45例新生儿脑梗死的临床特点及危险因素

Clinical characteristics and risk factors of cerebral infarction in 45 newborns

目的总结新生儿脑梗死的临床特点,分析其危险因素,为该病的临床诊断及早期干预提供一定的经验。方法回顾性分析2012年6月至2020年7月西安交通大学附属儿童医院新生儿重症医学科收治的新生儿脑梗死患儿(n=45)的人口学基线资料、临床表现、颅脑影像学特点,并以1∶2比例选择出生年月和胎龄与脑梗死患儿匹配的90例无脑血管病变的新生儿作为对照组。单因素分析采用两独立样本t检验、秩和检验、χ^(2)检验或校正χ^(2)检验,采用二元logistic回归分析新生儿脑梗死的危险因素。结果45例临床诊断新生儿脑梗死的患儿中小于胎龄儿8例,巨大儿3例;中位发病日龄为1 d(1~2 d),71%(32/45)以抽搐为首发症状,以呼吸暂停、呼吸窘迫为主诉入院者分别占4%(2/45),以反应差为主要表现者占11%(5/45),9%(4/45)无明显临床表现;颅脑MRI及血管成像检查发现病变位于左侧大脑半球者25例(56%),右侧者16例(36%),双侧均有病变者4例(9%);病变累及丘脑、基底节者11例;病变区域供血动脉为大脑中动脉的17例(38%),大脑前动脉1例,大脑后动脉4例,大脑前中动脉4例,大脑中后动脉16例,大脑前中后动脉3例。单因素分析显示脑梗死组与对照组比较,小于胎龄儿[18%(8/45)与6%(5/90),χ^(2)=5.15]、阴道试产失败中转剖宫产[18%(8/45)与1%(1/90),χ^(2)=10.85]、羊水胎粪污染[33%(15/45)与9%(8/90),χ^(2)=12.68]、宫内窘迫[20%(9/45)与3%(3/90),χ^(2)=8.34]、生后窒息[16%(7/45)与2%(2/90),χ^(2)=6.56]的比例均较高(P值均<0.05);二元logistic回归分析显示小于胎龄儿(OR=3.981,95%CI:1.075~14.742,P=0.039)、阴道试产失败中转剖宫产(OR=17.959,95%CI:2.032~158.698,P=0.009)、宫内窘迫(OR=5.756,95%CI:1.129~29.331,P=0.035)是新生儿脑梗死的独立危险因素。结论新生儿脑梗死多以抽搐为首发症状,亦存在无明显症状者,病灶多累及大脑中动脉。小于胎龄儿、阴道试产失败中转剖宫产和宫内窘迫可能增加新生儿脑梗死的发生风险。

Objective To summarize the clinical characteristics of neonatal cerebral infarction and its risk factors,so as to provide a reference for clinical diagnosis and early prevention of the disease.Methods This study retrospectively analyzed the demographic data,clinical manifestations and brain imaging features of neonates with cerebral infarction(n=45)admitted to the Department of Neonatal Critical Care Medicine of the Affiliated Children's Hospital of Xi'an Jiaotong University from June 2012 to July 2020.Ninety newborns without cerebrovascular disease matched for date of birth and gestational age were selected as the control.Two independent sample t-test,rank-sum test,Chi-square or corrected Chi-square test were used for univariate analysis and binary logistic regression were applied for analyzing the risk factors for neonatal cerebral infarction.Results A total of 45 infants with clinically diagnosed neonatal cerebral infarction were enrolled,including eight small for gestational age and three macrosomia infants.The median age at disease onset was 1 d(1-2 d).There were 71%(32/45)presenting with convulsions as the first symptom,4%(2/45)admitted with apnea and respiratory distress as the chief complaints,respectively,11%(5/45)having poor response and 9%(4/45)showing no obvious clinical manifestations.Cranial MRI and magnetic resonance angiography identified left hemisphere lesion in 25 cases(56%),right hemisphere lesion in 16(36%)and both in four(9%).Thalamus and basal ganglia were involved in 11 cases.The lesions were supplied by middle cerebral artery[38%(17/45)],anterior cerebral artery(n=1),posterior cerebral artery(n=4),anterior and middle cerebral arteries(n=4),middle and posterior cerebral arteries(n=16),or anterior,middle and posterior cerebral arteries(n=3).Univariate analysis showed that the proportions of small for gestational age[18%(8/45)vs 6%(5/90),χ^(2)=5.15],cesarean section after failure of trial of labor[18%(8/45)vs 1%(1/90),χ^(2)=10.85],meconium stained amniotic fluid[33%(15/45)vs 9%(8/90),χ^(2)=12.68],fetal distress[20%(9/45)vs 3%(3/90),χ^(2)=8.34]and neonatal asphyxia[16%(7/45)vs 2%(2/90),χ^(2)=6.56]were all higher in the infarcted infants than those in the control(all P<0.05).Binary logistic regression analysis revealed that small for gestational age(OR=3.981,95%CI:1.075-14.742,P=0.039),cesarean section after failure of trial of labor(OR=17.959,95%CI:2.032-158.698,P=0.009)and fetal distress(OR=5.756,95%CI:1.129-29.331,P=0.035)were independent risk factors for neonatal cerebral infarction.Conclusions Most neonates with cerebral infarction would have convulsions initially,while some are asymptomatic.Middle cerebral arteries are often involved in the lesion.The risk of this disease may be increased in small for gestational age infants,cesarean section after failure of trial of labor and fetal distressed cases.