• Trauma
• Prematurity
• Coagulopathies related to vitamin K deficiency, hemophilia, idiopathic thrombocytopenic purpura, protein C deficiency, hemolytic-uremic syndrome, disseminated intravascular coagulation, leukemia
• Brain tumors
• Encephalitis, especially herpes simplex infection
• Intracranial aneurysms
• Arteriovenous malformations
• Hypertension
• Cocaine use
• Cerebral infarction

• Epidural hematoma (blood between the dura mater and the skull) is frequently from arterial bleeding related to skull fracture; however, approximately one-fourth of epidural hematomas in children are from venous bleeding.
• Subdural hematoma (blood between the dura mater and the arachnoid membrane) is frequently from venous bleeding resulting from trauma or a coagulopathy.
• Subarachnoid hemorrhage (blood between the arachnoid membrane and brain) is frequently from a ruptured intracranial aneurysm.
• Blood within the brain parenchyma can be the result of trauma, infections such as herpes simplex encephalitis, brain tumors, venous sinus thrombosis, or cerebral infarction.
• Subependymal germinal matrix hemorrhage occurs in newborns, more commonly in premature infants that are less than 34 weeks gestational age.
• Intraventricular hemorrhage most commonly occurs when either an intraparenchymal or subependymal germinal matrix hemorrhage extends into the ventricular system.

• Death
• Increased intracranial pressure
• Hydrocephalus
• Vasospasm
• Seizures
• Motor, visual, and cognitive deficits

• Stroke
• Brain tumor
• Migraine headache

• Vascular malformation
• Aneurysm
• Trauma
• Tumor
• Bleeding disorder
• Embolism
• Encephalitis
• Idiopathic

• Headache
• Change in consciousness
• Seizures
• Visual problems
• Epistaxis

• Onset of symptoms most frequently acute to subacute
• Change in cognitive function, including decline of consciousness, alertness, and meaningful interaction with the environment
• Seizures
• Focal motor weakness
• Signs of increased intracranial pressure, such as Cushing triad (hypertension, bradycardia, abnormal respirations), papilledema, pupils that do not constrict to light, ophthalmoparesis, decorticate or decerebrate posturing
• If associated with trauma, there may be:
  • Leakage of cerebrospinal fluid from the ear or nose
  • Battle sign: bruising over the mastoid process suggestive of basilar skull fracture
  • Macewen sign: percussion of the skull gives a cracked pot sound suggestive of skull fracture
  • Racoon eyes: periorbital ecchymosis suggestive of recent head trauma
  • Retinal hemorrhages
• Herpes simplex type 1 encephalitis: frequently presents with fever, cognitive impairment, seizures
• Germinal matrix hemorrhages are frequently clinically silent but may present with apnea in the newborn.
• Intraventricular blood may present with signs of increased intracranial pressure caused by communicating hydrocephalus.
• Subarachnoid hemorrhage frequently presents as the worst headache ever experienced, subhyaloid hemorrhages, and signs of meningeal irritation.

• Computed tomography (CT) of the head is the most important study to obtain when considering intracranial hemorrhage in the differential diagnosis because of its relative convenience, speed, and low false-negative rate. Acute blood appears as areas of increased density on head CT; however, after approximately 3 days, the blood will appear progressively less dense.
• Magnetic resonance imaging (MRI) is frequently less useful for diagnosing acute hemorrhage unless signal sequences are specifically adjusted to look for blood.
• MRI is the diagnostic study of choice for venous sinus thrombosis.
• Lumbar puncture, if not contraindicated because of increased intracranial pressure, thrombocytopenia, or skin infection, will show red blood cells and xanthochromia if the blood is contiguous with the ventricular system.
• Angiography, either with conventional dye or using magnetic resonance angiography, is helpful when looking for vasospasm and arterial venous malformations.
• Head ultrasound is the most convenient method for diagnosing subependymal germinal matrix hemorrhages in infants.

• Acyclovir therapy should be instituted if herpes simplex type 1 encephalitis is considered, because, if untreated, there is a high rate of mortality.
• Intracranial aneurysms are frequently amenable to neurosurgical intervention to decrease the likelihood of rebleeding; in addition, careful control of increased intracranial pressure, decreasing vasospasm with nimodipine, and prompt attention to hydrocephalus are necessary.
• Neurosurgical intervention is frequently necessary for subdural and epidural hematomas.

• Using automobile seatbelts; using bicycle, skating, and skateboarding helmets; preventing child abuse; practicing diving safety; preventing falls; maintaining safe driving speeds; keeping children away from firearms

Golden GS. In: Swaiman KF, ed. Pediatric neurology principles and practice, 2nd ed. St. Louis: Mosby, 1994:791–799.

Medeiros D, Buchanan GR. Major hemorrhage in children with idiopathic thrombocytopenic purpura: immediate response to therapy and long-term outcome. J Pediatr 1998;133(3):334–339.

Wear WE. Index of suspicion. Case 3 presentation. Pediatr Rev 1997;18(7):248, 250–251.