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Fatores de prognóstico neurológico da hemorragia intraventricular associada à prematuridade
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A Hemorragia Intraventricular (HIV) da prematuridade – hemorragia dentro dos ventrículos cerebrais por rotura de vasos da matriz germinal– é a principal causa de hidrocefalia infantil em países desenvolvidos e uma causa importante de mortalidade e morbilidade em recém-nascidos pré-termo. A sua incidência ronda os 15-20% em recém-nascidos (RN) com muito baixo peso à nascença e aumenta inversamente ao mesmo. A HIV divide-se em 4 graus (I-IV) e, na ausência de resolução espontânea, pode progredir para dilatação ventricular pós-hemorrágica (DVPH) ou hidrocefalia póshemorrágica da prematuridade (HPHP). A dificuldade de regulação do fluxo sanguíneo cerebral inerente à prematuridade constitui uma ameaça à frágil vasculatura da matriz germinal, propiciando à sua rotura. Simultaneamente, pensa-se que fenómenos tais como aracnoidite obstrutiva da fossa posterior e uma reação inflamatória cerebral difusa contribuam para o impedimento da drenagem do líquido cefalorraquidiano (LCR). A lesão concomitante da substância branca periventricular afeta a mielinização do córtex cerebral, comprometendo o normal desenvolvimento e predispondo a um futuro compromisso neurocognitivo. O diagnóstico de HIV da prematuridade é baseado no exame clínico e, fundamentalmente, na ecografia transfontanelar. No entanto, deve ser tida em conta a variabilidade interoperador e o subdiagnóstico intrínsecos a este método, em caso de operadores menos experientes. No sentido de colmatar as vulnerabilidades associadas à ecografia transfontanelar, tem-se verificado, nos últimos anos, a emergência da RMN como método de diagnóstico complementar. No que concerne ao tratamento, não existe um protocolo universalmente aceite, pelo que a indicação, o timing e o tipo de procedimento continuam a apresentar-se como um grande desafio. Com base na literatura revista, são apresentadas as vantagens e desvantagens comparativas dos métodos utilizados para drenar o excesso de LCR, tanto temporária como permanentemente. Todavia, são necessários mais estudos por forma a otimizar a abordagem destes pacientes e obter o melhor prognóstico possível.
Intraventricular Haemorrhage of Prematurity – haemorrhage into the cerebral ventricles resulting from the rupture of the germinal matrix vessels – is the leading cause of infant hydrocephalus in developed countries and responsible for morbidity and mortality in preterm newborns. Its incidence is about 15-20% in newborns with very low birth weight and it increases inversely to the weight. Intraventricular haemorrhage can be subdivided into 4 degrees according to its severity and, if not spontaneously resolved, it can progress to post-haemorrhagic ventricular dilation or post-haemorrhagic hydrocephalus of prematurity. The difficulty in regulating the cerebral blood flow that is inherent to prematurity constitutes a threat to the fragile vasculature of the germinal matrix, which trends towards rupture. It is thought that phenomena such as obstructive arachnoiditis of posterior fossae, along with a diffuse cerebral inflammation, contribute to prevent the drainage of the cerebrospinal fluid. The damage of the periventricular white matter affects the myelinization of the cerebral cortex, compromising the normal development of the brain tissue and predisposing to a neurodevelopment impairment. The diagnosis of Intraventricular Haemorrhage of Prematurity is based primarily on clinical examination and on transfontanelar ultrasound. However, its inter-operator variability and its sub diagnosis must be taken into account, especially in what concerns less experienced operators. The MRI has emerged in the last few years as an important exam, in order to fill in the blanks of the transfontanelar ultrasound. There’s no widely accepted protocol for treatment and so the indication, timing and the type of procedure itself continue to present a huge challenge for the clinicians. Based on the literature reviewed, I will present the comparative advantages and disadvantages of the various methods used to drain the excessive cerebrospinal fluid, both temporarily and permanently. Nevertheless, more investigation is needed in order to optimise the approach to these patients and to obtain the best possible prognosis.
Intraventricular Haemorrhage of Prematurity – haemorrhage into the cerebral ventricles resulting from the rupture of the germinal matrix vessels – is the leading cause of infant hydrocephalus in developed countries and responsible for morbidity and mortality in preterm newborns. Its incidence is about 15-20% in newborns with very low birth weight and it increases inversely to the weight. Intraventricular haemorrhage can be subdivided into 4 degrees according to its severity and, if not spontaneously resolved, it can progress to post-haemorrhagic ventricular dilation or post-haemorrhagic hydrocephalus of prematurity. The difficulty in regulating the cerebral blood flow that is inherent to prematurity constitutes a threat to the fragile vasculature of the germinal matrix, which trends towards rupture. It is thought that phenomena such as obstructive arachnoiditis of posterior fossae, along with a diffuse cerebral inflammation, contribute to prevent the drainage of the cerebrospinal fluid. The damage of the periventricular white matter affects the myelinization of the cerebral cortex, compromising the normal development of the brain tissue and predisposing to a neurodevelopment impairment. The diagnosis of Intraventricular Haemorrhage of Prematurity is based primarily on clinical examination and on transfontanelar ultrasound. However, its inter-operator variability and its sub diagnosis must be taken into account, especially in what concerns less experienced operators. The MRI has emerged in the last few years as an important exam, in order to fill in the blanks of the transfontanelar ultrasound. There’s no widely accepted protocol for treatment and so the indication, timing and the type of procedure itself continue to present a huge challenge for the clinicians. Based on the literature reviewed, I will present the comparative advantages and disadvantages of the various methods used to drain the excessive cerebrospinal fluid, both temporarily and permanently. Nevertheless, more investigation is needed in order to optimise the approach to these patients and to obtain the best possible prognosis.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021
Palavras-chave
Hidrocefalia pós-hemorrágica da prematuridade Hemorragia intraventricular Hemorragia da matriz germinal Dilatação ventricular póshemorrágica| Recém-nascido pré-termo Neurocirurgia