Disclosures: Lindsay A. Smith, MD: No financial relationships or conflicts of interest

Case Diagnosis: A 68-year-old woman admitted to the acute inpatient rehabilitation unit developed non-traumatic subdural hematoma requiring emergency burr hole evacuation while recovering from idiopathic autoimmune encephalitis.

Case Description: The patient was hospitalized for refractory focal status epilepticus. New onset refractory partial epilepsy of autoimmune etiology was diagnosed given psychiatric symptom onset before admission, inflammatory markers on lumbar puncture, and positive serum antibodies.

Setting: County Rehabilitation Hospital

Assessment/Results: On hospital day 74, the patient was transferred to acute inpatient rehabilitation. Emotional lability, fluctuating mental status, and cognitive deficits persisted. Chemical DVT prophylaxis with enoxaparin 40mg daily was continued as she was not ambulating. On day hospital 81, the patient became somnolent but arousable. Emesis was observed. Upon physician examination, the patient was comatose with anisocoria. Head CT revealed a large, acute on chronic left-sided subdural hematoma with midline shift. Importantly, no traumatic head injuries were witnessed or documented during the patient’s acute medical and inpatient rehabilitation admissions. Neurosurgery performed emergency burr hole evacuation and the patient was transferred to the ICU.

Discussion: Chemical venous thromboembolism (VTE) prophylaxis is recommended by the American Society of Hematology for acutely ill hospitalized patients at typical risk. In rehabilitation settings, chemical VTE may be discontinued for patients consistently ambulating or with elevated bleeding risk. Intracranial hemorrhage has been reported in acute infectious encephalitis; however, we found no reports in the literature of intracranial hemorrhage associated with autoimmune encephalitis, let alone hemorrhage occurring 2 months after encephalitis onset. Research demonstrates increased permeability of central nervous system (CNS) vasculature in the presence of proinflammatory molecules associated with encephalitis. Autoimmune encephalitis patients may therefore benefit from consideration of alternative VTE prophylaxis measures (e.g., pneumatic compression devices and aggressive early mobility and ambulation).

Conclusion: Further investigation into hemorrhagic complications after autoimmune encephalitis is needed to guide VTE prophylaxis recommendations.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/non-traumatic-subdural-hematoma-complicating-autoimmune-encephalitis-in-an-inpatient-rehabilitation-patient-receiving-chemical-venous-thromboembolism-vte-prophylaxis/