Although it is extremely rare, a few cases of giant cell arteritis (GCA) associated with chronic subdural hematoma (SDH) have been reported.1,2

A 68-year-old woman, who had no history of provoking falls, seizures, alcoholism, or coagulopathy, presented with recent-onset pulsatile headache, fever, and mild dizziness. Physical investigation revealed funicular right temporal artery with tenderness (Figure 1A, arrow) and jaw claudication. She had no visual loss, eruption, or muscle stiffness and pain. Laboratory findings showed high levels of C-reactive protein (CRP; 169.5 mg/L) and erythrocyte sedimentation rate (106 mm/h). The test results for antinuclear antibody, antineutrophil cytoplasmic antibodies, and rheumatoid factor were negative. The interferon-γ release assay for Mycobacterium tuberculosis infection (T-SPOT.TB test) and blood culture tests were also negative. Vascular ultrasonography showed thickening of the right temporal arterial wall in the presence of edema. Notably, computed tomography demonstrated SDH (Figure 1C, arrow) despite no history of trauma. The biopsy specimen from the right temporal artery demonstrated lympho-plasma cellular infiltrate without giant cells from the endothelium to the tunica media (Figure 1B, arrow). Therefore, she was diagnosed with cranial GCA and SDH. Oral prednisolone (0.5 mg/kg daily) was initiated. After 3 months, her symptoms and laboratory and imaging findings (Figure 1D) completely improved without flare.

(A) Physical finding of funicular right temporal artery with tenderness (arrow). (B) Pathological finding of GCA (arrows). (C) Subdural hematoma before treatment (arrows). (D) Resolution of the subdural hematoma after treatment.

A link between SDH and GCA can be considered in the present case, and the possible mechanism for this link might be vasculitic arterial damage leading to bleeding from small subdural arteries that traverse the subdural space.2 Regardless of causal link or coincidental finding, SDH can be encountered in rare GCA cases. Clinicians should be aware of such a possibility, especially when headaches persist despite starting glucocorticoid therapy.