What Are the Causes of a Petechial Hemorrhage?

Intracranial hemorrhage (ICH), also known as hemorrhagic cerebrovascular disease or hemorrhagic stroke, is caused by the overflow of blood into the cranial cavity due to cerebrovascular rupture. According to different bleeding sites, ICH can be divided into cerebral hemorrhage, subarachnoid hemorrhage and subdural hemorrhage. No matter what causes the intracranial hemorrhage in children, there are many similarities in clinical manifestations, but the prognosis depends on different diseases and is therefore very different. The timely diagnosis and treatment are also the key factors that directly affect the prognosis.

Basic Information

nickname

Hemorrhagic cerebrovascular disease, hemorrhagic stroke

Visiting department

Pediatric Surgery, Brain Surgery, Neurology

Common locations

Cerebrovascular

Common causes

Hematopathy, cerebrovascular dysplasia, and traumatic trauma

Common symptoms

Headache, vomiting, hemiplegia, sensory disturbance, unconsciousness, etc.

Causes of intracranial hemorrhage in children

Many hematological diseases, cerebrovascular development abnormalities, and other intracranial and extracranial lesions are related to the occurrence of ICH in children. The etiology can be single or caused by a combination of multiple etiologies. It is common in craniocerebral trauma, neonatal birth injury, and hypoxia often causes intracranial hemorrhage. Thrombocytopenic purpura, aplastic anemia, hemophilia, leukemia, brain tumors, late-onset vitamin K deficiency, etc. also often cause intracranial hemorrhage.

Cerebral vascular malformation

Cerebrovascular malformation is one of the common causes of ICH in childhood, which can be divided into congenital, infectious and traumatic. Congenital cerebrovascular malformations include hemangiomas and arteriovenous fistulas. Infectious cerebral arteriovenous malformations, such as intracranial bacterial or fungal aneurysms, are caused by infection emboli of infective endocarditis; human immunodeficiency virus infection can also cause the occurrence of intracranial aneurysms in children. Traumatic cerebral arteriovenous malformations are rare. Other types of cerebral vascular malformations include capillary dilatation, cavernous hemangioma, malformation of the meningeal veins and capillaries, and abnormal brain blood vessel networks.

Blood disease

Hematopathy is an important cause of cerebrovascular disease in children. ICH occurs in 2.2% to 7.4% of children with hemophilia. ICH occurs in 10% of children with idiopathic thrombocytopenic purpura. ICH can occur in other blood diseases such as leukemia, aplastic anemia, hemolytic anemia, diffuse intravascular coagulation, and coagulopathy, as well as complications of anticoagulation therapy.

3. Intracranial hemorrhage of newborn

The main causes of neonatal intracranial hemorrhage (NICH) are birth injury and hypoxia. The former is gradually decreasing and the latter is increasing. Among them, the immature infants with a birth weight of less than 1500g at <34 weeks of pregnancy are as high as 40% to 50%.

4. Other

The cause of ICH in some children is unknown and is called idiopathic cerebral hemorrhage. Craniocerebral trauma, intracranial tumors, toxic encephalopathy, etc. can also be caused by various other causes such as vitamin K deficiency, vitamin C deficiency, liver disease, hypertension or connective tissue disease.

Clinical manifestations of intracranial hemorrhage in children

Cerebral hemorrhage

Refers to bleeding caused by ruptured blood vessels in the brain parenchyma. It is common in the cerebral hemisphere, and sub-census hemorrhage (cerebellum or brain stem) is rare. Before the onset of trauma, excessive excitement and other incentives. Onset is more acute, and common symptoms include sudden headache, vomiting, hemiplegia, aphasia, seizures, blurred vision or blindness, sensory disturbance, blood pressure, heart rate, respiratory changes, and disturbance of consciousness. Severe children generally have obvious changes in vital signs, and are easily associated with gastrointestinal bleeding, abnormal heart and lung function, water and electrolyte disorders, and particularly severe cases may be accompanied by death of cerebral hernia. Hematomas that break into the subarachnoid space often have obvious signs of meningeal irritation. Ventricular hemorrhage often manifests as deep coma, limb paralysis, early high fever, bilateral pupil shrinkage, and denervated tonic-like attacks.

2. Primary subarachnoid hemorrhage

Primary subarachnoid hemorrhage refers to rupture of blood vessels in the skull base or brain surface caused by non-traumatic causes, and a large amount of blood flows directly into the subarachnoid space; in secondary cases, the blood flow penetrates the brain after cerebral hemorrhage. The tissue spread to the ventricles and subarachnoid space. Aneurysms, arteriovenous malformations, and other vascular abnormalities are more common in older children over 6 years of age, and they tend to increase with age.

Often the onset is sharp, mainly manifested by meningeal irritation and intracranial hypertension caused by blood stimulation or increased volume, such as neck stiffness, severe headache, jet vomiting, and so on. More than half of the cases had disturbances of consciousness, paleness, and seizures. Fever often occurs within 2 to 3 days of the beginning of the illness. Subarachnoid hemorrhage caused by the rupture of convex blood vessels in the brain. When the lesion is near the frontal and temporal lobes, obvious mental symptoms often appear, which can be expressed as nonsense, talking to oneself, imitating language, and emptying movements. Wait. May be accompanied by hematoma or cerebral infarction and focal neurological signs, such as limb paralysis, cerebral nerve abnormalities and so on. Fundus examination revealed subvitreal bleeding.

3. Subdural hemorrhage

More common in infants. It is usually divided into two types: supra-cerebellar and sub-cerebellar. The former is the most common, and it is mostly caused by a small bridge vein tear on the surface of the brain. The latter is mostly caused by a tear in the cerebellum. Hematomas caused by subdural hemorrhage mostly occur at the top of the brain, most of which are bilateral. Subdural hemorrhage located on the convex surface of the cerebral hemisphere, if the amount of bleeding is small, there are no obvious symptoms; if the amount of bleeding is large, there may be focal signs such as increased intracranial pressure, disturbance of consciousness, seizures or hemiplegia, strabismus, etc. Death from secondary hernia. Subdural subdural hematomas usually bleed a lot, and often appear coma, dysfunction of the eyeballs, pupils that are unequal in size, disappear light reflections, and have irregular brain breathing symptoms such as inadequate breathing. The disease progresses very quickly, and most of the breathing stops within hours. And death.

4.NICH

It mainly includes four types of periventricular-ventricular hemorrhage, subdural hemorrhage, primary subarachnoid hemorrhage, and cerebral parenchymal hemorrhage. Hemorrhage can also occur in the cerebellum, thalamus, and basal nucleus. Periventricular-ventricular hemorrhage mainly occurs in immature infants with a small gestational age. It is caused by ruptured capillaries in the germinal layer under the ventricular membrane. It occurs more than 24 to 48 hours after birth, and most of them are sudden and progressive. Deterioration, deep coma, denervation, and convulsions soon after birth, death in more than a few hours; but a few symptoms may be atypical at the beginning, with conscious disturbances, limited "micro-scale" convulsions, eye movement disorders, limb function Obstacles, etc., symptoms fluctuate, sometimes light and severe, and more able to survive, but easily complicated by hydrocephalus. The clinical manifestations of neonatal subdural hemorrhage are similar to those mentioned above. The clinical manifestations of primary subarachnoid hemorrhage are related to the amount of bleeding. There is no symptoms and signs when there is slight bleeding, only bloody cerebrospinal fluid. When there is more bleeding, drowsiness and convulsions often occur 2 to 3 days after birth, which can cause bleeding. Hydrocephalus; massive hemorrhage is rare, severe, and died shortly after birth. The degree of cerebral parenchymal hemorrhage varies widely, and can be roughly divided into spotted hemorrhage, premature infants with multifocal cerebral hemorrhage, and cerebral parenchymal hemorrhage caused by cerebral vascular malformations: simple spotted cerebral parenchymal hemorrhage has no obvious clinical symptoms in the clinic. Generally, no serious problems of the nervous system are left; premature infants with multifocal cerebral parenchymal hemorrhage mostly occur in gestational weeks and premature infants with small birth weights. The clinical neurological abnormalities are obvious, the prognosis is poor, and the outcome is multifocal brain tissue. Liquefaction; cerebral parenchymal hemorrhage caused by cerebral vascular malformations is mostly sudden, and the prognosis is related to the location, size of the bleeding focus, the degree of edema of the surrounding tissues, and the treatment status. Cerebellar hemorrhage can cause quadriplegia, superficial breathing, repeated asphyxia attacks, etc., due to compression of the brainstem, and die within a short time.

Pediatric intracranial hemorrhage examination

Laboratory inspection

(1) In general , anemia may be detected during ICH, the erythrocyte sedimentation rate is increased, and the number of peripheral white blood cells is increased. If it is caused by leukemia, naive cells are seen. Intracerebral hemorrhage caused by any cause, transient proteinuria, diabetes, and hyperglycemia can occur.

(2) Cerebrospinal fluid examination Applicable to the diagnosis of subarachnoid hemorrhage. If uniform bloody cerebrospinal fluid is found, the diagnosis can be confirmed with the exception of puncture injury. In neonates, it can still be distinguished by the presence or absence of hemosiderin-containing macrophages in the cerebrospinal fluid, if any, it is neonatal subarachnoid hemorrhage. Bloody cerebrospinal fluid can last for about 1 week, and the yellow stain of the supernatant gradually increases after centrifugation. In addition, cerebrospinal fluid pressure increased, protein increased, sugar was normal or slightly lower. However, if there is severe intracranial hypertension, or clinically suspected ICH in other parts, lumbar puncture should be postponed to avoid inducing cerebral hernia.

(3) Subdural puncture examination Applicable to the diagnosis of subdural hemorrhage. Newborns and infants who have not yet closed the frontal cardia are diagnosed by subdural puncture at the lateral angle of the frontal diaphragm. If there is a subdural hematoma, a red or yellow or watery liquid containing a large amount of protein can flow out. To determine if the subdural hematoma is bilateral, both sides of the anterior cardia should be punctured. It is of diagnostic significance to effluent more than 0.5ml after newborn puncture.

(4) Etiological examination Corresponding examinations, such as hemogram, coagulation function, and bone marrow aspiration, should be performed in combination with medical history and clinical manifestations to identify the cause of bleeding.

2. Other auxiliary inspections

(1) Craniocerebral CT is the first choice for diagnosis of ICH. It can accurately determine the location and extent of bleeding, and estimate the amount of bleeding and see the hydrocephalus after bleeding.

(2) Cranial brain B-ultrasound is suitable for infants and young children who have not yet closed their ankles. The diagnosis rate of ICH is high, and hematoma and changes in ventricle size can be understood at any time.

(3) Magnetic resonance angiography or cerebral angiography is the most reliable method to determine the cause of bleeding and the lesion. In particular, cerebral angiography can confirm the diagnosis and also perform interventional treatment.

(4) Electroencephalogram When performing an EEG examination during cerebral hemorrhage, localized slow wave focus can be found on the bleeding side, but it is not specific.

Diagnosis of intracranial hemorrhage in children

The possibility of ICH should be considered in any child with the above clinical manifestations. If there is a history of bleeding disorders or trauma, and no obvious manifestations of intracranial infection, the disease should be considered. Imaging examination should be performed in time to determine the cause.

Intracranial hemorrhage complications in children

Can cause hemiplegia, aphasia, seizures, blindness, sensory disturbances, disturbance of consciousness, repeated asphyxia attacks, etc., severe cases can be accompanied by death of cerebral hernia. And easy to be accompanied by gastrointestinal bleeding, abnormal heart and lung function, water, electrolyte disorders, hydrocephalus and so on.

Pediatric intracranial hemorrhage treatment

General treatment

Should rest in bed, keep quiet and reduce moving. If you need to move the sick child due to special circumstances (emergency examination, surgical treatment, etc.), keep the head fixed. Children with coma should be placed in the lateral position to keep the airway open. In high heat, you should cool down in time. Such as headache, irritability, can be given appropriate sedatives. Pay attention to maintaining water-electrolyte acid-base balance and sufficient heat supply. For neoventricular periventricular-ventricular hemorrhage, attention should be paid to correct hypotension and raise blood pressure to an appropriate level.

2. Etiology treatment

Give corresponding treatment for different causes. For patients with thrombocytopenia, timely transfusion of platelets or fresh blood; for hemophilia, transfusion of factor IX or factor IX; effective antibiotics and antifibrinolytic drugs should be used when the hypocoagulation of diffuse intravascular coagulation caused by infection For vitamin K deficiency, vitamin K and coagulation factor complexes or fresh blood should be infused.

3. Symptomatic treatment

Severe symptoms should be addressed in a timely manner, such as active anticonvulsions and control of cerebral edema and intracranial hypertension. Common anticonvulsants include clonazepam, chloral hydrate, phenobarbital and phenytoin sodium. Adrenocortical hormones are commonly used for the treatment of cerebral edema. Patients with intracranial hypertension can administer intravenous dehydration or diuretics.

4. Lumbar puncture

Repeated lumbar puncture and cerebrospinal fluid application are suitable for neonatal ventricular-ventricular hemorrhage and subarachnoid hemorrhage in children, which can reduce the occurrence of hydrocephalus. However, if the child has severe headache, frequent vomiting or extreme irritability and even early signs of cerebral hernia, lumbar puncture should be contraindicated to avoid inducing cerebral hernia.

For neoventricular periventricular-ventricular hemorrhage, the amount of cerebrospinal fluid can usually be 3 ~ 14ml. At first, it can be lumbar punctured once a day. When the brain CT or B ultrasound shows that the ventricle is significantly reduced or the cerebrospinal fluid flows out of each lumbar puncture <3 ~ 5ml, it can be changed once every other day or longer until the ventricle returns to normal size. The total course of treatment is usually 2 weeks to 1 month. Throughout the treatment process, dynamic monitoring of ultrasound is required.

5. Subdural puncture

It is suitable for the treatment of convex subdural hematoma in the cerebral hemisphere, especially when the anterior condyle is not closed. After the puncture is successful, the fluid should be allowed to flow out automatically, not with an empty needle. The amount of fluid flowing out each time should not be too large (generally not more than 15ml), otherwise rebleeding may be induced and even death may result. The puncture interval depends on the amount of subdural hemorrhage or intracranial pressure. Generally, the puncture can be performed once a day or every other day. Subdural hematomas on both sides are punctured on one side daily, alternately.

6. Surgical treatment

If there is a large amount of bleeding, severe parenchymal symptoms or dangerous symptoms such as cerebral hernia, surgery should be performed early to remove the hematoma. In general cases, cerebral angiography and surgery should be performed after the condition is stable, including the removal of hematomas and the treatment of local malformed blood vessels. It is usually appropriate to implement it about 2 weeks after the onset of the disease. Most of the subdural hemorrhage caused by bleeding from the convex bridge vein of the brain can be cured by repeated subdural puncture and drainage, and a few require surgery. For the treatment of neonatal ventricular-ventricular hemorrhage with hydrocephalus, it is advisable to repeat lumbar puncture and put appropriate amount of cerebrospinal fluid or add drugs such as acetazolamide, furosemide, or glycerol to reduce the generation of cerebrospinal fluid. If it is not effective, consider Surgical treatment.

7. Interventional Therapy

In the past 20 years or so, interventional therapy has developed rapidly, which has made some inoperable or difficult and dangerous lesions treated and improved the efficacy. Intravascular embolic materials currently used can be divided into solid embolic agents and liquid embolic agents. The former includes microspheres, absorbable gelatin sponges, polyhexanol, surgical silk, spring steel coils, balloons, etc. They mainly rely on the impact of blood flow to send embolic particles into the blood-supplying lesion area, and deform the cerebral arteriovenous malformations. Or the blood-supplying arterial branch of a vascular tumor is blocked. The latter are mainly silicone plastic liquid and -cyanoacrylate. Clinically, appropriate embolization agents and methods should be selected according to different situations. For internal carotid cavernous sinus fistula or other intracranial and external arteriovenous fistulas, detachable balloon endovascular embolization should be performed.

8. Rehabilitation

Once the ICH is stable, rehabilitation training should be performed, including passive exercise and functional training. People with limb paralysis should start the passive movement of paralyzed limbs as soon as possible; those with aphasia should insist on early speech training. Allow the child to take a seat and a stand as early as possible. If you cannot sit alone, you can take the seat first. If you have difficulty sitting, you can take the semi-seat position. If you can't stand alone, you can take the stand. You can start several times a day for a few minutes each time. Training time. In addition, it can be supplemented with acupuncture, massage, physiotherapy, etc. to reduce the sequelae of nerve injury.

Prognosis of intracranial hemorrhage in children

Cerebral arteriovenous malformations are prone to repeated bleeding, and the recurrence rate is higher; if blood flows into the ventricular system and the subarachnoid space, it is likely to cause cerebrospinal fluid circulation pathways to be blocked, absorption disorders, and hydrocephalus. Cerebral aneurysm rupture often produces intraparenchymal hemorrhage, and most cases die early. Survivors usually have neurological sequelae.

The prognosis of NICH is related to the type of bleeding. Periventricular-ventricular hemorrhage's recent prognosis is related to the amount of bleeding. The larger the amount of bleeding, the higher the incidence of hydrocephalus or the mortality rate. In the long-term follow-up, the patients with large hemorrhage will have severe mental loss and motor dysfunction. . Cerebellar hemorrhage has a poor prognosis and dies shortly after birth. Neonatal subarachnoid hemorrhage is mainly caused by venous rupture, and the amount of bleeding is small, and most of them have good prognosis. A few can also be caused by congenital intracranial aneurysm rupture. The condition is more critical, the prognosis is poor, and the mortality is as high as 40% . The prognosis of subdural hemorrhage is relatively good, while the prognosis of subdural hemorrhage is poor.

Prevention of intracranial hemorrhage in children

Prevent accidental traumatic brain injury, especially children with coagulopathy; prevent intracranial hemorrhage of newborns caused by birth injury and hypoxia; promote breastfeeding, and routinely supplement vitamin K agents after birth to prevent late-onset vitamin K deficiency To do a good job in vaccination and actively prevent and control various infectious diseases.