Not just another thunderclap headache : a case of isolated cortical vein thrombosis and subarachnoid haemorrhage

Abstract

DESCRIPTION: A 63-year-old woman presented with a severe frontal thunderclap headache associated with transient blurring of vision. No significant medical history other than blood hypertension was noted. On examination, there was no neck stiffness or fever, however, her blood pressure was 160/ 90 mm Hg. Ophthalmoscopic assessment excluded papilloedema and neurological examination was unremarkable. A non-contrast CTscan showed a small subarachnoid haemorrhage (SAH) in the frontal region bilaterally (figure 1A). A cerebral CT angiogram failed to reveal any aneurysms. She proceeded to have an MRI. The fluid-attenuated inversion recovery sequence confirmed the subarachnoid bleed (figure 1B), while the time of flight MR angiography was normal (figure 1C). An MR venogram ruled out thrombosis of the major venous sinuses (figure 2A), while the T1-weighted images confirmed thrombosis of the frontal cortical veins (figure 2B, C). The patient was started on heparin and the headaches gradually improved. [excerpt]