Departments of 1Neurosurgery and 2Surgery, University of Minnesota Medical School, Minneapolis, MN
Idiopathic thrombocytopenic purpura (ITP) is a rare autoimmune disorder that may be associated with life-threatening hemorrhages. Clinically significant bleeding often occurs with platelet counts less than 10,000. We present a unique case of ITP with spontaneous symptomatic posterior fossa hemorrhage that underwent successful splenectomy and posterior fossa hematoma evacuation.
A 62-year-old female with a history of medically refractory ITP and platelet count of 3,000 was admitted to the hospital following sudden onset of a severe occipital headache. She subsequently became agitated and confused, and a head CT revealed a 3.5 cm midline cerebellar hyperdensity with obliteration of the fourth ventricle and obstructive hydrocephalus. The patient was immediately brought to the operating room where neurosurgery placed a ventriculostomy, followed by an emergent splenectomy performed by the general surgery team. The neurosurgery team then performed a midline suboccipital craniectomy revealing a large cerebellar hematoma that was evacuated.
The patient tolerated the surgeries well with minimal blood loss and awoke neurologically intact. Although she demonstrated no evidence of recurrent bleeding, she was unable to be weaned from the ventriculostomy, eventually requiring a ventriculoperitoneal shunt on postoperative day six. She was subsequently discharged in stable condition.
This case represents a unique manifestation of ITP in which a life-threatening posterior fossa hemorrhage was successfully treated by emergent splenectomy followed by decompressive craniectomy. Neurosurgeons facing life-threatening intracranial hemorrhage in the setting of ITP should consider involving the general surgery team in expedient fashion, as emergent splenectomy at time of craniotomy may result in optimal operative management.