INTRACRANIAL HEMORRAGE IN TERM NEWBORNS:MANAGEMENT AND OUTCOMES

Oleh:

Heri Suhendra & Lisa Mayanti

Pembimbing:

Dr. N. Budi, Sp.BS

INTRODUCTION

Intracranial hemorrhage is defined as the pathologic accumulation of blood within the cranial vault.

Intraventricular hemorrhage is the most common type of intracranial hemorrhage in preterm newborns

ICH in term neonates usually occurs in the vicinity of the falx and tentorium cerebelli

INCIDENCE

A large prospective MRI (0.2 T) study of asymptomatic term newborns found an 8% prevalence of SDH

Out of 88 asymptomatic neonates born via vaginal delivery and undergoing cranial MRI (3 T) between the ages of 1 and 5 weeks, 17 term infants had ICH, for a study prevalence of 26%

Estimated local incidence of symptomatic ICH was 4.9/10,000 live births, with a regional incidence of 2.7/10,000 live births.

An average incidence of 3.8/10,000 live births.

Data analysis on nearly 600,000 average-weight infants (2500-4000 g) born to nulliparous women showed an incidence of ICH associated with spontaneous delivery, vacuum extraction delivery, and forceps delivery of 1 per 1900, 1 per 860, and 1 per 664 births, respectively [6].

TYPES

In the MRI study by Looney et al. [5], infratentorial subdural hemorrhage was the most frequent intracranial hemorrhage in a group of asymptomatic term newborns.

IVH is primarily a disorder of prematurity. The lower incidence of IVH in term newborns

(4.6%) compared with preterm newborns (50%) is thought to be due to the greater maturity of the brain.

SEVERITY

The severity of intracranial hemorrhage is classified as mild, moderate, or severe.

In newborns with ICH the clinical significance of volumetric measurement for the severity of intraparenchymal hemorrhage (small, <3 cm; medium, 3-6 cm; or large, >6 cm) or by using formula (ABC/2)

ROLE OF NEUROIMAGING

Cranial ultrasound Instrument transportability, low cost of operation, absence of exposure to radiation, and can be performed in the NICU.

Ischemic lession (8%) and Hemorrhagic lession (6%) from all abnormalities (20%) (35/177 in 6 and 48 hours)

CT scan is better than ultrasound in detecting SAH, diffuse parenchymal abnormality, small IVH

MRI is superior to CT in identifying hemorrhage, particulary for subacute to chronic hemorrhage and for extracerebral or infratentorial hemorrhages

RISK FACTORS

METHOD OF DELIVERY

The normal birth process itself may be traumatic enough to cause intracranial hemorrhage in term newborns [25].

A retrospective case-control study in 66 term infants imaged within 7 days after birth showed an increased risk of ICH with forceps-assisted delivery [18].

LOW APGAR SCORES AND PERINATAL ASPHYXIA

Among 11 cases of term neonates, intracranial hemorrhage was evidenced in all 3 of the infants who had 5-minute Apgar score of 7 or less [33].

Jhawar et al. [18] also reported that low Apgar scores, with and without requirement for resuscitation at birth, are risk factors for intracranial hemorrhage.

HEMATOLOGIC RISK FACTORS

ICH due to a bleeding disorder is rare in the term newborn, but tends to be more severe

Thrombocytopenia is the most common condition

Neonatal alloimmune thrombocytopenia occurs when mothers lacking the most common human platelet antigen among European origin (HPA-1a) become sensitized to that antigen present on fetal platelets.

Coagulopathies have been implicated in newborns with ICH. Hemophilia A, B and C, Von Willbrand disease

NEUROLOGIC FACTORS

Primary cerebral clinical entities leading to intracranial hemorrhage are rare in the first week

Several vascular malformations of the cerebral circulation may become symptomatic beyond the neonatal period, but only malformation of the great vein of Galen becomes symptomatic in the term newborn at birth and may present as cardiac failure rather than as intracranial hemorrhage

CLINICAL FEATURES

Term newborns with ICH may manifest with a neonatal seizure, decreased level of consciousness, or both,

The newborn’s history, including the setting in which the presentation occurs, maternal history and family history, and perinatal risk factors

An important initial consideration is whether the newborn was sick before the presentation.

The majority of neonates with ICH have no clinical symptoms, including some with moderate to severe hemorrhages

Clinical presentation depends on the etiology and compartment of the cranium involved with the hemorrhage or the pace with which intracranial pressure rises

Seizure was the most common presenting symptom of ICH in 7/11 term newborns

A retrospective analysis of 33 term infants with ICH revealed that 24/33 infants (72.3%) presented with seizure, respiratory distress, or apnea

Newborns with vitamin K deficiency often present with gastrointestinal bleeding

EXAMINATION

Eye examination by funduscopic examination my reveal retinal hemorrage

INVESTIGATION

Goals:1. To confirm the clinical suspicion of intracranial

abnormality 2. To define the type and the severity of the

intracranial hemorrhage3. To entertain evidence-based etiologic and

clinical differential diagnosis for the hemorrhage

4. To consider possible neurosurgical intervention5. To obtain a baseline study 6. To seek clues suggesting an underlying

cerebral abnormality

INVESTIGATION

Laboratory Investigation

• Noncontrast CT Scan

• Cranial ultrasound

• Lumbar puncture

• MRI

Hemetologic Investigation

• Complete blood count

• Prothrombin time

• Activated partial prothrombin time

EEG• Documentin

gthe epileptic focus

• Providing information the func-tional integrity of the brain

TREATMENT

Treatment• Provide

adequate ventilation

• Prevent matabolic acidosis

• Keep vital organs well perfuse

Hematologic Management• Monitor Hb

level• Vit.K

deficiency give 1 mg of vit.K IV

• Thrombo-cytopenia tranfuse platelet

• Coagulopaty transfuse Fresh-Frozen Plasma

Neurosurgical

• Massive intracranial hemorrage

• Post hemorragic hydrocepha-lus

DIFFERENTIAL DIAGNOSIS

Underlying cerebral infarction Sinus venous trombosis Neonatal herpes simplex

NEUROLOGIC OUTCOMES

Depands on: extent (compartmental, lobar or both), the severity, the etiology, low gestasional age, early occurance of recurrent seizure, and the need for multiple anticonvulsant to control seizures

Outcomes usually good with concervative medical treatment or potential for serious neurologic outcome, including death of lifelong disability

MEDICOLEGAL IMPLICATION

Delay diagnosis can become the source of medicolegal liability

Decreased medicolegal risk by earliest documentation of high-risk pregnancy, difficult labor delivery, or prenatal diagnosis of intracranial abnormalities

ILUSTRASI CASE

IDENTITAS

Nama: M. Iqbal Usia : 2 bulan J.Kelamin : Laki-laki Alamat : Makaman Ilir RT.7 Agama : Islam MRS : 20 Maret 2012

ANAMNESA Keluhan Utama: Pucat Riwayat Penyakit Sekarang:

Orang tua menyadari anaknya tampak pucat sejak 2 hari sebelum masuk rumah sakit. Selain itu disertai dengan anak yang terlihat lemas dan tidak mau menyusu. Timbul demam pula sejak 2 hari yang lalu dan anak juga mengalami muntah-muntah dengan frekuensi sekitar 5x per hari. Selain itu mata pasien yang sebelah kiri sulit untuk membuka, dan keluar banyak kotoran dari mata tersebut. Tidak ada riwayat perdarahan atau pun BAB hitam. Setelah itu pasien kemudian dirawat di Melati, selama perawatan pasien pernah mengalami kejang sebanyak 2 kali, dan kemudian dilakukan pemeriksaan CT Scan dan ditemukan adanya perdarahan di kepala.

Riwayat Penyakit Dahulu:Pasien belum pernah mengalami hal serupa sebelumnya.

Riwayat Penyakit Keluarga:Pasien merupakan anak ke 3 dari 3 bersaudara, dan tidak ada saudara pasien ataupun keluarga yang mengalami hal serupa.

Riwayat Kelahiran dan Kehamilan:Pasien lahir di Klinik Bidan dengan usia kandungan 36 minggu. Pasien lahir spontan, tanpa menggunakan vacum/forcep, langsung menangis, bergerak aktif dan kulit tidak tampak kebiruan. Pada saat hamil ibu rajin memeriksakan kehamilan di bidan, ibu tidak pernah sakit pada saat hamil. Selama hamil terkadang ibu meminum obat sakit kepala.

PEMERIKSAAN FISIK

Keadaan Umum : Sakit sedang.

Tanda vital Nadi : 120x/menit RR : 48x/menit Suhu : 36,8 °C

Kepala/leher: Normocephal, konjungtiva

anemis (-), sclera ikterik (-), pupil isokor diameter 3

mm/3mm, reflex cahaya (+/+), pembesaran KGB (-), discharge di orbita sinistra

Paru: Fremitus raba D=S, Sonor di

seluruh lapangan paru, suara nafas vesikuler, rhonki

(-/-), wheezing (-/-)

Jantung: S1S2 tunggal regular,

murmur (-)

Abdomen : Soefl, organomegali (-), timpani, Bising usus (+)

kesan normal, turgor kulit kembali cepat

Ekstremitas: Akral hangat, edema (-)

PEMERIKSAAN PENUNJANG

Pemeriksaan hasil

Lekosit 11.300 /mm3

Hb 4.1 g/dl

HCT 12.8 %

Trombosit 513.000 /mm3

APTT 32 detik

PT 21.3 detik

BT 3 detik

CT 9 detik

Diagnosis: Diagnosis Awal : Obs. Anemia Diagnosis Akhir : ICH + SDH

Penatalaksanaan: IVFD KAEN 4A 20 tpm Transfusi PRC Cefotaxim inj. 3x150 mg Paracetamol 3x0.5 cc Pro craniotomy

LAPORAN OPERASI

Operasi tanggal 26-03-2012 Diagnosa pre-operatif : ICH + SDH Diagnosa post-operatif : ICH + SDH Tindakan : Craniotomy Terapi post-operasi:

Sopirom 2 x 150 mgAntrain inj. 3 x 50 mgFenitoin 3 x 8 mgKalnex inj. 3 x 100 mgKoreksi APTT/PT Inj. Vit. K 1 x 1 mg IM (3 hr)

Transfusi FFP 50 cc

TERIMA KASIH