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8
DIAGNOSTIC AND EVOLUTIONARY ASPECTS
OF INTRAVENTRICULAR HEMORRHAGE
IN PRETERM INFANTS
Mariana Boia1,2, Aniko Maria Manea1,2, Delia Maria Nicoara1
1
Louis Turcanu Childrens Emergency Hospital, Timisoara
2
Victor Babes University of Medicine and Pharmacy, Timisoara
ABSTRACT
Objectives. The aim of this study was to asses the risk factors, the grades of severity, and the complications
associated with intraventricular hemorrhage.
Methods. The retrospective study, conducted over a period of five years in the Neonatology Clinic Timisoara,
included 514 preterm infants with specific sonographic signs of intraventricular hemorrhage (IV).
Results. The incidence varied indirectly proportional to gestational age, being higher among preterm VLBW
and ELBW. The main incriminated risk factors were: acidosis, respiratory distress syndrome, hypoxia and hy-
percarbia. The distribution of cases based on the degree of severity was as follows: grade I, 204 patients
(39.68%), grade II, 142 patients (27.62%), grade III, 91 cases (17.70%) and grade IV, 77 cases (15%). Most
cases were asymptomatic, being diagnosed based on routine ultrasound. 36% had saltatory evolution, with
progressive deterioration of neurologic status, altered muscle tone and respiratory distress. 21% had cata-
strophic evolution with bulging fontanelle, projectile vomiting, seizures, decerebrate posturing, and apneic
spells. Upon follow-up at 6 months, the outcome of the sonographic signs depended on the severity of the
bleed, 28.9% cases presented complete resorption, 35% germinal matrix cyst and 25.87% ventriculomegaly.
Conclusions. Transfontanellar ultrasound was the diagnostic method of choice. Most intraventricular bleed-
ings were diagnosed among VLBW and ELBW infants, and were severe forms of disease. Mild and medium
forms of disease had good outcome, with partial/ complete resolution of the ultrasonographic signs. Posthemor-
rhagic obstructive hydrocephalus was the most common complication.
Coresponding author:
Mariana Boia, Louis Turcanu Childrens Emergency Hospital, 2 Dr. Iosif Nemoianu Str., Timisoara
RESULTS
Cranial ultrasonography was the elective diag-
The study included 514 cases out of 3017 pre- nostic investigation, hemorrhagic lesions having as
term infants admitted between 2007-2012, the inci- ultrasonographic correspondent increased echo-
dence of the disease being 17.03%. The incidence genicity in the periventricular region.
was inversely related to gestational age, higher
among preterm infants with very low and extreme-
ly low birth weight (64%, respectively 78%).
14% of cases presented intrapartum risk factors
such as: acute hipoxia, complicated labour, precipi-
tate delivery; postnatal factors included: acidosis,
hypoxia, hypercarbia and respiratory distress syn-
drome.
the intraventricular haemorrhage (23); the venous with saltatory evolution had subacute onset, in 1-3
pressure can be increased by compression of the days, with hypotonia, nystagmus and posture disor-
head during labour (24), respiratory distress, tra- ders. The clinical picture of the catastrophic cases
cheal suctioning (25), high peak inspiratory pres- included respiratory disorders (apneic spells, incre-
sure (26). IVH occurs almost exclusively in the first ased oxygen demand), seizures, somnolence, dece-
three days of life (27). rebrate posture, bulging anterior fontanelle, projec-
Recent studies have demonstrated a significant tile vomiting, protrusion and mastication movements,
correlation between early red blood cells (RBW) fixation of pupils, hypotension and bradycardia, su-
transfusions and severe IVH. This may be due to dden decrease of hemoglobin/hematocrit and glu-
the lack of deformability of the transfused RBC, cose metabolism disorders. Cases with marked
that can clog the capillary flow, thereby increasing deterioration of general wellbeing disclosed ultra-
the pressure upstream and leading to capillary rup- sonographic changes: the big hiperreflectogenic
ture (28-30). Repeated early RBC transfusions in- lessions from inside the lateral ventricles and the
hibit the erythropoietin synthesis, critical neuropro- cerebral parenchyma were followed by major neu-
tective factor (31-32). Therefore, efforts of reducing ropathological lesions: multicystic encephalomala-
the necessity of early RBC transfusions (by delayed cia, porencephaly, cerebral atrophy and evolutive
cord clamping (33), or cord milking (34), and ad- hydrocephalus.
ministration of recombined erythropoietin (35)
may reduce the incidence of IVH severity by up to CONCLUSIONS
50%. 7 percent of the studied preterms received
blood tranfusions in the first days of life. Cranial ultrasonography was the method of
Germinal matrix hemorrhage and extension of choice in establishing the correct diagnosis.
the hemorrhage into the lateral ventricles without The prevalence of IVH was 17.03%, being high-
hydrocephalus (first and second degree IVH), al- est among VLBW and ELBW preterms, wich pre-
though having a high incidence (39,68, respective- sented severe forms of disease. Although ultraso-
ly 27,62%), were asymptomatic or accompanied by nography, a rapid and simple diagnostic method,
discrete symptomatology with good neurological has certain advantages compared to other types of
outcome. This is the reason why all preterm infants imagistic methods (dynamic evaluation, prompt
< 30 weeks should be screened by cranial ultraso- recognition of complications, lower costs), in cur-
nography at 7-14 days postnatal life and at 36-40 rent medical practice, cerebral MRI or CT are nec-
weeks postmenstrual age (36). in the absence of essary in cases that need ventriculoperitoneal shunt.
signs of intracranial pressure and of seizures, the The mild and moderate forms of disease had sat-
first cranial ultrasound was performed between 3-7 isfactory outcome, with complete/partial remission
days of life among the studied lot. of ultrasonographic signs.
The prevalence of severe disease was similar to Posthemorrhagic obstructive hydrocephalus
the one from the literature (25% third degree, and was the most common complication, in 29,50% of
15% fourth degree IVH). in almost half of the cases (26,04% of preterms with third degree IVH,
cases the ultrasonographic lesions had no clinical and 58,33% of those with forth degree IVH).
correspondent. The symptomatology of the cases
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STUDII CAZUISTICE
8
ASPECTE DE DIAGNOSTIC I EVOLUIE ALE
HEMORAGIEI INTRAVENTRICULARE LA
PREMATURI
Mariana Boia1,2, Aniko Maria Manea1,2, Delia Maria Nicoar1
1
Spitalul Clinic de Urgen pentru Copii Louis urcanu, Timioara
2
Universitatea de Medicin i Farmacie Victor Babe, Timioara
REZUMAT
Obiective. Lucrarea de fa are ca scop analiza factorilor de risc, a gradelor de severitate i a complicaiilor
asociate hemoragiei intraventriculare.
Material i metod. Studiul retrospectiv, pe o perioad de 5 ani, analizeaz 514 cazuri de prematuri cu semne
ecografice specifice de hemoragie intraventricular tratai n Clinica de Puericultur i Neonatologie Timioara.
Rezultate. Incidena bolii a variat indirect proporional cu vrsta de gestaie, fiind mai crescut n rndul
prematurilor VLBW i ELBW. Principalii factori de risc incriminai au fost acidoza, sindromul de detres
respiratorie, hipoxia i hipercarbia. Repartiia cazurilor pe grade de severitate a fost urmtoarea: gradul I 204
cazuri (39,68%), gradul II 142 cazuri (27,62%), gradul III 91 cazuri (17,70%) i gradul IV 77 de cazuri
(15%). Majoritatea cazurilor au fost asimptomatice, fiind diagnosticate n urma efecturii de rutin a ecografiei
TF. 36% au avut evoluie saltatorie, cu deteriorarea progresiv a statutului neurologic, alterarea tonusului
muscular i tulburri ale frecvenei respiratorii. 21% au prezentat evoluie catastrofal, cu bombarea fontanelei
anterioare, dehisciena suturilor craniene, vrsturi n jet, convulsii, postur de decerebrare i perioade de
apnee. Evoluia la 6 luni a formaiunilor hiperreflectogene a variat n funcie de stadiul evolutiv al bolii, 28,9%
dintre cazuri prezentnd resorbtie complet, 35% chist n matricea germinal i 25,87% ventriculomegalie.
Concluzii. Ecografia transfontanelar a fost metoda de elecie n stabilirea diagnosticului pozitiv. Ponderea mai
mare a hemoragiei IV a fost ntlnit n rndul prematurilor VLBW i ELBW, n rndul crora au predominat
formele severe de boal. Formele uoare i medii de boal au avut evoluie bun, soldat n majoritatea
cazurilor cu remisiunea parial/complet a semnelor ecografice. Hidrocefalia obstructiv posthemoragic a
fost cea mai frecvent complicaie.
Adresa de coresponden:
Mariana Boia, Spitalul Clinic de Urgen pentru Copii Louis urcanu, Str. Dr. Iosif Nemoianu nr. 2, Timioara
encefalograma, computer tomografie i rezonan 63% dintre prematuri s-au nscut pe cale natural,
magnetic nuclear cerebral) prognosticul pe ter- 47% prin cezarian.
men lung. n formele severe de afectare cerebral Prevalena hemoragiei intraventriculare a fost
prognosticul imediat al bolii, respectiv gradul de mai mare n rndul prematurilor VLBW 64,21%
supravieuire, variaz n funcie de factorii de risc i ELBW 78,5%, comparativ cu restul cazurilor
cumulai, de detresele vitale asociate i de gradul (25,19%).
de imaturitate cerebral. n ceea ce privete tabloul clinic, majoritatea ca-
zurilor au fost asimptomatice (43%), fiind diagnos-
MATERIAL I METOD ticate n urma efecturii de rutin a ecografiei TF.
Un procent de 36% au avut evoluie saltatorie, cu
Studiul a fost efectuat retrospectiv pe o perioad deteriorarea progresiv a statutului neurologic, al-
de 5 ani (ianuarie 2007 decembrie 2012) n Cli- terarea tonusului muscular, tulburri ale frecvenei
nica de Puericultur i Neonatologie Timioara. Au respiratorii i ale micrilor globilor oculari. Restul
fost inclui n studiu nou-nscuii prematuri care au de 21% au prezentat un tablou clinic catastrofal, cu
prezentat semne ecografice specifice de hemoragie bombarea fontanelei anterioare, dehisciena suturi-
intraventricular. Criteriile de excludere au fost: lor craniene, vrsturi n jet, plafonarea privirii, nis-
malformaiile cerebrale, bolile metabolice, infeciile tagmus, micri de masticaie, convulsii, postura de
sistemului nervos central i sindroamele genetice. decerebrare, perioade de apnee i tulburri de ritm
Metoda de elecie pentru stabilirea diagnosticului a cardiac.
fost ecografia transfontanelar, efectuat ca test
screening. S-a utilizat sonda sectorial de 5 MHz,
examinarea efectundu-se n dinamic.
REZULTATE
Lotul studiat a cuprins 514 cazuri dintr-un nu-
mr total de 3.017 nou-nscui prematur n perioada
2007-2012, incidena bolii fiind de 17,03%. Inci-
dena bolii a variat indirect proporional cu vrsta
de gestaie, fiind mai crescut n rndul prematurilor GRAFICUL 2. Evoluia clinic
VLBW (very low birth weight) i ELBW (extremely
low birth weight): 64%, respectiv 78%. Investigaia paraclinic de elecie a fost ecografia
Factorii de risc incriminai au fost multipli, n transfontanelar, leziunile hemoragice avnd drept
14% dintre cazuri fiind cert incriminai factori in- corespondent ultrasonografic formaiuni hiperreflec-
trapartum (hipoxia acut la natere, nateri labo- togene la nivelul matricei germinale, n interiorul
rioase, travaliu precipitat); factorii posnatali au in- ventriculilor laterali, iar n formele severe de boal
clus: acidoza, hipoxia, hipercarbia i sindromul de i n parenchimul cerebral adiacent.
detres respiratorie.
enterocolita ulceronecrotic
pneumotorax
patologie utero-placentar
nateri precipitate
asfixie intrapartum
hTA
administrare NaHCO3
resuscitare nn prelungit
convulsii
hipercarbie
hipoxemie
sindrom de detres respiratorie
acidoz
FIGURA 3.
CT cerebral
hemoragie IV
FIGURA 2. ETF: hemoragie IV grad IV grad IV
(seciune coronar posterioar)
FIGURA 4.
CT cerebral
hemoragie IV
grad IV
crize de apnee-cianoz
convulsii
paralizie cerebral
leucomalacia periventricular
bral se efectueaz de rutin la cazurile care necesit Hidrocefalia obstructiv posthemoragic a fost
montare de valva de drenaj ventriculo-peritoneal. cea mai frecvent complicaie ntlnit la pacienii
Formele uoare i medii de boal au avut o evo- cu forme severe de boal, avnd o prevalen de
luie bun, soldat n majoritatea cazurilor cu remi- 58,33%.
siunea parial/complet a semnelor ecografice.