Case Report

Asymptomatic Massive Subdural Hematoma in a Patient with Bitemporal Agenesis and Bilateral Temporal Arachnoid Cysts

Authors: Dimitra S. Ziaka, MD, Andreas T. Kouyialis, MD, Efstathios J. Boviatsis, MD, Damianos E. Sakas, MD

Abstract

The case of a 38-year-old man with a history of chronic migraine is reported. Despite a 3 week history of changes in his migraine pattern, a normal neurologic examination led to conservative treatment. He later presented with worsening headaches and imbalance; tendon reflexes were increased on the right side, and brain computed tomography and magnetic resonance imaging revealed a massive subacute subdural hematoma over the left hemisphere, developing on the grounds of bilateral temporal agenesis. The presence of bilateral temporal arachnoid cysts along with bitemporal agenesis altered clinical findings, causing only mild symptoms where an otherwise acute and devastating neurologic deterioration would be expected.


Key Points


* Headache is a common medical condition, and management depends on the diagnosis.


* Neuroimaging in patients with headache is expensive and has a low diagnostic yield, so a good history, and neurologic examination are necessary to identify “red flags” that signal the potential for a significant pathology.


* Up to 10% of patients with headaches seen in the emergency department and diagnosed as suffering a primary headache will have secondary causes which may be overlooked.


* Any form of change in the pattern of migraines should never be underestimated and should always require clinical follow-up and neuroimaging studies.


* Bilateral temporal arachnoid cysts occur in up to 80% of patients with glutaric aciduria type 1, and this condition should be excluded before any form of surgery because this will have devastating neurologic consequences.

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