新生儿脑梗死的预后及其危险因素

Prognosis and risk factors of neonatal cerebral infarction

目的 总结新生儿脑梗死的预后及其危险因素. 方法 2002年1月至2010年12月,北京大学第一医院新生儿科经影像学检查共确诊新生儿脑梗死44例,通过神经系统临床表现、Gesell评分、头颅影像学检查、脑电图、视听诱发电位等神经系统检查综合评判患儿是否存在神经系统后遗症,并通过单因素及多因素Logistic回归分析影响新生儿脑梗死神经系统不良预后的危险因素. 结果 共随访到38例患儿,随访率为86％,其中5例患儿放弃治疗后死亡,病死率为13％（5/38）.3例因随访年龄＜6个月尚无法判断后遗症情况,其余30例患儿有后遗症者15例,无后遗症者1 5例,后遗症的发生率为50％（15/30）.1 5例遗留后遗症者均有运动障碍,合并癫痫8例,合并认知障碍8例,合并视觉障碍5例.有后遗症的新生儿脑梗死患儿脑损伤范围较大（梗死范围包括至少一个脑叶）、影像学结局差（治疗后至少1个月影像学显示脑梗死病灶扩大或持续存在）、存在严重合并症的比例分别为14/15、13/15和8/15,高于无后遗症组（分别为4/15、5/15和1/15）,差异均有统计学意义（x2值分别为13.889、8.889和7.778,Jp值均＜0.05）.多因素分析发现,损伤范围大与新生儿脑梗死遗留神经系统后遗症密切相关（OR=38.500,95％CI：3.749～395.407,P=0.002）,而影像学结局差（OR=8.563,95％CI：0.909～80.683,P=0.061）和存在严重合并症（OR=18.024,95％CI：0.516～630.163,P=0.111）与遗留后遗症无关.损伤大脑中动脉主干者遗留运动障碍的可能性较大（OR=6.000,95％CI：1.172～3.725,P=0.025）;损伤范围大者遗留癫痫的可能性较大（x2=7.273,P=0.010）;遗留认知障碍者脑损伤范围大的比例为8/8,明显高于无认知障碍者（46％,10/22）,脑损伤范围与遗留认知障碍有关（x2=7.273,P=0.010）. 结论 新生儿脑梗死患儿存在多种神经系统后遗症,其中运动障碍最常见.新生儿脑梗死患儿脑损伤范围较大者遗留神经系统后遗症的可能性较大.

Objective To determine the prognosis and risk factors of neonatal cerebral infarction.Methods From January 2002 to December 2010,44 newborn infants were diagnosed with cerebral infarction by imaging examinations at Peking University First Hospital.The neurodevelopmental outcomes of these newborn infants were followed up and evaluated by clinical manifestations,Gesell development scale,cranial imaging,electroencephalogram and auditory evoked potential.Factors related to prognosis were analyzed with single and multi-factor Logistic regression analysis.Results Thirty-eight （86％） cases were followed up,and of these cases,five children died and the results of three were inconclusive due to small age （less than 6 months old）.Among the remaining 30 children,neurodevelopmental outcome was normal in 15 cases and abnormal in the remaining 15 cases,thus,the incidence of sequelae was 50％ （15/30） and the mortality rate was 13％ （5/38）.Of the 15 abnormal cases,all had cerebral palsy and movement retardation,eight cases had cognitive impairment,eight cases had epilepsy and five had visual impairment.The incidence of large cerebral infarction （more than one lobe） was 14/15,worse cranial imaging outcome （one month after treatment,cerebral infarction lesion still present or had expanded）was 13/15,and severe complications was 8/15 in the newborns with sequelae,which were higher than in those without sequelae （4/15,5/15 and 1/15,respectively） （x2=13.889,8.889 and 7.778,all P＜0.05）.Logistic regression analysis showed that large cerebral infarction was a risk factor for sequelae （OR=38.500,95％C1：3.749-395.407,P=0.002）,however,worse cranial imaging outcome （OR=8.563,95％CI：0.909-80.683,P=0.061） and severe complications （OR=18.024,95％CI：0.516-630.163,P=0.111） were not risk factors for sequelae.Cerebral infarction with middle cerebral artery injury had a high risk of movement retardation （OR=6.000,95％CI：1.172-3.725,P=0.025）,and those with a large cerebral infarction were more likely to have epilepsy （x2=7.273,P=0.010）.The incidence of large cerebral infarction in the newborn infants with cognitive impairment was 8/8,which was much higher than in those without cognitive impairment （46％,10/22）,thus,infarct area may be related to cognitive ability （x2=7.273,P=0.010）.Conclusions Neonatal cerebral infarction might result in many types of sequelae,with motor impairment being the most common form.A large cerebral infarction is more likely to result in abnormal neurodevelopmental outcome.