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Neurological Rehabilitation

(Kiosk 3) Cortical Spreading Depression After Subdural Hematoma Evacuation Presenting with Headaches and Aphasia: A Case Report

Saturday, November 18, 2023
8:00 AM – 9:15 AM CT

    Primary Author(s)

  • Miriam Bekhit, MD, Other

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

    • Co-Author(s)

  • Michael Khalil, DO

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

  • Armaan Shah, Other

    Medical Student
    SUNY Downstate Health Sciences University
    Brooklyn, New York

  • Jason Do, DO

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    333 Schermerhorn st, Apt 10P, New York

  • JM

    Jack Mensch, MD

    Associate Chairman Dept. Of Rehabilitation Medicine
    Staten Island University Hospital
    Edison, New Jersey

  • SA

    Sanjeev Agarwal, MD

    Program Director
    SUNY Downstate Medical Center
    Brooklyn, New York

Case Diagnosis: 75-year-old male with cortical spreading depression (CSD) causing intermittent transient neurological symptoms (TNS) after subdural hematoma (SDH) evacuation.

Case Description or Program Description: 75-year-old male with past medical history of paroxysmal atrial fibrillation presented for one week of worsening weakness, headache and difficulty ambulating. He was noted to have a mechanical fall with head trauma three weeks prior. Head computerized tomography (CT) without contrast was significant for acute on subacute SDH with left to right midline shift. Patient underwent left craniotomy and evacuation then middle meningeal artery embolization two days later. He was started on levetiracetam for seizure prophylaxis. One week post-operative, he developed recurrent intermittent episodes of confusion, lethargy, headaches and aphasia despite unremarkable CT and magnetic resonance imaging of the brain.

Setting: Inpatient rehabilitation facility

Assessment/Results: Patient was transferred to neurology service for adjustment of anti-epileptic medications. Multiple video electroencephalograms showed no epileptiform activity. He was diagnosed with CSD and eventually stabilized on lamotrigine while weaning off the levetiracetam.

Discussion (relevance): CSD is a neurophysiological phenomenon characterized by abrupt changes in intracellular ion gradients and sustained depolarization of neurons manifested as a slow velocity depolarizing wave spreading in cerebral gray matter followed by electrical silence. This increases metabolic demand which perfusion cannot meet and results in relative ischemia. This clinically presents as TNS. Our case represents a rare instance of a patient who underwent SDH evacuation and presented with TNS with no change in repeat imaging and surface electroencephalogram. However, in contrast to other case reports where patients presented only with aphasia, this patient presented with many symptoms including intractable headaches.

Conclusions: This case sheds light on the new clinical entity of Nonepileptic, Stereotypical, and Intermittent Symptoms (NESIS) that can occur in patients after SDH evacuation. More research is needed to determine incidence, prognosis and proper management.