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IntracranialHemorrhageoftheNewborn
(ICH)IntracranialHemorrhageofthe1Contentsmastered:ThemaincausesofneonatalICHThemechanismofPVH-IVH
ClassificationandmanifestationofPVH-IVHDiagnosisofneonatalICHPreventionofneonatalICHContentsmastered:2AseverediseaseinneonateRelatedtoperinatalasphyxiaandtrauma,andmaturityoffetusTherearefourmajortypesSubduralhemorrhage
Primarysubarachnoidhemorrhage
Intracerebellarhemorrhage
Periventricular-intraventricularhemorrhage(PVH-IVH)
IntroductionAseverediseaseinneonateInt3EtiologyandEpidemiologyofICH
Trauma(epidural,subdural,orsubarachnoid)fetalheadistoolargecomparedwiththesizeofthepelvicoutletprolongedlabor/breechorprecipitantdeliveriesDeliverywithmechanicalassistanceAsphyxia/Hypoxic-ischemicencephalopathy
Maturityofneonate:germinalmatrix,PVH/IVHfor
20-30%infantswithBW<1500gEtiologyandEpidemiologyofI4Primaryhemorrhagicdisturbance(subarachnoidorintracerebral)DICisoimmunethrombocytopenianeonatalvitaminKdeficiency(maternalphenobarbitalorphenytoin)
CongenitalvascularanormalityIatrogenichemorrhage(sucktioning,infusing,ventilating)Primaryhemorrhagicdisturbanc5PVH/IVH
MostcommonneonatalintracranialhemorrhageOccursprimarilyinprematureinfantsIncidenceisinverselyproportionalwithbirthweight:60~70%of500-to750-ginfants,10~20%of1000-to1500-ginfants
Occasionallyseeninnear-termandterminfants
Rarelypresentatbirth50%onthe1stday,80~90%betweenbirthandthe3rdday20~40%progressduringthe1stweekDelayedhemorrhageafterthe1stweekin10~15%ofthecasesNew-onsetIVHisrareafterthe1stmonthofliferegardlessofthebirthweightPVH/IVHMostcommonneonatal6PathogenesisofPVH/IVHGelatinoussubependymalgerminalmatrixatperiventricularareaEmbryonalneuronsandfetalglialcellsImmaturebloodvesselsofgerminalmatrix:thinwallsfortheirrelativelylargesize,lackofamuscularislayerPoorextravascularsupport:immatureinterendothelialjunctionsPredictivefactorsoreventsPrematurity,RDS,Hypoxic-ischemicorhypotensiveinjury,reperfusion,increasedordecreasedCBF,pneumothorax,hypervolemia,hypertension,etcPathogenesisofPVH/IVHGelat7PathogenesisofPVH/IVHIntravascularfactorsFluctuatingcerebralbloodflow,occurringprenatallyorpostnatally(relatedtopressure-passivecerebralcirculation,mechanicalventilation,sucktion,infusion)Increasingofcerebralvenouspressure(mechanicalventilation,rapidinfusionorinfusionofhyperosmoticliquid)Plateletandcoagulationdisturbances(hypercoagulablestate,vitaminK)VascularfactorsImmaturevesselsinthegerminalmatrixLackmuscleandcollagen,susceptibletorupture(germinalmatrix)Vascularborderzonewithmoremitochondria,morevulnerabletoischemiaPathogenesisofPVH/IVHIntra8PathogenesisofPVH/IVHExtravascularfactorsNosupportivestromaaroundthevesselsExcessivefibrinokinasePeriventricularleukomalacia(PVL)PrenatalorneonatalischemicorreperfusioninjuryNecrosisoftheperiventricularwhitematterDamagetothecortico-spinalfibersintheinternalcapsulePathogenesisofPVH/IVHExtra9CommonClinicalSigns/SymptomsofICH
ChangeofconsciousnessAbnormaleyessigns/movementIncreasedintracranialpressureIrregularrespiratorypatternorapneaChangeofmuscletonePupilssignsOthers:jaundice,anemia,etcCommonClinicalSigns/Symptoms10ClinicalManifestationMostcommonsymptomsarediminishedorabsentMororeflex,poormuscletone,lethargy,apneaandsomnolenceOftenhaveaprecipitousdeteriorationonthe2ndor3rddayPeriodsofapnea,pallor,orcyanosisFailuretosuckAbnormaleyesigns,fixedpupilsAhigh-pitched,shrillcryMusculartwitching,convulsion,decreasedmuscletone,orparalysisMetabolicacidosis,shock,decreasedhematocritTensenessandbulgingoffontanelSevereneurologicaldepressionorcomaAsymptomaticperiodsornoclinicalmanifestationsClinicalManifestationMostcom11ClinicalManifestationPeriventriularLeukomalacia(PVL)Symmetric,non-hemorrhagicischemicinjuryOftencoexistswithIVHUsuallyasymptomaticatearlydaysBecomingspasticdiplegiainlaterinfancywhentheneurologicsequelaeofwhitematternecrosisbecomeapparentEarlyechodensephase(3~10daysoflife)Echolucent(cystic)phase(14~20daysoflife)ClinicalManifestationPeriven12ClinicalManifestation
PVH/IVH
threeclinicaltypesCatastrophicSyndrome:veryfew
clinicaldeteriorationinminutestohours,profoundalterationinneurologicstate,stupororcomahypotension,apnea,bulgingfontanel,dropinhematocrit,bradycardia,generalizedtonicseizures,etc.SaltatorySyndrome:
overhourstodays
SilentSyndrome:60-70%,hemorrhageslimitedtothegerminalmatrixarea.noclinicalmanifestationswhatever,anddifficulttopredictitspresencebyclinicalcriteria
ClinicalManifestationPVH/I13ClassificationofPVH/IVH(Grading)
Pathologicchangesdependedonamountofhemorrhageandareconsistenttoclinicalfeatures
Mild(70%,40%I+30%II)GradeI:Isolatedsubependymal
hemorrhageGradeII:IntraventricularhemorrhagewithnormalventricularsizeModerate(20%)GradeIII:Intraventricularhemorrhagewithacuteventriculardilation
Severe(10%)GradeIV:IntraventricularhemorrhagewithparenchymalhemorrhagePapileLA,JPediatr1978;92:529~534.ClassificationofPVH/IVH(Gra14Diagnosis
History:preterm,VLBW,asphyxia,trauma,iatrogenicfactorsClinicalmanifestationTransfontanelcranialultrasonography(real-time)Computedtomography(CT)Magneticresonanceimaging(MRI)Magneticresonancespectroscopy(MRS)DiagnosisHistory:preterm,VL15
routineheadultrasoundsfor“all”infants≤1500gBW
Firstly,5-7daySecondly,28-30dayorbeforedischargeIfPVH-IVHisdetected,aserialultrasoundshouldbedoneweeklytoevaluateprogressionofventriculardilitationorcysticchange.routineheadultrasoundsfor16PossiblePrenatalInterventions
Preventionofprematurity
MosteffectivemeansofpreventionofPVH/IVH
Transportationofinfantsin-utero
decreasedincidenceofICHcomparedtopostnataltransport
Antenatalcorticosteroids
↓PVH/IVH,maturationofbloodvessels/↓prostaglandinsynthesis
AntenataladministrationofvitaminK
↓PVH/IVH,improvementinprothrombinactivity
Antenatalphenobarbital
↓severePVH/IVH,controversial
Optimalmanagementoflaboranddelivery
noconsistentresultsPossiblePrenatalIntervention17PossiblePostnatalInterventions
Appropriateneonatalresuscitation
avoidhypercapnia,rapidinfusionandhypertonicsolutions
Correction/preventionofhemodynamicdisturbances
avoidexcessivehandling,suctioning;useadequateventilation
Correctionofabnormalitiesofcoagulation
freshfrozenplasmacandecreaseincidenceofPVH/IVH,notseveretype
Postnatalphenobarbital
inconsistent,currentdatadonotsupportroutineuseforprevention
Ethamsylate
stabilizationofthefragilegerminalmatrixvessels
VitaminE
free-radicalscavenger;conflictingdata
Indomethacin
↓CBFandfluctuationsinsystemicBP;closureofPDA;acceleratesmaturationofthegerminalmatrixmicrovasculaturePossiblePostnatalInterventio18PrognosisofPVH/IVHDeterminationoftheextentofhemorrhageisimportanttoassesstheprobabilityofneurologicmorbidity,whichdependson:Degreeofpathologicgrades
50%ofextensivehemorrhage(gradeIIIandIV)haveneorologicsequelaeWithaccompanyingPVL(3-10%ofBW<1500g),hashighriskwithmostlyspasticdiplegiaPrognosisofPVH/IVHDeterminat19PrognosisofPVH/IVH
GerminalMatrixDestructionDestructionofthematrixanditsglialprecursorsDisruptthedevelopmentofneuron-glialunitsinthecortexHemorrhageisfrequentlyreplacedbyformationofacyst(USvisible)Hydrocephalus50%ofgradeIII/IVPVH/IVHwillhavestatic/transientventriculamegaly50%willrequiretreatmentforposthemorrhagichydrocephalisAcute(within2wks)orindolent(evolvesoverweeks)
PeriventricularHemorrhagicInfractionParenchymalhemorrhageoccursin10%ofsurvivinginfantsUsuallyoccursonthesamesideofthelargerIVHPrognosisofPVH/IVHGerminal20Sonogramsareusefultomonitoranextensionofthehemorrhageandpost-hemorrhagiccomplications(hydrocephalus)whichevenisuncommon(--13%)
Forhydrocephalus,enlargementofthelateralventriclesmayprecedechangeinheadcircumference.Soserialcranialsonographyisneeded.
SerialLumbarPuncturesareusedtocontrolincreasedintracranialpressureandpreventhydrocephalusSurgicalintervention
ManagementofPost-HemorrhagicHydrocephalus
Sonogramsareusefultomonit21新生兒顱內(nèi)出血(Intracranial-Hemorrhage-of-the-Newborn)課件22新生兒顱內(nèi)出血(Intracranial-Hemorrhage-of-the-Newborn)課件23新生兒顱內(nèi)出血(Intracranial-Hemorrhage-of-the-Newborn)課件24新生兒顱內(nèi)出血(Intracranial-Hemorrhage-of-the-Newborn)課件25新生兒顱內(nèi)出血(Intracranial-Hemorrhage-of-the-Newborn)課件26Thankyou!Thankyou!27IntracranialHemorrhageoftheNewborn
(ICH)IntracranialHemorrhageofthe28Contentsmastered:ThemaincausesofneonatalICHThemechanismofPVH-IVH
ClassificationandmanifestationofPVH-IVHDiagnosisofneonatalICHPreventionofneonatalICHContentsmastered:29AseverediseaseinneonateRelatedtoperinatalasphyxiaandtrauma,andmaturityoffetusTherearefourmajortypesSubduralhemorrhage
Primarysubarachnoidhemorrhage
Intracerebellarhemorrhage
Periventricular-intraventricularhemorrhage(PVH-IVH)
IntroductionAseverediseaseinneonateInt30EtiologyandEpidemiologyofICH
Trauma(epidural,subdural,orsubarachnoid)fetalheadistoolargecomparedwiththesizeofthepelvicoutletprolongedlabor/breechorprecipitantdeliveriesDeliverywithmechanicalassistanceAsphyxia/Hypoxic-ischemicencephalopathy
Maturityofneonate:germinalmatrix,PVH/IVHfor
20-30%infantswithBW<1500gEtiologyandEpidemiologyofI31Primaryhemorrhagicdisturbance(subarachnoidorintracerebral)DICisoimmunethrombocytopenianeonatalvitaminKdeficiency(maternalphenobarbitalorphenytoin)
CongenitalvascularanormalityIatrogenichemorrhage(sucktioning,infusing,ventilating)Primaryhemorrhagicdisturbanc32PVH/IVH
MostcommonneonatalintracranialhemorrhageOccursprimarilyinprematureinfantsIncidenceisinverselyproportionalwithbirthweight:60~70%of500-to750-ginfants,10~20%of1000-to1500-ginfants
Occasionallyseeninnear-termandterminfants
Rarelypresentatbirth50%onthe1stday,80~90%betweenbirthandthe3rdday20~40%progressduringthe1stweekDelayedhemorrhageafterthe1stweekin10~15%ofthecasesNew-onsetIVHisrareafterthe1stmonthofliferegardlessofthebirthweightPVH/IVHMostcommonneonatal33PathogenesisofPVH/IVHGelatinoussubependymalgerminalmatrixatperiventricularareaEmbryonalneuronsandfetalglialcellsImmaturebloodvesselsofgerminalmatrix:thinwallsfortheirrelativelylargesize,lackofamuscularislayerPoorextravascularsupport:immatureinterendothelialjunctionsPredictivefactorsoreventsPrematurity,RDS,Hypoxic-ischemicorhypotensiveinjury,reperfusion,increasedordecreasedCBF,pneumothorax,hypervolemia,hypertension,etcPathogenesisofPVH/IVHGelat34PathogenesisofPVH/IVHIntravascularfactorsFluctuatingcerebralbloodflow,occurringprenatallyorpostnatally(relatedtopressure-passivecerebralcirculation,mechanicalventilation,sucktion,infusion)Increasingofcerebralvenouspressure(mechanicalventilation,rapidinfusionorinfusionofhyperosmoticliquid)Plateletandcoagulationdisturbances(hypercoagulablestate,vitaminK)VascularfactorsImmaturevesselsinthegerminalmatrixLackmuscleandcollagen,susceptibletorupture(germinalmatrix)Vascularborderzonewithmoremitochondria,morevulnerabletoischemiaPathogenesisofPVH/IVHIntra35PathogenesisofPVH/IVHExtravascularfactorsNosupportivestromaaroundthevesselsExcessivefibrinokinasePeriventricularleukomalacia(PVL)PrenatalorneonatalischemicorreperfusioninjuryNecrosisoftheperiventricularwhitematterDamagetothecortico-spinalfibersintheinternalcapsulePathogenesisofPVH/IVHExtra36CommonClinicalSigns/SymptomsofICH
ChangeofconsciousnessAbnormaleyessigns/movementIncreasedintracranialpressureIrregularrespiratorypatternorapneaChangeofmuscletonePupilssignsOthers:jaundice,anemia,etcCommonClinicalSigns/Symptoms37ClinicalManifestationMostcommonsymptomsarediminishedorabsentMororeflex,poormuscletone,lethargy,apneaandsomnolenceOftenhaveaprecipitousdeteriorationonthe2ndor3rddayPeriodsofapnea,pallor,orcyanosisFailuretosuckAbnormaleyesigns,fixedpupilsAhigh-pitched,shrillcryMusculartwitching,convulsion,decreasedmuscletone,orparalysisMetabolicacidosis,shock,decreasedhematocritTensenessandbulgingoffontanelSevereneurologicaldepressionorcomaAsymptomaticperiodsornoclinicalmanifestationsClinicalManifestationMostcom38ClinicalManifestationPeriventriularLeukomalacia(PVL)Symmetric,non-hemorrhagicischemicinjuryOftencoexistswithIVHUsuallyasymptomaticatearlydaysBecomingspasticdiplegiainlaterinfancywhentheneurologicsequelaeofwhitematternecrosisbecomeapparentEarlyechodensephase(3~10daysoflife)Echolucent(cystic)phase(14~20daysoflife)ClinicalManifestationPeriven39ClinicalManifestation
PVH/IVH
threeclinicaltypesCatastrophicSyndrome:veryfew
clinicaldeteriorationinminutestohours,profoundalterationinneurologicstate,stupororcomahypotension,apnea,bulgingfontanel,dropinhematocrit,bradycardia,generalizedtonicseizures,etc.SaltatorySyndrome:
overhourstodays
SilentSyndrome:60-70%,hemorrhageslimitedtothegerminalmatrixarea.noclinicalmanifestationswhatever,anddifficulttopredictitspresencebyclinicalcriteria
ClinicalManifestationPVH/I40ClassificationofPVH/IVH(Grading)
Pathologicchangesdependedonamountofhemorrhageandareconsistenttoclinicalfeatures
Mild(70%,40%I+30%II)GradeI:Isolatedsubependymal
hemorrhageGradeII:IntraventricularhemorrhagewithnormalventricularsizeModerate(20%)GradeIII:Intraventricularhemorrhagewithacuteventriculardilation
Severe(10%)GradeIV:IntraventricularhemorrhagewithparenchymalhemorrhagePapileLA,JPediatr1978;92:529~534.ClassificationofPVH/IVH(Gra41Diagnosis
History:preterm,VLBW,asphyxia,trauma,iatrogenicfactorsClinicalmanifestationTransfontanelcranialultrasonography(real-time)Computedtomography(CT)Magneticresonanceimaging(MRI)Magneticresonancespectroscopy(MRS)DiagnosisHistory:preterm,VL42
routineheadultrasoundsfor“all”infants≤1500gBW
Firstly,5-7daySecondly,28-30dayorbeforedischargeIfPVH-IVHisdetected,aserialultrasoundshouldbedoneweeklytoevaluateprogressionofventriculardilitationorcysticchange.routineheadultrasoundsfor43PossiblePrenatalInterventions
Preventionofprematurity
MosteffectivemeansofpreventionofPVH/IVH
Transportationofinfantsin-utero
decreasedincidenceofICHcomparedtopostnataltransport
Antenatalcorticosteroids
↓PVH/IVH,maturationofbloodvessels/↓prostaglandinsynthesis
AntenataladministrationofvitaminK
↓PVH/IVH,improvementinprothrombinactivity
Antenatalphenobarbital
↓severePVH/IVH,controversial
Optimalmanagementoflaboranddelivery
noconsistentresultsPossiblePrenatalIntervention44PossiblePostnatalInterventions
Appropriateneonatalresuscitation
avoidhypercapnia,rapidinfusionandhypertonicsolutions
Correction/preventionofhemodynamicdisturbances
avoidexcessivehandling,suctioning;useadequateventilation
Correctionofabnormalitiesofcoagulation
freshfrozenplasmacandecreaseincidenceofPVH/IVH,notseveretype
Postnatalphenobarbital
inconsistent,currentdatadonotsupportroutineuseforprevention
Ethamsylate
stabilizationofthefragilegerminalmatrixvessels
VitaminE
free-radicalscavenger;conflictingdata
Indomethacin
↓CBFandfluctuationsinsystemicBP;closureofPDA;acc
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