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NEUROIMAGE
Year : 2014  |  Volume : 62  |  Issue : 5  |  Page : 582-583

Multiple hemorrhagic infarcts in thrombotic thrombocytopenic purpura


1 Department of General Medicine, Muslim Educational Society Medical College, Perinthalmanna, Kerala, India
2 Department of Radiodiagnosis, Muslim Educational Society Medical College, Perinthalmanna, Kerala, India

Date of Web Publication12-Nov-2014

Correspondence Address:
Jemshad Alungal
Department of General Medicine, M.E.S. Medical College, Perinthalmanna - 679 338, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.144521

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How to cite this article:
Alungal J, Abdulla MC, Koya JM, Jenner P F. Multiple hemorrhagic infarcts in thrombotic thrombocytopenic purpura. Neurol India 2014;62:582-3

How to cite this URL:
Alungal J, Abdulla MC, Koya JM, Jenner P F. Multiple hemorrhagic infarcts in thrombotic thrombocytopenic purpura. Neurol India [serial online] 2014 [cited 2019 Nov 20];62:582-3. Available from: http://www.neurologyindia.com/text.asp?2014/62/5/582/144521


A 57-year-old male presented with low-grade fever and upper abdominal pain for 2 months. He was known to have Type 2 diabetes mellitus, systemic hypertension, and ischemic heart disease. He had pallor, jaundice, and had no other signs. He had severe thrombocytopenia and features of microangiopathic hemolysis. A diagnosis of thrombotic thrombocytopenic purpura (TTP) due to clopidogrel was made excluding the other causes, and he was started on plasmapheresis. After a few cycles of plasmapheresis, he developed altered behavior. Magnetic resonance imaging (MRI) of brain revealed multiple regions of restricted diffusion in both cerebral hemispheres, with cortical laminar necrosis and microhemorrhages within most lesions; suggestive of hemorrhagic infarcts [Figure 1]. Plasmapheresis was continued, but despite all efforts he succumbed to his illness 2 days later.
Figure 1: Contrast MRI of brain. (a) T2Wand (b) DWI reveal cortical and subcortical regions of restricted diffusion in both cerebral hemispheres; some of which show reduced, while others show increased signal on ADC mapping. (c) These lesions show focal hemorrhages, best appreciated on SWI (d); and also nonenhancing gyral T1W-hyperintensities, as seen on (e) T1W and (f) Contrast-T1W keeping with multiple hemorrhagic infarcts with cortical laminar necrosis. MRI = Magnetic resonance imaging, T2W = T2-weighted, DWI = Diffusion-weighted imaging, ADC = Apparent diffusion coefficient,SWI = Susceptibility-weighted imaging, T1W = T1-weighted

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End-organ dysfunction in TTP is due to microangiopathic disturbances. In TTP, thrombi formation occurs due to release of multimers of von Willebrand factor due to deficiency of ADAMTS13enzyme. Damage to endothelial cells within the blood vessel wall accelerates formation of platelet-rich microthrombi which cause microinfarctions of affected tissue and consequent neurological manifestations. [1] Imaging patterns in TTP include Frank hematoma, ischemic infarctions, and reversible bilateral cerebral edema. [2],[3] Multifocal hemorrhagic infarctions due to TTP is very rare. Only one single similar case has been described. [4] Plasma exchange remains the mainstay of treatment for TTP. Other treatment options include glucocorticoids, rituximab, and other immunosuppressants. We report a rare case of multifocal hemorrhagic infarcts in TTP.

 
  References Top

1.
Hawley JS, Ney JP, Swanberg MM. Subarachnoid pneumocephalus from epiduralsteroid injection. Headache 2005;45:247-8.  Back to cited text no. 1
    
2.
Bakshi R, Shaikh ZA, Bates VE, Kinkel PR. Thrombotic thrombocytopenic purpura: Brain CT and MRI findings in 12 patients. Neurology 1999;52:1285-8.  Back to cited text no. 2
    
3.
Garewal M, Yahya S, Ward C, Singh N, Cruz-Flores S. MRI changes in thrombotic microangiopathy secondary to malignant hypertension. J Neuroimaging 2007;17:178-80.  Back to cited text no. 3
    
4.
Ellchuk TN1, Shah LM, Hewlett RH, Osborn AG. Suspicious neuroimaging pattern of thrombotic microangiopathy. AJNR Am J Neuroradiol 2011;32:734-8.  Back to cited text no. 4
    


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2 Clopidogrel
Reactions Weekly. 2015; 1533(1): 138
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