S U R V I V O R S O F I N T R A C R A I M I A L H E M O R R H A G E ( I C H ) f |
U. v. Loeu/enich, Cl. Birkle
I n t r a c r a n i a l Hemorrhage is .one of the most common causes of d e a t h in n e u b o r n and in p r e m a t u r e babies. W i t h improving Neo-
natal I n t e n s i v e Care more and more i n f a n t s are able to survive ICH, but the quality of survival does not seem to be encoura- ging (2, 3). On the other h a n d , uue f o u n d that about 40 % of our p a t i e n t s surv/iving clinically diagnosed ICH never shoiyed
any a b n o r m a l i t y . M a t e r i a l :
From 1972 to 1976 43 n e u b o r n and p r e m a t u r e i n f a n t s iuho sur- v/iv/ed ICH luere t r e a t e d in our Neujborn I n t e n s i v e Care U n i t . 27 i n f a n t s , i.e. 63 ± 13 % (90 % - c o n f i d e n c e r ä n g e ) tuere p r e - m a t u r e u/ith a gestational age of 36 u/eeks p . m . pr less, the re- mainder of 16 had a gestational age of 37 to 40 lueeks p . m . . On-
set of Symptoms was seen in 18 babies (42 ± 14 %} d u r i n g the second day of l i f e , s i g n i f i c a n t l y more ö f t e n than d u r i n g all other days ( I s t to 30s), see Fig. 1.
50 - 40 -
30 - 20 - 10 - 0 -
Fig. 1:
Gipset, of Symptoms of I C H . d = day.
L e n g t h of the bars in- d i d a t e s 90 % - c o n f i - dende r ä n g e ,
also in the folloiuing f i g u r e s .
1. 2. 3. 4. 5. 7. & 9. >9. d
33 out of 43 i n f a n t s had blood stained c e r e b r o s p i n a l f l u i d ( C S F ) , i.e. 77 12 %. If bloody CSF uuas f o u n d by l u m b a r punc- t u r e , a c i s t e r n a l tap iuas added to e x c l u d e iatrogenic bleeding.
27 i n f a n t s (63 ± 13 %} shou/ed a sudden drop of h e m o g l o b i n - c o n c e n t r a t i o n ( H b ) in the c a p i l l a r y blood of at least 3 g / dl ujithin one d a y , 31 b a b i e s (72 12 %) had c o n v u l s i o n s , 27
(63 13 %) s u f f e r e d f r o m apneic spells, and 17 (40 i 13 %) developed m a r k e d h y p e r e x c i t a b i l i t y , see Fig. 2. If CSF was not f o u n d to be blood stained, a sudden drop of Hb t o g e t h e r lyith
at least tujo of the n e u r o l o g i c a l S y m p t o m s m e n t i o n e d above .ujere challenged b e f o r e m a k i n g the diagnosis of I C H .
Follouj up e x a m i n a t i o n s luere done by staff m e m b e r s d u r i n g our consultation h o u r s f o r high risk i n f a n t s . Only a feu; babies
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100 -
50
J
Fig. 2:
Frequency of Symptoms of ICH.
CSF = blood stained ce- rebrospinal fluid.
Hb = sudden drop of he- moglobin - concentration
in capillary blood.
Con = convulsions.
Ap = apneic spells.
Hy = marked hyperexci- tability.
CSF Hb Con Ap Hy
ujere follou/ed by thair ouin pediatricians. Final judgment about the outcome of the i n f a n t was made ujhen the i n f a n t was at least one year old. All judgments ujere based on the biological age, i.e. the age of the i n f a n t ujas reduced to the time after a ges- tation of 40 u/eeks p . m . .
Results:
Out of our 43 survivors of ICH 6 i n f a n t s (14 i 10 %} shoujed severe neurologic defects, including marked cerebral palsy, impaired mental d e v e l o p m e n t , or microcephalus. Amazingly, no case of hydrocephalus was f o u n d .
6 other i n f a n t s ujere detected to s u f f e r from mild neuromotor handicap. In 14 i n f a n t s (33 ± 13 %} uue sau/ transitory neurolo- gic d e f e c t s , such äs prolonged presistence of primitive re- flexes, slight cerebral paresis of one limb, or retardation of dev/elopmental milestones. All these troubles disappeared u/ithin some months u n d e r physiotherapy, sometimes also ujithout any t r e a t m e n t .
17 survivors (40 t 13 ^) never shouied any abnormality (Fig. 3).
These results do not shoui any correlation \uith the severity of Symptoms d u r i n g the neonatal period.
The p a t t e r n of neurologic damage uuas the folloujing one (Fig. 4):
Quadriplegia was f o u n d in 7 (16 10 %} of the survivors, hemi- paresis in 5 (12 ± 9 %}. Most of the abnormal i n f a n t s , namely 14 (33 i 13 %} shoujed mild neuromotor impairments ujithout any characteristic p a t t e r n .
Discussion:
Our folloiü up study of the" 43 survivors of ICH from our IMeui- born I n t e n s i v e Care Unit from 1972 to 1976 shoius that the qua- lity of survival is not at all äs catastrophic äs uje had assu- med from the previous available literature. On the other hand the rate of severly handicapped i n f a n t s is h i g h e r than the ave- rage f o u n d in p r e m a t u r e l y born i n f a n t s (revieuj of the recent l i t e r a t u r e s. 1) and even higher than in survivors of neonatal m e n i n g i t i s (5, 6: 8 to 9.^.)·
Our study is limited in tiuo respects:
1. Clinical diagnosis of ICH does not allouj any Interpretation
about localisation and size of b l e e d i n g . NG d i f f e r e n t i a t i o n is
possible betujeen subarachnoid and i n t r a v e n t r i c u l a r hemorrhage.
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50 H
40 -
30 -
20 -
10 -
0 -l sh
mh th
Fig. 3:
Frequency of sequelae a f t e r I C H . sh = severe h a n d i c a p . mh = mild handicap.
th = t r a n s i t o r y h a n d i c a p . 0 = no sequelae.
50 H
40 "
30 -
20 -
10 -
0 J TP HP UP
Fig. 4:
F r e q u e n c y of d i f f e r e n t pat- t e r n s of n e u r o l o g i c sequelae of I C H . TP = q u a r d r i p l e g i a . HP = h e m i p a r e s i s . UP = un- characteristic cerebral pal- sy ( " f o r m e s f r u s t e s " ) ·
0 = no h a n d i c a p . 2. Long term follouu up e x a m i n a t i o n s tuere not made.
I n f o r m a t i o n about localisation and extension of ICH may only be gained by means of c o m p u t e r i z e d t d m o g r a p h y of the c r a n i u m ( C T ) . It seems that r o u t i n e use of CT ujill detect by f a r mgre cases of ICH than clinical diagnosis alone: R e c e n t l y a coopera- tive study iLas u n d e r t a k e n by the American Society f o r P e d i a t r i c R e s e a r c h : 633 p r e m a t u r e i n f a n t s ujith b i r t h lyeights beloiu 1,500 grams luere e x a m i n e d ; 280 (44 %) had signs of ICH in the CT - scan. 80 i n f a n t s out of 121 (66 %) s u r v i v e d ICH ( 4 ) . There- f o r e one might conclude that only more severe f o r m s of ICH can be diagnosed c l i n i c a l l y . On the other hand it may be of parti- c u l a r interest to get I n f o r m a t i o n about the p r o g n o s i s of these latter f o r m s \uhich can be diagnose'd e w e r y i u h e r e .
A l t h o u g h ue do not have any knoiuledge about the long term pro- gnosis of our s u r v i w o r s , e.g. concerning b e h a u i g u r disturban- ces or intellectual d e v e l o p m e n t , u;e may state that severe
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n e u r o l o g i c sequelae are not to be expected so o f t e n that cessation of l i f e saving measures seems to be j u s t i f i e d a f t e r clinical diagnosis of ICH alone.
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