Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis

Abstract

Rationale:Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is characterized by a pattern of extravasated blood restricted to the perimesencephalic cisterns, normal angiographic findings, and an excellent prognosis with an uneventful course and low risks of complication. The precise etiology of bleeding in patients with PNSAH has not yet been established. The most common hypothesis is that PNSAH is venous in origin. Intracranial venous hypertension has been considered as the pivotal factor in the pathogenesis of PNSAH. The underlying venous pathology such as straight sinus stenosis, jugular vein occlusion may contribute to PNSAH. We describe a patient in whom transverse sinus thrombosis preceded intracranial venous hypertension and PNSAH. These findings supported that the source of the subarachnoid hemorrhage is venous in origin.Patient concerns and diagnoses:A 45-year-old right-handed man was admitted to the hospital with a sudden onset of severe headache associated with nausea, vomiting, and mild photophobia for 6 hours. The patient was fully conscious and totally alert. An emergency brain computed tomography (CT) revealed an acute subarachnoid hemorrhage restricted to the perimesencephalic cisterns. CT angiography revealed no evidence of an intracranial aneurysm or underlying vascular malformation. Digital subtraction angiography of arterial and capillary phases confirmed the CT angiographic findings. Assessment of the venous phase demonstrated right transverse sinus thrombosis. Magnetic resonance imaging confirmed the diagnosis of cerebral venous sinus thrombosis (CVST). Lumbar puncture revealed an opening pressure of 360 mmH2O, suggestive of intracranial venous hypertension. Grave disease was diagnosed by endocrinological investigation.Interventions:Low-molecular-weight heparin, followed by oral warfarin, was initiated immediately as the treatment for cerebral venous sinus thrombosis and PNSAH.Outcomes:The patient discharged without any neurologic defect after 3 weeks of hospital stay. MR venography revealed recanalization of right transverse sinus at the 6-month follow-up. No clinical or neuroimaging evidence of relapse was detected at 12 months follow-up.Lessons:Hyperthyroidism may contribute to the development of CVST. The presence of acute transverse sinus thrombosis, as a cause of PNSAH, provides further support for the hypothesis that the source of PNSAH is venous in origin and intracranial venous hypertension plays a critical role in the pathogenesis of PNSAH.

The Eagle Jugular Syndrome

“…The relationship between the upper internal jugular vein bone nutcracker and the p-SAH could be a novel and intriguing finding. This variety of the subarachnoid hemorrhage is thought to be caused mainly by intracranial venous anomalies, but there are no reports in literature about its relationship with extracranial venous anomalies [22,23]. In our series imaging at the intracranial level completely excluded the presence of any kind of vascular anomalies.…”

“…In few studies the compression of the IJV was related to pseudotumor cerebri [13,14] or to headaches [13]. In many others, the jugular variant was significantly associated with persistent headache, and among comorbidities, to the peri-mesencephalic subarachnoid hemorrhage (p-SAH), both possibly related to cerebral venous hypertension [15,16,22,23]. p-SAH is a particular kind of subarachnoid hemorrhage not associated to an evident vascular malformation, like aneurysms or arteriovenous malformations and with an usually good prognosis.…”

“…The blood is mainly located in the cerebral basal cisterns and the cause is still debated. Among the hypothesized causes, a hypertensive venous bleeding (like coming from a particular variant of Basal vein of Rosenthal or an occluded venous sinus) is the most reliable [22,23].…”

Perimesencephalic non-aneurysmal subarachnoid haemorrhage

“…4 The clinical presentation is otherwise similar to those patients with aneurysmal SAH: with sudden headache, meningism, photophobia, nausea and vomiting being the most common symptoms.…”

Spinal dural arteriovenous fistula presenting with subarachnoid hemorrhage

“…In a recent study, transverse sinus thrombosis associated with peripheral arterial aneurysm SAH was reported. [ 18 ] There are many reports about SAH caused by spinal vascular malformations, but the difference between our article and their reports is that our paper is not a simple case description. Instead, we summarized the “traps” in the process of the diagnosis and treatment of SAH by this case.…”