Cerebral ischemia in newborns

Cerebral ischemia is a condition that develops in response to oxygen starvation due to cerebral circulatory failure.

There are acute and chronic cerebral ischemia. Acute ischemia occurs with a sharp development of oxygen starvation and occurs as a transient ischemic attack or ischemic stroke (cerebral infarction). Chronic ischemia develops gradually in response to long-term cerebral circulatory failure.

In this article we will look at chronic cerebral ischemia.

Chronic cerebral ischemia is a special type of cerebral vascular pathology, caused by a slowly progressive diffuse disruption of the blood supply to the brain with gradually increasing various defects in its functioning. The term “chronic cerebral ischemia” is used in accordance with the International Classification of Diseases, 10th revision, instead of the previously used term “dyscirculatory encephalopathy”.

Signs and symptoms of cerebral ischemia in newborns

The disease manifests itself with obvious symptoms that attract attention.

• The child is easily excitable, cries for no reason, sleeps poorly, shudders, and has tremors.
• Muscle tone is reduced, the baby moves little, has difficulty sucking and swallowing.
• The fontanel is enlarged, intracranial pressure is increased due to the fact that fluid accumulates in the brain.
• Convulsions, twitching of the limbs and head, as well as comatose states with loss of coordination of movements and consciousness occur.
• The newborn's skin takes on a marbled hue.
• The functioning of the gastrointestinal tract is disrupted - bloating, constipation, and diarrhea are observed.

Diagnosis of chronic cerebral ischemia

If you suspect chronic cerebral ischemia or any other cerebrovascular accident, you should consult a neurologist. At the Aximed neurology clinic, during a consultation, an experienced specialist will examine the patient’s complaints, clarify his personal and family history, and conduct a physical examination and neurological tests.

Mandatory examinations that the doctor will prescribe are as follows:

• laboratory blood tests
• ophthalmologist consultation
• MRI of the brain
• Dopplerography of head and neck vessels
• electroencephalogram
• therapist consultation
• X-ray of the cervical spine
• and other studies as indicated

How does cerebral ischemia occur?

In 70% of cases, ischemia occurs in the fetus in the womb and is associated with the formation of a blood clot in one of the vessels supplying the brain, or with insufficient development of the vessel. Most often, the disease is diagnosed in premature babies whose vascular system is not yet fully formed.

As a result, an insufficient amount of blood enters the vital organ, and with it, oxygen. Delay in providing medical care leads to damage to larger areas of the brain, cerebral hemorrhage and other serious consequences.

Causes of development of chronic cerebral ischemia

The causes of the development of chronic cerebral ischemia are closely related to atherosclerotic stenosis, thrombosis, and embolism. A certain role is played by post-traumatic dissection of the vertebral arteries, extravasal (extravascular) compression due to pathology of the spine or neck muscles, deformation of the arteries with constant or periodic disturbances in their patency, and hemorheological changes in the blood. It must be borne in mind that symptoms similar to those that occur with chronic ischemia can be caused not only by vascular, but also by other factors - chronic infection, neuroses, allergic conditions, malignant tumors and other reasons with which a differential diagnosis should be made .

Signs of impaired cerebral blood flow are observed in the following diseases:

• hypertension,
• atherosclerosis,
• hypotension,
• vasculitis (inflammation of blood vessels) of allergic and infectious etiology,
• thromboangiitis obliterans,
• skull injuries,
• abnormalities of the cerebral vascular bed and aneurysms,
• disturbances in cardiac activity,
• blood diseases,
• endocrine pathology,
• kidney diseases and other diseases.

The development of chronic cerebral ischemia is promoted by a number of reasons, which are commonly called risk factors. Risk factors are divided into correctable and non-correctable. Uncorrectable factors include old age, gender, and hereditary predisposition. It is known, for example, that a stroke or encephalopathy in parents increases the likelihood of vascular diseases in children. These factors cannot be influenced, but they help to identify in advance those at increased risk of developing vascular pathology and help prevent the development of the disease. The main correctable factors in the development of chronic ischemia are atherosclerosis and hypertension. Diabetes mellitus, smoking, alcohol, obesity, insufficient physical activity, poor nutrition are the reasons that lead to the progression of atherosclerosis and the deterioration of the patient’s condition. In these cases, the blood coagulation and anticoagulation system is disrupted, and the development of atherosclerotic plaques is accelerated. Due to this, the lumen of the artery is reduced or completely blocked. At the same time, the crisis course of hypertension is especially dangerous: it leads to an increase in the load on the blood vessels of the brain.

Causes

In the vast majority of cases, the causes of cerebral ischemia in newborns are various disorders of gestation in recent weeks, as well as non-standard situations during childbirth.

• Detachment of the placenta or disruption of blood flow in it.
• Compression of the umbilical cord, suffocation of the fetus.
• Congenital heart defects.
• Circulatory problems.
• Intrauterine hypoxia.
• Infection during childbirth.
• Openness of the ductus arteriosus.
• Acute placental insufficiency.

Risk factors

Various vascular and neurological pathologies, problems with blood pressure (especially hereditary) in the mother should alert the doctor who is managing the pregnancy. Also, risk factors for cerebral ischemia in a child are:

• mother's age is more than 35 years;
• endocrine diseases;
• premature, prolonged labor;
• multiple pregnancy;
• late toxicosis;
• failure of the mother to follow a healthy lifestyle;
• exacerbation of chronic or acute diseases in the mother during pregnancy.

Diagnostics

The disease is usually diagnosed within the first few hours.

The presence of pathology is indicated by deviations in checking reflexes and a general blood test . Typically, the analysis shows an increased level of carbon dioxide in the body.

If obvious symptoms of a serious illness are detected magnetic resonance imaging , as well as electroencephalography , which reveals hidden convulsions and other abnormalities in the functioning of the brain.

Cerebral ischemia grade 2

A dangerous form of the disease. It is characterized by:

• severe apnea (stopping breathing during sleep);
• decreased grasping and sucking reflexes;
• weak muscle tone;
• increase in head shape due to fluid accumulation;
• lack of coordination;
• loss of consciousness;
• changes in skin color.

Most often, grade 2 ischemia manifests itself in the first day of a newborn’s life, and symptoms can be observed for 2-4 weeks. At this time, the child is carefully monitored by doctors, and he undergoes a course of therapy. If necessary, surgery is performed to remove the blood clot.

Hypoxic-ischemic encephalopathy in children

A neurological examination of a newborn child should begin with the standardization of examination conditions, since inadequate room temperature and the nature of lighting affect the resulting reflexes, reactions, etc. The examination is carried out at the optimal room temperature of about 24-26 ° C after 1-2 minutes of adaptation of the child in the unfolded position. form under a radiant heat source. At low temperatures, it is more likely to get a reaction of increased muscle tone and tremor, at high temperatures - muscle hypotension. Lighting should be symmetrical in relation to the newborn, since light incident on one side causes a narrowing of the pupil and palpebral fissure on the side of illumination. During examination, it is necessary that the child’s head is in the sagittal plane, since due to the asymmetric cervical-tonic reflex, a decrease in muscle tone is noted on the side of the head rotation, and an increase on the opposite side.

It is also necessary to take into account the time that has passed since the last feeding, since after saturation the baby is relaxed, he may have reduced muscle tone and a number of reflexes and reactions, and before feeding the newborn may be in a state of relative hypoglycemia, leading to restlessness, tremors and increased muscle soreness. tone.

Next, it is advisable to determine the state in which the newborn is, since the same indicators of reflexes and reactions can be physiological for one state of the child and pathological for another.

The sociability of a newborn as the main indicator of general activity is assessed by the reaction of displeasure in the presence of discomfort (forced awakening, hunger, wet diapers, etc.) and the speed of calming when eliminating irritating factors, as well as by the response to positive stimuli (response to affectionate speech, stroking, picking up).

The interaction between the child and the doctor is essential in determining the communication skills and behavior of a newborn, and therefore the role of not only the newborn’s reactions is important, but also the doctor’s persistence in receiving them, his positivity towards the child during examination. To assess a child’s sociability, the difference in auditory and visual reactions to animate (the doctor’s face and voice) and inanimate (artificial and natural light sources, rattle, bell, clap) stimuli is important. The presence of search, palm-oral, grasping reflexes and the Babinsky reflex indicates the presence of tactile sensitivity. Pricking a child with a needle causes frowning of the eyebrows, clenching of the eyes, wrinkling of the nasolabial furrow, opening of the mouth, pouting of the lips, stretching of the mouth, tension of the tongue, trembling of the chin, screaming, as well as a motor reaction: flexion with adduction of the limbs. A painful reaction occurs a few seconds after the application of irritation, which is due to slow conduction through the nerves of the newborn due to insufficient myelination.

A decrease in the listed reactions may be either a sign of depression of the central nervous system as a result of a number of somatic and neurological diseases, or damage to the corresponding analyzer. Thus, lack of response to pain may be a consequence of hereditary sensory polyneuropathy.

Among the signs of the child’s general activity, spontaneous motor activity should be noted. Its assessment is quite subjective and depends on the doctor’s experience, but objectification is possible only by analyzing a video recording of activity for 1 hour. Typically, spontaneous movements consist of periodic flexion and extension of the legs, their crossing, pushing away from the support; movements of the hands at chest level in the elbow and wrist joints with clenching of fists. The presence of a choreoathetoid component in movements, which is physiological for newborns, indicates the predominance of extrapyramidal (striatal) motility and consists in restlessness of the tongue, spreading and independent movements of the fingers.

The facial expressions of a newborn are quite rich and, as a rule, symmetrical and consist of squeezing the eyes, frowning the forehead, deepening the nasolabial folds, tense the tongue, and open the mouth. Facial asymmetry is possible on the first day due to the peculiarities of the passage of the baby’s head through the birth canal. On the other hand, facial asymmetry may be due to damage to the cranial innervation.

The doctor studies the child’s pupils, the movement of the eyeball, the state of the palpebral fissure, etc., the symmetry of mouth opening when yawning and screaming, swallowing, screaming, and the muscles of the tongue.

It should be noted that tremor as a periodic oscillation around a fixed axis of a certain amplitude and frequency occurs in almost half of newborns. Low-amplitude, high-frequency tremor when a newborn is crying or excited, as well as in some stages of sleep, is a physiological phenomenon. In terms of prevalence, tremor can affect the chin, tongue, and limbs.

Muscle tone is the most important characteristic of the motor activity of a newborn. We can talk about the child’s active muscle tone (posture) and passive, the value of which is determined by checking mobility in the joints. A healthy full-term baby has a so-called fetal position due to a flexor increase in tone (arms are bent in all joints, brought to the body and pressed to the chest, hands are clenched into fists, the thumbs of the hands lie under the other four; legs are bent at the joints and abducted in hips, dorsiflexion predominates in the feet). In some cases, a predominant physiological increase in muscle tone in the arms compared to the legs and neck extension are noted. The active muscle tone of the newborn can also be judged by holding the baby in the air face down, with the baby's head in line with the body, the baby's arms slightly bent and legs extended. “Sinking” of the child’s head when he is pulled up by the shoulder girdle (symptom of “flaccid shoulders”) in full-term newborns occurs both with hypoxic parasagittal lesions of the brain and with injury to the cervical spinal cord.

The assessment of reflex activity is carried out on the basis of at least three tests of this reflex. If the reflex amplitude is maintained in all three tests or the amplitude decreases slightly in the third, the reflex is considered normal; if the initial amplitude value is low, persists in three tests or progressively decreases with repeated testing of the reflex, and also if repeated stimulation is necessary to obtain the reflex, it is considered reduced.

Testing of abdominal and cremasteric reflexes is of limited value in neonatology due to their variability in detection and severity.

Of particular importance is checking the reflexes of newborns (“primary”, “unconditioned” reflexes). Most of the reflexes of newborns reflect the evolutionary maturity of the child, his functional state, and only some of them have a specific topical significance. Due to their large number, it is necessary to focus on the most informative ones. When stroking the baby's skin in the area of ​​the corner of the mouth, the head turns towards the stimulus (search reflex), when a finger lightly touches the newborn's lips, the lips stretch (proboscis reflex), and when a pacifier is placed in the mouth, sucking movements occur (sucking reflex). When pressing on the thenar area, the child opens his mouth, tilts his head, bends his shoulders and forearms (Babkin's palmar-oral reflex), when placing fingers in the newborn's hand, the researcher's fingers are grasped (upper grasp reflex), and if the child can be lifted, the Robinson reflex occurs. When the skin of the back along the spine is irritated, the newborn bends the torso in an arc open towards the irritation (Galant reflex). A child raised under the armpits bends his legs in all joints, and when placed on a support, he stands on half-bent legs (support reflex); when bending forward, the child makes stepping movements (stepping reflex), while crossing his legs in the lower third of the lower leg is possible. In the position of the child on his stomach, when the researcher’s palms are applied to his feet, a reflex repulsion and crawling occurs (Bauer reflex). When pressing on the ball of the foot in the area of ​​the II-III toe, plantar flexion occurs (inferior grasping reflex of Verkom), and when the sole is irritated by strokes, its extension and fan-shaped divergence of the toes occurs (Babinsky reflex).

It should be noted that a dynamic study of the state of the nervous system of healthy newborns indicates the presence of transient physiological changes in the neurological status of the child in almost half of the children. Therefore, to classify a particular deviation in the neurological status of a newborn as physiological or pathological, it is necessary to evaluate it in connection with other phenomena, dynamic observation, and in some cases the use of adequate additional research methods.

The neurological status of the newborn can be normal or deviant, and among the options for the latter, one of the following neurological syndromes is noted: increased excitability, muscle hypertension or hypotension, apathy, hemisyndrome; or their combinations. In Russia, the most common classification of lesions of the nervous system in newborns and young children is Yu. A. Yakunin et al. Within the framework of this classification, hypoxic encephalopathy is considered as a particular manifestation of the pathology of the nervous system of this period. In the classification of Yu. A. Yakunin et al. consider the periods of action of the harmful factor: prenatal (embryonic, early fetal) and perinatal (antenatal or late fetal, intranatal and neonatal). The dominant factors, in addition to hypoxia, include trauma, infection, intoxication, inborn errors of metabolism, chromosomal aberrations, unspecified and unclassified conditions. According to the severity, encephalopathy can be mild, moderate, or severe. Among the levels of damage are the meninges, cerebral cortex, subcortical structures, trunk, spinal cord, peripheral nerves, combined forms.

Cerebral ischemia grade 3

The most severe form, in which:

• the baby has no reflexes;
• the child falls into a coma;
• heart rhythm is disrupted;
• blood pressure rises sharply;
• there are problems with independent breathing;
• strabismus is observed.

An experienced doctor can already determine the presence of signs and symptoms of grade 3 cerebral ischemia in the first 5 minutes of a newborn’s life. In this case, the child is sent to intensive care and, if necessary, connected to a ventilator.

Treatment of cerebral ischemia in newborns

The goal of treatment is to restore normal blood circulation in the brain tissue, prevent pathological changes and eliminate the consequences of ischemia. For stage 1 disease, treatment usually involves prescribing massage to improve blood circulation.

For diseases of the 2nd and 3rd degrees, drug therapy and surgery are used to remove a blood clot in the vessel and restore the structure of the vascular bed. In difficult cases, the baby undergoes a rehabilitation course of intensive therapy.

Treatment of chronic cerebral ischemia

Depending on the stage of the disease, its causes and the patient’s condition, different treatment tactics can be chosen.

First of all, treatment measures will be aimed at eliminating the causes of ischemia. For these purposes, medications are used (lowering blood pressure, reducing cholesterol levels and blood viscosity, reducing elevated blood glucose levels, neurometabolics, venotonics, improving cognitive functions, and others. Physiotherapy and therapeutic massages are successfully used in the complex of therapeutic measures. According to indications, surgical intervention is performed - in the presence of tumors, vascular aneurysms, severe heart defects.

When treating grade 2 and 3 cerebral ischemia, the patient needs rehabilitation measures that will slow down the progression of the disease, help alleviate symptoms, social adaptation and improve the quality of life. An individual recovery program will be developed for the patient, taking into account the patient’s current condition, the degree of brain damage and the neurologist’s prognosis.

Neurologists at the Aximed clinic remind you that if treatment for chronic cerebral ischemia is started in a timely manner, the prognosis is positive, however, the disease is prone to progression and complications, therefore, if you have this diagnosis, you must regularly undergo a medical examination and follow the doctor’s instructions regarding medications, diet and a healthy lifestyle .

Prognosis and consequences of cerebral ischemia

It is much more effective to eliminate ischemia itself after the birth of a baby than to treat its complications. Among the consequences of cerebral ischemia of the 2nd degree:

• sleep disorders;
• headache;
• irritability;
• isolation;
• physical inactivity.
• Stage 3 disease has severe consequences:
• cerebral palsy;
• attention deficit disorder;
• mental retardation;
• Graefe's symptom, etc.

If all actions to eliminate ischemia were carried out by doctors in a timely manner, then the symptoms disappear during the rehabilitation period, which usually lasts 6-12 months.

Symptoms and stages of development of chronic cerebral ischemia

Chronic ischemia of the brain is a progressive disease, which is accompanied by increasing disturbances in the functioning of the central, peripheral and autonomic nervous systems. The first signs of the disease often go unnoticed, since they do not have any acute manifestations, but are expressed in general malaise, headaches, drowsiness, absent-mindedness, irritability. Usually this condition is attributed to overwork or age-related changes, however, the onset of cerebral ischemia may be hidden under it. It is very important to seek medical help in a timely manner.

Manifestations of chronic cerebral ischemia are divided into three stages: initial manifestations, subcompensation and decompensation.

Stage 1 is dominated by subjective disorders in the form of headaches and a feeling of heaviness in the head, general weakness, increased fatigue, emotional lability, dizziness, decreased memory and attention, and sleep disturbances. These phenomena are accompanied, although mild, but quite persistent objective disorders in the form of anisoreflexia (difference in symmetrical tendon reflexes), discoordination phenomena, oculomotor insufficiency, symptoms of oral automatism, memory loss and asthenia. At this stage, as a rule, the formation of distinct neurological syndromes (except for asthenic) has not yet occurred, and with adequate therapy, it is possible to reduce the severity or eliminate both individual symptoms and the disease as a whole.

The complaints of patients with the 2nd stage of CCI more often include memory impairment, loss of ability to work, dizziness, instability when walking, and manifestations of an asthenic symptom complex are less often present. At the same time, focal symptoms become more distinct: revival of reflexes of oral automatism, central insufficiency of the facial and hypoglossal nerves, coordination and oculomotor disorders, pyramidal insufficiency, amyostatic syndrome, increased mnestic-intellectual disorders. At this stage, it is possible to identify certain dominant neurological syndromes - discoordination, pyramidal, amyostatic, dysmnestic, etc., which can help in prescribing symptomatic treatment. At this stage, the patient’s social and work activity is already disrupted; in some cases, even in everyday affairs, the help of strangers is already required. It is impossible to completely reverse the changes that have occurred in the nervous system, but it is possible to neutralize the symptoms and slow down the progression of the disease.

At the 3rd stage of CCI, objective neurological disorders in the form of discoordination, pyramidal, pseudobulbar, amyostatic, and psychoorganic syndromes are more pronounced. Paroxysmal conditions—falls, fainting—are more common. In the stage of decompensation, cerebral circulation disorders are possible in the form of “small strokes” or prolonged reversible ischemic neurological deficit, the duration of focal disorders in which ranges from 24 hours to 2 weeks. At the same time, the clinical picture of diffuse insufficiency of blood supply to the brain corresponds to that of moderate encephalopathy. Another manifestation of decompensation may be a progressive “complete stroke” and residual effects after it. This stage of the process with diffuse damage corresponds to the clinical picture of severe encephalopathy. Focal symptoms are often combined with diffuse manifestations of brain failure. Treatment at this stage is rather supportive in nature, since most of the brain damage and functions lost as a result are irreversible.

Along with the progression of neurological symptoms, as the pathological process develops in the neurons of the brain, an increase in cognitive disorders occurs. This applies not only to memory and intelligence, which are impaired in the 3rd stage to the level of dementia, but also to such neuropsychological syndromes as praxis (the ability to perform successive complexes of conscious voluntary movements and perform purposeful actions according to a plan developed by individual practice) and gnosis (recognition of objects ( objects, persons) with the preservation of elementary forms of sensitivity, vision, hearing. Initial, essentially subclinical disorders of these functions are observed already in the 1st stage, then they intensify, change, and become distinct. The 2nd and especially 3rd stages of the disease are characterized by severe disorders of higher brain functions, which sharply reduces the quality of life and social adaptation of patients.

Regardless of at what stage signs of chronic cerebral ischemia are detected, it is important to consult a doctor as quickly as possible, since at an early stage of the disease the changes are still reversible, and at later stages it is possible to stop the progression of the disease and improve the quality of life and social adaptation.