Multifocal intracranial hemorrhage on emergency brain CT in a child with end-stage nephrotic syndrome

Spontaneous intracranial hemorrhage is a rare complication of pediatric nephrotic syndrome. We report a 10-year-old girl with steroid-resistant impure nephrotic syndrome complicated by end-stage renal disease on chronic hemodialysis, presenting with acute impairment of consciousness and hypertensive emergency (182/112 mmHg). Coagulation tests were entirely normal despite active hemorrhage, consistent with uremic qualitative platelet dysfunction not detected by conventional screening. Emergency noncontrast brain CT demonstrated multifocal intraparenchymal hematomas, extensive intraventricular hemorrhage with triventricular flooding, acute obstructive hydrocephalus, a 9 mm midline shift, basal cistern effacement, and posterior fossa hematoma with fourth ventricle collapse. Management included orotracheal intubation, intravenous nicardipine, hypertonic saline, and external ventricular drain placement. The patient died on day 4. This case illustrates that normal coagulation tests should not delay emergency brain CT in uremic children with acute neurological deterioration, and that the CT pattern of multifocal hemorrhage with intraventricular involvement carries a poor prognosis.