Acute subdural hematoma in spontaneous intracranial hypotension: illustrative case and review of the literature.

Introduction: Spinal cerebrospinal fluid (CSF) leaks cause spontaneous intracranial hypotension (SIH) and are a recognized cause of chronic subdural hematoma (cSDH). In contrast, acute subdural hematoma (aSDH) without trauma as the initial manifestation of a spinal CSF leak appears to be exceedingly rare. Research question: Can a primary non-traumatic aSDH represent the first manifestation of a spinal CSF leak. Material and methods: We report an illustrative case of a 52-year-old man presenting with a non-traumatic aSDH requiring emergency surgical evacuation together with a PRISMA-based literature review of the literature on subdural hematomas associated with SIH/spinal CSF leaks. PubMed and Embase databases were systematically screened. Diagnostic workup included cranial imaging, digital subtraction angiography, spinal MRI, and dynamic subtraction myelography. Results: The literature review identified 14 eligible publications. SIH-associated subdural hematomas were predominantly chronic or mixed acute-on-chronic in nature, whereas primary acute presentations were exceedingly uncommon. No documented case of a primary non-traumatic aSDH caused by a spinal CSF leak was identified. In the presented case, repeated cranial vascular imaging revealed no vascular pathology. The patient developed recurrent subdural hematomas requiring multiple surgical interventions. Subsequent spinal imaging demonstrated a ventral CSF leak at T5/6 caused by a discogenic microspur. Minimally invasive transdural surgical repair resulted in complete clinical and radiological resolution. Discussion and conclusion: Primary non-traumatic aSDH may represent the first manifestation of a spinal CSF leak. In unexplained or recurrent subdural hematomas, dedicated spinal CSF leak diagnostics should be considered, as definitive closure of the underlying leak represents the causal treatment.