Intracranial hemorrhage (ICH) in children with immune thrombocytopenia (ITP): study of 40 cases

Abstract

Intracranial hemorrhage (ICH) is a rare but devastating complication of childhood immune thrombocytopenia purpura (ITP). A survey of ICH from 1987 to 2000 identified cases of ICH in childhood ITP in the United States. Forty patients with ICH and 80 matched ITP control subjects were accrued. The estimated incidence of ICH was 0.19% to 0.78%. Platelet counts were less than 20 ؋ 10 9 /L in 90% and less than 10 ؋ 10 9 /L in 75% of children with ICH. Eighteen (45%) children developed ICH within 7 days of diagnosis of ITP; for 10 of these, ICH was the presenting feature of ITP. Twelve (30%) children had chronic ITP. Head trauma and hematuria were the most prominent features associated with ICH, identified in 33% and 22.5% of the patients with ICH and 1 and none of the controls (both P < .001). Bleeding beyond petechiae and ecchymoses was also linked to ICH. Mortality was 25%; a further 25% had neurologic sequelae. Strategies by which high-risk children could be identified were considered, and the costs of preventive combination treatment were estimated. Children with severe thrombocytopenia plus head trauma and/or hematuria appeared to be at particularly high risk of ICH. Aggressive treatment of these children may be appropriate. (Blood. 2009;114:4777-4783)

Occult hemorrhage in children with severe ITP

“…Previous research in children with ITP identified gross/microscopic hematuria as being potentially associated with risk of ICH [5]. Our findings suggest that microscopic hematuria is much more frequent (27% in our case series) than previously speculated in children with ITP, even when compared with healthy children.…”

“…While hematuria (occult or overt) and other noncutaneous hemorrhage has been described as being associated with ICH [5], to our knowledge no prior studies have specifically investigated the frequency or clinical relevance of occult hemorrhage in ITP. The results of this study demonstrate that on average nearly 27% of children with severe ITP, defined as thrombocytopenia 10,000/mm 3 , have occult bleeding demonstrable in the urinary tract and that such bleeding is more common than overt symptomatic hematuria.…”

“…Yet, in 2009 Psaila et al reported that microscopic as well as gross hematuria in children with ITP was associated with clinically apparent intracranial hemorrhage (ICH) [5]. However, limited information regarding microscopic hematuria in a comparison group of ITP patients without ICH rendered such an association less convincing.…”

Diagnosis and management of chronic ITP: comments from an ICIS expert group

“…Major bleeding, including spontaneous intracerebral haemorrhage, occurs predominantly in patients with platelet counts <20×10 9 /L, generally <10×10 9 /L [16,17]. Haemorrhagic complications may be more common in patients older than 60 years of age and those with comorbidities.…”

Use of Recombinant Factor VIIa in a Pediatric Patient With Initial Presentation of Refractory Acute Immune Thrombocytopenic Purpura and Severe Bleeding

“…3 Severe bleeding is a rare complication of ITP, with the incidence of intracranial hemorrhage ranging from 0.1% to 1%. [4][5][6] Other severe bleeding manifestations can present as epistaxis, gastrointestinal bleeding, menorrhagia, and hematuria. 7 Since ITP resolves spontaneously in most children, treatment is controversial; however, in children in children requiring therapy due to severe thrombocytopenia or bleeding, the 3 standard treatments include intravenous anti-D immune globulin, intravenous immunoglobulin G (IVIG), and steroids.…”