新生儿颅内出血Intracranial-Hemorrhage-of-the-Newborn

Intracranial Hemorrhage of the Newborn(ICH)Contents mastered:lThe main causes of neonatal ICHlThe mechanism of PVH-IVH lClassification and manifestation of PVH-IVHlDiagnosis of neonatal ICH lPrevention of neonatal ICHA severe disease in neonateRelated to perinatal asphyxia and trauma,and maturity of fetusThere are four major types Subdural hemorrhage Primary subarachnoid hemorrhage Intracerebellar hemorrhage Periventricular-intraventricular hemorrhage (PVH-IVH)IntroductionEtiology and Epidemiology of ICH Trauma(epidural,Trauma(epidural,subduralsubdural,or,or subarachnoidsubarachnoid)fetal fetal head head is is too too large large compared compared with with the the size size of of the the pelvic pelvic outletoutlet prolonged labor/breech or precipitant deliveriesprolonged labor/breech or precipitant deliveries Delivery with mechanical assistance Delivery with mechanical assistance Asphyxia/Hypoxic-ischemic encephalopathy Asphyxia/Hypoxic-ischemic encephalopathy Maturity of neonate:germinal matrix,PVH/IVH PVH/IVH forfor 20-20-30%infants with BW1500g30%infants with BW1500gPrimary hemorrhagic disturbance Primary hemorrhagic disturbance(subarachnoidsubarachnoid or or intracerebralintracerebral)DICDIC isoimmuneisoimmune thrombocytopenia thrombocytopenia neonatal vitamin K deficiency(maternal neonatal vitamin K deficiency(maternal phenobarbitalphenobarbital or or phenytoinphenytoin)Congenital vascular Congenital vascular anormalityanormality Iatrogenic hemorrhage(Iatrogenic hemorrhage(sucktioningsucktioning,infusing,infusing,ventilating)ventilating)PVH/IVH Most common neonatal intracranial hemorrhageMost common neonatal intracranial hemorrhage Occurs primarily in premature infants Occurs primarily in premature infants Incidence Incidence is inversely proportional with birthweightis inversely proportional with 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 infantsOccasionally seen in near-term and term infants Rarely present at birthRarely present at birth 50%on the 150%on the 1st st day,8090%between birth and the 3 day,8090%between birth and the 3rdrd day day 2040%progress during the 12040%progress during the 1st st week week Delayed hemorrhage after the 1Delayed hemorrhage after the 1st st week in 1015%of the cases week in 1015%of the cases New-onset New-onset IVH IVH is is rare rare after after the the 1 1st st month month of of life life regardless regardless of of the the birthweightbirthweightPathogenesis of PVH/IVHGelatinous Gelatinous subependymalsubependymal germinal matrix germinal matrix at at periventricularperiventricular area area EmbryonalEmbryonal neurons and fetal neurons and fetal glialglial cells cellsImmature blood vessels of germinal matrix:thin walls for essels of germinal matrix:thin walls for their relatively large size,lack of a muscularis layertheir relatively large size,lack of a muscularis layer Poor extravascular support:Poor extravascular support:immature interendothelial immature interendothelial junctionsjunctions Predictive factors or eventsPredictive factors or events PrematurityPrematurity,RDS,Hypoxic-ischemic or,RDS,Hypoxic-ischemic or hypotensivehypotensive injury,injury,reperfusion,increased or decreased CBF,reperfusion,increased or decreased CBF,pneumothoraxpneumothorax,hypervolemiahypervolemia,hypertension,etc,hypertension,etc Pathogenesis of PVH/IVHIntravascular factorsIntravascular factors Fluctuating Fluctuating cerebral cerebral blood blood flow,flow,occurring occurring prenatallyprenatally or or postnatallypostnatally (related(related to to pressure-passive pressure-passive cerebral cerebral circulation,circulation,mechanical mechanical ventilation,ventilation,sucktionsucktion,infusion),infusion)Increasing Increasing of of cerebral cerebral venous venous pressure pressure(mechanical(mechanical ventilation,ventilation,rapid rapid infusion or infusion of infusion or infusion of hyperosmotichyperosmotic liquid)liquid)Platelet Platelet and and coagulation coagulation disturbances disturbances(hypercoagulablehypercoagulable state,state,vitamin vitamin K)K)Vascular factorsVascular factors Immature vessels in the germinal matrixImmature vessels in the germinal matrix Lack muscle and collagen,susceptible to rupture(germinal matrix)Lack muscle and collagen,susceptible to rupture(germinal matrix)Vascular Vascular border border zone zone with with more more mitochondria,mitochondria,more more vulnerable vulnerable to to ischemia ischemia Pathogenesis of PVH/IVHExtravascularExtravascular factors factors No supportive No supportive stromastroma around the vessels around the vessels Excessive Excessive fibrinokinasefibrinokinasePeriventricularPeriventricular leukomalacialeukomalacia(PVL)(PVL)Prenatal or neonatal ischemic or reperfusion injuryPrenatal or neonatal ischemic or reperfusion injury Necrosis of the Necrosis of the periventricularperiventricular white matter white matter Damage to the Damage to the corticocortico-spinal fibers in the internal capsule-spinal fibers in the internal capsuleCommon Clinical Signs/Symptoms of ICH Change of consciousnessChange of consciousness Abnormal eyes signs/movement Abnormal eyes signs/movement Increased intracranial pressure Increased intracranial pressure Irregular respiratory pattern or apnea Irregular respiratory pattern or apnea Change of muscle tone Change of muscle tone Pupils signs Pupils signs Others:jaundice,anemia,etc Others:jaundice,anemia,etcClinical ManifestationMost Most common common symptoms symptoms are are diminished diminished or or absent absent Moro Moro reflex,poor muscle tone,lethargy,apnea and somnolencereflex,poor muscle tone,lethargy,apnea and somnolence Often have a precipitous deterioration on the 2 Often have a precipitous deterioration on the 2ndnd or 3 or 3rdrd day day Periods of apnea,pallor,or cyanosisPeriods of apnea,pallor,or cyanosis Failure to suckFailure to suck 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 Tenseness and bulging of fontanelTenseness and bulging of fontanel Severe neurological depression or coma Severe neurological depression or coma Asymptomatic periods or no clinical manifestations Asymptomatic periods or no clinical manifestationsClinical Manifestation PeriventriularPeriventriular LeukomalaciaLeukomalacia(PVL)(PVL)Symmetric,non-hemorrhagic ischemic injurySymmetric,non-hemorrhagic ischemic injury Often coexists with IVHOften coexists with IVH Usually asymptomatic at early daysUsually asymptomatic at early days Becoming Becoming spastic spastic diplegiadiplegia in in later later infancy infancy when when the the neurologicneurologic sequelaesequelae of of white white matter matter necrosis necrosis become become apparentapparent 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)Clinical Manifestation PVH/IVHPVH/IVH three clinical typesthree clinical typesCatastrophic Syndrome:Catastrophic Syndrome:very fewvery few clinical deterioration in minutes to hoursclinical deterioration in minutes to hours,profound profound alteration alteration in in neurologicneurologic state,state,stupor stupor or or comacoma hypotension,hypotension,apnea,apnea,bulging bulging fontanel,fontanel,drop drop in in hematocrithematocrit,bradycardia,bradycardia,generalized tonic seizures,generalized tonic seizures,etcetc.Saltatory Syndrome:Saltatory Syndrome:over hours to daysover hours to days Silent Silent Syndrome:Syndrome:60-70%,60-70%,hemorrhages hemorrhages limited limited to to the the germinal germinal matrix matrix area.area.no no clinical clinical manifestations manifestations whatever,whatever,and and difficult to predict its presence by clinical criteriadifficult to predict its presence by clinical criteria Classification of PVH/IVH(Grading)Pathologic changes depended on amount of hemorrhage and Pathologic changes depended on amount of hemorrhage and are consistent to clinical features are consistent to clinical features Mild(70%,40%I+30%II)Mild(70%,40%I+30%II)Grade I:Isolated Grade I:Isolated subependymalsubependymal hemorrhage hemorrhage Grade II:Grade II:IntraventricularIntraventricular hemorrhage with normal ventricular size hemorrhage with normal ventricular size Moderate(20%)Moderate(20%)Grade III:Grade III:IntraventricularIntraventricular hemorrhage with acute ventricular dilation hemorrhage with acute ventricular dilation Severe(10%)Severe(10%)Grade IV:Grade IV:IntraventricularIntraventricular hemorrhage with hemorrhage with parenchymalparenchymal hemorrhage hemorrhagePapile LA,J Pediatr 1978;92:529534.Diagnosis History:History:preterm,preterm,VLBWVLBW,asphyxia,asphyxia,trauma,iatrogenic factors trauma,iatrogenic factors Clinical manifestation Clinical manifestation TransfontanelTransfontanel cranial cranial ultrasonographyultrasonography (real-(real-time)time)Computed tomography(CT)Computed tomography(CT)Magnetic resonance imaging(MRI)Magnetic resonance imaging(MRI)Magnetic resonance spectroscopy(MRS)routine head ultrasounds for“all”infants 1500g BW Firstly,5-7 day Firstly,5-7 day Secondly,28-30 day or before dischargeSecondly,28-30 day or before discharge If If PVH-IVH PVH-IVH is is detected,detected,a a serial serial ultrasound ultrasound should should be be done done weekly weekly to to evaluate evaluate progression progression of of ventricular ventricular dilitationdilitation or cystic change.or cystic change.Possible Prenatal Interventions Prevention of Prevention of prematurityprematurity 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 corticosteroidsAntenatal corticosteroids PVH/IVH,maturation of blood vessels/prostaglandin synthesisPVH/IVH,maturation of blood vessels/prostaglandin synthesis Antenatal administration of vitamin KAntenatal administration of vitamin K PVH/IVH,improvement in PVH/IVH,improvement in prothrombinprothrombin activity activity Antenatal Antenatal phenobarbitalphenobarbital severe PVH/IVH,controversialsevere PVH/IVH,controversial Optimal management of labor and deliveryOptimal management of labor and delivery no consistent resultsno consistent resultsPossible Postnatal Interventions Appropriate neonatal resuscitationAppropriate neonatal resuscitation avoid avoid hypercapniahypercapnia,rapid infusion and hypertonic solutions,rapid infusion and hypertonic 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 coagulationCorrection 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 EVitamin 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 microvasculature accelerates maturation of the germinal matrix microvasculaturePrognosis of PVH/IVHDetermination Determination of of the the extent extent of of hemorrhage hemorrhage is is important important to to assess assess the the probability probability of of neurologicneurologic morbidity,morbidity,which which depends depends on:on:Degree of pathologic gradesDegree of pathologic grades 50%of extensive hemorrhage(grade III and IV)have 50%of extensive hemorrhage(grade III and IV)have neorologicneorologic sequelaesequelae With With accompanying accompanying PVL PVL(3-10%(3-10%of of BW1500g),BW1500g),has has high high risk with mostly spastic risk with mostly spastic diplegia diplegia Prognosis of PVH/IVH Germinal Matrix DestructionGerminal Matrix Destruction Destruction of the matrix and its Destruction of the matrix and its glialglial precursors precursors Disrupt the development of neuron-Disrupt the development of neuron-glialglial units in the cortex units in the cortex Hemorrhage is frequently replaced by formation of a cyst(US visible)Hemorrhage is frequently replaced by formation of a cyst(US visible)Hydrocephalus Hydrocephalus 50%of grade III/IV PVH/IVH will have static/transient 50%of grade III/IV PVH/IVH will have static/transient ventriculamegalyventriculamegaly 50%will require treatment for 50%will require treatment for posthemorrhagicposthemorrhagic hydrocephalishydrocephalis Acute(within 2 wks)or indolent(evolves over weeks)Acute(within 2 wks)or indolent(evolves over weeks)PeriventricularPeriventricular Hemorrhagic Infraction Hemorrhagic Infraction ParenchymalParenchymal hemorrhage occurs in 10%of surviving infants hemorrhage occurs in 10%of surviving infants Usually occurs on the same side of the larger IVHUsually occurs on the same side of the larger IVH Sonograms are useful to monitor an extension of the Sonograms are useful to monitor an extension of the hemorrhage and post-hemorrhagic complications hemorrhage and post-hemorrhagic complications (hydrocephalus)which even is uncommon(-13%)(hydrocephalus)which even is uncommon(-13%)For hydrocephalus,enlargement of the lateral ventricles For hydrocephalus,enlargement of the lateral ventricles may precede change in head circumference.So serial may precede change in head circumference.So serial cranial cranial sonographysonography is needed.is needed.Serial Lumbar Punctures Serial Lumbar Punctures are are used to control increased used to control increased intracranial pressure intracranial pressure and and prevent hydrocephalus prevent hydrocephalus Surgical intervention Surgical intervention Management of Post-Hemorrhagic Hydrocephalus