Pseudo-subarachnoid hemorrhage and gadolinium encephalopathy following lumbar epidural steroid injection

• Main Authors: Andrew Platt, MD, Faten El Ammar, MD, John Collins, MD, PHD, Edwin Ramos, MD, Fernando D. Goldenberg, MD
• Format: Article
• Language: English
• Published: Elsevier 2020-10-01
• Series: Radiology Case Reports
• Subjects: Aneurysmal subarachnoid hemorrhage mimic; False subarachnoid hemorrhage; Pseudo-subarachnoid hemorrhage; Gadolinium encephalopathy; Lumbar epidural steroid injection; Intrathecal injection of gadolinium
• Online Access: http://www.sciencedirect.com/science/article/pii/S1930043320303824

Patients with imaging findings concerning for subarachnoid hemorrhage, however, with no evidence of hemorrhage following autopsy or cerebrospinal fluid testing are diagnosed with having pseudo-subarachnoid hemorrhage. A 73-year-old female presented to the emergency department with altered mental status one day after undergoing a lumbar epidural steroid injection at an outside hospital; a noncontrast computed tomography scan of the head revealed evidence of diffuse hyperdensity within the subarachnoid space concerning for subarachnoid hemorrhage. The patient underwent magnetic resonance imaging which demonstrated diffuse opacification of the cerebrospinal fluid spaces with gadolinium and the diagnoses of pseudo-subarachnoid hemorrhage and gadolinium encephalopathy were made. The combination of the neurologic symptoms related to gadolinium encephalopathy and the radiographic findings of pseudo-subarachnoid hemorrhage can create a clinical presentation nearly identical to ruptured aneurysmal subarachnoid hemorrhage. Patient history, magnetic resonance imaging findings, and temporal changes in computed tomography provide vital tools in establishing a diagnosis of pseudo-subarachnoid hemorrhage, especially after an iatrogenic intrathecal contrast administration.