Introduction: Route of absorption of blood in the cerebrospinal fluid spaces following subarachnoid hemorrhage (SAH) is not clearly known. There are reports of intraventricular blood being absorbed through the spinal subdural space following endoscopic third ventriculostomy (Cartmill and Vloeberghs, 2000). We present a case report of a patient who had a spontaneous SAH who needed surgery for symptomatic subdural hematoma in the lumbar region.

Methods: 54 year old man presented with a sudden onset of severe headache, diplopia, and drowsiness (Hunt and Hess grade 3). CT scan showed perimesencephalic hemorrhage and intraventricular hemorrhage. CTA was negative for any vascular lesions. Four days later he started developing increasing weakness of the lower extremities with complete paraplegia. MRI scan of the entire spine was done. There was a small subdural hematoma in the cervical and thoracic spine but the lumbar spine showed a large subdural hematoma which was surgically evacuated. The patient’s motor strength improved to almost his baseline prior to discharge.

Results: We present a case of spontaneous angio-negative perimesencephalic SAH with subsequent symptomatic subdural hematoma in the lumbar spine six days following ictus.

Conclusions: There are several case reports that have been reported documenting spinal subdural hematoma following subarachnoid hemorrhage. There is one published report of thoracolumbar subdural hemorrhage following endoscopic third ventriculostomy. With the exception of the ventriculostomy case, most of the reported spinal SDH patients became symptomatic within the first week of ictus. Anatomical juxtaposition of the arachnoid layer with the inner dural layer allows absorption of the blood from the subarachnoid space through the subdural space. The symptomatic subdural hematomas represent a high volume transport of subarachnoid blood through this pathway through the subdural space. It is tempting to speculate whether this pathway plays a role in the absorption of blood and other products in the CSF.

Patient Care: This will give us further insight into subarachnoid hemorrhage patients in regards to potential sequelae of different CSF absorption pathways

Learning Objectives: Consider CSF pathways for re-absorption of subarachnoid blood products

References: Lumbar Subdural Hematoma From Intracranial Subarachnoid Hemorrhage Presenting With Bilateral Foot Drop: Case Report; James S. Waldron, MD Michael C. Oh, MD, PhD Dean Chou, MD Spinal Subdural Hematoma: A Sequela of a Ruptured Intracranial Aneurysm?;Satoshi Yamaguchi,* Kazutoshi Hida,* Minoru Akino,† Shunsuke Yano,† and Yoshinobu Iwasaki The fate of the cerebrospinal fluid after neuroendoscopic third ventriculostomy; Maria Cartmill Michael Vloeberghs