Giant Cell Arteritis Presenting with Bilateral Subdural Haematomas of Arterial Origin

摘要

Giant cell arteritis or temporal arteritis is an inflammatory condition affecting medium to large sized vessels, particularly the cranial arteries. A 76-year-old man with no significant past medical history presented to the emergency department with a 3-week history of diffuse headaches associated with fever, loss of appetite, weight loss and general malaise. A CT scan of the brain showed bilateral shallow chronic low density subdural haematomas. A complete laboratory panel was unremarkable except for a raised erythrocyte sedimentation rate and elevated C-reactive protein. A transthoracic echocardiogram and CT scan of the body were unremarkable. MRI of the brain confirmed bilateral old subdural collections and showed marked vessel wall enhancement in the frontal branches of the left superficial temporal artery. A left temporal artery biopsy confirmed giant cell temporal arteritis. We speculate that a vasculitic process in the small subdural arteries may have contributed to our patient’s spontaneous subdural haematomas.LEARNING POINTS class="unordered" style="list-style-type:disc">A contrast-enhanced T1 axial fat-suppressed MRI of the brain is a non-invasive modality of diagnostic value in giant cell arteritis (GCA); increased access to high resolution MRI technology may reduce the requirement for invasive temporal artery biopsy in the future.Subdural hematomas may be of arterial origin; GCA has been reported in association with subdural hematomas but causation is not proven.GCA must be suspected in patients presenting with headaches and raised inflammatory markers even in the absence of classic features or dual pathology as failure to recognize and treat promptly could lead to permanent visual loss. class="kwd-title">Keywords: Giant cell arteritis, subdural hematoma, arterial origin class="head no_bottom_margin" id="__sec2title">CASE PRESENTATIONWe present the case of a 76-year-old Irish man who attended the emergency department complaining of having headaches for the last 3 weeks. He had no previous history of headaches. His symptoms initially started after he had used a new treadmill and presented as gradual occipital headaches that eventually spread to the frontal area. The headaches were described as dull, diffuse, constant and throbbing in nature with transient relief obtained with administration of paracetamol. The headaches were associated with fevers, sweats, fatigue and a decreased appetite. The patient had attended his general practitioner at the end of the second week and was given an oral antibiotic with no improvement. The patient then decided to visit the emergency department.A detailed history was taken in which our patient denied any visual disturbance, neck stiffness, rash, disorientation, dizziness, tinnitus, aches/pains, weakness or jaw pain. He denied temporal headache or tenderness. He also denied any head injury, trauma or loss of consciousness.He had no significant past medical history apart from right-sided glaucoma and no regular medication use, and denied substance abuse. He had no significant family history. He was an active retired factory worker who lives at home with his wife. He is a lifelong non-smoker and denied excessive alcohol intake.Full examination was unremarkable apart from a temperature of >38°C, a soft pan-systolic murmur and a decreased non-tender left temporal pulse. A laboratory panel was unremarkable apart from raised inflammatory markers and neutrophil leucocytosis ().>Table 1Laboratory panel.