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CASE REPORT
Year : 2007  |  Volume : 10  |  Issue : 3  |  Page : 184-186
 

Conservative management of subdural hematoma in idiopathic thrombocytopenic purpura: Report of two cases and review of literature


1 Department of Medicine, Medical College, Trivandrum, Kerala, India
2 Department of Neurology, Medical College, Trivandrum, Kerala, India

Correspondence Address:
Robert Mathew
Department of Neurology, Medical College, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.34801

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   Abstract 

Intracranial hemorrhage (ICH) is the most serious complication of idiopathic thrombocytopenic purpura (ITP) and is potentially fatal. It is rare, affecting 1% or less of patients and is usually subarachnoid or intracerebral. Isolated subdural hematoma (SDH) is rare and only few cases have been reported. Two cases of acute SDH (ASDH) are reported which resolved with conservative management. One of the patients later developed intracerebral hematoma also. In ITP, contrary to traumatic ASDH, the brain parenchyma is well preserved and hence conservative management may be safe in selected patients. However, only a prospective randomized control study will give the final answer.
Both the patients developed the hematoma consequent to low platelet count, which was not detected earlier due to inadequate follow-up. In a developing country, where proper follow-up is often lacking these problems are likely to be more common and are probably underreported. Increased awareness is therefore important to ensure proper follow-up and early intervention.


Keywords: Hematoma, idiopathic thrombocytopenic purpura, subdural


How to cite this article:
Sunitha R, Mathew R, Thomas M. Conservative management of subdural hematoma in idiopathic thrombocytopenic purpura: Report of two cases and review of literature. Ann Indian Acad Neurol 2007;10:184-6

How to cite this URL:
Sunitha R, Mathew R, Thomas M. Conservative management of subdural hematoma in idiopathic thrombocytopenic purpura: Report of two cases and review of literature. Ann Indian Acad Neurol [serial online] 2007 [cited 2019 Dec 15];10:184-6. Available from: http://www.annalsofian.org/text.asp?2007/10/3/184/34801



   Introduction Top


Intracranial hemorrhage (ICH) is the most serious complication of idiopathic thrombocytopenic purpura (ITP). It is rare, affecting 1% or less of patients with severe thrombocytopenia. The hemorrhages are usually subarachnoid or intracerebral and often multiple. Isolated subdural hematoma (SDH) is rare and only few cases have been reported. [1] We report two cases of SDH, which resolved with conservative management.


   Case Reports Top


Case 1

A 27-year-old lady developed severe post partum bleeding and she underwent hysterectomy. Two days later she presented with severe diffuse headache. She had bilateral papilloedema and no other focal deficits. Computerized tomography (CT) scan of the brain showed acute SDH in the left parietotemporal regions measuring one cm in thickness producing significant mass effect [Figure - 1].

Her hemoglobin level was 10 gm% and platelet count 73,000/mm 3 . Peripheral smear showed reduced platelet count only. A bone marrow examination showed mild hypochromic normocytic erythrocytes and thrombocytopenia. Coagulation work-up was negative. She was diagnosed as having ITP. Immediate surgical evacuation was withheld in view of low platelet count and absence of focal deficits. She was kept under close observation, to intervene if worsening occurs. She was given anti-edema measures (Intravenous mannitol), platelet transfusion and parenteral steroids. She improved symptomatically and a repeat CT scan after two weeks showed substantial resolution of the hematoma. She was lost to follow-up.

She presented one year later with right hemiplegia and hemianopia and CT scan showed a left occipital hematoma measuring approximately 60 cm 3 and complete resolution of the previous subdural hemorrhage. Her platelet count was 15,000/mm 3 . She made a good recovery in one month's time.

Case 2

A 23-year-old lady, primigravida presented with history of bleeding from oral cavity, hematurea, melena and hemoptysis in sixth month of gestation. Her hemoglobin was 6 gm%, ESR 100 mm/1 st hour and platelet count was 22,000/mm 3 . Her total WBC count and differential counts were normal. Peripheral smear showed microcytic hypochromic anemia and thrombocytopenia. Screening tests for collagen vascular disease was negative. Liver and renal function tests were within normal limits. A diagnosis of ITP was made. She was initiated on steroids. Ten days later she was readmitted with a five days history of right-sided headache and vomiting. Neurologic examination was normal except for bilateral papill- edema. Magnetic resonance imaging scans showed right frontotemporoparietal sub acute subdural hematoma, which was 2 cm in thickness with compression of ipsilateral ventricle and midline shift [Figure - 2]. Her platelet count was only 10,000/mm 3 . Immediate surgical evacuation was deferred, as platelet count was low and she was well-preserved neurologically. She was started on antiedema measures (Intravenous mannitol) and parenteral steroid. In spite of platelet transfusion her counts continued to drop until she was started on mycophenolate mofetil, after which it improved. Her headache improved substantially with anti-edema measures. She had a full term normal vaginal delivery and the platelet count of the neonate was normal. She never had any subsequent headache and repeated neurological examination on follow-up visits revealed resolution of papilledema and no focal deficits. A repeat CT scan could not be done as patient refused it in the context of symptomatic improvement. Last review was made over the phone after one year and she did not have any symptoms.


   Discussion Top


Subdural hematoma is an extremely rare entity in ITP. So far only very few cases have been reported in the literature. [1],[2],[3],[4],[5],[6] Of these, majority of the cases are from Asia and at least five cases are from India. To the best of our knowledge, no cases have so far been reported in which the same patient developed subdural and intracerebral hematoma. Both the patients developed the hematoma consequent to low platelet count, which was not detected earlier due to inadequate follow-up. In a developing country where proper follow-up is often lacking these problems are likely to be common and are probably underreported.

The diagnosis of ITP is based principally on the exclusion of other causes of thrombocytopenia using the history, physical examination, blood count, peripheral blood film, autoimmune profile and other investigations. [7] As per the guidelines of the British Society for Hematology our patients had Idiopathic Thrombocytopenic Purpura.

Patients with a platelet count of less than 10,000/mm 3 are at risk of developing ICH. In majority of cases ICH is either subarachnoid or parenchymal. SDH usually occurs as an extension of a parenchymal bleed. The basic pathology in thrombocytopenia is proposed to be capillary leak and this may become confluent in severe cases leading to frank intracerebral hematoma. This intracerebral source of bleeding probably explains the rarity of subdural hematoma in ITP. [8]

In view of rarity of the condition no definite guidelines exist, as to the management of subdural hematoma. An ASDH with a thickness greater than 10 mm or a midline shift greater than 5 mm on CT scan would generally be surgically evacuated, regardless of the neurologic status. Patients with anticoagulant induced hemorrhages needs urgent reversal of anticoagulantion before surgical intervention. Both of our patients had more than 1 cm thickness of the hematoma and hence the ideal management would have been correction of thrombocytopenia and emergency surgical intervention. However immediate surgery could not be done due to technical reasons. They were just managed conservatively and they did make a good recovery. The decision for conservative management was further supported by the lack of focal deficits.

Guidelines on the management of subdural hematoma are formulated based on traumatic subdural hematoma. The basic difference between the ASDH occurring as a consequence of hematological disorder and trauma, probably, is in the extent of underlying parenchymal injury. In acute traumatic subdural injury, over one half is unconscious from the moment of injury indicating the frequency of accompanying parenchymal injury. This will definitely have a bearing on the prognosis of those patients who are not intervened surgically. Because of the absence of associated parenchymal injury the outcome may be better in non-traumatic ASDH. For the same size of subdural hematoma chances of complications like brain edema and herniation may be less in non-traumatic ASDH. Trial of conservative management may be safe in selected situations. More and more cases are being reported of patients being managed conservatively under these circumstances. [2],[3],[9],[10] For chronic SDH in ITP also, trial of conservative management has been suggested as there is chance for spontaneous resolution. [2] The recovery of our patients with conservative management further supports these facts.

 
   References Top

1.Miyamoto T, Sasaki K, Ohshima T, Matsumoto K, Itoh J. A case of chronic subdural hematoma associated with idiopathic thrombocytopenic purpura (ITP). No Shinkei Geka 1997;25:157-61.  Back to cited text no. 1    
2.Seckin H, Kazanci A, Yigitkanli K, Simsek S, Kars HZ. Chronic subdural hematoma in patients with idiopathic thrombocytopenic purpura: A case report and review of the literature. Surg Neurol 2006;66:411-4  Back to cited text no. 2    
3.Gupta SK, Khosla VK, Verma SC. Spontaneous resolution of chronic subdural haematoma secondary to chronic idiopathic thrombocytopenic purpura. Neurol India 1997;45:95-7.  Back to cited text no. 3    
4.Sreedharan PS, Rakesh S, Sajeev S, Pavithran K, Thomas M. Subdural haematoma with spontaneous resolution-rare manifestation of idiopathic thrombocytopenic purpura. J Assoc Physicians India 2000;48:432-4.  Back to cited text no. 4  [PUBMED]  
5.Shinmyozu K, Okadome T, Maruyama Y, Maruyama I, Osame M, Tara M. Occurrence of subdural hematoma closely associated with danazol administration in a patient with refractory ITP. Rinsho Ketsueki 1990;31:674-5.  Back to cited text no. 5  [PUBMED]  
6.Hirano A, Ueoka H. Successful treatment of an elderly patient with idiopathic thrombocytopenic purpura accompanied with chronic subdural hematoma, using a Chinese herbal medicine, EK-49 and ascorbic acid. Nippon Ronen Igakkai Zasshi 2001;38:224-8.  Back to cited text no. 6  [PUBMED]  
7.British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol 2003;120:574-96.  Back to cited text no. 7  [PUBMED]  
8.Samuels MA. Neurologic manifestations of hematologic diseases. In : Asbury AK, McDonald W, editors. Diseases of the Nervous System-Clinical Neurobiology. 2 nd ed. W.B Sanders Company: Philadelphia; 1992. p. 1516.  Back to cited text no. 8    
9.Lee MS, Kim WC. Intracranial hemorrhage associated with idiopathic thrombocytopenic purpura: Report of seven patients and a meta-analysis. Neurology 1998;50:1160-3.  Back to cited text no. 9  [PUBMED]  
10.Meena AK, Murthy JM. Subdural haematoma in a patient with immune thrombocytopenic purpura. Neurol India 1999;47:335-7.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2]


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