早产儿脑室周围白质软化与脐血一氧化氮的关系

目的探讨早产儿脑室周围白质软化(PVL)的高危因素、发病机制及其早期诊断方法。方法采集PVL早产儿宫内缺氧缺血病史;采用ELISA检测PVL早产儿脐血TORCH-IgM抗体;应用硝酸还原酶法检测脐血一氧化氮(NO)水平。结果PVL组52例早产儿中39例有宫内缺氧缺血病史且脐血TORCH-IgM抗体阳性率明显高于对照组(P<0.05);PVL组脐血NO水平明显高于对照组(P<0.05)。结论宫内缺氧缺血和感染是早产儿PVL的高危因素。过量NO可能在PVL发生机制中起重要作用;脐血NO水平检测对早产儿PVL有早期诊断价值。     

Possible Etiological Factors in Extensive Periventricular Leukomalacia of Preterm Infants

ABSTRACT. 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.     

新生儿脑室周围白质软化的危险因素及预后

目的调查5年来新生儿脑室周围白质软化（PVL）发生率、危险因素及预后。方法对2000年12月～2005年11月本院记录资料较完整的806例新生儿中遗留脑性瘫痪61例患儿,至少2次头颅B超或MRI检查,确诊且排除其他疾病的PVL患儿26例为研究组。同期住院的35例无PVL的脑性瘫痪患儿为对照组。行PVL高危多因素回归分析、预后调查。结果PVL26例中早产儿占8.45%,足月儿占1.35%。重度窒息（x3）、孕周（x1）、颅内出血（x14）、低血压（x8）是PVL发生的主要高危因素,其OR值分别为2.843、3.575、3.268、1.947。妊娠高血压综合征、新生儿呼吸窘迫综合征、宫内感染对PVL发生的影响差异也有显著性（Pa〈0.05）。结论PVL发生率高,致病因素复杂,预后差,主要后遗症为痉挛性瘫痪及智力低下。     

脑室周围白质软化早产儿血清半胱氨酸蛋白酶-1和白细胞介素-18水平的变化

目的 研究脑室周围白质软化(PVL)早产儿血清半胱氨酸蛋白酶-1(Caspase-1)和IL-18水平的变化及二者的相关性,探讨PVL的发病机制及Caspase-1、IL-18的临床意义.方法 采用酶联免疫吸附法(ELISA)检测日龄48～72 h的13例PVL早产儿(PVL组)、17例脑室内出血(IVH)早产儿(IVH组)及20例健康对照早产儿(对照组)出生第3天血清Caspase-1和IL-18的水平.采用SPSS 13.0软件进行统计学分析.结果 PVL组早产儿血清Caspase-1和IL-18均明显高于IVH组和对照组早产儿,两组比较差异均有统计学意义(Pa＜0.05);IVH组和对照组早产儿血清Caspase-1和IL-18比较差异无统计学意义(P＞0.05);PVL组早产儿血清Caspase-1和IL-18呈正相关(r=0.965,P=0.000).结论 Caspase-1和IL-18参与了早产儿PVL的发病机制,联合测定Caspase-1和IL-18可作为早期诊断早产儿PVL的方法之一.     

Etiological Factors Associated with the Development of Periventricular Leukomalacia

ABSTRACT. Prenatal, intrapartum and postnatal factors are compared between 15 preterm infants, known to have periventricular leukomalacia (PVL) on ultrasound and 15 infants of similar birthweight and gestation who ultrasonographically showed no evidence of cystic lesions, and who are known to be neurologically normal at follow up. Prenatally, the incidence of antepartum haemorrhage was significantly higher in the PVL group. Intrapartum factors were similar between the two groups but postnatally, the PVL group had significantly lower PaCO₂ readings during the first 72 h of life. It is postulated that a severe maternal bleed in late pregnancy and neonatal hypocarbia could significantly decrease cerebral perfusion and cause areas of ischaemia and infarction resulting in periventricular leukomalacia.     

未成熟大鼠实验性脑室周围白质软化动物模型的建立及评价

目的建立2日龄SD大鼠脑室周围白质软化(PVL)动物模型,并进行评价。方法2日龄SD大鼠65只,随机分为PVL组和对照组。PVL组行右侧颈总动脉结扎手术,6%氧、94%氮混合气体处理4 h,分别在缺氧后72 h,14及28 d处死;对照组行假手术,不进行缺氧处理,时间段与PVL组配对。模型评价方法:常规HE染色及电镜检查;免疫组化学观察PVL72 h组胶质纤维酸性蛋白(GFAP)、β淀粉样前体蛋白(-βAPP)、O4和PVL 14 d组髓磷脂碱性蛋白(MBP)改变;采用悬吊、倾斜板、旷场和圆筒试验对术后28 d大鼠进行神经行为学检测。结果HE染色和电镜显示PVL组早期右侧侧脑室周围脑白质损害,远期并脑室扩大,髓鞘减少。免疫组织化学显示PVL组大鼠白质GFAP和-βAPP阳性染色A值较对照组明显增强,GFAP阳性细胞平均直径较对照组增大;PVL组大鼠MBP阳性染色较对照组减弱;O4阳性标记的异常细胞数较对照组增多。神经行为学检测PVL组与对照组织比较有明显异常。结论2日龄SD大鼠右侧颈总动脉结扎-缺氧模型符合PVL病理及行为改变。     

Ultrasonographic Findings in Periventricular Leukomalacia in the Newborn: Two Cases Associated with Early Onset Group B Streptococcal Sepsis

The ultrasonographic findings in periventricular leukomalacia (PVL) in the newborn are described, and the relationship between PVL and group B streptococcal (GBS) infection is discussed. Two newborn infants (one preterm and one term) suffered from early onset GBS sepsis with shock; they showed increased echogenicity in the periventricular regions; one of them developed cystic changes. These findings might be due to decreased perfusion of the periventricular end arterial zone. It is suggested that serial ultrasonography should be performed in neonates who suffer hypoxic-ischemic brain injury.     

儿童脑室周围白质软化磁共振表现与临床的关系

目的 探讨儿章脑室周围白质软化(PVL)MRI表现与临床症状的相关性.方法 选取本科47例PVL患儿.回顾性调查其围生期感染、出生体质量、胎龄及窄息情况;分析其MRI表现,包括脑室周围异常高信号、脑室扩大、皮质损伤、脑白质减少程度和胼胝体发育不良,进行PVL、腩性瘫痪(脑瘫)程度及语占障碍分级及视听觉筛查、智力检测,语言发育明显落后的患儿进行孤独症筛查:≥2岁应用孤独症行为量表(ABC),<2岁应用孤独症儿童评定量表(CARS),有抽搐发作的患儿进行脑电图(EEG)检查.分析PVL分级与胎龄、出牛体质量、围生期感染、窒息、脑瘫及语言障碍程度、视听觉障碍、智力及癫痫的相关性.结果 47例患儿中3例运动发育正常,其中完伞性耳聋2例,孤独症1例,余44例均诊断为脑瘫,其中听力障碍24例,视觉障碍19例,其中1例皮质盲,发育商正常仅1例,并癫痼发作11例,其中West综合征2例.按照白质异常信号的范围.脑室扩大及白质减少程度、胼胝体发育情况及有无皮质损害将PVL分为3级.其中Ⅰ级14例,Ⅱ级21例,Ⅲ级12例.围生期感染可导致PVL分级上升(P=0.011);胎龄、出生体质量、窒息与PVL.分级无明显相关性(P>0.05);随着PVL级别的上升,脑瘫、智力低下程度加重(P=0.019、0.000),视觉障碍增多(P=0.024);脑白质减少程度与语言障碍、智力低下、听觉障碍程度及视觉障碍均有相关性(P=0.000、0.000、0.001、0.000);脑室扩大程度与语言发育障碍、智力低下程度及视觉障碍有明显相关性(P=0.000、0.000、0.000);伴随皮质损害时,听觉障碍程度加重(P=0.000);胼胝体发育不良时,脑瘫、语言障碍、智力低下程度加重(P=0.008、0.001、0.000);癫痼的发生与PVL分级及MRI表现无明显相关.结论 减少围牛期感染町减轻PVL程度;PVL影响患儿的运动、语言、视听觉及智力发育,其MRI表现可反映临床及预后,程度越重,预后越差,合并胼胝体发育不良时预后不良.     

早期丰富环境干预对未成熟大鼠脑室周围白质软化脑功能的影响

目的探讨早期丰富环境干预对未成熟大鼠脑室周围白质软化(PVL)损伤后神经行为及生长相关蛋白(GAP-43)表达的影响。方法选择2日龄SD大鼠制作PVL模型,随机分为干预组、非干预组、假手术组、对照组,各40只。假手术组仅分离左侧颈总动脉,不予结扎和缺氧,非干预组和假手术组均饲养于标准环境中,不进行丰富环境干预。干预组于术后第4天行触摸和丰富环境干预,总干预时间为28d。干预结束后行神经行为学检测,同时分别于术后第4、11、18、25、32天取各组大鼠海马脑组织,采用RT-PCR技术检测GAP-43 mRNA表达。结果干预组大鼠于生后5周龄感觉运动功能及学习记忆能力较非干预组明显改善[(悬吊试验:(4.5±1.5)minvs(3.1±0.9)min;斜坡试验:(2.3±0.7)svs(3.9±1.1)s;逃避潜伏期:(4.86±2.94)svs(15.0±11.23)s;空间探索能力:(62.89±8.69)%vs(43.99±8.29)%Pa<0.05]。干预组海马GAP-43 mRNA表达于术后第11、18、25、32天的光密度比值较非干预组明显增高[(3.21±0.45)vs(2.63±0.32);(2.74±0.34)vs(2.47±0.25);(2.14±0.29)vs(1.75±0.19);(1.96±0.25)vs(1.63±0.15)Pa<0.01]。结论早期适度丰富环境干预可增强未成熟大鼠PVL脑功能的恢复,GAP-43增多可能是其脑功能恢复机制之一。     

3-硝基丙酸脑内注射诱导新生鼠脑室周围脑白质软化模型的建立

目的探讨脑内注射3-硝基丙酸（3-NPA）建立新生鼠脑室周围白质软化（PVL）模型的可行性，探索可靠的造模方法。方法新生5d（P5）SD大鼠64只，随机分成NPA与磷酸盐缓冲液（PBS）组，每组32只，脑立体定位仪定位于左侧脑室上方胼胝体，分别注入3-NPA（300mmol／L）和等量PBS，于造模后24h（P6）、48h（P7）、72h（P8）、9d（P14）灌注固定取脑，作HE染色及少突胶质细胞04、髓鞘碱性蛋白（MBP）免疫组织化学染色。结果HE染色显示P6、P7、P8NPA组皮质下及脑室周围白质出现疏松及液化灶，P14出现脑室扩大，脑室指数较PBS组高，有显著性差异（P〈0．01），脑皮质无明显变化；04染色示NPA组阳性细胞较PBS组明显减少，差异有显著性（P〈0．01）；MBP免疫染色示NPA组平均光密度值较PBS组低，有显著性差异（P〈0．05）。结论3-NPA脑内注射诱导新生鼠PVL模型以脑室周围白质损伤为突出表现，皮质无明显改变，可作为疾病研究的可靠模型。     

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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。     

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。     

Cerebral palsy of cystic periventricular leukomalacia in low-birth-weight infants

We studied ultrasound findings and neurodevelopmental outcome of 24 infants weighing 2500 g or less with cystic periventricular leukomalacia. Fourteen infants had symmetrical cysts in the parietal or occipital region (group 1) and 10 had non-symmetrical cysts (group 2). Each infant was followed for more than 4 years of age (mean 5 years and 7 months). Twenty out of 24 (83.3%) children developed cerebral palsy. All of group 1 had cerebral palsy (8 diplegia and 6 ataxic diplegia), while 6 (60%) in group 2 developed cerebral palsy (4 diplegia and 2 hemiplegia). There was a significant difference in the incidence of cerebral palsy and motor ability between the two groups. The size and site of the cyst did not predict cerebral palsy. The presence of symmetrical cysts in the parietal or occipital region is a highly reliablable neurosonographic finding for predicting cerebral palsy.     

Diagnosis and evolution of periventricular leukomalacia: a study with real-time ultrasound

Periventricular leukomalacia is an ischemic lesion in periventricular white matter of premature infants. Hemorrhage into the ischemic area occurs in up to 25% of cases. We report two cases in which the diagnosis of periventricular leukomalacia was made during life with real-time ultrasound scanning. In one case, serial scans demonstrated the evolution of echodense regions, observed in the first 3 days of life, to cystic echolucent areas at 4 weeks. In the second case, periventricular echodense areas did not precede the occurrence of cystic echolucent lesions. This may reflect a more chronic ischemic cerebral insult (consistent with recurrent apnea and bradycardia) rather than a presumed acute episode of cerebral ischemia (with or without secondary hemorrhage) sustained by the first case. Real-time ultrasound scanning is a simple, non-invasive technique with which to document the evolution of periventricular leukomalacia, and thus to define the clinical neurological correlates in the neonatal period.     

Periventricular leukomalacia associated with hypocarbia

We here report a case of periventricular leukomalacia (PVL) associated with hypocarbia which remained even after extubation. The patient had no risk factors affecting PVL development other than hypocarbia. We consider that the irregular tachypnea which remained after extubation might be attributable to overdriving of ventilation of central neurogenic origin. Our patient's clinical course suggests that sodium bicarbonate drip infusion is a very effective way to alter the set point of respiratory neuronal drive of the patient with central neurogenic hyperventilation.     

Periventricular haemorrhage and leukomalacia in extremely low birthweight infants

Forty (49%) of 82 extremely low birthweight (ELBW, <1000 g) infants had periventricular haemorrhage (PVH). Ten (12%) had germinal layer haemorrhage (GLH) alone, 16 (20%) had intraventricular haemorrhage (IVH) and 14 (17%) had intracerebral haemorrhage (ICH). Almost all the cases of PVH had developed by 4 days of age. Small-for-gestational age infants (12% of study population) had a significantly lower incidence and severity of PVH than appropriate-for-gestational age infants. Of 94 infants born between 23 and 28 weeks gestation, 45 (48%) had PVH. The PVH incidence was 60% in those of 23-26 weeks and 38% in those of 27-28 weeks. The hospital survival rate of ELBW infants was 69% in those without PVH and 43% in those with PVH; 70% in GLH alone; 50% in IVH and 14% in ICH. Three survivors developed post-haemorrhage hydrocephalus of whom two required ventriculoperitoneal shunting. Five survivors developed periventricular leukomalacia (PVL) evidenced by cysts identified between 3 and 7 weeks of age. A significant decrease in the incidence of PVH occurred over the study period (67% in 1982, 38% in 1983 and 33% in 1984). This decrease was seen for ail grades of PVH. The reasons for this decreased incidence are still to be ascertained but this trend suggests that improvements in neonatal intensive care have the potential to improve the neurological outcome of more recent ELBW survivors.     

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??Abstract:Objective??Using the skill of head ultrasound to make an early diagnosis for preterm infants with periventricular leukomalacia??PVL????analyze some related risk factors which may result in PVL. Methods??Between Jan. 2006 and Jun. 2009??443 preterm infants were chosen?? who were born in Anhui Provincial Children’s Hospital. All subjects were divided into PVL group??125?? and non PVL group??318????non Cystic PVL group??116?? and Cystic PVL group??9?? by different grades of PVL. The factors of PVL were analyzed by Backward Stepwise Logistic regression. Results??Univariate factor analysis showed?? the difference was significant ??P < 0.05 or P < 0.01??among gestational age?? birth weight?? delivery pattern?? hypothermia?? apnea?? blood sugar?? myocardial enzyme?? postnatal infection?? cAMP receptor protein and albumin between PVL group and non PVL group. Multiple factors Logistic regression showed?? low birth weight and incidence of uterine-incision delivery?? postnatal infection?? higher level of myocardial enzyme and albumin were risk factors of PVL?? and postnatal infection was risk factor of cystic PVL. Conclusion??Low birth weight?? spontaneous delivery?? postnatal infection and high levels of albumin and myocardial enzyme are risk factors of PVL. Preterm infants with postnatal infection have higher incidence of cystic PVL.     

Subependymal pseudocysts: ultrasound diagnosis and findings at follow-up

During a two-year period, subependymal pseudocysts were diagnosed in 24 infants using cranial ultrasound: 8 were located at the external angle of the lateral ventricle and 16 at the caudothalamic notch. Associated congenital anomalies were present in six infants and CMV was isolated in one case. Four of the eight infants with pseudocysts at the external angle were one half of twins. As all but one of the surviving infants with pseudocysts were normal at follow-up (at 3–24 months of age), it is important to make a distinction between pseudocysts and extensive cystic periventricular leukomalacia, as the latter condition invariably leads to cerebral palsy and/or visual impairment.