HELLP Syndrome with Spontaneous subdural haematoma and intracerebral haemorrhage

A 32-year old primigravida,with prolonged labour and fetal distress, fell unconscious during labour.

Refereed to our neuro institute for further investigation and management. 

No history of trauma. 

On admission MRI Brain shows:

Left fronto parietal subdural haematoma with max with 13mm, T1 bright signals of hematoma attributed to Meth Hb – a sub acute stage blood degradation product.

An associated left frontal intracerebral hematoma. 

Significant mass effect, mid line shift with internal herniation. 

MR Angiography of Brain normal. No obvious aneurysm. 

No abnormal adjacent T2 flow voids to suggest any vascular malformation.

MR Venography of Brain normal, particularly superior sagittal sinus. 

No obvious cortical vein thrombosis on GRE. 

Patient underwent emergency decompressive craniotomy.

Follow up CT shows:

Left anterior craniotomy with evacuation of left fronto parietal subdural hematoma and left frontal intra parenchymal bleed.
Complete reversal of mass effect and mid line shift. No mid brain compression.
Bilateral frontal subdural pneumocephalus noted, which also regressed on subsequent follow studies. 

Patient is clinically improving, residual right hemiparesis. 

During this a diagnosis of HELLP syndrome with Disseminated Intravascular Coagulation (DIC) was made, as her Platelet count was 50,000/μL (low), e/o hemolysis on peripheral blood smear with Serum lactate dehydrogenase : 800 IU/L (Abnormal) and Serum aspartate aminotransferase : 80 IU/L (Abnormal)

HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome can result in a fatal intracranial haemorrhage during the perinatal period. 

Patients with HELLP syndrome should be managed as high-risk, which requires an excellent working relationship of the physicians involved. Prompt recognition of intracranial haemorrhagic complications and neurosurgical intervention are particularly important.