Autonomic dysreflexia: the concealed killer behind recurrent cerebral hemorrhage in spinal cord injury-a case report with management insights.

Autonomic dysreflexia (AD) is a potentially life-threatening complication of high-level spinal cord injury (SCI), marked by paroxysmal hypertension. Although cerebrovascular events can be triggered by severe hypertension, the direct association between AD and intracerebral hemorrhage (ICH) necessitates increased clinical awareness. We present a case of a 71-year-old male with a complete C3 SCI (American Spinal Injury Association Impairment Scale grade A). On May 24, 2025, the patient developed an acute episode of AD following defecation, characterized by a sudden, severe headache and transient loss of consciousness, with elevated blood pressure (BP) of 178/101 mmHg. Emergency computed tomography revealed a right occipital ICH (3.6 × 1.8 cm) with concomitant subarachnoid hemorrhage. A follow-up cranial imaging examination on June 21, 2025, revealed a new contralateral hematoma (3.4 × 3.0 cm) in the left frontal lobe. Notably, a follow-up 24-h ambulatory blood pressure monitoring performed between the two hemorrhagic events (on June 20, 2025) revealed markedly elevated blood pressure variability, with a systolic BP standard deviation of 32.7 mmHg (compared with 31.8 mmHg recorded before the initial hemorrhage). Pre-event 24-h ambulatory blood pressure monitoring performed on March 21, 2025, had already demonstrated marked blood pressure variability (BPV), which may reflect the patient's underlying autonomic dysregulation. The association between this extreme BPV and the subsequent ICH remains a subject for hypothesis generation. The hematomas resolved following a regimen of antihypertensive therapy (nitrendipine), osmotic diuresis (mannitol), and meticulous management of triggering factors. This case demonstrates that AD in high cervical SCI can precipitate severe ICH, with extreme BPV potentially serving as a synergistic risk factor. Clinicians should maintain high vigilance for new-onset severe headache in patients with SCI at or above T6, ensuring prompt BP assessment and identification of AD triggers. Future studies are required to investigate whether long-term BPV stabilization could mitigate hemorrhagic risk in this population.