701 - When a Headache Isn’t Just a Headache: Acute Subdural Hematoma and Cerebral Venous Sinus Thrombosis in a Young Athlete

Case Diagnosis: Spontaneous Acute right sided subdural hematoma (SDH) with concurrent cerebral venous sinus thrombosis (CVST) in an 18-year-old female athlete

Case Description: 18-year-old competitive ice hockey player with a remote concussion in 2012, presented with a 3 day history of severe right sided posterior headache radiating to the eye and temple, intermittent blurred vision, and nausea. She denied recent trauma or prior migraines. The patient reported a recent breakup and was taking oral contraceptives. Examination revealed intact cognition, cranial nerves, and motor function. Non-contrast head CT demonstrated acute SDH along the right tentorial leaflet. CT venography revealed acute CVST of the right dural venous sinus extending to the internal jugular vein. She received seizure prophylaxis  and corticosteroids. Neurology and neurosurgery were consulted for angiography and anticoagulation planning.

Discussions: Headache in young athletes with a history of concussion may resemble post-concussive headache or migraine, but the presence of atypical features should raise suspicion for secondary causes. CVST presenting with SDH is particularly rare in otherwise healthy adolescents. In this case, risk factors likely included oral contraceptive use, psychosocial stress, and potentially intensive contact sport participation, though hematologic disturbances must be excluded. This case also raises the possibility that strenuous physical activity may serve as a prothrombotic trigger, an underexplored area in sports neurology. Misattributing such cases to primary migraine or post-concussion headache alone may delay timely, potentially lifesaving interventions.

Conclusions: This case emphasizes the importance of distinguishing primary headache from vascular etiologies in young athletes. Beyond acute stabilization, comprehensive care must include counseling on anticoagulation, risk of recurrence, and individualized return to play decisions. The psychosocial burden, particularly anxiety regarding athletic identity and future participation, warrants integration of mental health support. Recognition of nontraditional risk factors such as intensive sport underscores the need for further research into exercise related thrombosis and careful long term follow up.