New Data on Seizures and Risk Factors in Pediatric ICH

February 08, 2013

One of the largest prospective studies of children and neonates with intracranial hemorrhage (ICH) has provided more information on presenting symptoms and risk factors for worse outcomes, which will help in the diagnosis and long-term treatment of patients with this condition.

The results show that seizures are very common at presentation in children and neonates with ICH. The study showed the importance of electroencephalography (EEG) monitoring in these children, which found a high incidence of subclinical seizures.

The study was presented at the International Stroke Conference (ISC) 2013 by Lauren A. Beslow-Kaye, MD, MSCE, from Yale University School of Medicine, New Haven, Connecticut, and simultaneously published online in JAMA Neurology.

"This is an ongoing cohort study of children and neonates (excluding premature neonates) with spontaneous ICH," Dr. Beslow-Kaye commented to Medscape Medical News. "If we can understand risk factors and predict outcomes for ICH in children, we can do more to intervene and reduce bad outcomes.

"We know that larger hemorrhagic volume and seizures and epilepsy increase bad outcomes, but there is a gap in knowledge about the prevalence of seizures both in the acute setting and in the longer term," she added. "The clinical implications of our findings are that we can now give parents a little bit more information on what they might expect in terms of seizures and epilepsy after their child has had an ICH."

Dr. Lauren A. Beslow-Kaye

Highest Risk

The study cohort included 73 patients (20 neonates and 53 older children) with ICH who were followed over time in a prospective manner. Results showed that 60% of neonates and 43% of older children had symptomatic seizures in the acute phase (within 7 days of the ICH).

"This indicates that acute symptomatic seizures are more common in children than in adults, in whom seizures are reported in 7% to 31%, and that children with ICH present with seizures more commonly than children with arterial ischemic stroke, in whom seizures are reported as a presenting symptom in 22%," the researchers note.

At 1 year, 18% had had a symptomatic seizure in the remote period (after the first 7 days). At 2 years, this had increased to one third of children.

Epilepsy (defined as 2 or more seizures) had been diagnosed in 4% of patients at 1 year and 13% at 2 years.

Another important finding, Dr. Beslow-Kaye reported, was that children with an increased intracranial pressure after the hemorrhage were particularly at risk for remote symptomatic seizures and epilepsy.

Continuous EEG was performed in 65% of perinatal patients and in about one third of childhood patients, and subclinical seizures were found to occur in 28% of these patients. In addition, 75% of childhood patients with electrographic-only seizures on continuous EEG had elevated intracranial pressure, suggesting that children with elevated intracranial pressure after ICH may derive particular benefit from continuous EEG monitoring and from more aggressive seizure management in the acute setting.

"Neonates and children with raised intracranial pressure are at the highest risk of developing epilepsy and are therefore in need of urgent intervention to reduce the intracranial pressure and intensified monitoring in the long term," Dr. Beslow-Kaye said. "It is important to identify epilepsy early, so that medication can be started. Untreated epilepsy can be dangerous."

She noted that ICH occurs in around 1 per 100,000 babies and children each year. About 5% to 25% of cases are fatal. The cause is not always known but it can be due to vascular malformations.

In an accompanying editorial, Geoffrey L. Heyer, MD, and E. Steve Roach, MD, from Nationwide Children's Hospital, Columbus, Ohio, explain that both ischemic and hemorrhagic stroke are relatively rare in children, and risk factors and clinical outcomes after stroke remain poorly understood. They say the current study "adds another piece to a very large puzzle."

They propose that the definitions of acute symptomatic seizures and remote symptomatic seizures used in this study become standard for future research addressing poststroke seizures in children, which will allow reasonable comparisons to be made between similar studies.

The study was supported by the National Institutes of Health, the L. Morton Morley Funds of the Philadelphia Foundation, and the June and Steve Wolfson Family Fund for Neurological Research. The authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online February 7, 2013. Abstract Editorial