Giant Cell Arteritis Presenting with Bilateral Subdural Haematomas of Arterial Origin

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: 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.