Intracranial hemorrhage in children

Introduction to intracranial hemorrhage in children Intracranial hemorrhage (ICH), also known as hemorrhagic cerebrovascular disease or hemorrhagic stroke, is caused by cerebral vascular rupture causing blood to overflow into the cranial cavity. Depending on the location of the bleeding, ICH can be divided into cerebral hemorrhage and subarachnoid space. Hemorrhage and subdural hemorrhage, etc., regardless of the cause of pediatric ICH, its clinical manifestations have many similarities, but the prognosis is very different depending on the disease, and whether the diagnosis and treatment are timely also directly affect the prognosis The key factor. basic knowledge The proportion of the disease: the proportion of the disease in a specific group is 0.01%-0.02% Susceptible people: children Mode of infection: non-infectious Complications: hemiplegia, aphasia, somatosensory disorder, disturbance of consciousness

Causes of intracranial hemorrhage in children

Cerebrovascular malformations (30%):

Cerebral arteriovenous malformation is one of the common causes of childhood ICH. It can be divided into congenital, infectious and traumatic. Congenital cerebral vascular malformations include hemangioma and arteriovenous fistula. The former is caused by defects in the development of the vascular wall. Found in the bifurcation of the distal small artery, the aneurysm with a diameter of 6 ~ 15mm is prone to rupture and hemorrhage; the latter is caused by the movement of the capillary system between the venous system, and the short circuit between the veins is short-circuited, resulting in the artery of the ward. Expanded into an aneurysmal-like malformation, and oppressed the surrounding brain tissue, easy to rupture bleeding, more common with Galen venous malformation, infectious cerebral arteriovenous malformations such as intracranial bacterial or fungal aneurysms, infective endocarditis Infection with emboli; human immunodeficiency virus infection can also lead to the occurrence of intracranial aneurysms in children, traumatic cerebral arteriovenous malformation is rare, only occurs in the cavernous sinus, because the internal carotid artery is located here, so the trauma can be Carotid-cavernous sinus fistula.

Other types of cerebrovascular malformations include telangiectasia, cavernous hemangioma, dementia of the soft meningeal vein and capillaries, and abnormal vascular network (Moyamoya disease) in the brain.

Blood disease (25%):

Hematological disease is an important cause of cerebrovascular disease in children. 50% of blood cases at autopsy found spontaneous cerebral hemorrhage, and ICH occurred in 2.2% to 7.4% of children with hemophilia. In children with idiopathic thrombocytopenic purpura ICH occurs in 10% of patients with ICH, such as leukemia, aplastic anemia, hemolytic anemia, diffuse intravascular coagulation, blood clotting disorders, and complications of anticoagulant therapy.

Other causes of the skull (20%):

Including craniocerebral trauma, intracranial tumors, cerebral arteritis, toxic encephalopathy. ICH is caused by various other causes including vitamin K deficiency, vitamin C deficiency, liver disease, hypertension, infection or connective tissue disease.

Other (15%):

There are still some reasons for pediatric ICH. The cerebral hemorrhage without cause is called pediatric idiopathic cerebral hemorrhage. It has been reported in the literature that pediatric idiopathic cerebral hemorrhage is caused by rupture of microaneurysmoid vascular malformation, so it is not The real cause is unknown, but because the aneurysm is too small, neuroimaging examinations such as CT scans and cerebral angiography cannot be found.

Prevention of intracranial hemorrhage in children

1. Strengthen maternal health care work, timely discover high-risk pregnancies, prevent premature birth, improve obstetric field technology, and reduce birth trauma and asphyxia caused by dystocia. Patients with a history of primary thrombocytopenic purpura should be treated with glucocorticoid intravenous immunoglobulin.

2. Prevention of accidental craniocerebral trauma, especially in children with coagulopathy.

3. Prevention of neonatal intracranial hemorrhage caused by birth injury and hypoxia.

4. Hospitalization. Promote breastfeeding, routine vitamin G supplementation after birth to prevent late-onset vitamin K deficiency 5. Do a good job in vaccination, and actively prevent and treat various infectious diseases.

Pediatric intracranial hemorrhage complications Complications, hemiplegia, aphasia, somatosensory disturbance

Can cause hemiplegia, aphasia, seizures, hemianopia, sensory disturbances, disturbance of consciousness, repeated asphyxia episodes, etc., severe cases may be associated with cerebral palsy death, and easily associated with gastrointestinal bleeding, abnormal heart and lung function, water, electrolyte disorders, brain accumulation Water, etc.

1. Frequent paroxysmal respiratory rhythm and apnea, accompanied by convulsions. There were convulsions and coma in the late stage. The complexion is pale, the front is bulging, the eyes are gazing, the pupils are not equal or loose, and the light reflection disappears. Extremely severe can die in the labor process or only weak heartbeat after birth. Although it is actively recovered, it will still be invalid.

2. Survivors often have neurological sequelae.

Symptoms of intracranial hemorrhage in children Common symptoms Cranial suture prematurely closed intracranial hypertension, high heat, sensory disturbance, consciousness disorder, pale cerebral meningeal irritation, coma, cerebral palsy, lethargy

Brain hemorrhage

It refers to the hemorrhage caused by rupture of blood vessels in the brain parenchyma. It is common in the cerebral hemisphere. The cerebral hemorrhage (cerebellum or brain stem) is less common. There may be trauma, excessive excitement and other predisposing factors before the onset. The onset is more urgent, and the common manifestations are sudden. Headache, vomiting, hemiplegia, aphasia, seizures, blurred or eccentric blindness, sensory disturbances, blood pressure, heart rate, respiratory changes, disturbance of consciousness, etc., severely ill children generally have obvious changes in vital signs, and are easily associated with digestion Hemorrhage, abnormal cardiopulmonary function, water, electrolyte imbalance, especially severe cases may be associated with cerebral palsy death, hematoma broke into the subarachnoid space often have obvious meningeal irritation, ventricular hemorrhage often manifests as deep coma, soft limbs, limbs, Early high fever, bilateral pupils shrink, go to the brain for a straight attack.

2. Primary subarachnoid hemorrhage (subdural hemorrhage)

Primary subarachnoid hemorrhage refers to rupture of the skull base or cerebral surface caused by non-traumatic causes, a large amount of blood directly flows into the subarachnoid space; and secondary is due to cerebral hemorrhage, blood flow through the brain Tissue spread to the ventricles and subarachnoid space, subarachnoid hemorrhage in children is rarer than in adults, due to aneurysm, arteriovenous malformations and other vascular abnormalities are more common in older children over 6 years old, and there are The trend of increasing age and increasing.

Often onset, acute manifestations of meningeal irritation and intracranial hypertension caused by increased blood stimulation or volume, such as neck stiffness, severe headache, jet vomiting, etc., more than half of the cases have disturbance of consciousness, pale and seizures, In the first 2 to 3 days of the disease, there is often fever, subarachnoid hemorrhage caused by rupture of the convex blood vessels in the brain. If the lesion is close to the frontal lobe, the temporal lobe often shows obvious mental symptoms, which can be expressed as nonsense. Self-speaking, imitating language and emptying movements, etc., may be accompanied by hematoma or cerebral infarction and focal neurological signs, such as limb paralysis, cranial nerve abnormalities, etc., fundus examination can be seen under the vitreous hemorrhage.

3. Subdural hemorrhage

Infants and young children are more common, usually divided into two types: the cerebellum and the cerebellum. The former is the most common, mostly due to the thin bridge vein tear on the surface of the brain; the latter is mostly caused by the tear of the cerebellum, subdural Most of the hematoma formed by hemorrhage occurs at the top of the brain, most of which are bilateral, but the degree of bleeding can be asymmetric, and the clinical manifestations vary greatly. The subdural hemorrhage is located in the convex surface of the cerebral hemisphere. If the amount of bleeding is small, there is no obvious symptom; If the amount of bleeding is large, there may be increased intracranial pressure, disturbance of consciousness, seizures or hemiplegia, strabismus and other focal signs, and even secondary cerebral palsy leading to death. The subdural hematoma usually has more bleeding, often coma. Eye movement disorder, pupils are not large and the light reflection disappears, the brain is under pressure and other symptoms of brain stem compression, the disease progresses extremely rapidly, and the respiratory arrest is stopped within a few hours.

4.NICH

It mainly includes four types of periventricular-intraventricular hemorrhage, cerebellar hemorrhage, primary subarachnoid hemorrhage and subdural hemorrhage. Periventricular-intraventricular hemorrhage mainly occurs in immature children with small gestational age, originating from the ependymal membrane. The rupture of the hairy layer under the germinal layer is more than 24 to 48 hours after birth, most of the onset is rapid, progressive deterioration, short coma soon after birth, deafness and convulsions, and death within more than a few hours; However, a few symptoms can also be atypical at the beginning, but may have conscious disturbances, limited "micro-small" convulsions, eye movement disorders, limb dysfunction, etc. Symptoms and undulations, when light and heavy, can survive, but easy to concomitate hydrocephalus, cerebellum Bleeding can cause quadriplegia due to pressure on the brain stem, superficial breathing, repeated asphyxia episodes, etc., all died within 36 hours after the disease. The clinical manifestations of neonatal subarachnoid hemorrhage are related to the amount of bleeding. There is no symptom when there is slight bleeding. Signs, only blood cerebrospinal fluid, common in premature infants; more bleeding, often 2 to 3 days after birth, drowsiness, convulsions, can cause hydrocephalus after hemorrhage, more common in full-term children; Blood rare, serious condition, died shortly after birth, similar to the clinical manifestations of hemorrhage, subdural hemorrhage and subdural neonatal front are talking about.

Examination of intracranial hemorrhage in children

1. General inspection

There may be anemia in ICH, erythrocyte sedimentation rate, and the number of peripheral white blood cells increases. If the leukemia is caused by leukemia, any cause of cerebral hemorrhage may have transient proteinuria, diabetes, and hyperglycemia.

2. Cerebrospinal fluid examination

Applicable to the diagnosis of subarachnoid hemorrhage, such as the discovery of homogeneous blood cerebrospinal fluid, except for puncture injury can be clearly diagnosed, the identification method can be used to continuously dispense the cerebrospinal fluid into three tubes for several minutes, if the cerebrospinal fluid color is observed to be uniform Without clots, the supernatant turned yellow, and the occult blood test was positive, suggesting that there was bleeding before the lumbar puncture, and the injury was caused by non-lumbar puncture. In neonates, there may be no hemosiderin macrophages in the cerebrospinal fluid. Differentiate, if there is neonatal subarachnoid hemorrhage, blood cerebrospinal fluid can last for about 1 week, the yellow stain of the supernatant after centrifugation gradually increased, and the pressure of cerebrospinal fluid increased, the protein increased, the sugar was normal or slightly lower, However, if there is severe intracranial hypertension, or clinically suspected ICH in other areas, the lumbar puncture should be suspended to avoid cerebral palsy.

3. Subdural puncture examination

It is suitable for the diagnosis of supratentorial subdural hemorrhage. It can be diagnosed by subdural puncture of the anterior iliac crest in infants and infants whose anterior cardia has not been closed. Under normal circumstances, the needle enters the subdural space. The liquid may flow out or only a few drops of clear liquid. If there is a subdural hematoma, a red or yellow or watery liquid containing a large amount of protein may be discharged to determine whether the subdural hematoma is bilateral or not. Both sides should be punctured, which is diagnostic for the discharge of more than 0.5ml of fluid after neonatal puncture.

4. Etiology check

Corresponding examinations should be performed in combination with medical history and clinical manifestations, such as blood, coagulation, bone marrow aspiration, etc., to identify the cause of bleeding.

5. Brain CT

It is the first choice for the diagnosis of ICH. It can accurately determine the location and extent of bleeding, and can estimate the amount of bleeding and the hydrocephalus after bleeding. However, a small amount of bleeding in the brain stem can cause false negatives.

6. Brain B ultrasound

It is suitable for infants with anterior and posterior patency. The diagnosis rate of ICH is high, and it can be carried out at the bedside. It has the advantages of convenience, safety and economy, and can be dynamically observed to understand the changes of hematoma and ventricle size at any time.

7. Magnetic resonance angiography or cerebral angiography

It is the most reliable method to determine the cause of bleeding and the location of the lesion, especially the cerebral angiography can determine the diagnosis, but also the interventional treatment, but the patient needs to be moved, the examination time is longer, generally after the condition is stable, or applicable to The condition is critical and requires preoperative examination of the emergency surgeon.

8. EEG

EEG examination during cerebral hemorrhage revealed a localized slow wave lesion on the bleeding side, but no specificity.

Diagnosis and diagnosis of intracranial hemorrhage in children

diagnosis

According to the cause, the symptoms can be diagnosed. If there is a history of bleeding disease or trauma, and there is no obvious manifestation of intracranial infection, the disease should be considered, and the laboratory and auxiliary examination should be selected in time to confirm the diagnosis.

Differential diagnosis

Neck infection

When children have chronic tonsillitis and cervical lymphadenopathy, unilateral or bilateral occlusion of the cervical internal carotid artery can occur, which is characterized by fever, neck tenderness, and then sudden hemiplegia, which must be cultured through the throat or lymph node specimens. To determine pathogenic microorganisms, arterial angiography can be found in carotid occlusion and should be treated with antibiotics.

2. Carotid artery injury

Pediatric corporal punishment or a seemingly minor injury during exercise can cause thrombosis or rupture in the carotid artery in children. Symptoms often occur several hours after trauma, sometimes even days, often with hemiplegia, eccentric sensation and hemianopia. Symptoms may be temporary or persistent, but there may be some recovery. Ultrasound imaging, MRI, and angiography may reveal cervical carotid occlusion, and anticoagulant therapy and surgical repair have no effect on hemiplegia.

3. Congenital heart disease

Infants with cyanotic heart disease often have venous thrombosis. The first symptom is sudden onset of hemiplegia, accompanied by headache, convulsions, and loss of consciousness. The start of seizures may be localized and recurrent, but then becomes a systemic episode, MRI It is a better way to find venous thrombosis and emboli. The treatment is mainly symptomatic supportive therapy, correcting dehydration and controlling intracranial pressure, while osmotic diuretics are banned, because it can further promote thrombosis. Infarction is often hemorrhagic, contraindications. Anticoagulant therapy, because it is impossible to distinguish whether the thrombosis is aseptic or bacterial, all patients should be treated with antibiotics.

4. rheumatic heart disease

Children with rheumatic heart disease are mostly due to bacterial endocarditis or embolism caused by sputum on the valve during surgery. Therefore, blood culture must be repeated to identify pathogenic microorganisms and actively give antibiotics.

5. Moyamoya disease

Moyamoya disease is a slow progression, beginning with the occlusion of the bilateral internal carotid siphon, and sometimes the vascular occlusion of the basilar artery, manifested as recurrent headaches or sudden hemiparesis, which gradually recovers, but is completely Before recovery, hemiparesis may occur on the ipsilateral or contralateral side, loss of unilateral sensation or aphasia, poor prognosis, most patients with chronic weakness of one or both limbs, epilepsy and mental retardation, some may die, CT or MRI often A large area of cerebral infarction is indicated, which is caused by internal carotid artery stenosis. A definitive diagnosis requires an angiographic examination. It has been reported that intravenous verapamil is effective in the early stage of the disease.

6. Hypersensitivity vasculitis (hypersensive vasculitis)

Almost half of allergic vasculitis has headache and EEG abnormalities, and 1/3 of the cases have localized neurological signs, which account for 1/2 of hemiplegia. There may be seizures before hemiplegia, but also sensation of hemiplegic sensation. And aphasia, the above performance can be persistent, CT or MRI often shows infarction and / or bleeding, can be treated with corticosteroids.

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