Diagnosis and management of subdural haematoma complicating bone marrow transplantation

[Prognostic analysis and predictive model construction of bleeding events in allogeneic hematopoietic stem cell transplant patients]

Objective: To study hematopoietic stem cell transplantation-related bleeding prognosis and construct a bleeding prediction model. Methods: The clinical data of 555 patients with malignant hematologic diseases who underwent allogeneic hematopoietic stem cell transplantation between May 1(st) 2004, and April 1(st) 2012 was analyzed retrospectively, and a prediction model was constructed. Results: Of the 555 patients, a total of 302 (54.0% ) patients exhibited bleeding events of varying degrees, including 151 (27.0% ) with grade Ⅰ bleeding, 63 (11.0% ) with grade Ⅱ bleeding, 48 (9.0% ) with grade Ⅲ bleeding, and 40 (7.0% ) with grade Ⅳ bleeding. Multifactorial analysis showed that the overall mortality (HR=12.53, 95% CI 7.91-19.87, P<0.001) and non-recurrence mortality (HR=23.79, 95% CI 12.23-46.26, P<0.001) were higher in patients with higher bleeding grades (Ⅲ and Ⅳ bleeding) compared to those with lower bleeding grades. Additionally, the donor's underlying disease, graft-versus-host disease (GVHD) score, poor platelet reconstitution, and ineffective platelet transfusion were independently associated with bleeding risk. The bleeding model constructed using the above variables showed good accuracy (C-Index=0.934) , and its efficacy was significantly higher than previous bleeding models. Conclusion: Hematopoietic stem cell transplant patients are at increased risk of death after a bleeding event. The cross-validated bleeding risk prediction model is valuable for early intervention.

Intracranial Hemorrhage Following Oral Low-Dose Methotrexate After Multiple Toxicities Caused by High-Dose Methotrexate in Childhood Acute Lymphoblastic Leukemia

An 11-year-old male patient with the deletion of IKZF1 (Ikaros family zinc finger 1) and positive Breakpoint Cluster Region-C-Abelson oncogene 1(BCR-ABL1) acute lymphoblastic leukemia developed mucositis, gastrointestinal toxicity, hepatotoxicity, myelosuppression, and severe dermatologic toxicity during the first and second courses of high-dose methotrexate. The patient recovered completely after therapy. However, intracranial hemorrhage (ICH) occurred following oral methotrexate at a dose of 25 mg/m² in maintenance treatment, and he had neurological sequelae including hemiplegic paralysis.

Cerebrovascular disease after allogeneic hematopoietic stem cell transplantation: incidence, risk, and clinical outcome

Cerebrovascular complications after hematopoietic stem cell transplantation (HSCT) cause serious morbidity and often contribute to mortality. The incidence, risk factors, and outcome of cerebrovascular disease (CVD) after allogeneic HSCT remain poorly defined. We retrospectively evaluated 459 adult patients who underwent allogeneic HSCT at a tertiary medical center between January 2003 and December 2015. A total of 20 patients (4.4%) developed post-transplant CVD. All cerebrovascular accidents occurred in the first two years post-transplant. The two-year incidences of post-transplant CVD, intracranial hemorrhage, and cerebrovascular infarction were 6.1%, 3.2%, and 3.2%, respectively. The incidence rate of CVD within two years after HSCT was 34.7 (95% CI 22.3 to - 53.7) per 1000 person-years, which was about tenfold higher than the general Taiwanese population. The only significant risk factor associated with post-transplant CVD is prior exposure to three or more courses of high-dose cytarabine. Post-transplant CVD is associated with dismal outcome and early mortality. The median overall survival of patients with post-transplant CVD was markedly reduced compared with those without CVD (8.0 vs. 60.6 months). Most patients with post-transplant CVD died within two months after the CVD events. Our study demonstrates that CVD remains a devastating complication after allogeneic HSCT in the modern era.

Brain Imaging Findings and Neurologic Complications after Allogenic Hematopoietic Stem Cell Transplantation in Children

Hematopoietic stem cell transplantation (HSCT) is the only therapy for a subset of patients with malignant and nonmalignant diseases. Central nervous system (CNS) complications continue to be an important cause of morbidity and significantly contribute to mortality after HSCT. These complications include infections, cerebrovascular lesions, therapy-induced diseases, metabolic disturbances, and post-HSCT carcinogenesis. Following HSCT, three phases can be identified on the basis of the patient's immune status: the pre-engraftment period (<30 days after HSCT), the early postengraftment period (30-100 days after HSCT), and the late postengraftment period (>100 days after HSCT). There is a distinct relationship between the patient's degree of immunodeficiency after HSCT and the incidence of various complications that may occur. Early diagnosis of CNS complications is crucial for successful management and a good prognosis, and computed tomography and magnetic resonance imaging play an important role in achieving these goals. The global increase in the use of HSCT requires radiologists to be familiar with CNS complications, their relationship to the patient's immune status, and their imaging appearances. This article describes the clinical background of HSCT; reviews the incidence, causes, and timeline of brain complications in children who underwent allogenic HSCT; and identifies the characteristic imaging findings of these disorders. ^©RSNA, 2018.

Imaging spectrum of central nervous system complications of hematopoietic stem cell and solid organ transplantation

Neurologic complications are common after hematopoietic stem cell transplantation (HSCT) and solid organ transplantation (SOT) and affect 30-60% of transplant recipients. The aim of this article is to provide a practical imaging approach based on the timeline and etiology of CNS abnormalities, and neurologic complications related to transplantation of specific organs. The lesions will be classified based upon the interval from HSCT procedure: pre-engraftment period <30 days, early post-engraftment period 30-100 days, late post-engraftment period >100 days, and the interval from SOT procedure: postoperative phase 1-4 weeks, early posttransplant syndromes 1-6 months, late posttransplant syndromes >6 months. Further differentiation will be based on etiology: infections, drug toxicity, metabolic derangements, cerebrovascular complications, and posttransplantation malignancies. In addition, differentiation will be based on complications specific to the type of transplantation: allogeneic and autologous hematopoietic stem cells (HSC), heart, lung, kidney, pancreas, and liver. Thus, in this article we emphasize the strategic role of neuroradiology in the diagnosis and response to treatment by utilizing a methodical approach in the work up of patients with neurologic complications after transplantation.

Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation

Neurologic complications after hematopoietic stem cell transplantation are frequently life-threatening, and their clinical management can be highly challenging. A wide spectrum of causative factors-including drug-related toxicities; infections sustained by virus, bacteria, or invasive molds; metabolic encephalopathy; cerebrovascular disorders; immune-mediated disorders; and disease recurrence-may lead to potentially lethal complications. Moreover, given that some neurologic complications are not uncommonly diagnosed post mortem, their overall incidence is likely to be underestimated. Their prompt recognition and timely treatment are of paramount importance to reduce the risk for transplantation-related death.

Central Nervous System Complications of Hematopoietic Stem Cell Transplant

Hematopoietic stem cell transplantation (SCT) is now commonly used to treat several hematologic and nonhematologic diseases. Central nervous system (CNS) complications post-transplantation occur commonly in the first year and result in increased mortality from infectious, toxic, metabolic, or vascular causes. Infections secondary to aspergillus, toxoplasma and viruses cause many of the complications. Drug-related toxicities arising from conditioning regimens and graft-versus-host disease prophylaxis, as well as intraparenchymal hemorrhage, are not uncommon and can result in increased morbidity. Secondary CNS cancers have a higher incidence 5 or more years after allogeneic SCT.

Subdural hemorrhage - a serious complication post-intrathecal chemotherapy. A case report and review of literature

We need to have a high index of suspicion for subdural hemorrhage (SDH) post-lumbar puncture in hematological patients given their increased risk and the significant morbidity and mortality associated with SDHs.

Haemostasis and safety measures before lumbar puncture in the haematology ward: the Danish routines

BACKGROUND/AIMS

Thrombocytopenia and the increasing use and variety of antithrombotic drugs is a challenge prior to lumbar puncture. This study examined the Danish haematology practice regarding drug pausation, assessment of haemostasis and whether fundoscopy is a routine safety measure.

METHODS

An online survey with questions pertaining to precautions of haemostasis and application of fundoscopy was sent by e-mail to all 12 haematology wards in Denmark.

RESULTS

Eleven sites participated. Five (45%) reported no pausation of antiplatelet drugs at all. The mean platelet limit prior to lumbar puncture was 50 × 10(9)/l (range 10-50 × 10(9)/l). Seven (64%) sites had an international normalised ratio limit of 1.5, and the remaining 4 had values between 1.0 and 2.5. Two (18%) reported occasional use of thromboelastography or platelet analysis to assess the bleeding risk. Fundoscopy is routinely performed in 4 (36%) departments.

CONCLUSION

We report considerable variation in the routine handling of antithrombotics and thrombocytopenia in patients set for lumbar puncture in Danish haematology departments. The diversity may be explained by and related to different opinions in the literature. Common national guidelines are warranted and there is a need for studies to establish an evidence-based approach for the management of patients at risk of bleeding when lumbar puncture or another invasive procedure is indicated.

Sphingolipids in human synovial fluid--a lipidomic study

Articular synovial fluid (SF) is a complex mixture of components that regulate nutrition, communication, shock absorption, and lubrication. Alterations in its composition can be pathogenic. This lipidomic investigation aims to quantify the composition of sphingolipids (sphingomyelins, ceramides, and hexosyl- and dihexosylceramides) and minor glycerophospholipid species, including (lyso)phosphatidic acid, (lyso)phosphatidylglycerol, and bis(monoacylglycero)phosphate species, in the SF of knee joints from unaffected controls and from patients with early (eOA) and late (lOA) stages of osteoarthritis (OA), and rheumatoid arthritis (RA).

SF without cells and cellular debris from 9 postmortem donors (control), 18 RA, 17 eOA, and 13 lOA patients were extracted to measure lipid species using electrospray ionization tandem mass spectrometry - directly or coupled with hydrophilic interaction liquid chromatography.

We provide a novel, detailed overview of sphingolipid and minor glycerophospholipid species in human SF. A total of 41, 48, and 50 lipid species were significantly increased in eOA, lOA, and RA SF, respectively when compared with normal SF.

The level of 21 lipid species differed in eOA SF versus SF from lOA, an observation that can be used to develop biomarkers. Sphingolipids can alter synovial inflammation and the repair responses of damaged joints. Thus, our lipidomic study provides the foundation for studying the biosynthesis and function of lipid species in health and most prevalent joint diseases.

Intracranial hemorrhage following allogeneic hematopoietic stem cell transplantation

Charts and radiographs of 622 allogeneic hematopoietic stem cell transplant (HSCT) recipients, over a 20-year period, were retrospectively reviewed for intracranial hemorrhage (ICH) following transplant. A total of 21 cases of ICH were identified (3.4%) including 15 cases of intraparenchymal hemorrhage (IPH), two cases of subarachnoid hemorrhage (SAH), and four cases of subdural hematoma (SDH). The median time from transplantation to the onset of ICH was 63 days (range, 6-3,488 days). The clinical features of post-transplant ICH patients were similar and included hypertension, diabetes mellitus, chronic graft-versus-host disease (GVHD), systemic infection, and veno occlusive disease (VOD), recently referred to as sinusoidal obstruction syndrome, in addition to severe thrombocytopenia. Mortality rate was especially high (89%) after IPH with a median survival of 2 days (range, 0-148 days). In contrast, all patients with SAH or SDH following HSCT survived. The cause of post-transplant ICH appears to be multifactorial, including thrombocytopenia, hypertension, acute GVHD, VOD, and radiation therapy. Most patients in our series displayed severe thrombocytopenia at the onset of ICH, even though adequate prophylactic platelet transfusions were given. By univariate analysis, cord blood transplantation, acute GVHD, systemic infection, and VOD were related to the incidence of ICH, whereas prior CNS episodes and radiation therapy did not reach statistical significance. A multivariate analysis with logistic regression identified acute GVHD as the only factor that significantly influenced ICH occurrence.

Management of stroke in cancer

Cerebrovascular disorders, including brain infarction, brain hemorrhage, and cerebral venous thrombosis, can occur as an early sign of cancer, but typically occur late in the clinical course. These disorders are due to a variety of pathogenic mechanisms, including coagulation disorders associated with the cancer, invasion or compression of vessels from tumor in or adjacent to the brain, and the adverse effects of cancer therapy. The appropriate therapy for these cerebrovascular disorders is empiric in most instances, because as yet there are no prospective treatment trials for them. A review of the existing literature reveals that improvement in patient quality of life and prevention of further cerebrovascular events can be obtained in some clinical situations.

Lumbar puncture and subdural hygroma and hematomas in hematopoietic cell transplant patients

We reviewed records of hematopoietic cell transplantation (HCT) patients seen over the past 10 years who had head scan documentation of subdural fluid collections. A total of 17 patients were identified: 13 with allogeneic and 4 with autologous HCT (0.71% of allogeneic and 0.13% of autologous HCT patients seen in this time interval). Although less than 20% of HCT patients have lumbar puncture, 8 of the 17 subdural patients had lumbar puncture. The lumbar puncture was done 5-112 days (median 46 days) before subdural detection. Acute lymphocytic leukemia was the diagnosis in five of these eight; whereas, either acute myelogenous leukemia or myelodysplasia was the diagnosis in seven of the nine patients without lumbar puncture. In the patient group with lumbar puncture, subdurals were diagnosed earlier after HCT (median 25 days versus 5 months in the patient group without lumbar puncture) and were more often hygromas (37.5 versus 0%). These results support the suggestion of lumbar puncture or intrathecal therapy as a risk factor for subdurals. The presumptive mechanism involves lumbar cerebrospinal leak, low intracranial pressure, downward displacement of the brain, cerebrospinal fluid accumulation into the inner dural layers of the cerebral convexities (hygromas) and bleeding into these fluid collections (hematomas).

Intracerebral hematoma as a complication of intrathecal methotrexate administration

Neurotoxicity of methotrexate is a well-documented issue, but development of an intracerebral hematoma following administration of intrathecal methotrexate is an extremely rare entity. A 6-year-old male with the diagnosis of non-Hodgkin lymphoma was put on a treatment regimen, including intrathecal methotrexate. Six days following the last intrathecal methotrexate administration, the patient developed a deteriorating state of consciousness. There was no history of trauma. Coagulation studies and platelet count were normal. Magnetic resonance imaging of the brain demonstrated a large left frontoparietal hematoma. Intracerebral hematoma may be a very rare, but serious, complication of intrathecal methotrexate administration.

Intraspinal and intracranial hemorrhage after lumbar puncture

Two cases of spinal epidural hematoma and two cases of intracranial subdural hematoma after lumbar puncture (LP) are reported in children receiving chemotherapy for acute lymphoblastic leukemia and non-Hodgkin lymphoma. The bleeding was asymptomatic but interfered with treatment in one case, and caused either severe backache or headache but no neurological deficit in the other three patients. The platelet counts were 8 and 46 x 10(9)/L in two patients and were normal in the other patients at the time of LP. All recovered without surgical treatment. There is an inherent, albeit uncommon, risk of bleeding into the central nervous system associated with LP in children with cancer and should be distinguished from postdural puncture headache (PDPH). Thrombocytopenia is not always an accompanying factor.

Neurologic complications of cancer chemotherapy

Neurotoxicity related to cancer therapy is a common problem in oncology practice. Neurologic side effects can be dose-limiting, can inhibit treatment, and can substantially diminish quality of life. Symptoms may appear acutely after treatment, or remotely after therapy has been discontinued. Multiple therapies may share similar toxicities, and certain agents may potentiate symptoms. When faced with the development of neurologic complaints, familiarity with the most common complications is helpful in determining the etiology of these symptoms. This review will discuss the common complications of both established and novel agents used to treat cancer.

Nonmyeloablative allogeneic bone marrow transplantation for treatment of myelodysplastic syndrome complicated by recent intracerebral hemorrhage

A patient with intracerebral hemorrhage is considered ineligible for hematopoietic stem cell transplantation (HSCT). We report a 49-year-old woman with myelodysplastic syndrome (MDS) complicated by refractoriness to platelet transfusion and intracerebral hemorrhage, who underwent allogeneic bone marrow transplantation from an HLA-identical unrelated male donor. Nine days before the scheduled transplantation, she developed dysarthria and right hemiparesis; computed tomography (CT) of the brain disclosed an acute hematoma in the left parietal lobe exceeding 3 cm in diameter. She underwent conditioning with reduced-intensity, including fludarabine (30 mg/m2/day on days -8 to -3), busulfan (4 mg/kg/day on days -6 and -5), and total body irradiation (4 Gy on day -2). Two weeks after transplantation, dysarthria and right hemiparesis began to resolve, and CT showed spontaneous resolution of the hematoma. Simultaneously, engraftment was confirmed. Thus, recent stroke may be not an absolute contraindication for HSCT.

Use of intrathecal prophylaxis in allogeneic haematopoietic stem cell transplantation for malignant blood diseases: a survey of the European Group for Blood and Marrow Transplantation (EBMT)

SUMMARY

A survey was carried out among EBMT centres to describe the current practice concerning intrathecal (i.t.) prophylaxis in allogeneic stem cell transplantation for malignant diseases in patients with no central nervous system (CNS) manifestations of the disease at any time. A total of 90 centres reported their practice: 42 centres (47%) never used pre-transplant i.t. prophylaxis as part of the conditioning, whereas 48 centres (53%) gave i.t. prophylaxis to selected groups. The main indications were acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), and lymphoma (53, 33, and 23% of all centres, respectively). Prophylaxis was usually given to all patients with ALL, but often restricted to high-risk patients in AML and lymphoma. Of the 90 centres, 29 (32%) gave prophylactic i.t. treatment after the transplantation, mainly for the same indications as pre-transplant. This survey illustrates the heterogeneity in the current practice of i.t. prophylaxis in allogeneic transplantation for malignant blood disorders in Europe. The documentation in the literature to support the use of i.t. prophylaxis as part of transplantation for malignant diseases in patients without preceding CNS involvement is sparse. Based on the rarity of isolated CNS relapse after allogeneic stem cell transplantation, EBMT does not recommend routine i.t. prophylaxis to patients without prior CNS involvement.

Fatal bihemispheric intracerebral hemorrhage after burrhole evacuation of chronic subdural hematoma in a bone marrow-transplanted patient: case report and review of the literature

BACKGROUND

Intracranial hemorrhage seems to be a relatively frequent complication following bone marrow transplantation (BMT). The neurosurgical management of these patients can be problematic.

CASE DESCRIPTION

We report about a 46-year-old patient, who had BMT because of a Pre-T-ALL and who developed symptomatic bihemispheric chronic subdural hematomas (cSDHs). Pre-T-ALL is a form of an acute lymphatic leukemia of T cell type characterized by certain immunologic markers with a worse prognosis. A few hours after evacuation of the cSDHs, the patient developed a fulminant intracerebral hemorrhage on each hemisphere and expired 2 days later. We reviewed the literature reporting similar cases to discuss the indication for a neurosurgical intervention.

CONCLUSION

We presume a higher incidence of intracranial hemorrhage in BMT patients than reported. This is caused by the pathologically altered parenchyma related to the extensive therapy in these patients. BMT patients are typically at high risk for intracranial bleeding and are treated conservatively or surgically. We cannot generally recommend the conservative management for symptomatic subdural hematomas/hygromas. The risk for an acute worsening, secondary to repeated hemorrhage, is equivalent to the risk of surgical intervention. Although the outcome of our case is tragic, it should not deter surgical intervention.

Anxiety, depressive, and posttraumatic stress disorders among mothers of pediatric survivors of hematopoietic stem cell transplantation

OBJECTIVE

To examine the prevalence and predictors of anxiety, depression, and posttraumatic stress disorder among mothers of children who underwent hematopoietic stem cell transplantation (HSCT).

METHODS

A total of 111 mothers of children who survived HSCT completed self-report measures of psychological functioning at the time of HSCT and self-report measures and a structured psychiatric interview 18 months after HSCT. Demographic data and medical data were also collected.

RESULTS

Approximately 20% of mothers had clinically significant distress reactions. When subthreshold posttraumatic stress disorder was included, nearly one third of mothers met the criterion for persistent distress. Mothers with 1 of the 4 psychiatric diagnoses reported a significantly lower quality of life, suggesting that the diagnoses had an impact on their general quality of life. Mothers who had 1 of the 4 diagnoses at 18 months were younger and had higher anxiety and depressive symptoms at the time of HSCT.

CONCLUSIONS

A subset of mothers of children who survive HSCT may require psychological intervention. Mothers who are most at risk are younger and evidence anxiety and depressive symptoms at the time of transplantation.

Neurologic complications of bone marrow transplantation

The various forms of HSCT are or will soon be accepted treatments for an ever-increasing number of hematologic and solid cancers. Attempts to reduce the mortality and morbidity of HSCT and at the same time preserve or increase its efficacy in tumor control include development of nonmyeloablative allogeneic stem-cell transplant strategies [208] and allogeneic laboratory research-enhancing graft acceptance [209,210]. Eventually, these efforts will reduce complication rates of HSCT, including neurologic complications. In the interim, the consultant neuro-oncologist or neurologist with a specific inteest in this field is faced with complex clinical syndromes, neuroradiologic imaging studies and neurophysiologic tests, and generally poorly understood pathophysiologic mechanisms. Prospective studies of HSCT patients in large transplantation centers using clinical registries are needed.

Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies

Does an expanded subarachnoid space predispose to subdural bleeding? What does heterogeneity in the appearance of a subdural collection on CT or MRI imaging indicate? Spontaneous rebleeding? Minor re-injury? Major re-injury? In some specific cases, answers to these questions have important forensic implications. To conclude objectively that an infant's intracranial hemorrhage or rebleeding resulted from inflicted injury or re-injury requires an in-depth understanding of the pathogenesis of posttraumatic subdural and subarachnoid collections. The authors present two cases of indoor, accidental, pediatric, closed-head trauma that resulted in intracranial rebleeding. Both accidental cranial impacts occurred in medical settings and were independently witnessed by medical personnel. In addition, the authors summarize the relevant medical literature regarding pediatric intracranial bleeding and rebleeding.

Intracranial hemorrhage following bone marrow transplantation: an autopsy study of 58 patients

Autopsy files of 180 patients were reviewed, who died after BMT between July 1987 and June 1998 and 58 (32.2%) cases, who had experienced intracranial hemorrhage (ICH) were selected. Age, sex, underlying disease, preparatory regimens, immunoprophylaxis, chronic and acute GVHD, survival of the patients and localization and size of hemorrhages were evaluated. There were 33 males and 25 females, with a mean age of 23.4 years. The main underlying disorders for which BMT was performed included SAA (n = 21), CML (n = 13) and AML (n = 10). Forty patients were found to have intraparenchymal hemorrhage, 35 had subarachnoid hemorrhage and eight patients had subdural hemorrhage. In 16 cases the CNS hemorrhage was so extensive that it was considered to be the main cause of death. There was no significant statistical difference concerning sex (P = 0.217), age (P = 0.296), underlying disease (P= 0.352), preparatory regimens (P = 0.07), immunoprophylaxis (P = 0.914), chronic and acute graft-versus-host disease (P = 0.107 and P = 0.631, respectively) and survival (P = 0.701) when comparing patients with or without ICH. However, the number of cases in which the CNS was defined as the main cause of death was higher among patients with ICH than in patients without ICH (n = 16 vs 15) (P = 0.011). We conclude that ICH is common and has a significant mortality rate following BMT.

Anxiety and depression in mothers of children undergoing bone marrow transplant: symptom prevalence and use of the Beck depression and Beck anxiety inventories as screening instruments

This study examined anxiety and depressive symptoms among 115 mothers of children undergoing bone marrow transplant and evaluated the ability of the Beck Anxiety Inventory (BAI; A. T. Beck, N. Epstein, et al., 1988) and the Beck Depression Inventory (BDI; A. T. Beck, 1978) to serve as screening tools for assessing generalized anxiety disorder (GAD), panic disorder (PD), and major depressive disorder (MDD). Mothers with BAI or BDI scores greater than or equal to 14 were administered a structured clinical interview. An additional 20% was randomly selected for interview to determine whether the scale cutoff was an accurate screening method. Among the 64 mothers interviewed, 20% received at least I of the 3 diagnoses. Although the BAI did not demonstrate predictive accuracy in assessing GAD and PD, the BDI did in assessing MDD. The results suggest that a subset of mothers may have an anxiety or depressive disorder and that investigators should use caution before using the BAI as a screening instrument for anxiety disorder.

Acute bleeding complications in patients after bone marrow transplantation

Acute bleeding is a frequent complication that commonly associates with increased morbidity after bone marrow transplantation. Except for diffuse alveolar hemorrhage and cerebral hemorrhage, bleeding is infrequently recorded as a direct cause of death. Yet outcome analyses showed that bleeding from any reviewed site was associated with reduced survival. Reduced survival was correlated with bleeding intensity and the number of bleeding sites. These data point to the need to monitor all manifestations of bleeding, as bleeding may identify patients at risk for bone marrow transplantation toxicity. Until recently, prophylactic platelet transfusions were commonly given at a trigger of 20 x 10(9)/L. Whereas bleeding is more likely to occur when platelet counts drop to low levels, most bleeding episodes were recorded with platelet counts greater than 20 x 10(9)/L, suggesting causes other than profound thrombocytopenia in the pathogenesis of bleeding. Given that a trigger of 10 x 10(9)/L has become accepted for prophylactic platelet transfusions, care should be taken to ensure that parameters other than the incidence of bleeding have not been adversely affected.