Comment on "A rare case of Wilson disease associated with intracerebral hemorrhage".

The case reported by Singh et al. [1] describing a rare case of Wilson’s disease with intracranial hemorrhage (ICH), which concluded that penicillamine administration in this particular patient may have caused bone marrow suppression and low platelet count was very interesting. Bone marrow suppression and thrombocytopenia are known complications of penicillamine use reported in up to 10% of cases [2] that can cause bleeding, including ICH. However, the level of coagulopathy based on laboratory parameters (platelet count: 43 × 109/L, international normalized ratio [INR]: 1.65) was not severe enough to have caused massive bleeding leading to intraventricular extension in a patient with cirrhosis [3].

The authors have also commented that marijuana users are more likely to have ICH. The patient being an alcohol user as well could have had inadvertent head injuries [4]. Although not independent predictors of ICH, marijuana and alcohol use are more likely to cause ICH.

Additionally, we would like to point out that in a young patient presenting with ICH, a search for an intracranial aneurysm should have been considered and cerebral angiography could have been performed.

It is also our observation that the trigger for transfusion was the absolute levels of platelets and INR in the presence of an intracranial bleed in a patient with cirrhosis. However, the current practice is to transfuse products based on viscoelastic hemostatic assays such as TEG or ROTEM, as such patients could be in a procoagulant state despite the deranged coagulation parameters [5].