Brain Injury in Pre-Term Infants
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Brain Injury in Pre-Term Infants

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Dr. Maynard’s presentation on the description of the types of brain injuries in pre-term infants (presented on 3/24/11).

Dr. Maynard’s presentation on the description of the types of brain injuries in pre-term infants (presented on 3/24/11).

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Brain Injury in Pre-Term Infants Brain Injury in Pre-Term Infants Presentation Transcript

  • Brain Injury in Pre-Term Infants Roy Maynard, M.D. March 24, 2011
  • Objectives for Brain Injury in Pre-Term Infants • Identify types of brain injury in pre-term infants. • Appreciate the incidence of Grade 1-IV intraventricular hemorrhages in very low birth weight infants. • Understand the neurodevelopmental implications of Periventricular Leukomalacia in very low birth weight infants. 2 of 74
  • Types of Brain Injury• Periventricular Leukomalacia (PVL)• Severe Intraventricular/Periventricular Hemorrhage (IVH/PVH)• Posthemorrhagic Hydrocephalus• Other patterns of neuronal injury 3 of 74
  • IVH/PVH of the Pre-Term Infant • Epidemiology • Pathogenesis – germinal matrix anatomy – factors: • intravascular • vascular • extravascular – spread of IVH • Diagnosis and Management • Neurodevelopmental Outcomes 4 of 74
  • What is the magnitude of brain injury in pre-term infants? Pre-Term Infants (BW<1500g)No. born in U.S. ………………………..55,000/yr.Survival…………………………………..90%Incidence of: IVH (Grade 3&4)………………………3-21% PVL ……………………………………. 2-5%Morbidity in survivors: Spastic/motor deficits…………………10% Cognitive/behavioral…………………..25-50% 5 of 74
  • Incidence: Grade 3 & 4 IVH Vermont Oxford Network Children’s Minneapolis 25% Occurrence 20 21 1994-2002 15 16 10 11 9 9 8 5 6 4 3 3 No. Patients 38,576 465 46,183 483 50,253 516 59,403 617 194,415 2,081 0 501-750 751-1000 1001-1250 1251-1500 501-1500 Birth Weight (501-1500 grams) 6 of 74
  • Incidence: PVL Vermont Oxford Network Children’s Minneapolis 10% Occurrence 9 1994-2002 8 7 6 5 5 5 4 4 3 3 3 3 2 2 2 2 1 1 No. Patients 38,576 465 46,183 483 50,253 516 59,403 617 194,415 2,081 0 501-750 751-1000 1001-1250 1251-1500 501-1500 Birth Weight (501-1500 grams) 7 of 74
  • IVH/PVH of the Pre-Term Infant • Epidemiology • Pathogenesis – germinal matrix anatomy – factors: • intravascular • vascular • extravascular – spread of IVH • Diagnosis and Management • Neurodevelopmental Outcomes 8 of 74
  • Germinal Matrix (Primary site of IVH/PVH) Arachnoid Villi GM Occipital CP HornMonro 3rd Luschka 4th Magendie Germinal Matrix Choroid Plexus 9 of 74
  • Germinal Matrix• Primitive cellular region ventrolateral to LV – prominent: 26-32 weeks – involuted: term• Contains pluripotential migrating cells – neurons, astrocytes, oligodendroglia• Contains immature blood vessels: – thin walls (lack muscularis layer) – immature cell junctions & basal laminae 10 of 74
  • IVH/PVH of the Pre-Term Infant • Epidemiology • Pathogenesis – germinal matrix anatomy – factors: • intravascular • vascular • extravascular – spread of IVH • Diagnosis and Management • Neurodevelopmental Outcomes 11 of 74
  • Pathogenesis of IVH/PVH Factors• Intravascular – regulation of CBF, BP, Blood volume – platelet-capillary function – blood-clotting function• Vascular• Extravascular 12 of 74
  • Intravascular Factors• Pressure-passive cerebral circulation factors: ↑ blood pressure will increase cerebral blood flow• Increase in central venous pressure will increase cerebral venous pressure• Increase pressure within the brain’s blood vessels may lead to rupture of fragile blood vessel(s) and bleeding – Tracheal suctioning – Pneumothorax 13 of 74
  • Vascular Factors Intrinsic properties of GM vessels• Immature vascular structures – Larger and lack muscle/collagen – Incomplete basal laminae – More susceptible to rupture• More susceptible to hypoxic/ischemic insult – Vascular border zone in GM – Endothelium contain ↑ mitochondria – ↑ need for oxidative metabolism 14 of 74
  • Spread of IVH/PVH• 40% stays in GM (Grade 1 IVH)• 60% enters ventricles (Grade 2 & 3 IVH) – Large IVH → obstructs CSF flow • Aqueduct of Sylvius, Luschka, Magendie • Rapidly progressive hydrocephalus – Small IVH → retards CSF absorption • Obliterative arachnoiditis of basilar cisterns • Slow evolving hydrocephalus• PV Hemorrhagic Infarction (Grade 4 IVH) 15 of 74
  • IVH/PVH of the Pre-Term Infant • Epidemiology • Pathogenesis – germinal matrix anatomy – factors: • intravascular • vascular • extravascular – spread of IVH • Diagnosis and Management • Neurodevelopmental Outcomes 16 of 74
  • Diagnosis and Management Grading IVH/PVH (Papile)• Grade 1: GM hemorrhage only• Grade 2: GM hemorrhage extending into LV without ventriculomegaly• Grade 3: IVH with ventriculomegaly• Grade 4: Intraparenchymal hemorrhage vs. Periventricular hemorrhagic infarction J Pediatr 1978; 92: 529-34 17 of 74
  • Normal Anatomy Arachnoid Villi GM Occipital CP HornMonro 3rd Luschka 4th Magendie Germinal Matrix Choroid Plexus 18 of 74
  • Grade 1 IVH (Blood in GM only) Arachnoid Villi GM Occipital CP HornMonro 3rd Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 19 of 74
  • Grade 2 IVH (Blood in LV without ventriculomegaly) Arachnoid Villi GM Occipital CP HornMonro 3rd Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 20 of 74
  • Grade 3 IVH (Blood in LV with ventriculomegaly) Lateral Ventricle Blood on Arachnoid Ventriculomegaly Villi GM Occipital CP Horn Monro OBLITERATIVE 3rd ARACHNOIDITIS Luschka 4th Germinal Matrix MagendieSlowlyEvolving Choroid PlexusHydrocephalus Blood 21 of 74
  • Grade 3 IVH (Blood in LV with ventriculomegaly) Lateral Ventricle Arachnoid Villi Ventriculomegaly GM Occipital Obstruction CP Horn Monro at Foramen 3rd of Monro Luschka 4th Germinal Matrix MagendieRapidlyProgressive Choroid PlexusHydrocephalus Blood 22 of 74
  • Grade 4 IVH(Periventricular Hemorrhagic Infarction) PVHI Arachnoid Villi v GM Occipital CP HornMonro 3rd Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 23 of 74
  • PV Hemorrhagic Infarction Pathogenesis Germinal Matrix/IVH ↓ PV Venous Congestion ↓ PV Ischemia ↓ PV Hemorrhagic Infarction 24 of 74
  • Begins as Grade 1-2 IVHIVHin rightlateralventricle 25 of 74
  • May Evolve to Grade 3 IVHMassive IVH on right • obstruction at foramen of Monro • unilateral ventricular dilatation Coronal Section 26 of 74
  • Periventricular Hemorrhagic Infarction IVH IVHEarlyEvolvingPVHI Coronal Section 27 of 74
  • Diagnosis and Management Timing of IVH/PVH• 90% occur within first 72H – 50%: <24H – 25%: >24H & <48H – 15%: >48H & <72H• 20-40% progress further – Maximal extension occurs 3-5 days after initial insult Volpe: Neurology of the Newborn: 1995 Saunders 28 of 74
  • Conclusions• Most intracranial pathology in sick pre-term infants is clinically silent.• Severe lesions most often occur in tiniest of pre-term neonates.• Shift toward a delayed presentation of the clinically significant lesions. Arch Pediatr Adolesc Med 2000; 154: 822-826 29 of 74
  • Diagnosis and Management Cranial Imaging of IVH/PVHUltrasonography • Preferred diagnostic technique equivalent resolution portable, practicalCT Scan • Subdural hemorrhageMRI Scan • Posterior fossa lesionsPET Scan • Complicated cerebral lesions 30 of 74
  • Normal Cranial Ultrasound Lateral3rd VentricleVentricle Coronal View 31 of 74
  • Normal Cranial Ultrasound Lateral3rd VentricleVentricle Coronal View 32 of 74
  • Normal Cranial Ultrasound 3rd Ventricle Lateral Choroid Ventricle Plexus Coronal View 33 of 74
  • Grade 1 Intraventricular Hemorrhage (Blood in GM only) Arachnoid Villi GM Occipital CP Horn Monro 3rd Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 34 of 74
  • Grade 1 IVH SEHparasagittal view 35 of 74
  • Acute Subependymal Hemorrhage Bilateral Grade 1 IVH SEH Coronal View 36 of 74
  • Acute Subependymal Hemorrhage Grade 1 IVH SEH CP Left Parasagittal View 37 of 74
  • Grade 2 IVH (Blood in LV without ventriculomegaly) Arachnoid Villi GM Occipital CP HornMonro 3rd Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 38 of 74
  • Grade 2 IVH Echogenic blood fills < 50% of ventricleParasagittal View 39 of 74
  • Grade 2 IVHClot in posteriorright horn Posterior Coronal View 40 of 74
  • Grade II IVHGrade 2 IVH SEH Clot in Posterior Horn on R parasagittal viewParasagittal View 41 of 74
  • Grade 3 IVH (Blood in LV with ventriculomegaly) Lateral Ventricle Arachnoid Villi Ventriculomegaly GM OccipitalObstruction CP Horn Monroat Foramen 3rd of Monro Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 42 of 74
  • Grade 3 IVHLarge blood clot fillingand distending LV Parasagittal View 43 of 74
  • Grade 3 IVH (Blood in LV with ventriculomegaly) Lateral Ventricle Blood on Arachnoid Ventriculomegaly Villi GM Occipital CP Horn Monro OBLITERATIVE 3rd ARACHNOIDITIS Luschka 4th Germinal Matrix MagendieSlowlyEvolving Choroid PlexusHydrocephalus Blood 44 of 74
  • Posthemorrhagic Hydrocephalus Extraventricular Obstruction of CSF From Obliterative Arachnoiditis LV LV LV LV Coronal View 45 of 74
  • Grade III IVH Grade 3 IVH Dilated,Dilated, blood-filledblood-filled frontal hornfrontal horns Coronal View Coronal view 46 of 74
  • Grade 3 IVH Dilated lateral ventricleHemorrhage inLateral Ventricle Parasagittal View 47 of 74
  • Evolution of Grade 3 IVH Hemorrhage filling lateral ventricle body occipital temporalParasagittal View Initial scan 48 of 74
  • Evolution of Grade 3 IVHRetraction Ventricularof IVH clot Dilatation coronal view Coronal View F/U scan weeks later F/U scan weeks later 49 of 74
  • Evolution of Grade 3 IVH Coronal View 50 of 74 F/U scan weeks later
  • Grade 4 IVH(Periventricular Hemorrhagic Infarction) PVHI Arachnoid Villi v GM Occipital CP HornMonro 3rd Luschka 4th Germinal Matrix Magendie Choroid Plexus Blood 51 of 74
  • Evolution of Periventricular Hemorrhagic Infarction Bulging SEH coronal view Coronal View 52 of 74 Day 7 (scan #1) Day 7 (scan #1)
  • Evolution of Periventricular Hemorrhagic Infarction Increasing size of crescentic PVED  PVHI Bulging SEH coronal view Coronal View 53 of 74 Day 7 (scan #2)
  • Evolution of Periventricular Hemorrhagic Infarction Increasing size of crescentic PVED  PVHI coronal view Coronal View 54 of 74 Day 7 (scan #3) Day 7 (scan #3)
  • Evolution of Periventricular Hemorrhagic Infarction Large Porencephalic Cyst Coronal view coronal View 55 of 74 2 Months Later 2 months later
  • Periventricular Hemorrhagic Infarction (9 days) PED Ventricular dilatation IVH Parasagittal View 56 of 74
  • Periventricular Hemorrhagic Infarction (3 weeks of age) Cyst Formation • tissue necrosis • clot retraction Parasagittal View 57 of 74
  • Periventricular Hemorrhagic Infarction (2 months of age) Porencephalic cyst Parasagittal View 58 of 74
  • Periventricular Leukomalacia Periventricular Leukomalacia (PVL) PVL has emerged as the prinicipal form of brain injury in the premature infant 59 of 74
  • What is PVL?1. Death of white matter (WM) in the brain’s Periventricular (PV) region2. Caused by decrease in O2 or blood flow to PV WM area of brainPeriventricular white matter containsnerve fibers that carry messages fromthe brain to the body’s muscles 60 of 74
  • What is PVL?3. Most common Ischemic injury in pre-term infants4. Occurs in Border Vascular Zone • end of arterial distributions5. Diagnostic hallmarks include: • Initial: PV echodensities • Later: PV cystic changes 61 of 74
  • Importance of Diagnosis?Surviving pre-term infants with PVLare at risk for the following: • Cerebral Palsy (CP), • intellectual impairment • visual/hearing disturbances 62 of 74
  • Periventricular LeukomalaciaPathogenesis (3 interacting factors) 1. Periventricular vascular anatomic physiologic factors 2. Cerebral Ischemia and pressure- passive cerebral circulation 3. Maturation-dependent vulnerability of cerebral white matter Oligodendroglial precursors 63 of 74
  • Periventricular Leukomalacia Periventricular Vascular Anatomic Physiologic Factors Short Penetrator Vessels • Basal Penetrator Vessels 64 of 74
  • Clinical Correlates of PVLDiagnostic Methods Clinical Correlates MRI/DWI • Diffuse Cognitive/Behavioral Pre-Oligo Injury DeficitsCranial SpasticUltrasound diplegia• Focal Necrosis 65 of 74
  • Periventricular LeukomalaciaPathogenesis (3 interacting factors) 1. Periventricular vascular anatomic physiologic factors 2. Cerebral Ischemia and pressure-passive cerebral circulation 3. Maturation-dependent vulnerability of cerebral white matter Oligodendroglial precursors 66 of 74
  • Periventricular LeukomalaciaCBF Autoregulation with Maturation 180 Narrow Regulatory 160 Control Window Normal Regulatory CBF (% of normal) 140 Control Window 120 100 80 60 40 Premature Child Newborn 20 0 0 10 20 30 40 50 60 70 80 MABP (mmHg) 67 of 74
  • PVL: Diagnosis & Management Coronal View Coronal View1-week-old pre-term infant without 1-week-old pre-term infant. Peri-PVL. The periventricular echo- ventricular echotexture is increased,texture is normal. consistent with early changes of PVL. 68 of 74
  • PVL: Diagnosis & Management Parasagittal View PVL Coronal View Cysts3-week-old pre-term infant. Multiple periventricular cyststypical of established periventricular leukomalacia. 69 of 74
  • Diagnosis and Management Postnatal Treatment• Postnatal resuscitation (NICU)• Maximize risk for fluctuation CBF & BP – avoid unnecessary BP, suctioning, rapid infusions, pneumothorax – avoid ventilator asynchrony• Correct coagulation disturbances• Indomethacin• Antioxidants (SOD)• Management of post-hemorrhagic hydrocephalus 70 of 74
  • IVH/PVH of the Pre-Term Infant • Epidemiology • Pathogenesis – germinal matrix anatomy – factors: • intravascular • vascular • extravascular – spread of IVH • Diagnosis and Management • Neurodevelopmental Outcomes 71 of 74
  • Neurodevelopmental Outcome Classification 72 of 74
  • Neurodevelopmental Outcome 23-26 weeks GA (552 infants: 1986-1998) -- Mean Age: 48.6 months Normal Mild-Mod. Impaired Severely Impaired% Occurrence 80 79 70 70 66 60 64 50 40 39 30 31 31 20 21 17 18 18 10 12 13 11 11 0 Normal U/S Grade 1&2 IVH Grade 3 IVH Grade 4 IVH PVL 73 of 74
  • Q&AThank you for attending! 74 of 74