Raul Bejar

Antenatal origin of neurologic damage in newborn infants. I. Preterm infants.

Currently, the diagnosis of white matter necrosis may be performed with echoencephalography when cysts are observed in the white matter adjacent to the lateral ventricles. One hundred twenty-seven infants with a gestational age

Echoencephalographic findings in neonates assciiated with maternal cocaine and methamphetamine use: Incidence and clinical correlates

Term neonates (n = 74) exposed antenatally to cocaine, methamphetamine, or cocaine and a narcotic but without any other known perinatal complications were prospectively examined with cranial ultrasonography to detect the presence of central nervous system injury. These studies were compared with those of a drug-free but clinically ill group of infants (n = 87) at risk for hypoxicischemic encephalopathy, and with those of infants who were well. Cranial abnormalities were detected by ultrasonography in 35.1% of the drug-exposed infants, similar to the incidence in the infants at risk for hypoxic-ischemic injury (p = 0.7) but significantly greater than the 5.3% incidence of abnormalities in normal infants (p less than 0.001). The lesions in the drug-exposed infants were intraventricular hemorrhage, echodensities known to be associated with necrosis, and cavitary lesions; they were focused in the basal ganglion, frontal lobes, and posterior fossa. The presence of ultrasonographic abnormalities was not predicted by standard neonatal clinical assessment or by other perinatal risk factors present in the drug-using population. The types of cerebral injury are consistent with those seen in adult cocaine and methamphetamine abusers and are probably related to the vasoconstrictive properties of these drugs. Antenatal exposure to stimulant drugs is associated with significant risk for cerebral injury, even among seemingly normal term neonates.

Antenatal origin of neurologic damage in newborn infantsII. Multiple gestations

Necrosis of the cerebral white matter may be identified in living infants with echoencephalography. Echoencephalographic studies were performed in 89 twins and 12 triplets at less than 36 weeks of gestation to determine the incidence and complications associated with antenatal necrosis of the cerebral white matter. Antenatal necrosis of the cerebral white matter was identified when brain atrophy or cavities in the white matter were present by day 3 of life. Fourteen infants (13.8%) were considered to have antenatal necrosis of the cerebral white matter. The incidence of antenatal necrosis of the cerebral white matter was higher in monochorionic than in dichorionic infants (30% vs 3.3%; p less than 0.001). Univariate analysis showed that antenatal necrosis of the cerebral white matter was significantly associated with polyhydramnios, intrauterine fetal death of the cotwin, hydrops, multiple placental vascular connections, and placental artery-to-artery, vein-to-vein, and artery-to-vein anastomosis. Logistic regression analysis showed that antenatal necrosis of the cerebral white matter was predicted by the presence of either artery-to-artery or vein-to-vein anastomosis and by intrauterine fetal death of a cotwin. Vein-to-vein anastomosis had the strongest association, because 89% of seven infants with vein-to-vein anastomosis demonstrated antenatal necrosis of the cerebral white matter (p = 0.003). Monochorionic multiple gestations frequently are complicated by antenatal necrosis of the cerebral white matter. Multiple vascular connections with vein-to-vein anastomosis appear as the most important associated factor for antenatal necrosis of the cerebral white matter in this population.

Placement of umbilical venous catheters with use of bedside real-time ultrasonography

Real-time ultrasonography was used to assess the position of umbilical venous catheters tips in 79 newborn infants (birth weight range, 400 to 4200 gm). The position of the umbilical venous catheters determined by ultrasonography was compared with the projection of the catheter tip on the closest vertebral body shown on a standard chest radiograph. Of the catheters initially placed with radiographic guidance, 56% were repositioned because of unsatisfactory location. Ultrasonography is more precise than radiography because it allows direct visualization of the catheter tips in relation to internal vascular structures. When ultrasonography is unavailable, placement at the ninth thoracic vertebral body ensures safe positioning.

Ventriculoperitoneal Shunts in Low Birth Weight Infants with Intracranial Hemorrhage: Neurodevelopmental outcome

Fifty preterm infants (mean birth weight, 1266 +/- 303 g; mean gestational age, 30 +/- 2 weeks) who required a ventriculoperitoneal (VP) shunt for posthemorrhagic hydrocephalus (92% with Grade III or IV hemorrhage) were followed for neurodevelopmental problems. VP shunts were placed at a median age of 29 days (range, 18 to 87 days) after serial lumbar punctures failed to control progressive and symptomatic ventriculomegaly. A total of 34 infants (68%) required one shunt revision or more, and the overall infection rate per patient was 50%. Seven infants died, 2 from shunt infections. The infants were evaluated with audiological, ophthalmological, and neurodevelopmental examinations. Of the survivors, 11 (28%) have severe visual loss and 10 (24%) have hearing impairment. Of the infants, 21 (49%) have severe motor handicaps and 19 (38%) have seizure disorders. Developmental and motor scores were obtained using the Bayley or Knobloch-Gesell scales. Seven infants (18%) have normal developmental outcomes; 26 (60%) have multiple handicaps. Grade IV hemorrhage or the occurrence of seizures was a predictor of poor neurodevelopmental outcome. We conclude that progressive posthemorrhagic hydrocephalus in low birth weight infants is associated with multiple handicaps despite early VP shunt placement.

Maternal floor infarction of the placenta: Association with central nervous system injury and adverse neurodevelopmental outcome

OBJECTIVE: To compare cranial ultrasound studies and neurodevelopmental outcome of preterm infants affected by maternal floor infarction (MFI) of the placenta to gestational age-matched controls over an 8-year period from a single institution.STUDY DESIGN: Retrospective case/control study.RESULTS: Compared to gestational age-matched controls, infants born to mothers with MFI had a higher incidence of CNS injury on neonatal cranial ultrasound examinations and at follow-up were more likely to have a suspicious or abnormal neurologic examination. MFI cases had lower developmental scores in all areas tested and were more likely to have neurodevelopmental impairment.CONCLUSION: Infants born to mothers with MFI should have serial neonatal cranial ultrasound examinations to detect CNS injury and neurodevelopmental assessment during early childhood.

Positive rolandic sharp waves in the EEG of the premature infant

Ninety-seven EEGs from 30 premature infants found to have multifocal white matter necrosis on ultrasound (US) or autopsy were reviewed retrospectively. Twenty infants had intraparenchymal echodensities on US that developed into cystic lesions, a finding consistent with periventricular leukomalacia; 8 had intraparenchymal hemorrhages; and 2 had white matter necrosis at autopsy. Four of these infants had no intraventricular hemorrhage. Positive sharp waves in the central (rolandic) regions (PRS) were identified in 22 of these 30 infants (73%) and in 0 of 30 age-matched controls (p < 0.001). The presence of PRS on the EEG of the premature infant has a high correlation with white matter necrosis rather than with intraventricular hemorrhage. In all cases, this EEG pattern was present prior to the development of cavitations when echodensities were present on US.

Predictors of early childhood outcome in candidates for extracorporeal membrane oxygenation

OBJECTIVE To examine the effect of neonatal risk factors and treatment strategy on pulmonary, growth, and neurodevelopmental outcome of candidates for extracorporeal membrane oxygenation (ECMO). DESIGN We prospectively assessed growth and neurodevelopmental outcome in a cohort of 190 neonates who had severe respiratory failure, no major congenital anomalies, and met institutional criteria for the use of ECMO. The relationships among perinatal risk factors, neonatal outcome, postnatal growth, and neurodevelopmental outcome were studied by univariate and multivariate analyses. RESULTS Compared with 52 infants successfully treated with conventional or high-frequency ventilation, the 138 ECMO survivors were more mature, had earlier, more severe pulmonary disease, and were more likely to have meconium aspiration. The ECMO survivors had significantly fewer ventilator days (9 vs 11), hospital days (23 vs 29), and less (12% vs 25%) chronic lung disease (CLD). At 12 to 30 months, mean developmental scores of ECMO survivors were similar to those of infants who survived without ECMO. Infants with CLD had significantly lower motor scores (86 +/- 23 vs 100 +/- 19) and were more likely to have cerebral palsy (27% vs 6%) than those without CLD. The risk of adverse neurodevelopmental outcome was independently increased by CLD (odds ratio, 2.4; confidence interval, 1.2 to 4.6) and moderate or severe neonatal neuroimaging abnormalities (odds ratio, 6.4; confidence interval, 1.9 to 21.9). CONCLUSIONS Neonatal ECMO candidates treated with ECMO did as well or better than neonates whose conditions were managed with alternate treatment strategies. Adverse neurodevelopmental outcome was predicted by moderate or severe neonatal neuroimaging abnormalities and CLD, not by treatment with ECMO.

NEONATAL SUBEPENDYMAL GIANT CELL ASTROCYTOMA ASSOCIATED WITH TUBEROUS SCLEROSIS : MRI, CT, AND ULTRASOUND CORRELATION

We describe a term newborn with tuberous sclerosis who presented with a neonatal brain tumor, diagnosed as a subependymal giant cell astrocytoma. We compare the various imaging modalities used in the diagnosis of this tumor.

Prolonged bleeding time in preterm infants receiving indomethacin for patent ductus arteriosus

Sequential bleeding times were performed on 25 preterm infants receiving intravenous indomethacin for closure of the patent ductus arteriosus. Prolongation of bleeding time was observed after the initial dose of indomethacin, with an increase from a pretreatment mean of 3.6 minutes to 8.7 minutes. The bleeding time was not further prolonged at the end of the three-dose course of indomethacin, but was still elevated 48 hours after the completion of therapy. Clinical bleeding developed in six of the patients, but was generally limited to occult hematuria. Serial echoencephalography during indomethacin therapy showed progression from mild periventricular-intraventricular hemorrhage to moderate or severe grades in five of 21 infants at risk for this complication. However, no clear temporal relationship between indomethacin administration and intraventricular hemorrhage extension was observed, and no difference in the degree of bleeding time prolongation was noted between infants with and without hemorrhage extension. Other factors, including surfactant deficiency, amount of volume expansion used, and lowest PO2 in the first day of life, did distinguish those with hemorrhage extension. The results suggest that indomethacin-induced platelet dysfunction is not associated with major hemorrhagic complications in the majority of preterm infants with patent ductus arteriosus.