Intensive care needs and predictors of in hospital mortality following spontaneous intracranial hemorrhage in children - A ten year single centre retrospective study

Abstract

Objective: To study the clinical profile, intensive care needs and predictors of in hospital mortality in children with Spontaneous Intracranial Hemorrhage (SICH). Material and methods: Retrospective observational study in a tertiary care pediatric intensive care unit (PICU) of a teaching and referral hospital where 105 children aged > 1 month to 12 years with SICH admitted between January 2009 and May 2018 were assessed for in-hospital mortality as primary outcome. Survivors and non-survivors were compared to determine predictors of outcome. Results: The median (IQR) age of study subjects was 6 (2.25, 70) months, with 76 (72.4%) boys. Altered sensorium (n=87, 82.9%) and seizures (n=73, 69.5%), and pallor (n=66, 62.9%) and bulging anterior fontanelle (n=52, 49.5) were common presenting symptoms and signs respectively. Median (IQR) Glasgow Coma Scale (GCS) at admission was 10 (6,13) with features of herniation in 27 (25.7%). Arteriovenous malformation was the commonest cause of bleed among older children whereas late hemorrhagic disease of newborn was predominant cause among infants. Commonest site of bleed was intracerebral (n=47, 44.8%) followed by subdural (n=26; 24.8%). Sixteen (15.2%) children died during hospital stay. On univariate analysis, GCS<8, higher PRISM-III (>20), need for intubation at admission, development of shock and Acute kidney injury (AKI) during hospital stay and refractory status epilepticus requiring thiopentone coma were found to be significant predictors of mortality. Focal seizures were however associated with better survival [OR 0.12; 95% CI:0.03-0.47; p-0.002]. Age, site or etiology of bleed did not affect outcome. On multivariable analysis, progression to AKI [OR 5.86; 95% CI:1.53-22.4; p-0.01] predicted poor outcome. Conclusions: Etiology of SICH varies with age. Age or site of bleed did not predict outcome. Refractory status requiring thiopentone and development of MODS (shock, AKI) were associated with poor outcome.