Computerized tomography in the management of intracranial bleeding in hemophilia

Blood-fluid levels in the brain

17 cases reviewed prospectively over a period of 4 months highlight the varied appearance of blood-fluid levels in intracranial cystic lesions of different aetiologies; a finding which has not featured significantly in the medical literature. Four types of intracranial cysts demonstrating blood-fluid levels have been categorised according to the nature of the pathology, i.e. primary neoplasms of the brain, metastatic deposits to the brain in cases of extraneural malignancies, lesions of vascular aetiology and intraparenchymal bleeds secondary to trauma. The group of four primary intracranial neoplasms lists an oligodendroglioma, a recurrent tumour in a case of Von Hippel-Lindau syndrome, a Grade 3 astrocytoma and an acoustic schwannoma. Four cases of metastatic deposits to the brain were each secondary to primary malignant neoplasms of the breast, liver, ovary and lung. Of seven cases of a vascular aetiology, three resulted from arterial infarction, two from hypertension and one each from venous infarction and following anticoagulant therapy. Intracranial cysts within tumours have been postulated to occur secondary to a breakdown of the blood-brain barrier (BBB) rather than as a result of tumoural degeneration, as was thought probable earlier.

Fatal clival subdural hematoma in a hemophiliac

We report the case of a hemophiliac in whom developed an unusual site of intracranial bleeding, a subdural hematoma that extended in the posterior fossa anteriorly from the clivus into the upper spinal subdural space. The hematoma was delayed in onset and was fatal. We review the current management recommendations for hemophiliac patients with head injury and the clinical presentation of intracranial bleeding in hemophiliacs. The necessity for Factor VIII replacement and serial computed tomography scans is emphasized.

Head trauma in children with congenital coagulation disorders

Bleeding is the most frequent cause of death in children with congenital coagulation disorders, and intracranial (IC) hemorrhage accounts for the majority of mortality in all age groups. Even minor head trauma may produce significant IC pathology. Immediate diagnosis and rapid medical management are mandatory if morbidity and mortality are to be minimized. Although computed tomographic (CT) scans provide accurate diagnostic information, reliable criteria for the use of this expensive technology in children with hemophilia and von Willebrand's disease have not been defined. In this study the clinical symptoms and the time of initial assessment and therapy of head-injured children with congenital coagulopathies were evaluated and correlated with CT findings. Between 1985 and 1992, 123 patients with hemophilia A, hemophilia B, or von Willebrand's's disease received follow-up at this institution. One hundred nine episodes of head injury were recorded in 43 patients, and 66 CT scans were obtained. The most frequent mechanism of injury was a simple fall at play (62%). Only 5 patients had an IC injury demonstrable with CT (4.5% of 110 episodes). Vomiting was reported in 4 of 5 patients with IC hemorrhage (ICH), and all 5 presented with an altered mental status (Glasgow coma scale [GCS] (mean) = 10) and focal neurological deficit. These findings were infrequently observed (vomiting, 5 of 105; GCS (mean) = 15; neurological deficits 0 of 105) in children who either did not undergo CT or whose CT scan results were normal.(ABSTRACT TRUNCATED AT 250 WORDS)

Experience with the hemophiliac child in a pediatric emergency department

We conducted a retrospective chart review of all hemophiliacs followed by our pediatric hematology service from January 1, 1980 to December 31, 1989 inclusive, to determine the frequency and nature of their visits to our Emergency Department (ED). Of 36 patients studied, 26 were Factor VIII deficient (13 mild, 3 moderate, and 10 severe) and 10 had Factor IX deficiency (7 mild and 3 severe). No patient had red blood cell (RBC) antibodies or factor inhibitors. One patient was HBsAg positive and 4 patients were HIV positive. One hundred and twenty-six ED visits [98 (78%) in the 1-5 age group] occurred. Soft tissue hematomas accounted for 48% of total injuries, hemarthroses for 24%, and head injuries for 12%. Twelve patients were admitted to hospital for observation or ongoing factor replacement. Of 15 episodes of head injuries, 1 patient had intracranial hemorrhages on 2 occasions, while 13 received prophylactic factor replacement and recovered uneventfully. Despite the availability of home factor replacement, the ED remains an important locus for the management of the pediatric patient with hemophilia.

Significance of the fluid-blood interface in intracranial hematomas in anticoagulated patients

Six patients receiving anticoagulant medication who had laboratory evidence of impaired hemostasis as manifested by laboratory parameters exceeding the therapeutic range developed intracranial hemorrhages. None of these patients had a history of preceding trauma. None of the 6 anticoagulated had CNS symptoms prior to initiation of anticoagulant medication. Within the intracranial hemorrhage there was a fluid-blood interface in these 6 patients; this finding was seen only in hemorrhages in anticoagulated patients. In 3 cases the fluid-blood interface changed to a homogeneous hyperdense lesion when adequate hemostasis was achieved. In one case there were multiple hemorrhages and in the other there was a solitary intracerebral hemorrhage.

The surgical management of intracranial hematomas in hemophiliac children. A prospective study

A prospective study was undertaken to treat all intracranial hematomas in hemophiliac A children under a uniform protocol. Patient selection was obtained by early CT scan of all hemophiliacs presenting with neurological symptoms and routine hematological screening for coagulopathies of all pediatric intracranial hematomas, spontaneous or traumatic. Nine patients, of whom seven came under category 1 and two under category 2, were entered into this study. There were eight subdural hematomas, one epidural hematoma, and one intracerebral hematoma. Surgery was required in every patient. Human factor VIII concentrate was used for replacement up to 100% just before and 3 days after surgery. Thereafter, it was maintained at 50% up to the 10th postoperative day. There was no operative or late mortality. At 6-month follow-up, eight of nine patients had recovered completely with no residual neurological deficit. We conclude that early diagnosis, prompt surgical intervention, and perfect normalization of hemostatic defect are essential in improving the outcome of these patients.

Intracranial hemorrhage secondary to von Willebrand's disease and trauma

A rare juvenile case of traumatic hemorrhage in the basal ganglia with intraventricular hematoma, associated with von Willebrand's disease, is reported. Hemostatic management of von Willebrand's disease and our surgical method for treatment of intraventricular hemorrhage are discussed briefly.

Intracranial hemorrhage in hemophilic children. CT follow-up

In a follow-up examination of intracranial hemorrhage in hemophilic children, 9 patients were examined clinically and with CT. The results stress the value of CT in the evaluation of hemophilic children with possible head trauma. The extent of the structural brain damage after intracranial hemorrhage in most cases is more marked than clinically expected, and such damage may also be present in patients who clinically have no neurologic sequelae.

Congenital bleeding disorders: hemophilia and von Willebrand's disease

Treatment of hemophilia and von Willebrand's disease has become easier in recent years because of the development of more effective factor replacement products. The median age and the life expectancy of patients with hemophilia have risen markedly, as has the median age at death.

Intracranial fluid-blood levels in the anticoagulated patient

This report documents that anticoagulation may cause multiple intracranial fluid-blood levels.

Neurological complications in hemophilia

The clinical data of 59 patients with hemophilia A or B are reviewed. Intracranial bleeding was observed in 6 patients and a minor bleeding episode was assumed in a further 8 patients. Neurosurgical evacuation of the hematoma was necessary in 2 cases and the remaining patients were treated solely with factor VIII or IX. In 10 patients a peripheral nerve lesion was observed, paresis of the femoral nerve being the most frequent (5 cases). Two patients showed a lesion of the lumbar and sacral plexus, 2 patients a lesion of the radial nerve and one patient a lesion of the cutaneous femoris lateralis nerve.

Hemophilia

The clinical manifestations of hemophilia depend upon both age and the severity of the factor VIII or IX deficiency. Hemophilia A and B cannot be differentiated on clinical grounds. Laboratory tests include platelet count, prothrombin time, partial thromboplastin time, and bleeding time.