新生儿颅内出血（英文）课件

IntracranialHemorrhageoftheNewbornEtiologyandEpidemiologyofICHTrauma(epidural,subdural,orsubarachnoid)fetalheadistoolargeinproportiontothesizeofthepelvicoutletprolongedlabor/breechorprecipitatedeliveriesMechanicalassistancewithdeliveryAsphyxia/HypoxicischemicencephalopathyPrematureinfants(peri-/intraventricularhemorrhage,PVH/IVH)Primaryhemorrhagicdisturbance(subarachnoidorintracerebral)DICisoimmunethrombocytopenianeonatalvitaminKdeficiency(maternalphenobarbitalorphenytoin)CongenitalvascularanomalyIatrogenichemorrhage(sucktioning,infusing,ventilating)IncidenceofPVH/IVHMostcommonneonatalintracranialhemorrhageOccursprimarilyinprematureinfantsIncidenceincreaseswithdecreasingbirthweight:60~70%of500-to750-ginfants,10~20%of1000-to1500-ginfantsOccasionallyseeninnear-termandterminfantsRarelypresentatbirth50%occuronthe1stday,80~90%occurbetweenbirthandthe3rdday20~40%progressduringthe1stweekDelayedhemorrhagemayoccurafterthe1stweekin10~15%ofthecasesNew-onsetIVHisrareafterthe1stmonthofliferegardlessofthebirthweightPathogenesisofPVH/IVHGelatinoussubependymalgerminalmatrix(periventricular)EmbryonalneuronsandfetalglialcellsImmaturebloodvesselsandhighlyvascularareaPoortissuevascularsupportPredisposingfactorsoreventsPrematurity,RDS,Hypoxic-ischemicorhypotensiveinjury,reperfusion,increasedordecreasedCBF,pneumothorax,hypervolemia,hypertension,etcPeriventricularleukomalacia(PVL)PrenatalorneonatalischemicorreperfusioninjuryNecrosisoftheperiventricularwhitematterDamagetothecortico-spinalfibersintheinternalcapsulePathogenesisofPVH/IVHIntravascularfactorsFluctuatingcerebralbloodflow(relatedtomechanicsofventilation)IncreasinginCBF(pressure-passivecerebralcirculationinprematureinfants)IncreasesincerebralvenouspressureDecreasesinCBF(occurringprenatallyorpostnatally)Plateletandcoagulationdisturbances(hypercoagulablestate,vitaminK)VascularfactorsImmaturevesselsinthegerminalmatrixLackmuscleandcollagen,susceptibletoruptureVascularborderzonewithmoremitochondria,morevulnerabletoischemiaExtravascularfactorsNosupportivestromaaroundthevesselsExcessivefibrinolyticactivityCommonClinicalSigns/SymptomsChangeofconsciousnessAbnormaleyessigns/movementIncreasedintracranialpressureIrregularrespiratorypatternorapneaChangesofmuscletonePupilssignsOthers:jaundice,anemia,etcClinicalManifestationMostcommonsymptomsarediminishedorabsentMororeflex,poormuscletone,lethargy,apneaandsomnolenceOftenhaveaprecipitousdeteriorationonthe2ndor3rddaysPeriodsofapnea,pallor,orcyanosisFailuretosuckwellAbnormaleyesigns,fixedpupilsAhigh-pitched,shrillcryMusculartwitching,convulsion,decreasedmuscletone,orparalysisMetabolicacidosis,shock,decreasedhematocritTenseandbulgingoffontanelSevereneurologicaldepressionorcomaAsymptomaticperiodsornoclinicalmanifestationsDiagnosisHistoryClinicalmanifestationTransfontanelcranialultrasonography(real-time)Computedtomography(CT)Magneticresonanceimaging(MRI)Magneticresonancespectroscopy(MRS)PossiblePrenatalInterventionsPreventionofprematurityMosteffectivemeansofpreventionofPVH/IVHTransportationofinfantsin-uterodecreasedincidenceofICHcomparedtopostnataltransportAntenatalcorticosteroids↓PVH/IVH,maturationofbloodvessels/↓prostaglandinsynthesisAntenataladministrationofvitaminK↓PVH/IVH,improvementinprothrombinactivityAntenatalphenobarbital↓severePVH/IVH,controversialOptimalmanagementoflaboranddeliverynoconsistentresultsPossiblePostnatalInterventionsAppropriateneonatalresuscitationavoidhypercarbia,rapidinfusionandhypertonicsolutionsCorrection/preventionofhemodynamicdisturbancesavoidexcessivehandling,suctioning;useadequateventilationCorrectionofabnormalitiesofcoagulationfreshfrozenplasmacandecreaseincidenceofPVH/IVH,notseveretypePostnatalphenobarbitalinconsistent,currentdatadonotsupportroutineuseforpreventionEthamsylatestabilizationofthefragilegerminalmatrixvesselsVitaminEfree-radicalscavenger;conflictingdataIndomethacin↓CBFandfluctuationsinsystemicBP;closureofPDA;acceleratesmaturationofthegerminalmatrixmicrovasculature