1、Intracranial Hemorrhage of the NewbornEtiology and Epidemiology of ICH Trauma (epidural, subdural, or subarachnoid)fetal head is too large in proportion to the size of the pelvic outletprolonged labor/breech or precipitate deliveriesMechanical assistance with delivery Asphyxia/Hypoxic ischemic encep

2、halopathy Premature infants (peri-/intraventricular hemorrhage, PVH/IVH) Primary hemorrhagic disturbance (subarachnoid or intracerebral)DICisoimmune thrombocytopenianeonatal vitamin K deficiency (maternal phenobarbital or phenytoin) Congenital vascular anomaly Iatrogenic hemorrhage (sucktioning, inf

3、using, ventilating) Incidence of PVH/IVH Most common neonatal intracranial hemorrhage Occurs primarily in premature infantsIncidence increases with decreasing 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

4、at birth50% occur on the 1st day, 8090% occur between birth and the 3rd day2040% progress during the 1st weekDelayed hemorrhage may occur after the 1st week in 1015% of the cases New-onset IVH is rare after the 1st month of life regardless of the birthweightPathogenesis of PVH/IVH Gelatinous subepen

5、dymal germinal matrix (periventricular)Embryonal neurons and fetal glial cellsImmature blood vessels and highly vascular areaPoor tissue vascular support Predisposing factors or eventsPrematurity, RDS, Hypoxic-ischemic or hypotensive injury, reperfusion, increased or decreased CBF, pneumothorax, hyp

6、ervolemia, hypertension, etc Periventricular leukomalacia (PVL)Prenatal or neonatal ischemic or reperfusion injuryNecrosis of the periventricular white matterDamage to the cortico-spinal fibers in the internal capsulePathogenesis of PVH/IVH Intravascular factorsFluctuating cerebral blood flow (relat

7、ed to mechanics of ventilation)Increasing in CBF (pressure-passive cerebral circulation in premature infants)Increases in cerebral venous pressureDecreases in CBF (occurring prenatally or postnatally)Platelet and coagulation disturbances (hypercoagulable state, vitamin K) Vascular factorsImmature ve

8、ssels in the germinal matrixLack muscle and collagen, susceptible to ruptureVascular border zone with more mitochondria, more vulnerable to ischemia Extravascular factorsNo supportive stroma around the vesselsExcessive fibrinolytic activityCommon Clinical Signs/Symptoms Change of consciousness Abnor

9、mal eyes signs/movement Increased intracranial pressure Irregular respiratory pattern or apnea Changes of muscle tone Pupils signs Others: jaundice, anemia, etcClinical Manifestation Most common symptoms are diminished or absent Moro reflex, poor muscle tone, lethargy, apnea and somnolence Often hav

10、e a precipitous deterioration on the 2nd or 3rd daysPeriods of apnea, pallor, or cyanosisFailure to suck wellAbnormal eye signs, fixed pupilsA high-pitched, shrill cryMuscular twitching, convulsion, decreased muscle tone, or paralysisMetabolic acidosis, shock, decreased hematocrit Tense and bulging

11、of fontanelSevere neurological depression or coma Asymptomatic periods or no clinical manifestationsDiagnosis History Clinical manifestation Transfontanel cranial ultrasonography (real-time) Computed tomography (CT) Magnetic resonance imaging (MRI) Magnetic resonance spectroscopy (MRS)Possible Prena

12、tal Interventions Prevention of prematurity Most effective means of prevention of PVH/IVH Transportation of infants in-utero decreased incidence of ICH compared to postnatal transport Antenatal corticosteroids PVH/IVH, maturation of blood vessels/prostaglandin synthesis Antenatal administration of v

13、itamin K PVH/IVH, improvement in prothrombin activity Antenatal phenobarbital severe PVH/IVH, controversial Optimal management of labor and delivery no consistent resultsPossible Postnatal Interventions Appropriate neonatal resuscitation avoid hypercarbia, rapid infusion and hypertonic solutions Cor

14、rection/prevention of hemodynamic disturbances avoid excessive handling, suctioning; use adequate ventilation Correction of abnormalities of coagulation fresh frozen plasma can decrease incidence of PVH/IVH, not severe type Postnatal phenobarbital inconsistent, current data do not support routine use for prevention Ethamsylate stabiliza