新生儿缺氧缺血脑病ppt课件.ppt

HYPOXIC-ISCHEMICENCEPHALOPATHY,DEFINITION,HIE:Hypoxic-ischemicdamageofthebrainresultingfromperinatalasphyxia;Braindysfunction：encephalopathyPrimarycauseofpermanentdamagetoCNS.,ETIOLOGY,Fetalasphyxia(80%-90%)AnyprocessthatImpairsmaternaloxygenationDecreasesbloodflowfromthemothertotheplacentaorfrompaecentatothefetusImpairsgasexchangeacrosstheplacentaoratthefetaltissureIncreasesfetalO2requirementwillexacerbateperinatalasphyxia,ETIOLOGY,Fetalasphyxia(80%-90%)MaternalHypertension;Vasculardisease;Diabetes;Druguse;Hypotension;Infection;Hypoxiafrompulmonary,cardiac,orneurologicdiseasePlacentalorcordalPlacentalinfarctionorfibrosis;abruption;prematureseparation;insuficiencyCordalprolapse;entanglement;trueknot;compression;abnormalvesselsFetalHydrops;Infection;IUGR;Postterm,ETIOLOGY,Diseasesafterbirth(10%)SevereanemiaSevereCHDShockRespiratoryfailure(centralorperipheral),Theproblem,Severeasphyxia:2-4per1000full-termbirths2050%mortality25%ofthesurvivorswillexhibitpermanentneuropsychologicalhandicaps:MentalretardationCerebralpalsyEpilepsyLearningdisability,PATHOPHYSIOLOGY,CBFchangesduetocardiacdysfunction3:696.Copyright1976,AmericanMedicalAssociation.,HIE临床分度,NeurologicSequelae,CerebralpalsyMentalretardationAuditorydysfunctionVisualdysfunctionLanguagedifficultiesEpilepsyHydroencephalus,UltrasonicExamination,Edema(diffuseduniformincreasedecho,midlineshift,ventricularcompression)Hemorrhage:increasedecho(usefulinpreterminfants)Infarctandnecrosis:focalormultifocalechoNucleiandbasalgangliainjury:symetrichyper-echoPVL:symetricirregularperiventricularhyper-echo,CranialComputedTomographyScan,Edema:diffusedhypodensity(2-4daysaftertheinsult)Hemorrhage:focalhyperdensityInfarctandnecrosis:focalormultifocalhypodensityNucleiandbasalgangliainjury:symetrichyperdensityPVLinpreterm:symetricperiventricularhypodensity,MagneticResonanceImaging(MRI)normalsignalsinbrain,GMWMCSFBoneFatT1WIhighlowlowlowhighT2WIlowhighhighlowhigh,T1WIT2WI,MagneticResonanceImaging(MRI)abnormalsignalsinbrain,HemoInfarEdemaCystT1WI高低低低T2WI低高高高,T2WI,T1WI,MRI、CT及B超比较,神经病理类型MRICTB超选择性神经元坏死脑皮质+基底节和丘脑+脑干+矢状旁区脑损害+脑室周围白质软化+局灶和多灶缺血脑损害+VolpeJJ.NeurologyoftheNewborn.4ed,2001.338.,EarlyStage5d,Cerebraledema,图1生后24h,图2生后7d,图1示脑实质弥漫性点状强回声，基底节回声增强更为显著，侧脑室显示不清脑水肿图2脑实质和基底节回声基本恢复正常，侧脑室显示清晰脑水肿消失,头颅B超,4439Hemorrhage,ConvalescentStage（neurondeath）710dlater,infarct,cortexandsubcorticalleukomalacia（CT值6Hu),Nucleiandbasalgangliainjury,7dCTscan,SequelaeStage：34Wkslater，cysticchange,orpretermPVL,1W,PVL（Ultrasound）,3W,PVL（Ultrasound）,5W,14M,PVL（CT）,18M,MRI,T1,T2,PVL诊断（MRI影象）,MRI,MildHIE,左顶叶局灶性水肿，T2WI信号增高，皮层变薄，灰白质分界欠清，而正常灰白质的高低相间的柱状影消失。,MRI,SevereHIE（3d）,T1WI,T2WI,双侧大脑皮层深部呈线条状高信号,双侧弥漫性脑水肿,白质信号增高,灰质变薄,灰白质分界消失,丘脑异常高信号，示大理石样基底节（箭头）；脑萎缩；硬脑膜下积液（箭头）,SevereHIE（3M）,MRI,MRI,SevereHIE:infarct,T2WI,DWI,左侧顶枕叶大面积脑梗死（箭头），呈楔形高信号,DIAGNOSIS&DIFFERENTDx,FetaldistressorbirthasphyxiaCNSsymptoms(24hs)RO:otherdiseasesmanifestedbyseizures,MANAGEMENT,CPRIntensiveCare(monitorvitalsigns)OxygensupplyPaO250-70mmHg(6.65-9.31kPa)PaCO240mmHg(5.32kPa)keepadequatebrainperfusion(systolicPabove50mmHg)Dopamine3-5ug/kg/mini.v.gtt.dobutamine2.5-10ug/kg/mini.v.gtt.,MANAGEMENT,Anti-convulsion1.Phenobarbital(1stline)Lordingdose10-20mg/kgivMaintaindose(after12hr.)5mg/kg/db.i.d.for7days2.Dilantin(2ndline)Lordingdose:15-20mg/kgi.v.slowly1mg/kg/MinMaintaindose(after6-12hr.)3-4mg/kg/db.i.d.ort.i.d.3.Valium(1stchoiceforseizuresstatus)0.1-0.3mg/kgi.v.4.Chloralhydrate0.5ml/kg,MANAGEMENT,Controlofbrainedema1.Controlefluidintake:60-80ml/kg/d2.Furosemide(Lasix)0.5-1.0mg/kgb.i.d.3.Albumin:0.51g/kg,i.v.q.db.i.d.4.20%Mannitol1.25ml-2.5ml/kgq4h-q6hCorrectacidosis,hypoglycemia,hypocalcemiaSodiumBicarbonatei.v.keeppH7.3-7.4,NeuroprotectiveStrategies,Hypothermia,1950scasereportsinasphyxiatednewbornsimmersedinatubofcoldwatersuccessful1970sDrowningvictimsupto40minintactsurvivalFollowingCardiopulmonarybypass(28-30C)discontiued1980sanimalstudieswithmildhypothermia(32-35C),Hypothermiaeffects,Coolingeffectsmanyorallpathwaysleadingtocelldeathcellularmetabolicdemandsexcessiveaccumulationofcytotoxins(glutamate,oxygenfreeradicals)Suppressingin