Subarachnoid hemorrahage in a young patient with a factor V Leiden thrombophilia: case report and literature review

Introduction: Cerebral venous thrombosis, including thrombosis of cerebral veins and major dural sinuses, is an uncommon disorder in the general population. However, it has a higher frequency among patients younger than 40 years old, patients with thrombophilia, and women who are pregnant or receiving hormonal contraception. The annual incidence is estimated to be 3 to 4 cases per million. Coexisting cerebral vein thrombosis and aneurysmal disease in the setting of acute subarachnoid hemorrhage is exceedingly rare. These rare situations put difficult problems of diagnosis and treatment. Case Report: We present the case of a 42year-old man patient who was diagnosed with thrombophilia of heterozygous factor V Leiden mutation and right ischemic stroke internal carotid cerebral artery four years ago. The patient presented with nausea, vomiting, a progressive severe headache that had lasted for a few days, followed by a rapid deterioration in the level of consciousness.On admission, the patient was in a comatose state, GCS score 5, mydriasis with bilaterally preservation of fotomotor reflex, stiff neck, acute respiratory failure and vegetative disorder. Cerebral CT scan showed a acute tetraventricular hydrocephalus and subarachnoid hemorrhage and cerebral four vessels angiography showed an left posterior communicating artery aneurysms and complete occlusion of right internal carotid artery.The aneurysm was managed with endovascular coiling with 100% occlusion achieved and acute hydrocephalus was treated first with external ventricular drainage and in a second time with ventriculoperitoneal shunt.The immediate and late outcome of patient has been addicted to several complications: acute bacterial meningitis, left hemiparesis, bronchopneumonia, urinary infection, malfunction of external ventricular drainage end swallowing disorders. Conclusion: In this report, the authors discuss the case of a coexistence ruptured aneurysm of the left posterior communicating artery in one patient known with factor V Leiden thrombophilia and proximal right ICA occlusion.This associated is more rare and dangerous, but curable disease. The case clearly illustrates both the difficulty in establishing the cause of subarachnoid hemorrhage in the presence of both aneurismal and CVST disease as well as the initiation of postendovascular coil embolization anticoagulation therapy. Endovascular coil embolization of the aneurysm was thus undertaken, with subsequent heparin anticoagulation to attempt to prevent Romanian Neurosurgery (2013) XX 2: 170 – 179 171 thrombus propagation.This neurosurgical strategy for treatment of a patient conducted to excellent results.