INTRACRANIAL HAEMORRHAGE IN HAEMOPHILIA

Delivery and neuraxial technique outcomes in patients with hemophilia and in hemophilia carriers: a systematic review

Female carriers are more common than males with hemophilia and unrecognized factor VIII or IX deficiency is associated with intrauterine growth retardation, epidural hematomas, blood transfusion, and peripartum hemorrhage. A review was conducted to assess the evidence for professional society recommendations for > 50% factor levels during labor. Two searches of Pubmed, CINAHL, Cochrane, and Google Scholar were completed in October 2019. The first for case reports and series described neuraxial techniques in patients with hemophilia-regardless of sex, age, or pregnant status. The second for case reports and series described bleeding outcomes of parturients with hemophilia. Primary outcomes were diagnosis of neuraxial hematoma (first search) and postpartum bleeding complications (second search). Thirteen articles (n = 134) described neuraxial techniques in patients with hemophilia. Neuraxial hematoma with paraplegia occurred in 3/134 patients-all had a factor level of 1%. Nineteen articles (2712 deliveries in 2657 women) described bleeding outcomes. Postpartum hemorrhage occurred in 7.1% (193/2712) of deliveries, of which 60% necessitated blood transfusion. Postpartum bleeding complications were twice as likely (51.0% [25/49] vs. 25.6% [52/203], P < 0.001) with factor activity < 50%. Therefore, factor levels should be assessed and increased above 50% prior to neuraxial technique and delivery.Trial registration: PROSPERO 2018 CRD42018110215.

Intracerebellar haemorrage in a haemophilia child

Hemophilia A is an inherited, X-linked, recessive disorder caused by deficiency of clotting factor VIII. Intracranial hemorrhage is the leading cause of morbidity and mortality in these patients. Use of factor replacement products and medications had improved outcome in these patients. But in developing countries many such patients are not able to afford factor replacement products. We report a case of traumatic intracerebellar hemorrage in a hemophilia child. This child presented to us as a case of sub-acute intracerebellar hemorrage, he was managed conservatively with six units of fresh frozen plasma transfusion. He improved clinically and on follow-up investigation hematoma was found to have dissolved spontaneously. Through this report we want to emphasize that those cases of hemophilia presenting with acute or sub-acute intracranial bleed, conservative approach through procoagulant transfusion and intravenous fibrinolysis inhibitors should be tried as first line of management. Before daring for surgery sufficient amount of factor replacement should be kept available.

Long-term consequences of intracranial haemorrhage in children with haemophilia

Intracranial haemorrhages (ICH) in children with haemophilia are rare, and the outcome is variable, ranging from no apparent impairment to death. The aim of this investigation was to identify if children with haemophilia and ICH, have any long-term problems with motor function, visual motor integration or strengths and difficulties compared with a control group. A review of the Haemophilia Database at Great Ormond Street Hospital for Children NHS Trust was undertaken to identify boys with haemophilia and a history of ICH, as well as a control group of peers with no such history. Boys were born between January 1994 and December 2002. All boys were assessed using the movement Assessment Battery for Children, the Developmental Test of Visual Motor Integration and The Strengths and Difficulties Questionnaire as standardized assessments of motor competence, visual motor integration and behavioural difficulties. Six boys with haemophilia and ICH and 11 controls (mean age: 7 years; range: 4-12 years) were assessed. Children with ICH were significantly more likely to have problems with motor function and visual motor integration (Fisher's exact: P < 0.05). In addition, they had a tendency towards more problems with strengths and difficulties than their peer group (Fisher's exact: P = 0.06). Five of the six boys who had sustained an ICH were in mainstream schools; four requiring assistance with their education. The results of this small study suggest that ICH may signify long-term consequences for boys with haemophilia. The multidisciplinary team need to be aware of the rare but potentially important impact on motor function, visual motor integration and behaviour, which may inhibit the child from functioning optimally. An agreed comprehensive battery of assessments in collaboration with schools and healthcare workers is required to identify impairments to enable prompt interventions to be co-ordinated.

Optimal management of an aneurysmal subarachnoid hemorrhage in a patient with known factor XI deficiency: a case report

The authors report a rare case of an acute cerebral aneurysm rupture in a patient with a known factor XI deficiency. Aneurysmal subarachnoid hemorrhage (SAH) accounts for a high mortality and morbidity rate. When SAH is associated with an inherited coagulation disorder such as hemophilia C, an unexpected and possible increase in hemorrhagic stroke and increase in bleeding during surgery and in the postoperative period could lead to an extremely bad outcome. Clinical management consists of rapid correction of the coagulation disorder before undergoing any invasive intracranial procedure. Such an optimal therapeutic strategy must be under the care of a multidisciplinary medical and surgical team. Human factor XI concentrate (Hemoleven, Laboratoire Français du Fractionnement et des Biotechnologies [LFB], Les Ulis, France) was used successfully in this case report. New treatment using recombinant factor VIIa is discussed.

The incidence and outcome of intracranial haemorrhage in newborns with haemophilia: analysis of the Nationwide Inpatient Sample database

The incidence of intracranial haemorrhage (ICH) in newborns with haemophilia is unknown. Retrospective studies, estimate the incidence to be around 3%. Because of this uncertainty, we analysed the largest inpatient database in the USA, the Nationwide Inpatient Sample (NIS), to better approximate the incidence of ICH in these patients. ICD-9 coding data were used to reference NIS entries of haemophilia (A, B or C) or von Willebrand's disease (VWD), with intraventricular (IVH), subarachnoid (SAH), subdural (SDH) and/or intraparenchymal (IPH) haemorrhage. Of 9.2 x 10(7) hospitalizations from 1988 to 2001, 11% or 1 x 10(7) were newborns. Of these, 0.00527%, or 580 were diagnosed with haemophilia or VWD. Twenty of 580, or 3.4%, experienced an ICH. The ICH rate in non-haemophilic newborns was 0.11% (P value: <0.0001). The rate of ICH among term haemophilic newborns without sepsis, respiratory distress syndrome (RDS) or congenital heart disease (CHD), delivered without vacuum assist was 1.9%. One death occurred on the day of birth in a term neonate with haemophilia C. The mean length of stay for ICH patients with haemophilia was 28 days (median 28, range: 6-143 days). The mean hospital charges for the group were 102,072 dollars (median 67,551 dollars, range: 9624-467,132 dollars). These data add credence to the estimates of ICH in haemophilic newborns and may guide treatment strategies around the time of their birth. Further, uncomplicated delivery of term, otherwise healthy haemophilic newborns may carry a lesser risk of ICH.

Intracranial haemorrhages in French haemophilia patients (1991-2001): clinical presentation, management and prognosis factors for death

Intracranial haemorrhage (ICH) is known to be a severe although uncommon complication of haemophilia. A national survey has been conducted in France in order to collect information about ICHs which occurred in haemophiliacs between 1991 and 2001 and to propose recommendations for the diagnostic and treatment of ICH. Within this period, 123 episodes of ICH were recorded from 106 patients. Two-thirds of ICH concerned patients with severe haemophilia. Half of the cases occurred in patients under 15 years of age, 67.2% of which were post-traumatic. Ten cases occurred in neonates with three fatal outcomes. Overall mortality was high (21.9%) suggesting that availability of clotting factor concentrates has not improved the prognosis of this event. Morbidity was also high with 60% of long-term sequelae. The following parameters have been identified as prognostic factors for death: thrombocytopenia, HCV infection, intraventricular or intraparenchymatous haemorrhage. A delay in diagnosis was mentioned in 43.3% of cases, often related to the lack of recognition of the initial symptoms, which may be very common (apathy, tearfulness in young children and headache in elder patients). Delayed replacement therapy was recorded in 37.2% of cases. Emergency units initially dealt with half of these patients. Information concerning recognition and management of these episodes, not only in severe haemophilia, but also in moderate and mild forms, should be regularly supplied to paediatricians in maternity and physicians from emergency units, as well as to patients and their relatives.

Intracranial haemorrhage as initial presentation of severe haemophilia B: case report and review of Mayo Clinic Comprehensive Hemophilia Center experience

A neonate who had intracranial haemorrhage (ICH) at birth received a diagnosis of severe haemophilia B at 6 months of age. ICH had been the initial presentation of his bleeding disorder. His family history was negative for haemophilia. Review of our institutional experience as well as the literature indicates that intracranial bleeding as the initial presentation of haemophilia is rare.

Spontaneous intracerebral hemorrhage due to coagulation disorders

Although intracranial hemorrhage accounts for approximately 10 to 15% of all cases of stroke, it is associated with a high mortality rate. Bleeding disorders account for a small but significant risk factor associated with intracranial hemorrhage. In conditions such as hemophilia and acute leukemia associated with thrombocytopenia, massive intracranial hemorrhage is often the cause of death. The authors present a comprehensive review of both the physiology of hemostasis and the pathophysiology underlying spontaneous ICH due to coagulation disorders. These disorders are divided into acquired conditions, including iatrogenic and neoplastic coagulopathies, and congenital problems, including hemophilia and rarer diseases. The authors also discuss clinical features, diagnosis, and management of intracranial hemorrhage resulting from these bleeding disorders.

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)

Safety of lumbar puncture in patients with hemophilia

STUDY OBJECTIVE

To determine the safety of lumbar puncture in patients with hemophilia who are pretreated with clotting factor.

DESIGN

Retrospective analysis of medical records between 1980 and 1990.

SETTING

Three hospitals, each serving as a regional hemophilia center.

PARTICIPANTS

Thirty-three patients with hemophilia A or B who received one or more lumbar puncture.

INTERVENTION

All patients received replacement of deficient factor before the lumbar puncture. Serious post-lumbar puncture complications were defined as motor or sensory deficits, incontinence, or documented intraspinal hemorrhage.

RESULTS

Thirty-three patients with hemophilia A or B received a total of 52 lumbar punctures during the study period. Thirty of 33 patients (91%) had severe baseline factor deficiency, two (6%) had moderate deficiency, and one (3%) had mild deficiency. There were no serious complications reported as a result of the lumbar puncture. The 95% confidence interval for the risk of a serious complication was 0% to 5.8%.

CONCLUSION

With adequate factor replacement, a lumbar puncture can be done safely in patients with hemophilia.

Mendelian etiologies of stroke

There are many genetic disorders associated with an increased risk for stroke that may easily be overlooked in the evaluation of both adult and pediatric acute stroke victims. The recognition of a genetic disorder as the cause of a stroke has important implications not only for the immediate care of the stroke victim, but often also for others in the patient's family who may be at risk for the same disease and for whom preventive measures sometimes can be taken. We present here a comprehensive review of genetic disorders associated with stroke in the nongeriatric age groups for which a causative role in the evolution of stroke has been recognized or is likely. For each disorder, the major clinical and biochemical characteristics as well as the probable pathogenetic mechanisms of stroke are discussed, together with the appropriate testing required to screen for and confirm the diagnosis. The great variety of genetic disorders and mechanisms causing stroke underscores the increasing importance of understanding genetic disease for appropriate diagnosis and treatment of a common clinical problem affecting both children and adults.

Spontaneous massive haemorrhage into acoustic neuroma during anticoagulation therapy

We report the case of a 58-year old man who bled into an undiagnosed acoustic neuroma while on long-term anticoagulation therapy which was commenced following aortic valve replacement. The patient presented with multiple cranial nerve-paralysis of sudden onset. The tumour was subtotally removed but died 5 days postoperatively from recurrent haemorrhage into the tumour bed.

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.

Chronic subdural hematoma presenting as spontaneous subarachnoid hemorrhage. Report of six cases

Six cases of chronic subdural hematoma presenting with the clinical findings of acute subarachnoid hemorrhage are reported. No systemic or focal cause for the bleeding was found, and possible mechanisms are discussed.

Spontaneous intracranial bleeding in hemorrhagic diathesis

Eight patients with spontaneous intracranial bleeding secondary to hemophilia A, afibrinogenemia, and thrombocytopenia are described. The clinical picture was that of increased intracranial pressure of gradual onset with variable signs and symptoms. Both the hemostatic defect and the intracranial bleeding were proved by laboratory investigations and CT scanning. Mortality was 75% (six of eight patients). The two remaining patients recovered completely following combined medical and surgical treatment, and are alive and well.

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.

Intracerebral haematoma in an infant with haemophilia A

A nine-weeks-old infant with haemophilia A developed an intracerebral haematoma. Intracranial operation and removal of the haematoma were performed safely under the cover of highly potent AHF cryoprecipitate. Computerized tomography of the brain is very useful for neurosurgical care of the haemophiliac patients as a noninvasive and atraumatic method of examination. The literature of intracranial operations in infants with haemophilia A under the age of one year is reviewed.

Intraspinal bleeding in haemophilia: successful treatment with factor VIII concentrate

A severely affected haemophilic boy became tetraparetic as a result of a spontaneously occurring intraspinal haematoma. Myelography defined the extent of the lesion and showed it to be extradural in site. Infusion of large doses of factor VIII concentrate led to dramatic improvement and avoided the need to operate.

[Intracranial and spinal hemorrhage in haemophilia (author's transl)]

Among 234 hemophiliacs, 14 patients (5.9%) with intracranial and 1 patient (0.4%) with intramedullary hemorrhage were observed and examined. The average age at the time of hemorrhage was 17 years in patients with severe hemophilia and 43 years in patients with moderate hemophilia. The patients with mild hemophilia and intracranial bleeding were 5 and 58 years old, respectively. Eight intracerebral, 3 subdural and 4 subarachnoid hemorrhages were encountered. In 7 cases bleeding was posttraumatic and in 5 it occurred spontaneously. In 2 patients hemorrhage followed a sudden increase of intracranial pressure. In 1 patient reliable data could not be obtained. Four of the 8 patients with intracerebral bleeding died; all survivors displayed some residual neurological abnormalities. All patients suffering from subarachnoid bleeding recovered completely. No serious complications were encountered after 3 lumbar punctures, 5 cerebral angiographies and after 1 myelography. Only in 1 case with an acquired inhibitor did a local hematoma develop at the site of puncture for the angiography. The same diagnostic procedures should be performed after substitution therapy with anti-hemophiliac plasma in a hemophiliac without inhibitor as in non-hemophiliacs if intracranial or intramedullar bleeding is suspected. In hemophiliacs with an anticoagulant, angiography or lumbar puncture should be performed only in exceptional cases.

Chronic subdural hematoma: concepts of physiopathogenesis. A review

From the present review it seems clear that the physiopathogenesis of the chronic subdural hematoma is far from being completely understood. However, an analysis of the known data can be summarized as follows: The development of subdural hematomas most likely occurs following minimal trauma in those patients with predisposing factors. Experimental data substantiates the fact that an accumulation of clotted blood in the subdural or subcutaneous space induced the formation of the fibroplastic neomembrane. The hypothesis that blood must come in contact with cerebrospinal fluid in order for the growth to occur, is still controversial. It has been virtually disproven that osmosis, referring to the electrolyte gradient as measured by freezing point depression, has any significance as a growth inducing factor. The protein oncotic gradient theory, having been the most widely accepted explanation as to the progressive enlargement of the subdural hematoma sac, has little experimental data supporting it. A larger body of clinical evidence exists supporting the concept that plasma and/or erythrocytes continuously penetrate into the subdural cavity, where enhanced fibrinolytic activity is present. However, this chronic rebleeding cannot fully explain the observed growth, because the composition of the hematoma fluid is smoewhat different from serum or plasma, and the protein content is also progressively diluted by fluid arising from an unknown source. There is some clinical and experimental evidence to suggest that a production-reabsorption balance may be a significant growth variable. No work has been done to define the role, if any, of local inflammatory mechanisms in the chronic subdural hematoma. Sound clinical evidence has shown that after the initial formation of the subdural clot, growth follows, than a slow, complete reabsorption usually occurs. Aside from the plausible production-reabsorption balance concept, it is not known why the evolution proceeds in this manner.

Intracranial hemorrhage in patients with hemophilia

✓ Intracranial hemorrhage occurred in four patients with hemophilia following mild head trauma. Three patients had severe factor VIII (antihemophilic factor, AHF) deficiency while one had mild (5.5%) AHF deficiency. The authors stress the need for immediate AHF replacement therapy and appropriate neurosurgical work-up, and a joint effort by hematologist and neurosurgeon to minimize neurological damage. In the four patients, three subdural hematomas, one epidural and one intracerebral hematoma were safely evacuated.

Production of clinical form of chronic subdural hematoma in experimental animals

✓ A method for producing a clinical form of experimental chronic subdural hematoma is reported. When blood is mixed with cerebrospinal fluid and incubated, a peculiar clot is formed which, when inoculated into the subdural space of dogs or monkeys, grows gradually. Histologically the capsule of the hematoma is comparable to that seen in human chronic subdural hematoma. In some animals progressive hemiparesis develops.

Two types of spontaneous intracerebral hemorrhage due to hypertension

✓ Analysis of 150 postmortem examinations indicates that spontaneous intracerebral hemorrhage in hypertensive patients develops in two ways. In the first, hemorrhage crushes the surrounding tissue, tamponades the ventricles, and produces a fatal increase in intracranial pressure. Operation on such patients does not improve the results obtained by conservative treatment. In the second type, the hemorrhage is self-limited; the hematoma that frequently develops behaves as an expanding lesion, and operative treatment can be helpful after the initial shock interval has passed. Diagnostic differentiation of the two types is not possible immediately after the stroke.

Epidural hemaoma in hemophilia: successful treatment

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Intracranial ventricular haemorrhage as a first presentation of haemophilia. A case of successful surgical management

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Intracranial hemorrhage in infancy and childhood. Classification and outline of management

Many observations suggest that certain nonprogressive neurologic disorders are the sequelae of intracerebral or intracranial hemorrhage or both, but the role played by these factors as well as hypoxia is difficult to ascertain even at autopsy. As a rule, intracranial bleeding in infants (neonates excluded) and children is secondary to trauma. Some of these children are left with some neurologic deficit, depending upon the site and severity of the breeding and the promptness of therapy.