1549 - Spontaneous Subdural Hemorrhage After Recent Intravenous Immunoglobulin and Steroid Therapy: A Post-Anticoagulation Complication

Case Diagnosis: spontaneous subdural hemorrhage (SDH) after the initiation of anticoagulation therapy for deep vein thrombosis (DVT), following recent intravenous immunoglobulin (IVIG) and steroid treatment.

Case Description: A 61-year-old male with lower extremity (LE) weakness was initially treated with Intravenous immunoglobulin (IVIG) for 5 days due to suspicion of Guillain-Barré syndrome (GBS). However, following further evaluation, his diagnosis was revised to myeloradiculitis, and he was subsequently started on Intravenous (IV) steroids for 5 days. Due to weakness, the patient was admitted to an acute rehabilitation facility. During his stay, he began to complain of calf pain. Duplex ultrasonography revealed left soleal deep vein thrombosis (DVT). The patient was started on therapeutic anticoagulation. A week later the patient had a sudden onset of severe nausea, vomiting, and headache. A computed tomography scan of the head revealed bilateral subdural hemorrhage (SDH). Surgery was indicated at that time. A thorough patient interview revealed no trauma or inciting event for the bleeding leading to the diagnosis of spontaneous SDH in the setting of recent IVIG and IV steroids.

Discussions: GBS is an acute inflammatory process that leads to demyelinating neuropathy. Treatment usually involves intravenous immunoglobulin (IVIg) or plasmapheresis, but these therapies can increase the risk of complications like thromboembolism, vasospasm, and intracranial hemorrhage. Also, IV Steroids can weaken blood vessels, theoretically increasing the likelihood of intracranial bleeding in high-risk patients.

Conclusions: This case underscores the rare but critical complication of spontaneous subdural hemorrhage in the context of recent IVIG treatment, particularly after anticoagulation therapy. The initiation of anticoagulation in an individual with recent IVIG may precipitate severe hemorrhagic events. Early monitoring and risk assessment for anticoagulation therapy is essential to mitigate adverse events and improve patient outcomes in such complex cases.