Subdural hematoma (SDH) usually occurs secondary to trauma, in bleeding disorders it may occur spontaneously. It is a rare complication of immune thrombocytopenia. Here we report a case of 45 years female presenting with presenting with complaints of headache, palpitation and menorrhagia and later diagnosed to be a case of Grave's disease with thrombocytopenia with sub dural hematoma. No such case reports are available in literature

Chandek, S

Diwan, S

Kakani, A

Kumar, S

Nitey, PO

English

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Subdural Hematoma in Grave’s Disease Induced Thrombocytopenia.

Sunil Kumar

Sanjay Diwan

Shailee Chandek

Pratik Nitey

Anand Kakani

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 1 
 
  
 
 
Case Report: 
Subdural Hematoma in Grave’s Disease Induced Thrombocytopenia. 
 
Authors 
Sunil Kumar, Associate Professor, Department of Medicine, 
Sanjay Diwan, Professor, Department of Medicine, 
Shailee Chandek, Resident, Department of Medicine, 
Pratik Nitey, Resident, Department of Medicine, 
Anand Kakani, Professor, Department of Neurosurgery, 
Jawahar Lal Nehru Medical College, DMIMSU, Sawangi, Wardha, India. 
 
Address for Correspondence 
Dr. Sunil Kumar, 
Associate Professor, 
Department of Medicine, 
DMIMS, Sawangi, 
Wardha, India. 
E-mail: sunilkumarmed@gmail.com 
 
Citation 
Kumar S, Diwan S, Chandek S, Nitey PO, Kakani A. Subdural Hematoma in Grave’s Disease Induced Thrombocytopenia. Online J 
Health Allied Scs.2012;11(4):17. Available at URL: http://www.ojhas.org/issue44/2012-4-17.html 
 
Open Access Archives 
http://cogprints.org/view/subjects/OJHAS.html 
http://openmed.nic.in/view/subjects/ojhas.html 
 
Submitted: Nov 3, 2012; Accepted: Jan 6, 2013; Published: Jan 25, 2013 
 
Abstract: Subdural hematoma (SDH) usually occurs 
secondary to trauma, in bleeding disorders it may occur 
spontaneously. It is a rare complication of immune 
thrombocytopenia. Here we report a case of 45 years female 
presenting with presenting with complaints of headache, 
palpitation and menorrhagia and later diagnosed to be a case 
of Grave’s disease with thrombocytopenia with sub dural 
hematoma. No such case reports are available in literature. 
Key Words: Subdural hematoma; Thrombocytopenia; 
Hyperthyroidism; Graves disease. 
Introduction 
Subdural hematoma (SDH) usually occurs secondary to 
trauma, in bleeding disorders it may occur spontaneously. It 
is a rare complication of immune thrombocytopenia.1 Mild 
thrombocytopenia is frequently observed in patients with 
Graves’disease.2 It is estimated that there is Graves disease in 
8-14% of the patients with idiopathic thrombocytopenic 
purpura and 43% of the untreated hyperthyroid cases have 
platelet count below 150.000/cumm.3 Here we report a case 
of 45 years female presenting with complaints of headache, 
palpitation and oligomenorrhoea and later diagnosed to be a 
case of graves disease with thrombocytopenia with sub dural 
hematoma. No such case reports are available in literature. 
Case Report 
A 45 years old female presented in medicine out patient 
department of this hospital with complaints of headache since 
3 months, palpitation since 2 months and irregular 
menstruation since 4 cycles. Headache was intermittent, right 
sided, throbbing type associated with episodes of vomiting. 
She also had significant weight loss since 5-6 months. On 
history, patient also complains of diplopia since 15 days. 
There was no history of hypertension, diabetes mellitus, and 
pulmonary tuberculosis. On examination her pulse was 
130bpm regular and blood pressure of 126/70mm Hg. She 
had diffuse swelling in neck region. Her investigation 
revealed hemoglobin 7.6gm/dL, with peripheral smear 
suggestive of normocytic normochromic red blood cells and 
absolute platelet count of 29000/cumm. Her thyroid profile 
was free T3 517ng/dL, free T4 >13µg/dL and TSH 
0.13µiu/ml. Fine needle aspiration cytology from thyroid was 
suggestive of nodular goitre. Her thyroid peroxidase antibody 
(TPO) was > 600, suggestive of Grave’s disease. Her fundus 
examination revealed early papilloedema. Her MRI brain 
revealed subdural bleed extending from high parietal to 
occipital region in different stages more on right side with 
mild cerebral edema (Figure 1). Patient was taken for right 
fronto-parietal burr hole and about 50cc of altered coloured 
liquefied blood drained from sub dural space. She was given 
Mannitol and injection Dexamethasone. She was put on 
Carbimazole 40mg once a day and Propranolol 40mg once a 
day. Patient responded to treatment and the platelet count 
increased to 2.8lacs/cumm. The final diagnosis was Grave’s 
disease with anaemia and autoimmune thrombocytopenia. 
She responded well to treatment and doing well on follow up. 
 
Figure 1: MRI brain showing subdural bleed extending 
from high parietal to occipital region with mild cerebral 
edema 
 
This work is licensed under a 
Creative Commons Attribution- 
No Derivative Works 2.5 India License 
Online Journal of Health and Allied Sciences 
Peer Reviewed, Open Access, Free Online Journal 
Published Quarterly :  Mangalore, South India : ISSN 0972-5997 
Volume 11, Issue 4; Oct-Dec 2012 
 2 
 
Discussion 
Association between hyperthyroidism particularly 
autoimmune thyroid disorder like grave’s disease and 
thrombocytopenia is uncommon but well known 
entity.2 Several mechanisms have been described to explain 
thrombocytopenia in hyperthyroidism. There may be shorter 
life span and increased platelet turnover during the 
hypermetabolic state due to increased splenic clearance and 
reticuloendothelial phagocytic activity.4,5 An immunologic 
phenomenon is another mechanism to explain 
thrombocytopenia in hyperthyroidism, particulary in 
autoimmune thyroid disease. Platelet autoantibodies or anti-
platelet immunoglobulin G was observed in 83% of 
thrombocytopenic patients who also had Graves’ and 
Hashimoto’s thyroiditis. Among those with autoimmune 
thyroid disease without thrombocytopenia, platelet antibodies 
were seen in 10%. The autoantibodies demonstrated included 
platelet-associated immunoglobulin G (PAIg) and platelet 
autoantibodies IgG directed against glycoprotein Ib and 
glycoprotein IIb/IIIa located on the platelet surface.6 In our 
case, a high level of TPO suggested the diagnosis of Grave’s 
disease and thrombocytopenia was probably immunological, 
as it responded with carbimazole. Platelet-specific 
immunoglobulin was not measured due to non affordability. 
Its value in diagnosis is, however, limited due to the low 
sensitivity and specificity of the tests.7 If the platelet count 
decreases to less than 20,000/μl, Intracerebral haematoma or 
subarachnoid haemorrhage is more frequently reported. 
Subdural haematoma usually occurs as an extension of a 
parenchymal bleed. Isolated subdural haematoma is an 
extremely rare entity in immune thrombocytopenia. So far, 
only very few cases have been reported in the 
literature.1,8,9 The basic pathology in thrombocytopenia is 
proposed to be capillary leak and this may become confluent 
in severe cases, leading to frank intracerebral haematoma. 
Because of the absence of associated parenchymal injury, the 
outcome may be better in non-traumatic subdural 
haematoma. For the same size of subdural haematoma, 
chances of complications like brain oedema and herniation 
may be less in non-traumatic SDH. However in this case 
there was papilloedema which may be due to brain edema 
and increased intracranial pressure thus necessitating 
neurosurgical intervention. 
 
Conclusion 
An association between thrombocytopenia and 
hyperthyroidism/Grave’s disease exists. Platelet 
abnormalities can be a direct effect of a hypermetabolic state 
or due to an autoimmune process similar to autoimmune 
thyroid disease. Resolution of thrombocytopenia occurs with 
normalization of thyroid functions. Subdural hematoma may 
be the cause of headache in some cases of Grave’s disease.  
 
References 
1. Sreedharan PS, Rakesh S, Sajeev S, Pavithran K, 
Thomas M. Subdural haematoma with spontaneous 
resolution—rare manifestation of idiopathic 
thrombocytopenic purpura. J Assoc Physicians India 
2000;48:432-434. 
2. Brent GA. Graves’ disease. N Engl J Med 
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3. Liechty RD. The thyrotoxicosis-thrombocytopenia 
connection. Surgery 1983;94:966-968. 
4. Cheung E, Liebman HA. Thyroid disease in patients 
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5. Gill H, Hwang YY, Tse E. Primary immune 
thrombocytopenia responding to antithyroid treatment 
in a patient with Graves’ disease. Ann Hematol 
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6. Cordiano I, Betterle C, Spadaccino CA, Soini B, 
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7. Konkle BA. Disorders of the platelets and vessel wall. 
In: Longo DL, Fauci AS, Kasper DL, Hauser SL, 
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medicine,18th edn. New York: McGraw-Hill Inc, 2012. 
p. 968. 
8. Seçkin H, Kazanci A, Yigitkanli K, Simsek S, Kars HZ. 
Chronic subdural haematoma in patients with idiopathic 
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the literature. Surg Neurol. 2006;66:411–414. 
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Subdural Hematoma in Grave’s Disease Induced Thrombocytopenia.

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