Pediatric Intracerebral Hemorrhage Research Articles

Abstract TMP60: Contralesional Brain Regions Mirror the Volume Changes of Their Homologous Counterparts in the Ipsilesional Hemisphere in Children During the First Year After Unilateral Intracerebral Hemorrhage

Introduction: Structural changes following intracerebral hemorrhage (ICH) caused by ruptured brain vascular malformations (VMs) remain poorly understood. We conducted a longitudinal study to examine changes across ipsilesional and contralesional hemispheres after unilateral ICH, mainly in the temporoparietal area. Methods: Brain MRI was acquired in 8 patients aged 8-18 years ( Mean =15.13, SD =3.18) at presentation of ICH prior to treatment (baseline/Session 1) and repeated at 6 months (Session 2) and 12 months (Session 3) post-treatment. Using FreeSurfer 7.4.0, T1 and T2 FLAIR MR images were segmented into cortical and subcortical regions, with gray matter (GM) parcellated based on the DKT atlas. SynthSeg refined lesion extraction for more precise measurements of brain volume. Volume changes were quantified as percent change from baseline with signed values denoting increase or decrease. Pearson correlation and permutation testing ( n =5000) evaluated associations of homologous versus non-homologous regions. Results: There were significant correlations between the volume changes of homologous GM regions, for both Session 2 ( R =0.57, p <0.001) and Session 3 ( R =0.50, p <0.001), and of homologous GM in hemispheric lobes (Session 2: R =0.69, p <0.001; Session 3: R =0.67, p <0.001). Permutation tests confirmed that correlations of volume changes were greater for homologous than non-homologous regions and lobes for Sessions 2 and 3 ( p <0.001 except Session 3 lobes: p =0.016). Conclusions: We observed structural covariance of volume changes between homologous regions, most pronounced in the first 6 months after unilateral ICH. This indicates network-mediated distant effects of ICH, with atrophy reflected by diaschisis and volume recovery mirrored by positive neuroplasticity of contralateral homologs. Lesion-network mapping with correlation to long-term outcome would elucidate the effects of this long-range neuroplasticity following pediatric ICH.

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Mortality and functional outcome after pediatric intracerebral hemorrhage: cohort study and meta-analysis.

The clinical outcome of pediatric intracerebral hemorrhage (pICH) is rarely reported in a comprehensive way. In this cohort study, systematic review, and meta-analysis of patients with pICH, the authors aimed to describe the basic clinical outcomes of pICH. Children who received treatment for pICH at the authors' institution were prospectively enrolled in the cohort in 2008; data since 2000 were retrospectively included, and data through October 2019 were analyzed. The authors then searched PubMed and conducted a systematic review of relevant articles published since 1990. Data from the identified populations and patients from the cohort study were pooled into a multicategory meta-analysis and analyzed with regard to clinical outcomes. Among 243 children screened for inclusion, 231 patients were included. The median (IQR) age at ictus was 9.6 (4.6-12.5) years, and 128 patients (53%) were male. After a median (IQR) follow-up of 33 (13-63) months, 132 patients (57.4%) had a favorable clinical outcome, of whom 58 (44%) had no residual symptoms. Nineteen studies were included in the meta-analysis. Overall, the proportion of children with complete recovery was 27% (95% CI 19%-36%; Q = 49.6; I2 = 76%); of those with residual deficits, the complete recovery rate was 48.1% (95% CI 40%-57%; Q = 75.3; I2 = 81%). When pooled with the cohort study, the aggregate case-fatality rate at the last follow-up was 17.3% (95% CI 12%-24%; Q = 101.6; I2 = 81%). Here, the authors showed that 1 in 6 children died after pICH, and the majority of children had residual neurological deficits at the latest follow-up. Results from the cohort study also indicate that children with vascular lesions as the etiology of pICH had significantly better clinical functional outcomes.

Abstract P585: Age- and Sex-Specific Temporal Trends in the Incidence of Pediatric Stroke in New York State From 2006-2016

Objectives: 1. To estimate sex- and race-specific incidence of pediatric stroke by age group 2. To describe trends in pediatric stroke incidence in New York(NY) from 2006 to 2016 Methods: International Classification of Disease codes were used to retrospectively to identify all acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral venous thrombosis (CVT) admissions in pediatric patients (0-19 years old [yo]) in the 2006-2016 NY State Inpatients Database (SID; total N=4,083). Incident counts were combined with annual US Census data to compute age- and sex-specific incidence. Joinpoint regression was used to evaluate trends in incidence over time. Results: Across the study period, 52% of all pediatric strokes were AIS, 23% ICH, 11% SAH, and 14% CVT. Total stroke incidence/100,000 population was 47.8 and the age-standardized incidence in >=1yo was 4.8. Incidence differed by age (1-4yo: 4.4, 5-9yo: 3.6, 10-14yo: 4.5, and 15-19yo: 6.7), but not by sex. Age-standardized incidence of strokes in >=1yo also differed by race (Blacks 5.9, Whites 4.0, Hispanics 3.3, Asians/Pacific Islanders 3.1). While there was no change in overall stroke, AIS, or SAH incidence, ICH (annualized percentage change [APC] 4.3%, 95%CI 1.7-6.9) and CVT (APC 4.1, 95%CI 1.22-6.25%) increased over time. When stratified by age, overall stroke incidence increased over time in 15-19 yo (APC 1.3%, 95%CI 0.27-2.35, p=0.019), but not in other age groups. Conclusion: We observed increasing incidence in pediatric ICH, CVT, and overall stroke in 15-19 yo in the state of NY. Pediatric stroke incidence in NY is disproportionately higher in blacks compared to other races. Further investigation is warranted to determine the association of these changes with risk factors, lifestyle and systems of care.

Etiology of intracerebral hemorrhage in children: cohort study, systematic review, and meta-analysis.

Understanding the etiological spectrum of nontraumatic pediatric intracerebral hemorrhage (pICH) is key to the diagnostic workup and care pathway. The authors aimed to evaluate the etiological spectrum of diseases underlying pICH. Children treated at the authors' institution for a pICH were included in an inception cohort initiated in 2008 and retrospectively inclusive to 2000, which was analyzed in October 2019. They then conducted a systematic review of relevant articles in PubMed published between 1990 and 2019, identifying cohorts with pICH. Identified populations and patients from the authors' cohort were pooled in a multicategory meta-analysis. A total of 243 children with pICH were analyzed in the cohort study. The final primary diagnosis was an intracranial vascular lesion in 190 patients (78.2%), a complication of a cardiac disease in 17 (7.0%), and a coagulation disorder in 14 (5.8%). Hematological and cardiological etiologies were disproportionately more frequent in children younger than 2 years (p < 0.001). The systematic review identified 1309 children in 23 relevant records pooled in the meta-analysis. Overall, there was significant heterogeneity. The dominant etiology was vascular lesion, with an aggregate prevalence of 0.59 (95% CI 0.45-0.64; p < 0.001, Q = 302.8, I2 = 92%). In 18 studies reporting a detailed etiological spectrum, arteriovenous malformation was the dominant etiology (68.3% [95% CI 64.2%-70.9%] of all vascular causes), followed by cavernoma (15.7% [95% CI 13.0%-18.2%]). The most frequent etiology of pICH is brain arteriovenous malformation. The probability of an underlying vascular etiology increases with age, and, conversely, hematological and cardiac causes are dominant causes in children younger than 2 years.

Hemorrhage Expansion After Pediatric Intracerebral Hemorrhage.

Significant hemorrhage expansion (sHE) is a known predictor of poor outcome after an intracerebral hemorrhage (ICH) in adults but remains poorly reported in children. In a large inception cohort, we aimed to explore the prevalence of sHE, its associations with clinical outcomes, and its clinical-imaging predictors in children. Children admitted between January 2000 and March 2020 at a quaternary care pediatric hospital were screened for inclusion. Sample was restricted to children with 2 computed tomography scans within 72 hours of ICH onset, and a minimal clinical follow-up of months. sHE was defined as an increase from baseline ICH volume by 6 cc or 33% on follow-up computed tomography. Clinical outcome was assessed at 12 months with the King's Outcome Scale for Childhood Head Injury score and defined as favorable for scores ≥5. Fifty-two children met inclusion criteria, among which 8 (15%) demonstrated sHE, and 18 (34.6%) any degree of expansion. Children with sHE had more frequent coagulation disorders (25.0% versus 2.3%; P=0.022). After multivariable adjustment, only the presence of coagulation disorders at baseline remained independently associated with sHE (adjusted odds ratio, 14.4 [95% CI, 1.04-217]; P=0.048). sHE was independently associated with poor outcome (King's Outcome Scale for Childhood Head Injury <5A, odds ratio, 5.77 [95% CI, 1.01-38.95]; P=0.043). sHE is a frequent phenomenon after admission for a pediatric ICH and more so in children with coagulation defects. As sHE was strongly associated with poorer clinical outcomes, these data mandate a baseline coagulation work up and questions the need for protocolized repeat head computed tomography in children admitted for pediatric ICH.

Neuroimaging of Pediatric Intracerebral Hemorrhage.

Hemorrhagic strokes account for half of all strokes seen in children, and the etiologies of these hemorrhagic strokes differ greatly from those seen in adult patients. This review gives an overview about incidence and etiologies as well as presentation of children with intracerebral hemorrhage and with differential diagnoses in the emergency department. Most importantly it describes how neuroimaging of children with intracerebral hemorrhage should be tailored to specific situations and clinical contexts and recommends specific imaging protocols for acute and repeat imaging. In this context it is important to keep in mind the high prevalence of underlying vascular lesions and adapt the imaging protocol accordingly, meaning that vascular imaging plays a key role regardless of modality. Magnetic resonance imaging (MRI), including advanced sequences, should be favored whenever possible at the acute phase.

First Line Onyx Embolization in Ruptured Pediatric Arteriovenous Malformations : Safety and Efficacy.

Brain arteriovenous malformations (bAVM) are the main cause of pediatric intracerebral hemorrhage (pICH). Embolization with Onyx (ev3, Irvine, CA, USA) in children with ruptured bAVM has been infrequently reported. The aim of this study was to assess the safety and efficacy profile of Onyx embolization as first line endovascular treatment of ruptured pediatric bAVMs. Children with non-traumatic pICH due to bAVM rupture at apediatric quaternary care center were prospectively enrolled in aregistry and retrospectively analyzed between 2013 and 2018. Clinical and demographic data, treatment modalities and clinical imaging follow-up were retrieved, and detailed procedural data were retrospectively assessed by two investigators. The safety (procedural morbidity and mortality) and efficacy (obliteration and interval rebleeding) were evaluated. In this study 29children treated for abAVM by Onyx embolization were included (14girls, 48%; median age 11.1years, interquartile range, IQR 8.1-12.7years) with atotal of 72endovascular sessions (median of 2sessions per patient IQR 1-3). The AVMs were deeply located in 23patients (79%). No systemic complications occurred, and no child experienced embolization-related persistent neurological deficits. Non-clinically relevant complications were observed during five procedures, unrelated to Onyx. After amean follow-up of 31months from rupture complete obliteration rates were 100%, 89%, 29%, 14% in bAVM Spetzler Martin gradesI, II, III andIV-V, respectively. It was found that Onyx embolization is safe and represents agood option for an initial treatment approach, in asequential treatment strategy for pediatric ruptured brain AVMs. Younger age may not be an argument to deny Onyx embolization.

Nontraumatic Pediatric Intracerebral Hemorrhage.

Nontraumatic Pediatric Intracerebral Hemorrhage.

Neurologic Outcome Predictors in Pediatric Intracerebral Hemorrhage: A Prospective Study.

Intracerebral hemorrhage is a considerable source of morbidity and mortality. This 3-center study describes outcomes of pediatric intracerebral hemorrhage and identifies 2-year neurological outcome predictors. Children 29 days to 18 years of age presenting with intracerebral hemorrhage from March 2007 to May 2015 were enrolled prospectively. Exclusion criteria included trauma; intracranial tumor; hemorrhagic transformation of arterial ischemic stroke or cerebral sinovenous thrombosis; isolated subdural, epidural, or subarachnoid hemorrhage; and abnormal baseline neurological function. Intracerebral hemorrhage and total brain volumes were measured on neuroimaging. The Pediatric Stroke Outcome Measure assessed outcomes. Sixty-nine children were included (median age: 9.7 years; interquartile range: 2.2-14). Six children (9%) died during hospitalization. Outcomes in survivors were assessed at early follow-up in 98% (median 3.1 months; interquartile range: 3.1-3.8) and at later follow-up in 94% (median: 2.1 years; interquartile range: 1.3-2.8). Over a third had a significant disability at 2 years (Pediatric Stroke Outcome Measure >2). Total Pediatric Stroke Outcome Measure score improved over time (P=0.0003), paralleling improvements in the sensorimotor subscore (P=0.0004). Altered mental status (odds ratio, 13; 95% confidence interval, 3.9-46; P<0.001), hemorrhage volume ≥4% of total brain volume (odds ratio, 17; 95% confidence interval, 1.9-156; P=0.01), and intensive care unit length of stay (odds ratio, 1.1; 95% confidence interval, 1.0-1.2; P=0.002) were significantly associated with poor 2-year outcome. Over one third of children experienced significant disability at 2 years. Improvements in outcomes were driven by recovery of sensorimotor function. Altered mental status, hemorrhage volume ≥4% of total brain volume, and intensive care unit length of stay were independent predictors of significant disability at 2 years.

Predictors of Outcome in Patients with Pediatric Intracerebral Hemorrhage: Development and Validation of a Modified Score.

Purpose To propose and validate a modified pediatric intracerebral hemorrhage (PICH) (mPICH) score and to compare its association with functional outcome to that of the original PICH score. Materials and Methods Data from prospectively included patients were retrospectively analyzed. Consecutive patients with nontraumatic PICH who had undergone clinical follow-up were included. The study population was divided into a development cohort (2008-2012, n = 100) and a validation cohort (2013-2016, n = 43). An mPICH score was developed after variables associated with poor outcome were identified at multivariate analysis (King's Outcome Scale for Childhood Head Injury score < 5a) in the development cohort. The accuracy of the score for prediction of poor outcome was evaluated (sensitivity, specificity). Discrimination and calibration of associations between the mPICH score and poor outcome cohorts were assessed (C statistics, Hosmer-Lemeshow test). Results The mPICH score assessed as follows: brain herniation, four points; altered mental status, three points; hydrocephalus, two points; infratentorial PICH, two points; intraventricular hemorrhage, one point; PICH volume greater than 2% of total brain volume, one point. An mPICH score greater than 5 was associated with severe disability or worse, with sensitivity of 97% (95% confidence interval [CI]: 83%, 100%) and specificity of 61% (95% CI: 49%, 73%). The C statistic was 0.81 (95% CI: 0.73, 0.89). In the validation cohort, sensitivity and specificity were 95.2% (95% CI: 76%, 99%) and 77% (95% CI: 55%, 92%), respectively. There was no significant difference between the observed and predicted risks of poor outcome (P = .46). Conclusion An mPICH score was developed as a simple clinical and imaging grading scale for acute prognosis in patients with PICH. © RSNA, 2017.

Cognitive functioning over 2 years after intracerebral hemorrhage in school-aged children.

Previous research investigating outcomes after pediatric intracerebral hemorrhage (ICH) has generally been limited to global and sensorimotor outcomes. This study examined cognitive outcomes after spontaneous ICH in school-aged children with serial assessments over 2 years after stroke. Seven children (age range 6-16y, median 13; six males, one female; 57% white, 43% black) presenting with spontaneous ICH (six arteriovenous malformations) were assessed at 3 months, 12 months, and 24 months after stroke. The Pediatric Stroke Outcome Measure (PSOM) quantified neurological outcome and Wechsler Intelligence Scales measured cognitive outcomes: verbal comprehension, perceptual reasoning, working memory, and processing speed. PSOM scales showed improved neurological function over the first 12 months, with mild to no sensorimotor deficits and moderate overall deficits at 1- and 2-year follow-ups (median 2-year sensorimotor PSOM=0.5, total PSOM=1.5). Changes in cognitive function indicated a different trajectory; verbal comprehension and perceptual reasoning improved over 24 months; low performance was sustained in processing speed and working memory. Age-normed centile scores decreased between 1- and 2-year follow-ups for working memory, suggesting emerging deficits compared with peers. Early and serial cognitive testing in children with ICH is needed to assess cognitive functioning and support children in school as they age and cognitive deficits become more apparent and important for function. In children with intracerebral hemorrhage (ICH), motor function improved between 3 months and 24 months. Improvements in cognitive function were variable between 3 months and 24 months. Working memory centiles declined, suggesting emerging deficits compared with peers. Processing speed improved but remained significantly below the 50th centile. Cognitive impact of ICH may increase with age in children.

Role of ghrelin in small intestinal motility following pediatric intracerebral hemorrhage in mice

Small intestinal motility (SIM) disorder is a common complication following pediatric intracerebral hemorrhage(ICH), leading to a poor prognosis in patients. Previous studies have shown that ghrelin is involved in SIM in various diseases; however, the role of ghrelin in pediatric ICH‑induced SIM disorder remains to be elucidated. The present study was designed to investigate the association between ghrelin and SIM post‑ICH, and to examine the effect of exogenous ghrelin administration on SIM invivo. An ICH model was induced in mice by autologous blood infusion. Neurobehavioral deficits were evaluated using a Rotarod test, forelimb placing test, and corner turn test. Intestinal mucosal damage was examined using hematoxylin and eosin staining. SIM was measured using charcoal meal staining. An enzyme‑linked immunosorbent assay was used to evaluate serum levels of ghrelin and nitric oxide (NO). Reverse transcription‑quantitative polymerase chain reaction and western blot analyses were performed to determine the levels of inducible nitric oxide synthase (iNOS), neuronal nitric oxide synthase (nNOS) and endothelial nitric oxide synthase (eNOS) at the mRNA and protein levels. Nω‑nitro‑L‑arginine methyl ester hydrochloride (L‑NAME), L‑arginine, atropine, phentolamine and propranolol were used to manipulate the putative pathways induced by ghrelin. Neurological dysfunction was observed post‑ICH. ICH caused damage to the intestinal mucosa and delayed SIM. Serum levels of ghrelin increased between 3h and 3days, peaking at 12h, and showed a significant negative correlation with SIM post‑ICH. Ghrelin administration dose‑dependently attenua-ted ICH‑induced SIM disorder. Ghrelin also decreased NO levels by downregulating the mRNA and protein expression levels of iNOS, but not those of nNOS or eNOS, post‑ICH. Consistently, the effect was enhanced by L‑NAME and weakened by L‑arginine, respectively. The protective effect of ghrelin was eradicated by atropine, but not phentolamine or propranolol. These findings suggested that ghrelin ameliorated SIM disorder by downregulating iNOS/NO via the cholinergic pathway. Therefore, ghrelin may serve as a potential biomarker and useful target in ICH‑induced SIM disorder.

Educational Placement After Pediatric Intracerebral Hemorrhage

BackgroundThis study describes educational placement of school-aged children after spontaneous intracerebral hemorrhage and examines whether educational placement is associated with severity of neurological deficits. MethodsChildren with spontaneous intracerebral hemorrhage presenting from 2007 to 2013 were prospectively enrolled at three tertiary children's hospitals. The Pediatric Stroke Outcome Measure and parental interview gathered information about neurological outcome, school attendance, and educational placement. ResultsThe cohort of 92 enrolled children included 42 school-aged children (6 to 17 years) with intracerebral hemorrhage. Four children died; one was excluded because of preexisting cognitive deficits. Thirty-seven children completed three-month follow-up, and 30 completed 12-month follow-up. At 12 months, 14 children (46.7%) received regular age-appropriate programming, 12 (40%) attended school with in-class services, three (10%) were in special education programs, and one child (3.3%) received home-based services because of intracerebral hemorrhage–related deficits. Of 30 children with three- and 12-month follow-up, 14 (46.7%) improved their education status, 13 (43.3%) remained at the same education level, and three (10%) began to receive in-class services. An increasing Pediatric Stroke Outcome Measure score predicted the need for educational modifications at three months (odds ratio, 3.3; 95% confidence interval, 1.4 to 7.9; P = 0.007) and at 12 months (odds ratio, 2.1; 95% confidence interval, 1.1 to 3.9; P = 0.025). ConclusionsMost children returned to school within a year after intracerebral hemorrhage, and many had a reduction in the intensity of educational support. However, a great need for educational services persisted at 12 months after intracerebral hemorrhage with fewer than half enrolled in regular age-appropriate classes. Worse deficits on the Pediatric Stroke Outcome Measure were associated with remedial educational placement.

Spontaneous intracerebral hemorrhage: A pediatric case of undetermined etiology and review of literature

Cerebrovascular disorders, particularly intracerebral hemorrhage (ICH), rarely occur in children. The most common underlying cause for ICH in the pediatric population is arteriovenous malformation (AVM). The best approach to diagnostic evaluation of pediatric ICH is unknown due to its low incidence (2-3/100,000 children). In recent years, early discovery of underlying cause of pediatric ICH has been possible due to a more widespread use of imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). We report a case of a 5-year-old boy with a ICH of unknown etiology. He presented with left hemiparesis and left facial droop for one hour. Non- contrast CT scan demonstrated right periventricular hematoma extending to all ventricles. Follow-up MRI, CT angiography and DSA were unremarkable. Laboratory findings including liver function tests, hematologic studies were normal. Screening for hemoglobinopathies was negative. Transthoracic echocardiography was unremarkable. Surgery for ventricular drain place- ment and intense physical therapy were performed. During the follow ups at 1 and 6 mo of initial admission, repeat brain MRI and magnetic resonance angiography were unremarkable. The complete diagnostic evaluation in children presenting with ICH of undetermined origin is critically important,but stillthe etiol- ogy may not be identified in some cases. As AVMs are the most common cause of ICH in children and may rarely regress following hemorrhage, our patient's normal follow-up imaging may be related to such a spontaneous thrombosis of an underlying AVM.

Pediatric Intracerebral Hemorrhage Score

The intracerebral hemorrhage (ICH) score is the most commonly used clinical grading scale for outcome prediction after adult ICH. We created a similar scale in children to inform clinical care and assist in clinical research. Children, full-term newborns to 18 years, with spontaneous ICH were prospectively enrolled from 2007 to 2012 at 3 centers. The pediatric ICH score was created by identifying factors associated with poor outcome. The score's ability to detect moderate disability or worse and severe disability or death was examined with sensitivity, specificity, and area under the receiver operating characteristic curve. The pediatric ICH score components include ICH volume>2% to 3.99% of total brain volume (TBV): 1 point; ICH volume≥4% TBV: 2 points; acute hydrocephalus: 1 point; herniation: 1 point; and infratentorial location: 1 point. The score ranges from 0 to 5. At 3-month follow-up of 60 children, 10 were severely disabled or dead, 30 had moderate disability, and 20 had good recovery. A pediatric ICH score≥1 predicted moderate disability or worse with a sensitivity of 75% (95% confidence interval [CI], 59% to 87%) and a specificity of 70% (95% CI, 46% to 88%). A pediatric ICH score≥2 predicted severe disability or death with a sensitivity and specificity of 90% (95% CI, 55% to 99%) and 68% (95% CI, 53% to 80%), respectively. The area under the receiver operating characteristic curve for classifying outcome as severe disability or death was 0.88 (95% CI, 0.78-0.97). The pediatric ICH score is a simple clinical grading scale that may ultimately be used for risk stratification, clinical care, and research.

Pediatric Intracerebral Hemorrhage, Acute Seizures, and Epilepsy

Pediatric Intracerebral Hemorrhage, Acute Seizures, and Epilepsy

Abstract TMP99: Pediatric Intracerebral Hemorrhage: Acute Symptomatic Seizures and Epilepsy

Background and Objectives: We aimed to define the incidence of acute symptomatic seizures and of remote symptomatic seizures and epilepsy after spontaneous pediatric intracerebral hemorrhage (ICH). Methods: Pediatric patients with spontaneous ICH presenting between 2007 and 2012 at three tertiary care centers were prospectively identified. Acute symptomatic seizures were defined as seizures occurring from presentation to 7 days after ICH. Survival analysis was used to assess development of a first remote symptomatic seizure and epilepsy (2 or more unprovoked seizures &gt;7 days after ICH). Log-rank tests were used to examine putative risk factors for development of remote symptomatic seizures and epilepsy. Results: Seventy-three pediatric subjects with spontaneous ICH were identified, including 20 perinatal (≥37 weeks gestation to 28 days) and 53 childhood subjects (&gt;28 days to &lt;18 years). Acute symptomatic seizures occurred in 12 (60%) perinatal and 23 (43%) childhood subjects, p=.29, Fisher’s exact. Median age of childhood subjects with acute symptomatic seizures was younger than those without (2.2 versus 10.8 years, p=.006, rank-sum). Electrographic-only seizures occurred in 28% of 32 subjects who had continuous EEG monitoring. Follow-up was not different between perinatal and childhood subjects (median 371 versus 340 days), p=.68, rank-sum. One and two-year remote symptomatic seizure-free survival were 82% (95% CI 68-91%) and 67% (95% CI 46-82%). One and two-year epilepsy-free survival were 96% (95% CI 83-99%) and 87% (95% CI 65-95%). Elevated intracranial pressure (ICP) requiring urgent intervention was a risk factor for remote symptomatic seizures and epilepsy (p=.024 and p=.037, log-rank test). Conclusions: Acute symptomatic seizures are common in both perinatal and childhood ICH. Continuous EEG monitoring may identify electrographic-only seizures in some subjects. By two-years after ICH it is estimated that about one-third of patients will have a single remote symptomatic seizures and that about 13% will develop epilepsy. Elevated ICP requiring intervention is a risk factor for remote symptomatic seizures and epilepsy.

Cancer Risks from CT Scans: Now We Have Data, What Next?

Ten years after the suggestion that CT scans might produce a small cancer risk, Pearce et al have shown that this is almost certainly the case, and they have confirmed the numerical magnitude of the risks; more complete epidemiologic studies are needed and several are indeed in progress, but in the interim, estimation of medical radiation risks based on atomic bomb survivor data appears to yield reasonable results.

Evaluation of Intraventricular Hemorrhage in Pediatric Intracerebral Hemorrhage

Previous studies of pediatric intracerebral hemorrhage have investigated isolated intraparenchymal hemorrhage. The authors investigated whether detailed assessment of intraventricular hemorrhage enhanced outcome prediction after intracerebral hemorrhage. They prospectively enrolled 46 children, full-term to 17 years, median age 2.7 years, with spontaneous intraparenchymal hemorrhage and/or intraventricular hemorrhage. Outcome was assessed with the King's Outcome Scale for Childhood Head Injury. Twenty-six (57%) had intraparenchymal hemorrhage, 10 (22%) had pure intraventricular hemorrhage, and 10 (22%) had both. There were 2 deaths, both with intraparenchymal hemorrhage and intraventricular hemorrhage volume ≥4% of total brain volume. Presence of intraventricular hemorrhage was not associated with poor outcome, but hydrocephalus showed a trend (P = .09) toward poor outcome. In receiver operating characteristic curve analysis, combined intraparenchymal hemorrhage and intraventricular hemorrhage volume also showed a trend toward better outcome prediction than intraparenchymal hemorrhage volume alone. Although not an independent outcome predictor, future studies should assess intraventricular hemorrhage qualitatively and quantitatively.