Periventricular edema in the newborn is that it is
Clinic, diagnosis, prognosis, complications of periventricular leukomalacia
Thus, the main clinical symptoms of suboptimalthe early period is: 1) a decrease in the tone of the lower extremities, 2) an increase in the tone in the cervical extensors, 3) attacks of apnea and bradycardia, 4) hyperexcitability, 5) pseudobulbar paralysis with pale extremities and 6) seizures.
In the electroencephalographic (EEG) studyin the initial stage, many children show paroxysmal activity and EEG depression. EEG data are used to predict the consequences of submarines. At the same time, the specificity of the manifestations of PL on the EEG is low (including the amplitude integrated EEG).
The greatest distribution in the diagnosis of submarinesreceived a neurosonographic examination (NSG), which is performed through a large fontanel in 2 planes - coronary and sagittal. Changing the angle of the sensor allows you to evaluate the structure of the brain in its various departments and identify various damages. PL are attributed to the group of ischemic lesions of periventricular areas of the lateral ventricles of the brain. Etiosfree cystic formations are formed in the place of previously detected foci of compaction. Such changes are called "cystic PL". The average period of cyst formation is 19 days from the moment of birth. The most pronounced echographic manifestations of PL were observed at 3-5 days of life, with increased echogenicity persistently preserved until 10 days, and subsequently formed single or multiple cysts of periventricular areas of the brain (Valid MA et al. 2005). In the NSH study of deeply premature infants (less than 1500 g), PL was detected in 31.9% of children. The authors found the following changes depending on the stage of the process: areas of increased zhoplotnosti, cysts (localized and common, ventriculomegaly and cerebral atrophy
There is a classification of the degrees of gravity of submarines,based on the data of neurosonography (see above). Particularly difficult is the diagnosis of PL in the acute phase, since the halo of increased periventricular echo density is normally present in premature newborns. These changes may disappear within 2-3 weeks after birth and indicate any circulatory disorders in periventricular areas of the brain.
Evaluating the results of the neurosonicresearch (NSG). it should be borne in mind that, firstly, increased echocardiography is not synonymous with PL, it can be pockets of moderate cerebral edema, telencephalic leukoencephalopathy, astrogliosis, periventricular hemorrhagic infarction, encephalitis and other pathological processes. Moreover, in 85% of cases of first-degree PL, complete recovery is observed, which is doubtful when PL is understood as a process with obligatory necrosis of the brain tissue. It is absolutely true that AB Palchik and NP Shabalov (2000) remark that "the researcher sees zones of increased or decreased echogenicity, and not" edema, "" ischemia, "" hemorrhage, "" clot, "" calcificat, "" "leukomalacia," and so on; on the basis of neurosonography, he can only assume the causes and essence of the altered echogenicity. " Secondly, it is doubtful to attribute all cases of the 4th degree of the submarine to the widespread lesions of the white matter of the semi-oval centers to the true submarine. Such lesions are more typical for multicystic encephalomalacia or the so-called "complex PL", and not for PL with characteristic periventricular foci. I believe that an improvement in the neurosonographic classification of submarines is required. Neurosonography made it possible to make a breakthrough in the diagnosis of submarines, to popularize this defeat as one of the most studied. At the same time, a comprehensive study of other cerebral lesions is necessary in order not to engage in hyperdiagnosis of the submarine and not to include any lesions in the white matter of the cerebral hemispheres to the submarine.
With the so-called "non-cystic" form of PLNSG-study can be negative in 50-70% of cases, therefore it is expedient to conduct repeated studies (dynamic scanning). This increases the diagnostic informative value of the NSH in the submarine.
Especially a lot of misconceptions arise when evaluating"Cyst" and "pseudocyst" white matter of the brain, which ultrasound specialists do not differentiate between themselves. Therefore, the detected cysts in neonates of the first days of life are mistakenly attributed to the submarine, which appeared antenatally. PL is basically a postnatal process, and in the first days of life pseudocysts, representing a malformation of the brain, and not true cysts, can be detected. Pseudocysts have nothing to do with submarines, although they can be combined with submarines.
In my studies I found a high frequencylesions of visual radiance and recommended for the diagnosis of submarines "a more thorough examination of the function of vision." It is gratifying that such studies have now appeared. It was revealed that in children with submarines in 100% of cases, ophthalmologic complications are observed. In 80.3% of children with submarines there is a syndrome of enlarged excavation of the optic nerve disc, which indicates transsynaptic neuronal degeneration and retrograde degeneration of axons. Since the foci of the submarine are mainly bilateral, in the overwhelming majority of cases (93.4%) bilaterous lesions of the optic disc are detected. Other ophthalmic disorders were also revealed: deformation of the optic nerve disk, its atrophy, hypoplasia, etc. It should be noted that extensions of optic nerve excavation can be detected in other pathological processes of the brain if they affect visual radiance and striatal cortex. Early diagnosis of ophthalmologic pathology in newborns with subtypes allows the appointment of timely treatment, avoid significant visual deprivation and prescribe more effective functional rehabilitation.
To diagnose and predict the formation of submarines inCurrently, research is recommended in the serum of the brain neurotrophic factor (BDNF) and the specific protein of astrocytic glia S-100. An increase in the S-100 concentration with high reliability allows predicting the development of severe structural brain damage, especially when combined with sublevels with IVF, when the excess of the norm was observed 10-12 times. In newborns with submarines, the serum concentration of BDNF is low.
Forecast of the submarine. According to my and literary data, in the case of submarines, the cortico-spinal tract, visual and auditory radiance, are primarily affected. The consequence of PL are 1) cerebral palsy (more often spastic diplegia, with severe quadriplegia lesions), 2) delay in psychomotor development, and 3) visual impairment (violations of fixation, nystagmus, strabismus, etc.). Hearing functions may be impaired. According to ON Malinovskaya et al. (2005), the outcome of PL is 1) recovery (19.5%), 2) cerebral palsy (80.5%), 3) convulsive syndrome and epilepsy (37.5%), and 4) delay in psycho-speech development (66%). All children with developmental delay suffered from cerebral palsy, and the more significant the motor disorders, the ruder the violations of psycho-speech development. In all children with 3 and 4 degrees of severity according to
NSG developed cerebral palsy. Such an outcome as recovery can cause objections, since the very minimal damage to the brain in submarines is accompanied by the destruction of nerve fibers, their retrograde degeneration, astrogliosis, etc. It should be assumed that not all cases of submarines according to NSG research are cases of a true submarine. At the same time, such consequences as epilepsy are probably associated with lesions of cortical structures and the hippocampal subculum, which are very sensitive to hypoxia. It is necessary to differentiate among themselves the consequences of PL and the consequences of other concomitant lesions of the brain, which is a difficult task.
According to J. Volpe (2003), 10% of survivors of deeply premature infants (up to 1500 grams) with PD suffer from cerebral palsy, and 50% later have psychomotor abnormalities.
In cerebral palsy according to NSG, five main typesdisorders: submarine (33.1%), posthemorrhagic pantencephaly, developmental abnormalities, cortical and subcortical atrophy, damage to the basal ganglia (Gainetdinova DD 2001). PL and cerebral palsy are different nosological units. According to my data, cysts in the white matter of the brain with a characteristic predominance in certain parts of the brain (see topography) are formed after the transferred PL, the white matter is atrophied to some extent, and in case of severe degree of damage the corpus callosum, the cortex of the large hemispheres are hypoplastic and the lateral Ventriculomegaly occurs.
It is believed that cerebral palsy is formed in all children with submarines,not holding their head to 6 months. of the adjusted age. And the severity of the submarine depends on the prognosis of neurological disorders. In the first grade PL, all children moved independently, with PL 2 nd they moved independently or with the support of 80% of children, and at grade 3 - only 15% of children moved independently, and 45% of patients did not move and could not sit on their own.
Antenataldiagnosis of chorioamnionitis followed by the introduction of the mother at 24-31 weeks of pregnancy betamethasone, which positively affects the protective reaction of the fetus during inflammation. It is important to prevent premature birth, not to use drugs (cocaine), to diagnose intrauterine infections, to prevent prolonged hypogarbia with artificial ventilation, etc.
Many researched indicate the role of the factortumor necrosis (TNF) in the development of PL (causes arterial hypotension, enhances intravascular coagulation, contributes to the death of oligodendrocytes, etc.). At the same time, corticosteroids block the production of TNF by astrocytes and reduce its activity, which makes it possible to consider their application in the treatment and prevention of submarines to be justified. However, there is evidence that the early introduction of dexamethasone in preterm infants with SDM correlates with the development of submarine. With early therapy with dexamethasone, the frequency of neurological complications and cerebral palsy increases in the first three days of life. Therefore, it is recommended to use this drug after the 2nd week of life or to use alternative drugs (budesonide, bulimicort) and inhaled steroids (fluticasone, beclomethasone).
Children who are on the ventilator are very importantto control blood gases, because it is proved that hyperoxia, hypercapnia and acidosis are risk factors for the development of submarines. The therapeutic measures for PL are in many respects similar to those in the treatment of "hypoxic-ischemic encephalopathy". This introduction of antioxidants, inhibitors of oxygen radicals, calcium channel blockers and calcium antagonists and the like. D. Advisable to use known and long cranio-cerebral hypothermia (chilling the head) that promotes slowing of metabolic processes in the brain and reducing the risk of ischemic lesions Sgiach it.
In PL therapy it is important to use drugs,improving cerebral circulation (vinpocetine, stugeron, nicergoline) and nootropics (piracetam). With respiratory distress syndrome, it is advisable to administer surfactant preparations that reduce the severity of respiratory disorders and reduce the need for ventilation, and thereby reduce the risk of new foci of submarines. In the treatment of cerebral palsy caused by PL, the use of cerebrolysin is recommended (Gainetdinova D D. 2001), which has anti-clastogenic and antioxidant activity. All the development of the treatment of cerebral ischemia and hypoxic-ischemic encephalopathy of the third degree is appropriate to use in the treatment of submarines.
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