脑室周围-脑室内出血后脑实质损害及其对神经发育影响

目的 认识脑室周围一脑室内出血所致的脑实质损害及其对小儿神经发育的影响。方法 经颅脑超声确诊为脑室周围一脑室内出血并伴脑室扩大的新生儿157例，分析侧脑室扩大程度与脑实质损害的关系。通过随访，了解这些小儿神经发育状况，总结脑实质损害程度与新生儿期后神经发育的关系。结果 91例患儿存在不同程度的脑实质损害迹象；脑室周围白质损害最为明显，62例为一过性，29例在4周时白质病变不消失或形成脑室旁白质软化，7例同时存在出血性脑梗塞；脑实质损害的严重性与脑室扩大的程度有关；部分患儿在新生儿期后颅脑超声检查时发现脑结构异常；随访月龄在3个月以上的72例患儿中，智能发育轻度异常29例，严重异常7例，神经发育异常与脑实质损害程度有关。结论 严重的脑室周围一脑室内出血可继发脑实质损伤，应注意脑室扩大所致的脑室旁白质病变及出血性脑梗塞。脑实质损伤可导致神经发育异常。     

Episodes of hypocarbia and early-onset sepsis are risk factors for cystic periventricular leukomalacia in the preterm infant

Background

Septic episodes in preterm infants recently have been reported to be associated with periventricular leukomalacia (PVL). The role of hypocarbia as an independent risk factor for PVL in clinical studies raises many questions without conclusive answers.

Aims

To evaluate risk factors for cystic PVL focussing on the influence of hypocarbia.

Study design

Retrospective single centre case-control study.

Subjects

Preterm infants 24 to 35 weeks of gestational age and matched (1:2 for gender, birth year, gestational age and birth weight) controls.

Outcome measures

Multivariate analysis of perinatal factors being associated with cystic PVL diagnosed by serial ultrasound examinations.

Results

Univariate analysis of risk factors revealed lower 5 and 10 min Apgar scores, and higher rates of neonatal seizures, early-onset sepsis, neonatal steroids, respiratory distress syndrome with surfactant replacement therapy, and episodes of hypocarbia significantly being associated with PVL. Multivariate analysis using a logistic regression model revealed early-onset sepsis and hypocarbia being significantly associated with PVL (p = .022 and .024, respectively). Lowest PaCO₂ values did not differ as did not the duration of hypocarbia, but the onset of hypocarbia was significantly later in PVL cases compared to controls (mean 26 vs. 15 h, p = .033). Neurodevelopmental follow-up at a median time of 46 months was poor showing 88% of the cases having an adverse neurological outcome.

Conclusion

We found early-onset sepsis and episodes of hypocarbia within the first days of life being independently associated with PVL.     

Unilateral parenchymal haemorrhagic infarction in the preterm infant.

A unilateral parenchymal haemorrhage associated with a germinal matrix-intraventricular haemorrhage (GMH-IVH) is still an important problem in the preterm infant and especially in those who are very immature. This type of lesion is now considered mainly to be caused by impaired drainage of the veins in the periventricular white matter and is often referred to as a venous infarction. The risk factors and neonatal imaging findings, as well as neurodevelopmental outcome and imaging data in infancy, of this type of lesion differ from those found in children with bilateral periventricular leukomalacia. An effort should, therefore, always be made to make a distinction between these two types of lesions. In our experience it is possible to make this distinction in most cases, when performing both sequential ultrasonography as well as selective magnetic resonance imaging during the neonatal period.     

Hyperbilirubinemia, hypocarbia and periventricular leukomalacia in preterm infants: relationship to cerebral palsy

This study comprised 103 preterm infants with a gestational age less than 33 weeks who were born in Tampere University Hospital and who were followed up to two years of age. Sixty-four perinatal variables were compared to ultrasound findings in the neonatal period and neurologic handicap at the age of two years. Duration of hypocarbia (PCO2 < or = 30 mmHg) during the first 72 h and hyperbilirubinemia (the mean level of serum total bilirubin) at three days of age were independently and significantly related to periventricular leukomalacia, but not directly to cerebral palsy. The only perinatal variables related independently and significantly to cerebral palsy at two years of age were periventricular leukomalacia and ventriculomegaly. According to these results, periventricular leukomalacia was the main predictor of cerebral palsy in preterm infants. In addition to hypocarbia, hyperbilirubinemia may also be involved in the pathogenesis of extensive (severe cystic) periventricular leukomalacia.     

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目的探讨早产儿囊性脑室周围白质软化症(cPVL)与低碳酸血症及机械通气的关系。方法比较cPVL与非cPVL早产儿(各10例)生后3d内发生的低碳酸血症(至少2次PaCO2<3.33kPa)情况以及每天机械通气参数,两组在胎龄、出生体重、性别及临床情况方面统计均无差异。结果cPVL组发生低碳酸血症几率为70%,明显高于非cPVL组的20%(P=0.02),而两组每天机械通气参数无差异。结论早产儿cPVL的发生与低碳酸血症有关,似乎与过度通气无关。     

Neonatal MRI in preterm infants with periventricular leukomalacia and mild disability

Background: The aim of the present study was to describe the neonatal magnetic resonance imaging (MRI) findings of preterm infants with periventricular leukomalacia and mild neurological disability. Methods: MRI findings at term equivalent were retrospectively investigated in eight preterm infants with mild disability and periventricular leukomalacia diagnosed on MRI in infancy. Results: Linear, spotted, or macular areas of hyperintensity on T1‐weighted imaging and hypointensity on T2‐weighted imaging were identified in all subjects in the white matter lateral to the body of the lateral ventricle. No cystic lesions were seen. These findings were more widespread and more clearly visualized on T2‐weighted imaging than T1‐weighted imaging. Conclusions: Linear, spotted, or macular lesions that are hyperintense on T1‐weighted imaging and hypointense on T2‐weighted imaging are possibly compatible with periventricular leukomalacia.     

Association of septic shock caused by early-onset group B streptococcal sepsis and periventricular leukomalacia in the preterm infant

Early-onset group B streptococcal sepsis frequently produces shock in preterm infants, a condition also felt to be contributory to the development of periventricular leukomalacia. During a 2-year study period, 628 preterm infants who were admitted to the neonatal intensive care unit underwent serial sonographic brain scanning; periventricular leukomalacia was diagnosed in eight infants (1.2%). The four infants (100%) who survived group B streptococcal sepsis with septic shock developed periventricular leukomalacia, whereas none of the four survivors (0%) of septic shock caused by other organisms and three of 27 survivors (11%) of shock not caused by infection developed periventricular leukomalacia. Because of the frequency of this lesion, it is suggested that all preterm survivors of group B streptococcal sepsis with septic shock should have serial sonography screening for detection of periventricular leukomalacia. Early detection will not assure cure but may facilitate prognostication, follow-up, and earlier institution of rehabilitative therapy to produce a better outcome.     

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目的探讨弥散加权核磁成像(DWI)对早产儿脑室周围白质软化(PVL)的诊断价值。方法收集2008年1月至2009年8月因缺氧而收住新疆医科大学第一附属医院重症监护室(NICU)疑似PVL的早产儿55例,对其进行头颅B超检查,并将患儿分为PVL组(15例)及对照组(40例),同步行DWI检查并测定弥散系数(ADC值),分析DWI诊断早产儿PVL的灵敏度和特异度等。结果 DWI诊断PVL的灵敏度为66.7%,特异度为95.0%。结论 DWI可以作为早期诊断早产儿PVL的影像学检查方法。     

Neurosonographic features of periventricular echodensities associated with cerebral palsy in preterm infants

We studied the value of neonatal neurosonograms in preterm infants for predicting the development of cerebral palsy (CP). All infants born at less than 33 weeks of gestation who were admitted to the intensive care nursery of Thomas Jefferson University Hospital from 1982 to 1986 were serially studied with cranial ultrasound methods that reliably detect neonatal periventricular echodensities (PVE) and cysts that are 2 mm in diameter or larger. PVE were graded as mild or as moderate to severe, and cyst size was classified by widest diameter as either large (greater than or equal to 3 mm) or small (less than 3 mm). All 127 surviving infants with PVE or cyst formation or both were followed until spastic forms of CP could be diagnosed or excluded during late infancy. All 26 of the infants in whom spastic CP developed had moderate or severe PVE in the area superior and lateral to the caudothalamic notch as noted on the parasagittal images of the neonatal neurosonograms. All these infants also developed cysts in the periventricular region within the area of the previously noted PVE. Mild or moderate to severe PVE were not associated with the development of spastic CP in 101 infants. Cysts developed in the area of PVE in the neurosonographic studies of 42 of these 101 infants. Mild PVE without cysts and moderate to severe PVE without cysts had negative predictive values for CP of 69% and 76%, respectively. By contrast, the presence of moderate to severe PVEs with large cyst formation had positive and negative predictive values of 90% and 93%, respectively, and was the most sensitive and specific neurosonographic finding for predicting CP, with an efficiency of 92%. The presence or absence of intracranial hemorrhage did not increase the efficiency of the ultrasound test results.     

Early gastrointestinal function and nutritional status in preterm infants with cystic periventricular leukomalacia

OBJECTIVE: To retrospectively investigate the early gastrointestinal function and the nutritional status of very low birth weight (VLBW) infants with cystic periventricular leukomalacia (PVL). METHODS: Sixty-five VLBW infants who were admitted to Kakogawa Municipal Hospital were divided into 2 groups: 5 infants were in the PVL group, and the remaining 60 infants were in the normal group. The gastrointestinal function of the infants in the early neonatal period was compared between the 2 groups using an analysis of gastric aspirates and abdominal radiographs, and pulsed-Doppler ultrasonographic measurement of the flow velocity in the superior mesenteric artery (SMA). RESULTS: In the first week, there were more days in which abdominal gastric residual fluids occurred in the PVL group than in the normal group. The occurrence of abnormal findings in the abdominal radiograph within the first 7 days was significantly higher in the PVL group than in the normal group. Longitudinal ultrasonographic comparisons of the SMA flow velocity showed that the mean values in peak systolic velocity and in time-averaged velocity were both significantly higher in the PVL group than in the normal group before 7 days of life. Both the total volume of milk ingested and the total energy intake in the PVL group were significantly lower than in the normal group within the first 2 weeks of life. CONCLUSIONS: Despite the low number of infants with PVL, we may suggest that the gastrointestinal function of the preterm infants with cystic PVL may deteriorate significantly compared to normal infants in the early neonatal period of life, and consequently, the early nutritional intakes in the PVL infants are inferior to those in the normal infants.     

新生儿出血性及梗死性脑血管病诊治探讨

目的：提高对新生儿脑血管病的认识,探讨其临床发病特点及诊断方法。方法：选用不同的影像学方法对9例由于脑血管畸形所致的新生儿脑实质出血, 17例不同部位脑梗死患儿进行了检查、确诊,并依据神经系统症状,分析临床发病特点。结果：9例脑实质出血发生于额叶、颞叶和枕叶,其中7例在生后72h内发病; 10例因脑血管发育异常致大脑前动脉、中动脉、后动脉供血区梗死; 7例继发于不同疾病,为分支血管供血障碍所致的继发性脑梗死。典型的临床特征是频繁惊厥。结论：新生儿脑血管病最显著的临床症状是频繁惊厥,影像学检查为确诊提供了科学依据,早期治疗对预后有改善作用。     

Risk factors associated with the development of peri-intraventricular haemorrhage and periventricular leukomalacia

81 preterm infants of 34 weeks' gestation or less were prospectively and sequentially examined by means of real-time ultrasound in order to identify which clinical risk factors might be associated with the development of peri-intraventricular haemorrhage (PVH) and periventricular leukomalacia (PVL). Infants were allocated in three groups: group A (n = 44): with normal scans; group B (n = 24): with isolated PVH, and group C (n = 13): with PVL. 28 obstetrical and neonatal factors were compared within the three groups using two methods of statistical analysis (2 x 2 chi 2 analysis and multivariate logistic regression analysis). Hyaline membrane disease, acidosis, pneumothorax and Apgar score at 10 min were statistically associated with PVH. The multivariate logistic regression analysis showed that need for resuscitation, hyaline membrane disease, acidosis and gestational age were the most important factors. Gestational age, seizures, hyaline membrane disease, apnoea with hypoxaemia and bradycardia were strongly associated with PVL. These results suggest that a low gestational age, the need for resuscitation and a respiratory distress syndrome with its consequences might lead to PVH, whereas a low gestational age, hypoxaemia and cardiocirculatory disturbances might decrease cerebral perfusion and result into PVL.     

早产儿脑室内出血和脑室周围白质软化的临床表现及治疗

脑室内出血（IVH）和脑室周围白质软化（PVL）均是极低出生体重（VLBW）早产儿常见的脑损伤类型,尽管其发生均与早产儿脑室周围血液动力学和解剖学因素相关,前者主要为出血性病变,而后者则为早产儿脑室周围白质的缺血性病变,两种损害常可同时存在。     

Respiratory distress syndrome-associated inflammation is related to early but not late peri/intraventricular hemorrhage in preterm infants

OBJECTIVE: To investigate whether or not peri/intraventricular hemorrhages (PIVHs) occurring in the first 12 hours of life (early PIVHs) are related to respiratory distress syndrome (RDS)-associated inflammatory factors in contrast to PIVHs developing after 12 hours of life (late PIVHs). STUDY DESIGN: Blood samples obtained at 0 to 12 hours, 48 to 72 hours, and 168 hours of life were evaluated for determination of the proinflammatory cytokines interleukin (IL)-8 and IL-6, tumor necrosis factor (TNF)-alpha, and malondialdehyde (MDA) as measures of lipid peroxidation. Simultaneously, cranial ultrasonography was performed in 114 neonates under 32 weeks gestational age. RESULTS: Out of the total study group of 114 neonates, 67 (59%) had RDS. Early PIVH occurred in 16 neonates, 14 of whom (88%) had RDS. Late PIVHs occurred in 12 neonates. Neonates with RDS had higher IL-8 and IL-6 levels at 0 to 12 hours (P < .0001; < .0001) and at 48 to 72 hours (P < .001; < .01) than those without RDS. Neonates with early PIVH had higher IL-8 (P < .02), IL-6 (P < .02), and MDA (P < .01) levels at 0 to 12 hours than those with late PIVH or no PIVH. Those with early PIVH had higher IL-8 levels at 48 to 72 hours than those without PIVH (P < .02). Multiple linear regression revealed an association between RDS/early PIVH and IL-8, IL-6, and MDA levels. CONCLUSIONS: An RDS-associated increase in proinflammatory cytokine and MDA levels was associated with early PIVHs, but not with late PIVHs, suggesting a different etiopathogenesis in early versus late PIVHs.     

Blood pressure fluctuation and intraventricular hemorrhage in the preterm infant of less than 31 weeks' gestation

A total of 22 infants of less than 31 weeks' gestation who were mechanically ventilated for a minimum of 12 hours for respiratory distress syndrome were studied. The coefficient of variation of direct systolic pressure was measured each minute from six to 36 hours of age and averaged per hour after birth with a microcomputer-based system of data collection. At the start of recording, the ultrasound scan appeared normal in each infant, but intraventricular hemorrhage developed in ten infants less than 36 hours of age. Twelve infants remained free of intraventricular hemorrhages. BP fluctuation was greater for a longer proportion of measured time in infants in whom intraventricular hemorrhage did not develop compared with those in whom it did develop P less than .05). These findings do not support a causal relationship between BP fluctuation and intraventricular hemorrhage within the range of coefficient of variation studied.     

Postnatal changes in total body water and extracellular volume in the preterm infant with respiratory distress syndrome

Body water compartment changes were assessed during postnatal weight loss in 14 infants with respiratory distress syndrome. Total body water and extracellular volume were measured by dilution methods on the first day of life and again between the third and sixth days of life. Extracellular volume changes were calculated between the first and second determinations by measurement of chloride balance. Fluid therapy was prescribed to allow negative net water balance and a 1% to 3% reduction in body weight per day. All infants had concurrent reductions in body weight, total body water, and extracellular volume. Progressive daily extracellular volume reduction concurrent with weight loss was also apparent from chloride balance data. The correlation of changes in body weight with extracellular volume in individual subjects was poor (r = 0.05). We speculate that variations between sodium and free water balance in the sick preterm infant may be responsible for variability in the distribution of postnatal body water losses. Assessment of hydration in the newborn infant should include consideration of sodium balance and alterations of serum osmolality, and changes in body weight.     

Markers of oxidative injury in the cerebrospinal fluid of a premature infant with meningitis and periventricular leukomalacia

Free radicals have been hypothesized to play a key role in the evolution of periventricular leukomalacia, although direct evidence of oxidative injury in the human infant is lacking. This case report is the first to demonstrate a marked elevation in the levels of lipid and protein oxidative products in the cerebrospinal fluid during the evolution of periventricular leukomalacia in a premature infant with meningitis.