A novel quantitative simple brain metric using MR imaging for preterm infants

BACKGROUND AND PURPOSE

The application of volumetric techniques to preterm infants has revealed brain volume reductions. Such quantitative data are not available in routine neonatal radiologic care. The objective of this study was to develop simple brain metrics to compare brain size in preterm and term infants and to correlate these metrics with brain volumes from volumetric MR imaging techniques.

MATERIALS AND METHODS

MR images from 189 preterm infants <30 weeks' gestational age or <1250 g birthweight scanned at term-equivalent age and 36 term infants were studied. Fifteen tissue and fluid measures were systematically evaluated on 4 selected sections. The results were correlated with total brain, gray matter, white matter, and CSF volumes.

RESULTS

The mean bifrontal, biparietal, and transverse cerebellar diameters were reduced (-11.6%, 95% confidence interval [CI], -13.8% to -9.3%; -12%, 95% CI, -14% to -9.8%; and -8.7%, 95% CI, -10.5% to -7% respectively) and the mean left ventricle diameter was increased (+22.3%, 95% CI, 2.9%-41.6%) in preterm infants (P < .01). Strong correlations were found between the bifrontal and biparietal measures with total brain tissue volume, whereas the size of the ventricles and the interhemispheric measure correlated with CSF volume. Intraobserver reliability was high (intraclass correlation coefficients [ICC], >0.7), where interobserver agreement was acceptable for tissue measures (ICC, >0.6) but lower for fluid measures (ICC, <0.4).

CONCLUSIONS

Simple brain metrics at term-equivalent age showed smaller brain diameters and increased ventricle size in preterm infants compared with full-term infants. These measures represent a reliable and easily applicable method to quantify brain growth and assess brain atrophy in this at-risk population.

Traumatic arteriovenous malformation following maxillary Le Fort I osteotomy

OBJECTIVE

Complications following maxillary Le Fort I osteotomy are rare. The authors present the rare complication of an arteriovenous malformation following such a procedure in a 25-year-old woman with a cleft lip and palate that was treated successfully with radiologically guided embolization.

Odontogenic keratocyst in a 5-year-old child: a rare cause of maxillary swelling in children

Odontogenic keratocysts in children are uncommon. They are cysts of the jaws that have a tendency for recurrence and are usually seen in adults. We report an exceptionally rare case in a young child and discuss its management.

Developmental coordination disorder at 8 years of age in a regional cohort of extremely-low-birthweight or very preterm infants

The aims of this study were to determine the motor outcome of extremely-low-birthweight (ELBW; <1000g) or very preterm (<28wks) children compared with normal birthweight (NBW) children, to establish the perinatal associations of developmental coordination disorder (DCD) and its cognitive and behavioural consequences. Participants were consecutive surviving ELBW or very preterm children and randomly selected NBW(>2499g) children born in the state of Victoria, Australia, in 1991 or 1992. Main outcomes were: (1) results of the Movement Assessment Battery for Children (MABC) at 8 years of age; (2) cognitive function; (3) academic progress; and (4) behaviour. Of 298 consecutive ELBW/very preterm survivors, 255 (85.6%; 117 males, 138 females) had the MABC at a mean age of 8 years 8 months. More ELBW/very preterm children (9.5%) had DCD than the NBW group (2%, p=0.001). Only male sex increased the likelihood of DCD in ELBW/very preterm children (p=0.017). ELBW/very preterm children with DCD had worse cognitive function and academic test scores (up to 1SD below those without DCD); they also had more adaptive behaviour and externalizing problems, but not internalizing problems. DCD is more common in ELBW/very preterm children, has few perinatal correlates, and is associated with poor cognitive and academic performance as well as increased behaviour problems.

The conservative management of facial fractures: indications and outcomes

BACKGROUND

With little in the published literature on the conservative management of facial fractures we set out to determine whether our current criteria for treatment are valid.

METHOD

Two hundred and thirty adult patients with fractures of the facial skeleton were treated conservatively by our unit between February 1997 and January 2003. Their notes were reviewed retrospectively.

RESULTS

Most patients were males (76%), the average age was 38 years, and drugs or alcohol were a significant aspect of the history in 30% of the cases. The most common mechanism of injury was assault (47%), followed by falls and sporting injuries. Fifty percent of the fractures involved the orbital or orbito-zygomatic complex, and 55% had associated injuries. Average follow-up was for six weeks (range 0-44 weeks). Most patients were managed conservatively based on our current criteria of un-displaced/minimally displaced fracture (57%); or minimal/no symptoms (24%). At final review, a number had residual symptoms, but only three required corrective surgery. The other reasons for conservative management included patient non-compliance (11%), and medical contraindications (8%).

CONCLUSION

Our results support current indications for the conservative management of facial fractures, but emphasise the need for ongoing follow-up of these patients.

Three-dimensional computed tomography cephalometry of plagiocephaly: asymmetry and shape analysis

OBJECTIVE

To investigate facial asymmetry associated with both deformational and synostotic plagiocephaly and to identify variables based on skeletal landmarks that distinguish the conditions and quantify severity.

DESIGN

Retrospective, cross sectional.

SETTING

Australian Craniofacial Unit, Adelaide.

MAIN OUTCOME MEASURES

Proportional differences between bilateral distances and principal component (PC) analysis of the skeletal landmarks.

PATIENTS

The three-dimensional positions of 78 osseous landmarks were determined from computed tomography (CT) scans of 21 patients with deformational plagiocephaly (DP), 20 patients with unilateral coronal synostosis (UCS), and 2 patients with unilateral lambdoid synostosis (ULS).

RESULTS

For both DP and UCS, significant asymmetry was found for the orbital depths, mandibular lengths, maxillary depths, zygomatic arch lengths, lateral base of the parietal bone, and the angle between the anterior and the posterior cranial base projected onto the axial plane. The small sample size for ULS precluded definitive statistical statements but allowed some useful comparisons with the other conditions. The first three PC scores were able to distinguish among the three conditions and which side was affected.

CONCLUSIONS

The asymmetry of the cranial base and facial structures, arising from localized abnormality or deformational forces in either the frontal or the occipital regions, can be quantified by a plethora of bilateral features or summarized by PC analysis.

An unusual complication of mandibular distraction

BACKGROUND

The authors present an unusual complication of mandibular distraction in a child with the curious condition of multiple pterygium syndrome is presented.

CASE REPORT

The patient was a Caucasian male with severe pterygia in his neck. As a result of his limited mouth opening and restricted upper airway leading to obstruction, he underwent lengthening of his mandible by distraction, which significantly improved his breathing. During his follow-up, it was observed that an unusually elongated permanent molar was present in an abnormal position.

CONCLUSION

This case highlights the need to carefully plan the sites for osteotomy and the potential for damage to the developing permanent dentition in young children.

Do Craniosynostosis Syndrome Phenotypes with Both FGFR2 and TWIST Mutations have a Worse Clinical Outcome?

We present three cases with both FGFR2 mutations and novel TWIST sequence variants. The clinical outcome in this cohort is compared with that in individuals with a single mutation.

Differences in the single-oral-dose pharmacokinetics and urinary excretion of paracetamol and its conjugates between Hong Kong Chinese and Caucasian subjects

BACKGROUND AND OBJECTIVES

The present study was conducted to determine if ethnic differences exist for single oral dose pharmacokinetics of paracetamol and its conjugates between Hong Kong Chinese and Caucasian subjects.

METHODS

Twenty healthy Chinese (n = 11) and Caucasian (n = 9) subjects, aged 21-44 years, 11 male and nine female, were given oral paracetamol syrup 20 mg/kg, following an overnight fast. Paracetamol and its metabolites (glucuronide, sulphate, cysteine and mercapturic acid conjugates) were measured in serial plasma samples (0.25, 0.5, 0.75, 1.0, 1.5, 2, 3,...,12, 24 h) and urine collections (0-24 h) by high-performance liquid chromatography.

RESULTS

In Chinese subjects, the (mean range) peak plasma concentration of paracetamol was 23.8 mug/mL (17.9-32.3) and time to attain this peak 0.66 h (0.5-0.75). This was lower (P < 0.015) at 18.7 microg/mL (14.4-22.9) and achieved later (P < 0.033) at 1.06 h (0.5-2.0) in Caucasians. In Chinese subjects, plasma levels of glucuronide were lower, sulphate higher and cysteine conjugates significantly lower than in Caucasians (P < 0.05). Chinese subjects excreted 6% more sulphate and 5% less glucuronide. They also excreted significantly less mercapturic acid conjugates (P < 0.001).

DISCUSSION AND CONCLUSION

Chinese subjects show more rapid absorption of paracetamol, a tendency to produce less glucuronide but more sulphate conjugates and reduced production of cysteine and mercapturic acid conjugates. The latter may help to protect against hepatotoxicity following paracetamol overdose.

Improved neurosensory outcome at 8 years of age of extremely low birthweight children born in Victoria over three distinct eras

AIM

To determine neurosensory outcome at 8 years of age of extremely low birthweight (ELBW) children born in the 1990s, how it varies with birth weight, and how it compares with ELBW children born in the 1980s and 1970s.

METHODS

Subjects were born in the state of Victoria during 1991-92 and comprised 224 of 241 consecutive survivors with a birth weight of 500-999 g, and 223 of 262 normal birthweight (NBW) controls who had been randomly selected at birth. The comparison cohorts from earlier eras comprised 87 of 89 consecutive ELBW survivors born in 1979-80, 206 of 212 consecutive ELBW survivors born in 1985-87, and 51 of 60 randomly selected NBW survivors born in 1981-82. Survivors were assessed for neurological impairments (cerebral palsy, blindness, deafness, intellectual impairment) and disabilities at 8 years of age by paediatricians and psychologists blinded to perinatal details.

RESULTS

For the 1991-92 cohorts, the rate of neurosensory disability was substantially higher in ELBW children compared with NBW controls (p<0.0001). Within the ELBW group, neurosensory disability was more prevalent in children with a birth weight of <750 g compared with a birth weight of 750-999 g (p = 0.024). Disability rates were lower in the 1991-92 ELBW cohort compared with the ELBW cohort born in 1979-80 (p = 0.046).

CONCLUSIONS

Neurosensory disability rates at school age were more common in ELBW children born in the 1990s compared with NBW controls, and were significantly more common in the 500-749 g birthweight subgroup, but have improved compared with ELBW children born in earlier eras.

Neurodevelopmental sequelae of intraventricular haemorrhage at 8 years of age in a regional cohort of ELBW/very preterm infants

BACKGROUND

Major grades of intraventricular haemorrhage (IVH) are associated with adverse neurodevelopmental sequelae in early childhood but the extent of problems in specific cognitive areas, such as executive function, and the contribution of lesser grades of IVH to neurodevelopmental problems at school age are not well described.

AIMS

To determine the neuromotor, cognitive and educational outcome of extremely low birthweight (ELBW, birthweight <1000 g) or very preterm (<28 weeks) infants at 8 years of age related to the severity of IVH diagnosed in the newborn period.

DESIGN

Regional cohort study.

PATIENTS

Consecutive surviving children of either birthweight <1000 g or gestational age <28 weeks born in the state of Victoria in 1991 or 1992.

MAIN OUTCOME MEASURES

Neurological impairments and disabilities, cognitive function and academic progress.

RESULTS

Of 298 consecutive ELBW/very preterm survivors 270 (90.6%) with cranial ultrasound data were assessed at 8 years of age. Cerebral palsy, poor motor performance and major neurosensory disability were more prevalent with increasing severity of IVH. Cognitive functioning across domains was worse with increasing severity of IVH. Most of the differences were attributable to the few (n=6) survivors who had grade 4 IVH; there were few substantial differences between survivors with lesser grades of IVH.

CONCLUSIONS

Neurodevelopmental dysfunction at school age in ELBW/very preterm survivors varies little with increasing severity of IVH, with the exception of grade 4 IVH.

Multidisciplinary management of Opitz G BBB syndrome

Opitz G BBB syndrome is a rare condition characterized by the 3 major anomalies of hypertelorism, cleft lip and palate, and hypospadias, although there may be other associated anomalies. The underlying genetic causes are complex and consist of both X-linked recessive and autosomal dominant forms of the disorder. Previously, there have been publications on the underlying genetics and case reports, but there have been few reports regarding the long-term outcome. The aim in this study was to review the range of clinical presentation and evaluate outcomes of the multidisciplinary management of a cohort of patients with Opitz G BBB syndrome. In a 25-year period, 7 patients with Opitz G BBB syndrome were managed by the Australian Craniofacial Unit (ACFU), 5 male and 2 female. Most of the patients are now reaching skeletal maturity. Each one presented with a range of severity in the triad of hypertelorism, cleft lip and palate, and hypospadias anomalies. The males all exhibited the triad of anomalies, while the females both had hypertelorism, only 1 had isolated cleft palate, and neither had any genitourinary anomalies. Each patient underwent multidisciplinary assessment to make a treatment plan for staged management of different anomalies. Plan for surgical corrections of facial anomalies were performed according to the unit's protocol management of both hypertelorism and cleft lip and palate, but the presence of these coexisting anomalies required adjustment of the standard protocol of management of cleft lip and palate. In conclusion, we recommend that patients with Opitz G BBB syndrome require careful evaluation, and management of the anomalies should be in a coordinated manner by a multidisciplinary team.