A 77-year-old male initially presented to our hospital after a fall with bilateral frontal contusions, traumatic subarachnoid hemorrhage, and bilateral subdural hematomas (SDH). Approximately one month later, he re-presented with altered mental status, confusion, and seizures. Neuroimaging showed worsening bilateral chronic subdural hematomas with mass effect. He underwent hematoma evacuation with bilateral burr holes and middle meningeal artery (MMA) Onyx embolization. Three weeks later, he re-presented with generalized tonic-clonic seizures, found to have an acute intraparenchymal hemorrhage, and extensive CVSTs with embolization material seen in the transverse and superior sagittal sinuses on CT Venogram.
Given the extent of the patient’s CVST and history of chronic subdural hematomas, there was a risk-benefit discussion regarding whether to start anticoagulation, the first-line treatment for CVST. After starting anticoagulation, the patient developed a worsening of his subdural hemorrhage. After goals of care discussions with the family, they elected for no further escalation of care given severe neurologic injury, and the patient was transitioned to hospice.