Bilateral Subdural Hematomas in Spontaneous Intracranial Hypotension: A Systematic Review With Case Illustration Publisher



Safari Dehnavi N ; Riyahi Zaniyani F ; Bagherzadeh S ; Khoshnevisan A ; Amin U ; Amin SW ; Rogers A ; Rostami M ; Alikhani P ; Shafizadeh M
Source: Surgical Neurology International Published:2026

Abstract

Background: Spontaneous intracranial hypotension (SIH) is a well-recognized but often underdiagnosed cause of secondary subdural hematoma (SDH), particularly in younger patients who frequently present with bilateral collections. The role of lumbar puncture (LP) remains controversial in this setting, as additional cerebrospinal fluid removal may destabilize intracranial pressure and precipitate or worsen SDH. Methods: We performed a systematic review of SIH cases associated with bilateral SDH. When possible, we reconstructed a patient-level dataset to analyze clinical presentation, LP context, management strategies, and outcomes. We also describe a middle-aged man with orthostatic headache and fever who presented with thin, chronic-appearing bilateral SDH in the setting of SIH. Following a diagnostic LP performed to exclude meningitis, he developed a rapidly progressive, extensive bilateral mixed-density SDH requiring urgent burr-hole evacuation. Results: Fifty-nine studies were included, totaling 485 patients with SIH, of whom 182 had bilateral SDH. From these, we assembled a patient-level cohort of 59 individuals with SIH-associated SDH. The mean age was 47 years, and 81.4% were male. Orthostatic headache was present in 76.3%, whereas coma or stupor occurred in 25.4%. In this cohort, 62.7% had no LP, 30.5% underwent LP only after SDH diagnosis, and 6.8% had clearly post-LP SDH. Management included SDH surgery in 67.8%, epidural blood patch in 67.8%, and open leak repair in 11.9%. The overall SDH recurrence rate was 27.1%, with the highest recurrence (55.6%) in patients who underwent LP after SDH recognition. No deaths were reported. Conclusion: Bilateral SDH in the context of SIH mainly affects younger patients and requires a combined strategy of SDH evacuation (when indicated) and leak-directed therapy. Although true post-LP bilateral SDH appears uncommon, LP may reveal or amplify an already unstable low-pressure state. Given the low certainty and incomplete temporal data in many reports, our findings support cautious consideration and avoidance of routine LP solely to document opening pressure in suspected SIH. ©2026 Published by Scientific Scholar on behalf of Surgical Neurology International. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.