Morden Frances Tiffany Cava, Caballero Clark Gianni, Abella Maveric, Conching Andie, Gang Hannah, Noh Thomas
Division of Neurological Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States.
Surg Neurol Int. 2023 Jun 30;14:223. doi: 10.25259/SNI_1051_2022. eCollection 2023.
Surgical decompression for the treatment of chronic subdural hematomas (cSDHs) is irrefutably effective; however, its utility in managing cSDH in patients with comorbid coagulopathy remains controversial. The optimal threshold for platelet transfusion in cSDH management is <100,000/mm, according to guidelines from the American Association of Blood Banks GRADE framework. This threshold may be unachievable in refractory thrombocytopenia, though surgical intervention may still be warranted. We present a patient with symptomatic cSDH and transfusion-refractory thrombocytopenia successfully treated with middle meningeal artery embolization (eMMA). We also review the literature to identify management approaches for cSDH with severe thrombocytopenia.
A 74-year-old male with acute myeloid leukemia presented to the emergency department with persistent headache and emesis following fall without head trauma. Computed tomography (CT) revealed a 12 mm right-sided, mixed density SDH. Platelets were <2000/mm initially, which stabilized to 20,000 following platelet transfusions. He then underwent right eMMA without surgical evacuation. He received intermittent platelet transfusions with platelet goal >20,000 and was discharged on hospital day 24 with resolving SDH on CT.
High-risk surgical patients with refractory thrombocytopenia and symptomatic cSDH may be successfully treated with eMMA without surgical evacuation. A platelet goal of 20,000/mm before and following surgical intervention proved beneficial for our patient. Similarly, a literature review of seven cases of cSDH with comorbid thrombocytopenia revealed five patients undergoing surgical evacuation following initial medical management. Three cases reported a platelet goal of 20,000. All seven cases resulted in stable or resolving SDH with platelets >20,000 at discharge.
手术减压治疗慢性硬膜下血肿（cSDH）的有效性无可争议；然而，其在合并凝血功能障碍患者中治疗cSDH的效用仍存在争议。根据美国血库协会GRADE框架指南，cSDH管理中血小板输注的最佳阈值是<100,000/mm³。不过，在难治性血小板减少症中可能无法达到这个阈值，尽管仍可能需要进行手术干预。我们报告了一名有症状的cSDH和输血难治性血小板减少症患者，成功接受了脑膜中动脉栓塞术（eMMA）治疗。我们还回顾了文献，以确定严重血小板减少症患者cSDH的管理方法。
一名74岁急性髓系白血病男性因跌倒后无头部外伤但持续头痛和呕吐就诊于急诊科。计算机断层扫描（CT）显示右侧有一个12毫米的混合密度硬膜下血肿。最初血小板计数<2000/mm³，输注血小板后稳定在20,000/mm³。然后他接受了右侧eMMA，未进行手术引流。他接受了间歇性血小板输注，血小板目标>20,000/mm³，在住院第24天出院，CT显示硬膜下血肿消退。
难治性血小板减少症且有症状的cSDH高危手术患者可通过eMMA成功治疗，无需手术引流。手术干预前后血小板目标为20,000/mm³对我们的患者有益。同样，对7例合并血小板减少症的cSDH病例的文献回顾显示，5例患者在初始药物治疗后接受了手术引流。3例报告血小板目标为20,000/mm³。所有7例病例均导致硬膜下血肿稳定或消退，出院时血小板>20,000/mm³。
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