a 27-year - old woman presented with acute onset of severe diffuse headache for one day and slurred speech for 4 hours . she had not previously been on contraceptive pills , and did not have any personal or family history of venous thrombosis , autoimmune disease , or hematologic disease . laboratory examination showed a normal complete blood count and normal renal , hepatic , and coagulation profiles . urgent brain ct revealed temporal hemorrhage surrounded by an extensive hypodense area ( figure 1 ) . an mri using a 3.0 t scanner revealed a hyperintense lesion surrounded by a large hypointense area on t1-weighted images ( figure 2a ) , and a hypointense lesion surrounded by a large hyperintense area on t2-weighted and fluid - attenuated inversion recovery ( flair ) images ( figures 2b & 2c ) . after administration of gadopentetic acid dimeglumine salt , no obvious contrast enhancement was seen on t1-weighted images . magnetic resonance venography ( mrv ) showed that the left transverse and sigmoid sinuses were completely occluded ( figure 2d ) . a brain digital subtraction angiography ( dsa ) confirmed thrombosis of the left transverse and sigmoid sinuses with engorgement of the superficial veins in the left hemisphere ( figure 3 ) , but was negative for vascular malformations such as aneurysm , arteriovenous malformation ( avm ) , and dural arteriovenous fistula . transvaginal sonography revealed an early intrauterine pregnancy , the gestational sac was 555 mm in size , and the fetal germ , or fetal heart could not be detected . a cvst with cerebral hemorrhage was diagnosed according to clinical data . to control intracranial hypertension , treatment with mannitol was commenced immediately , and dose - adjusted low - molecular - weight heparin ( 9600 units / day for 10 days ) was started 3 days after the onset of cvst to maintain activated partial thromboplastin time between 1.5 and 2.0 times of control value . when a repeat ct showed that the cerebral hemorrhage had regressed , heparin was substituted with oral warfarin . two months later , mrv showed recanalization of the left transverse and sigmoid sinuses ( figure 4 ) , and remained asymptomatic in the following years . non - contrast axial scan reveals temporal hemorrhage surrounded by a large hypodense area . magnetic resonance imaging ( mri ) and magnetic resonance venography ( mrv ) upon admission showing : a ) the lesion appears hyperintense surrounded by a large hypointense area on t1-weighted mri , b ) hypointense surrounded by a large hyperintense area on t2-weighted mri , c ) fluid - attenuated inversion recovery mri . d ) mrv shows complete occlusion of the left transverse and sigmoid sinuses . digital subtraction angiography ( dsa ) upon admission . anteroposterior view reveals complete thrombosis of the left transverse and sigmoid sinuses as well as engorgement of the superficial veins in left hemisphere . a cvst is an uncommon but serious neurological emergency , the overall death , and dependency rate are approximately 10 - 15%.4 pregnancy and puerperium induces changes in the coagulation system , increasing the risk of cvst . the period of greatest risk for cvst includes the third trimester of pregnancy , and the first 4 postpartum weeks.5 only a few cases of cvst in early pregnancy have been reported.3,5,6 - 8 a cvst with cerebral hemorrhage in early pregnancy is extremely rare , lavin et al3 reported the first case of cvst with cerebral hemorrhage at 8 weeks of pregnancy , the patient died because of massive cerebral venous infarction with edema.3 the clinical manifestations of cvst are non - specific . the most frequent symptoms are headache , seizures , neurological deficit , and decreased level of consciousness.9 signs of cerebral hernia can appear in patients with mass effects , such as edema , infarction , and hemorrhage . because of the wide spectrum of symptoms and signs of cvst , it can be difficult to arrive at the correct diagnosis based on clinical assessment alone . hemorrhage , edema , and infarction can be detected on ct , a hyperdense lesion can be found occasionally in the venous sinus indicating thrombosis . an mri can differentiate cvst from tumor apoplexy , and mrv can reveal sinus occlusion . cerebral angiography is invasive and involves radiation ; however , this method allows the detection of sinus thrombosis . other vascular abnormalities such as aneurysm , arteriovenous fistula , and avm can also be excluded by dsa . an mri and mrv are non - invasive and do not involve radiation , we therefore , consider that the combination of mri and mrv is the best choice for the investigation of suspected cvst in pregnant women . there have been no large trials of anticoagulation in pregnancy , and recommendations are based on case series and the opinions of experts . nonetheless , anticoagulation is believed to be beneficial for patients with cvst and hemorrhagic complications . among 29 patients with intracranial hemorrhage and cvst treated with low - molecular - weight heparin ( 180 anti - factor xa units / kg / day for 3 weeks ) , de bruijn et al10 reported 6 deaths , none of which were attributable to fresh or exacerbated cerebral hemorrhage . although the best time to start anticoagulation treatment is not known , repeating ct or mri to confirm that the intracranial hemorrhage is regressing or at least not progressing is advisable before starting anticoagulation . the use of local thrombolysis for cvst was first reported by weatherby8 in 2003 , who achieved a successful outcome in a patient who developed cvst in early pregnancy . the use of endovascular treatment for cvst should be considered in patients who are resistant to anticoagulation therapy , have worsening symptoms , do not have intracranial hemorrhage , and are not at risk for impending herniation.11 decompressive hemicraniectomy could be life - saving and even lead to an excellent outcome in cvst patients with impending transtentorial herniation because of large hemorrhagic venous infarcts.12 in patients with cvst in early pregnancy , early management of the embryo to eliminate the triggered spontaneous coagulation might also contribute toward recovery.5 in conclusion , cvst with cerebral hemorrhage can occur in early pregnancy . an mri combined with mrv may be the best choice for the investigation of a suspected cvst in a pregnant woman . anticoagulation therapy may be beneficial in curing cvst , even in pregnant patients with intracranial hemorrhage . in our patient , anticoagulation was successful when administered 3 days after the onset of the disease . algahtani ha , abdu ap , shami am , hassan ae , madkour ma , al - ghamdi sm , et al . cerebral venous sinus thrombosis in saudi arabia . kajtazi ni , zimmerman va , arulneyam jc , al - shami sy , al - senani fm .
cerebral venous sinus thrombosis ( cvst ) rarely induces cerebral hemorrhage , and cvst with cerebral hemorrhage during early pregnancy is extremely rare . upon literature review , 
 we are able to find only one case of cvst with cerebral hemorrhage in early pregnancy . in this paper 
 , we report another case of a 27-year - old patient who developed cvst with cerebral hemorrhage in her fifth week of pregnancy . 
 although the optimal treatment for this infrequent condition remains controversial , we adopted anticoagulation as the first choice of treatment and obtained favorable results .