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Original Investigation |

Frequency of Hematoma Expansion After Spontaneous Intracerebral Hemorrhage in Children

Lauren A. Beslow, MD, MSCE1; Rebecca N. Ichord, MD2; Melissa C. Gindville, BS, MS3; Jonathan T. Kleinman, MD4; Rachel A. Bastian, BA2; Sabrina E. Smith, MD, PhD5; Daniel J. Licht, MD2; Argye E. Hillis, MD, MA6; Lori C. Jordan, MD, PhD3
[+] Author Affiliations
1Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, Connecticut
2Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
3Division of Child Neurology, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
4Stanford Stroke Center, Palo Alto, California
5Division of Pediatric Neurology, Kaiser Permanente Oakland Medical Center, Oakland, California
6Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Neurol. 2014;71(2):165-171. doi:10.1001/jamaneurol.2013.4672.
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Importance  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.

Objective  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).

Main Outcome and Measure  Primary outcome was prevalence of hematoma expansion.

Results  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).

Conclusions and Relevance  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.

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Figure 1.
Study Participants

Flowchart of included and excluded children. CT indicates computed tomography; ICH, intracerebral hemorrhage; and IVH, intraventricular hemorrhage.

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Figure 2.
Example of Hematoma Expansion

Hematoma expansion 40% between first (A-B) (30 mL) and second (C-D) (42 mL) computed tomography scan 2.3 hours apart.

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