(709) The Complex Management of Chronic Myeloid Leukemia Presenting as Intracerebral Hemorrhage

Introduction: Chronic myelogenous leukemia (CML) is a hematological malignancy characterized by the overproduction of myeloid cells. While advancements in targeted therapies have significantly improved the prognosis and management of CML, patients may still experience severe complications particularly when treatment adherence is compromised. Intracerebral hemorrhage (ICH) is an unusual complication in CML, with few reported cases found in the literature. Here, we present a case of a severe ICH in a middle-aged woman with CML and severe leukocytosis managed outside of the standard of care with chemotherapy and leukapheresis.

Description: Our patient was admitted to the Neuro Intensive Care unit as a stroke alert with expressive aphasia, right total hemiparesis, and altered mental status. In the emergency room, a CT brain revealed an extensive acute left frontal hemorrhage with a significant midline shift. CBC was significant for WBC of > 440.000 x 10^9/L (too numerous to count). She had a history of CML untreated for three years. Peripheral smear revealed a chronic phase of CML. She had an abnormal coagulation panel requiring cryoprecipitate transfusions. The neurosurgeon advised against surgery, given the high chance of coagulopathy compromising the surgical procedure. Instead, the patient was immediately started on hydroxyurea, and motion was made for emergent leukapheresis. After 1 round of leukapheresis, her WBC remained unmeasurable, ultimately requiring five treatments over two days to achieve a WBC of < 100.000 x 10^9/L. Subsequent tumor lysis syndrome was managed with rasburicase, allopurinol, and aggressive intravenous hydration. Follow-up brain CT remained stable but her deficits persisted.

Discussion: This case underscores the complex interplay and management between hematologic malignancies and cerebrovascular events. Our team deviated from the standard of care of CML in the chronic phase by initiating leukapheresis. The high WBC created stasis, likely leading to vascular occlusion and subsequent hemorrhagic conversion. Such a presentation needs to be better documented in the literature. The rapid management of her leukocytosis was a crucial component in preventing further neurological deterioration and improving long-term outcomes in this patient.