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Early Identification of Neurological Abnormalities in the NICU Infant Max Wiznitzer, M.D. Division of Pediatric Neurology Rainbow Babies and Children’s.

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Presentation on theme: "Early Identification of Neurological Abnormalities in the NICU Infant Max Wiznitzer, M.D. Division of Pediatric Neurology Rainbow Babies and Children’s."— Presentation transcript:

1 Early Identification of Neurological Abnormalities in the NICU Infant Max Wiznitzer, M.D. Division of Pediatric Neurology Rainbow Babies and Children’s Hospital Cleveland, Ohio

2 Common Problems in the NICU Prematurity IVH=Intraventricular Hemorrhage PVL=Perventricular Leukomalacia Neonatal encephalopathy Hypoxic-Ischemic Infarction Seizures

3 Intraventricular Hemorrhage Causation Preterm Term Presentation Catastrophic- Fortunately rare Saltatory-More common; stuttering evolution Silent-Most common Grading severity

4 *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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7 *OUTCOME and PROGNOSIS: Progressive Ventricular Neurological Severity of IVH Mortality (%) Dilatation (%) Sequelae (%) Grade I Grade II Grade III IPE (In general, outcomes with IVH Grade I or II are similar to infants without IVH.)

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11 *Clinical Features Catastrophic Syndrome Evolves in minutes to hours Deep stupor or coma Respiratory arrhythmia, hypoventilation, apnea Generalized tonic seizures, “Decerebrate” posturing Eyes- Pupils fixed, no Doll’s eye Flaccid quadriparesis

12 *Clinical Features Catastrophic Syndrome (cont.) Falling Hematocrit Bulging Anterior Fontanelle Hypotension, Bradycardia Temperature derangements Metabolic acidosis, DIC, Jaundice Abnormalities of glucose and water homeostasis (Hyperglycemia, SIADH)

13 *Clinical Features Saltatory syndrome Stuttering evolution : hours to day Altered level of consciousness Altered motility (usually decreased ) Hypotonia Abnormally tight popliteal angle (84% if IVH, 10% if no IVH) Abnormal eye position / movement Respiratory disturbance

14 *Clinical Features Clinically silent syndrome: Careful, serial clinical assessments will miss 25-50% of infants with IVH Most valuable sign is unexplained fall of Hematocrit or failure of Hematocrit to rise after a transfusion More common with smaller bleeds (with associated better prognosis )

15 Intraventricular Hemorrhage Consequences Hydrocephalus Germinal matrix damage Hemorrhagic infarction Assessment Ultrasound MRI Evoked potentials

16 Neonatal Encephalopathy Periventricular Leukomalacia Hypoxic-ischemic encephalopathy Near total/profound asphyxia Prolonged partial asphyxia Infarction (stroke) Arterial Venous

17 Hypoxic-ischemia Encephalopathy Diagnosis Clinical evolution Impact and timing of cell death Necrosis Apoptosis Radiologic assessment Ultrasound CT scan MRI Use of EEG

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19 Use of Technology for Early Identification of Problems MRI Evoked potentials EEG Near Infrared Spectroscopy Examination Analysis of Angles (Amiel-Tison) Assessment of general movements (Prechtl)


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