Recurrent Multi-level Spinal Subdural Hematoma in Granulomatosis with Polyangiitis: A Therapeutic Dilemma Between Ischemia and Hemorrhage.

Spinal subdural hematoma (SSDH) associated with granulomatosis with polyangiitis (GPA) is extremely rare. A 63-year-old man with GPA and recurrent cerebral infarctions developed multi-level SSDHs while receiving immunotherapy and antithrombotic therapy. The hematomas were resolved conservatively, but they recurred in the posterior fossa and thoracic spine one year later. High cerebrospinal fluid interleukin-6 levels during ischemic events suggest active central nervous system vasculitis. This case illustrates a critical therapeutic dilemma: managing the competing risks of vasculitic ischemic stroke and hemorrhagic complications, such as SSDH. This case highlights the importance of balancing aggressive immunotherapy to suppress the vasculitis activity with cautious antithrombotic management.