Management of Basal Ganglia Hemorrhage with Severe Thrombocytosis
Immediate Clarification and Management
This patient has severe thrombocytosis (platelet count 13 lacs = 1,300,000/μL), NOT thrombocytopenia, which fundamentally changes the management approach for intracranial hemorrhage.
Critical First Steps
Immediately discontinue any antiplatelet agents (aspirin, clopidogrel, NSAIDs) if the patient is taking them, as these exacerbate bleeding risk in the setting of both thrombocytosis and active intracranial hemorrhage 1
Obtain urgent neurosurgical consultation for evaluation of the basal ganglia bleed, as surgical intervention may be needed depending on hematoma size, mass effect, and neurological deterioration 1
Admit to intensive care unit for close neurological monitoring and blood pressure control, as intracranial hemorrhage requires intensive management regardless of platelet count 2
Platelet-Lowering Therapy
Initiate cytoreductive therapy urgently to lower the platelet count below 600,000/μL, as extreme thrombocytosis (>1,000/μL) paradoxically increases bleeding risk due to acquired von Willebrand syndrome 1
Hydroxyurea is the first-line agent for rapid platelet reduction in this emergency setting, typically started at 15-20 mg/kg/day, as it can begin lowering counts within 48-72 hours 1
Consider plateletpheresis if the patient has progressive neurological deterioration or expanding hematoma, as this provides the most rapid platelet reduction (can lower count by 30-50% within hours) while cytoreductive therapy takes effect 1
Blood Pressure Management
Target systolic blood pressure <140 mmHg (or even <130 mmHg in the first 24 hours if tolerated) to minimize hematoma expansion, using IV agents like nicardipine or labetalol for precise control 1
Avoid excessive blood pressure lowering below systolic 120 mmHg, as this may compromise cerebral perfusion in the setting of increased intracranial pressure 1
Diagnostic Workup
Obtain urgent CT head without contrast to assess hematoma size, location, mass effect, and presence of intraventricular extension 1
Perform complete blood count with peripheral smear to confirm platelet count and evaluate for myeloproliferative neoplasm features (giant platelets, abnormal white cells) 1
Test for JAK2 V617F mutation, BCR-ABL, and MPL mutations to identify underlying myeloproliferative neoplasm (essential thrombocythemia, polycythemia vera, or chronic myeloid leukemia), as this guides long-term management 1
Measure von Willebrand factor activity and ristocetin cofactor if available, as these are often reduced in extreme thrombocytosis and explain the bleeding tendency 1
Common Pitfalls to Avoid
Do NOT give platelet transfusions - this would be catastrophic in a patient with thrombocytosis and would worsen both bleeding and thrombotic risk 3, 1
Do NOT use aspirin acutely - while aspirin is often used in myeloproliferative disorders to prevent thrombosis, it is absolutely contraindicated in the setting of active intracranial hemorrhage 1
Do NOT delay cytoreduction - waiting for definitive diagnosis of the myeloproliferative disorder before starting hydroxyurea can allow continued bleeding; start treatment immediately based on the extreme platelet count 1
Monitoring Parameters
Recheck platelet count daily until it falls below 600,000/μL, then every 2-3 days until stable 1
Repeat CT head at 24 hours or sooner if neurological status changes, to assess for hematoma expansion 1
Monitor neurological status hourly using Glasgow Coma Scale and focal neurological examination 1
Long-Term Management After Acute Phase
Continue hydroxyurea to maintain platelet count between 200,000-400,000/μL once the acute hemorrhage has stabilized 1
Consider low-dose aspirin (81 mg daily) only after complete resolution of the intracranial hemorrhage (typically 4-6 weeks minimum) and confirmation that platelet count is controlled, to prevent future thrombotic events 1
Refer to hematology-oncology for long-term management of the underlying myeloproliferative neoplasm 1