Objective: To report an atypical presentation of suspected parkinsonism following surgical evacuation of an acute on chronic subdural hematoma (SDH).

Background: The spectrum/mechanism of movement disorders post-acute TBI is heterogeneous. Though traumatic brain injury is associated with chronic Parkinson’s, limited literature suggests SDH is a rare cause of potentially reversible acute-subacute parkinsonism.

Method: Case report and literature review.

Results: A 64-year-old male presents 8 months after hemicraniectomy for a right-sided 2.6 cm acute-on-chronic subdural with a 4 mm leftward midline shift from a fall. He complains of bilateral tremor with action which started 1 month after surgery. He denies smell change, orthostasis, constipation, hallucinations, or REM behavioral disorder symptoms. There is no family history of Parkinson’s disease, essential tremor, or dopaminergic medication.

On exam, the patient displayed global bradykinesia, bilateral rigidity, bilateral mixed action and postural tremor (no resting tremor), and shuffling gait. His UPDRS Part III score was 34. MRI showed hematoma resolution without new intracranial abnormalities. Propranolol partially reduced action tremor, and a carbidopa-levodopa trial was initiated.

Conclusion: This case highlights the clinical heterogeneity of acute-subacute parkinsonism following subdural. This is the first case presenting with mixed action tremor and parkinsonism. Notable features include bilateral onset, parkinsonian features, and lack of resting tremor. Bilateral symptoms from a unilateral SDH support the theory that subdural midline shift may cause bi-putaminal hypoperfusion. Given this mechanism, there is a possible role for improvement post-decompression and adjunct carbidopa-levodopa. Further research is needed to understand the clinical endophenotypes of post-TBI parkinsonism.

References: [1] Instead of “REM symptoms,” consider using “REM behavior disorder symptoms” (or, if space is limited, “RBD symptoms”).
[2] When mentioning the tremor response to propranolol, you might specify “action tremor.”
Just to provide additional context, action tremor can occur in the context of Parkinsonism, as long as the resting tremor is present, and this is not necessarily the re-emergent tremor. Therefore in your case, I agree that the action tremor and the parkinsonism are two separate conditions.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/subdural-hematoma-leading-to-subacute-secondary-parkinsonism/