11SatishKumar_Appearance 100 Satish Kumar et al Isolated thrombocytopenia in acute subdural hematoma Appearance of isolated thrombocytopenia in a patient of acute subdural hematoma S. Satish Kumar1, M. Srinivas1, K. Raghu1, P. Shashidhar1, Amit Agrawal2 1Professor of Emergency Medicine, Department of Emergency Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) 2Professor of Neurosurgery, Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) Abstract: Thrombocytopenia in critically ill patients probably reflects the severity of the underlying illness and these patients have a higher mortality due to the severity of overall clinical status. In present article we report a case of acute subdural hematoma who developed progressive thrombocytopenia resulting in fatal outcome. A 75 year gentleman presented with history of sudden onset headache and lapsed into altered sensorium. There was history of trivial fall before he developed headache. The patient was deeply comatose with pupils bilateral 2 mm and reacting to light. Computerized tomography (CT) scan brain showed large right fronto-temporo-parietal acute subdural hematoma with mass effect and midline shift. Post-operatively he was kept on elective ventilation. On following days the patient continues to develop thrombocytopenia (Day- 3 Platelet count 75,000, day-4 60,000, day-5 25,000). Thrombocytopenia is a common but a potentially life-threatening condition problem and has been considered to play a role in worsening the prognosis of critically ill patients in intensive care unit. Few studies statistically examine the strength of the association between risk factors and outcomes related to thrombocytopenia, additional research is recommended to identify putative molecular determinants. Key words: Thrombocytopenia, acute subdural hematoma, trivial, head injury Introduction Thrombocytopenia is a common but a potentially life-threatening condition problem and has been considered to play a role in worsening the prognosis of critically ill patients in intensive care unit. (1, 2) In present article we report a case of acute subdural hematoma who developed progressive thrombocytopenia resulting in fatal outcome. Romanian Neurosurgery (2015) XXIX (XXII) 1: 100 - 102 101 Case report A 75 year gentleman presented with history of sudden onset headache and lapsed into altered sensorium. He was in altered sensorium since then. He was a known hypertensive on regular medication. There was no history of diabetes. There was history of trivial fall before he developed headache. On examination in the emergency department pulse rate was 100/minute, blood pressure was 150/100 mmHg, saturation was 82% on room air, chest examination bilateral crepitations. The patient was deeply comatose with pupils bilateral 2 mm and reacting reacting to light. Extraocular movements were full. Blood investigations including coagulation profile and platelet count (1,65,000/mm3) were normal. Computerized tomography (CT) scan brain showed large right fronto-temporo- parietal acute subdural hematoma with mass effect and midline shift. Post-operatively he was kept on elective ventilation. On following days the patient continues to develop thrombocytopenia (Day-3 Platelet count 75,000, day-4 60,000, day-5 25,000). The patient febrile (102oF) but there was no clinical evidence of bleeding. Coagulation profile was normal. Then antibiotics were changed and platelet count was marginally improved (Day- 6 60,000, day-7 1,00,000). However there was no improvement in general condition. Peripheral smear was normal except mild thrombocytopenia. The patient did not improve and expired on 10th day post injury. Discussion The mechanism of isolated thrombocytopenia in septicemia is largely unknown, (3) several mechanisms including compensated disseminated intravascular coagulation, (4) increased platelet destruction, (5) or some impairment of platelet production (6) have been proposed as the possible causes. Septicemia, have been identified as the major independent risk factor for thrombocytopenia (2, 7-9) as thrombocytopenia can occur early in the course of septicemia even before the pathogen is cultured from the blood. 10 Platelet counts are measured just as frequently as hemoglobin, in the critical care unit, still platelet counts have not been well studied among critically ill patients. (3) Thrombocytopenia may occur in patients with septicemia without laboratory evidence of disturbed coagulation profile. (10-12) Validity of platelet count as a predictor of bleeding and correction of thrombocytopenia with platelet transfusions, is uncertain, (3) as major bleeding has not been defined consistently across studies. (13, 14) Just on the basis of laboratory findings alone, replacement therapy is not recommended and is required only in patients who are actively bleeding, who require an invasive procedure, or who are at risk for bleeding complications. (2, 15) Conclusion Thrombocytopenia in critically ill patients probably reflects the severity of the underlying illness and these patients have a higher mortality due to the severity of overall clinical status. (3, 16- 19) Few studies statistically examine the strength of the association between risk factors and outcomes related to thrombocytopenia, (3) additional research is recommended to identify putative molecular determinants and patho- genetic mechanisms causing isolated thrombocytopenia in critically ill patients because of septicemia. (20) 102 Satish Kumar et al Isolated thrombocytopenia in acute subdural hematoma Correspondence Dr. Amit Agrawal Professor of Neurosurgery Department of Neurosurgery Narayana Medical College Hospital Chinthareddypalem Nellore-524003 Andhra Pradesh (India) Email- dramitagrawal@gmail.com dramit_in@yahoo.com Mobile- +91-8096410032 References 1. Shah RA, Musthaq A, Khardori N. Vancomycin- induced thrombocytopenia in a 60-year-old man: a case report. J Med Case Reports 2009;3:7290. 2. Stephan F, Hollande J, Richard O, Cheffi A, Maier- Redelsperger M, Flahault A. Thrombocytopenia in a surgical ICU. Chest 1999;115:1363-1370. 3. Hui P, Cook DJ, Lim W, Fraser GA, Arnold DM. The frequency and clinical significance of thrombocytopenia complicating critical illness: a systematic review. Chest 2011;139:271-278. 4. Neame PB, Kelton JG, Walker IR, Stewart IO, Nossel HL, Hirsh J. Thrombocytopenia in septicemia: the role of disseminated intravascular coagulation. Blood 1980;56:88-92. 5. 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