Idiopathic Thrombocytopenia and minor head injury
Date First Published:
May 10, 2010
Last Updated:
May 10, 2010
Report by:
Dr Alison Sheehan, ST3 (Royal Manchester Childrens Hospital)
Search checked by:
Dr Niamh Collins, Royal Manchester Childrens Hospital
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
Pubmed database, advanced search using the same search terms and limited to human and english, dates 01/01/1980-10/05/2010
Search Details:
[(((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.}
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.
Pubmed search produced 1500 papers of which 3 papers were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intracranial haemorrhage in idiopathic thrombocytopenic purpura. Paediatric Haematology Forum of the British Society for Haematology. 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. |
| Intracranial hemorrhage (ICH) in children with immune thrombocytopenia (ITP): study of 40 cases. Psaila, B., Petrovic, A., Page, LK., Menell, J., Schonholz, M. and Bussel, J.B. 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. |
| Intracranial hemorrhage in childhood immune thrombocytopenic purpura. Choudhary, DR., Naithani, R., Mahapatra, M., Kumar, R., Mishra, P. and Saxena, R. 2009 India | 750 patients with ITP | Retrospective | Intracranial Haemorrhage | 17 patients developed Intracranial haemorrhage, 4 of which were precipitated by head injury | Retrospective study |
Author Commentary:
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.
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:
- Lilleyman, J.S. Intracranial haemorrhage in idiopathic thrombocytopenic purpura. Paediatric Haematology Forum of the British Society for Haematology.
- 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.
- Choudhary, DR., Naithani, R., Mahapatra, M., Kumar, R., Mishra, P. and Saxena, R.. Intracranial hemorrhage in childhood immune thrombocytopenic purpura.