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Three Part Question

What is the [incidence/risk of intracranial bleeding] in [children with idiopathic thrombocytopenia] who sustain a [mild head injury]?

Clinical Scenario

A four year old boy presents to the emergency department following a fall at school. He sustained a 2cm haematoma to his right forehead. His GCS is 15/15. His mum is concerned as he has idiopathic thrombocytopenia and has been advised to bring him to hospital as he is at risk of intracranial bleeding. You wonder whether this patient should have an urgent CT Brain scan in view of his thrombocytopenia.

Search Strategy

Medline 1980-2010 using ovid interface and journals@ovid full text database, multifield search.
Pubmed database, advanced search using the same search terms and limited to human and english, dates 01/01/1980-10/05/2010
[(((idiopathic thrombocytopenia or immune thrombocytopenia purpura or immune thrombocytopenic purpura) and intracranial haemorrhage) or intracranial hemorrhage or intracranial bleeding) and head injury and children.af.}

Search Outcome

Medline search produced 608 papers of which one paper was relevant but did not answer the three part question.
Pubmed search produced 1500 papers of which 3 papers were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lilleyman, J.S 1994 United Kingdom	14 children with ITP who had Intracranial haemorrhage	Retrospective	Intracranial haemorrhage	2/14 patients had head injury prior to intracranial haemorrhage	Small number of patients. Retrospective Study.
Psaila et al 2009 USA	120 children with ITP, 40 had intracranial haemorrhage and 80 as a control	Retrospective and Prospective	Intracranial Haemorrhage	13/40 patients had head injury prior to intracranial haemorrhage	Small number of patients. Retrospective Study.
Choudhary et al 2009 India	750 patients with ITP	Retrospective	Intracranial Haemorrhage	17 patients developed Intracranial haemorrhage, 4 of which were precipitated by head injury	Retrospective study

Comment(s)

The three retrospective studies identified children with ITP who developed haemorrhage following a head injury. However, none of the studies explained how the intracranial haemorrhage was diagnosed, what types of bleeds occurred, what form of trauma led to the haemorrhage, how the patients presented to the emergency department nor what symptoms they developed that warranted further investigation.

Clinical Bottom Line

Idiopathic thrombocytopenia (ITP) in childhood is rarely complicated by serious bleeding. While intracranial haemorrhage (ICH) is the most feared serious complication, it only occurs in 0.3% of cases. Every reported case of ICH has arisen in a child with a platelet count (< 20 x 109/L). There are no specific studies investigating intracranial haemorrhage secondary to mild head injury in children with ITP. Therefore clinical judgement should prevail and platelet count should be measured. If platelet count is <20 or the patient has any features suggestive of intracranial haemorrhage an urgent CT scan should be requested, otherwise clinical observation for a significant time period should be sufficient.

References

1. Lilleyman, J.S Intracranial haemorrhage in idiopathic thrombocytopenic purpura. Paediatric Haematology Forum of the British Society for Haematology. Archives of Disease in Childhood 1994; 71: 251-253
2. Psaila, B., Petrovic, A., Page, LK., Menell, J., Schonholz, M. and Bussel, J.B. Intracranial hemorrhage (ICH) in children with immune thrombocytopenia (ITP): study of 40 cases. Blood 26 November 2009, Vol. 114, No. 23, pp. 4777-4783
3. Choudhary, DR., Naithani, R., Mahapatra, M., Kumar, R., Mishra, P. and Saxena, R. Intracranial hemorrhage in childhood immune thrombocytopenic purpura. Pediartic Blood Cancer 2009 April;52(4): 529-31