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Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : OE01 - OE08 Full Version

Cerebral Venous Thrombosis Presenting as Cortical Subarachnoid Haemorrhage- A Case Report and Review


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52829.16457
Parag Rameshrao Aradhey, Kedar Takalkar, Jiwan Kinkar, Tushar Patil

1. Associate Professor, Department of Neurology, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India. 2. Assistant Professor, Department of Neurology, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India. 3. Assistant Professor, Department of Neurology, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India. 4. Professor and Head, Department of Neurology, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India.

Correspondence Address :
Dr. Parag Rameshrao Aradhey,
Associate Professor, Department of Neurology, JNMC, DMIMS (DU), Sawangi,
Wardha, Nagpur, Maharashtra, India.
E-mail: paragpgmed@gmail.com

Abstract

In the presence of Subarachnoid Haemorrhage (SAH), diagnosis of underlying Cerebral Venous Thrombosis (CVT) is challenging as there is no difference in clinical presentation and therapeutically it is important because CVT needs to be treated with anticoagulant, unlike SAH. This article is about a 50-year-old male presenting with headache, right hemiparesis, and recurrent seizures. Computed Tomography (CT) head was suggestive of SAH in right posterior parietal region. But Magnetic Resonance Imaging (MRI) venogram showed cerebral venous sinus thrombosis. Hence, he was treated with anticoagulants. The patient showed significant clinical improvement. SAH secondary to underlying CVT is a relatively rare entity. After reviewing medical literature of such cases, 42 case reports and case series forming 95 cases of SAH secondary to CVT were found.

Keywords

Anticoagulation, Cerebral venous infarction, Non aneurysmal subarachnoid haemorrhage

Case Report

A 50-year-old male presented with complaints of headache and giddiness for two days, followed by generalised tonic clonic seizures for 2-3 minutes and post ictal drowsiness, which lasted for 20 minutes. Same day in the afternoon, he had second episode of convulsion after which, his relatives brought him to the hospital. There was no history of seizures, diabetes or hypertension. Patient was non alcoholic.

On clinical examination, the patient was afebrile, his pulse 72/minute regular, Blood Pressure (BP) 140/80 and Oxygen Saturation (SpO2) was 98% on room air. He was drowsy, pupils were normal in size, reacting to light. Motor examination showed right sided hemiplegia. Planters were bilaterally extensor. Fundus examination showed bilateral papilledema. His non contrast Computed Tomography (NCCT) head was suggestive of SAH in right posterior parietal region (Table/Fig 1).

The patient was admitted to Intensive Care Unit (ICU), and was started on intravenous levetiracetam 1 g twice daily and phenytoin 100 mg three times daily; but he continued to have recurrent right focal clonic seizures on second day too. So, intravenous lacosamide 200 mg, twice daily, was added and further he was put on midazolam infusion for two days. Finally, on the fourth day of admission, the seizures were controlled. In view of recurrent seizures and presence of SAH on CT head, MRI brain with MR angiogram and MR venography was done, which was suggestive of severe attenuation of superior sagittal sinus and bilateral transverse sinuses (Table/Fig 2). The cerebral angiogram was normal. In view of venous sinus thrombosis with SAH, the patient was started on injection enoxaparin 0.6 mL subcutaneous once daily, on the fourth day of admission.

After three days of once daily enoxaparin doses, repeat NCCT head was done which showed organised parasagittal parieto-occipital bleed with no evidence of SAH. The patient was continued on subcutaneous injection enoxaparin 0.6 mL twice a day for further one week. He showed significant improvement at the end of two weeks, as his level of consciousness improved, there was no headache and right-side motor power improved from grade 1/5 to 3/5. He had no seizures since day four of admission. The patient was discharged on antiepileptics and anticoagulant drugs. He was reassessed on follow-up after 15 days of discharge when his right-side motor power was 4-5/5, and he was completely seizure-free.

Discussion

Rupture of an intracranial aneurysm is usually the most common cause of spontaneous SAH causing SAH in 85% cases. But in almost 15% of patients of spontaneous SAH, bleeding source of subarachnoid bleed cannot be identified despite repeated neuroimaging (1).

CVT is one of the causes of spontaneous non aneurysmal SAH though considered rare (2). (Table/Fig 3) shows some of the causes of SAH. The reported cases SAH secondary to CVT, seems to be increasing over the years. Panda S et al., reported 10 (4.3%) of 233 patients of CVT having SAH (3). In a retrospective review, Oda S et al., found 3% of CVT cases with SAH (4). Boukobza M et al., reported 22 cases (6.63%; 22/332) of CVT presenting as SAH without haemorrhagic brain lesion (5). The most likely reason for increasing number of cases appears to be the technological advances in radiological diagnosis and widespread availability in the last few years (6). This entity is diagnostically and therapeutically distinct because of better prognosis and needs treatment with anticoagulants unlike aneurysmal SAH.

Literature review for SAH, secondary to CVT, was conducted on PubMed, MedLine and Google Scholar. The keywords were subarachnoid haemorrhaged, cerebral venous thrombosis, cortical SAH, and non aneurysmal SAH. There were 51 articles where these terms were present in abstract/title published from 1995 to 2021. These articles were screened, and the reference lists were also checked to find out relevant articles. Finally, 41 journal articles including case reports and reviews were compiled, which included a total of 95 cases. These cases were reviewed for their available demographic data, clinical and neuroimaging findings.

Diagnosis of CVT in presence of SAH poses diagnostic and therapeutic challenges (1). CVT should be considered in the differential diagnosis of patients presenting with SAH without evidence of an aneurysm.

Approximately 80% of cases of SAH occur in people aged 40-65 years of age (2), and though CVT in males has uniform age distribution, females suffer from CVT at younger age of 20-35 years (6). The present review included total 95 cases of CVT complicated with SAH at presentation. Mean age of patients was 43.6 years (range 14-83 years). There were 54 females (54/95) with a mean age of 43 years, and 41 males with a mean age of 44 years. Thus, there was no significant age difference. CVT is seen in females routinely (F:M 1.29:1) (6) and a female dominance is also found in cases of aneurysmal SAH (F:M 3:2) (2). In the present review, the F:M ratio was 1.31: 1 in cases of SAH secondary to CVT, which is not different from that observed in the cases of aneurysmal SAH or CVT.

Aneurysmal SAH presents with seizure in 10-25% of cases in the acute phase (7). On the other hand, seizures are more common and recurrent in CVT at presentation, occurring in about 40% of patients (8). Ferro JM et al., found that about 39.2% (245/624) patients had seizures and 58 patients (9.3%) had focal seizures (9). In the present review of 95 cases of SAH secondary to CVT, 36 (37.9%) patients had seizures which included generalised tonic clonic seizures or focal seizures (Table/Fig 4). Focal neurological deficit was reported in 10.3% of 213 patients of SAH in a case series (10). While in case of CVT, focal deficit was seen in upto 44% of patients which include motor weakness, aphasia and ataxia (8). Aphasia is also a common neurological defect, that is observed in 19-24% of CVT patients. (6). In the present case review as well, focal neurological deficit was reported in 35.8% (34/95) which included hemiparesis, monoparesis, sensory deficit, aphasia, dysarthria. Signs of meningism like Kernig’s Sign, Brudzinski sign or neck stiffness was reported in 19/95 cases (20%). Small number of patients had dysarthria, aphasia or visual symptoms like blurring or aura (Table/Fig 4).

The SAH commonly presents as thunderclap headache, “the worst headache of life”- striking suddenly like a clap of thunder (7). But thunderclap headaches have been reported in 5-13% of CVT cases too (8). It is difficult to distinguish a thunderclap headache in CVT from that of subarachnoid haemorrhage. In this review, the most common presenting symptom was moderate to severe headache (76.8%), of which, 20% patients presented with thunderclap headache, which continued as mild to moderate ache. CVT presents with altered consciousness in 20-30.6% of patients (8). SAH patients also present with loss of consciousness in 45% of cases, due to increased intracranial tension and 10% patients may remain comatose for several days (2). In the present review, 24.2% (23/95) cases had altered level of consciousness in the form of reduced level of vigilance, drowsiness, or disorientation. Papilledema is a common manifestation of CVT that was observed in 28-67.5% of CVT patients (8). In cases of SAH, papilledema and sub-hyaloid haemorrhage may be evident in 20-30% of patients (2). In the present review, 13.7% patients with SAH secondary to CVT had papilledema. Though papilledema was reported in these cases of SAH secondary to CVT, it is difficult on clinical grounds solely to suspect that SAH visible on neuroimaging is secondary to CVT.

Smoking and heavy alcohol consumption are strong risk factors for SAH (2). Risk of SAH also increases during pregnancy (1). Though there are very few case reports showing smoking as a risk factor for CVT by causing significant polycythemia, a case-control study showed no relationship (12). Though alcohol consumption has not been mentioned as independent risk factor for CVT (6), some studies had suggested associated dehydration and hyperviscosity related to alcoholism as predisposing factor for CVT (13),(14). Oral Contraceptive Pills (OCP), hyper-homocysteinemia, hypercoagulable states are not risk factors for subarachnoid haemorrhage (2). In the present case review, 9 (9.5%) patients had a history of alcoholism and two patients were smokers. The most common predisposing condition for CVT was OCP (21.05%) in females, and alcoholism was the most common predisposing factor in male patients (9.5%). In majority of the patients, no predisposing factor was found (38.95%). Thus, the present review of cases of SAH secondary to CVT revealed risk factor profile which are similar to risk profile of CVT cases as compared to SAH. This may raise suspicion of underlying CVT in case of non-aneurysmal SAH (Table/Fig 5).

Spontaneous SAH is caused by ruptured cerebral aneurysm in 85% of patients and non aneurysmal peri mesencephalic haemorrhage accounts for 10% of cases (1). In these cases, SAH mainly involves the skull base (2). In the present case review, the most common location of SAH was cortical, involving convexity of cerebral hemisphere in 87 patients (91.58%), while 5 patients (5.26) had peri mesencephalic SAH. Typical aneurysmal distribution was also reported in 3 cases (3.16%) (Table/Fig 4). Therefore, when SAH is localised at the cerebral convexity, CVT should be ruled out as underlying cause.

In majority of these reported cases, most commonly, superior sagittal sinus was thrombosed with variable involvement of other major venous sinuses (84/95) while seven cases had only isolated cortical vein thrombosis. There were four cases in which venography was not available (Table/Fig 4). In patients presenting with non aneurysmal SAH, the diagnosis of CVT is relatively straight when there was a major sinus thrombosis. By contrast, the diagnosis was challenging when there is an isolated cortical vein thrombosis (4),(15). Even in the absence of SAH, CVT is difficult to diagnose, because of the variable number and location (1). The largest veins are detectable on MRV or CT venography (6). When there is a SAH localised at the convexity T2 MR sequences are crucial. It shows thrombosed cortical vein as an hypointense tubular structure while SAH appears as a slight hemosiderin deposit (5). So, review of neuroimaging findings of these cases shows that SAH localised at the cortical convexity area should raise the possibility of thrombosis of the cerebral venous sinuses or cortical vein and should be evaluated. Thus, the localisation of cortical SAH appears to be a good indicator of the involved venous structure. The diagnosis of CVT in a patient with SAH is crucial, because it needs to be treated with heparin, but it is contraindicated in all other causes of SAH (11). Most of the reviewed cases were treated with either conventional heparin or low molecular weight heparin followed by oral anticoagulant. One case report by Arevalo-Lorido JC and Carretero-Gomez J mentioned that patient was initially treated with once daily dose of LMWH and after 3 days, the dose was increased to two times daily (16). No other case report mentioned the dose of heparin used. Hegazi MO et al., reported a case of SAH secondary to CVT where they started anticoagulation after 3-4 days on evidence of reduced SAH component on repeat neuroimaging (17). But none of these cases included in the present review showed worsening of SAH after starting anticoagulant therapy. (Table/Fig 6) shows a total of 95 cases which were reviewed for their available demographic data, clinical and neuroimaging findings (3),(4),(5),(13),(15),(16),(17),(18),(19),(20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30),(31),(32),(33),(34),(35),(36),(37),(38),(39),(40),(41),(42),(43),(44),(45),(46),(47),(48),(49),(50).

Limitation(s)

The review had significant limitations because of variability of information reported in each case, and lack of clinical data in some papers or insufficient neuroimaging data in others. There is also a chance of selection bias, but this was not a statistical problem as the present data collected yields information on clinic-radiological features, and it is not intended to compare outcome morbidity or mortality.

Conclusion

In patients with non aneurysmal SAH, MRI/ CT venography should be done to rule out cerebral venous sinus thrombosis. Presence of cortical pattern of SAH and risk factors for CVT should raise suspicion of underlying venous thrombosis. Diagnosing CVT in these cases is therapeutically important in view of starting anticoagulant treatment.

References

1.
Marder CP, Narla V, Fink JR, Tozer Fink KR. Subarachnoid hemorrhage: Beyond aneurysms. Am J Roentgenol. 2014;202(1):25-37. [crossref] [PubMed]
2.
Tibor Becske; (2018, December 7) Subarachnoid Hemmorrhage 2018 Medscape; https://emedicine.medscape.com/article/1164341-clinical.
3.
Panda S, Prashantha DK, Ravi Shankar S, Nagaraja D. Localized convexity subarachnoid haemorrhage-a sign of early cerebral venous sinus thrombosis. Eur J Neurol. 2010;17(10):1249-58. [crossref] [PubMed]
4.
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DOI and Others

DOI: 10.7860/JCDR/2022/52829.16457

Date of Submission: Oct 11, 2021
Date of Peer Review: Jan 12, 2022
Date of Acceptance: Apr 12, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
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• Manual Googling: Apr 05, 2022
• iThenticate Software: May 19, 2022 (13%)

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