early identification of neurological abnormalities in the nicu infant max wiznitzer, m.d. division...
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Early Identification of Neurological Abnormalities in the NICU Infant
Max Wiznitzer, M.D.
Division of Pediatric NeurologyRainbow Babies and Children’s HospitalCleveland, Ohio
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Common Problems in the NICU
PrematurityIVH=Intraventricular HemorrhagePVL=Perventricular Leukomalacia
Neonatal encephalopathyHypoxic-IschemicInfarction
Seizures
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Intraventricular Hemorrhage
CausationPretermTerm
PresentationCatastrophic- Fortunately rareSaltatory-More common; stuttering evolution Silent-Most common
Grading severity
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*GRADING OF IVH (per J. Volpe):
-Grade I: Bleeding confined to periventricular area (germinal matrix)
-Grade II: Intraventricular bleeding (10-50% of ventricular area on sagittal view)
-Grade III: Intraventricular bleeding (>50% of ventricular area or distends ventricle)
-Intra-parenchymal echodensity (IPE) represents periventricular hemorrhagic infarction and is often referred to as Grade IV IVH.
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*OUTCOME and PROGNOSIS:
Progressive Ventricular Neurological
Severity of IVH Mortality (%) Dilatation (%) Sequelae (%)
Grade I 5 5 5
Grade II 10 20 15
Grade III 20 55 35
IPE 50 80 90
(In general, outcomes with IVH Grade I or II are similar to infants without IVH.)
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*Clinical FeaturesCatastrophic Syndrome
Evolves in minutes to hoursDeep stupor or comaRespiratory arrhythmia, hypoventilation, apneaGeneralized tonic seizures, “Decerebrate” posturingEyes- Pupils fixed, no Doll’s eyeFlaccid quadriparesis
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*Clinical FeaturesCatastrophic Syndrome (cont.)
Falling Hematocrit
Bulging Anterior Fontanelle
Hypotension, Bradycardia
Temperature derangements
Metabolic acidosis, DIC, Jaundice
Abnormalities of glucose and water homeostasis (Hyperglycemia, SIADH)
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*Clinical Features
Saltatory syndromeStuttering evolution : hours to dayAltered level of consciousnessAltered motility (usually decreased )HypotoniaAbnormally tight popliteal angle (84% if IVH, 10% if no IVH)Abnormal eye position / movementRespiratory disturbance
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*Clinical Features
Clinically silent syndrome:Careful, serial clinical assessments will miss 25-50% of infants with IVHMost valuable sign is unexplained fall of Hematocrit or failure of Hematocrit to rise after a transfusionMore common with smaller bleeds
(with associated better prognosis )
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Intraventricular Hemorrhage
ConsequencesHydrocephalusGerminal matrix damageHemorrhagic infarction
AssessmentUltrasoundMRIEvoked potentials
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Neonatal EncephalopathyPeriventricular LeukomalaciaHypoxic-ischemic encephalopathy
Near total/profound asphyxiaProlonged partial asphyxia
Infarction (stroke)ArterialVenous
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Hypoxic-ischemia Encephalopathy
DiagnosisClinical evolution
Impact and timing of cell deathNecrosisApoptosis
Radiologic assessmentUltrasoundCT scanMRI
Use of EEG
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Use of Technology for Early Identification of ProblemsMRIEvoked potentialsEEGNear Infrared SpectroscopyExamination
Analysis of Angles (Amiel-Tison)Assessment of general movements (Prechtl)