Life-threatening intraparenchymal hematoma due to immune thrombocytopenic purpura: illustrative case.

backgroundLife-threatening intraparenchymal hematoma (IPH) is an uncommon yet challenging complication of immune thrombocytopenia (ITP) in adults. OBSERVATIONS: A 26-year-old man with a history of medically refractory chronic ITP experienced abrupt neurological deterioration due to a large left frontal IPH. His platelet count was 8 × 103/μL. Following the administration of high-dose dexamethasone, intravenous immunoglobulin (IVIG), and platelet transfusions, an emergency craniotomy and hematoma evacuation were performed. After surgery, the patient regained consciousness, and his platelet levels initially improved. The patient was advised to undergo an elective splenectomy within a week as a definitive measure for ITP; however, his platelet count dropped to 9 × 103/μL by day 6 postsurgery. An urgent splenectomy was performed, resulting in an immediate as well as long-term improvement in platelet count. LESSONS: This case highlights critical lessons in the management of IPH secondary to ITP. In the event of life-threatening IPH, emergency craniotomy and hematoma evacuation are necessary. Platelet support is achieved through transfusion, IVIG, and steroids. Splenectomy should be performed as soon as feasible following the evacuation of a hematoma to prevent the recurrence of thrombocytopenia, which may result in rebleeding. Collaboration among neurosurgeons, hematologists, and intensivists is key to a satisfactory outcome. https://thejns.org/doi/10.3171/CASE25394.