(Kiosk 3) An Unusual Presentation of a Recurrent Spontaneous Subdural Hematoma: A Case Report

Case Diagnosis: 60-year-old man with bilateral, non-traumatic subdural hematomas (SDHs)

Case Description or Program Description: 60-year-old patient with a history of hypertension, hyperlipidemia, daily alcohol consumption, and no recent trauma presented with altered mental status and diminished coordination. Computed tomography (CT) revealed bilateral acute to subacute SDHs, and the patient underwent bilateral frontopariental Burr holes for pressure relief. He was discharged to acute inpatient rehabilitation (AIR) with left sided weakness and mild cognitive deficits. Rehabilitation team adhered to recommendations against anticoagulation or anti-platelet agents. Functional assessment scores were stable to improving. Initial CT showed stable/improving SDHs. His stay was complicated by intermittent headaches without new neurologic deficits.

Setting: Stand-alone rehabilitation hospital and tertiary care hospital

Assessment/Results: A repeat CT performed in the rehabilitation setting to evaluate his headache revealed significantly increased size of left SDH. He was transferred to acute care for left middle meningeal artery (MMA) embolization. Further workup did not reveal the cause of initial or recurrent SDHs. The patient was able to return to AIR following MMA embolization. At discharge from AIR, he was supervision to independent level with activities of daily living and mobility and cognitive measures.

Discussion (relevance): Recurrent SDH was unusual given his risk factors like alcohol consumption and hypertension were controlled and additional risk factors often more strongly associated with SDH including trauma or anticoagulation use were minimized. The patient lacked new focal neurological deficits or functional decline, so a recurrent bleed of this magnitude requiring prompt neurosurgical management was surprising. Suspicion was lower for SDH, but the availability of on-site CT services, helping to minimize therapy disruption, made imaging this patient for headache more reasonable.

Conclusions: In patients with a history of spontaneous SDH, physiatrists should be aware of unusual presentations of recurrent spontaneous bleeds. A lower threshold to image similar patients, even in the absence of functional decline, may be reasonable.