eb-6de1f6def781","added_by":"auto","created_at":"2024-12-16 16:59:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":925065,"visible":true,"origin":"","legend":"\u003cp\u003e(\u003cstrong\u003eA:\u003c/strong\u003e \u003cstrong\u003eFLAIR\u003c/strong\u003e, axial section of the brain showing Subarachnoid hemorrhage in left Sylvian fissure and left temporal sulci), (\u003cstrong\u003eB:\u003c/strong\u003e \u003cstrong\u003eMRV\u003c/strong\u003e, showing loss of signals from the left transverse and sigmoid sinus), (\u003cstrong\u003eC:\u003c/strong\u003e \u003cstrong\u003eFLAIR\u003c/strong\u003e, showing loss of signals void in the left transverse and sigmoid sinus), (\u003cstrong\u003eD:\u003c/strong\u003eAxial view of \u003cstrong\u003eCT brain\u003c/strong\u003e after 10 days of treatment, showing resolution).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5394133/v1/0ea9753fa12b5518e80cf20e.png"},{"id":71563038,"identity":"3db631bd-1916-46c6-9e03-f1337b16eb24","added_by":"auto","created_at":"2024-12-16 17:15:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1231221,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5394133/v1/26a44324-448d-4b8e-86dc-0be4b1f79f64.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Aneurysms, Subarachnoid Hemorrhage Unraveling Dural Venous Sinus Thrombosis: A Rare Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eSometimes the diagnosis of Dural Venous Sinus Thrombosis (DVST) becomes challenging, and is even more difficult when the patient initially presents with signs and symptoms of subarachnoid hemorrhage (SAH)\u003csup\u003e1\u003c/sup\u003e. DVST presents in various ways including severe headache, visual symptoms such as blurry vision, any of the manifestations of stroke such as paralysis of the face and limbs unilaterally, and seizures\u003csup\u003e2\u003c/sup\u003e. SAH is often caused by vascular abnormalities especially aneurysm in 85% of cases and generally DVST is not taken into consideration in the workup of SAH. Surprisingly, there are very limited reports on patients who exhibit radiological signs of subarachnoid hemorrhage (SAH) in conjunction with deep venous sinus thrombosis (DVST)\u003csup\u003e3\u003c/sup\u003e. SAH in these instances can be attributed to multiple rationales including an elevation in venous pressure within the draining venous tributaries\u003csup\u003e4\u003c/sup\u003e. The purpose of this case report is to understand a unique way in which DVST can manifest, such as SAH in our case.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 22-year-old male with no co-morbidities and laborer by profession was brought to the emergency department with left-sided weakness and severe headache accompanied by loss of consciousness and an episode of vomiting for four days. The patient was in his usual state of health when he suddenly developed a severe holocranial headache and subsequently, there was weakness on the left side of his body. On arrival, his blood pressure was 100/60 in both arms, pulse rate of 81 beats per minute (bpm), Oxygen saturation of 98% at room air, and temperature of 98\u0026nbsp;. On examination, the patient was oriented to time, place and person with a GCS score of 15/15. He was photophobic and all the signs of meningeal irritation neck stiffness, kerning, Brudzinski, and jolt accentuation test were positive. Fundoscopy showed slight blurring of optic discs bilaterally but his pupillary reflexes and ocular movements were normal and symmetrical. Power in the right upper and lower limbs was normal while on the left side, it was 4/5 in the upper limb and 3/5 in the lower one, though plantar were down-going bilaterally. Reflexes in the left upper limb were brisk but there was no clonus in either limb. Cardiac auscultation revealed normal S\u003csub\u003e1\u0026nbsp;\u003c/sub\u003eand S\u003csub\u003e2\u0026nbsp;\u003c/sub\u003ewith no added sounds or carotid bruit. The rest of the examination was unremarkable with abdominal examination revealing no visceromegaly or renal bruit. MRI brain with MRV was ordered which showed \u0026ldquo;left transverse and sigmoid venous sinus thrombosis and minimal subarachnoid hemorrhage along left sylvian cistern and along the convexities of the left temporoparietal region\u0026rdquo; \u003cstrong\u003e(Figure 01)\u003c/strong\u003e. Subsequently, a lumbar puncture was done which shows numerous RBCs.\u003c/p\u003e\n\u003cp\u003eUltrasound abdomen and pelvis was done to rule out polycystic kidney disease as a potential cause of subarachnoid hemorrhage due to weak cerebral vasculature and the study revealed normal kidneys and other viscera. The patient was started on Tab Nimodipine and other supportive measures. Serological tests were ordered to know if there was any underlying defective coagulation problem. Coagulation profile results were normal \u003cstrong\u003e(Table 01)\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 01: Lab investigations of the patient.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"589\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eS.NO\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003eEntity of Investigation \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eResults \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eNormal Range\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eTLC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e24.8\u0026times;10\u003csup\u003e3\u003c/sup\u003e/ul\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e4-11\u0026times;10\u003csup\u003e3\u003c/sup\u003e/ul\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eDLC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eNeutrophils\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e89.5%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e40-75%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eLymphocytes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e4.9%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e20-45%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eMonocytes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e5.4%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e2-10%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eHemoglobin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e14.8g/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e11.5-17.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePlatelets\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e339/ul\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e150-450/ul\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBlood urea\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e23.2mg/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e10-50mg/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eCreatinine\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e0.98mg/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e0.3-0.9mg/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eCoagulation profile\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003eAPTT\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 154px;\"\u003e\n \u003cp\u003e32seconds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 146px;\"\u003e\n \u003cp\u003e30seconds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003ePT\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e14seconds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e12seconds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eINR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eTT\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e13\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e12-19 sec\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eProtein C\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e85\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e65-135 IU/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eProtein S \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e94\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e60-150%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eFibrinogen \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e240\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e200-400mg/dl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eAnti-thrombin III\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e94\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e80-130%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eHomocysteine \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026lt;15mcmol/l\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHis electrocardiogram was normal as well. Three weeks on the initial medications the patient showed very little clinical improvement with bouts of severe headache. Tab Apixaban 5mg BID was subsequently added to his treatment regimen along with Tab Escitalopram 10mg. One week later, the patient showed significant improvement in his overall condition with almost complete resolution of signs and symptoms of meningeal irritation and episodes of headaches. His limb weakness resolved and he was able to ambulate without assistance. CT-Scan Brain showed \u0026ldquo;A normal study with the resolution of thrombosis and the subarachnoid hemorrhage\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eThe patient was discharged with a follow-up scheduled in six weeks; she was doing well.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDVST\u0026nbsp;presents a tricky situation even to experienced clinicians when it presents unusually like SAH. DVST can present in multiple ways including severe headache, visual symptoms such as blurry vision, any of the manifestations of stroke such as paralysis of the face and limbs, and seizures\u003csup\u003e2\u003c/sup\u003e. SAH is caused by a ruptured aneurysm in 85% of cases\u003csup\u003e5\u003c/sup\u003e and by non-aneurysmal peri mesencephalic hemorrhage in 10%; the rest of 5% is related to multiple uncommon causes such as Dural arteriovenous fistula, arterial dissection, and cocaine abuse\u003csup\u003e3\u003c/sup\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exact mechanism of SAH in the setting of DVST is unknown. It may be caused by the leak of venous parenchymal hemorrhagic infarcts into the subarachnoid space\u003csup\u003e4\u003c/sup\u003e. Hypertension may cause tear of the enlarged, delicate walled subarachnoid cortical veins that do not contain smooth muscle fibers. DVST can cause a confined inflammatory response and can also cause SAH, resulting in enhanced endothelial permeability\u003csup\u003e3\u003c/sup\u003e. Rupture of delicate walled cortical veins secondary to venous hypertension with\u0026nbsp;DVST may also lead to SAH\u003csup\u003e4\u003c/sup\u003e. Dilatation of the cortical veins as a result of DVST, may tear and leak blood into the subarachnoid space and lead to SAH\u003csup\u003e6\u003c/sup\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNeuroimaging modalities include Computed Tomography (CT)/ Computed Tomography Venography (CTV), Magnetic Resonance Imaging (MRI)/ Magnetic Resonance Venography (MRV), and Cerebral Angiography\u003csup\u003e7\u003c/sup\u003e. Whenever there is SAH involving convexity plus there is sparing of the basal cistern, it is advisable to proceed with specialized vascular imaging of the intracranial arteries as well as the dural sinuses\u003csup\u003e8\u003c/sup\u003e. Digital subtraction angiography (DSA) continues to be considered the preeminent imaging modality in current practice to look for cerebral artery aneurysms. However, being an invasive procedure with potential complications\u003c/p\u003e\n\u003cp\u003eDSA is therefore usually not the first-line imaging test except perhaps in patients with acute SAH\u003csup\u003e9\u003c/sup\u003e. Conventional imaging modalities such as computed tomography (CT) or magnetic resonance (MR) angiography targeting the arterial structures of the circle of Willis are insufficient for visualizing the distal arteries and the venous system concurrently within a single imaging session, therefore they may miss it\u003csup\u003e10\u003c/sup\u003e. Systematic consideration of DVST in the diagnostic workup of SAH involving cerebral convexities is necessary,\u003csup\u003e11\u003c/sup\u003e otherwise there is a high probability of the condition going undetected when these noninvasive angiographic techniques are used\u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe management strategy for DVST primarily comprises general supportive interventions, anticoagulant therapy, and endovascular thrombolysis\u003csup\u003e7\u003c/sup\u003e.\u0026nbsp;The safety of heparin in the treatment of dural venous sinus thrombosis has been established in a randomized controlled trial involving 20 patients\u003csup\u003e13\u003c/sup\u003e, another study showed promising results with a combination of low molecular heparin and oral anticoagulation in 60 patients, although the results were non-significant statistically\u003csup\u003e14\u003c/sup\u003e. Currently, direct oral anticoagulants (DOACs) are also used for anticoagulation in the management of DVST.\u0026nbsp;Several studies have demonstrated that DOACs, in comparison to warfarin, exhibited comparable clinical and radiographic outcomes as well as safety profiles\u003csup\u003e15,16\u003c/sup\u003e. \u003csup\u003e\u0026nbsp;\u003c/sup\u003eIn our case, we also used DOACs (apixaban) with the patient showing significant improvement.\u0026nbsp;Although multiple studies also showed no significant benefit of anticoagulation in patients with DVST\u003csup\u003e13\u003c/sup\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe recuperation rate of individuals diagnosed with DVST was found to be 80%\u0026nbsp;with different durations of several weeks or months needed to return to a state of normalcy\u003csup\u003e17\u003c/sup\u003e.\u0026nbsp;Seizures and occurrences of new thrombotic events were noted as the predominant complications during the subsequent monitoring period\u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe presentation of DVST is highly variable. The physicians should keep a high suspicion of DVST if a patient presents with SAH but has no aneurysmal component or basal cistern involvement on imaging, in addition, if blood is found in the cerebral convexities, this further supports this possibility. In these cases, it is recommended to provide immediate treatment with anticoagulation, depending on the patient's hemostatic stability.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eDVST:\u0026nbsp;\u003c/strong\u003eDural venous sinus thrombosis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSAH:\u0026nbsp;\u003c/strong\u003eSubarachnoid hemorrhage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDOACs:\u0026nbsp;\u003c/strong\u003eDirect oral anticoagulants.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRV:\u0026nbsp;\u003c/strong\u003eMagnetic resonance venography.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRA:\u0026nbsp;\u003c/strong\u003eMagnetic resonance arteriography.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT scan:\u0026nbsp;\u003c/strong\u003eComputed tomographic scan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDSA:\u0026nbsp;\u003c/strong\u003eDigital subtraction angiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003cstrong\u003ethics Approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained before collecting data, explaining the publication of neuroimaging and medical history without revealing the patient\u0026apos;s identity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data is available upon the request of editor-in-chief of the journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003cstrong\u003e\u0026nbsp;Interests:\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOppenheim C, Domigo V, Gauvrit JY, Lamy C, Mackowiak-Cordoliani MA, Pruvo JP, et all. 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PMID: 35199774; PMCID: PMC9200019.\u003c/li\u003e\n\u003cli\u003eLin JH, Kwan SY, Wu D. Cerebral venous thrombosis initially presenting with acute subarachnoid hemorrhage. J Chin Med Assoc. 2006 Jun;69(6):282-5. doi: 10.1016/S1726-4901(09)70258-8. PMID: 16863016.\u003c/li\u003e\n\u003cli\u003eExpert Panel on Neurologic Imaging: Salmela MB, Mortazavi S, Jagadeesan BD, Broderick DF, Burns J, Deshmukh TK, Harvey HB, Hoang J, Hunt CH, Kennedy TA, Khalessi AA, Mack W, Patel ND, Perlmutter JS, Policeni B, Schroeder JW, Setzen G, Whitehead MT, Cornelius RS, Corey AS. ACR Appropriateness Criteria\u0026reg; Cerebrovascular Disease. J Am Coll Radiol. 2017 May;14(5S): S34-S61. doi: 10.1016/j.jacr.2017.01.051. PMID: 28473091.\u003c/li\u003e\n\u003cli\u003eWang YF, Fuh JL, Lirng JF, Chang FC, Wang SJ. Spontaneous intracranial hypotension with isolated cortical vein thrombosis and subarachnoid haemorrhage. Cephalalgia. 2007 Dec;27(12):1413-7. doi: 10.1111/j.1468-2982.2007.01437.x. Epub 2007 Sep 19. 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Circulation. 2014 Aug 19;130(8):e68-70. doi: 10.1161/CIRCULATIONAHA.113.008018. PMID: 25135131.\u003c/li\u003e\n\u003cli\u003eFerro JM, Canh\u0026atilde;o P, Stam J, Bousser MG, Barinagarrementeria F; ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004 Mar;35(3):664-70. doi: 10.1161/01.STR.0000117571.76197.26. Epub 2004 Feb 19. PMID: 14976332.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dural venous sinus thrombosis, Subarachnoid hemorrhage, Lumber puncture, MRI with MRV, Direct oral anticoagulant","lastPublishedDoi":"10.21203/rs.3.rs-5394133/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5394133/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDural venous sinus thrombosis (DVST) can be challenging for clinicians, especially when presenting with subarachnoid hemorrhage (SAH)-like symptoms. DVST presents with headache, vision loss, paralysis and seizures.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe report a case of a 22-year-old male with left-sided weakness, severe headache and loss of consciousness. Examination revealed left-sided weakness and optic disc blurring. Lumbar puncture showed numerous RBCs. MRI brain with Magnetic Resonance Venography (MRV) revealed \u0026ldquo;left transverse and sigmoid venous sinus thrombosis and minimal subarachnoid hemorrhage.\u0026rdquo; A diagnosis of SAH secondary to DVST was made. The patient was treated with Apixaban, resulting in resolution of DVST and SAH.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights the need for early recognition of DVST in SAH patients lacking aneurysmal components or basal cistern involvement and its management with anticoagulation if hemodynamically stable.\u003c/p\u003e","manuscriptTitle":"Beyond Aneurysms, Subarachnoid Hemorrhage Unraveling Dural Venous Sinus Thrombosis: A Rare Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 16:58:55","doi":"10.21203/rs.3.rs-5394133/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5ba1f98-bf5b-4390-b8c2-5caf6747d4d7","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-16T16:58:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-16 16:58:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5394133","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5394133","identity":"rs-5394133","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}