Subacute convexity subdural hematoma in a child with malignant Tourette syndrome: a case report

Tourette syndrome is usually benign, but in malignant forms violent motor tics can cause serious injury. We describe a 14-year-old boy with malignant Tourette syndrome and comorbid attention-deficit/hyperactivity and obsessive-compulsive disorders who developed progressive, treatment-refractory trunk and head tics despite multiple pharmacological regimens. Headache and vomiting were initially attributed to recent psychopharmacological changes, and neurological examination and laboratory tests were unremarkable. A brain MRI ordered to investigate these symptoms unexpectedly revealed a subacute, multiseptated subdural hematoma over the left fronto-temporo-parietal convexity with marked midline shift and impending uncal herniation, in the absence of any reported direct head trauma. The patient underwent urgent small frontoparietal craniotomy with evacuation of the collection, preferred over burr holes due to the septated morphology. Postoperative CT confirmed satisfactory decompression, and he was discharged six days later neurologically intact. This case illustrates that repetitive, violent head tics in malignant Tourette syndrome may generate closed, subclinical head injury sufficient to cause subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial haemorrhage in patients with malignant tics and new headaches or vomiting, and avoid attributing such symptoms solely to medication side effects.