1、Intracranial Hemorrhage Intracranial Hemorrhage of the Newbornof the Newborn (ICH)(ICH)Contents mastered:The main causes of neonatal ICH The mechanism of PVH-IVH Classification and manifestation of PVH-IVH Diagnosis of neonatal ICH Prevention of neonatal ICH A severe disease in neonate Related to pe
2、rinatal asphyxia and trauma,and maturity of fetus There are four major types Subdural hemorrhage Primary subarachnoid hemorrhage Intracerebellar hemorrhage Periventricular-intraventricular hemorrhage (PVH-IVH)Introduction Etiology and Epidemiology of ICHEtiology and Epidemiology of ICH Trauma(epidur
3、al,subdural,or subarachnoid)fetal head is too large compared with the size of the pelvic outlet prolonged labor/breech or precipitant deliveries Delivery with mechanical assistance Asphyxia/Hypoxic-ischemic encephalopathy Maturity of neonate:germinal matrix,PVH/IVH for 20-30%infants with BW1500g Pri
4、mary hemorrhagic disturbance(subarachnoid or intracerebral)DIC isoimmune thrombocytopenia neonatal vitamin K deficiency(maternal phenobarbital or phenytoin)Congenital vascular anormality Iatrogenic hemorrhage(sucktioning,infusing,ventilating)PVH/IVHPVH/IVH Most common neonatal intracranial hemorrhag
5、e Occurs primarily in premature infants Incidence is inversely proportional with birthweight:6070%of 500-to 750-g infants,1020%of 1000-to 1500-g infants Occasionally seen in near-term and term infants Rarely present at birth 50%on the 1st day,8090%between birth and the 3rd day 2040%progress during t
6、he 1st week Delayed hemorrhage after the 1st week in 1015%of the cases New-onset IVH is rare after the 1st month of life regardless of the birthweight Pathogenesis of Pathogenesis of PVH/IVHPVH/IVH Gelatinous subependymal germinal matrix at periventricular area Embryonal neurons and fetal glial cell
7、s Immature blood vessels of germinal matrix:thin walls for their relatively large size,lack of a muscularis layer Poor extravascular support:immature interendothelial junctions Predictive factors or events Prematurity,RDS,Hypoxic-ischemic or hypotensive injury,reperfusion,increased or decreased CBF,
8、pneumothorax,hypervolemia,hypertension,etc Pathogenesis of Pathogenesis of PVH/IVHPVH/IVH Intravascular factors Fluctuating cerebral blood flow,occurring prenatally or postnatally(related to pressure-passive cerebral circulation,mechanical ventilation,sucktion,infusion)Increasing of cerebral venous
9、pressure(mechanical ventilation,rapid infusion or infusion of hyperosmotic liquid)Platelet and coagulation disturbances(hypercoagulable state,vitamin K)Vascular factors Immature vessels in the germinal matrix Lack muscle and collagen,susceptible to rupture(germinal matrix)Vascular border zone with m
10、ore mitochondria,more vulnerable to ischemia Pathogenesis of Pathogenesis of PVH/IVHPVH/IVH Extravascular factors No supportive stroma around the vessels Excessive fibrinokinase Periventricular leukomalacia(PVL)Prenatal or neonatal ischemic or reperfusion injury Necrosis of the periventricular white
11、 matter Damage to the cortico-spinal fibers in the internal capsule Common Clinical Common Clinical Signs/Symptoms of ICHSigns/Symptoms of ICH Change of consciousness Abnormal eyes signs/movement Increased intracranial pressure Irregular respiratory pattern or apnea Change of muscle tone Pupils sign
12、s Others:jaundice,anemia,etc Clinical ManifestationClinical Manifestation Most common symptoms are diminished or absent Moro reflex,poor muscle tone,lethargy,apnea and somnolence Often have a precipitous deterioration on the 2nd or 3rd day Periods of apnea,pallor,or cyanosis Failure to suck Abnormal
13、 eye signs,fixed pupils A high-pitched,shrill cry Muscular twitching,convulsion,decreased muscle tone,or paralysis Metabolic acidosis,shock,decreased hematocrit Tenseness and bulging of fontanel Severe neurological depression or coma Asymptomatic periods or no clinical manifestations Clinical Manife
14、stationClinical Manifestation Periventriular Leukomalacia(PVL)Symmetric,non-hemorrhagic ischemic injury Often coexists with IVH Usually asymptomatic at early days Becoming spastic diplegia in later infancy when the neurologic sequelae of white matter necrosis become apparent Early echodense phase(31
15、0 days of life)Echolucent(cystic)phase(1420 days of life)Clinical ManifestationClinical Manifestation PVH/IVH three clinical types Catastrophic Syndrome:very few clinical deterioration in minutes to hours,profound alteration in neurologic state,stupor or coma hypotension,apnea,bulging fontanel,drop
16、in hematocrit,bradycardia,generalized tonic seizures,etc.Saltatory Syndrome:over hours to days Silent Syndrome:60-70%,hemorrhages limited to the germinal matrix area.no clinical manifestations whatever,and difficult to predict its presence by clinical criteria Classification of PVH/IVH(Grading)Classification of PVH/IVH(Grading)Pathologic changes depended on amount of hemorrhage and are consistent to clinical features Mild(70%,40%I+30%II)Grade I:Isolated subependymal hemorrhage Grade II:Intravent
