早产儿脑损伤诊治新进展课件.ppt

1、1232005年，中华医学会儿科学分会新生儿学组对我国进行大范围的早产儿流行病学调查1：19.70%7.80%新生儿科住院患儿中早产儿产科出生的新生儿中早产儿发生率复旦大学建立中国新生儿协作网一出生新生儿数据库，进行调查分析1：活产出生新生儿106078例，其中早产儿10498例，早产儿总发生率9.90；东北、华北、西北地区早产儿发生率低于10，而华东、华中、华南、西南地区的早产儿发生率超过10，在10.04一12.46之间。1李娜,刘丽红.早产儿临床流行病学研究现状J.国际儿科学杂志,2016,43(7).456Volpe,J.J.(2009).Brain injury in prematu

2、re infants:a complex amalgam of destructive and developmental disturbances.Lancet Neurology 8(1):110-124.大约在10周的时候底板层开始出现、丘脑传入神经侵入底板、底板的尺寸开始增大底板出现大量的丘脑传入神经，在底板上形成谷氨酸能和GABA能神经元突触、轴突快速生长，特别是在脑周区域（投影、连合、协作)丘脑传入神经进入大脑皮层、胼胝体（连合）和联合体轴突进入底板、底板达到最大胼胝体（连合）和联合体的神经纤维进入大脑皮层、底板层逐渐减小89Bayless,S and J.Stevenson(20

3、07).Executive functions in school-age children born very prematurely.“Early Human Development83(4):247-254.采用常规方法治疗的130位患儿（排除具有明显缺陷的），在6-12岁这个年龄段，IQ和执行力评分与正常儿童相比偏低。101112每每1000例存活新生儿的脑瘫发生率例存活新生儿的脑瘫发生率胎 龄（周）3031-3233-3435-3637-4142+010100131415161718192021一、一、22一、一、2324 252627282930311 1、脑血流的波动、脑血流的波

4、动振动、移动，疼痛、挣扎振动、移动，疼痛、挣扎不正确的气管内吸引不正确的气管内吸引2 2、脑血流增加、脑血流增加 快速扩容，高碳酸血症，惊厥，低血糖快速扩容，高碳酸血症，惊厥，低血糖3233低碳酸血症低碳酸血症机械通气早产儿，机械通气早产儿，PVLPVL发生率发生率38-60%38-60%341、宫内缺氧、宫内缺氧2 2、出生时窒息、出生时窒息3 3、反复呼吸暂停、反复呼吸暂停351 1、心力衰竭、心力衰竭2 2、休克、休克3 3、脑血管收缩、脑血管收缩4 4、心动过缓、心动过缓5 5、心脏骤停、心脏骤停36373839Wu,et al.2002,Ment Retard Dev Disabil

5、 Res Rev404142Volpe,J.J.(2009).Brain injury in premature infants:a complex amalgam of destructive and developmental disturbances.Lancet Neurology 8(1):110-124.Figure2:Mainneuronal/axonalstructuresaffectedinprematureinfantswithperiventricularleukomalaciaFigure1:Cysticandnon-cysticperiven tricular leu

6、komalacia(PVL)with perivent ricular haemorrhagicinfarction(PHI)444546474849505152535455565758596061626364Objective:To compare rmortality and neurologic outcome of term neonates with HIE admitted to our NICUduring two time periods,before and after introduction of the therapeutic controlled hypothermi

7、a.Patients and methods:41 newborns(period 1:2005-2007)and 20 newborns(period 2:2008-2010)wererespectively studied.Anoxo-ischemic criteria were similar and neurological criteria used the Sarnat scoring.Infants with moderate or severe HIE(Sarnat 2 or 3)were treated with therapeutic hypothermia in peri

8、od 2.Results:Mean gestational age(38.6 vs 38.5 weeks),outborn neonates(83%vs 95%)and mean arrival timein the unit(3.4 vs.4.1 hours of life)were comparable.Mortality(44%vs 25%)and poor outcome(death orsignificant neurologic disability)(48.7%vs.40%)decreased in the period 2 and normalised neurologicex

9、amination at seven days of age was more frequent in this period(44%vs.60%).Survival with normaloutcome or minor neurologic sequelae was similar during the two periods:91%vs 80%at the median age of42 months vs 12.1 months.Conclusion:Introduction of controlled therapeutic hypothermia for term HIE neon

10、ates decreased mortality without increasing short term major neurological neurodevelopmental disability in survivors.Initial neurologic evaluation with EEG or aEEG may improve our criteria for hypothermia.1中国医师协会新生儿专业委员会.早产儿脑损伤诊断与防治专家共识J.中国当代儿科杂志,2012,14(12):883-884.2 Marcoux,M.O.,et al.(2011).Hypox

11、ic Ischemic Encephalopathy in the Newborn:Better Survival and Prognosis with Protective Controlled Therapeutic Hypothermia.Pediatric Research 70:189-189.65u 胎龄32周，体重1.5kg早产儿，男女不限；u 对照组：常规治疗；u 干预组：入组后在常规治疗基础上纠正胎龄30-32周开始，每日肌肉注射（恩经复18g），连续给药28天结束治疗；u 用法用量：每支（恩经复）用0.5ml注射用水稀释后按剂量18g/d给药，1次/日肌肉注射，每次交替变更

12、注射部位（左右股外侧肌肉）。660.160.04足月儿对照组0.150.04早产儿对照组0.4180.879 0.150.05早产儿干预组豆状核 0.160.04足月对照0.150.10早产儿对照组0.8730.14 0.150.04早产儿干预组枕叶白质0.130.05足月儿对照组0.110.03早产儿对照组0.0253.80 0.130.36早产儿干预组额叶白质0.420.07足月儿对照组 0.410.07早产儿对照组0.0045.78 0.460.07早产儿干预组内囊后肢P PF Fs s组别组别部位部位67三组间各三组间各ROIROI区区FAFA值比较值比较68早产儿对照组早产儿对照组早

13、产干预月组早产干预月组足月对照组足月对照组69x部位部位组别组别x xs sF FP P内囊后肢早产儿干预组1.151.123.960.0228*早产儿对照组1.140.09足月对照1.100.06额叶白质早产儿干预组1.850.2924.290.000*早产儿对照组 1.770.26足月对照1.500.17枕叶白质早产儿干预组1.620.2118.690.000*早产儿对照组1.600.23足月对照1.400.11豆状核早产儿干预组1.270.1513.0710.000*早产儿对照组1.240.10足月儿对照组1.160.0770 x三组间各三组间各ROIROI区区ADCADC值值 71x早

14、产对照组早产对照组早产干预组早产干预组足月对照组足月对照组72总发育商社会交往语言精细动作大运动适应性140.00120.00100.0080.0060.0040.0020.000.00平平均均发发育育商商对照组实验组 两组间纠正月龄两组间纠正月龄3 3月时发育商比较月时发育商比较 干预组25人对照组21人结论：鼠神经生长因子可以促进早产儿深部及周围脑白质髓鞘化成熟结论：鼠神经生长因子可以促进早产儿深部及周围脑白质髓鞘化成熟73结论：早产儿新生儿期应用鼠神经生长因子，有助于促进神经细胞结论：早产儿新生儿期应用鼠神经生长因子，有助于促进神经细胞生长发育、优化早产儿脑功能生长发育、优化早产儿脑功能74结论：早产儿新生儿期应用鼠神经生长因子，有助于促进神经细胞结论：早产儿新生儿期应用鼠神经生长因子，有助于促进神经细胞生长发育、优化早产儿脑功能生长发育、优化早产儿脑功能757677787980818283