Neuro. Development. Judy Philbrook, NNP-BC. ! Primary neurulation! Prosencepahlic! Neuronal proliferation. ! 3-4 weeks! 2-3 months!

Transcription

1 Neuro Judy Philbrook, NNP-BC Microsoft clip art Development! Primary neurulation! Prosencepahlic! Neuronal proliferation! Neuronal migration! Organization! Myelination! 3-4 weeks! 2-3 months! 3-4 months! 3-5 months! 5 months to years 1

2 Associated disorders! Primary neurulation! Prosencepahlic! Neuronal proliferation! Neuronal migration! Organization! Myelination! Anencephaly, myelomeningocele! Holoprosencephaly, midline defects! Sturge-Weber! Agenesis of the corpus callosum! Retardation! Acquired/inherited diseases Anatomy Verklan, et. al.; Core Curriculum for Neonatal Intensive Care Nursing, Elsevier, Philadelphia, 2004 Physiology! Brain needs glucose and oxygen l Preterm has minimal glucose stores l Cerebral blood flow is affected by ph, oxygenation, osmolarity, and calcium ion and potassium levels l Hypotension ischemia l Hypertension - hemorrhage 2

3 Neuro Assessment! History! Observation l State, posture, movement, respiratory activity! Physical exam l Skull size and shape, face, spine, cranial nerve function, muscle tone, reflexes Neurological disorders Anencephaly! Failure of the anterior neural tube closure! Skull bones absent, absent cerebellum! Identified with prenatal ultrasound! Outcome 75 % are stillborn, survival unlikely beyond neonatal period 3

4 Microcephaly! Occipital-frontal circumference > 2 SD below the mean! Risk factors! Pathophysiology l Occurs between 3-4 months gestation l Neuronal proliferation defect! Presentation! Outcome Up To Date Hydrocephalus! Excess CSF in the ventricles l Decrease in reabsorption l Overproduction (rare)! Pathophysiology l Aqueductal outflow obstruction obstructive, noncommunicating l Most common l May progress rapidly l Communicating, nonobstructive - Flow between ventricles and subarachnoid space 4

5 Up To Date Congenital Hydrocephalus Risk Factors! Aqueductal stenosis! Dandy Walker cyst! Myelomeningocele with Arnold-Chiari malformation! Congenital masses and tumors! Congenital infection l Toxo l CMV Up ToDate Up To Date 5

6 Congenital Hydrocephalus! Presentation large head, widened sutures, full fontanel, sun setting eyes! Needs head ultrasound and/or CT! VP shunt l Signs of infection or blockage l Irritability, vomiting, increasing head size, lethargy, changes in feeding patterns, bulging fontanel Posthemorrhagic Hydrocephalus! Caused by dilatation of the ventricles after IVH occurs in ~50% of infants with IVH! Care l Weekly OFC l Ultrasound! Serial LP, Reservoir placement, VP shunt Myelomeningocele! Neural tube defect l Meningocele (protrusion of meninges) l Myelocele (spinal cord or nerve roots) l Myelomeningocele (both)! Risk factors! Pathophysiology l Failure of the neural tube to close l 80% lumbar Up To Date 6

7 Myelomeningocele! Management l Prenatal diagnosis l Wrap with sterile gauze moistened with warm NS l Maintain in prone position l Obtain neuro and urology consults! Outcome l Survival 90% l 80% or more have normal intelligence and 85% are ambulatory Encephalocele! Neural herniation with or without brain tissue! Prenatal ultrasound! Outcome: Early surgery recommended! 50% complicated with hydrocephalus Up To Date Craniosynostosis! Premature closure of the sutures! Cause unclear! 1 in 2000 to 2500 births! Presentation: abnormal skull shape, suture line has bony prominence! Treatment: surgery 7

8 Verklan, et. al.; Core Curriculum for Neonatal Intensive Care Nursing, Elsevier, Philadelphia, 2004 Birth Injuries! Any injury that occurs during the birth process! Caused by: l cephalopelvic disproportion l prolonged labor l abnormal presentation (face, brow presentation) Which one?! Which crosses the suture lines?! Which resolves the quickest?! Which may lead to shock and hypovolemia?! Answer choices: a) caput succedaneum b) cephalohematoma c) subgaleal hemorrhage 8

9 newborns.stanford.edu newborns.stanford.edu 9

10 Other birth injuries! Skull fractures! Brachial nerve plexus injuries l Erb s palsy l Klumpke l Erb-Duchenne-Klumpke! Facial nerve palsy Intracranial Hemorrhages Types! Subdural! Subarachnoid! Intracerebellar! Periventricular-intraventricular! Periventricular leukomalacia 10

11 Periventricular-Intraventricular! Bleeding into the brain s ventricular system (graded)! Incidence l 30-40% of < 1500 grams l 50% occur in first 24 hours, 80% by 48 hours, 90% by 72 hours! Presentation l Unnoticeable to dramatic! Diagnosis: Head ultrasound Verklan, et. al.; Core Curriculum for Neonatal Intensive Care Nursing, Elsevier, Philadelphia, 2004 IVH Risk Factors! <34 weeks! Asphyxia! Low 5 min Apgar! Acidosis! Hypo or hypertension! Low Hct! RDS on vent! Rapid administration of bicarb or volume expansion! Coagulopathy! Pneumothorax! PDA ligation! Transport 11

12 PVL! Ischemic and necrotic white matter! Hypotension impairs cerebral blood flow! Outcome l Spastic dysplasia l Motor deficits l Visual impairment Up To Date! Definition Subdural Hemorrhage l Laceration of major veins and sinuses! Incidence - < 10% of ICH s! Risk Factors l Large head compared to birth canal l Breech delivery (vaginal) l Malpresentation l Forceps, vacuum! Pathophysiology l Excessive molding, elongation stretching and tearing of venous sinuses! Presentation l Decreased level of consciousness l Seizure activity l Asymmetry of motor reflexes l Day 2-3: signs of increasing intracranial pressure/ signs of brainstem disturbance! Diagnosis l CT, MRI! Outcome l Poor prognosis with major laceration of tentorium and falx l Mortality 45% l May develop hydrocephalus and other sequelae 12

13 Subarachnoid Hemorrhage! Definition l An intracranial hemorrhage into the CSF space between the arachnoid and pial membranes on the surface of the brain! Pathophysiology l Bleeding (venous origin) into the subarachnoid space l May be caused by trauma! Common type of intracranial hemorrhage! Presentation l No symptoms l Seizure activity may begin on day 2, esp. term l Apnea more common in preterm! Diagnosis l By exclusion other forms of ICH are eliminated by CT scan! Outcome l Usually normal 90% of babies who had seizures have normal follow-up Intracerebellar Hemorrhage! Definition l Hemorrhage within the cerebellum from primary bleeding or extension of IVH l Associated with resp distress, hypoxic events, prematurity and traumatic delivery! Diagnosed via CT! Outcome l Better in term than preterm l Probable neuro deficits 13

14 Seizures! Not a disease, but a symptom! Results from excessive electrical discharge of neurons Seizures - Presentation! Subtle most common (lip smacking, blinking)! Tonic tonic extension of extremities or extension of lower extremities and flexion of upper extremities! Multifocal clonic clonic movements one limb to another with no pattern! Myoclonic rare; jerks Seizures! Diagnostic eval l Physical l Lab work l Sepsis workup l EEG, CT, head ultrasound l Neuro consult! Medications l Phenobarbital l Phenytoin l Fosphenytoin l Lorazepam 14

15 HIE! Brain injury due to asphyxia! Clinical presentation staging l Stage I (mild encephalopathy) l Hyperalert state, normal muscle tone, no convulsions l Stage 2 (moderate encephalopathy) l Lethargy, hypotonia, increased reflexes, weak suck l Critical period improves or deteriorates (seizures, cerebral edema, lethargy) l Stage 3 (severe encephalopathy) l Loss of consciousness l Seizures appear within 12 hours! Care l Prevent perinatal hypoxia, ischemia and asphyxia l Maintain oxygenation and acid base balance l Treat seizures l Hypothermia (head cooling) l > 35 weeks with ph 7, base deficit 16 OR l Cord ph or first gas ph OR base deficit -10 to -15.9, OR no blood gas and a history of an acute perinatal event and wither a 10 min Apgar 5 or continued need for ventilation support for at least first 10 postnatal minutes! Outcome l Based on severity of brain insult Meningitis! Infection in the CNS (viral, bacterial, fungal)! Diagnosis: CSF (low glucose, organism present, elevated WBC and protein)! Treatment l Antibiotics l Repeat LP 15

16 References! Verklan, et. al.; Core Curriculum for Neonatal Intensive Care Nursing, Elsevier, Philadelphia,