Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, Connecticut.
Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
JAMA Neurol. 2014 Feb;71(2):165-71. doi: 10.1001/jamaneurol.2013.4672.
Hematoma expansion is the only modifiable predictor of outcome in adult intracerebral hemorrhage; however, the frequency and clinical significance of hematoma expansion after childhood intracerebral hemorrhage are unknown.
To assess the frequency and extent of hematoma expansion in children with nontraumatic intracerebral hemorrhage.
DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study at 3 tertiary care pediatric hospitals. Children (≥ 37 weeks' gestation to 18 years) with nontraumatic intracerebral hemorrhage were enrolled in a study from 2007 to 2012 focused on predictors of outcome. For this planned substudy of hematoma expansion, neonates 28 days or younger and participants with isolated intraventricular hemorrhage were excluded. Children with 2 head computed tomography (CT) scans within 48 hours were evaluated for hematoma expansion and were compared with children with only 1 head CT scan. Consent for the primary cohort was obtained from 73 of 87 eligible participants (84%); 41 of 73 children enrolled in the primary cohort met all inclusion/exclusion criteria for this substudy, in whom 22 had 2 head CT scans obtained within 48 hours that could be evaluated for hematoma expansion. Within our substudy cohort, 21 of 41 (51%) were male, 25 of 41 (61%) were white, 16 of 41 (39%) were black, and median age was 7.7 years (interquartile range, 2.0-13.4 years).
Primary outcome was prevalence of hematoma expansion.
Of 73 children, 41 (56%) met inclusion criteria, and 22 (30%) had 2 head CT scans to evaluate expansion. Among these 22 children, median time from symptom onset to first CT was 2 hours (interquartile range, 1.3-6.5 hours). Median baseline hemorrhage volume was 19.5 mL, 1.6% of brain volume. Hematoma expansion occurred in 7 of 22 (32%). Median expansion was 4 mL (interquartile range, 1-11 mL). Three children had significant (>33%) expansion; 2 required urgent hematoma evacuation. Expansion was not associated with poorer outcome. Compared with children with only 1 head CT scan within 48 hours, children with 2 head CT scans had larger baseline hemorrhage volumes (P = .05) and were more likely to receive treatment for elevated intracranial pressure (P < .001).
Hematoma expansion occurs in children with intracerebral hemorrhage and may require urgent treatment. Repeat CT should be considered in children with either large hemorrhage or increased intracranial pressure.
血肿扩大是成人颅内出血结局的唯一可改变的预测因素；然而，儿童颅内出血后血肿扩大的频率和临床意义尚不清楚。
评估非外伤性颅内出血儿童的血肿扩大频率和程度。
设计、地点和参与者：在 3 家三级儿童保健医院进行前瞻性观察队列研究。2007 年至 2012 年，对患有非外伤性颅内出血的儿童进行了一项研究，重点是对结局的预测因素。对于本研究中关于血肿扩大的计划子研究，排除了 28 天或更小的新生儿和仅伴有单纯脑室内出血的参与者。对在 48 小时内进行了 2 次头部计算机断层扫描（CT）的儿童进行血肿扩大评估，并与仅进行了 1 次头部 CT 扫描的儿童进行比较。对符合条件的 73 名参与者中的 73 名（84%）进行了原发性队列的同意书签署；在纳入的 73 名儿童中，有 41 名符合本亚研究的所有纳入/排除标准，其中 22 名在 48 小时内获得了 2 次头部 CT 扫描，可用于评估血肿扩大。在我们的子研究队列中，41 名儿童中有 21 名（51%）为男性，41 名中有 25 名（61%）为白人，41 名中有 16 名（39%）为黑人，中位年龄为 7.7 岁（四分位距，2.0-13.4 岁）。
主要结局是血肿扩大的发生率。
在 73 名儿童中，有 41 名（56%）符合纳入标准，22 名（30%）进行了 2 次头部 CT 扫描以评估血肿扩大。在这 22 名儿童中，从症状发作到首次 CT 的中位时间为 2 小时（四分位距，1.3-6.5 小时）。中位基线出血体积为 19.5 mL，占脑体积的 1.6%。血肿扩大发生在 22 名儿童中的 7 名（32%）。中位扩大为 4 mL（四分位距，1-11 mL）。3 名儿童血肿扩大明显（>33%）；2 名需要紧急血肿清除术。血肿扩大与较差的结局无关。与在 48 小时内仅接受 1 次头部 CT 扫描的儿童相比，接受 2 次头部 CT 扫描的儿童的基线出血体积更大（P=0.05），更有可能接受颅内压升高的治疗（P<0.001）。
儿童颅内出血会发生血肿扩大，可能需要紧急治疗。对于出血量大或颅内压升高的儿童，应考虑重复 CT 检查。
