What is the treatment for a pediatric patient with an intracranial hemorrhage (ICH) due to a fall?

Treatment of Pediatric Intracranial Hemorrhage Due to Fall

Immediate stabilization with airway protection, aggressive blood pressure control to systolic 130-140 mmHg, correction of any coagulopathy, and intensive neurocritical care monitoring form the cornerstone of management for pediatric traumatic intracranial hemorrhage. 1

Immediate Stabilization (First Hour)

Airway and Breathing:

• Secure airway if Glasgow Coma Scale (GCS) ≤8 or signs of herniation are present 2
• Optimize respiratory effort to maintain adequate oxygenation and prevent secondary brain injury 1

Hemodynamic Management:

• Control systemic hypertension immediately if presenting within 6 hours of injury 1
• Target systolic blood pressure 130-140 mmHg within the first hour 2, 3
• Never allow systolic BP to drop below 100 mmHg or mean arterial pressure below 80 mmHg to maintain cerebral perfusion 3
• Assess for dual circulatory compromise from both hemorrhage and potential ongoing bleeding 1

Seizure Prevention:

• Treat clinical seizures immediately with antiseizure medications 3
• Do NOT use prophylactic antiseizure drugs routinely unless seizures are documented, as they may be associated with increased death and disability 4

Critical Diagnostic Evaluation

Imaging:

• Non-contrast head CT is the standard diagnostic tool for initial assessment 5
• For infants, transcranial ultrasound is best for initial assessment, with MRA to define vascular pathology if needed 2
• Obtain baseline imaging within the first hour and repeat at 24 hours to assess for hematoma expansion 2

Laboratory Assessment:

• Urgent evaluation for coagulation defects, as 14.7% of pediatric intracranial hemorrhages are associated with coagulopathies 1
• Complete blood count with platelet count, coagulation studies (PT/INR, aPTT), liver function tests 1
• Vitamin K levels in infants to rule out vitamin K deficiency bleeding (VKDB), a common etiology in this age group 6

Coagulopathy Reversal (If Present)

Anticoagulation Reversal:

• If on warfarin: administer prothrombin complex concentrate (PCC) plus IV vitamin K immediately—do NOT use fresh frozen plasma 2, 3
• Reverse anticoagulation immediately as this is of the essence 5
• Maintain platelet count >50,000/mm³ for any intervention 3

Intracranial Pressure Management

Medical Management:

• Elevate head of bed 30 degrees 4
• Mannitol 0.25-2 g/kg IV over 30-60 minutes for reduction of intracranial pressure (FDA-approved for pediatric use at 1-2 g/kg or 30-60 g/m² body surface area) 7
• Monitor for signs of herniation (present in 25.7% of pediatric cases) 6
• Consider ventriculostomy for intraventricular hemorrhage with hydrocephalus 5

Monitoring Requirements:

• Hourly neurological assessments using GCS for the first 24 hours 3
• Continuous monitoring in pediatric intensive care unit with neuroscience expertise 3, 6
• Monitor for clinical deterioration, as 20% of patients experience GCS decrease of ≥2 points in the first hours 2

Surgical Considerations

Indications for Neurosurgical Consultation:

• Evaluate for underlying vascular abnormalities (arteriovenous malformations are common in older children) 2, 6
• Consider surgical or endovascular obliteration of aneurysms and AVMs when clinically feasible, given 4.5% annual risk of recurrent hemorrhage from untreated lesions 1
• Decompressive craniectomy may be considered for life-threatening mass effect, though type of management (conservative vs. surgical) did not affect outcome in one pediatric series 6
• Digital subtraction angiography (DSA) provides best anatomic resolution but carries high risk in infants (neurovascular damage, cerebral ischemia, death) 2

Pediatric-Specific Considerations

Volume Calculations:

• Measure hemorrhage volume as percentage of total brain volume, as the same absolute volume represents substantially different proportions in infants versus adolescents 2
• Smaller brain volumes in infants mean smaller hemorrhages can cause more severe effects 2

Common Etiologies by Age:

• Infants: Vitamin K deficiency bleeding (VKDB) most common 6
• Older children: Arteriovenous malformations (AVM) most common 6
• Traumatic pseudoaneurysms represent approximately one-third of pediatric intracranial aneurysms and require treatment given high mortality 2

Prevention of Complications

Thromboembolic Prophylaxis:

• Begin intermittent pneumatic compression on admission day 3
• Avoid graduated compression stockings 3

Aspiration Prevention:

• Perform formal dysphagia screening before any oral intake to reduce pneumonia risk 3

Avoid Common Pitfalls:

• Do NOT institute DNR orders or withdraw support in first 48 hours—early prognostication is unreliable and creates self-fulfilling prophecies 3
• Do NOT use antiemetics like prochlorperazine that cause hypotension and mask neurological deterioration 4
• Do NOT perform ultra-early surgery within 4 hours due to increased rebleeding risk 3

Prognostic Factors

Predictors of Poor Outcome:

• GCS <8 at presentation 6
• Pediatric Risk of Mortality (PRISM III) score >20 6
• Need for intubation and thiopentone coma for refractory ICP 6
• Progression to acute kidney injury (OR 5.86 for mortality) 6
• Severe decompensation at presentation 6

Favorable Prognostic Factors:

• Seizures paradoxically associated with better survival (OR 0.12) 6
• Children typically tolerate subarachnoid hemorrhage better than adults with better recovery and outcomes 2

Follow-Up and Long-Term Management

Imaging Surveillance:

• For traumatic lesions, long-term follow-up imaging is indispensable, as aneurysms may develop in delayed manner following vessel wall weakening 2
• Document outcome within 30 days or ensure appropriate transition of care 1

Specialized Follow-Up:

• Children with identified bleeding disorders require long-term hematology follow-up and preventive strategies 1
• Intensive rehabilitation services for survivors with persistent deficits 3