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| Year : 1999 | Volume
: 47
| Issue : 4 | Page : 335-7 |
Subdural haematoma in a patient with immune thrombocytopenic purpura.
Meena AK, Murthy JM
Departments of Neurology, Radiology and Imageology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, 500082, India.
Correspondence Address:
Departments of Neurology, Radiology and Imageology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, 500082, India.
A patient with bilateral subdural haematomas in association with idiopathic thrombocytopenic purpura is documented. She was managed successfully with platelet rich plasma and immunosuppressive therapy with steroids.
How to cite this article:
Meena A K, Murthy J M. Subdural haematoma in a patient with immune thrombocytopenic purpura. Neurol India 1999;47:335 |
Neurological complication of idiopathic thrombocytopenic purpura (ITP) are mainly due to haemorrhage into the intracranial compartment and is dependent on the severity of thrombocytopenia. In the earlier studies, the incidence of intracranial haemorrhage ranged from 0.65 to 26 per cent.[1] However, more recent surveys showed an incidence of about 2 per cent.[2] The decrease in the incidence of this complication is mainly due to early diagnosis and better management. Among the intracranial haemorrhages, the most common is parenchymal bleed.[1],[3],[4] Subdural haematoma (SDH) is rare and only few cases have been documented.[3],[5],[6],[7],[8] This report documents subdural haematoma in a patient with ITP.
A 33 year old lady was admitted with a history of petechial spots all over the body now and then since four months. She also had history of menorrhagia for which she underwent hysterectomy under spinal anaesthesia five months before admission. Following the operation she developed headache. The intensity of headache became severe and continuous. There was no history of vomitings or seizures. On examination she was normotensive. Few purpuric spots were noted on her upper limbs. Spleen was palpable. Neurologic examination showed an alert individual with normal higher functions. Ocular fundi showed bilateral papilloedema and cranial nerves were normal. Motor, sensory and cerebellar systems were normal. Deep tendon reflexes were normally elicitable on either side and plantars were downgoing. Mild neck stiffness was noted.
Haematological investigations revealed a haemoglobin of 12.7 gm/dl with a normal total and differential leukocytic counts. Platelet count was 15,000/cumm. Liver and renal function tests were normal and tests for collagen vascular diseases were negative. Bone marrow aspiration cytology showed an increase in the megakaryocyte series, which consisted of monolobate and multilobate forms. There was a prominence of erythyroid cells, which were normoblastic in maturation. Myeloid series were normal and in orderly maturation. A CT scan of the brain showed bilateral subdural haematomas (hyperdense) in the parieto-occipital regions with out any mass affect [Figure - 1]. Patient was managed conservatively with infusions of platelet rich plasma and oral steroids. On the first day, she was given four packs of platelet rich plasma (fresh) with which the platelet count rose to 55,000/cumm. She needed infusion of platelet rich plasma (2-3 packs) on three occasions to keep platelet count around 80,000 -1,00,000 mm3. She showed steady improvement in her symptoms. CT Scan of the brain repeated 10 days after admission showed partial resolution of subdural haematoma. Her platelet counts were serially monitored. At the time of last follow-up the platelet count was 2 lac ( )/mm3 and she was on maintenance dose of steroids. Repeat CT scan done at 7 weeks follow-up showed complete resolution of subdural haematomas.
Subdural haematoma and subarachnoid haemorrhage (SAH) occur usually as an extension of an intracerebral haemorrhage.[1] Isolated subdural haematoma is a rare complication in patients with idiopathic thrombocytopenic purpura. Sebe et al[7] could review only four patients including their own patient with chronic subdural haematoma complicating ITP till 1982. This complication has also been reported in a patient with drug induced thrombocytopenia[9] and in patients with thrombocytopenia in association with aplastic anaemia,[10] and myelofibrosis.[11] Subdural haematomas usually occur on the superolateral surfaces of the hemispheres but can also occur in the interhemispheric region.[12] In the present case there was clear temporal relation between onset of symptoms and spinal anaesthesia. The causal relation between the two remains a speculation.
The site, size, and the presence of midline shift on CT scan will influence the management protocols.[13] Patients can be managed medically if the clinical condition is stable and the subdural haematoma is small, without significant midline shift on CT scan as in the present case. It will be appropriate to bring up the platelet counts quickly with platelet rich plasma initially as immunosuppressive therapy will take time to correct platelet counts. In our patient subdural haematomas were hyperdense on CT scan, suggestive of fresh bleed. To prevent further accumulation of blood, platelet count was maintained between 80,000-1,00,000/cumm with repeated platelet rich plasma infusions. The role of surgery in the management of these patients is not clear. Any deterioration in the clinical condition during the conservative treatment, necessitates evacuation of the haematoma.[9],[11],[13] Safety and advantage of needle evacuation in subdural haematoma has been documented in patients with bleeding diathesis.[11] Such recourse can be resorted to if there is threat to life in patients with thrombocytopenia and subdural haematoma and uncorrected haemostatic deficiency.
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