What labs and studies should be ordered for a patient presenting with recurrent ecchymosis (bruising) and headache?

Diagnostic Workup for Recurrent Ecchymosis and Headache

For a patient presenting with recurrent ecchymosis (bruising) and headache, a comprehensive laboratory and imaging workup should include complete blood count with platelets, coagulation studies, inflammatory markers, and brain imaging to rule out intracranial pathology.

Initial Laboratory Evaluation

Hematologic Workup

• Complete blood count (CBC) including platelets to evaluate for thrombocytopenia or anemia 1
• Coagulation studies including:
  • Prothrombin time (PT) with international normalized ratio (INR) 1
  • Activated partial thromboplastin time (aPTT) 1
  • Fibrinogen levels 1
  • Advanced coagulation tests if initial studies are abnormal or clinical suspicion is high:
    • Factor VIII and IX levels 1
    • von Willebrand activity 1
    • Factor XI and XIII levels in selected cases 1

Inflammatory and Biochemical Markers

• C-reactive protein (CRP) 1
• Erythrocyte sedimentation rate (ESR) 1
• Liver function tests (AST, ALT, bilirubin) 1
• Renal function tests (BUN, creatinine, eGFR) 1
• Glucose 1
• Cardiac troponin and ECG (to evaluate for cardiac involvement) 1

Additional Laboratory Tests

• Toxicology screen (to rule out substance-induced causes) 1
• Urinalysis (to evaluate for renal involvement) 1
• Serum calcium, phosphorus, and alkaline phosphatase (if bone metabolism disorders are suspected) 1

Imaging Studies

Brain Imaging

• MRI of the brain with and without contrast is the preferred initial imaging study for patients with headache and unexplained ecchymosis 1

  • This can detect potential causes such as:
    • Cerebral venous thrombosis 1
    • Intracranial hypotension 1
    • Subdural hematoma 2
    • Brain tumors 1

• If MRI is not immediately available and symptoms are concerning:

  • Non-contrast CT of the head should be performed 1
  • Consider CT venography if there is concern for venous sinus thrombosis 1

Additional Imaging Based on Clinical Findings

• MR venography (MRV) if cerebral venous thrombosis is suspected 1
• MR angiography (MRA) if vascular abnormalities are suspected 1
• Spinal imaging if intracranial hypotension from CSF leak is suspected 1

Special Considerations

When to Suspect Intracranial Pathology

• Headache characteristics that warrant more urgent imaging:
  • New onset or change in pattern 1
  • Headache that worsens with Valsalva maneuver 1
  • Headache that awakens patient from sleep 1
  • Progressive worsening of headache 1
  • Thunderclap onset (suggests aneurysm or venous thrombosis) 1

When to Consider Rare Associations

• Recurrent facial ecchymosis with headache has been reported in case studies as a rare manifestation of primary headache disorders 3, 4, 5
• Consider skin biopsy of ecchymotic areas if vasculitis is suspected 3, 4

Medication and Supplement Review

• Evaluate for medications that affect coagulation:
  • Anticoagulants 1
  • Antiplatelet agents 1
  • NSAIDs 1
• Check for herbal supplements that may affect coagulation (e.g., Ginkgo biloba has been associated with subdural hematoma) 2

Clinical Pitfalls to Avoid

• Don't assume ecchymosis is always due to trauma; it can be a sign of underlying bleeding disorders or vascular abnormalities 6
• Don't miss the association between recurrent ecchymosis and intracranial pathology, particularly cerebral venous thrombosis 1
• Don't overlook the possibility of spontaneous intracranial hypotension, which can precipitate cerebral venous thrombosis 1
• Don't delay imaging in patients with concerning neurological symptoms accompanying headache and ecchymosis 1
• Don't forget to consider child physical abuse in pediatric cases with unexplained bruising and headache 1