新生儿颅内出血英文.ppt

IntracranialHemorrhageoftheNewborn,EtiologyandEpidemiologyofICH,Trauma(epidural,subdural,orsubarachnoid)fetalheadistoolargeinproportiontothesizeofthepelvicoutletprolongedlabor/breechorprecipitatedeliveriesMechanicalassistancewithdeliveryAsphyxia/HypoxicischemicencephalopathyPrematureinfants(peri-/intraventricularhemorrhage,PVH/IVH)Primaryhemorrhagicdisturbance(subarachnoidorintracerebral)DICisoimmunethrombocytopenianeonatalvitaminKdeficiency(maternalphenobarbitalorphenytoin)CongenitalvascularanomalyIatrogenichemorrhage(sucktioning,infusing,ventilating),IncidenceofPVH/IVH,MostcommonneonatalintracranialhemorrhageOccursprimarilyinprematureinfantsIncidenceincreaseswithdecreasingbirthweight:6070%of500-to750-ginfants,1020%of1000-to1500-ginfantsOccasionallyseeninnear-termandterminfantsRarelypresentatbirth50%occuronthe1stday,8090%occurbetweenbirthandthe3rdday2040%progressduringthe1stweekDelayedhemorrhagemayoccurafterthe1stweekin1015%ofthecasesNew-onsetIVHisrareafterthe1stmonthofliferegardlessofthebirthweight,PathogenesisofPVH/IVH,Gelatinoussubependymalgerminalmatrix(periventricular)EmbryonalneuronsandfetalglialcellsImmaturebloodvesselsandhighlyvascularareaPoortissuevascularsupportPredisposingfactorsoreventsPrematurity,RDS,Hypoxic-ischemicorhypotensiveinjury,reperfusion,increasedordecreasedCBF,pneumothorax,hypervolemia,hypertension,etcPeriventricularleukomalacia(PVL)PrenatalorneonatalischemicorreperfusioninjuryNecrosisoftheperiventricularwhitematterDamagetothecortico-spinalfibersintheinternalcapsule,PathogenesisofPVH/IVH,IntravascularfactorsFluctuatingcerebralbloodflow(relatedtomechanicsofventilation)IncreasinginCBF(pressure-passivecerebralcirculationinprematureinfants)IncreasesincerebralvenouspressureDecreasesinCBF(occurringprenatallyorpostnatally)Plateletandcoagulationdisturbances(hypercoagulablestate,vitaminK)VascularfactorsImmaturevesselsinthegerminalmatrixLackmuscleandcollagen,susceptibletoruptureVascularborderzonewithmoremitochondria,morevulnerabletoischemiaExtravascularfactorsNosupportivestromaaroundthevesselsExcessivefibrinolyticactivity,CommonClinicalSigns/Symptoms,ChangeofconsciousnessAbnormaleyessigns/movementIncreasedintracranialpressureIrregularrespiratorypatternorapneaChangesofmuscletonePupilssignsOthers:jaundice,anemia,etc,ClinicalManifestation,MostcommonsymptomsarediminishedorabsentMororeflex,poormuscletone,lethargy,apneaandsomnolenceOftenhaveaprecipitousdeteriorationonthe2ndor3rddaysPeriodsofapnea,pallor,orcyanosisFailuretosuckwellAbnormaleyesigns,fixedpupilsAhigh-pitched,shrillcryMusculartwitching,convulsion,decreasedmuscletone,orparalysisMetabolicacidosis,shock,decreasedhematocritTenseandbulgingoffontanelSevereneurologicaldepressionorcomaAsymptomaticperiodsornoclinicalmanifestations,ClinicalManifestation,PeriventriularLeukomalacia(PVL)Symmetric,non-hemorrhagicischemicinjuryOftencoexistswithIVHUsuallyasymptomaticatearlydaysBecomingspasticdiplegiainlaterinfancywhentheneurologicsequelaeofwhitematternecrosisbecomeapparentEarlyechodensephase(310daysoflife)Echolucent(cystic)phase(1420daysoflife),ClassificationofPVH/IVH(Grading),Mild(70%,40%I+30%II)GradeI:IsolatedperiventricularhemorrhageGradeII:IntraventricularhemorrhagewithnormalventricularsizeModerate(20%)GradeIII:IntraventricularhemorrhagewithacuteventriculardilationSevere(10%)GradeIV:Intraventricularhemorrhagewithparenchymalhemorrhage,PapileLA,JPediatr1978;92:529534.,Diagnosis,HistoryClinicalmanifestationTransfontanelcranialultrasonography(real-time)Computedtomography(CT)Magneticresonanceimaging(MRI)Magneticresonancespectroscopy(MRS),PossiblePrenatalInterventions,PreventionofprematurityMosteffectivemeansofpreventionofPVH/IVHTransportationofinfantsin-uterodecreasedincidenceofICHcomparedtopostnataltransportAntenatalcorticosteroidsPVH/IVH,maturationofbloodvessels/prostaglandinsynthesisAntenataladministrationofvitaminKPVH/IVH,improvementinprothrombinactivityAntenatalphenobarbitalseverePVH/IVH,controversialOptimalmanagementoflaboranddeliverynoconsistentresults,PossiblePostnatalInterventions,Appropriateneonatalresuscitationavoidhypercarbia,rapidinfusionandhypertonicsolutionsCorrection/preventionofhemodynamicdisturbancesavoidexcessivehandling,suctioning;useadequateventilationCorrectionofabnormalitiesofcoagulationfreshfrozenplasmacandecreaseincidenceofPVH/IVH,notseveretypePostnatalphenobarbitalinconsistent,currentdatadonotsupportroutineuseforpreventionEthamsylatestabilizationofthefragilegerminalmatrixvesselsVitaminEfree-radicalscavenger;conflictingdataIndomethacinCBFandfluctuationsinsystemicBP;closureofPDA;acceleratesmaturationofthegerminalmatrixmicrovasculature,PrognosisofPVH/IVH,GerminalMatrixDestructionDestructionofthematrixanditsglialprecursorsDisruptthedevelopmentofneuron-glialunitsinthecortexHemorrhageisfrequentlyreplacedbyformationofacyst(USvisible)Hydrocephalus50%ofgradeIII/IVPVH/IVHwillhavestatic/