Intraventricular Hemorrhage in the Neonate. NICU Night Team Curriculum

Transcription

1 Intraventricular Hemrrhage in the Nenate NICU Night Team Curriculum

2 Objectives T describe the epidemilgy and risk factrs f IVH T understand the anatmy and pathphysilgy invlved in IVH T demnstrate the grading system f IVH T cmprehend the sequelae f high-grade IVH

3 Case Tw day ld 750g 25 4 / 7 week GA male brn by vertex, vaginal delivery t a mther wh received gd PNC after rupture f membranes 10 hurs prir t delivery and precipitus labr. Otherwise healthy pregnancy. Medicatins during pregnancy: Prenatal vitamin Ampicillin during labr fr unknwn GBS status x 2 dses Betamethasne x 2 Delivery Curse: NSVD, nuchal crd x1, easily reduced Apgars: 5 1, 8 5 Initially given Psitive pressure ventilatin then intubated Given ne dse f surfactant in delivery rm Transferred t ICN and placed n SIMV with vlume cntrl

4 Case (cnt.) Vital signs remained stable thrugh Days 0 and 1 Fluids given thrugh TPN at ttal fluids: 120 cc/kg/d Patient started n Ampicillin and Gentamicin until bld culture negative x 48 hurs Chemistries stable, checked q12h Admissin hemglbin was 12.4, but drpped t 8.6 at 48 hurs f life WHAT IS THE DIFFERENTIAL DIAGNOSIS FOR ACUTE DROP IN HEMOGLOBIN IN A NEONATE?

5 Differential Diagnsis Bld Lss Cephalhematma Intraventricular Hemrrhage Subdural Hemrrhage Subgaleal Liver Rupture Spleen Rupture Pulmnary Hemrrhage Hemlysis Secndary t Infectin Sepsis Viral Bacterial TORCH Iatrgenic

6 In ur patient, ultrasund revealed: Grade III IVH

7 Epidemilgy and Risk Factrs Amng extremely premature babies: IVH rates have declined frm 50-80% in 1980s t current rate f 10-15% 1 Cntinues t be a significant prblem as imprved survival f extremely premature infants has resulted in mre survivrs with this injury What are the majr risk factrs fr IVH? 1. Vlpe JJ. Neurlgy f the Newbrn, 4 th Editin, WB Saunders, Philadelphia p 428

8 1. Vermnt Oxfrd Netwrk table Vlpe JJ. Neurlgy f the Newbrn, 4 th Editin, WB Saunders, Philadelphia p McCrea HJ and Ment LR Clinical Perinatlgy (35(4): 777-vii Risk Factrs fr IVH 1. Prematurity: Occurs mst frequently in infants brn <32 weeks r <1500g Incidence is 26% fr infants weighing g 2 The highest prevalence is in the least mature infants Mrtality: ~15% 2 (wrse prgnsis with increasing severity) 2. Timing: Virtually all IVH in premature infants ccurs in first five days 2 50, 25, and 15% n the first, secnd and third day, respectively 2 By the end f the first week, 90% f hemrrhages can be detected 3 3. Other Risk Factrs 3 : Intrapartum asphyxia Chriamninitis Hypxemia Hypercarbia Pnuemthrax/Pulmnary Hemrrhage Maternal fertility treatment

9 Anatmy and Pathphysilgy Arterial supply t the subependymal germinal matrix at 29 weeks gestatin 2 The Germinal Matrix in Premature Infants 1 The germinal matrix is a highly cellular layer in the subependymal, subventricular zne that gives rise t neurns and glia during develpment The immature germinal matrix is highly vascularized by fragile micrvessels In respnse t hypertensin, hypxia, hypercapnia r acidsis, cerebral bld flw increases placing stress n vasculature Hemrrhage in preterm babies ften begins in the germinal matrix and may extend t ventricular system 1. McCrea HJ and Ment LR Clinical Perinatlgy (35(4): 777-vii 2. Image frm Hambletn G, and Wiggleswrth JS Archives f Diseases in Childhd 51(9): 651.

10 Hw is the diagnsis f IVH made? Cranial Ultrasund is the screening methd f chice Up t half f infants with IVH may be asymptmatic Accrding t the American Academy f Neurlgy and the Practice Cmmittee f Child Neurlgy Sciety: Rutine ultrasund shuld be perfrmed n all infants <30weeks gest age Screening shuld be perfrmed a 7-14 days and repeated at weeks CT r MRI ffer n advantage in detectin f IVH

11 Grading IVH Image frm

12 Grade That Hemrrhage!! 1. Where is the hemrrhage? 2. Name the Anatmy 3. Grade the Hemrrhage Nrmal Anatmy Germinal Matrix Extensin int Lateral Ventricle (n dilatin) Chrid Plexus Grade II Hemrrhage Extensin int lateral ventricle withut dilatin Image frm

13 Name the Sequelae f Intraventricular Hemrrhage

14 NIH-PA Authr Manuscript NIH-PA Authr Manuscript Sequelae f IVH 1. Psthemrrhagic Hydrcephalus Usually presents with rapid increases in head circumference Signs and symptms may nt be evident fr several weeks due t cmpliance f nenatal brain Believed t be due t impaired CSF reabsrptin fllwing the inflammatin related t bld in the CSF McCrea and N Ment prven effective interventins Page 14 have been described t date Serial cranial ultrasunds and MRI studies frm a preterm male infant brn at 24 weeks f gestatin. The initial diagnsis f Grade 3 IVH at age 3 days (panel A) was fllwed by parenchymal invlvement f hemrrhage, r Grade 4 IVH, n pstnatal day 4 (arrw, panel B). A cranial ultrasund perfrmed n day 10 because f increasing ccipitfrntal head circumference and full fntanel revealed bilateral ventriculmegaly, residual intraventricular bld and a develping prencephaly (arrw, panel C). MRI study at 2 mnths demnstrated ventriculmegaly (panel D). Because f excessive increase in head circumference and increasing spasticity, the patient underwent third ventriculstmy fllwing MRI scan at age 6 mnths (panel E). Figure 1. McCrea HJ and Ment LR Clinical Perinatlgy (35(4): 777-vii

15 Sequelae f IVH 2. Periventricular Leukmalacia (PVL) Classic white matter abnrmality fllwing IVH Attributed t prfund and lng-lasting decreases in CSF PVL may prgress t prencephly (Greek fr hle in the brain ) Depending n severity, may lead t spastic dysplagia, visual defects, r cgnitive impairment McCrea and Ment Page 15 Serial cranial ultrasunds f a 30 week preterm male with Grade 3 IVH and hemrrhagic PVL at age 10 days (panel A). Repeat ultrasund 3 weeks later demnstrated unilateral ventriculmegaly and periventricular cystic cavities cnsistent with PVL (panel B). Figure 2. Serial cranial ultrasunds f a 30 week preterm male with Grade 3 IVH and hemrrhagic PVL at age 10 days (panel A). Repeat ultrasund 3 weeks later demnstrated unilateral ventriculmegaly and periventricular cystic cavities cnsistent with PVL (panel B). McCrea HJ and Ment LR Clinical Perinatlgy (35(4): 777-vii

16 Sequelae f IVH 3. Seizures 4. Cerebral Palsy 5. Mental Retardatin Risk fr majr neurlgical deficits: Grade I:5-9% Grade II: 11-15% Grade III: 30-40% Grade IV: 50-70%

17 Preventive Strategies Many ptential pharmaclgic interventins have been studied, thugh few are currently in wide use* Pharmaclgic Agent Phenbarbital Indmethacin Ibuprfen Pavuln Ethamsylate Vitamin E Prpsed Mechanism Stabilize bld pressure and free radical prductin Prmtes micrvasculature maturatin; blunt fluctuatins in BP and cerebral bld flw Imprve autregulatin and cerebral bld flw Prevent asynchrnus breathing in ventilated newbrns; secndary BP stabilizatin Prmte platelet adhesin, increase capillary basement membrane stability Free Radical Prtectin *see ntes sectin fr mre details Adapted frm McCrea HJ and Ment LR Clinical Perinatlgy (35(4): 777-vii

18 Cnclusin IVH remains a cmmn prblem f extreme prematurity Hemrrhage ften arises frm vasculature f the germinal matrix Severe neurdevelpmental sequelae can arise and is assciated with increasing severity f the hemrrhage Very few, if any, gd preventive strategies are available