我国早产儿脑室周围白质软化发生率的多中心调查报告

目的：在中华医学会儿科分会新生儿学组的发起下，国内十余家大型医院于2005年1月始进行了为期近两年的《早产儿脑损伤》多中心协作研究。该文报告我国10家三级甲等医院近两年对早产儿脑室周围白质软化（PVL）发生率的调查结果。方法：2005年1月至2006年8月期间，各参加单位对所有胎龄<37周的早产儿在生后7 d内常规进行初次床边头颅B超检查，以后每隔3～7 d复查一次，直至出院。结果：10单位共出生或收住早产儿4 933例，总PVL发生率为2.3％（112/4 933），囊性PVL发生率为0.3％（16/4 933）。分别为I级PVL 85.7％（96/112），II级PVL 12.5%（14/112），III级PVL 1.8％（2/112），无IV级PVL。4家妇婴医院的早产儿PVL总发生率非常显著低于6家综合性或儿童专科医院（1.4% vs. 2.8％）（χ2＝10.284，P<0.01）。与发生囊性PVL相关的可能高危因素为阴道分娩和机械呼吸。结论：该调查数据基本可以反映我国主要大城市早产儿PVL发生率的情况。提高对PVL尤其是非囊性脑室周围白质损伤的超声识别率，是今后临床要大力加强的重点     

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。     

早产儿脑室周围-脑室内出血与脑室周围白质软化的诊断建议

早产儿常见脑损伤主要为脑室周围．脑室内出血（PVH-IVH）和脑室周围白质软化（PVL）,与早产儿中枢神经系统的解剖生理学和神经生物学发育不成熟密切相关。前者为出血性病变,常导致脑室内出血后脑积水和脑室周围出血性髓静脉梗死等严重并发症。后者为缺血性病变,也与官内感染有关。其中局部PVL的病理特征是白质少突胶质细胞前体的急性坏死,在后期可形成多发小囊腔。弥漫性PVL又称为弥漫性白质损伤,其病理特征是白质少突胶质细胞前体的凋亡性死亡,少见出现囊腔改变。局部和弥漫性PVL最终均导致脑白质容量减小和髓鞘化受损。PVH-IVH和PVL是引起早产儿早期死亡、脑瘫、视、听和认知障碍的主要原因。     

早产儿脑室周围白质软化的高危因素及防治

目的 分析早产儿脑室周围白质软化(PVL)的临床资料,为早产儿PVL防治提供理论依据.方法 收集2004年1月至2008年3月我院NICU早产儿的临床资料、生后3～7 d头颅B超检查情况进行动态观察研究,对多种围生期高危因素进行Logistic回归分析.结果 835例早产儿,PVL 105例,发生率达12.6%,其中59例出现囊性变.PVL发生与下列因素有关:胎龄小、低出生体质量、窒息、肺透明膜病、呼吸暂停、呼吸衰竭、肺出血、低血糖、感染、低血压、凝血异常、低碳酸血症、胎膜早破、贫血、机械通气.结论 PVL在早产儿比较常见,其发生与多种因素密切相关,头部B超可对早产儿PVL做出早期诊断,临床上应避免或及时治疗引起PVL的因素.     

早产儿脑室周围白质软化的早期诊断

早产儿脑室周围白质软化（Periventricularleukmalailia，PVL）所致的脑性瘫痪（Cerebralpalsy，CP）有增加倾势。本文应用超声波图象诊断技术对PVL进行早期诊断，预测CP的发生，并对围生因素进行分析。一、对象：1995年11月～1997年6月在我院住院的早产）L36例进行连续超声波检查。胎龄28～32Wb9例，～34WhiZ例，～37Wkls例。出生体重一150Ogll例，～20O0gl4例，～250Og9例，＞250092例；单胎26例，双胎1O例；适于胎龄儿（AGA）23例，小于胎龄儿（SGA）13例。各种原因致低氧血症16例，颅内高压症3例，低血压2例，低PaCO21例。…     

白介素18与早产儿脑室周围白质软化的相关性研究

目的 探讨白介素18(IL-18)在早产儿脑室周围白质软化(PVL)发病机制中的作用,为早产儿PVL的早期诊断及防治提供可能的理论依据.方法 经头颅B超诊断为PVL早产儿21例,对照组早产儿20例,应用酶联免疫吸附试验测定出生6 h内血清IL-18值.结果 根据头颅B超结果,将PVL组患儿分为Ⅰ级8例,Ⅱ级6例,Ⅲ级5例及Ⅳ级2例.Ⅰ级PVL患儿血清IL-18水平明显高于对照组(P<0.05);Ⅱ级PVL患儿明显高于Ⅰ级(P<0.05);Ⅲ级明显高于Ⅱ级(P<0.05).PVL组脑瘫发生率明显高于对照组(P<0.05).结论 早产儿血清IL-18水平升高与早产儿PVL的发生密切相关,在出生时可作为一个早期预测指标,并为防治早产儿PVL发生提供可能的理论依据.     

中国人群早产儿脑室周围白质软化危险因素的meta分析

目的探讨中国人群早产儿发生脑室周围白质软化的主要危险因素,为今后防治工作提供依据。方法利用meta分析方法分析国内14篇关于早产儿脑室周围白质软化危险因素的研究文献。累计病例748例,对照3 366例。根据齐性检验结果选择计算各危险因素合并比值比(OR)及其95%可信区间(95%CI)模型。结果脑室周围白质软化发生的OR值(95%CI)分别为:产前使用激素0.46(0.34～0.61),胎膜早破3.60(1.40～9.24),胎龄5.05(2.66～9.58),低出生体质量2.78(2.30～3.35),重度窒息5.35(2.09～13.68),感染4.46(3.08～6.44),机械通气3.67(1.74～7.72),低碳酸血症4.49(2.03～9.94),脑室内出血2.00(1.15～3.45),酸中毒1.58(1.19～2.08)。结论胎膜早破、胎龄、低出生体质量、重度窒息、感染、机械通气、低碳酸血症、脑室内出血和酸中毒是中国人群早产儿脑室周围白质软化发病的主要危险因素,产前使用激素可能为脑室周围白质软化的保护因素。     

一氧化氮对脑室周围白质软化早产儿神经发育的影响

目的探讨一氧化氮(NO)在合并脑室周围白质软化(PVL)的早产儿神经发育中的作用。方法采用随机、对照实验,对合并PVL的106例早产儿,在出生后24h内随机分成吸入NO组(第1天10×10-6,以后改为5×10-6继续用6d)和对照组(吸入氧气7d),在纠正胎龄18个月时采用贝利发育量表评估其神经发育。结果吸入NO组贝利评分明显高于对照组(P<0.05),贝利评分低于70分的发生率明显低于对照组(P<0.05)。结论合并脑室周围白质软化早产儿采用吸入NO治疗,有利于促进其神经发育。     

早产儿脑室周围／脑室内出血及其防治

早产儿尤其是出生体重小于1500g的极低出生体重儿(VLBWI)和超低出生体重儿(EIBWI)，由围生期缺氧缺血引起的脑损伤主要表现为脑室周围／脑室内出血。其发病机制、病理改变和临床表现与足月儿缺氧缺血性脑病不同；治疗方法和预后判断也不一致，必须区别对待。近年来国内由于新法复苏的推广，新生儿窒息尤其是重度窒息发生率明显降低，新生儿缺氧缺血性脑病发生率也随之降低；另一方面，由于早产儿存活率提高，早产儿围生期缺氧引起的脑室周围／脑室内出血及其神经后遗症显得更为突出，成为影响早产儿预后最重要因素之一。     

早产儿脑室周围白质软化的多因素分析

目的　探讨早产儿脑室周围白质软化 (PVL)的高危因素。方法　对合并PVL与未合并PVL的早产儿(各 2 6例 )进行病例对照研究 ,对 18种危险因素进行Logistic回归分析。结果　胎膜早破 (PROM )、生后 4h内的pH值、动脉氧分压、生后 3d内最低二氧化碳分压、生后第 1周超声发现脑室周围强回声团 (PVE)的OR值分别为 2 383、3 2 77、3 76 9、3 96 5、1 931(P <0 0 1)。建立的早产儿PVL主效应模型为Logit(P) =β0 +0 897PROM - 1 346PaO2 - 1 2 78pH - 1 4 6 7PaCO2 +0 792PVE(χ2 =2 1 378,P =0 0 0 1)。结论　PROM、低氧血症、酸中毒、低碳酸血症、PVE为早产儿PVL的高危因素。     

Correlation of grading and duration of periventricular echodensities with neurodevelopmental outcome in preterm infants

Background Transient periventricular echodensities (PVE) in preterm infants affect neurodevelopmental outcome.Objective To correlate the duration and grading of PVE with neurodevelopmental outcome.Materials and methods A retrospective, single-centre cohort study of infants with PVE diagnosed by ultrasonography from 1995 to 2000 with blinded grading and recognition of duration of PVE.Results A total of 72 infants (median gestational age 32 weeks, median birth weight 1,668 g) were diagnosed as having PVE. Minor neurological abnormalities were diagnosed in seven (10%), cerebral palsy in six (8%), developmental delay in seven (10%), and mild mental retardation in two (3%) of the infants. Differences regarding adverse outcome were not significant between infants with severity grade 1 compared to severity grade 2 (16% and 22%, respectively). There was a significant increase in adverse neurodevelopmental outcome with increasing duration of PVE. Of 33 infants with duration of PVE <7 days, 1 (3%) had an adverse neurodevelopmental outcome, compared to 6 (24%) of 25 infants with a duration of PVE of 7–14 days, and 6 (43%) of 14 infants with a duration of PVE >14 days (P<0.002, RR 7.920, 95% CI 1.017–61.661; P<0.001, RR 14.143, 95% CI 1.871–106.895, respectively).Conclusion The duration, but not the grading, of transient PVE was significantly correlated with neurodevelopmental outcome.     

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.     

早产儿囊性脑室周围白质软化症高危因素探讨

目的探讨早产儿囊性脑室周围白质软化症(cPVL)的高危因素。方法对cPVL(12例)与非cPVL早产儿(30例)进行回顾性研究,对多种围产期高危因素进行Logistic回归分析。结果胎膜早破、生后48 h内PaCO2<3.33 kPa(25 mm Hg)、生后4 h内pH<7.25、生后1周内发现脑室周围强回声的OR值分别为2.125、3.312、2.820和3.712(P<0.05或P<0.01)。结论胎膜早破、生后48 h内PaCO2<3.33 kPa、生后4 h内pH<7.25、生后1周内脑室周围有强回声为早产儿cPVL的高危因素。     

Amplitude-integrated electroencephalography in preterm infants with cystic periventricular leukomalacia

Aim

This study aimed to assess amplitude-integrated electroencephalography (aEEG) findings in preterm infants with cystic periventricular leukomalacia (cPVL) in the early neonatal period.

Methods

We analyzed five infants with cPVL, whose gestational age was between 27 and 30 weeks, and 15 matched control infants. Two-channel (C3-O1 and C4-O2) aEEG was obtained by digital conversion from a conventional electroencephalogram, which was recorded at days 0-5, 6-13, and 21-34 in each infant. We evaluated the averaged two-channel values of several measurements using visual and quantitative analyses.

Results

Infants with cPVL had a significant higher maximal upper-margin amplitude value, with a median of 47.5 μV (range of 42.5-60) compared with the control infants (median, 33.8; range, 23.8-50) in the second visual-analysis record. Infants with cPVL also had a significantly higher mean upper-margin amplitude value, with a median of 18.8 μV (range, 17.7-23.2) compared with the control infants (median, 16.3; range, 10.3-19.0) in the second quantitative-analysis record.

Conclusions

We demonstrated that the upper-margin amplitude of aEEG in infants with cPVL was significantly higher than that in the control infants at 6-13 days after birth.     

Correlation between neuroimaging and neurological outcome in periventricular leukomalacia: Diagnostic criteria

BACKGROUND: Periventricular leukomalacia (PVL) is the most important factor in cerebral palsy in preterm infants. METHODS: In the present study, we investigated 747 preterm infants of less than 36 weeks gestation who were repeatedly examined by cranial ultrasonography and computed tomography (CT) scanning at around 40 weeks of corrected post-menstrual age. The clinical course of these infants was followed for more than 3 years and they were examined by magnetic resonance imaging (MRI) between 12 and 18 months of age. RESULTS: Single examinations in early infancy were not sufficient to diagnose PVL, but the combination of ultrasonography, CT and MRI examinations allowed the clinical diagnosis of PVL. In preterm infants, clinical PVL could be predicted from cystic PVL and periventricular echogenicity (PVE) 3 or PVE 2 prolonged over 3 weeks on ultrasonography and confirmed by MRI after 11 months of corrected age. CONCLUSIONS: We tried to determine diagnostic criteria for PVL by neuroimaging. Such criteria from neuroimaging for PVL may be useful for determining the exact occurrence rate of and clinical risk factors for PVL.     

早产儿脑室旁白质损伤发病机制的研究进展

脑室旁白质损伤是早产儿特征性脑损伤,也是早产儿最重要的脑病类型之一。其病理变化主要包括脑白质的凝固性坏死、少突胶质细胞损伤、髓鞘损害、轴突损伤以及坏死部位出现反应性胶质化和小胶质细胞浸润等,这些病变与新生儿期后的神经系统后遗症密切相关。早产儿脑室旁白质软化的发病机制主要是与脑血管发育未成熟和少突胶质细胞前体细胞损伤易感性有关。本文通过文献复习对早产儿脑室旁白质损伤发病机制的研究进展进行概述,为临床预防和诊治提供理论依据。     

Possible etiological factors in extensive periventricular leukomalacia of preterm infants

During a twelve-month period five cases of extensive periventricular leukomalacia (PVL) in preterm infants with a gestational age of 31-32 weeks were diagnosed by routine ultrasound screening of preterm infants. The perinatal courses and later development of these infants were compared with 12 other infants with a comparable gestational age born during the same time period. PVL babies were delivered more often by the vaginal route (p = 0.0034), and their mean highest serum total bilirubin value was significantly higher (p = 0.0054) than that of the control infants. The mean value of the highest blood pH during the first 72 hours of life was also significantly higher (p = 0.0311) in PVL babies than in control babies. On the basis of these results we speculate that in addition to ischaemia in the periventricular area, bilirubin toxicity may play an additional role in the severe damage seen in extensive 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.     

组织学绒毛膜羊膜炎与小于34周早产儿脑室周围白质软化的相关性分析

目的探讨组织学绒毛膜羊膜炎(histologic chorioamnionitis,HCA)与<34周早产儿脑室周围白质软化(periventricular leukomalacia,PVL)的相关性。方法选取2018年1月至12月于青岛市妇女儿童医院产科出生、孕母行胎盘病理检查并转入NICU接受治疗、胎龄<34周的早产儿作为研究对象,共计287例。根据孕母胎盘病理检查结果分为HCA阳性组(167例)和HCA阴性组(120例),比较2组患儿的PVL发生率。将研究对象中已诊断为PVL的41例早产儿,根据孕母胎盘病理检查结果及HCA分期标准,分为非HCA组、HCA早期组、HCA中晚期组3组,比较各组PVL严重程度、患儿临床资料、并发症及校正胎龄至6月龄时的随访情况。结果HCA阳性组PVL占19.16%(32/167),HCA阴性组PVL占7.50%(9/120),2组PVL发生率比较差异有统计学意义(P<0.05)。已诊断为PVL的<34周早产儿中,非HCA组21.95%(9/41),HCA早期组31.71%(13/41),HCA中晚期组46.34%(19/41),3组间PVL严重程度、1 min Apgar评分、生后24 h白细胞计数、支气管肺发育不良发生率、住院天数、抗生素应用天数、校正胎龄至6月龄时的智力发育指数(mental development index,MDI)和精神运动发育指数(psychomotor development index,PDI)比较差异均有统计学意义(P均<0.05),且HCA炎症程度与PVL严重程度呈正相关(rs=0.374,P=0.016)。结论HCA与<34周早产儿PVL的发生有相关性,随着HCA炎症程度增加,PVL的发生率、严重程度增加。母亲存在HCA的<34周早产儿随炎症严重程度进展,其生后24 h白细胞计数升高,支气管肺发育不良发生率、抗生素使用率增加,住院时间延长,校正胎龄至6月龄时MDI、PDI分数降低。     

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.