Intracranial haematomas following bone marrow transplantation

Summary:Autopsy files of 180 patients were reviewed, who died after BMT between July 1987 and June 1998 and 58 (32.2%) cases, who had experienced intracranial hemorrhage (ICH) were selected. Age, sex, underlying disease, preparatory regimens, immunoprophylaxis, chronic and acute GVHD, survival of the patients and localization and size of hemorrhages were evaluated. There were 33 males and 25 females, with a mean age of 23.4 years. The main underlying disorders for which BMT was performed included SAA (n = 21), CML (n = 13) and AML (n = 10). Forty patients were found to have intraparenchymal hemorrhage, 35 had subarachnoid hemorrhage and eight patients had subdural hemorrhage. In 16 cases the CNS hemorrhage was so extensive that it was considered to be the main cause of death. There was no significant statistical difference concerning sex (P = 0.217), age (P = 0.296), underlying disease (P = 0.352), preparatory regimens (P = 0.07), immunoprophylaxis (P = 0.914), chronic and acute graft-versus-host disease (P = 0.107 and P = 0.631, respectively) and survival (P = 0.701) when comparing patients with or without ICH. However, the number of cases in which the CNS was defined as the main cause of death was higher among patients with ICH than in patients without ICH (n = 16 vs 15) (P = 0.011). We conclude that ICH is common and has a significant mortality rate following BMT. Bone Marrow Transplantation (2002) 29, 29-32. DOI: 10.1038/sj/bmt/1703315 Keywords: bone marrow transplantation; central nervous system; cerebrovascular diseases; hemorrhage Bone marrow transplantation (BMT) has significantly contributed to the therapy of life-threatening hematological and non-hematological disorders. However, the central nervous

Section: Discussionmentioning

confidence: 95%

Intracranial hemorrhage following bone marrow transplantation: an autopsy study of 58 patients

Bleggi-Torres

Werner

Gasparetto

et al. 2002

“…1 This may be due to several factors, such as malignancy, thrombocytopenia, heparin treatment and intrathecal treatment. It is difficult to say which risk factors are of importance, because SDH is a rare event.…”

Section: Discussionmentioning

confidence: 99%

“…However, they are more common in patients with leukaemia and after haematopoietic stem cell transplantation (HSCT). 1 The reported incidences of SDH vary depending on the diagnosis and treatment. [2][3][4] Post-puncture headache has been said to be caused by cerebrospinal fluid leakage, followed by decreased intracranial pressure, leading to traction of pain-sensitive vessels that also may rupture.…”

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confidence: 99%

Bilateral subdural haematomas following lumbar puncture in three haematopoietic stem cell transplant recipients

Hentschke

Hägglund

Mattsson

et al. 1999

Summary:Between 1990 and 1996, three patients (1.1%), all with CML, among 272 patients with haematological malignancies, developed bilateral subdural haematomas (SDH) after treatment with i.t. MTX before HSCT in our unit. Since October 1996, we have given i.t. MTX only to patients at increased risk of CNS leukaemia such as ALL and AML M4 or M5. We suggest that intrathecal treatment before HSCT should only be given to patients at increased risk of CNS leukaemia. Keywords: bone marrow transplantation; methotrexate; lumbar puncture; subdural haematoma; CML Subdural haematomas have been observed after dural puncture and are normally a rare complication. However, they are more common in patients with leukaemia and after haematopoietic stem cell transplantation (HSCT). 1 The reported incidences of SDH vary depending on the diagnosis and treatment. [2][3][4] Post-puncture headache has been said to be caused by cerebrospinal fluid leakage, followed by decreased intracranial pressure, leading to traction of pain-sensitive vessels that also may rupture. 5 Post-puncture headache that does not disappear is therefore an indication for computerized tomography (CT). Treatment for SDH may be conservative but surgical drainage is often necessary. 6 Patients, methods and resultsTwo of three patients with CML underwent conditioning with CY 60 mg/kg i.v. once daily for 2 days and TBI 10 Gy (9 Gy to the lungs). One patient received BU 4 mg/kg p.o. in divided doses daily for 4 days and CY 60 mg/kg i.v. once daily for 2 days. 7 GVHD prophylaxis consisted of CYA, in combination with MTX. 8 Two patients were also treated with heparin 100 U/kg/day from day −4 as Correspondence: Dr P Hentschke, Centre for Allogeneic Stem Cell Transplantation, Huddinge Hospital, B56, SE-141 86 Huddinge, Sweden Received 27 November 1998; accepted 13 May 1999 VOD prophylaxis. 9 Intrathecal MTX was given on day −2 to one patient, on days −9 and −2 to one patient and on day −9 to another patient. Post-puncture headache developed immediately after i.t. MTX in all patients. Bilateral subdural haematomas were diagnosed by CT between days +11 and +27 after HSCT. Surgical drainage was performed in all three patients and two patients are alive and well 8. and 3 years after HSCT, respectively. One patient died of liver failure 5 months after HSCT. Case 1A 34-year-old male with CML underwent BMT from an HLA-identical brother in October 1990 after treatment with BU and CY. I.t. MTX was given on day −2 before BMT and was followed by the immediate onset of headache that resolved spontaneously. At this time, his platelet count was 100 ϫ 10 9 /l, prothrombin time and partial thromboplastin time were normal. Ten days after HSCT, he again developed a bilateral frontal headache which was different from the initial headache. His platelet count at this time was 10 ϫ 10 9 /l. Five days later, he complained of nausea and vomiting and became somnolent. CT on day +20 revealed bilateral SDH about 1 cm wide on the left side and 0.5 cm on the right side with slight displacement of the...

“…Other reports associated intracranial hemorrhage with thrombocytopenia. 19,20 It is possible that rare, but serious complications are more common with low platelet counts. In our study, samples of both pulmonary and intracranial hemorrhage (on the first bleeding day) were small.…”

Section: Tablementioning

confidence: 99%

“…In 24 patients who bled they identified 'high platelet consumption factors' (eg disseminated intravascular coagulation, fever, sepsis, veno-occlusive disease of the liver, mucositis) as associated risk factors for bleeding. Thrombocytopenia was significantly associated with intracranial hemorrhage after BMT, 19,20 but many reports on bleeding from other sites (gastrointestinal hemorrhage, hemorrhagic cystitis, pulmonary hemorrhage) have not identified thrombocytopenia as a main cause of bleeding, implicating other etiologies (eg preparative regimen toxicity, infections, graft-vs-host disease). [21][22][23][24][25][26][27][28][29][30][31][32] We have previously studied 1402 patients for bleeding complications within 100 days after BMT.…”

mentioning

confidence: 99%

Acute bleeding and thrombocytopenia after bone marrow transplantation

Nevo¹,

Enger²,

Hartley³

et al. 2001

Summary:The relationship between hemorrhage and low platelet count was first established in patients with acute leukemia, and has been widely applied to thrombocytopenic patients, including BMT patients. Yet, the role of thrombocytopenia in bleeding post BMT has not been systematically studied. We evaluated the risk of bleeding and outcome associated with thrombocytopenia in BMT patients who had prophylactic platelet transfusions at a trigger of 20 × 10 9 /l. Thrombocytopenia was investigated in 321 patients with moderate or severe bleeding (BLD), and in a matched comparison group of 287 patients who did not bleed (NBLD). Profound thrombocytopenia (р10 × 10 9 /l) was found in 8.6% of the BLD patients during the week before the bleeding onset, significantly more frequent than in NBLD patients (2.1% to 4%, P Ͻ 0.02), during weeks 2 to 6 post BMT (the period when 75% of the bleeding initiated). On the first day of bleeding, platelet counts Յ10 × 10 9 /l were found in 13.5%, 11-20 × 10 9 /l in 20.4%, and Ͼ20 × 10 9 /l in 66.1% of all episodes. Overall survival in BLD patients was not associated with the severity of thrombocytopenia before bleeding onset. Severity of thrombocytopenia was significantly associated with reduced survival in NBLD patients. We concluded that bleeding post BMT was significantly associated with thrombocytopenia, but the attributable risk of bleeding from profound thrombocytopenia was not large. Thrombocytopenia may be an important clinical sign in NBLD patients, and should be further explored in relation to acute toxicities other than bleeding. Bone Marrow Transplantation (2001) 27, 65-72.