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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 308-310

Intraventricular hemorrhage in a patient with chronic myeloid leukemia and anterior communicating artery aneurysm


Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission21-Mar-2013
Date of Decision09-Apr-2013
Date of Acceptance03-May-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Pravin Salunke
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.115076

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How to cite this article:
Aggarwal A, Salunke P, Mathuriya SN, Futane S. Intraventricular hemorrhage in a patient with chronic myeloid leukemia and anterior communicating artery aneurysm. Neurol India 2013;61:308-10

How to cite this URL:
Aggarwal A, Salunke P, Mathuriya SN, Futane S. Intraventricular hemorrhage in a patient with chronic myeloid leukemia and anterior communicating artery aneurysm. Neurol India [serial online] 2013 [cited 2021 Mar 1];61:308-10. Available from: https://www.neurologyindia.com/text.asp?2013/61/3/308/115076


Sir,

Intracerebral (ICH) and/or intraventricular hemorrhage (IVH) in patients with leukemia is a common cause of mortality. [1] Occasionally, ICH may be the initial presentation of previously undiagnosed leukemia. [2] We present a case of spontaneous IVH due to chronic myeloid leukemia (CML) that masqueraded as a ruptured anterior communicating artery (Acom) aneurysm.

A 60-year-old male with no known co-morbidities presented with sudden onset headache and transient loss of consciousness. At presentation, patient was conscious and oriented with no focal neurological deficits. Cranial computed tomography (CT) revealed IVH predominantly in the third ventricle [Figure 1]a and b. CT-angiogram showed Acom artery aneurysm [Figure 1]c. Results of laboratory investigations are given in [Table 1]. Marked leukocytosis and deranged coagulation profile was noticed. He was operated (after correction of deranged coagulation profile) with a provisional diagnosis of ruptured A com aneurysm to prevent rebleed. Intraoperatively, there was a small aneurysm arising from Acom-A2 junction, directed posterosuperiorly, which was successfully clipped. However, the aneurysm appeared unruptured. Post-operatively, patient was drowsy with no focal deficits. The investigations showed persistent leukocytosis and deranged coagulation profile and normal platelet count [Table 1]. There was no improvement in coagulation profile despite Vitamin K and repeated transfusion of fresh frozen plasma. On post-operative day 4, patient deteriorated further in sensorium. Serial CT head revealed hydrocephalus, which was treated with ventriculo-peritoneal shunt [Figure 1]d-g. There was no clinical improvement though CT showed decompressed ventricles. The consistently raised total leukocyte count (TLC), suggestive of a leukemoid reaction was attributed to infection. However, raised pre-operative TLC and absence of fever made the possibility of infection less likely. Peripheral smear showed blast cells. Patient underwent bone marrow aspiration. Reverse transcriptase analysis identified a BCR/ABL Philadelphia translocation t (9;22)(q34;q11), which is characteristic of CML. Unfortunately, patient succumbed, before the bone marrow report was received.
Figure 1: (a and b) pre‑operative non‑contrast computed tomography (NCCT) head showing intraventricular blood. (c) CT Angio shows Acom artery aneurysm. (d) Post‑operative NCCT head with clip artifact seen. (e) NCCT head on post‑operative day 4 showing ventriculomegaly (f and g) NCCT head showing adequately decompressed ventricles with shunt in situ

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Table 1: Results of laboratory tests during hospital stay

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Spontaneous IVH/ICH is frequently encountered in neurosurgical practice and is commonly due to hypertension, ruptured aneurysms, arterio-venous malformations, coagulation disorder and vasculopathies. [3] This patient represents a unique situation in which IVH was the initial presentation of previously undiagnosed CML. Presence of A-com artery aneurysm on CT-angiogram masqueraded the IVH. Though ruptured Acom artery aneurysms may present with IVH alone, persistent leukocytosis with coagulopathy should have raised the suspicion of lympho-proliferative disorders. [4] The exact patho-physiology of ICH in leukemia is unknown. Leukocytosis possibly leads to increased blood viscosity and stagnation of blood in small cerebral blood vessels, thereby increasing the intravascular pressure giving rise to rupture. Besides, it may be associated with coagulopathy and thrombocytopenia. Surgical therapy has a little role in management of such hematomas. Treatment should be directed at correcting the coagulopathy, thrombocytopenia, leukocytosis (leukophoresis) and chemotherapy. [3]

In this patient, we got biased by the presence of A-com artery aneurysm thinking it to be sole cause of bleed. Leukocytosis was wrongly attributed to infection or IVH, itself. Therefore, presence of marked leukocytosis and abnormal coagulation profile in a case of ICH/IVH should raise the suspicion of lymphoproliferative disorders and a proper workup should be carried out on an emergent basis before any major surgical intervention.

 
  References Top

1.Fritz RD, Forkner CE Jr, Freireich EJ, Frei E 3 rd , Thomas LB. The association of fatal intracranial hemorrhage and blast crisis in patients with acute leukemia. N Engl J Med 1959;261:59-64.  Back to cited text no. 1
    
2.Naunheim MR, Nahed BV, Walcott BP, Kahle KT, Soupir CP, Cahill DP, et al. Diagnosis of acute lymphoblastic leukemia from intracerebral hemorrhage and blast crisis. A case report and review of the literature. Clin Neurol Neurosurg 2010;112:575-7.  Back to cited text no. 2
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3.Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med 2001;344:1450-60.  Back to cited text no. 3
[PUBMED]    
4.Thai QA, Raza SM, Pradilla G, Tamargo RJ. Aneurysmal rupture without subarachnoid hemorrhage: Case series and literature review. Neurosurgery 2005;57:225-9.  Back to cited text no. 4
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