Intracranial Hemorrhage after Blunt Head Trauma in Children with Bleeding Disorders Lois K. Lee, MD, MPH, Peter S. Dayan, MD, MSc, Michael J. Gerardi, MD, Dominic A. Borgialli, DO, MPH, Mohamed K. Badawy, MD, James M. Callahan, MD, Kathleen A. Lillis, MD, Rachel M. Stanley, MD, Marc H. Gorelick, MD, MSCE, Li Dong, MSc, Sally Jo Zuspan, RN, MSN, James F. Holmes, MD, MPH, and Nathan Kuppermann, MD, MPH, and the Traumatic Brain Injury Study Group for the Pediatric Emergency Care Applied Research Network (PECARN) Objective To determine computerized tomography (CT) use and prevalence of traumatic intracranial hemorrhage (ICH) in children with and without congenital and acquired bleeding disorders. Study design We compared CT use and ICH prevalence in children with and without bleeding disorders in a mul- ticenter cohort study of 43 904 children <18 years old with blunt head trauma evaluated in 25 emergency depart- ments. Results A total of 230 children had bleeding disorders; all had Glasgow Coma Scale (GCS) scores of 14 to 15. These children had higher CT rates than children without bleeding disorders and GCS scores of 14 to 15 (risk ratio, 2.29; 95% CI, 2.15 to 2.44). Of the children who underwent imaging with CT, 2 of 186 children with bleeding disor- ders had ICH (1.1%; 95% CI, 0.1 to 3.8) , compared with 655 of 14 969 children without bleeding disorders (4.4%; 95% CI, 4.1-4.7; rate ratio, 0.25; 95% CI, 0.06 to 0.98). Both children with bleeding disorders and ICHs had symp- toms; none of the children required neurosurgery. Conclusion In children with head trauma, CTs are obtained twice as often in children with bleeding disorders, although ICHs occurred in only 1.1%, and these patients had symptoms. Routine CT imaging after head trauma may not be required in children without symptoms who have congenital and acquired bleeding disorders. (J Pediatr 2011;158:1003-8). I ntracranial hemorrhage (ICH) is a significant and potentially life-threatening complication for children with congenital or acquired bleeding disorders. 1-9 There is evidence that these children are at increased risk for sustaining ICH even after minor blunt head trauma. 2,6,10 Studies in children with hemophilia have reported ICH rates of 2% to 16% after head trauma, including some children with no signs or symptoms of trauma. The risk of ICH varies with the severity of hemophilia, and children with severe hemophilia (factor level <1%) are at highest risk, from spontaneous and traumatic ICH. 2,10-13 Although there are few studies on the risk of ICH after head trauma in children with von Willebrand disease, they seem to be at less risk than children with hemophilia. 2,12,14 The risk of ICH in patients with other congenital and acquired bleeding dis- orders is less well described. 1,2,15 In patients with immune (idiopathic) thrombo- cytopenic purpura (ITP), ICH, including spontaneous and traumatic, is rare, with a reported incidence of 0.1% to 1.0%. 1,9,16,17 However, the prevention of ICH has been a primary goal in the management of ITP, because ICH risk cor- relates with the severity of thrombocytopenia. 1,4,17 The ICH risk in patients who have taken anti-coagulants has only been reported in adults, with differing con- clusions about the risk of anti-coagulation therapy. 18-22 From the Department of Pediatrics, Harvard Medical School, Boston, MA (L.L.); Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY (P.D.); Department of Emergency Medicine, Atlantic Health System, Morristown Memorial Hospital, Morristown, NJ (M.Gerardi); Department of Emergency Medicine, University of Michigan School of Medicine and Hurley Medical Center, Flint, MI (D.B.); Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY (M.B.); Departments of Emergency Medicine and Pediatrics, SUNY-Upstate Medical University, Syracuse, NY (J.C.); Department of Pediatrics and Emergency Medicine, SUNY-Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY (K.L.); Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI (R.S.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI (M.Gorelick); Department of Pediatrics, University of Utah and PECARN Central Data Management and Coordinating Center, Salt Lake City, UT (L.D., S.Z.); and Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA (J.H., N.K.) List of members of the Traumatic Brain Injury Study Group for the Pediatric Emergency Care Applied Research Network (PECARN) available at www.jpeds. com (Appendix). Supported by a grant from the Health Resources and Services Administration/Maternal and Child Health Bu- reau, Division of Research, Education, and Training, and the Emergency Medical Services of Children program (R40MC02461). The Pediatric Emergency Care Applied Research Network is supported by cooperative agree- ments U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the Emergency Medical Services of Children program of the Health Re- sources and Services Administration/Maternal and Child Health Bureau, Division of Research. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2011 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2010.11.036 CT Computerized tomography ED Emergency department GCS Glasgow Coma Scale ICH Intracranial hemorrhage ITP Immune (idiopathic) thrombocytopenic purpura LOC Loss of consciousness PECARN Pediatric Emergency Care Applied Research Network RR Rate ratio 1003