Subarachnoid Hemorrhage and Spinal Subdural Hematoma Due to Acute CSF Hypotension

Christopher S. Graffeo, Avital Perry, Eelco F. M. Wijdicks

Intracranial subarachnoid hemorrhage (SAH) and spinal subdural hematoma (SDH) are rare complications of spine surgery, thought to be precipitated by cerebrospinal fluid (CSF) hypotension in the setting of an intraoperative durotomy or postoperative CSF leak. Considerable clinical variability has been reported, requiring a high level of clinical suspicion in patients with a new, unexplained neurologic deficit after spine surgery. Case report. An 84-year-old man developed symptomatic spinal stenosis with bilateral lower extremity pseudoclaudication. He underwent L3-5 laminectomy at an outside institution, complicated by a small, incidental, unrepairable intraoperative durotomy. On postoperative day 2, he became confused; and head CT demonstrated intracranial SAH with blood products along the superior cerebellum and bilateral posterior Sylvian fissures. He was transferred to our neurosciences ICU for routine SAH care, with improvement in encephalopathy over several days of supportive care. On postoperative day 10, the patient developed new bilateral lower extremity weakness; MRI of the lumbar spine demonstrated worsening acute spinal SDH above the laminectomy defect, from L4-T12. He was taken to the OR for decompression, at which time a complex 1.5-cm lumbar durotomy was identified and repaired primarily. We report the first case of simultaneous intracranial SAH and spinal SDH attributable to postoperative CSF hypotension in the setting of a known intraoperative durotomy. Although rare, each of these entities has the potential to precipitate a poor neurologic outcome, which may be mitigated by early recognition and treatment.