新生兒出血後水腦的神經發展預後分析

Neurodevelopmental Outcome after Posthemorrhagic Hydrocephalus in Newborn Infants

李英齊(Inn-Chi Lee)

指導教授 ： 陳家玉

中山醫學大學/醫學院/醫學研究所/碩士(2007年)

摘要

即使在當代最先進的新生兒加護病房照護下，新生兒腦出血仍然是早產兒照護上一個廣泛且長期存在的問題。出血後水腦是新生兒腦出血後主要的後遺症。對這些水腦病人，在加護病房的處理與腦室引流管的放置與否非常重要，但仍然無ㄧ致的看法。而腦室引流管放置與否及之後神經發展的預後因子仍需要更多的研究。在這篇研究中我們試者解答置放與不置放腦室引流管的不同，及尋找這些病人在矯正年齡一歲以上的神經發展預後因子。
材料與方法：
在這個回溯性病例與對照組研究，我們收集了83個腦出血病例，其等級依照Papile等人所描述的方法為第二級至第四級。在這些病例中有45個出現出血後水腦，排除了15個有合併先天性異常、染色體異常、腦膜炎或在超音波上有明顯腦萎縮的病人。我們先比較早期死亡與存活者是否有不同臨床特徵。對存活病例，我們區分了這些病人為有置放腦室引流管及無置放兩組，來比較他們是否有不同的特徵及神經發展預後。而對這些病人追蹤至矯正年齡大於一歲的病例，我們以神經發展狀況區分成四組，分別為正常、輕度、中度及重度來分別比較不同的預後因子。
結果：
在三十個出血後水腦的病人，10(33%)個在第一次住院中早期死亡。在分析早期死亡與存活因子上，妊娠周數、腦出血等級及出生時的Apgar 分數有明顯的不同。而存活的病人中，其中12(60%)個病例，最後有放腦室引流管，8(40%)個沒有。在這二組中，我們發現腦出血第三級比第二級有較多的機會放管子，此外有放引流管的病人比沒放引流管的病人，有較多晚期死亡比率，分別為40%與0%；及較少的神經發展正常的比率，分別為0%與50%，而在姙娠週數、出生體重、性別上這兩組並無明顯不同。而腦脊髓液中檢驗值包括最大紅血球量、最低葡萄糖濃度與最高蛋白質濃度也無明顯不同。在以矯正年齡大於一歲的神經發展預後因子上，我們發現水腦的程度上，快速進行的水腦比慢速進行的水腦有較差的神經發展預後。第三級腦出血造成的水腦也比第二級有較差的預後。而其他因子包括姙娠週數、出生體重、性別、Apgar分數、使用氣管內管天數、腦室穿刺次數、脊髓液的最低葡萄糖濃度與最高蛋白質濃度在神經發展預後上並無明顯不同。
結論:
在新生兒出血後水腦病人，需要置放腦室引流管的病例，比不需置放腦室引流管的病例有較差的神經發展預後，及較高的晚期死亡率。 在我們的研究中顯示這可能與起始出血的程度與水腦進行的程度有關。

關鍵字

關鍵字：出血後水腦 ； 腦室引流管 ； 神經發展 ； 預後

並列摘要

Although neonatal intraventricular hemorrhage (IVH) has been declined after surfactant use and modern advance intensive care, it is still a persistent issue and challenge to clinician in neonatal care. Posthemorrhagic hydrocephalus (PHH) is a major complication after IVH. Some infants with PHH will spontaneously remit finally but others will be dependent of shunt. The role of ventriculoperitoneal (VP) shunt and prognostic factor to neurodevelopmental outcomes in PHH infants are still controversial and have no consistency from previous reports, and are worthy of further study. In the study, we try to delineate the advantages and disadvantages of VP shunt and find the prognostic factors to neurodevelopmental outcome at the corrected age over 1-year old.
Method:
In the case-control study, we retrospectively collected 45 infants with PHH since 2002 to 2007. After excluding 5 had congenital anomalies, 1 chromosome anomaly, 7 severe cystic encephalomalacia, and 2 neonatal child abuses, total 30 cases were enrolled into our study. We analyzed the clinical characteristics of these cases, and compared them with and without early mortality. For the survival cases, we divided them into two groups with implanting of VP shunts, and without shunts. For evaluating the neurodevelopmental outcomes and prognostic factors of these patients at corrected age over 1-year old, we classified these patients into four groups, normal, mild, moderate, and severe abnormal outcomes according to their neurological and developmental examinations.
Result:
Of 30 PHH cases, the initial IVH stagings were 8 in grade 2, 18 in grade 3 and 4 in grade 4. 10(33%) were early death during first admission and 4(13%) were late death after first discharges. We found that the gestational age, degree of IVH and Apgar scores were statistical different between survival and early death cases. Of 20 survival cases, there were no statistical difference in gestational age, birth weight, gender, maximal red cell numbers of cerebral ventricular fluid, lowest glucose level and total protein between these patients with and without shunting. Those patients with grade 3 IVH had higher ratio to implant shunts finally in comparison with those with grade 2. Of those PHH infants with final shunting had had more late death and fewer normal neurodevelpmental outcomes at corrected age over 1-year old. There were no statistical difference in gestational age, birth weight, gender, maximal red cell numbers of cerebral ventricular fluid, lowest glucose level and total protein to neurodevelopmental outcomes at corrected age over 1-year old. The statistical difference only existed in the degree of IVH and the status of hydrocephalus, rapidly or slowly progressive.
Conclusion: Of the PHH infants, those with shunts had worse neurodevelpmental outcomes and more late death in comparison with those without shunts. The higher degree of IVH and rapidly progressive hydrocephalus resulted in worse neurodevelopmental outcomes at corrected age over 1-year old in our study.

並列關鍵字

Keywords: posthemorrhagic hydrocephalus ； ventriculoperitoneal shunt ； neurodevelopmental ； outcome

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