Intracranial Hemorrhage In Children Research Articles

Intracranial Hemorrhage in Childhood Acute Leukemia: Incidence, Characteristics, and Contributing Factors

BackgroundAmong all cancers, hematologic malignancy has the highest rate of intracranial hemorrhage. However, there are limited data on intracranial hemorrhage in childhood acute leukemia. We aimed to determine the incidence, characteristics, and factors associated with intracranial hemorrhage in children with acute leukemia. MethodsWe reviewed a database of patients aged one month to 15 years diagnosed with acute leukemia during 2003 to 2016 at a hospital in Thailand. Characteristics of patients with intracranial hemorrhage were compared with those of patients without intracranial hemorrhage. Multiple logistic regression was used to determine the associated factors. We performed survival analyses to compare survival and hazard ratios between groups. ResultsThere were 494 children with acute leukemia (acute lymphoblastic leukemia 367, acute myelogenous leukemia 127). Median age was 4.9 years (interquartile range 3.0 to 9.2). Follow-up duration was 2.1 years. Intracranial hemorrhage occurred in 12 patients whose median age was 12.5 years (interquartile range 7.5 to 13.3). Incidence rate of intracranial hemorrhage was 6.2 (acute lymphoblastic leukemia 5.1, acute myelogenous leukemia 12.9) per 1000 person-years. Case fatality rate of intracranial hemorrhage was 75%. Patients with early intracranial hemorrhage had prolonged international normalized ratio and higher white blood cell count, whereas patients with late intracranial hemorrhage had more concurrent systemic infections. Most cases of intracranial hemorrhage were intraparenchymal with perihematomal edema. Median survival was 24 days in the intracranial hemorrhage group compared with four years in the non-intracranial hemorrhage group. Risk of death from intracranial hemorrhage was 3.2 times higher than that of the non-intracranial hemorrhage group. Age at diagnosis, initial white blood cell count, and lactate dehydrogenase were associated with increased risk of intracranial hemorrhage. ConclusionsIntracranial hemorrhage was common and often fatal in children with acute leukemia. Potential contributing factors differed by intracranial hemorrhage timing. Older age, white blood cell count, and lactate dehydrogenase were associated with high risk of intracranial hemorrhage.

Intracranial haemorrhage in children and adults with haemophilia A and B: a literature review of the last 20 years.

Intracranial haemorrhage (ICH) is the most serious event in haemophiliacs, resulting in high rates of mortality and disability. Although the use of a prophylaxis regimen has improved outcomes, the mortality caused by ICH is still around 20%. ICH is more frequent at two different ages: in childhood (mostly in children aged ≤2 years) and in adulthood (with known risk factors such as hypertension and age ≥60 years). Our review shows how ICH remains one of the worst problems of patients with haemophilia. Greater attention to risk factors and early symptoms, together with an appropriate early prophylaxis, may reduce the risk of severe intracranial haemorrhagic events.

Association between skull fractures and types of intracranial hematomas in children with head injury

Background and objective: Treating children with head injuries is one of the most frequent causes of admission to the neurosurgical emergency unit in Erbil city. In many cases, the parents ask whether the presence of a skull fracture in their child indicates any association with intracranial hemorrhage. Most of the previous studies focused on the association between skull fractures and intracranial hematomas in the adult population. We conducted this study to determine if there is a statistically significant association between skull fracture and types of intracranial hemorrhage in children. Methods: A descriptive study was conducted between July 2015 and July 2017 at West Erbil Emergency Hospital. The study sample included children with the head injury whose brain Computerized Tomography (CT)-scan showed intracranial hemorrhage. Data collected using a questionnaire prepared by the researcher. Data were analyzed using descriptive and inferential statistical tests. Results: A total of 201 children met the inclusion criteria; their ages ranged between 2 months and 17 years. Male to female ratio was 121:80. Highest percentages (64.7%) of children were 1-5 years old. The most common (72.63%) cause of head injury was fall from height. The most frequent (48.8%) intracranial hematoma encountered was an epidural hematoma, followed by intracerebral hematoma and subdural hematomas. There was a highly significant (P = 0.001) association between skull fractures and types of intracranial hematomas. Conclusion: In children, skull fracture increases the incidence of intracranial hematoma. Most common intracranial hematomas in order of frequency were an epidural hematoma, intracerebral hematoma, and subdural hematoma. The most common cause of head injury was fall from height. Most patients were males between one and five years old.

Intracranial Hemorrhage in Children With Inherited Bleeding Disorders: A Single Center Study in China.

Intracranial hemorrhage (ICH) is a life-threatening condition in children. Inherited bleeding disorders (IBD) have high risk of ICH. This single center study aims to identify the incidence, risk factors, and neurological outcome of ICH in children who suffer from IBD. From 2005 to 2017, 241 children with IBDs from Nanfang hospital, Department of Pediatrics, were evaluated. The ICH episodes were identified by medical history, general physical examination, detailed neurological examination, and computed tomographic or magnetic resonance imaging examination. The risk factors, location of ICH, management strategies, and outcome were noted. ICH was confirmed in 54/241 (22.4%) children with IBD among them 52/54 (96.2%) (95% confidence interval [CI], 91.1%-99.9%) were hemophilia A and hemophilia B patients. The overall risk of ICH among children with IBD was 22.4% (95% CI, 17.2%-27.8%). The median age of ICH was 30 months (0 to 204) and 18/54 (33.3%) (95% CI, 20.3%-46.3%) children had an ICH in the first year of life. Twenty-eight of 52 (53.8%) hemophilic children with ICH were assessed for inhibitor of FVIII and FIX. Nine of 28 (32%) hemophilic children with inhibitor developed the ICH. Six of 52 (11.5%) (95% CI, 2.6%-20.5%) hemophilic children had multiple episodes of ICH in which 4 were inhibitor positive. Thirteen of 54 (24%) (95% CI, 12.3%-35.9%) had positive family history of IBD. Twenty-two (36%) (95% CI, 23.7%-48.5%) of 61 ICH episodes were caused by trauma and 39 (63.9%) (95% CI, 51.5%-76.3%) were nontrauma related. Subdural hematoma was most frequently observed. Mortality risk from ICH in children with IBD was 5/54 (9.2%) (95% CI, 1.3%-17.2%). Eleven (22.4%) (95% CI, 10.3%-34.6%) of 49 survivors had known neurological squeal, whereas 38 (77.5%) (95% CI, 65.4%-89.7%) had no documented evidence of neurological impairment. Hemophilia is the most common IBD and most frequently associated with ICH. Risk and consequences of ICH in IBD were high during the first year of life while in older children better outcome may be expected. The optimal management of ICH depends on immediate recognition and prompt replacement therapy.

Clinical characteristics and prognosis of pediatric intracranial hemorrhage in pediatric intensive care unit: a prospective and single-center study

Objective To describe the etiology, clinical characteristics and prognosis in children with intracranial hemorrhage who were admitted to pediatric intensive care unit (PICU) and to analyze factors associated with poor prognosis, in order to provide evidence for prevention and early prognosis evaluation. Methods This was a prospective, single-center study including the children with intracranial hemorrhage who were admitted to PICU of Beijing Children′s Hospital from October 1, 2014 to January 31, 2017.Children′s basic information and survival on the 28th day after hospital discharge were collected.Prognosis was evaluated by means of pediatric cerebral performance category score (PCPC) or pediatric overall performance category score (POPC). The related factors with poor prognosis were analyzed. Results Ninety-five children(58 boys and 37 girls) were included; mortality at hospital and on the 28th day after discharge were 7.4% and 22.1%, respectively.Trauma(68.4%) was the most common cause for intracranial hemorrhage(ICH). The most common cause of spontaneous intracranial hemorrhage in infants was vitamin K deficiency (4/16 cases, 0.25), but hematological diseases in school-aged children (7/11 cases, 63.6%). Univariate analysis showed intraparenchymal, intraventricular, extradural hemorrhage.Multiple sites hemorrhage, trauma, hematological system diseases, surgery, and low Glasgow coma scale(GCS) at PICU discharge were associated with poor prognosis(χ2=9.653, 10.658, 7.237, 5.657, 10.966, 4.471, 7.429, 31.308, all P<0.05). Multivariate analysis showed that intraventricular hemorrhage and low GCS at PICU discharge were independent risk factors for poor prognosis(all P<0.001). ICH caused by trauma had a relatively better prognosis(P=0.015). Conclusions The majority of patients with ICH admitted to PICU are infants.The most common cause is trauma.The most common cause of spontaneous ICH in infants is vitamin K deficiency, but hematological diseases in school-aged children.ICH and low GCS at PICU discharge are independent risk factors for poor prognosis.ICH caused by trauma has a relatively better prognosis.Reducing accidental injury is the key to prevent ICH in children. Key words: Intracranial hemorrhage; Child; Trauma; Prognosis

A Retrospective Analysis of Intracranial Hemorrhage in Children with Hemophilia A.

To investigate the incidence, risk factors, clinical manifestations and prognosis of intracranial hemorrhage (ICH) in children with hemophilia A in a center of China, we conducted a retrospective analysis of 126 children with hemophilia A at our hospital in recent 4 years. Thirty-six children with hemophilia A (including 19 severe cases, and 17 moderate cases complicated with joint diseases) received low dose factor VIII (FVIII) prophylaxis, and none of them had ICH. However, 13 cases of hemophilia A not given prophylaxis were complicated with ICH (12 severe cases, and 1 moderate case) and demonstrated an incidence of 10.3% (13/126) in all patients, and 28.6% (12/42) in severe cases. Of the 13 cases, 9 severe ICH cases had a definite history of head injury, accounting for 69.2%. Headache was common in children >3 years, but somnolence, irritability, gaze or convulsions in children <3 years. The most common findings of cranial CT scan included intracranial hematoma (9/13), and less commonly observed were subependymal hemorrhage and intraventricular hemorrhage. After administration of FVIII, all patients survived. Hematoma of 6 cases was observed during CT reexamination after 1-3 months. During the follow-up period, only one case had slight activity limitation on one side of the limb, but steadily recovered. Besides the decreased concentration of FVIII, trauma is the most common risk factor of ICH in children with hemophilia A. The active treatment can improve the prognosis of ICH in children with hemophilia A.

Perturbations of BMP/TGF-β and VEGF/VEGFR signalling pathways in non-syndromic sporadic brain arteriovenous malformations (BAVM)

BackgroundBrain arteriovenous malformations (BAVM) represent a congenital anomaly of the cerebral vessels with a prevalence of 10–18/100 000. BAVM is the leading aetiology of intracranial haemorrhage in children. Our objective...

Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders.

Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT. We reviewed subjects <4 years of age in the Universal Data Collection database. ICH was categorized on the basis of association with trauma. Prevalence and probability of types of ICH were calculated for each bleeding disorder. Of 3717 subjects, 255 (6.9%) had any ICH and 206 (5.5%) had nontraumatic ICH. The highest prevalence of ICH was in severe hemophilia A (9.1%) and B (10.7%). Of the 1233 subjects <2 years of age in which the specific location of any ICH was known, 13 (1.1%) had spontaneous SDH (12 with severe hemophilia; 1 with type 1 vWD). The findings in the subject with vWD were not congruent with AHT. In congenital bleeding disorders, nontraumatic ICH occurs most commonly in severe hemophilia. In this study, vWD is not supported as a "mimic" of AHT.

Intracranial haemorrhage in children with inherited bleeding disorders in the UK 2003-2015: A national cohort study.

Intracranial haemorrhage in children with inherited bleeding disorders is a potentially life-threatening complication and presents a significant therapeutic challenge. To define the characteristics, management and outcomes of intracranial haemorrhage presenting in UK children ≤16years of age with inherited bleeding disorders from 2003 to 2015. Retrospective analysis of children treated at UK haemophilia centres. Of 66 children presenting with Intracranial haemorrhage (ICH), 82% had haemophilia A or B, 3% VWD and 15% a rare IBD. The IBD was a severe phenotype in 91%. The rates of ICH were 6.4 and 4.2 per 1000 patient years for haemophilia A and B, respectively. Median age at presentation was 4months (33% neonates; 91% children <2years of age). In neonates, delivery wasspontaneous vaginal (SV)in 11, instrumental in 6, caesarean in 4 and unknown in 1. In children with haemophilia, the risk of ICH after instrumental delivery was 10.6 times greater than after SV delivery. Trauma was more common in children >2years (67%) than in children 1month to 2years (18%; P=.027). Prior to ICH, only 4.5% of children were on prophylaxis. 6% of haemophiliacs had an inhibitor. The median duration of initial replacement therapy was 15days. Mortality was 13.5%. Neurological sequelae occurred in 39% of survivors, being more common following intracerebral bleeding. In haemophilia survivors, 52% subsequently developed a FVIII inhibitor. Intracranial haemorrhage occurs most frequently in children with severe IBDs, during the first 2years of life and in children not receiving prophylaxis. Intracranial haemorrhage often occurs without documented trauma.

The progress of nimodipine in the prevention and treatment of cerebral vasospasm after intracranial hemorrhage in children

One of the majority reasons for mortality and morbidity in children is cerebral vasospasm secondary to intracranial hemorrhage(CVSIH). CVSIH prevented and treated by nimodipine in adult patients have been widely reported in China and abroad, but only limited reports in children.We aimed to describe the mechanism and diagnosis of CVSIH in children, and also the mechanism, efficacy and safety of nimodipine. Key words: Nimodipine; Intracranial hemorrhage; Cerebral vasospasm; Children

Smooth muscle cells of intracranial vessels: from development to disease

Cerebrovascular diseases that cause ischaemic or haemorrhagic stroke with subsequent loss of life or functional capacity due to damage of the brain tissue are among the leading causes of human suffering and economic burden inflicted by diseases in the developed world. Diseases affecting intracranial vessels are significant contributors to ischaemic and haemorrhagic strokes. Brain arteriovenous malformations, which are a collection of abnormal blood vessels connecting arteries to veins, are the most common cause of intracranial haemorrhage in children and young adults. Saccular intracranial aneurysms, which are pathological saccular dilations mainly occurring at bifurcations of the large intracranial arteries near the circle of Willis, are highly prevalent in the middle-aged population, causing significant anxiety and concern; their rupture, although rare, is a significant cause of intracranial haemorrhage in those past middle age that is associated with a very sinister prognosis. Cerebral small-vessel disease, which comprise all pathological processes affecting vessels <500 microns in diameter, account for the majority of intracerebral haemorrhages and ∼25% of ischaemic strokes and 45% of dementias in the elderly. In this review, we summarize the developmental, structural, and functional features of intracranial vessels. We then describe the role of smooth muscle cells in brain arteriovenous malformations, intracranial aneurysms, and small-vessel diseases, and discuss how the peculiar ontogeny, structure, and function of intracranial vessels are related to the development of these diseases.

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

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.

Does the Addition of a "Black Bone" Sequence to a Fast Multisequence Trauma MR Protocol Allow MRI to Replace CT after Traumatic Brain Injury in Children?

Head CT is the current neuroimaging tool of choice in acute evaluation of pediatric head trauma. The potential cancer risks of CT-related ionizing radiation should limit its use in children. We evaluated the role of MR imaging, including a "black bone" sequence, compared with CT in detecting skull fractures and intracranial hemorrhages in children with acute head trauma. We performed a retrospective evaluation of 2D head CT and brain MR imaging studies including the black bone sequence of children with head trauma. Two experienced pediatric neuroradiologists in consensus created the standard of reference. Another pediatric neuroradiologist blinded to the diagnosis evaluated brain MR images and head CT images in 2 separate sessions. The presence of skull fractures and intracranial posttraumatic hemorrhages was evaluated. We calculated the sensitivity and specificity of CT and MR imaging with the black bone sequence in the diagnosis of skull fractures and intracranial hemorrhages. Twenty-eight children (24 boys; mean age, 4.89 years; range, 0-15.5 years) with head trauma were included. MR imaging with the black bone sequence revealed lower sensitivity (66.7% versus 100%) and specificity (87.5% versus 100%) in identifying skull fractures. Four of 6 incorrectly interpreted black bone MR imaging studies showed cranial sutures being misinterpreted as skull fractures and vice versa. Our preliminary results show that brain MR imaging complemented by a black bone sequence is a promising nonionizing alternative to head CT for the assessment of skull fractures in children. However, accuracy in the detection of linear fractures in young children and fractures of aerated bone remains limited.

Implications of Increased Weight Status for the Occurrence of Fall-Induced Intracranial Hemorrhage in Children Aged 4 Years or Younger.

The aim of this study was to investigate the association between increased weight status (IWS), a weight for age/sex at greater than the 95th percentile, and fall-induced intracranial hemorrhage (ICH) in children aged 4 years or younger. In 7072 children aged 4 years or younger with head injury who visited a tertiary care hospital emergency department in Korea from 2013 through 2015, the presence of fall-induced ICH was reviewed. The association between IWS and ICH was investigated by multivariable logistic regression. We retrospectively validated the Pediatric Emergency Care Applied Research Network rule alone and in combination with IWS for predicting ICH. Of 7072 children, 547 (7.7%) underwent computed tomography, of whom 451 (6.4%) were enrolled. Of these, 41 (9.1%; estimated event rate, 0.6%) had ICHs, and 26 (5.8%) had IWS. Increased weight status was more common in the children with ICH (P = 0.023). The association between IWS and ICH remained significant after adjustment (odds ratio, 5.24; 95% confidence interval [CI], 1.49-18.46; P = 0.010). The validation of the rule in combination with IWS showed no significant increases in a sensitivity (92.7% [95% CI, 80.1%-98.5%] to 95.7% [95% CI, 83.5%-99.4%]) and negative predictive value (98.2% [95% CI, 94.7%-99.4%] to 98.8% [95% CI, 95.4%-99.8%]). Increased weight status is associated with fall-induced ICH in children aged 4 years or younger. Information on weight status could be potentially helpful in predicting ICH in young children with fall-induced head injury.

Enlarged subarachnoid spaces and intracranial hemorrhage in children with accidental head trauma.

OBJECTIVE Benign external hydrocephalus (BEH) is an enlargement of the subarachnoid spaces (SASs) that can be seen in young children. It is controversial whether children with BEH are predisposed to developing subdural hemorrhage (SDH) with or without trauma. This issue is clinically relevant as a finding of unexplained SDH raises concerns about child abuse and often prompts child protection and law enforcement investigations. METHODS This retrospective study included children (1-24 months of age) who underwent head CT scanning after an accidental fall of less than 6 feet. Head CT scans were reviewed, cranial findings were documented, and the SAS was measured and qualitatively evaluated. Enlarged SAS was defined as an extraaxial space (EAS) greater than 4 mm on CT scans. Clinical measurements of head circumference (HC) were noted, and the head circumference percentile was calculated. The relationship between enlarged SAS and HC percentile, and enlarged SAS and intracranial hemorrhage (ICH), were investigated using bivariate analysis. RESULTS Of the 110 children included in this sample, 23 had EASs greater than 4 mm. The mean patient age was 6.8 months (median 6.0 months). Thirty-four patients (30.9%) had ICHs, including subarachnoid/subpial (6.2%), subdural (6.2%), epidural (5.0%), and unspecified extraaxial hemorrhage (16.5%). Enlarged SAS was positively associated with subarachnoid/subpial hemorrhage; there was no association between enlarged SASs and either SDH or epidural hemorrhage. A larger SAS was positively associated with larger HC percentile; however, HC percentile was not independently associated with ICH. CONCLUSIONS Enlarged SAS was not associated with SDH, but was associated with other ICHs. The authors' findings do not support the theory that BEH predisposes children to SDH with minor accidental trauma.

Characteristics and prognostic factors of intracranial hemorrhage in children

Objective Finding the characteristics and risk factors associatedwith prognosis in children suffering from intracranial hemorrhage.Methods This was a retrospective medical record review of chil-dren (older than 1 month old) admitted with intracranial hemor-rhage to the Department of Child Health the Sanglah Hospital,Denpasar, during the period of January 1998 to December 2000.Prognostic factors were identified by chi-square and multivariateanalysis with significance of p&lt;0.05Results There were 56 patients eligible for the study. Among themwere 35 (63%) males and 21 (27%) females. Forty-three (77%)were less than one year of age, 40 (71%) without history of traumaand the major clinical manifestation was paleness (89%). The mostcommon location was subdural bleeding, 21 patients (38%). Fac-tors associated with prognosis was the bleeding location (p&lt;0.05)Conclusions Intracranial hemorrhage was more common in malesand in infants. The most common clinical manifestation was pale-ness. Bleeding location was associated with prognosis

204 Pediatrics Arteriovenous Malformations Treatment With Stereotactic Radiosurgery Gamma Knife

Abstract Arteriovenous malformations (AVMs) are the most common cause of intracranial hemorrhages in children. It is estimated that 12.18% will be symptomatic during the childhood. AVM obliteration depends on several factors, among the most important is a proper stereotactic nidus definition followed by delivery of an adequate dose. We retrospectively reviewed 24 children (13 girls and 11 boys) treated with stereotactic radiosurgery Gamma knife (SRS GK) between 2001 and 2014. The median patient age was 14 years (range, 6-18 years.). The mean AVM volume was 4.5 cm (range, 0.15-18.50 cm). The mean marginal dose for the single treatment group (21 patients) was 22.48 Gy (range 18-25 Gy). We confirm closure by angiography when MRI shows potential obliteration. Mean follow-up was 60 months. Of 12 (50%) children affected by neurological deficits before treatment, 5 (42%) were stable, 4 (33%) improved, 3 (25%) completely recovered at last follow-up. Eight (33%) children presented with epilepsy, of whom 5 (62, 5%) were stable after treatment, 2 (25%) improved, and 1 (12.5%) healed; 12 (50%) presented with hemorrhage, while we observed also 1 (4%) case of hemorrhage in the latency period; no patient died because of rebleeding. Conformity index of the plans is 0.63 (0.34-0.95); the mean Pollock-Flickinger Score is 0.80. Complete obliteration was achieved for 16 AVMs (66.7%). Five AVMs were reduced (20.8%); 3 were stable (12, 5%). No new neurological deficits were discovered after the SRS treatment and at last follow-up. None of patients presented bleeding after an angiographically verified obliteration. Radiosurgery is a safe and effective treatment for AVMs in the pediatric population. Crucial for success is the use of a prescription dose between 18 and 25 Gy, that is the same prescription doses for adult population. Following this paradigm, it is possible to obtain results that fall on the higher end of the distribution curve that vary from 35% to 95%.

The incidence, risk and functional outcomes of intracranial haemorrhage in children with inherited bleeding disorders at one haemophilia center.

Intracranial haemorrhage (ICH) is the most serious bleeding event for patients with inherited bleeding disorders (IBD). The risks and long-term consequences remain unknown. This single-centre service evaluation aimed to identify the incidence, risks and long-term outcomes following ICH in patients with IBD. The IBD database and medical notes between 1987 and 2013 were reviewed. Children without apparent neurological deficit following ICH completed standardized assessments and supplementary information sheets. ICH was confirmed in 38/1111 children with IBD. The overall risk of ICH amongst children with IBD was 3.4% (95% CI: 2.5, 4.7%). However, 27/38 had an ICH in the first year of life, 18 of which were in the neonatal period. In children with IBD who had an ICH, the risks of ICH in the neonatal period or first year of life were 18/38 (47%) (95% CI: 32, 63%) and 27/38 (71%) (95% CI: 55, 83%) respectively. Mortality risk from ICH in children with an IBD was 5/38 (13%) (95% CI: 5.8, 27.3 %). Ten of 32 survivors had known neurological sequelae including motor disorder deficits (MDD) while 22 had no documented evidence of neurological impairment or MDD. Re-evaluation was possible in 17/22 children, 8 of whom demonstrated evidence of MDD. After re-evaluation, the risk of significant neurological MDD from ICH increased from 31% CI (95% CI: 18, 49%) to 56% CI (95% CI: 39, 72%). Risks and consequences of ICH in IBD were highest within the neonatal period and first year of life. MDD after ICH was not reliably identified in early life and ongoing monitoring in the first decade of life will facilitate educational support or physical rehabilitation.

Eosinopenia in Children following Traumatic Intracranial Hemorrhage Is Associated with Poor Prognosis and Prolonged Hospital Admission

Background: Neutrophilia is associated with brain injury and is frequently accompanied by eosinopenia. Although eosinopenia is a poor prognostic indicator for various diseases, its significance in intracranial events has not been investigated. Methods: We retrospectively included 22 pediatric patients (≤18 years old) who experienced traumatic intracranial hemorrhage between 2002 and 2015. Patients were divided into two groups based on the presence or absence of eosinopenia on admission, i.e. the proportion of eosinophils to total white blood cells <1.0%. Results: The mean Glasgow Coma Scale score was marginally lower in the eosinopenia group (14.1 vs. 12.0, p = 0.06). The mean Glasgow Outcome Scale-Extended (GOSE) score was significantly lower in the eosinopenia group (7.5 vs. 5.7, p = 0.02), and the mean length of hospital stay tended to be longer in patients with eosinopenia (7.8 vs. 28.4, p = 0.10). In our multivariate logistic regression analysis, eosinopenia was the only significant risk factor for poor outcome (GOSE score 1-7, OR 29.7, p = 0.03) and prolonged hospital stay (>2 weeks, OR 7.1, p = 0.047). Conclusion: These results demonstrate the significance of eosinopenia as a novel prognostic factor in traumatic intracranial hemorrhage in children.

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients.

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.