Evaluation of the predictive performance of an online voriconazole dose calculator in children.

BACKGROUND: The dosing of voriconazole is challenging in pediatrics. One approach to improve the dosing is through the use of Bayesian concentration-guided dosing software. Our study assessed the predictive performance of a freely available online voriconazole dose calculator in pediatric patients "NextDose" ( https://www.nextdose.org/ ). METHODS: Per each dose calculator, we predicted voriconazole concentrations. We did both a priori and a posteriori Bayesian predictions. RESULTS: A total of 51 patients were included in this study. For a priori predictions, bias was + 26% while imprecision was 70%. For a posteriori predictions, bias and imprecision were 0.01% and 46%. DISCUSSION: In conclusion, the available online dose calculator was overpredicting the concentrations before voriconazole observations were available. However, with just one measured concentration, the predictions improved with minimal bias and an acceptable level of imprecision. There is a need for more prospective studies evaluating the use of voriconazole dosing calculators in the pediatric population to assess if they can improve the achievement of therapeutic target concentrations compared to standard of care.

Treatment vegetable oil refinery wastewater by sequential electrocoagulation-electrooxidation process.

In the present study a sequential process composed of electrocoagulation (EC) followed by electrooxidation (EO) was utilized at the laboratory scale to remove the chemical oxygen demand (COD) from wastewater generated in Iraqi vegetable oil refinery plant.in the EC, impacts of operating variables such as current density (10-30 mA cm-2) and pH (4-10),and EC time (30-90 min) on the COD removal (RE%) were investigated using response surface methodology (RSM) based on Box- Behnken design(BBD). a mathematical correlation that relates the operating factors with RE% was developed and its regression coefficient was 99.02% confirming the significant of the model. Response surface plots showed that RE% increased with increasing current density and time while it decreased with increasing pH. The optimum removal with a lower cost for EC process were achieved at current density of 30mA/cm2, pH of 4, and electrolysis time of 90 min in which RE% of 69.19% was obtained with requirement of 0.513kWh/kg COD as specific energy consumption (SEC). The effluent exit from EC was treated by EO for a period of 240min at a current density of 30mA/cm2 and an initial pH value of 4 to obtain RE% of 96% at SEC of 1.554 kWh/kg COD. Combining EC with EO resulted in a total RE% of 98.72% and a total SEC of 2.067 kWh/kg COD. Based on the results of present study, the applicability of a sequential electrocoagulation-electrooxidation process for treatment vegetable oil wastewaters is feasible.

Medication-overuse headache: clinical profile and management strategies.

Medication-overuse headache (MOH) is a disabling secondary headache disorder, with challenging consequences for affected patients and health care resources. It is defined as headache that occurs on ≥ 15 days per month in a patient known to have primary headache disorder due to regular overuse of acute or abortive headache medication for more than 3 months. MOH affects 1-2% of the world's population in their productive age. New advances in headache neurosciences and development of new treatment options specific for headache, along with an understanding of the clinical profile and pathophysiological mechanisms of MOH, can help improve patient outcomes and decrease the burden on the health care system. This work will review MOH, identify updated clinical assessments and recent management approaches.

Prevalence and characteristics of shunt malfunction without ventricular size change at King Abdulaziz Medical City in Riyadh.

OBJECTIVES: To determine the prevalence of shunt malfunction without change in ventricle size in imaging modalities, and its clinical presentation. METHODS: A cross-sectional study conducted at King Abdulaziz Medical City, Riyadh, from June 2015 to May 2019. Patient's demographics, clinical presentation and changes in ventricle size were collected. Statistical analysis was done using SPSS version 23. RESULTS: The study included 42 patients who underwent shunt revision. Imaging showed no change in size in 10 (24%) patients, mild enlargement in 8 (19%), and obvious enlargement in 24 (57%). The mean age of diagnosis was 22±16.7. 55% of the patients were males, 45% females. The cause of the malfunction was ventricular catheter occlusion in 14 (34%) patients, 10 (24%) patients had valve-related malfunction, and peritoneal catheter occlusion was present in 6 (14%) patients, and 12 (28%) patients had a combination of the previously mentioned causes. Analysis of the association between ventricular size and headache, vomiting, seizure, confusion, and loss of consciousness in patients with unchanged ventricular size and those with increased ventricular size has shown no statistical significance. CONCLUSION: Shunt malfunction without ventricular size change was observed in 24% of all shunt malfunction patients. In addition, there was no relationship between ventricular size and patient symptoms.

Reciprocal Regulation of Glycolysis-Driven Th17 Pathogenicity and Regulatory T Cell Stability by Cdc42.

A balance between Th17 cells and regulatory T cells (Tregs) is important for host immunity and immune tolerance. The underlying molecular mechanisms remain poorly understood. Here we have identified Cdc42 as a central regulator of Th17/Treg balance. Deletion of Cdc42 in T cells enhanced Th17 differentiation but diminished induced Treg differentiation and suppressive function. Treg-specific deletion of Cdc42 decreased natural Tregs but increased effector T cells including Th17 cells. Notably, Cdc42-deficient Th17 cells became pathogenic associated with enhanced glycolysis and Cdc42-deficient Tregs became unstable associated with weakened glycolytic signaling. Inhibition of glycolysis in Cdc42-deficient Th17 cells diminished their pathogenicity and restoration of glycolysis in Cdc42-deficient Tregs rescued their instability. Intriguingly, Cdc42 deficiency in T cells led to exacerbated wasting disease in mouse models of colitis and Treg-specific deletion of Cdc42 caused early, fatal lymphoproliferative diseases. In summary, we show that Cdc42 is a bona fide regulator of peripheral tolerance through suppression of Th17 aberrant differentiation/pathogenicity and promotion of Treg differentiation/stability/function involving metabolic signaling and thus Cdc42 pathway might be harnessed in autoimmune disease therapy.

Carpal Tunnel Decompression Surgery Outcome and Effect of Diabetes.

OBJECTIVE: The benefits of carpal tunnel decompressive surgery (CTDS) among diabetic patients with carpal tunnel syndrome (CTS) were previously investigated through comparing the outcome before and after CTDS, and in comparison to nondiabetic CTS. We sought to investigate if diabetes mitigates the benefits of CTDS compared to not receiving CTDS. METHODS: In this retrospective study, we compared the risk of reporting any unfavorable outcomes among CTS patients (diabetic and nondiabetic) who underwent CTDS versus no CTDS after controlling for diabetes. We also compared the risk of reporting any unfavorable outcomes (waking up at night, pain during the day or during daily activities, or hand weakness) among diabetic CTS patients who underwent CTDS versus no CTDS after controlling for severity. RESULTS: We included 207 patients; of these, 105 patients had CTDS and 102 did not. There were 60 diabetic and 147 nondiabetic patients. The risk of any unfavorable outcomes was reduced by CTDS from 83.3 to 66.6%, with an odds ratio (OR), after controlling for diabetes, of 0.39 (95% confidence interval [CI] 0.20-0.78). Among diabetic patients, there was no difference between the CTDS and non-CTDS groups in the risk of reporting any unfavorable outcomes; however, after adjustment for severity, the risk of hand weakness was less with CTDS, with an OR of 0.13 (95% CI 0.02-0.86). CONCLUSION: Diabetes did not mitigate the benefits of CTDS. CTDS may prevent hand weakness among diabetic CTS patients.

Rational targeting Cdc42 restrains Th2 cell differentiation and prevents allergic airway inflammation.

BACKGROUND: Asthma is an allergic airway inflammation-driven disease that affects more than 300 million people world-wide. Targeted therapies for asthma are largely lacking. Although asthma symptoms can be prevented from worsening, asthma development cannot be prevented. Cdc42 GTPase has been shown to regulate actin cytoskeleton, cell proliferation and survival. OBJECTIVES: To investigate the role and targeting of Cdc42 in Th2 cell differentiation and Th2-mediated allergic airway inflammation. METHODS: Post-thymic Cdc42-deficient mice were generated by crossing Cdc42flox/flox mice with dLckicre transgenic mice in which Cre expression is driven by distal Lck promoter. Effects of post-thymic Cdc42 deletion and pharmacological targeting Cdc42 on Th2 cell differentiation were evaluated in vitro under Th2-polarized culture conditions. Effects of post-thymic Cdc42 deletion and pharmacological targeting Cdc42 on allergic airway inflammation were evaluated in ovalbumin- and/or house dust mite-induced mouse models of asthma. RESULTS: Post-thymic deletion of Cdc42 led to reduced peripheral CD8+ T cells and attenuated Th2 cell differentiation, with no effect on closely related Th1, Th17 and induced regulatory T (iTreg) cells. Post-thymic Cdc42 deficiency ameliorated allergic airway inflammation. The selective inhibition of Th2 cell differentiation by post-thymic deletion of Cdc42 was recapitulated by pharmacological targeting of Cdc42 with CASIN, a Cdc42 activity-specific chemical inhibitor. CASIN also alleviated allergic airway inflammation. CASIN-treated Cdc42-deficient mice showed comparable allergic airway inflammation to vehicle-treated Cdc42-deficient mice, indicative of negligible off-target effect of CASIN. CASIN had no effect on established allergic airway inflammation. CONCLUSION AND CLINICAL RELEVANCE: Cdc42 is required for Th2 cell differentiation and allergic airway inflammation, and rational targeting Cdc42 may serve as a preventive but not therapeutic approach for asthma control.

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit.

OBJECTIVE: To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit. METHODS: Participants were patients with first or recurrent stroke (n=60, age=49.02+/- 6.36 years, body mass index=32.95+/-5.67 kg/m2) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out. RESULTS: There were significant improvements in muscle strength of upper and lower extremities` muscles after treatment (p less than 0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p less than 0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p less than 0.01). CONCLUSION: This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

Experience With Iterative Reconstruction Techniques for Abdominopelvic Computed Tomography in Morbidly and Super Obese Patients.

OBJECTIVE: The aim of this study was to investigate the diagnostic performance of abdominopelvic computed tomography (CT) images reconstructed using filtered back projection (FBP) and iterative reconstruction (IR) algorithms in morbidly and super obese patients. MATERIALS AND METHODS: One hundred eighty-seven abdominopelvic CT examinations in portal venous phase were performed between February 2015 and February 2016 in 182 patients (mean age = 52 years, mean body mass index = 45.5). One hundred fourteen of 187 examinations were reconstructed using IR and 73 examinations were processed using FBP. Patients were further stratified based on body mass index. Sixty CT scans were reviewed by a single reader for image quality, image noise, and artifacts. Objective noise and attenuation were also determined. Size-specific dose estimate and CT dose index volume were compared and statistically analyzed. RESULTS: A diagnostic interpretation was rendered for all 187 examinations. A single-reader review of 60 cases showed greater diagnostic acceptability for IR when compared with FBP (image quality = 4.2 and 3.8 [P = 0.035], noise = 1.5 and 1.6 [P = 0.692], artifact = 1.4 and 1.5 [P = 0.759], respectively). For all examinations, the IR group had lower objective image noise (IR = 9.3 and FBP = 14.3; P < 0.001) and higher contrast-to-noise ratio (IR = 17.2 and FBP = 11.7; P < 0.001) without increase in radiation dose (size-specific dose estimate [IR = 15.1, FBP = 16.5 mGy; P = 0.045] and CT dose index volume [IR = 17.6, FBP = 18 mGy; P = 0.62]). CONCLUSIONS: In morbidly and super obese patients, diagnostic quality images could be reliably generated with minimal artifacts and noise using newer generation scanners integrated with IR without increasing radiation dose.

Medical students' perception of test anxiety triggered by different assessment modalities.

OBJECTIVES: Test anxiety is well known among medical students. However, little is known about test anxiety produced by different components of exam individually. This study aimed to stratify varying levels of test anxiety provoked by each exam modality and to explore the students perceptions about confounding factors. METHODS: A self-administered questionnaire was administered to medical students. The instrument contained four main themes; lifestyle, psychological and specific factors of information needs, learning styles, and perceived difficulty level of each assessment tool. RESULTS: A highest test anxiety score of 5 was ranked for "not scheduling available time" and "insufficient exercise" by 28.8 and 28.3% students, respectively. For "irrational thoughts about exam" and "fear to fail", a highest test anxiety score of 5 was scored by 28.8 and 25.7% students, respectively. The highest total anxiety score of 1255 was recorded for long case exam, followed by 975 for examiner-based objective structured clinical examination. Excessive course load and course not well covered by faculty were thought to be the main confounding factors. CONCLUSIONS: The examiner-based assessment modalities induced high test anxiety. Faculty is urged to cover core contents within stipulated time and to rigorously reform and update existing curricula to prepare relevant course material.

Sequence analysis of haemagglutinin and neuraminidase of H1N1 strain from a patient coinfected with Mycobacterium tuberculosis.

The 2009 H1N1 pandemic (H1N1pdm09) was associated with a considerable influenza-related morbidity and mortality. Among the complications, Mycobacterial tuberculosis was recorded as a coinfection with influenza in rare cases. The full-length sequences of the viral haemagglutinin and neuraminidase of H1N1pdm09 influenza A virus were analyzed from a recently infected patient. The patient was chronically infected with Mycobacterium tuberculosis. Molecular modelling and in-silico docking of the virus, and other selected strains with the drug oseltamivir were conducted and compared. Sequence analysis of the viral haemagglutinin revealed it to be closely related to the 6B.1 clade, with high identity to the circulating H1N1pdm09 strains, and confirmed that the virus still harbouring high affinity to the α-2,6-sialic acid human receptor. The viral neuraminidase showed high identity to the neuraminidase of the recently circulating strains of the virus with no evidence of the development of oseltamivir-resistant mutants. Regular monitoring of the circulating strains is recommended to screen for a possible emergence of drug-resistant strains.

RhoA orchestrates glycolysis for TH2 cell differentiation and allergic airway inflammation.

BACKGROUND: Mitochondrial metabolism is known to be important for T-cell activation. However, its involvement in effector T-cell differentiation has just begun to gain attention. Importantly, how metabolic pathways are integrated with T-cell activation and effector cell differentiation and function remains largely unknown. OBJECTIVE: We sought to test our hypothesis that RhoA GTPase orchestrates glycolysis for TH2 cell differentiation and TH2-mediated allergic airway inflammation. METHODS: Conditional RhoA-deficient mice were generated by crossing RhoA(flox/flox) mice with CD2-Cre transgenic mice. Effects of RhoA on TH2 differentiation were evaluated based on in vitro TH2-polarized culture conditions and in vivo in ovalbumin-induced allergic airway inflammation. Cytokine levels were measured by using intracellular staining and ELISA. T-cell metabolism was measured by using the Seahorse XF24 Analyzer and flow cytometry. RESULTS: Disruption of RhoA inhibited T-cell activation and TH2 differentiation in vitro and prevented the development of allergic airway inflammation in vivo, with no effect on TH1 cells. RhoA deficiency in activated T cells led to multiple defects in metabolic pathways, such as glycolysis and oxidative phosphorylation. Importantly, RhoA couples glycolysis to TH2 cell differentiation and allergic airway inflammation through regulating IL-4 receptor mRNA expression and TH2-specific signaling events. Finally, inhibition of Rho-associated protein kinase, an immediate downstream effector of RhoA, blocked TH2 differentiation and allergic airway inflammation. CONCLUSION: RhoA is a key component of the signaling cascades leading to TH2 differentiation and allergic airway inflammation at least in part through control of T-cell metabolism and the Rho-associated protein kinase pathway.

Rates of safety incident reporting in MRI in a large academic medical center.

PURPOSE: To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center. MATERIALS AND METHODS: This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident. RESULTS: A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290). CONCLUSION: MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center.

OBJECTIVES: Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. METHODS: This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. RESULTS: A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. CONCLUSION: Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. KEY POINTS: • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

New advances in prevention of migraine. Review of current practice and recent advances.

Despite being one of the most common disabling primary headaches, migraine continues to be underdiagnosed and under-treated. A migraine challenges not only the patient suffering from the migraine, but also physicians; especially in recognizing candidates for prophylaxis and selecting the appropriate preventive medication. Recently, there have been major advances in the diagnosis and treatment of migraine, with different guidelines of migraine management across the world. Here, we review migraines abortive and prophylactic medications, based on their pharmacologic category, citing their recommended doses, efficacy, and side effects. Additionally, we highlight the prophylactic treatment of specific patient populations and present suggested treatment approaches in view of recent international treatment guidelines that consider factors other than drug efficacy when choosing the optimal preventive therapy. Finally, we introduce drugs in different stages of development, which have novel mechanisms of action or have new therapeutic targets.

Hemichorea with unilateral MRI striatal hyperintensity in a Saudi patient with diabetes.

Hemichorea is a disorder characterized by abnormal, continuous, nonrhythmic, jerky, and distal movement involving one side of the body. It may result from cerebrovascular insult to basal ganglia, or from other causes including neoplasm, infection, and non-ketotic hyperglycemia. We report the clinical, laboratory, and neuroimaging data with treatment response of a Saudi woman who has diabetes with left side hemichorea, involving the face, and upper and lower extremities, with unilateral right striatal hyperintense signal changes in T1 weighted MRI, and a hyperglycemic state of longstanding uncontrolled diabetes. Literature review suggested a syndrome with a triad of symptoms: non-ketotic hyperglycemia, hemichorea, and T1 MRI striatal hyperintensities. As the number of internationally reported cases is still modest, reporting more patients will highlight aspects pertaining to the diagnosis and treatment of this condition. We present a patient who had a sustained therapeutic result from haloperidol and clonazepam.

Spinal cord infarction in giant cell arteritis associated with scalp necrosis.

Spinal cord infarction is extremely rare in patients with giant cell arteritis (GCA). There are only four case reports in the literature. We describe a 65-year-old man who presented with sudden paraplegia and back pain of 4-days duration with sensory loss below the umbilicus and bilateral scalp necrosis. Magnetic resonance imaging finding was consistent with dorsal spinal cord infarction. Biopsy of the temporal artery confirmed the diagnosis of GCA. The patient was treated with high dose of corticosteroids, which resulted in healing of the scalp ulcerations in 3 weeks, but the paraplegia was irreversible. To our knowledge, this is the first report of spinal cord infarction and simultaneous occurrence of bilateral scalp necrosis in a histopathologically proven GCA. Although literature about spinal cord involvement in GCA is very limited, cord infarction is associated with high mortality and therapeutic challenges since little is understood regarding the pathogenesis that leads to infarction.

Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports.

The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.

Update on neuropathic pain treatment for trigeminal neuralgia. The pharmacological and surgical options.

Trigeminal neuralgia is a syndrome of unilateral, paroxysmal, stabbing facial pain, originating from the trigeminal nerve. Careful history of typical symptoms is crucial for diagnosis. Most cases are caused by vascular compression of the trigeminal root adjacent to the pons leading to focal demyelination and ephaptic axonal transmission. Brain imaging is required to exclude secondary causes. Many medical and surgical treatments are available. Most patients respond well to pharmacotherapy; carbamazepine and oxcarbazepine are first line therapy, while lamotrigine and baclofen are considered second line treatments. Other drugs such as topiramate, levetiracetam, gabapentin, pregabalin, and botulinum toxin-A are alternative treatments. Surgical options are available if medications are no longer effective or tolerated. Microvascular decompression, gamma knife radiosurgery, and percutaneous rhizotomies are most promising surgical alternatives. This paper reviews the medical and surgical therapeutic options for the treatment of trigeminal neuralgia, based on available evidence and guidelines.

Acute subarachnoid hemorrhage. An unusual clinical presentation of cerebral venous sinus thrombosis.

Ruptured cerebral aneurysm is the most common cause of spontaneous subarachnoid hemorrhage (SAH). Rarely cerebral venous sinus thrombosis (CVST) may present initially as acute SAH, and clinically mimics aneurysmal bleed. We report 2 cases of CVST who presented with severe headache associated with neck pain and focal seizures. Non-contrast brain CT showed SAH, involving the sulci of the convexity of hemisphere (cSAH) without involving the basal cisterns. Both patients received treatment with anticoagulants and improved. Awareness of this unusual presentation of CVST is important for early diagnosis and treatment. The purpose of this paper is to emphasize the inclusion of vascular neuroimaging like MRI with venography or CT venography in the diagnostic workup of SAH, especially in a patient with strong clinical suspicion of CVST or in a patient where neuroimaging showed cSAH.