Management of Chronic Subdural Haematoma in a Case of Idiopathic Thrombocytopenic Purpura
A 19-year-old female patient was admitted with a history of headache and vomiting for last 1 month. Headache was more or less continuous and throbbing in nature, gradually increasing in intensity. There was history of right sided weakness since last 15 days. She had past history of menorrhagia at the time of menarche 5 years ago, for which she was treated conservatively and at this time she was diagnosed as a case of idiopathic thrombocytopenic purpura (ITP). She also had history of prolonged bleeding from wounds, gum bleeding, petechial rashes since birth. On examination she was conscious and normotensive, pallor present. Few purpuric spots were noted on her upper limbs. Patient was advised to take corticosteroids by her physician, but she was not taking any medication at the time of presentation. Neurologic examination showed an alert individual with normal higher functions with grade 2 power in both upper and lower limbs on right side. Hemiparesis developed gradually over a period of 20 days which corresponded to slow increase in the size of the chronic subdural haematoma and pressure effect over motor cortex. Ocular fundi showed bilateral papilloedema and cranial nerves were normal. Motor, sensory and cerebellar systems were normal. Deep tendon reflexes were exaggerated with plantars being up-going on right side. Spleen was not palpable.\nAt the time of admission, haematological investigations revealed haemoglobin of 9.0 gm/dl with normal total and differential leukocytic counts. Platelet count was 30,000/mm3. Liver and renal function tests were normal. Bone marrow aspiration cytology showed an increase in the megakaryocyte series, which consisted of monolobate and multilobate forms. CT scan of the brain showed a hypodense lesion at left posterior parietal and occipital region suggestive of chronic subdural haematoma with significant mass affect with effacement of ipsilateral ventricles []. She was given two units of platelet rich plasma (PRP) and three units of single donor platelet (SDP) with which the platelet count rose to 48,000/mm3 over a period of 15 days. This was done so as to make the patient fit for surgery and reduce chances of intra- and perioperative bleeding. However, she showed steady improvement in her symptoms with headache decreasing in frequency and intensity and no vomiting. Motor power on right side improved to grade 4. All these occurred gradually over a period of 15 days. CT scan of the brain repeated 22 days after admission showed gross resolution of subdural haematoma with no mass effect []. Another 2 units of platelet transfusions given. Her platelet counts were serially monitored. At the time of discharge, the platelet count was 60,000/ml and she was able to walk with complete power on right side. She was started on maintenance dose of steroids (10 mg/day) to reduce the platelet destruction by auto-antibodies.