Spontaneous acute subdural hematoma in a patient with multiple myeloma

Abstract

A b S T R A c TAcute spontaneous subdural hematoma in a patient of multiple myeloma receiving chemotherapy is an unknown event, needing an urgent neurosurgical management. We report this patient who presented with progressive neurological deterioration and a low platelet count. She was successfully managed by craniotomy and evacuation of subdural hematoma with intraoperative transfusion of platelets. The acute spontaneous subdural hematoma in her was probably related to the bleeding diathesis due to thrombocytopenia associated with chemotherapy. Bleeding diathesis is commonly seen in this disease and it has been estimated that as many as onethird of the patients with plasma cell myeloma may have this complication. [12,13] The common abnormalities contributing to bleeding diathesis include thrombocytopenia, platelet dysfunction related to uremia, hyperviscosity with bleeding tendency, disorders of coagulation factors, etc. The possible mechanisms by which coagulopathy could develop in patients with dysproteinemias in MM include: paraprotein interference with the normal function of coagulation factor(s) (i.e. by complexing with specific clotting factors), enhancement of the clearance of coagulation factor(s) by the reticuloendothelial system, anticoagulant activity of paraproteins, impaired normal platelet function, excessive fibrinolysis, and hyperviscosity. [2][3][4][5]12] Patients on bortezomib chemotherapy also often develop low platelet counts, but these usually recover rapidly.[14] During melphalan, prednisolone, and thalidomide chemotherapy, periodic blood tests are needed to ensure that an individual has adequate levels of white blood cells and platelets. The dose of melphalan must be adjusted based on these findings. Paul et al. reported one death due to SDH in the dexamethasone group in a study comparing bortezomib and high-dose dexamethasone for relapsed MM.[15] Thrombocytopenia does not usually result in any symptoms, but if the platelet count is very low there is an increased risk of bleeding. Transfusion of platelets may be required temporarily. Keith et al., in their review of 23 cases of MM, described one patient with unilateral large subdural collection looking like acute SDH on imageology, but subsequently it turned out to be a malignant effusion. [16] Spontaneous acute SDH is a rare but serious condition. This term is based simply on the absence of a traumatic history. [8,17,18] Mortality rate has been reported to be between 60 and 76.5%. [19] Early surgical intervention is often imperative for hematomas with significant mass effect. The survival rate for surgery within 4 h of acute onset compared to surgery after 4 h is 50 to 0%, respectively. Other favorable variables include a high glasgow coma score score upon admission, appropriate pupillary reactivity, and young age. CONCLUSIONAlthough coagulopathy-associated spontaneous acute SDH has been well documented, spontaneous acute SDH related to coagulopathy, particularly in MM, has never been recognized.