Intermittent paraparesis as manifestation of a bilateral chronic subdural haematoma

Chronic subdural haematomas are mainly related to slight or moderate head t rauma with consecutive lesion of bridge or cortical veins and bleeding in t he subdural space. Further predisposing factors are known impairment of coa gulation (coagulopathies, treatment with anticoagulants, alcohol abuse), ri sk factors for degenerative disease of the arteries (diabetes mellitus, art erial hypertension), and development of pressure gradients (hydrocephalus, epileptic seizures, lumbar puncture, CSF drainage and cerebral atrophy). Ch ronic subdural haematomas appear bilaterally in 20 to 25% of cases. We report on a 69-year-old male with a 4-day history of intermittent, proxi mal, painless paraparesis (BMA grade M2-5) without a trigger event. Sensibi lity was normal in all qualities and vigilance was not disturbed. Computed tomography of the neurocranium revealed a bitemporally located chronic subd ural haematoma with extension to parietal on both sides. Trepanation was pe rformed over the tuber parietale and temporoparietally on both sides, with release of 150 ml fluid. The neurologic deficits regressed totally within 1 2 hours postoperatively. To the best of our knowledge, we are the first to describe the clinical par adox of intermittent, painless paraparesis with preserved sensibility and w ithout disturbances of vigilance, as manifestation of a chronic subdural ha ematoma possibly leading to impairment of cerebral blood flow in the area o f the middle cerebral artery. Small changes in systemic blood pressure lead to changes in cerebral perfusion pressure due to vessel compression by the haematoma, thus explaining the intermittent character of the clinical pres entation.