Subdural Hematoma during Allogeneic Bone Marrow Transplantation for Chronic Myelogenous Leukemia

Hideki Akiyama, MD, PhD, Tokyo Metropolitan Komagome Hospital, 3-18-22, Honkomagome, Bunkyoku, Tokyo, 113 (Japan) Chronic subdural hematoma has been reported as one of the complications of childhood acute lymphocytic leukemia (ALL), acute promyelocytic leukemia (APL) and chronic myelogenous leukemia (CML) in the blastic phase [1-4]. We report a case with CML who developed subdural hematoma during bone marrow transplantation (BMT). A 24-year-old male was diagnosed as having Philadelphia-chromosome-positive CML in 1989. After having been treated with α interferon and hydroxyurea for 2 years, he underwent allogeneic BMT in June 1991 using busulfan and cyclophosphamide as a preparative regimen. The last preoperative bone marrow examination was performed on day -12 of BMT which revealed less than 2% of blasts and promyelocytes. Intrathecal treatment with methotrexate and cytosine arabinoside was performed on day -11 of BMT with normal findings of cerebrospinal fluid. Phenytoin had also been used as prophylaxis for neurological toxicity of busulfan. On the second day of busulfan, day -6 of BMT, he started to complain of headache on his forehead. Neurological examination was normal, and CT scanning of the whole brain performed on the same day did not show any abnormalities (fig. la). His serum level of phenytoin was within normal limits, and so were the coagulation studies. Because his symptoms seemed to be subsiding, he underwent BMT as scheduled. The post-BMT hospital course was unremarkable except for an episode of fever, which responded to antibiotics, and the exacerbating headache which restarted on day 1 without any history of head injury. Multiple neurological examinations including the examinations of his optic fundi had been persistently normal. His platelet counts had been maintained above 20 × 109/1 during the whole course of the BMT, and the coagulation studies also remained normal. A repeated CT scan of the brain was obtained on day 17 after the engraft -ment of the bone marrow had been confirmed, which revealed bilateral diffuse subdural hematoma and brain edema (fig. lb). Because of the low platelet and the neutrophil counts, he was followed with medical treatment and then underwent a drainage operation of the bilateral subdural hematoma on day 34. His