A 15-year-old high school football player initially presented to his primary care physician complaining of episodic headaches, total body stiffness, and severe nausea and vomiting for several days following participation in a football game. Viral meningitis was suspected, so the patient was started on oral prednisone. Of note, the patient had experienced mild back pain during the week preceding the game and was using ibuprofen for pain management. Symptoms gradually resolved over the next two weeks and the patient returned to baseline clinical status before resuming athletic activities.
Following participation in a subsequent football game, the patient was admitted to the hospital with recurrence and exacerbation of his previous symptoms. At this time, his headache was localized to the left side, body stiffness was most pronounced in the posterior thighs and lower back, and nausea and vomiting were persistent. The patient denied a recent history of fevers and had no evidence of neck stiffness. Neurological exam was unremarkable other than a mildly unsteady gait and did not reveal any focal deficits.
Clinical workup resulted in the diagnosis of intracranial and spinal subdural hematoma. CT and MRI of the head revealed a 2-3 mm thick intracranial subdural hematoma over the left cerebral hemisphere with extension into the interhemispheric fissure (Figure 1). A thin subdural hematoma was also noted over the left cerebellar hemisphere of the posterior fossa (Figure 2). MRI of the lumbar spine demonstrated a 3 mm wide dorsal subdural hematoma extending from L1 to L4 levels without compression of the conus medullaris or cauda equina nerve roots (Figure 3). Laboratory evaluation revealed no evidence of coagulopathy. The patient was managed conservatively and followed up on an outpatient basis following a two-day hospitalization.
Over the next week, the patient's headache and back pain resolved. However, lower limb pain progressed to pain radiating down the posterior thighs and lateral leg and was most pronounced in the right leg. Physical exam at this time was remarkable only for mild weakness of right knee extension and positive right-sided straight leg raise sign. Extensive imaging workup consisting of MRI of cervical and thoracic spine and MR angiography of the brain did not reveal any underlying vascular lesions.
With conservative clinical management, the patient slowly returned to baseline clinical status without residual neurologic deficits. Repeat imaging of the brain and spine 2 months later showed complete resolution of both prior subdural hematomas.