INTRACRANIAL HEMORRAGE IN TERM NEWBORNS: MANAGEMENT AND OUTCOMES

Oleh: Heri Suhendra & Lisa Mayanti Pembimbing: Dr. N. Budi, Sp.BS

INTRODUCTION
Intracranial hemorrhage is defined as the pathologic accumulation of blood within the cranial vault. Intraventricular hemorrhage is the most common type of intracranial hemorrhage in preterm newborns ICH in term neonates usually occurs in the vicinity of the falx and tentorium cerebelli

INCIDENCE
A large prospective MRI (0.2 T) study of asymptomatic term newborns found an 8% prevalence of SDH Out of 88 asymptomatic neonates born via vaginal delivery and undergoing cranial MRI (3 T) between the ages of 1 and 5 weeks, 17 term infants had ICH, for a study prevalence of 26%

Estimated local incidence of symptomatic ICH was 4.9/10,000 live births, with a regional incidence of 2.7/10,000 live births. An average incidence of 3.8/10,000 live births. Data analysis on nearly 600,000 average-weight infants (2500-4000 g) born to nulliparous women showed an incidence of ICH associated with spontaneous delivery, vacuum extraction delivery, and forceps delivery of 1 per 1900, 1 per 860, and 1 per 664 births, respectively [6].

TYPES
In the MRI study by Looney et al. [5], infratentorial subdural hemorrhage was the most frequent intracranial hemorrhage in a group of asymptomatic term newborns. IVH is primarily a disorder of prematurity. The lower incidence of IVH in term newborns (4.6%) compared with preterm newborns (50%) is thought to be due to the greater maturity of the brain.

SEVERITY
The severity of intracranial hemorrhage is classified as mild, moderate, or severe. In newborns with ICH the clinical significance of volumetric measurement for the severity of intraparenchymal hemorrhage (small, <3 cm; medium, 3-6 cm; or large, >6 cm) or by using formula (ABC/2)

ROLE OF NEUROIMAGING

Cranial ultrasound Instrument transportability, low cost of operation, absence of exposure to radiation, and can be performed in the NICU. Ischemic lession (8%) and Hemorrhagic lession (6%) from all abnormalities (20%) (35/177 in 6 and 48 hours) CT scan is better than ultrasound in detecting SAH, diffuse parenchymal abnormality, small IVH MRI is superior to CT in identifying hemorrhage, particulary for subacute to chronic hemorrhage and for extracerebral or infratentorial hemorrhages

RISK FACTORS

METHOD OF DELIVERY
The normal birth process itself may be traumatic enough to cause intracranial hemorrhage in term newborns [25]. A retrospective case-control study in 66 term infants imaged within 7 days after birth showed an increased risk of ICH with forceps-assisted delivery [18].

LOW APGAR SCORES AND PERINATAL ASPHYXIA

Among 11 cases of term neonates, intracranial hemorrhage was evidenced in all 3 of the infants who had 5-minute Apgar score of 7 or less [33]. Jhawar et al. [18] also reported that low Apgar scores, with and without requirement for resuscitation at birth, are risk factors for intracranial hemorrhage.

HEMATOLOGIC RISK FACTORS

ICH due to a bleeding disorder is rare in the term newborn, but tends to be more severe Thrombocytopenia is the most common condition Neonatal alloimmune thrombocytopenia occurs when mothers lacking the most common human platelet antigen among European origin (HPA-1a) become sensitized to that antigen present on fetal platelets. Coagulopathies have been implicated in newborns with ICH.

Hemophilia A, B and C, Von Willbrand disease

NEUROLOGIC FACTORS
Primary cerebral clinical entities leading to intracranial hemorrhage are rare in the first week Several vascular malformations of the cerebral circulation may become symptomatic beyond the neonatal period, but only malformation of the great vein of Galen becomes symptomatic in the term newborn at birth and may present as cardiac failure rather than as intracranial hemorrhage

CLINICAL FEATURES
Term newborns with ICH may manifest with a neonatal seizure, decreased level of consciousness, or both, The newborns history, including the setting in which the presentation occurs, maternal history and family history, and perinatal risk factors An important initial consideration is whether the newborn was sick before the presentation.

The majority of neonates with ICH have no clinical symptoms, including some with moderate to severe hemorrhages Clinical presentation depends on the etiology and compartment of the cranium involved with the hemorrhage or the pace with which intracranial pressure rises

Seizure was the most common presenting symptom of ICH in 7/11 term newborns A retrospective analysis of 33 term infants with ICH revealed that 24/33 infants (72.3%) presented with seizure, respiratory distress, or apnea Newborns with vitamin K deficiency often present with gastrointestinal bleeding

EXAMINATION
Clinical history is seen sugestive of cerebral insult do both general and neurologic examination

Physical examination vital sign, state of conciousness, abnormal posture or movement, patologic reflex

Eye examination by funduscopic examination my reveal retinal hemorrage

INVESTIGATION

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Goals: To confirm the clinical suspicion of intracranial abnormality To define the type and the severity of the intracranial hemorrhage To entertain evidence-based etiologic and clinical differential diagnosis for the hemorrhage To consider possible neurosurgical intervention To obtain a baseline study To seek clues suggesting an underlying cerebral abnormality

INVESTIGATION Hemetologic Investigation

Complete blood count Prothrombin time Activated partial prothrombin time

Laboratory Investigation Noncontrast CT Scan Cranial ultrasound Lumbar puncture MRI

EEG
Documentingt he epileptic focus Providing information the func-tional integrity of the brain

TREATMENT
Treatment Provide adequate ventilation Prevent matabolic acidosis Keep vital organs well perfuse Hematologic Management
Monitor Hb level Vit.K deficiency give 1 mg of vit.K IV Thrombocytopenia tranfuse platelet Coagulopaty transfuse Fresh-Frozen Plasma

Neurosurgical

Massive intracranial hemorrage Post hemorragic hydrocephalus

DIFFERENTIAL DIAGNOSIS
Underlying cerebral infarction Sinus venous trombosis Neonatal herpes simplex

NEUROLOGIC OUTCOMES
Depands on: extent (compartmental, lobar or both), the severity, the etiology, low gestasional age, early occurance of recurrent seizure, and the need for multiple anticonvulsant to control seizures Outcomes usually good with concervative medical treatment or potential for serious neurologic outcome, including death of lifelong disability

MEDICOLEGAL IMPLICATION
Delay diagnosis can become the source of medicolegal liability Decreased medicolegal risk by earliest documentation of high-risk pregnancy, difficult labor delivery, or prenatal diagnosis of intracranial abnormalities

ILUSTRASI CASE

IDENTITAS
Nama : M. Iqbal Usia : 2 bulan J.Kelamin : Laki-laki Alamat : Makaman Ilir RT.7 Agama : Islam MRS : 20 Maret 2012

ANAMNESA

Keluhan Utama: Pucat Riwayat Penyakit Sekarang: Orang tua menyadari anaknya tampak pucat sejak 2 hari sebelum masuk rumah sakit. Selain itu disertai dengan anak yang terlihat lemas dan tidak mau menyusu. Timbul demam pula sejak 2 hari yang lalu dan anak juga mengalami muntah-muntah dengan frekuensi sekitar 5x per hari. Selain itu mata pasien yang sebelah kiri sulit untuk membuka, dan keluar banyak kotoran dari mata tersebut. Tidak ada riwayat perdarahan atau pun BAB hitam. Setelah itu pasien kemudian dirawat di Melati, selama perawatan pasien pernah mengalami kejang sebanyak 2 kali, dan kemudian dilakukan pemeriksaan CT Scan dan ditemukan adanya perdarahan di kepala.

Riwayat Penyakit Dahulu: Pasien belum pernah mengalami hal serupa sebelumnya. Riwayat Penyakit Keluarga: Pasien merupakan anak ke 3 dari 3 bersaudara, dan tidak ada saudara pasien ataupun keluarga yang mengalami hal serupa. Riwayat Kelahiran dan Kehamilan: Pasien lahir di Klinik Bidan dengan usia kandungan 36 minggu. Pasien lahir spontan, tanpa menggunakan vacum/forcep, langsung menangis, bergerak aktif dan kulit tidak tampak kebiruan. Pada saat hamil ibu rajin memeriksakan kehamilan di bidan, ibu tidak pernah sakit pada saat hamil. Selama hamil terkadang ibu meminum obat sakit kepala.

PEMERIKSAAN FISIK

Keadaan Umum : Sakit sedang. Tanda vital Nadi : 120x/menit RR : 48x/menit Suhu : 36,8 C

Kepala/leher: Normocephal, konjungtiva anemis (-), sclera ikterik (-), pupil isokor diameter 3 mm/3mm, reflex cahaya (+/+), pembesaran KGB (-), discharge di orbita sinistra

Paru: Fremitus raba D=S, Sonor di seluruh lapangan paru, suara nafas vesikuler, rhonki (-/-), wheezing (-/-)

Jantung: S1S2 tunggal regular, murmur (-)

Abdomen : Soefl, organomegali (-), timpani, Bising usus (+) kesan normal, turgor kulit kembali cepat

Ekstremitas: Akral hangat, edema (-)

PEMERIKSAAN PENUNJANG
Pemeriksaan Lekosit Hb hasil 11.300 /mm3 4.1 g/dl

HCT
Trombosit APTT PT BT

12.8 %
513.000 /mm3 32 detik 21.3 detik 3 detik

CT

9 detik

Diagnosis: Diagnosis Awal Diagnosis Akhir

: Obs. Anemia : ICH + SDH

Penatalaksanaan: IVFD KAEN 4A 20 tpm Transfusi PRC Cefotaxim inj. 3x150 mg Paracetamol 3x0.5 cc Pro craniotomy

LAPORAN OPERASI
Operasi tanggal 26-03-2012 Diagnosa pre-operatif : ICH + SDH Diagnosa post-operatif : ICH + SDH Tindakan : Craniotomy Terapi post-operasi: Sopirom 2 x 150 mg Antrain inj. 3 x 50 mg Fenitoin 3 x 8 mg Kalnex inj. 3 x 100 mg Koreksi APTT/PT Inj. Vit. K 1 x 1 mg IM (3 hr) Transfusi FFP 50 cc

TERIMA KASIH