Spinal Subdural Hematoma Initially Misdiagnosed, Revealed by CT Brain Window Settings

TL;DR

A spinal subdural hematoma was misdiagnosed as a stroke but correctly identified using optimized CT imaging techniques.

Contribution

Highlights the importance of using brain window settings in CT scans to accurately diagnose spinal subdural hematomas.

Findings

A standard trunk CT initially failed to detect the spinal subdural hematoma.

Re-evaluating the CT with brain window settings revealed the hematoma and confirmed it with MRI.

The patient had minimal neurological recovery despite prompt surgical intervention.

Abstract

This case demonstrates that meticulous physical examination and optimized computed tomography (CT) windowing are crucial for diagnosing spinal subdural hematoma (SSH) when it mimics stroke. We present a 43-year-old man with a stroke-like onset of unilateral leg weakness that progressed to paraplegia. While a sensory level at T4 strongly suggested a spinal cord lesion, a standard trunk CT was initially interpreted as normal. The diagnosis of a C7-T4 SSH was ultimately established by re-reviewing the CT using brain window settings and was confirmed by magnetic resonance imaging. Despite emergent surgical decompression, the patient had minimal neurological recovery. This report underscores two key lessons: the diagnostic priority of spinal-specific signs (e.g., a sensory level) over misleading motor deficits, and the utility of applying brain window settings as a simple, effective technique to avoid misdiagnosing this critical condition.

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