新生儿颅内出血（intracranialhemorrhageofthenewborn）课件

Intracranial Hemorrhage of the Newborn ( ICH ),Contents mastered : The main causes of neonatal ICH The mechanism of PVH-IVH Classification and manifestation of PVH-IVH Diagnosis of neonatal ICH Prevention of neonatal ICH,A severe disease in neonate Related to perinatal asphyxia and trauma, and maturity of fetus There are four major types Subdural hemorrhage Primary subarachnoid hemorrhage Intracerebellar hemorrhage Periventricular-intraventricular hemorrhage (PVH-IVH),Introduction,Etiology and Epidemiology of ICH,Trauma (epidural, subdural, or subarachnoid) fetal head is too large compared with the size of the pelvic outlet prolonged labor/breech or precipitant deliveries Delivery with mechanical assistance Asphyxia/Hypoxic-ischemic encephalopathy Maturity of neonate: germinal matrix, PVH/IVH for 20-30% infants with BW1500g,Primary hemorrhagic disturbance (subarachnoid or intracerebral) DIC isoimmune thrombocytopenia neonatal vitamin K deficiency (maternal phenobarbital or phenytoin) Congenital vascular anormality Iatrogenic hemorrhage (sucktioning, infusing, ventilating),PVH / IVH,Most common neonatal intracranial hemorrhage Occurs primarily in premature infants Incidence is inversely proportional with birthweight: 6070% of 500- to 750-g infants, 1020% of 1000- to 1500-g infants Occasionally seen in near-term and term infants Rarely present at birth 50% on the 1st day, 8090% between birth and the 3rd day 2040% progress during the 1st week Delayed hemorrhage after the 1st week in 1015% of the cases New-onset IVH is rare after the 1st month of life regardless of the birthweight,Pathogenesis of PVH / IVH,Gelatinous subependymal germinal matrix at periventricular area Embryonal neurons and fetal glial cells Immature blood vessels of germinal matrix: thin walls for their relatively large size, lack of a muscularis layer Poor extravascular support: immature interendothelial junctions Predictive factors or events Prematurity, RDS, Hypoxic-ischemic or hypotensive injury, reperfusion, increased or decreased CBF, pneumothorax, hypervolemia, hypertension, etc,Pathogenesis of PVH / IVH,Intravascular factors Fluctuating cerebral blood flow, occurring prenatally or postnatally (related to pressure-passive cerebral circulation, mechanical ventilation, sucktion, infusion) Increasing of cerebral venous pressure (mechanical ventilation, rapid infusion or infusion of hyperosmotic liquid) Platelet and coagulation disturbances (hypercoagulable state, vitamin K) Vascular factors Immature vessels in the germinal matrix Lack muscle and collagen, susceptible to rupture (germinal matrix) Vascular border zone with more mitochondria, more vulnerable to ischemia,Pathogenesis of PVH / IVH,Extravascular factors No supportive stroma around the vessels Excessive fibrinokinase Periventricular leukomalacia (PVL) Prenatal or neonatal ischemic or reperfusion injury Necrosis of the periventricular white matter Damage to the cortico-spinal fibers in the internal capsule,Common Clinical Signs/Symptoms of ICH,Change of consciousness Abnormal eyes signs/movement Increased intracranial pressure Irregular respiratory pattern or apnea Change of muscle tone Pupils signs Others: jaundice, anemia, etc,Clinical Manifestation,Most common symptoms are diminished or absent Moro reflex, poor muscle tone, lethargy, apnea and somnolence Often have a precipitous deterioration on the 2nd or 3rd day Periods of apnea, pallor, or cyanosis Failure to suck Abnormal eye signs, fixed pupils A high-pitched, shrill cry Muscular twitching, convulsion, decreased muscle tone, or paralysis Metabolic acidosis, shock, decreased hematocrit Tenseness and bulging of fontanel Severe neurological depression or coma Asymptomatic periods or no clinical manifestations,Clinical Manifestation,Periventriular Leukomalacia (PVL) Symmetric, non-hemorrhagic ischemic injury Often coexists with IVH Usually asymptomatic at early days Becoming spastic diplegia in later infancy when the neurologic sequelae of white matter necrosis become apparent Early echodense phase (310 days of life) Echolucent (cystic) phase (1420 days of life),Clinical Manifestation,PVH / IVH three clinical types Catastrophic Syndrome: very few clinical deterioration in minutes to hours, profound alteration in neurologic state, stupor or coma hypotension, apnea, bulging fontanel, drop in hematocrit, bradycardia, generalized tonic seizures, etc. Saltatory Syndrome: over hours to days Silent Syndrome: 60-70%, hemorrhages limited to the germinal matrix area. no clinical manifestations whatever, and difficult to predict its presence by clinical criteria,Classification of PVH/IVH (Grading),Pathologic changes depended on amount of hemorrhage and are consistent to clinical features Mild (70%, 40% I + 30% II) Grade I: Isolated subependymal hemorrhage Grade II: Intraventricular hemorrhage with normal ventricular size Moderate (20%) Grade III: Intraventricular hemorrhage with acute ventricular dilation Severe (10%) Grade IV: Intraventricular hemorrhage with parenchymal hemorrhage,Papile LA, J Pediatr 1978; 92:529534.,Diagnosis,History: preterm, VLBW, asphyxia, trauma, iatrogenic factors Clinical manifestation Transfontanel cranial ultrasonography (real-time) Computed tomography (CT) Magnetic resonance imaging (MRI) Magnetic resonance spectroscopy (MRS),routine head ultrasounds for “all” infants 1500g BW Firstly, 5-7 day Secondly, 28-30 day or before discharge If PVH-IVH is detected, a serial ultrasound should be done weekly to evaluate progression of ventricular dilitation or cystic change.,Possible Prenatal Interventions,Prevention of prematurity Most effective means of prevention of PVH/IVH Transportation of infants in-utero decreased incidence of ICH compared to postnatal transport Antenatal corticosteroids PVH/IVH, maturation of blood vessels/prostaglandin synthesis Antenatal administration of vitamin K PVH/IVH, improvement in prothrombin activity Antenatal phenobarbital severe PVH/IVH, controversial Optimal management of labor and delivery no consistent results,Possible Postnatal Interventions,Appropriate neonatal resuscitation avoid hypercapnia, rapid infusion and hypertonic solutions Correction/prevention of hemodynamic disturbances avoid excessive handling, suctioning; use adequate ventilation Correction of abnormalities of coagulation fresh frozen plasma can decrease incidence of PVH/IVH, not severe type Postnatal phenobarbital inconsistent, current data do not support routine use for prevention Ethamsylate stabilization of the fragile germinal matrix vessels Vitamin E free-radical scavenger; conflicting data Indomethacin CBF and fluctuations in systemic BP; closure of PDA; accelerates maturation of the germinal matrix microvasculature,Prognosis of PVH/IVH,Determination of the extent of hemorrhage is important to assess the probability of neurologic morbidity, which depends on: Degree of pathologic grades 50% of extensive hemorrhage (grade III and IV) have neorologic sequelae With accompanying PVL (3-10% of BW1500g), has high risk with mostly spastic diplegia,Prognosis of PVH/IVH,Germinal Matrix Destruction Destruction of the matrix and its glial precursors Disrupt the development of neuron-glial units in the cortex Hemorrhage is frequently replaced by formation of a cyst (US visible) H