Keywords
multiplanar intracranial hemorrhage - coagulopathy - trivial trauma
Traumatic brain injury is the most common cause of simultaneous bleeding at multiple
planes on computed tomography (CT) of the brain. Systemic coagulopathies increase
the risk of symptomatic intracranial hemorrhage following trauma. Here, we report
a 56-year-old man who presented with four episodes of generalized seizures followed
by fall and head injury. He had history of chronic alcohol intake, last binge 2 days
prior to the fall. On evaluation, he had frontal contusion, with the Glasgow Coma
Scale (GCS) score of 12/15 and right hemiparesis. He had clinical features suggestive
of chronic liver disease. His CT of the head showed left temporal contusion along
with intraventricular extension, left temporal subdural hemorrhage, and right temporal
subarachnoid hemorrhage as shown in [Fig. 1]. There was no skull fracture on the bone window. His laboratory investigations revealed
thrombocytopenia (50,000/µL), deranged liver function test (LFT), and prolonged prothrombin
time (test: 16.4 seconds, control: 13, international normalized ratio [INR]: 1.34).
His coagulation parameters were corrected with platelet transfusion, fresh frozen
plasma, and he underwent left frontotemporal craniotomy and evacuation of hematoma.
He had uneventful postoperative recovery with residual sensory aphasia and discharged
2 weeks later. Coagulopathy is most commonly associated with intraparenchymal hemorrhage,
subdural is less often encountered, and combined subdural and intraparenchymal can
be seen rarely.[1] However, simultaneous bleeding in multiple planes in subdural, subarachnoid, intraparenchymal
with intraventricular extension following trivial trauma without open fracture as
seen in our patient is distinctly rare. The presence of multiple planar bleed should
alert the physician for presence of an underlying coagulopathy as it has different
therapeutic implications during perioperative period.[2]
Fig. 1 (A–C) CT brain axial view showing subdural/subarachnoid/parenchymal/intraventricular bleeds
in bilateral (left > right) temporoparietal region as pointed by different colored
arrows. No evidence of fracture (D) in coronal section. (E and F) CT angiogram revealing no abnormality.
Context
Multiplanar intracranial bleeds in the setting of trivial trauma is exceedingly rare
and occurrence of which should prompt the clinician to suspect underlying systemic
coagulopathy that may have different therapeutic implications during perioperative
period.
