Perimesencephalic Subarachnoid Hemorrhage Presenting with Headache and Ocular Hemorrhage in a Patient with Chemotherapy-induced Severe Thrombocytopenia

A 26-year-old female with severe thrombocytopenia (platelet count <20,000/μL) following combination chemotherapy (cisplatin, paclitaxel, pembrolizumab, and bevacizumab) for cervical cancer presented with new-onset headache and ocular hemorrhage. Perimesencephalic subarachnoid hemorrhage (pmSAH) was identified, which was subsequently complicated by disproportionate cerebral vasospasm and transient oculomotor nerve palsy. This case demonstrates that pmSAH, which is generally considered a benign venous hemorrhage, can follow an unusual course in the setting of profound bleeding diathesis and chemotherapy-induced vascular injury.