Rationale and Objectives
The purposes of this study were to retrospectively identify various etiologies underlying intracranial hemorrhages (ICHs) in term infants aged <2 years and their respective prevalence in this population and to describe the long-term clinical outcomes in these patients.
Materials and Methods
A retrospective review of the medical records and computed tomographic studies of the head in 798 term infants aged 0 to 24 months with suspected or known ICHs was conducted.
Results
ICHs were present in 195 of the 798 infants (24%). More than one type of ICH was present in 32%. Subdural hemorrhage was the most frequent type of ICH, occurring in 63% of the infants. Good clinical outcomes were present in 49% of the infants but varied depending on the location, etiology, and timing of the ICH.
Conclusion
The incidence of various etiologies of ICH depended on the ages of the infants. The overall clinical outcomes were good, with no long-term sequelae in half of the infants presenting with ICHs. In infants aged >4 weeks presenting with ICHs, special attention should be given to the possibility of nonaccidental trauma etiology, because this is common and has worse long-term outcomes.
The list of etiologies of intracranial hemorrhage (ICH) in the full-term infant population is long, with trauma being the most common etiology and the most common cause of morbidity and mortality . This list includes, among other entities, veno-occlusive disease, cerebrovascular accidents, sepsis, liver failure or platelet abnormalities, and tumors. Infants are at special risk for ICH from head trauma because of the thinness and increased pliability of their skulls. Previous studies have shown that even asymptomatic neonates can have ICHs following vaginal delivery , with one study finding a prevalence of 26% on the basis of magnetic resonance imaging . Besides trauma, many other causes of ICHs have been described , but to our knowledge, no data on prevalence are available in the literature.
The finding of ICH in the full-term infant population is typically made by ultrasound. However, over the past decade, there has been an increase in the use of computed tomography (CT) of the head in pediatric patients in emergency departments , including a 23% increase in the infant population . Besides its wide availability and low cost, the benefit of head CT lies in the early diagnosis of head trauma, which can reduce both morbidity and mortality.
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Materials and methods
Patient and Data Collection
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Table 1
Comparing Male and Female Infants, as a Whole and within Each Group, with Respect to Frequency and Type of Hemorrhage and Long-term Clinical Outcomes
All Patients Group A Group B Group C Variable M F M F M F M F Positive/total head CT 132/467 63/331 25/64 13/46 26/75 8/52 81/328 42/233 Positive/total CT (%) 28 ∗ 19 ∗ 39 28 35 † 15 † 25 18 Average age (d) 224.53 210.75 2.03 2.15 11.23 15.63 316.30 296.33 ICH SDH 80 (61%) 36 (57%) 13 (52%) 9 (69%) 14 (54%) 2 (25%) 53 (65%) 25 (60%) EDH 12 (9%) 7 (11%) 0 (0%) 0 (0%) 0 (0%) 1 (13%) 12 (15%) 6 (14%) SAH 28 (21%) 17 (27%) 12 (48%) 3 (23%) 4 (15%) 2 (25%) 12 (15%) 12 (29%) IPH 25 (19%) 13 (21%) 5 (20%) 3 (23%) 7 (27%) 4 (50%) 13 (16%) 6 (14%) IVH 18 (14%) 14 (22%) 5 (20%) 4 (31%) 9 (35%) 4 (50%) 4 (5%) 6 (14%) EAH 11 (8%) 5 (8%) 3 (12%) 1 (8%) 1 (4%) 1 (13%) 7 (9%) 3 (7%) Multiple 38 (29%) 25 (40%) 11 (44%) 5 (38%) 9 (35%) 6 (75%) 18 (22%) 14 (33%) Lost to follow-up 18 15 2 2 4 3 12 10 Clinical outcome No complication 55 (48%) 25 (52%) 16 (70%) 10 (91%) 8 (36%) 2 (40%) 31 (45%) 13 (41%) Developmental delay 12 (11%) 3 (6%) 1 (4%) 0 (0%) 3 (14%) 0 (0%) 8 (12%) 3 (9%) Seizure disorder 15 (13%) 7 (15%) 2 (9%) 1 (9%) 3 (14%) 0 (0%) 10 (14%) 6 (19%) Cerebral palsy 13 (11%) 4 (8%) 3 (13%) 1 (9%) 4 (18%) 0 (0%) 6 (9%) 3 (9%) Autism 2 (2%) 0 (0%) 1 (4%) 0 (0%) 0 (0%) 0 (0%) 1 (1%) 0 (0%) Death 21 (18%) 6 (13%) 3 (13%) 0 (0%) 6 (27%) 3 (60%) 12 (17%) 3 (9%)
CT, computed tomography; EAH, extra-axial hemorrhage; EDH, epidural hemorrhage; ICH, intracranial hemorrhage; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage.
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Table 2
Comparing Clinical Outcomes by Each Etiology for Each Etiology That Represented >10% of Patients within a Group with Intracranial Hemorrhages
Clinical Outcome Etiology by Group No Complication Developmental Delay Cerebral Palsy Epilepsy Death Group A Birth trauma ( n = 14) 11 (79%) 0 (0%) 2 (14%) 1 (7%) 1 (7%) Perinatal event ( n = 15) 11 (73%) 1 (7%) 1 (7%) 2 (13%) 2 (13%) Group B ECMO ( n = 11) 1 (9%) 1 (9%) 1 (9%) 0 (0%) 8 (73%) Unknown ( n = 6) 4 (67%) 1 (17%) 1 (17%) 1 (17%) 0 (0%) Group C Falls ( n = 20) 13 (65%) ∗ 2 (10%) 0 (0%) 2 (10%) 1 (5%) Abuse ( n = 26) 8 (31%) ∗ 5 (19%) 3 (12%) 6 (23%) 3 (12%) MVA ( n = 17) 8 (47%) 2 (12%) 1 (6%) 3 (18%) 4 (24%) Postoperative ( n = 12) 6 (50%) 0 (0%) 0 (0%) 1 (8%) 4 (33%)
ECMO, extracorporeal membrane oxygenation; MVA, motor vehicle accident.
Patients lost to follow-up were removed from evaluation of clinical outcome.
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Table 3
Comparing the Frequencies of the Types of Hemorrhages Present on the Basis of Etiology within Each Group
Type of Hemorrhage Etiology by Group SDH IPH EDH IVH SAH Multiple Group A Birth trauma ( n = 14) 11 (79%) 1 (7%) 0 (0%) 2 (14%) 4 (29%) 6 (43%) Perinatal event ( n = 17) 7 (41%) 4 (24%) 0 (0%) 5 (29%) 9 (53%) 6 (35%) Group B ECMO ( n = 16) 8 (50%) 7 (44%) 0 (0%) 6 (38%) 4 (25%) 9 (56%) Unknown ( n = 6) 5 (83%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) Group C Falls ( n = 33) 16 (48%) ∗ 13 (39%) 16 (48%) † 0 (0%) 2 (61%) 4 (12%) Abuse ( n = 28) 25 (89%) ∗ 5 (18%) 2 (7%) † 2 (7%) 7 (25%) 11 (39%) MVA ( n = 19) 12 (63%) 3 (16%) 2 (11%) 2 (11%) 11 (58%) ‡ 11 (58%) Postoperative ( n = 15) 11 (73%) 2 (13%) 0 (0%) 1 (7%) 3 (20%) 2 (13%)
ECMO, extracorporeal membrane oxygenation; EDH, epidural hemorrhage; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; MVA, motor vehicle accident; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage.
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Statistical Analysis
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Results
Patients
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Discussion
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