Disclosures: Christian Vangeison, DO: No financial relationships or conflicts of interest

Case Diagnosis: A 69-year-old male with a fatal spontaneous subdural hematoma (SDH).

Case Description or Program Description: This patient was admitted to an inpatient rehabilitation hospital for cardiac rehabilitation. The patient had a transient episode of unresponsiveness while receiving a nebulizer treatment for persistent cough. Two hours later, the patient became acutely unresponsive again without trauma and noted GCS of 10. The only anticoagulation administered within 24 hours was heparin for DVT prophylaxis. CT head revealed a large left-sided subdural hematoma, adjacent subarachnoid hemorrhage with 1.1cm midline shift and rightward subfalcine herniation. CTA was negative for vascular anomalies. The patient was taken for emergent decompressive craniotomy and evacuation of the SDH. Immediately postoperatively, the patient had a firm, tense craniectomy flap. Repeat CT showed reaccumulation of the SDH, blossoming of the left parietal intraparenchymal hemorrhage, Duret hemorrhage, and loss of gray-white matter differentiation throughout the left hemisphere. He had loss of brainstem reflexes. No further surgical intervention was offered. The patient was transferred to comfort care after goals of care discussion and passed away.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: The patient was diagnosed with SDH based on CT scan findings. After a thorough chart review, it was presumed that there was no preceding cause of the SDH. The only potential source of minor trauma may have been related to coughing.

Discussion (relevance): Spontaneous SDH results in 0.7-6.7% off all SDH. Known causes include vascular lesions, spontaneous intracranial hypotension, cortical artery bleeding, and coagulopathy among other exceedingly rare derivatives. Upwards of 37% of spontaneous SDH are fatal. Due to religious reasons, an autopsy was deferred on the patient leaving the exact etiology unknown.

Conclusions: Spontaneous SDH is a diagnosis worth consideration in patients that acutely decompensate at inpatient rehabilitation facilities. Neurologic deterioration can occur quickly, especially if arterial in origin. Therefore, timely escalation of care for surgical intervention is of utmost importance.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/spontaneous-subdural-hematoma-in-a-cardiac-rehabilitation-patient-a-case-report/