A Rare Case of Subdural Hematoma Associated with Intracranial Hypotension Following Rituximab Therapy in a Patient with Myasthenia Gravis

A Rare Case of Subdural Hematoma Associated with Intracranial Hypotension Following Rituximab Therapy in a Patient with Myasthenia Gravis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Rare Case of Subdural Hematoma Associated with Intracranial Hypotension Following Rituximab Therapy in a Patient with Myasthenia Gravis Yasmin Sahebzamani, Behnaz Ansari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7788877/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Spontaneous intracranial hypotension (SIH) is an underdiagnosed disorder most often presenting with postural headache and attributable to cerebrospinal fluid (CSF) leakage. Complications include brain sagging and subdural hematoma (SDH), which may carry significant morbidity. Rituximab, a chimeric monoclonal antibody targeting CD20, is widely prescribed for autoimmune diseases, including myasthenia gravis (MG). Although its safety profile is generally favorable, rare neurological complications have not been fully characterized. Case presentation: We describe a 40-year-old woman with a history of generalized MG, thymectomy, hypothyroidism, and chronic migraine who developed persistent headache following Rituximab infusion. The infusion on this occasion was administered more rapidly than in previous cycles. Her pain was severe, positional, and unresponsive to escalation of migraine prophylaxis. Neurological examination was unremarkable. Brain MRI revealed bilateral non-traumatic SDH, diffuse pachymeningeal enhancement, and cerebellar tonsillar descent, consistent with SIH. CT angiography and MR venography ruled out vascular abnormalities. Comprehensive autoimmune and infectious work-up was negative, and CSF analysis was normal. Conservative therapy with intravenous fluids and caffeine led to marked symptom improvement. Conclusion: This case highlights a rare occurrence of SIH complicated by bilateral SDH in temporal association with Rituximab infusion. While causality cannot be confirmed, the temporal relationship, absence of alternative risk factors, and response to conservative management suggest a possible drug-related contribution. Clinicians should consider SIH in patients with refractory or atypical headache after Rituximab therapy, as early recognition can prevent unnecessary interventions and allow for effective, non-invasive treatment. Further reports are needed to clarify whether Rituximab may predispose susceptible individuals to disturbances in CSF dynamics. Spontaneous intracranial hypotension Subdural hematoma Rituximab Myasthenia Gravis Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7788877","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":550701074,"identity":"afe0e901-92c9-4e28-b0a9-4839651b1987","order_by":0,"name":"Yasmin Sahebzamani","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yasmin","middleName":"","lastName":"Sahebzamani","suffix":""},{"id":550701075,"identity":"42e8f4e5-84dc-4491-b332-7ebb00ae8eb7","order_by":1,"name":"Behnaz 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Gravis","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spontaneous intracranial hypotension, Subdural hematoma, Rituximab, Myasthenia Gravis","lastPublishedDoi":"10.21203/rs.3.rs-7788877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7788877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nSpontaneous intracranial hypotension (SIH) is an underdiagnosed disorder most often presenting with postural headache and attributable to cerebrospinal fluid (CSF) leakage. Complications include brain sagging and subdural hematoma (SDH), which may carry significant morbidity. Rituximab, a chimeric monoclonal antibody targeting CD20, is widely prescribed for autoimmune diseases, including myasthenia gravis (MG). Although its safety profile is generally favorable, rare neurological complications have not been fully characterized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe describe a 40-year-old woman with a history of generalized MG, thymectomy, hypothyroidism, and chronic migraine who developed persistent headache following Rituximab infusion. The infusion on this occasion was administered more rapidly than in previous cycles. Her pain was severe, positional, and unresponsive to escalation of migraine prophylaxis. Neurological examination was unremarkable.\u003c/p\u003e\n\u003cp\u003eBrain MRI revealed bilateral non-traumatic SDH, diffuse pachymeningeal enhancement, and cerebellar tonsillar descent, consistent with SIH. CT angiography and MR venography ruled out vascular abnormalities. Comprehensive autoimmune and infectious work-up was negative, and CSF analysis was normal. Conservative therapy with intravenous fluids and caffeine led to marked symptom improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nThis case highlights a rare occurrence of SIH complicated by bilateral SDH in temporal association with Rituximab infusion. While causality cannot be confirmed, the temporal relationship, absence of alternative risk factors, and response to conservative management suggest a possible drug-related contribution. Clinicians should consider SIH in patients with refractory or atypical headache after Rituximab therapy, as early recognition can prevent unnecessary interventions and allow for effective, non-invasive treatment. Further reports are needed to clarify whether Rituximab may predispose susceptible individuals to disturbances in CSF dynamics.\u003c/p\u003e","manuscriptTitle":"A Rare Case of Subdural Hematoma Associated with Intracranial Hypotension Following Rituximab Therapy in a Patient with Myasthenia Gravis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-27 14:42:49","doi":"10.21203/rs.3.rs-7788877/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7b2c51d-02dc-418d-b843-7620f402fd44","owner":[],"postedDate":"November 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T13:54:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-27 14:42:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7788877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7788877","identity":"rs-7788877","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}