Decision-making for emergency craniotomy in traumatic intracranial hemorrhage with severe thrombocytopenia and coagulopathy in a patient with suspected acute leukemia: A case-based review

Background: Emergency craniotomy for traumatic intracranial hemorrhage is time-dependent, yet surgery may be futile when profound thrombocytopenia and coagulopathy prevent hemostasis and severe brain swelling is already present. Case Description: A young adult man with traumatic intracranial hemorrhage rapidly deteriorated to coma (Glasgow coma scale-3). Admission laboratories showed white blood cell count 72,300/µL, platelet count 12,000/µL, and prothrombin time-international normalized ratio 1.59, raising concern for an underlying hematologic disorder, including acute leukemia, with coagulopathy. Head computed tomography demonstrated a large frontal intraparenchymal hemorrhage with traumatic subarachnoid hemorrhage, intraventricular extension, and imaging features consistent with severe diffuse brain swelling. After intubation, emergency craniotomy was undertaken with perioperative transfusion of red blood cells, fresh frozen plasma, and platelets. Diffuse bleeding and marked brain swelling prevented durable hemostasis, and the patient died. Conclusion: When neurotrauma meets hematologic catastrophe, the decision to operate should incorporate both neurologic salvageability and the realistic probability of achieving usable hemostasis within the available time. Early estimation of attainable platelet correction, together with rapid coagulation assessment including fibrinogen when available, parallel hematology support, and a damage-control operative plan with pre-specified stopping rules may help frame surgery as a time-limited trial rather than a binary choice.