新生儿颅内出血(Intracranial-Hemorrhage-of-the-Newborn)PPT课件

.,1,IntracranialHemorrhageoftheNewborn(ICH),.,2,Contentsmastered:ThemaincausesofneonatalICHThemechanismofPVH-IVHClassificationandmanifestationofPVH-IVHDiagnosisofneonatalICHPreventionofneonatalICH,.,3,AseverediseaseinneonateRelatedtoperinatalasphyxiaandtrauma,andmaturityoffetusTherearefourmajortypesSubduralhemorrhagePrimarysubarachnoidhemorrhageIntracerebellarhemorrhagePeriventricular-intraventricularhemorrhage(PVH-IVH),Introduction,.,4,EtiologyandEpidemiologyofICH,Trauma(epidural,subdural,orsubarachnoid)fetalheadistoolargecomparedwiththesizeofthepelvicoutletprolongedlabor/breechorprecipitantdeliveriesDeliverywithmechanicalassistanceAsphyxia/Hypoxic-ischemicencephalopathyMaturityofneonate:germinalmatrix,PVH/IVHfor20-30%infantswithBW1500g,.,5,Primaryhemorrhagicdisturbance(subarachnoidorintracerebral)DICisoimmunethrombocytopenianeonatalvitaminKdeficiency(maternalphenobarbitalorphenytoin)CongenitalvascularanormalityIatrogenichemorrhage(sucktioning,infusing,ventilating),.,6,PVH/IVH,MostcommonneonatalintracranialhemorrhageOccursprimarilyinprematureinfantsIncidenceisinverselyproportionalwithbirthweight:6070%of500-to750-ginfants,1020%of1000-to1500-ginfantsOccasionallyseeninnear-termandterminfantsRarelypresentatbirth50%onthe1stday,8090%betweenbirthandthe3rdday2040%progressduringthe1stweekDelayedhemorrhageafterthe1stweekin1015%ofthecasesNew-onsetIVHisrareafterthe1stmonthofliferegardlessofthebirthweight,.,7,PathogenesisofPVH/IVH,GelatinoussubependymalgerminalmatrixatperiventricularareaEmbryonalneuronsandfetalglialcellsImmaturebloodvesselsofgerminalmatrix:thinwallsfortheirrelativelylargesize,lackofamuscularislayerPoorextravascularsupport:immatureinterendothelialjunctionsPredictivefactorsoreventsPrematurity,RDS,Hypoxic-ischemicorhypotensiveinjury,reperfusion,increasedordecreasedCBF,pneumothorax,hypervolemia,hypertension,etc,.,8,PathogenesisofPVH/IVH,IntravascularfactorsFluctuatingcerebralbloodflow,occurringprenatallyorpostnatally(relatedtopressure-passivecerebralcirculation,mechanicalventilation,sucktion,infusion)Increasingofcerebralvenouspressure(mechanicalventilation,rapidinfusionorinfusionofhyperosmoticliquid)Plateletandcoagulationdisturbances(hypercoagulablestate,vitaminK)VascularfactorsImmaturevesselsinthegerminalmatrixLackmuscleandcollagen,susceptibletorupture(germinalmatrix)Vascularborderzonewithmoremitochondria,morevulnerabletoischemia,.,9,PathogenesisofPVH/IVH,ExtravascularfactorsNosupportivestromaaroundthevesselsExcessivefibrinokinasePeriventricularleukomalacia(PVL)PrenatalorneonatalischemicorreperfusioninjuryNecrosisoftheperiventricularwhitematterDamagetothecortico-spinalfibersintheinternalcapsule,.,10,CommonClinicalSigns/SymptomsofICH,ChangeofconsciousnessAbnormaleyessigns/movementIncreasedintracranialpressureIrregularrespiratorypatternorapneaChangeofmuscletonePupilssignsOthers:jaundice,anemia,etc,.,11,ClinicalManifestation,MostcommonsymptomsarediminishedorabsentMororeflex,poormuscletone,lethargy,apneaandsomnolenceOftenhaveaprecipitousdeteriorationonthe2ndor3rddayPeriodsofapnea,pallor,orcyanosisFailuretosuckAbnormaleyesigns,fixedpupilsAhigh-pitched,shrillcryMusculartwitching,convulsion,decreasedmuscletone,orparalysisMetabolicacidosis,shock,decreasedhematocritTensenessandbulgingoffontanelSevereneurologicaldepressionorcomaAsymptomaticperiodsornoclinicalmanifestations,.,12,ClinicalManifestation,PeriventriularLeukomalacia(PVL)Symmetric,non-hemorrhagicischemicinjuryOftencoexistswithIVHUsuallyasymptomaticatearlydaysBecomingspasticdiplegiainlaterinfancywhentheneurologicsequelaeofwhitematternecrosisbecomeapparentEarlyechodensephase(310daysoflife)Echolucent(cystic)phase(1420daysoflife),.,13,ClinicalManifestation,PVH/IVHthreeclinicaltypesCatastrophicSyndrome:veryfewclinicaldeteriorationinminutestohours,profoundalterationinneurologicstate,stupororcomahypotension,apnea,bulgingfontanel,dropinhematocrit,bradycardia,generalizedtonicseizures,etc.SaltatorySyndrome:overhourstodaysSilentSyndrome:60-70%,hemorrhageslimitedtothegerminalmatrixarea.noclinicalmanifestationswhatever,anddifficulttopredictitspresencebyclinicalcriteria,.,14,ClassificationofPVH/IVH(Grading),PathologicchangesdependedonamountofhemorrhageandareconsistenttoclinicalfeaturesMild(70%,40%I+30%II)GradeI:IsolatedsubependymalhemorrhageGradeII:IntraventricularhemorrhagewithnormalventricularsizeModerate(20%)GradeIII:IntraventricularhemorrhagewithacuteventriculardilationSevere(10%)GradeIV:Intraventricularhemorrhagewithparenchymalhemorrhage,PapileLA,JPediatr1978;92:529534.,.,15,Diagnosis,History:preterm,VLBW,asphyxia,trauma,iatrogenicfactorsClinicalmanifestationTransfontanelcranialultrasonography(real-time)Computedtomography(CT)Magneticresonanceimaging(MRI)Magneticresonancespectroscopy(MRS),.,16,routineheadultrasoundsfor“all”infants1500gBWFirstly,5-7daySecondly,28-30dayorbeforedischargeIfPVH-IVHisdetected,aserialultrasoundshouldbedoneweeklytoevaluateprogressionofventriculardilitationorcysticchange.,.,17,PossiblePrenatalInterventions,PreventionofprematurityMosteffectivemeansofpreventionofPVH/IVHTransportationofinfantsin-uterodecreasedincidenceofICHcomparedtopostnataltransportAntenatalcorticosteroidsPVH/IVH,maturationofbloodvessels/prostaglandinsynthesisAntenataladministrationofvitaminKPVH/IVH,improvementinprothrombinactivityAntenatalphenobarbitalseverePVH/IVH,controversialOptimalmanagementoflaboranddeliverynoconsistentresults,.,18,PossiblePostnatalInterventions,Appropriateneonatalresuscitationavoidhypercapnia,rapidinfusionandhypertonicsolutionsCorrection/preventionofhemodynamicdisturbancesavoidexcessivehandling,suctioning;useadequateventilationCorrectionofabnormalitiesofcoagulationfreshfrozenplasmacandecreaseincidenceofPVH/IVH,notseveretypePostnatalphenobarbitalinconsistent,currentdatadonotsupportroutineuseforpreventionEthamsylatestabilizationofthefragilegerminalmatrixvesselsVitaminEfree-radicalscavenger;conflictingdataIndomethacinCBFandfluctuationsinsystemicBP;closureofPDA;acceleratesmaturationofthegerminalmatrixmicrovasculature,.,19,PrognosisofPVH/IVH,Determinationoftheextentofhemorrhageisimportanttoassesstheprobabilityofneurologicmorbidity,whichdependson:Degreeofpathologicgrades50%ofextensivehemorrhage(gradeIIIandIV)haveneorologicsequelaeWithaccompanyingPVL(3-10%ofBW1500g),hashighriskwithmostlyspasticdiplegia,.,20,PrognosisofPVH/IVH,GerminalMatrixDestructionDestructionofthematrixanditsglialprecursorsDisruptthedevelopmentofneuron-glialunitsinthecortexHemorrhageisfrequentlyreplacedbyformationofacyst(USvisible)Hydro