Neonatal Neurology



Neonatal Neurology





Intracranial Hemorrhage



  • Full term: (a) supratentorial subdural (rare; difficult deliveries); (b) primary subarachnoid of venous origin (focal seizures, benign course).


  • Premature (≤32 weeks of gestation): parenchymal, periventricular origin.


Periventricular-Intraventricular Hemorrhage (IVH)

Incidence 10–20%, especially in very small premature newborns (<900 g).


Pathophysiology

Arise in vascular germinal plate, near caudate and foramen of Monro (grades I to III), or brain parenchyma (grade IV).



  • Grade I: blood confined to germinal plate.


  • Grade II: extension into ventricle.


  • Grade III: blood filling ventricle, causing distension.


  • Grade IV: blood in brain parenchyma.


  • Source of hemorrhage (artery or vein) unclear.


Clinical Features



  • Grade I: usually asymptomatic.


  • Grade II: nonspecific irritability or lethargy.


  • Grade III: usually symptoms of hydrocephalus.


  • Grade IV: focal signs and mass effect; ≥50% mortality. Severe apnea, bradycardia, disconjugate eye movements, pupils fixed, extensor posturing, opisthotonos, clonic limb movements. Death may occur within hours.



Investigations

Hematocrit may drop by 20%.



  • CSF: many red blood cells; protein 250 to 1,200 mg/dL, but CSF may be normal.


  • Cranial ultrasound: shows site of blood in parenchyma and ventricles, ventricular size, shifts of major structures.


Treatment and Prognosis



  • Grades I, II: no treatment. 80% to 90% survival rate without overt neurologic abnormality, but long-term learning and behavior disorders common.


  • Grade III: no specific treatment if static or reversible ventriculomegaly with normal pressure. If progressive hydrocephalus, consider shunting procedures. Permanent shunts (ventriculoperitoneal) associated with frequent complications in small infants; temporary shunts usually placed in interim (e.g., ventriculo-subgaleal shunt). Overall, 40% incidence of future cerebral palsy and mental retardation.


  • Grade IV: high mortality; morbidity proportional to size of parenchymal hemorrhage.


Periventricular Leukomalacia (PVL)

Occurs in 10% of surviving infants with birth weight <1500 g; 50% of those with birth weight 500–1000 g.



  • Imaging: cysts in periventricular white matter (cranial ultrasound); hypomyelination in centrum semiovale, ventricular enlargement due to decreased white matter volume (MRI).


  • Clinical manifestations: spastic diplegia with damage to corticospinal fibers to the legs.


Hypoxic-Ischemic Encephalopathy (HIE)

Incidence 2 to 4 per 1,000 births. Can occur despite optimal obstetric management.



Pathology and Pathophysiology

Lesion location varies with gestational age. Preterm newborns: periventricular region, centrum semiovale. After 36 weeks of gestation: cerebral gray matter, basal ganglia, brainstem, cerebellar Purkinje cells.



  • Causes: abruptio placenta, uterine rupture, placental or umbilical cord dysfunction.

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Jul 27, 2016 | Posted by in NEUROLOGY | Comments Off on Neonatal Neurology

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