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MY9700720 Neonatal Intracranial Hemorrhage

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MY9700720 Neonatal Intracranial Hemorrhage MY9700720 PRI - PAEDIATRIC RADIOLOGY Neonatal Intracranial Hemorrhage In the fetal brain, the superficial cortical veins are poorly developed, and the highly vascular germinal matrix drains into the great vein of Galen and its Charles A. Gooding tributaries via thin-walled terminal branches of the thalamostriate vein. It is postulated that perinatal University of California, San Francisco, hypoxia causes circulatory failure, with generalized San Francisco, California, USA visceral venous congestion. Thrombosis with venous infarction or venous hemorrhage without infarction occurs in the terminal branches of the thalamostriate 6> Intracranial hemorrhage (ICH) is the most frequently vein within the germinal matrix. 8 Using chromium- 9 encountered neurological disturbance in neonatal 50-labelled red blood cells, Tsiantos et al. showed 10 medicine. Almost exclusively, it occurs in premature that most IVHs occur in the first 3 days of life. infants with birth weights less than 2,500 gm. The ltrasound and computed tomographic (CT) studies incidence of ICH is approximately 45% among have confirmed this. premature infants of less than 35 weeks' gestation1 or in those weighing less than 1,500 gm at birth. The Extensive experimental evidence has accumulated potential catastrophic nature of this entity is revealed attesting to the multi-factorial etiology of ICH. by the fact that ICH is the most common central Hypoxia and asphyxia seem to be specific precipitat- nervous system lesion found on postmortem exami- ing factors. It is known that the normal newborn nation of newborn infants.2 Bada et al.3 reported an maintains a constant cerebral blood flow despite 89% mortality rate for infants less than 1,000 gm and fluctuations in systemic blood pressure, a phenome- having intraventricular hemorrhage (IVH). In another non known as autoregulation. Studies have suggested study, IVH was the primary cause of death in one- that asphyxia may abolish this autoregulation, i.e., the third of infants weighing less than 1,000 gm.* It is cerebral blood flow parallels changes in systemic quite likely that, currently, proportionally even more blood pressure. Asphyxizcepisodes consist of a infants are dying from ICH as modern medical and combination of hypoxia, hypercapnia and acidosis. surgical techniques have reduced the death rates from other causes.5 Statistically linked risk factors in neonatal periven- tricular hemorrhage include prematurity, respiratory The purpose of this presentation is to review current distress syndrome, patentductusarteriosus, mechani- concepts regarding etiology, diagnosis, prevention, cal ventilation, hypercapnia, acidosis, and rapidcolloid treatment, and follow-up of infants with ICH. infusion. Pneumothorax has been strongly linked to subsequent hemorrhage,11 probably through a combi- Etiology nation of blood gas abnormality and hypertension. Approximately 75% to 90% of ICHs originate in the 6 germinal matrix. The germinal matrix is a highly The relationship of pneumothorax to the occurrence vascular subependymal structure adjacent to the lat- of IVH in the premature newborn was studied by Hill, eral ventricles, in the region of the caudothalamic et al.11 These investigators measured blood flow groove. It is a source of spongioblasts and neuro- velocity in the anterior cerebral artery by a transcuta- blasts, which migrate peripherally to form portions of neous Doppler technique.12 They found that at the the cerebral cortex, basal ganglia, and other forebrain time of pneumothorax there was a marked increase in structures. The germinal matrix is most pronounced flow velocity, especially during diastole, and that in the fetus of 6 and 8 months' gestation, and it with resolution of the pneumothorax, flow velocity decreases in size as the fetus matures. It is virtually 7 returned to normal levels over the ensuing hours. The absent in the full-term infant. Therefore it is not changes in flow velocity correlated closely with surpris,ng' that postmortem studies show a low systemic hemodynamic changes that occurred with .ncidence of ICH in stillbirths and that the majority of pneumothorax, i.e., an increase in mean systemic subependymal hemorrhages (SEHs) originate in in- blood pressure. Intraventricular hemorrhage docu- fants of between 28 to 34 weeks' gestation. mented by serial ultrasound scans was observed shortly 295 after the pneumothorax in the nine infants studied, as Head rotation to the side is known to increase intrac- well as in six additional infants that they mention in ranial pressure in the infant, and this may contribute the addendum to their study. Their data therefore to neurological morbidity of newborn infants either demonstrate a marked increase in flow velocity in the directly, by causing vascular distention leading to cerebral circulation at the time of pneumothorax. capillary rupture and IVH, or indirectly by producing This increase is important in the genesis of IVH, as cerebral edema and impairment of cerebral perfusion is suggested by the occurrence of IVH soon after the following asphyxia or IVH.18 cerebral hemodynamic changes occur. Hormonal neuropeptides such as B-endorphins, vaso- The close association between pneumothorax and the pressin, and prolactin are other possible participants exacerbation of IVH has been reported previously.13 in the pathogenesis of IVH.19 Lipscomb, et al.w reported that of 14 ventilated premature infants who developed pneumothorax, 12 Diagnosis (86%) developed IVH. They also showed that the Computed tomographic (CT) scanning and serial presence of extra-alveolar air is a significant risk ultrasound scanning of the neonate's head have factor for the development of IVH. These studies generated much information about ICH. Based on CT raise the question of whether pneumothorax is related scanning, a grading system for ICH has been proposed to IVH in a causative manner or whether pneumotho- byPapileetal.:20-21 rax and IVH are separate consequences of some common event. The data presented by Hill, et al. Grade 1: Subependymal suggest that the relationship is a causative one and that the pathogenetic mechanism includes an abrupt Grade 11: Intraventricular hemorrhage with- increase in cerebral blood flow at the time of pneu- out ventricular dilatation mothorax. Grade 111: Intraventricular hemorrhage with ventricular dilatation Birth asphyxia or trauma producing blood loss and hypotension may interfere with cerebral autoregula- Grade IV: Intraventricular hemorrhage with tion. Endotracheal tube blockage or displacement has parenchymal hemorrhage also been linked to hemorrhage.15 Severe degrees of 16 atelectasis may also be a cause. Intraventricular hemorrhage is often a clinically silent event. Papile et al.2© showed that 78% of the surviv- Meticulous care with continuous blood gas monitor- ing infants with IVH had no clinical evidence of IVH. ing may avert the often brief episodes which may not Furthermore, 20% of the infants without IVH had even be clinically recognized and which can lead to clinical signs suggestive of IVH. The analysis of the major ICH. Different insults predominate at different cerebrospinal fluid for protein and red blood cells was postnatal ages. Perinatal management may have a not helpful in determining which of the infants had significant role in reducing the incidence and severity IVH. of ICH. A reduced incidence of ICH is associated with delivery by caesarean section and absence of Shankaran, et al.22 developed a classification of ICH premature labour prior to delivery. Active resuscita- based on the ultrasonographic appearance of the tion with use of early respiratory support, avoidance hemorrhage. They performed real-time ultrasonic of the complications of artificial ventilation, and examinations on admission and every 3 days during attention to maintenance of a normal blood pressure the first 3 weeks of life in neonates less than 1,500 gm may be the prime factors associated with reduction in and when clinically indicated in other neonates. The severity of ICH. real-time sector scan was obtained through the ante- rior fontanelle using a 3.5- or 5.0-MHz transducer. Hemorrhages were sonographically classified as: New evidence indicates that use of pupillary dilators during ophthalmologic examination of the newborn may precipitate increased intracranial pressure, which Mild: Hemorrhage confined to the subependymal might be related to ICH.17 periventricular region or accompanied by a small amount of blood in the normal-sized lateral ventricle. 296 Moderate: Intermediate amount of blood in enlarged rhage/subependymal hemorrhage were found in 90% lateral ventricle. of 113 infants of 34 weeks' gestation. The disagree- ments between ultrasound and CT studies done in the Severe: Hemorrhage filling the entire lateral ventri- first week of life were only in cases of small cle forming a cast, or intracerebral extension hemorrhages. of the hemorrhage, or both. Norman showed that CT visualization of blood 23 Fleischer, et al. demonstrated a close relationship depends on the hemoglobin concentration.2" A hemo- between the severity of the ICH and the development globin concentration of 7 to 8 gm/100 ml has the same of progressive ventricular dilation. Eighty percent of attenuation value as the brain and therefore appears premature infants with minor bleeds (SEH or SEH/ isodense with the rest of the brain tissue. Bejar, et small IVH) did not develop significant ventricular al.27 demonstrated that ultrasound could detect fluid dilatation, whereas all infants with IVH
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