Albano et al. Journal of Medical Case Reports 2010, 4:225 http://www.jmedicalcasereports.com/content/4/1/225 Page 2 of 3 Figure 1 Cerebral computed tomography scan showing a small left cortical temporo-occipital hemorrhage, with mild mass effect and hypodense halo. hypodense halo (Figure 1). A carotid and vertebral duplex scan was normal, as was an arterial trans-cranial Doppler. Neuropsychological testing and a neuropsychiatric inter- view showed no cognitive impairment (Mini-Mental State Examination (MMSE) was 29 out of 30). Routine blood tests, including a platelet count and the plasma level of coagulation factors gave results within normal ranges. A peri-umbilical biopsy for systemic amyloidosis was normal. A cerebral MRI was not carried out because of the pre- sence of abdominal vascular clips. Therefore, a contrast- enhanced CT scan and a traditional digital subtraction angiography (DSA) were performed the following day to rule out the possibility of cerebral venous thrombosis or arteriovenous malformations. These tests provided no evi- dence of venous thrombosis or vascular malformations, whereas an air contrast ultrasound venography (ACUV) of the jugular veins showed a severe bilateral jugular valve incompetence, with a huge reflow to the brain during a Valsalva maneuver [6,7]. Our patient was discharged a week after presentation, with mild left hemianopia and alexia. The control CT scan showed a partial regression of the cerebral hemor- rhage. He was advised to be careful during physical activity and to frequently measure his blood pressure. Discussion We present a case of post-coital intra-cerebral venous hemorrhage in a patient with jugular valve incompetence. We suggest that the physical effort during sexual inter- course (during which our patient’s head was hanging off the bed in a slightly downwards position) could have caused the intra-cerebral hemorrhage as there was a close temporal relationship between the physical effort and neurological symptoms. Post-coital intra-cerebral hemorrhage has been pre- viously described in association with hypertension, the presence of vascular malformations, or the use of silde- nafil citrate [8-10]. Although our patient was not hypertensive, the possi- ble contribution of a hypertensive peak during the phy- sical effort cannot be excluded, although in cases described in the literature, such hemorrhages are situ- ated in the deep gray matter. In fact, above the circle of Willis, in the deep gray matter of the basal ganglia and thalamus, arterioles are closer to the direct pulse pres- sure of the large supplying arteries and there are no branches prior to the arterioles that allow stepwise reduction in pulse pressure [11,12]. In our patient, the lobar cortical hemorrhage was more probably related to local hemodynamic impairment. Lobar hemorrhages are usually due to amyloid angiopathy, vascular malforma- tions, neoplasm, coagulopathies, or the misuse of drugs. Our patient had no cognitive impairment, no systemic amyloidosis, no neoplasms, vascular malformations or history of drug misuse, so all these possible causes could be excluded. In reported cases of intra-cerebral hemorrhages due to cerebral venous thrombosis, the pathogenetic mechanism is thought to be the presence of an obstacle to venous out- flow represented by a venous thrombus. In our patient, the obstruction to venous flow was caused by the Valsalva maneuver together with the incompetence of the jugular valves, which was ‘severe’ according to the published clas- sification criteria [13]. The bilateral pathology of the jugu- lar veins did not allow good collateral outflow pathways, and physical effort together with forced expiration are known to be causes of raised cerebral venous pressure [14,15]. Jugular valve incompetence has been reported in association with transient global amnesia and transient monocular blindness [13,16,17], but, to the best of our knowledge, it has not been associated with increased risk of post-coital effort intra-cerebral hemorrhage. As our patient was not hypertensive, not under any treatment and not affected by any coagulation disorder, and a DSA showed no vascular malformation, we argue that the severe jugular valve incompetence, together with the head-down position, physical effort and forced expiration could have facilitated venous congestion and secondarily, intra-cerebral hemorrhage [14,15]. To the best of our knowledge, this is the first reported case of intra-cerebral hemorrhage during sexual inter- course in a subject with jugular valve incompetence.