国家级精品课程华中科技大学《儿科学》新生儿颅内出血课件

Intracranial Hemorrhage of the Newborn Etiology and Epidemiology of ICH Trauma Trauma (epidural, (epidural, subduralsubdural, or , or subarachnoidsubarachnoid) ) fetal head is too large in proportion to the size of the pelvic outletfetal head is too large in proportion to the size of the pelvic outlet prolonged labor/breech or precipitate deliveriesprolonged labor/breech or precipitate deliveries Mechanical assistance with delivery Mechanical assistance with delivery Asphyxia/Hypoxic Asphyxia/Hypoxic ischemic encephalopathy ischemic encephalopathy Premature infants Premature infants ( (periperi-/ -/intraventricularintraventricular hemorrhage, PVH/IVH) hemorrhage, PVH/IVH) Primary hemorrhagic disturbance Primary hemorrhagic disturbance ( (subarachnoidsubarachnoid or or intracerebralintracerebral) ) DICDIC isoimmune thrombocytopeniaisoimmune thrombocytopenia neonatal vitamin K deficiency (maternalneonatal vitamin K deficiency (maternal phenobarbital phenobarbital or or phenytoinphenytoin) ) Congenital vascular anomaly Congenital vascular anomaly Iatrogenic Iatrogenic hemorrhage ( hemorrhage (sucktioningsucktioning, infusing, ventilating) , infusing, ventilating) Incidence of PVH/IVH Most common neonatal Most common neonatal intracranialintracranial hemorrhage hemorrhage Occurs primarily in premature infants Occurs primarily in premature infants Incidence increases with decreasingIncidence increases with decreasing birthweight birthweight: : 6070% of 500- to 750-g infants, 1020% of 1000- to 1500-g infants 6070% of 500- to 750-g infants, 1020% of 1000- to 1500-g infants Occasionally seen in near-term and term infants Occasionally seen in near-term and term infants Rarely present at birth Rarely present at birth 50% occur on the 150% occur on the 1 st st day, 8090% occur between birth and the 3 day, 8090% occur between birth and the 3rd rd day day 2040% progress during the 12040% progress during the 1 st st week week Delayed hemorrhage may occur after the 1Delayed hemorrhage may occur after the 1 st st week in 1015% of the cases week in 1015% of the cases New-onset IVH is rare after the 1New-onset IVH is rare after the 1 st st month of life regardless of the month of life regardless of the birthweightbirthweight Pathogenesis of PVH/IVH Gelatinous Gelatinous subependymalsubependymal germinal matrix ( germinal matrix (periventricularperiventricular) ) EmbryonalEmbryonal neurons and fetal neurons and fetal glialglial cells cells Immature blood vessels and highly vascular areaImmature blood vessels and highly vascular area Poor tissue vascular support Poor tissue vascular support Predisposing factors or events Predisposing factors or events PrematurityPrematurity, RDS, Hypoxic-, RDS, Hypoxic-ischemicischemic or or hypotensivehypotensive injury, reperfusion, injury, reperfusion, increased or decreased CBF, increased or decreased CBF, pneumothoraxpneumothorax, , hypervolemiahypervolemia, hypertension, etc , hypertension, etc Periventricular leukomalacia Periventricular leukomalacia (PVL) (PVL) Prenatal or neonatal Prenatal or neonatal ischemic ischemic or reperfusion injuryor reperfusion injury Necrosis of the Necrosis of the periventricular periventricular white matterwhite matter Damage to the Damage to the corticocortico-spinal fibers in the internal capsule-spinal fibers in the internal capsule Pathogenesis of PVH/IVH IntravascularIntravascular factors factors Fluctuating cerebral blood flow (related to mechanics of ventilation)Fluctuating cerebral blood flow (related to mechanics of ventilation) Increasing in CBF (pressure-passive cerebral circulation in premature infants)Increasing in CBF (pressure-passive cerebral circulation in premature infants) Increases in cerebral venous pressureIncreases in cerebral venous pressure Decreases in CBF (occurring Decreases in CBF (occurring prenatally prenatally or or postnatallypostnatally) ) Platelet and coagulation disturbances (Platelet and coagulation disturbances (hypercoagulable hypercoagulable state, vitamin K)state, vitamin K) Vascular factors Vascular factors Immature vessels in the germinal matrixImmature vessels in the germinal matrix Lack muscle and collagen, susceptible to ruptureLack muscle and collagen, susceptible to rupture Vascular border zone with more mitochondria, more vulnerable to Vascular border zone with more mitochondria, more vulnerable to ischemia ischemia Extravascular Extravascular factorsfactors No supportive No supportive stromastroma around the vessels around the vessels Excessive Excessive fibrinolytic fibrinolytic activityactivity Common Clinical Signs/Symptoms Change of consciousnessChange of consciousness Abnormal eyes signs/movement Abnormal eyes signs/movement Increased Increased intracranial intracranial pressurepressure Irregular respiratory pattern or apnea Irregular respiratory pattern or apnea Changes of muscle tone Changes of muscle tone Pupils signs Pupils signs Others: jaundice, anemia, etc Others: jaundice, anemia, etc Clinical Manifestation Most common symptoms are diminished or absent Moro Most common symptoms are diminished or absent Moro reflex, poor muscle tone, lethargy, apnea and somnolence reflex, poor muscle tone, lethargy, apnea and somnolence Often have a precipitous deterioration on the 2 Often have a precipitous deterioration on the 2nd nd or 3 or 3rd rd days days Periods of apnea, pallor, or cyanosisPeriods of apnea, pallor, or cyanosis Failure to suck wellFailure to suck well Abnormal eye signs, fixed pupilsAbnormal eye signs, fixed pupils A high-pitched, shrill cryA high-pitched, shrill cry Muscular twitching, convulsion, decreased muscle tone, or paralysisMuscular twitching, convulsion, decreased muscle tone, or paralysis Metabolic acidosis, shock, decreased Metabolic acidosis, shock, decreased hematocrit hematocrit Tense and bulging of fontanelTense and bulging of fontanel Severe neurological depression or coma Severe neurological depression or coma Asymptomatic Asymptomatic periods or no clinical manifestations periods or no clinical manifestations Clinical Manifestation Periventriular LeukomalaciaPeriventriular Leukomalacia (PVL) (PVL) Symmetric, non-hemorrhagic Symmetric, non-hemorrhagic ischemic ischemic injuryinjury Often coexists with IVHOften coexists with IVH Usually Usually asymptomaticasymptomatic at early days at early days Becoming Becoming spasticspastic diplegiadiplegia in in later later infancy infancy when when the the neurologicneurologic sequelaesequelae of white matter necrosis become apparent of white matter necrosis become apparent Early Early echodenseechodense phase (310 days of life) phase (310 days of life) EcholucentEcholucent (cystic) phase (1420 days of life) (cystic) phase (1420 days of life) Classification of PVH/IVH (Grading) Mild (70%, 40% I + 30% II)Mild (70%, 40% I + 30% II) Grade I: Isolated Grade I: Isolated periventricularperiventricular hemorrhage hemorrhage Grade II:Grade II: Intraventricular Intraventricular hemorrhage with normal ventricular size hemorrhage with normal ventricular size Moderate (20%) Moderate (20%) Grade III:Grade III: Intraventricular Intraventricular hemorrhage with acute ventricular dilation hemorrhage with acute ventricular dilation Severe (10%) Severe (10%) Grade IV: Grade IV: IntraventricularIntraventricular hemorrhage with hemorrhage with parenchymal parenchymal hemorrhage hemorrhage Papile LA, J Pediatr 1978; 92:529534. Diagnosis HistoryHistory Clinical manifestation Clinical manifestation TransfontanelTransfontanel cranial cranial ultrasonography ultrasonography (real-(real- time)time) Computed Computed tomography tomography (CT)(CT) Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) Magnetic resonance spectroscopy (MRS) Possible Prenatal Interventions Prevention ofPrevention of prematurity prematurity Most effective means of prevention of PVH/IVHMost effective means of prevention of PVH/IVH Transportation of infants in- Transportation of infants in-uteroutero decreased incidence of ICH compared to postnatal transportdecreased incidence of ICH compared to postnatal transport Antenatal Antenatal corticosteroidscorticosteroids PVH/IVH, maturation of blood vessels/prostaglandin synthesisPVH/IVH, maturation of blood vessels/prostaglandin synthesis Antenatal administration of vitamin K Antenatal administration of vitamin K PVH/IVH, improvement inPVH/IVH, improvement in prothrombin prothrombin activity activity Antenatal Antenatal phenobarbitalphenobarbital severe PVH/IVH, controversialsevere PVH/IVH, controversial Optimal management of labor and delivery Optimal management of labor and delivery no consistent resultsno consistent results Possible Postnatal Interventions Appropriate neonatal resuscitationAppropriate neonatal resuscitation avoid avoid hypercarbiahypercarbia, rapid infusion and , rapid infusion and hypertonichypertonic solutions solutions Correction/prevention of Correction/prevention of hemodynamichemodynamic disturbances disturbances avoid excessive handling, suctioning; use adequate ventilationavoid excessive handling, suctioning; use adequate ventilation Correction of abnormalities of coagulation Correction of abnormalities of coagulation fresh frozen plasma can decrease incidence of PVH/IVH, not severe typefresh frozen plasma can decrease incidence of PVH/IVH, not severe type Postnatal Postnatal phenobarbitalphenobarbital inconsistent, current data do not support routine use for preventioninconsistent, current data do not support routine use for prevention EthamsylateEthamsylate stabilization of the fragile germinal matrix vesselsstabilization of the fragile germinal matrix vessels Vitamin E Vitamin E free-radical scavenger; conflicting datafree-radical scavenger; conflicting data IndomethacinIndomethacin CBF and fluctuations in systemic BP; closure of PDA;CBF and fluctuations in systemic BP; closure of PDA; accelerates maturation of the germinal matrix accelerates maturation of the germinal matrix microvasculaturemicrovasculature Prognosis of