A Axial slice of the initial cranial CT on the day of admission, with small intracerebral hemorrhage (ICH, white arrow) and mild adjacent subarachnoid hemorrhage (SAH) in the left temporal lobe, as well as discrete hyperdense triangle sign of the left transverse sinus (black arrow), suggestive for sinus thrombosis. tomography (CT) from the external hospital displayed a small, atypical left-sided intracerebral hemorrhage (ICH). Moreover, a hyperdense triangle sign of the left transverse and sigmoid sinus suggestive for CSVT (Fig.?1A) was present, but had been overlooked initially. Open in a separate window Fig.?1 Representative cranial CT (ACF, H) and MRI (G) images throughout the therapeutic course. A Axial slice of the initial cranial CT on the day of admission, with small intracerebral hemorrhage (ICH, white arrow) and mild adjacent subarachnoid hemorrhage (SAH) in the left temporal lobe, as well as discrete hyperdense triangle sign of the left transverse sinus (black arrow), suggestive for sinus thrombosis. B Corresponding axial slice of follow-up CT 3?h later with severe progression of left temporal ICH (white arrow) with mass effect, and SAH, and persistent discrete hyperdensity of the left transverse sinus (black arrow), as well as discrete adjacent subdural hemorrhage (SDH). C Coronal slice of the CT-angiography in an arterial phase, acquired immediately after B Itgav no signs of aneurysm, arteriovenous malformation or dural arteriovenous fistula. Superior and inferior sagittal sinus, as well as right transverse Gimeracil sinus are already contrasted (white arrows), whereas contrast is missing in the left transverse sinus (black arrow) in the arterial phase, again, suspicious for left-sided sinus thrombosis. In the post-venous phase 30?min later, D there is symmetric contrast enhancement of Gimeracil the somewhat hypoplastic and non-dilated left transverse and sigmoid sinus (black arrow) when compared to the right side (white arrow), ruling against acute occlusive sinus thrombosis. Left-sided cortical veins were difficult to assess because of mass effect, SAH and SDH, but seemed mainly contrasted. E After acute decompressive craniectomy and hematoma evacuation on the day of admission, coronal reformation of the postoperative CT shows recurrent mass effect of relapsing left temporal ICH and occlusive hydrocephalus with relevant midline shift to the right (white arrow) and compression of the cortex at the edge of the craniectomy (black arrow), indicating insufficient decompression. Corresponding coronal slice F of CT after operative revision on the following day with extended craniectomy (black arrow), repeat hematoma evacuation and implantation of an external ventricular drain in the frontal horn of the left lateral ventricle (white arrow), shows sufficient decompression. An axial reconstruction of a dynamic contrast-enhanced MRI angiography in the venous phase G on day 8 shows non-occlusive thrombosis of the hypoplastic left transverse sinus (white arrows), reaching from the torcula to the jugular foramen. Axial slice of the final CT H after bone flap reinsertion 4?months later with large porencephalic defect of the left temporal lobe after complete resorption of the hemorrhage, and no further complications After admission, she showed clinically deterioration of consciousness, severe aphasia, and a mild left-sided brachiocephalic hemiparesis. Laboratory testing revealed a low Gimeracil platelet count (47??109/l), a hemoglobin level of 12.1?g/dl, and normal hematocrit. Routine coagulation parameters were normal, but d-dimers were highly elevated with 35?mg/l FEU [