Atraumatic Bilateral Subdural Hematomas and Acute Pontine Ischemic Stroke Secondary to Spontaneous Intracranial Hypotension
Alyssa Kim1, Anna Torline2, Nicole Kerth2, Faraze Niazi2, Christopher Zammit2, Collin Herman2
1A.T. Still University School of Osteopathic Medicine in Arizona, 2Neurocritical Care, TriHealth
Objective:
To present a case of atraumatic bilateral subdural hematomas and pontine ischemic stroke from spontaneous intracranial hypotension.
Background:
Spontaneous intracranial hypotension (SIH) is an underrecognized clinical entity. It most commonly occurs as a consequence of spinal CSF leaks or CSF-venous fistulas. While subdural hematomas are uncommon complications of this condition, brainstem infarctions are even more rare. We present one such case of atraumatic bilateral subdural hematomas and acute pontine infarction ultimately linked to SIH.
Results:
A 60-year-old previously healthy male working as a commercial airline pilot presented to the emergency department with a one month history of positional headaches and a one day history of progressive lethargy. Head CT revealed bilateral acute-on-chronic subdural hematomas with significant mass effect. He underwent bilateral craniotomies for evacuation and bilateral middle meningeal artery embolizations on hospital day 1. His neurological status improved initially but on postoperative day 2, he developed new horizontal diplopia and mental status fluctuations. Continuous EEG showed no seizure activity. MRI brain WWO demonstrated a new pontine infarction and diffuse brain sagging consistent with intracranial hypotension. Subsequent total spine MRI WWO revealed focal enhancement at C2 concerning for CSF-venous fistula. He underwent CT myelography which failed to demonstrate a CSF leak or CSF-venous fistula. This was followed by digital subtraction myelography in the right and left lateral decubitus positions which showed no evidence of a CSF-venous fistula. The patient was managed conservatively and eventually discharged home with outpatient therapies.
Conclusions:
This case highlights an exceptionally rare presentation of atraumatic bilateral subdural hematomas and acute pontine ischemic stroke secondary to SIH. Given the limited literature describing this constellation, clinicians should maintain a high index of suspicion for SIH in patients with atraumatic bilateral subdural hematomas, particularly when postoperative recovery is atypical. Early recognition and targeted diagnostic evaluation are essential to prevent morbidity.
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