Chantrapa Bunyapen

Right common carotid artery ligation in extracorporeal membrane oxygenation

The effect of right common carotid artery ligation required for arteriovenous extracorporeal membrane oxygenation (ECMO) was investigated in 35 infants. Their neonatal course was reviewed for evidence of right-sided ischemia of the brain, as suggested by the presence of focal seizures, hemiparesis, focal abnormalities on electroencephalography, or infarct or hemorrhage demonstrable on neuroimaging studies. A significant incidence of left focal seizures (9/35) versus right focal seizures (2/35) was noted, suggesting an effect of the carotid ligation on right hemisphere function. Computed tomographic scans (20/35 infants), electroencephalograms (18/35), ultrasound scans (31/35), and neurologic examinations did not reveal an increased incidence of right hemisphere abnormalities. These data suggest that systematic evaluation of the effects of right common carotid ligation should proceed as discussion continues on expanding the use of ECMO.

Significance of seizures associated with extracorporeal membrane oxygenation

We previously reported a predominance of left focal motor seizures in infants receiving extracorporeal membrane oxygenation (ECMO), raising concerns about possible ischemia resulting from the right common carotid artery ligation. We therefore evaluated the neurologic and psychologic outcome at 2 years of age of all infants with ECMO-related seizures. Although 8 of 12 infants had left focal seizures in infancy, there was no lateralization of motor findings at 2 years of age; left hemiparesis was present in three of the infants and right hemiparesis in three. The developmental quotient was normal in 6 of 12 infants, low-average in three, borderline in two, and in the mentally handicapped range in one. We conclude that any ischemia resulting from carotid ligation is not great enough to produce long-term lateralizing findings but that seizures during ECMO are a risk factor for later cerebral palsy or developmental delay.

Seizures as a predictor of long-term neurodevelopmental outcome in survivors of neonatal extracorporeal membrane oxygenation (ECMO)

A longitudinal, prospective study was conducted to determine the long-term neurodevelopmental outcome in neonatal extracorporeal membrane oxygenation (ECMO) survivors with and without seizures. One hundred sixty-two ECMO survivors from March 1985 until November 1995 were eligible for follow-up. Sixty-four returned at preschool age (4—6 years). Thirty-nine infants did not experience neonatal seizures (group 1); however, 25 exhibited seizures before or during ECMO (group 2). Twelve infants referred for ECMO, but managed medically, served as a clinical comparison group (group 3). At school age (7—9 years), 32 ECMO children (16 with seizures) returned for neuropsychologic evaluation. The results indicated that the preschool seizure group (group 2) demonstrated a significantly lower mean IQ than group 1 or 3 (P = .002). Furthermore, 56% of group 2 had IQ scores ≤ 84 (≥ 1 SD below the mean). Group 2 also exhibited significantly higher rates of cerebral palsy (P ≤ .001) and speech-language disorder than group 1 or 3 (P < .001). At school age, the seizure group continued to perform below average on intelligence testing, with 50% scoring ≤ 84 and 38% receiving special education. This study extends the previous findings that seizures associated with neonatal ECMO are a primary risk factor for neurodevelopmental sequelae and confirms the need for long-term follow-up to assist with academic programming. (J Child Neurol 2004;19:930—934).

Predicting the Need for Exchange Transfusion in Newborn Infants A Comparison of Five Methods

The need for exchange transfusion was analyzed retrospectively using several different meth ods (total bilirubin binding capacity, birth weight, plasma protein level, and two published charts). These predictive methods were applied to 175 jaundiced infants for whom all the data were available and to 19 infants who were actually exchanged. Most of the patients were sick, premature infants. This study demonstrates the lack of agreement among the predictive methods.

Atypical presentation of a lacrimal duct cyst

A 40-week female term infant was born to a 20-year-old primagravida. Complications during pregnancy included a twovessel cord noted on prenatal ultrasound, trichomonas infection (treated during pregnancy) and a positive Group-B streptococcus status (treated prior to delivery). The infant was delivered by Cesarean section due to failure to progress. Apgar scores were 8 and 9 at 1 and 5 min, respectively. During the initial exam in the delivery room, the infant was noted to have an imperforate anus and the two-vessel cord was verified. An attempt was made to place a nasogastric (NG) tube, but it was very difficult to insert due to resistance. It was left at 10 cm and the infant was transferred to a tertiary medical center for further evaluation and care. On admission, the infant had increased work of breathing including tachypnea, nasal flaring and retractions. On the initial chest radiograph, the NG tube was not seen even though it was in the left nare at 10 cm. The NG tube was removed and an orogastric tube was placed. The subsequent radiograph showed the tube in proper placement with the tip in the stomach. After removal of the NG tube, the work of breathing improved significantly. Otolaryngology was consulted to evaluate the infant for choanal stenosis and they performed a bedside nasolaryngoscopy. They successfully passed a 5-French NG tube and prescribed intranasal neosynephrine to decrease any nasal inflammation that may have caused the obstruction. After the intervention, the neonatal team remained concerned about the infant’s breathing pattern so a computerized tomography scan of the sinuses was obtained to evaluate for choanal stenosis or atresia. The results showed a hypodense soft tissue mass involving the left lacrimal sac, which extended through the nasolacrimal duct into the inferior meatus (Figure 1). The mass measured 8.3 mm (anterior-posterior) by 6 mm (transverse) by 6 mm (craniocaudal). The choanae were normal although the mass displaced the inferior turbinate superiorly and medially. The formal diagnosis was a nasolacrimal duct mucocele (dacryocystocele). Pediatric ophthamology was consulted to evaluate and treat the dacryocystocele. The infant was taken for a nasolacrimal duct probing of the left eye. The puncta was noted to be very small and initially difficult to probe. It eventually dilated and a size 1.0 probe was placed through the lacrimal duct and dacryocystocele. The dacryocystocele was extracted through the nose. The infant’s postoperative course was unremarkable. A computerized tomography scan of the head was obtained on postoperative day 2 and showed interval resolution of the left lacrimal duct mucocele.

SCHOOL-AGED FOLLOW-UP OF EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) SURVIVORS. † 86

Prior results on 6 year olds showed that only those with ECMO and neonatal seizures performed poorly on some measures of intelligence, language, and academic skills. This study included 23, 7-9 year old ECMO graduates. Similar measures of intellectual, language, and academic skills were used in conjunction with memory and sensory-motor measures. Moreover, Language, Visual-Spatial, Verbal Memory, and Visual Memory Standard Score Quotients were created by grouping subtests purported to measure these constructs. Groups were divided by neurological findings (15 abnormal; 8 normal). No significant differences were detected. However, those children with abnormal findings approached significance on the Language, Visual-Spatial, and Visual Memory Quotients, the Stanford-Binet (4th ed.) Composite, the Arithmetic subtest of the Wide Range Achievement Test-Rev., and Failure to Maintain Set on the Wisconsin Card Sorting Test. A case-by-case analysis performed with the GA State Special Education Regulations revealed that 50% with normal and 53% with abnormal findings fit the criteria for a Learning Disability (LD). Thus, despite infant neurological status, school-aged ECMO survivors are at a 3 fold risk of having a LD compared to normals (14%). Further studies are needed to determine whether hypoxia and/or ECMO (specifically) contributes to this risk.