DOI: 10.33962/roneuro-2022-005 Management of nontraumatic intracranial haemorrhage (subdural hematoma) in immune thrombocytopenia. Case report D. Balasa, Al. Tunas, V. Stan, T. Adam Romanian Neurosurgery (2022) XXXVI (1): pp. 28-29 DOI: 10.33962/roneuro-2022-005 www.journals.lapub.co.uk/index.php/roneurosurgery Management of nontraumatic intracranial haemorrhage (subdural hematoma) in immune thrombocytopenia. Case report D. Balasa1, Al. Tunas1, V. Stan1, T. Adam2 1 Department of Neurosurgery, Clinical Emergency Hospital Constanta, ROMANIA 2 Department of Haematology, Clinical Emergency Hospital Constanta, ROMANIA ABSTRACT Intracranial haemorrhage is a devastating complication of immune thrombocytopenic purpura [1]. The occurrence of a spontaneous subdural hematoma in immune thrombocytopenia (ITP) is rare [2], affecting 1% or less of patients [3]. In ITP contrary to traumatic SDH the brain parenchyma is well preserved [3]. We present the case of a patient with immune thrombocytopenia, subdural haemorrhage and asymptomatic parietal parasagittal meningioma. Neurological parameters were closely monitored, including the level of consciousness, pupillary size, motor or sensorial deficit. He was managed successfully medically (platelet-rich plasma and steroids) and then surgically (craniotomy, subdural hematoma aspiration). INTRODUCTION We present tha case of a patient with imune thrombocytopenia intracerebral hemorhage and parietal parasagital meningioma. CASE REPORT We present the case of a patient who suferred a head trauma in unccleared conditions. He acuse mild left hemiparesis (ASIA 4/5), intense headache VAS 8/10, vomiting and diziness, from 3 days. Few purpuric spots were noted on all the four members. Medical datas revealed chronical ITP, without continous treatment Hemoglobine: 14,20 g/dl, TLC 4000/cm3. Coagulation tests were normal. Clinical exam revealed mild hemiparesis (ASIA 4/5), osteotendinous reflexes diminished on the left side, Babinsky on the left side, purpuric lesions on all the four members. Glasgow scale 15. CT scan of the head revealed hyperdensity in the subdural space in the temporo parieto occipital region on the right side, and in the subdural area in right posterior part of the sagital sinus,left parasagital meningioma. Keywords hematoma, subdural, subarachnoid haemorrhage, idiopathic thrombocytopenic purpura Corresponding author: Balasa Daniel Department of Neurosurgery, Clinical Emergency Hospital Constanta, Romania balasadaniel100@yahoo.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published March 2022 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 29 Management of nontraumatic intracranial haemorrhage (subdural hematoma) in immune thrombocytopenia l Figure 1. Temporoparietooccipital acute subdural hematoma (blue arrow). Acute subdural interemispheric (falx cerebri) (Pink arrow). Parietal parasagital meningioma (orange arrow). The patient was treated with Dexametazone 40 mg/day and platelet transfusion. After 4 days her platelet count rose to 130000/mm3 who allowed surgical intervention. Clinical status was stationary : intense headache (VAS 7/10), left hemiparesis (ASIA 4/5), vomiting 1-2/day, GCS 15. The patient was operated (frontotemporo- parietoociipital craniotomy, complete evacuation of the subdural hematoma). Figure 2. Complete evacuation of the subdural hematoma Clinical postoperative evolution was very good with healing of hemiparesis, of headache, vomiting and diziness. Persisted only slight left pyramidal syndrome. DISCUSSION Essential thrombocitopenia is revealed by constant diminution of the platelets without any cause. (Denis, Hayem, Frank. ) ITP was first described by Werlhofin 17354 as an aquired disorder which leads to immune mediated destruction of platelets characterised by low platelet count and normal coagulation studies4. intracranial hemorrhage is a devastating complication of ITP1,4. The occurence of a spontaneous subdural hematoma in immune thrombocytopenia (ITP) is rare2, affecting 1-2% or less of patients3,4,5. The clinical features are mainly headache, hemiparesis, signs of raised intracranial tension, altered consciousness4. Usually, subdural hematoma occurs, when are associatecd with ITP around the the top and side of the frontal and parietal lobes, in the posterior cranial fossa, near the falx cerebri and tentorium cerebelli4 . CONCLUSIONS - Medical treatment enabled us to achieve an adequate hemostasis wich was esential to be able to perform surgery in proper time. - Combination between medical treatment of imune thrombocitopenia and surgical treatment of acute subdural hematoma was mandatory for a good clininical and neurological evolution. REFERENCES 1. Pavithran K , Thomas M Management of subdural Hematoma in imune thrombocytopenic purpura: Report of seven patients and a literature review. Clinical Neurology and Neurosurgery, Vol 111, Issue 2, February 2009, 189-192 2. Mathews M H, Yu W, Chappell E T. Spontaneous Subdural Hematoma in the setting of Imune Thrombocytopenia Complicated by ischemis infarcts. Neuroradiol J, 2007 Apr 30 (2): 224-227. Epub 2007 Apr 30 3. Sunitha R, Mathew R, Thomas M. Conservative management of subdural hematoma in idiopathic thrombocytopenic purpura: Report of two cases and review of the literature. ANN Indian Acad Neurol 2007; 10: 184-6 4. Chatterjee S, Karmakar PS, Ghosh P, Ghosh A. Subdural Hematoma associated with thrombocytopenic purpura in two different settings.The journal of the association of Phisicians of India, 2010, vol 58, 504-506 5. Meena A K, Murthy J M. Subdural haematoma in a patient with immune thrombocytopenic purpura. Neurol India 1999;47:335. 6. Brill N. E., Rosenthal N. Treatment by splenectomy of essential thrombocytopenia (Purpura hemorrhagica). Arch Intern Med (Chic). 1923; 32 (6): 939-953.