早产儿脑室旁静脉性脑梗死:16例临床分析

Clinical analysis of periventricular venous cerebral infarction in 16 premature infants

目的:通过总结早产儿脑室旁静脉性脑梗死(periventricular venous cerebral infarction,PVI)患儿的临床病例特点和相关危险因素,及早做出诊断。方法:回顾性总结2013年1月1日至2018年12月31日在北京大学第三医院新生儿科住院、经超声诊断的16例新生儿PVI的病历资料,对其临床表现、超声表现、危险因素及结局进行分析。根据超声表现,将患儿脑损伤程度分为轻度PVI(n=5)和重度PVI(n=11);按患儿发病时间,分为典型PVI(发病时间为生后6~96 h,n=14)和非典型PVI(发病时间为生后<6 h或>96 h,n=2)。统计学分析采用Fisher精确概率法、单因素分析及多因素logistic回归分析。结果:(1)16例PVI患儿胎龄25+2~33+1周,中位胎龄27周;出生体重660~1760 g,中位出生体重1065 g。所有患儿生后1周超声影像均表现为PVI,其中11例在生后1周确诊,5例为漏诊,当时诊断为脑室周围-脑室内出血。临床表现为惊厥5例,余患儿表现均无特异性,所有患儿均存在Ⅲ级及以上脑室周围-脑室内出血。7例患儿累及双侧脑半球,5例累及左侧,4例累及右侧。15例大范围梗死。6例中线移位。6例生后4~25 d出现梗阻性脑积水,8例生后5~25 d出现脑实质软化。(2)轻度PVI组患儿的窒息发生率低于重度组(1/5与10/11,P=0.013),窒息是重度PVI的高危因素(OR=40.000,95%CI:1.982~807.100)。(3)典型与非典型PVI组的各临床危险因素比较,差异均无统计学意义(P值均>0.05)。(4)16例患儿中,9例放弃治疗后死亡,1例失访,5例后期智力运动发育落后,1例生长发育正常。轻度与重度PVI、典型与非典型PVI的预后(死亡及好转出院)比较,差异均无统计学意义(P值分别为0.365和0.700)。结论:早产儿PVI多发生于超低出生体重儿及极低出生体重儿,发生时间多在生后1周内。临床可表现为惊厥,但多无特异性。生后窒息可能导致重度PVI,PVI近期病死率较高,远期神经系统后遗症发生率较高。

Objective To summarize the clinical features and risk factors of periventricular venous cerebral infarction(PVI)in premature infants to prompt an early diagnosis.Methods Clinical data of 16 premature newborns diagnosed with PVI by ultrasound in the Department of Pediatrics of Peking University Third Hospital from January 1,2013,to December 31,2018,were retrospectively collected.The clinical manifestations,ultrasound findings,risk factors and outcomes were analyzed.Two allocations were performed to the patients:mild PVI group(n=5)or severe PVI group(n=11)according to the degree of brain injury suggested by ultrasound findings;and typical PVI group(onset time was 6-96 h after birth;n=14)or atypical PVI group(onset time was less than 6 h or more than 96 h after birth;n=2)according to the onset time.Chi-square or Fisher's exact test was used to analyze the differences in high risk factors and prognosis between the groups.Univariate and multivariate logistic regression analysis were used to analyze the high risk factors related to different groups.Correlations of the severity of brain injury and the onset time with PVI prognosis were analyzed using univariate analysis.Results(1)The gestational age of the 16 infants with PVI was 25+2-33+1 weeks(median 27 weeks).The birth weight ranged from 660 g to 1760 g(median 1065 g).All cases showed PVI under ultrasongraphy one week after birth,among which 11 was diagnosed and the other five were misdiagnosed as periventricular intraventricular hemorrhage GradeⅢ.Five cases presented with convulsion,while the others did not show any specific symptoms.All cases were shown periventricular intraventricular hemorrhage GradeⅢor above.Bilateral hemispheres were involved in seven cases,left hemisphere in five and right in four.There were 15 cases with massive infarction and six with midline displacement.Obstructive hydrocephalus occurred in six cases 4-25 d after birth,and eight patients had brain parenchyma softening 5-25 d after birth.(2)The incidence of asphyxia in the mild PVI group was lower than that in the severe PVI group(1/5 vs 10/11,P=0.013)and asphyxia was a high risk factor of severe PVI(OR=40.000,95%CI:1.982-807.100).(3)There was no significant difference in the clinical risk factors between the typical and atypical PVI groups(all P>0.05).(4)Among the 16 cases,nine died,one was lost to follow-up,five had delayed intelligence and motor development and one had normal growth and development.No significant difference in the prognosis(died or discharged after improvement)was found between the mild and severe PVI groups,or between the typical and atypical PVI groups(P=0.365 or 0.700).Conclusions PVI usually occurs in very or extremely low birth weight premature infants within one week after birth.Clinical manifestations of PVI include convulsions,but most are non-specific.Asphyxia may lead to severe PVI.PVI has a higher short-term mortality as well as a higher incidence of long-term neurological sequelae.