الفهرس 
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Abstract
Intracranial hemorrhage (ICH) is a major source of neonatal morbidity and mortality. In full term infants, it most often occurs during labor as the result of mechanical factors; however, in the pre-term infants it can occur even prior to labor or as late as the second week of life usually as a result of hemodynamic instability. Besides etiology, the location of hemorrhage, clinical presentation and neurological outcome also differs in the term and preterm infants. It is important for the radiologists to provide an accurate anatomic description of the compartment(s) confining the hemorrhage, as correct location may be an indicator to the underlying cause and provide a roadmap to the neurosurgeons if intervention is required.
The knowledge of the anatomic compartments is vital for interpreting the imaging findings in case of ICH and formulating a differential diagnosis. Cranial ultrasound is often used as the first imaging modality for newborns. CT is the preferred diagnostic study for evaluation of acute intracranial hemorrhage. MRI is indicated when subarachnoid bleed or posterior fossa hemorrhage is suspected. Prevention of ICH is a subject of great interest in premature newborns. Prenatal prophylaxis and improved obstetric and neonatal care in general markedly reduces the stress to premature fetus and neonate.
In newborns born prior to 32 weeks gestation, intraventricular hemorrhage is common and usually caused by germinal matrix hemorrhage. While less common in late preterm and term infants, hemorrhagic stroke (HS), defined as intraventricular, intraparenchymal or subarachnoid hemorrhage, also occurs in this group. Much less is known about risk factors and outcome of HS in late preterm and term infants, therefore the aim of this work was performing a clinical analysis and reviewing the data of 50 term and late preterm neonates (≥34 weeks gestation and ≤28 days of life) having intracranial hemorrhage by neuroradiological findings (CT or MRI Brain or transcranial U/S) with special consideration for the risk factors and neurological outcome.
All included neonates were subjected to detailed history taking as regard (maternal history of drug intake, pregnancy induced hypertension, type of delivery, history of prolonged labour, history of foetal distress ,instrumental use during labour and vitamin K administration).Detailed clinical examination was also done, laboratory investigations as complete blood count, prothrombine time and partially activated prothrombine time was done. Radiological investigation was done by CT, MRI Brain or transcranial U/S.
This study carried out at Neonatal Care Unit and Pediatric Neurology Clinic at Sohag University Hospitals, during the period from 1/1/2015 to 31/12/2015. The study included a total of 50 neonates meeting the inclusion criteria having intracranial hemorrhage with age range (≥34 weeks gestation and ≤28 days of life). The median age was 12 days and there were 23 males (46%) and 27 females (54%). The male to female ratio was (1:1.2).
As regard risk factors, 50% of the deliveries were normal vaginal delivery and 50%were cesarean section with 28% have difficult labour and 6% experienced instrumental deliveries. Neonates were delivered with Apgar score mean 8.8, range from 7 to 10 .Pregnancy induced hypertension was in 4% of cases. 6% of cases showed fetal distress. Vitamin K was administered in 64%, 6% hasn’t administered their dose and 3% not known. 8% had evidence of neonatal sepsis, 6%had no evidence of neonatal sepsis and 43% not known. The most frequent associated risk factors were absence of vitamin K administration followed by prolonged labour then neonatal sepsis.
As regard symptoms, about 50% of cases presented with convulsions, 16% presented by apnea, 8% presented by irritability, 20% presented by anemia,10% presented by jaundice, 22% presented by poor suckling and 2% presented by vomiting. So the most associated symptoms were convulsions followed by poor suckling and anemia respectively.
As regard outcome in our study, 8% had grade I, 14 % had grade II, 32% had grade III, 12%had grade IV, 14.5% had subdural hemorrhage and 20% had subarachnoid hemorrhage. So most patients have grade III intracranial hemorrhage and subarachnoid hemorrhage. According to the severity, in our study patients who had mild intracranial hemorrhage represented 48% and patients with moderate intracranial hemorrhage represented 30% and patients with severe intracranial hemorrhage represented 22%.
All newborns with subarachnoid hemorrhage showed a complete recovery. Disability is more likely to occur in a newborn with frontal lobe hemorrhage or when multiple intracranial compartments are involved and this was confirmed in our study which showed that all patients with subarachnoid hemorrhage had no neurological abnormalities in the follow up and patients who had grade III intracranial hemorrhage associated with the highest incidence of associated neurological abnormalities (71.43%). 33% of patients had abnormal neurological outcome in the follow up at the age of six months in the form hypotonia, spasticity, hydrocephalus, apathy and poor activity. These patients required physical, occupational, and/or speech therapy services. Hydrocephalus has reported in 6 cases in our study that required surgical intervention.
Conclusion:
Intracranial hemorrhage is a heterogeneous disorder with variable risk factors, etiologies, and neurologic outcome. Intraventricular hemorrhage (IVH) is mostly documented in premature infants, and the younger the gestational age, the more often it occurs .IVH is very rarely reported in full-term and late preterms neonates and may occur in these children with a variety of risk factors, in our study we tried to identify these risk factors and also the outcome and we found that the most frequent associated risk factors were absence of vitamin K administration followed by prolonged labour then neonatal sepsis. As regard outcome, 33% of patients had abnormal neurological outcome in the follow up at the age of six months in the form hypotonia, spasticity, hydrocephalus, apathy and poor activity. These patients required physical, occupational, and/or speech therapy services. Hydrocephalus had reported in 6 cases in our study that required surgical intervention.
Our recommendations are to inform pediatricians to raise their clinical suspicion to intracranial hemorrhage in neonates, detailed physical examination should be done including vital signs, state of consciousness, and abnormal posture or movement. Also we strongly recommend the importance of vitamin K administration because of its important role in the prevention of hemorrhagic disease of the newborns. Prolonged labor is one of the important risk factors of intracranial hemorrhage in neonates so good antenatal care and good obstetric evaluation to the risk factors will decrease the incidence of intracranial hemorrhage in neonates. AS intracranial hemorrhage is an important cause of neonatal morbidity and mortality, early diagnosis and prevention will improve the neurodevelopmental outcome.