Unusual Presentation of Cerebral Venous Sinus Thrombosis with Non-Aneurysmal Subarachnoid Hemorrhage, Intracerebral Hemorrhage and Pulmonary Thromboembolism in a 33-Year-Old Woman

Abstract

Cerebral venous sinus thrombosis (CVST) is a rare but important cause of stroke in young adults. Although hemorrhagic venous infarction is well recognized, subarachnoid hemorrhage (SAH) as a presentation of CVST is uncommon and can easily mimic aneurysmal rupture. We describe a 33-year-old woman who presented with acute severe headache. Non- contrast CT revealed both subarachnoid and intracerebral hemorrhage. CT angiography was normal, with no evidence of aneurysm or arteriovenous malformation. CT venography demonstrated thrombosis in the distal part of the left internal cerebral vein, confirming CVST. During hospitalization, pulmonary CT angiography performed for new-onset dyspnea also revealed pulmonary thromboembolism (PTE). The patient was treated with anticoagulation and achieved clinical stability without progression of hemorrhage. SAH due to CVST is rare, accounting for fewer than 3% of cases. Convexity-localized SAH and parenchymal hemorrhage should raise suspicion for venous origin, particularly when angiography is normal. Literature review demonstrates that CVST- associated SAH has often been misdiagnosed as aneurysmal hemorrhage. This case further highlights the potential for multisite venous thrombosis, as demonstrated by concomitant PTE. CVST should be considered in young patients with SAH and normal CTA findings. Venous imaging is essential for accurate diagnosis, and clinicians should remain vigilant for systemic thromboembolism.