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Footprints of coagulopathy
  1. R D Ecker,
  2. E F M Wijdicks
  1. Departments of Neurosurgery and Neurology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
  1. Correspondence to:
 Dr R D Ecker, MD, Department of Neurological Surgery, Joseph 1–229, St. Mary’s Hospital, 1216 Second Street, SW, Rochester, MN 55905, USA;
 ecker.robert{at}mayo.edu

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A 68 year old man with chronic atrial fibrillation and a St Jude valve in mitral position discontinued warfarin several days prior to a coronary angiogram. Forty eight hours after restarting his warfarin, while also on low molecular weight heparin and aspirin, he developed an acute motor aphasia and right hemiparesis. Computerised tomography (CT) in the emergency room revealed a large left frontal haemorrhage with multiple fluid blood levels (Fig 1). His INR was 2.4 on admission. Worsening in consciousness prompted emergent evacuation of the haematoma. Three months post-operatively he had only trace right sided weakness.

On CT, fluid blood levels in acute cerebral haematoma have a 59% sensitivity and 98% specificity for indicating underlying coagulopathy.1 The sharply demarcated interface represents a boundary between plasma and sedimented blood.2 Although all patients with intracerebral haemorrhage should routinely have PT, PTT, and platelet count performed, the fluid blood level on head CT may denote bleeding dyscrasias as the aetiology of haemorrhage. In fact, the CT scan may be available before the laboratory values return.

Figure 1

Sequential axial non-contrasted computerised tomography scans of the head demonstrating a large left frontal haemorrhage with multiple fluid blood levels and intraventricular extension.

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