Patil Shashikant, Nourbakhsh Ali, Thakur Jai Deep, Khan Imad Saeed, Guthikonda Bharat
Louisiana State University Health Science Center, Department of Neurosurgery, Shreveport, USA.
Turk Neurosurg. 2013;23(4):568-71. doi: 10.5137/1019-5149.JTN.5831-12.0.
Hemorrhagic complications of acute leukemia are well described and are a common cause of mortality in these patients. However, to our knowledge, fatal intracerebral hemorrhage (ICH) as an initial presentation of acute lymphocytic leukemia (ALL) has only been reported once. We report a case of previously undiagnosed ALL presenting with ICH. Our patient is a 17-year old male who was found unresponsive several hours after complaining of headache. Initial emergency room evaluation found the patient to have anisocoria with a fixed and dilated right pupil and demonstrated evidence of decorticate posturing. Imaging revealed a large right-sided intraparenchymal hemorrhage, intraventricular hemorrhage, midline shift, and uncal herniation. Laboratory evaluation showed marked leukocytosis with blastic predominance and evidence of disseminated intravascular coagulopathy. Emergent surgical intervention was performed. However, despite evacuation of the hematoma, the patient eventually progressed to clinical brain death. Usually, ICH is seen in ALL patients after the diagnosis has been made. We report a unique case of fatal intracranial hemorrhage as the initial presentation of ALL and discuss the possible management dilemmas to treat such entities. ALL should be kept in the broad differential diagnosis of spontaneous ICH, especially in a young patient with evidence of severe coagulopathy.
急性白血病的出血并发症已有详尽描述，是这些患者常见的死亡原因。然而，据我们所知，致命性脑出血（ICH）作为急性淋巴细胞白血病（ALL）的首发表现仅被报道过一次。我们报告一例以ICH为首发表现的既往未确诊ALL病例。我们的患者是一名17岁男性，在主诉头痛数小时后被发现无反应。急诊室初步评估发现患者存在瞳孔不等大，右侧瞳孔固定散大，并表现出去皮层姿势的迹象。影像学检查显示右侧脑实质内大量出血、脑室内出血、中线移位和钩回疝。实验室检查显示白细胞显著增多，以原始细胞为主，并存在弥散性血管内凝血的证据。进行了紧急手术干预。然而，尽管清除了血肿，患者最终仍进展为临床脑死亡。通常，ICH见于已确诊ALL的患者。我们报告了一例独特的病例，即致命性颅内出血作为ALL的首发表现，并讨论了治疗此类病例可能面临的管理困境。ALL应纳入自发性ICH的广泛鉴别诊断中，尤其是在有严重凝血功能障碍证据的年轻患者中。
