Effect of allopurinol on postasphyxial free radical formation, cerebral hemodynamics, and electrical brain activity

OBJECTIVE

Free radical-induced postasphyxial reperfusion injury has been recognized as an important cause of brain tissue damage. We investigated the effect of high-dose allopurinol (ALLO; 40 mg/kg), a xanthine-oxidase inhibitor and free radical scavenger, on free radical status in severely asphyxiated newborns and on postasphyxial cerebral perfusion and electrical brain activity.

METHODS

Free radical status was assessed by serial plasma determination of nonprotein-bound iron (microM), antioxidative capacity, and malondialdehyde (MDA; microM). Cerebral perfusion was investigated by monitoring changes in cerebral blood volume (delta CBV; mL/100 g brain tissue) with near infrared spectroscopy; electrocortical brain activity (ECBA) was assessed in microvolts by cerebral function monitor. Eleven infants received 40 mg/kg ALLO intravenously, and 11 infants served as controls (CONT). Plasma nonprotein-bound iron, antioxidative capacity, and MDA were measured before 4 hours, between 16 and 20 hours, and at the second and third days of age. Changes in CBV and ECBA were monitored between 4 and 8, 16 and 20, 58 and 62, and 104 and 110 hours of age.

RESULTS

Six CONT and two ALLO infants died after neurologic deterioration. No toxic side effects of ALLO were detected. Nonprotein-bound iron (mean +/- SEM) in the CONT group showed an initial rise (18.7 +/- 4.6 microM to 21.3 +/- 3.4 microM) but dropped to 7.4 +/- 3.5 microM at day 3; in the ALLO group it dropped from 15.5 +/- 4.6 microM to 0 microM at day 3. Uric acid was significantly lower in ALLO-treated infants from 16 hours of life on. MDA remained stable in the ALLO group, but increased in the CONT group at 8 to 16 hours versus < 4 hours (mean +/- SEM; 0.83 +/- 0.31 microM vs 0.50 +/- 0.14 microM). During 4 to 8 hours, delta CBV-CONT showed a larger drop than delta CBV-ALLO from baseline. During the subsequent registrations CBV remained stable in both groups. ECBA-CONT decreased, but ECBA-ALLO remained stable during 4 to 8 hours of age. Neonates who died had the largest drops in CBV and ECBA.

CONCLUSION

This study suggests a beneficial effect of ALLO treatment on free radical formation, CBV, and electrical brain activity, without toxic side effects.

High-dose phenobarbital therapy in term newborn infants with severe perinatal asphyxia: a randomized, prospective study with three-year follow-up

OBJECTIVE

To determine whether 40 mg/kg phenobarbital given to term infants with severe asphyxia would result in a lower incidence of seizures in the newborn period and an improved neurologic outcome.

METHODS

We conducted a randomized, controlled, prospective study. Entry criteria included (1) an initial arterial pH less than or equal to 7.0 with a base deficit 15 mEq/L or more, (2) Apgar score less than or equal to 3 at 5 minutes of age, or (3) failure to initiate spontaneous respiration by 10 minutes of age. Sample size was calculated to detect a 50% reduction in the incidence of neonatal seizures.

RESULTS

No differences were present between treatment and control groups with respect to severity of asphyxia assessed by initial arterial pH, base excess, cerebrospinal fluid lactate dehydrogenase concentration or detection of CSF creatine kinase of its BB isoenzyme. Seizures occurred in 9 of 15 infants in the treatment group and 14 of 16 infants in the control group (p = 0.11). No adverse effects were observed from phenobarbital on heart rate, respiratory rate, blood pressure, or arterial blood gas values. Three-year follow-up revealed normal outcome in 11 of 15 infants in the treatment group and 3 of 16 in the control group (p = 0.003).

CONCLUSION

Phenobarbital, when administered in a dose of 40 mg/kg intravenously over 1 hour in term, severely asphyxiated newborn infants appeared to be safe and was associated with a 27% reduction in the incidence of seizures and a significant improvement in neurologic outcome at 3 years of age.

Short- and long-term effects of perinatal asphyxia on monoamine, amino acid and glycolysis product levels measured in the basal ganglia of the rat

The effects of perinatal asphyxia on levels of dopamine (DA) and its metabolites, amino acids and glycolysis products, measured in tissue samples from substantia nigra (SN), striatum, ventral tegmental area (VTA), and nucleus accumbens (Acb), were studied 80 min to 8 days after birth with high performance liquid chromatography (HPLC). Furthermore, extracellular levels of DA, amino acids and glycolysis products were measured with in vivo microdialysis in the striatum 40-140 min and 4 weeks after birth. Asphyxia was induced by immersing foetus-containing uterus horns, removed from ready-to-deliver Sprague-Dawley rats, in a water bath at 37 degrees C for various time periods (0-22 min). Spontaneous- and caesarean-delivered pups were used as controls. Perinatal asphyxia led to a decrease in the rate of survival, depending upon the length of the insult. In parallel, lactate (LACT) levels were increased with the length of the insult in all examined brain regions, monitored ex vivo or in vivo immediately after birth. DA, glutamate (GLU) and aspartate (ASP) levels were also increased, mainly in tissue samples taken from the mesencephalon. Only minor changes were observed in tissue samples taken from the telencephalon. However, in experiments with in vivo microdialysis, DA and GLU levels were increased following 20-21 and 21-22 min of perinatal asphyxia, but the effect of K+ depolarisation on extracellular DA and ASP levels was strongly diminished. DA and metabolites increased with development in SN and striatum, with no clear differences between control and asphyctic rats. However, 8 days after birth, it was found that DA levels were increased, alternatively decreased in mesencephalic and telencephalic regions following 20-21 and 21-22 min of perinatal asphyxia, periods associated with 60% and 90% of perinatal mortality, respectively. Furthermore, in microdialysis experiments performed 4 weeks after birth, extracellular DA and its metabolites levels were also increased, alternatively decreased in rats exposed to a 20-21 and 21-22 min perinatal asphyctic insult. In this last group, GLU and ASP levels were also decreased. Furthermore, the effect of K+ depolarisation on DA and ASP levels was strongly decreased in both asphyctic groups. Thus, perinatal asphyxia produces short- and long-term consequences in general metabolism, and induces region-specific changes in several neurotransmitter systems, mainly affecting meso-telencephalic DA systems.

Biochemical alterations in neonatal hypoxic ischaemic brain damage

Asphyxiated (n = 39) and control (n = 23) were elected for the study. Free radical-mediated lipid peroxidation, prostaglandin E2 and vitamin E levels were studied and the degree of hypoxic ischaemic encephalopathy was determined in each case. In the hypoxic group the concentration of prostaglandin E2 activity (P < 0.05) and malondialdehyde levels (P < 0.01) were significantly higher when compared to that of controls. The high vitamin E concentrations in the asphyxiated infants supports the role of oxygen free radicals in hypoxic ischaemic encephalopathy of newborns.

Relation of deranged neonatal cerebral oxidative metabolism with neurodevelopmental outcome and head circumference at 4 years

Cerebral oxidative metabolism was studied using phosphorus magnetic resonance spectroscopy during the first week of life and neurodevelopmental outcome was assessed at 4 years in 62 infants who had clinical and/or biochemical evidence consistent with birth asphyxia (critically impaired intrapartum gas exchange). Twenty-one died and the neurodevelopmental status of the 41 who survived was assessed by a range of tests at age 4 years. The minimum recorded values for the cerebral phosphocreatine:inorganic phosphate concentration ratio (an index of oxidative metabolism) were related to outcome. The results showed significant relations between the extent of derangement of neonatal oxidative metabolism and a range of adverse outcomes, including death, and at 4 years reduced head growth and the presence and severity of neuromotor impairments, overall neurodevelopmental impairments, and cognitive functioning. Strong correlations between the extent of derangement of neonatal oxidative metabolism and outcome at 1 and 4 years were also shown. We conclude that the severities of adverse outcomes at 1 and 4 years of age were closely related to the extent of cerebral energy derangement in the first week of life, and we also conclude that primary intrapartum hypoxic-ischaemic cerebral injury was generally responsible for the events that led to death, microcephaly, and impaired

Cerebral blood flow and energy metabolism in the newborn

In normal newborn term and preterm infants CBF is relatively low corresponding to a low metabolic rate for oxygen, whereas cross-brain oxygen extraction is similar to that in adults. This provides for a considerable reserve capacity to deal with decreased CBF or decreased oxygen content in arterial blood. CBF reactivity to CO2 is normal, and the evidence is that pressure-flow autoregulation is present, even in very preterm infants. Absence of autoregulation and CBF-CO2 reactivity has been documented in severely asphyxiated infants, and in preterm infants who went on the develop severe intracranial hemorrhage. A number of methods are available to study CBF and brain metabolism in newborn infants. Several of them involve ionizing radiation, which has limited their use, even though it is unlikely that the associated risks are particularly high. Magnetic resonance spectroscopy has demonstrated a delayed disturbance of energy metabolism following severe asphyxia. Doppler ultrasound has rarely been helpful to obtain quantitative data. Near infrared spectrocopy has now been in use for more than 10 years. It has been slow to fulfill its promise as a continuous monitor of cerebral circulation and of oxygen sufficiency of neurons.

Perinatal asphyxia induces long-term changes in dopamine D1, D2, and D3 receptor binding in the rat brain

We have investigated the long-term effects of 15-16 min or 19-20 min of perinatal asphyxia on D1, D2, and D3 receptors (analyzed by quantitative autoradiography) in the mesotelencephalic dopamine systems of the 4-week-old rat. Perinatal asphyxia reduced D1 antagonist binding ([3H]SCH 23390 in the presence of ketanserine) in the accumbens nucleus, the olfactory tubercle, and the substantia nigra and increased D1 agonist binding ([3H]dopamine in the presence of spiperone) in the accumbens nucleus and the olfactory tubercle. No changes in D2 antagonist binding ([123]iodosulpride) were found, whereas D2 agonist binding ([3H]N-propylnorapomorphine, [3H]NPA) was reduced in the posterior part of the caudate-putamen, and following 19-20 min of asphyxia it was also reduced in the accumbens nucleus. D3 agonist binding (R/S-(+/-)-2-(N,N-di[2,3(n)-3H] propylamino)-7-hydroxy-1,2,3,4-tetrahydronaphthalene, [3H]7-OH-DPAT) was increased in the anterior part of the caudate-putamen following 15-16 min but not 19-20 min of asphyxia. The results indicate that perinatal asphyxia reduced the number of D1 receptors and increased D1 agonist affinity in the accumbens nucleus and the olfactory tubercle and reduced the number of D1 receptors in the substantia nigra. The number of D2 receptors was unchanged by asphyxia, whereas the D2 agonist affinity was reduced in the caudate-putamen and in the accumbens nucleus. D3 agonist binding was increased in the caudate-putamen selectively following 15-16 min of asphyxia. In conclusion, asphyxia during birth induces long-term changes in the binding characteristics of dopamine receptors in the mesotelencephalic dopamine systems, which may contribute to previously reported behavioral changes.

Measurement of cytochrome oxidase and mitochondrial energetics by near-infrared spectroscopy

Cytochrome oxidase is the terminal electron acceptor of the mitochondrial respiratory chain. It is responsible for the vast majority of oxygen consumption in the body and essential for the efficient generation of cellular ATP. The enzyme contains four redox active metal centres; one of these, the binuclear CuA centre, has a strong absorbance in the near-infrared that enables it to be detectable in vivo by near-infrared spectroscopy. However, the fact that the concentration of this centre is less than 10% of that of haemoglobin means that its detection is not a trivial matter. Unlike the case with deoxyhaemoglobin and oxyhaemoglobin, concentration changes of the total cytochrome oxidase protein occur very slowly (over days) and are therefore not easily detectable by near-infrared spectroscopy. However, the copper centre rapidly accepts and donates an electron, and can thus change its redox state quickly; this redox change is detectable by near-infrared spectroscopy. Many factors can affect the CuA redox state in vivo (Cooper et al. 1994), but most significant is likely to be the molecular oxygen concentration (at low oxygen tensions, electrons build up on CuA as reduction of oxygen by the enzyme starts to limit the steady-state rate of electron transfer). The factors underlying haemoglobin oxygenation, deoxygenation and blood volume changes are, in general, well understood by the clinicians and physiologists who perform near-infrared spectroscopy measurements. In contrast, the factors that control the steady-state redox level of CuA in cytochrome oxidase are still a matter of active debate, even amongst biochemists studying the isolated enzyme and mitochondria. Coupled with the difficulties of accurate in vivo measurements it is perhaps not surprising that the field of cytochrome oxidase near-infrared spectroscopy has a somewhat chequered past. Too often papers have been written with insufficient information to enable the measurements to be repeated and few attempts have been made to test the algorithms in vivo. In recent years a number of research groups and commercial spectrometer manufacturers have made a concerted attempt to not only say how they are attempting to measure cytochrome oxidase by near-infrared spectroscopy but also to demonstrate that they are really doing so. We applaud these attempts, which in general fall into three areas: first, modelling of data can be performed to determine what problems are likely to derail cytochrome oxidase detection algorithms (Matcher et al. 1995); secondly haemoglobin concentration changes can be made by haemodilution (using saline or artificial blood substitutes) in animals (Tamura 1993) or patients (Skov & Greisen 1994); and thirdly, the cytochrome oxidase redox state can be fixed by the use of mitochondrial inhibitors and then attempts make to cause spurious cytochrome changes by dramatically varying haemoglobin oxygenation, haemoglobin concentration and light scattering (Cooper et al. 1997). We have previously written reviews covering the difficulties of measuring the cytochrome near-infrared spectroscopy signal in vivo (Cooper et al. 1997) and the factors affecting the oxidation state of cytochrome oxidase CuA (Cooper et al. 1994). In this article we would like to strike a somewhat more optimistic note--we will stress the usefulness this measurement may have in the clinical environment, as well as describing conditions under which we can have confidence that we are measuring real changes in the CuA redox state.

Changes in cerebral cyclic nucleotides and cerebral blood flow during prolonged asphyxia and recovery in newborn pigs

Cerebrovascular reactivity is preserved after acute severe asphyxia/reventilation in piglets. We hypothesize that prolonged, partial asphyxia with hypotension causes loss of cerebrovascular reactivity and altered cerebral hemodynamics during recovery. We investigated the changes in cerebrospinal fluid cAMP and cGMP, pial arteriolar diameters and flow, and cerebral blood flow during 1 h of asphyxia and 1 h of recovery. During asphyxia, blood pressure decreased from 10 +/- 0.7 to 4.7 +/- 0.3 kPa and increased during recovery to 6 +/- 0.7 kPa. cAMP increased 3-fold by 20 min of asphyxia, returning to baseline at 40 min of asphyxia. During recovery, cAMP increased 2-fold initially, followed by a decrease to 50% below baseline. cGMP increased after 20 min of asphyxia, with maximum levels observed at 40 min; reventilation resulted in a transient increase in cGMP. Pial arteriolar diameters increased at the onset of asphyxia, then decreased toward baseline; during recovery, a similar pattern occurred. Blood flow to the cerebrum (microspheres) decreased during asphyxia and remained very low during recovery. Pial arteriolar flow but not pial arteriolar diameters followed the changes in cortical cerebral blood flow (i.e. virtually no flow during recovery). During recovery, pial arteriolar reactivity to isoproterenol and histamine decreased significantly. We conclude that 60 min of asphyxic-hypotensive insult results in alterations of cerebral cAMP metabolism which may compromise cellular communications during recovery. Prolonged asphyxia induces "no-reflow" during recovery, even when partial pressures of arterial CO2 and O2 have returned to baseline values, and blood pressure is within the autoregulatory range.

Anisotropic water diffusion in white and gray matter of the neonatal piglet brain before and after transient hypoxia-ischaemia

Measurements of tissue water apparent diffusion coefficient (ADC) performed with diffusion sensitization applied separately along the x, y, and z axes revealed significant diffusion anisotropy in both cerebral white and gray matter in six newborn (< 24 h old) piglets. Mean baseline white matter ADC for a particular region of interest was 125.8% (SD 32.0%; p < .001) greater when the diffusion gradients were applied along the y axis as compared to along the x. For the cortical gray matter region considered, the situation was reversed, the mean ADC value measured along x exceeding that along y by 15.2% (SD 6.1%; p < .01). Forty-three hours subsequent to a transient cerebral hypoxic-ischaemic insult, phosphorous MRS measurements indicated that the animals had suffered severe secondary cerebral energy failure. This was accompanied by a significant (p < .01) decrease in the white matter anisotropy, such that the mean y direction ADC now exceeded that along the x by only 70.9% (SD 29.4%; p < .03). There was no change in the gray matter anisotropy. The average of the ADC values measured in the x, y, and z directions had decreased by 35.3% (SD 18.5%; p < .01) in white matter and 31.4% (SD 21.9%; p < .05) in cortical gray matter. Diffusion anisotropy measurements may provide additional information useful in the characterisation of hypoxic-ischaemic injury in the neonatal brain, and must be considered if tissue water ADC values are to be unambiguously interpreted in this context.

Metabolite concentrations and relaxation in perinatal cerebral hypoxic-ischemic injury

Regional cerebral metabolite concentrations, principally of choline-containing compounds (Cho), total creatine (Cr), N-acetylaspartate (Naa), and lactate (Lac), can be quantified by in vivo proton magnetic resonance spectroscopy. In order to estimate a metabolite concentration, it is often necessary to measure the transverse relaxation time (T2). Metabolite T2s depend on cytosolic viscosity: as [adenosine triphosphate] falls leading to Na+/K+ pump failure, cytosolic water increases and T2s lengthen. In central grey-matter in human infants, Naa may be almost exclusively neuronal: Naa T2 may index neuronal edema and energy generation. In this preliminary report, metabolite concentrations and T2s have been measured in central grey matter in human infants suspected of perinatal hypoxic-ischemic cerebral injury. In infants who developed serious cerebral injury or died, [Cho] and [Naa] were low (the latter suggesting neuronal loss), [Lac] and all metabolite T2s were increased: the Naa T2 increase possibly reflected neuronal edema following failure of energy generation in a fraction of remaining neurons.

Proton magnetic resonance spectroscopy of the brain in normal preterm and term infants, and early changes after perinatal hypoxia-ischemia

The aims of this study were 1) to define normal perinatal maturational changes in proton metabolite peak-area ratios in two regions of the neonatal brain, the thalamic and occipitoparietal regions, and 2) to investigate abnormalities of these ratios after perinatal hypoxia-ischemia. Fifty-four infants were studied: 35 normal control infants at 31-42 wk of gestational plus postnatal age, and 19 "asphyxiated" infants suspected of cerebral hypoxic-ischemic injury. Proton spectra were collected at 2.4 tesla from (2 cm)3 voxels using the point-resolved spectroscopy technique with a 270-ms echo time. Lactate was detected in all infants studied. In the normal infants, lactate relative to N-acetylaspartate (NAA), choline and creatine was significantly greater in the occipitoparietal region than in the thalamus, and fell with increasing maturity in both regions, whereas NAA/ choline increased. The 19 asphyxiated infants were studied on a total of 34 occasions during the 1st wk of life (median age 1.8 d), at gestational plus postnatal ages of 27-41 wk. Maximum lactate/NAA was above 95% confidence limits for the control data in one or both regions in 11 of the 19 infants. Minimum NAA/choline was below 95% confidence limits in only one asphyxiated infants, who was later found to have congenital hypothyroidism. SD scores for lactate, relative to NAA, choline, and creatine, were higher in both regions in the asphyxiated infants compared with the normal infants, particularly in the thalamus. Early results of 1-y follow-up examinations indicate that raised lactate/NAA carries a poor long-term prognosis.

Increased levels of lipid peroxidation products malondialdehyde and 4-hydroxynonenal after perinatal hypoxia

For quantitative evaluation of lipid peroxidation after perinatal hypoxia in umbilical arterial cord blood samples from 109 healthy, acidotic, and asphyctic neonates with a gestational age ranging from 26 to 41 wk, the levels of aldehydic lipid peroxidation products malondialdehyde (MDA) and 4-hydroxynon-2-enal (HNE) were measured. Furthermore, the concentrations of oxidized and reduced glutathione (GSSH and GSH) and the purine compounds hypoxanthine and uric acid were determined. With increasing gestational age MDA and HNE levels increased. Furthermore, an increased level of GSH was also found. After perinatal hypoxia the concentrations of MDA and HNE rose distinctly (p < 0.001), reflecting sensitively the extent of in vivo lipid peroxidation. HNE is proposed to be a new parameter for quantitative evaluation of posthypoxic cellular damage in the perinatal period. HNE is a more specific parameter for estimation of lipid peroxidation processes in comparison with MDA. Additionally, HNE is cytotoxic and mutagenic at nanomolar concentrations. The increased levels of both MDA and HNE were accompanied by a strong decrease of GSH concentrations (p < 0.001), indicating the rapid consumption of GSH via a glutathione peroxidase reaction but additionally the high reactivity of HNE with sulfhydryl groups. During oxygen deficiency, increased levels of hypoxanthine (p < 0.01) and uric acid (p < 0.05) were due to the accelerated degradation of purine nucleotides. The rate of purine degradation including xanthine oxidase reactions characterizes the extent of an important radical source during oxygen deficiency, contributing to peroxidation of polyunsaturated fatty acids and the formation of peroxidation of polyunsaturated fatty acids and the formation of secondary aldehydic lipid peroxidation products.

Development of GABA and calcium binding proteins immunoreactivity in the rat hippocampus following neonatal anoxia

The consequences of neonatal anoxia (N2 100% for 25 min at 30 h after birth) on the rat hippocampus were studied 7-60 days postnatally with immunocytochemistry for gamma-aminobutyric acid (GABA), parvalbumin (PV) and calbindin-D28k (CB). In both sham-treated and anoxic rats, GABA immunoreactivity presented a mature expression since early stages, while PV and CB immunoreactivity showed a major postnatal development. In anoxic animals, a significant reduction in the number of hippocampal GABA-immunoreactive neurons was observed at all time-points analysed, a transitory effect on PV immunoreactivity was seen at P7 and P21, while no modifications in the number of CB-immunoreactive neurons could be found. Thus, selective vulnerability of GABA-containing neurons and relative resistance of neurons in which PV or CB immunoreactivity is present or is expressed later, occur in the hippocampus after neonatal anoxia. The role of calcium binding proteins (CBP) in nerve cell protection is discussed.

Cerebral metabolism within 18 hours of birth asphyxia: a proton magnetic resonance spectroscopy study

Proton magnetic resonance spectroscopy (1H MRS) was performed within 18 h of birth (median 13, range 4-18 h) on 16 term infants with clinical features of birth asphyxia. Ten infants with no evidence of birth asphyxia were studied as controls at 5-18 (median 8) h after birth. To detect delayed impairments in cerebral energy metabolism, 15 infants suspected of asphyxia underwent 31P MRS at 33-106 (median 62) h of age. Choline, creatine, and N-acetylaspartate (NAA) were detected in spectra located to the basal ganglia in all infants. Lactate was detected in 15 of the 16 infants suspected of asphyxia, but in only 4 of the 10 controls (p < 0.05, chi 2). Glutamine and glutamate (Glx) was detected in 11 infants suspected of asphyxia and in three controls, but this difference was not significant at the 5% level. The spectra revealed no other significant differences between asphyxiated infants and controls. In the asphyxiated infants, there was a negative correlation between the ratio of lactate to creatine in the first 18 h of life and phosphocreatine/inorganic phosphate (PCr/ P(i)) at 33-106 h (p < 0.001). Five severely asphyxiated infants had PCr/P(i) < 0.75 (median 0.53, range 0.14-0.65), indicating a poor neurodevelopmental prognosis, and a further infant died before PCr/Pi could be measured. Ten infants had PCr/P(i) > 0.75 (1.03, 0.76-1.49). Median lactate/creatine was 1.47 (range 0.67-3.81) in the six severely affected subjects, 0.38 (0-1.51) in the latter group, and 0 (0-0.6) in controls (p < 0.0005, Kruskall-Wallis). These results suggest that, after birth asphyxia, cerebral energy metabolism is abnormal during the period when 31P MRS characteristically gives normal results. 1H MRS might be of value in predicting which infants are likely to suffer a decline in cerebral high energy phosphate concentrations and subsequent neurodevelopmental impairment.

[Findings in cerebral proton spin resonance spectroscopy in newborn infants with asphyxia, and psychomotor development]

OBJECTIVE

To determine the relationship between the results of cerebral proton magnetic resonance spectroscopy (1H-MRS) and neuromotor development in neonates with hypoxia.

DESIGN

Descriptive.

SETTING

Wilhelmina Childrens' Hospital and University Hospital, Utrecht, The Netherlands.

METHODS

32 infants with hypoxic-ischaemic encephalopathy (Sarnat grade I (mild; n = 5), grade II (moderate; 20), grade III (severe; 7)) were examined at a mean of 8 days following the hypoxic event (range 2-22). 1H-MRS of the periventricular white matter and part of the basal ganglia was performed in a 1.5 T field: TR/TE: 2000/272 ms. Peak-to-peak NAA/Cho ratios were calculated. The presence of a lactate resonance was considered abnormal. Assessment of neuromotor development of the survivors was performed at 6, 9 and 18 months of age.

RESULTS

6 patients died (all grade III), 10 survived with handicaps (I grade III, 9 grade II). Handicaps consisted of spastic quadriplegia (n = 7), hemiplegia and mental retardation (n = 1), and global developmental delay (n = 2). The other 16 survivors were normal at 18 months. 1H-MRS showed NAA/Cho ratios of 0.97 (SD:0.13) in the patients with a normal outcome and 0.74 (0.17) in the patients with an adverse outcome (handicaps or death); p < 0.0001 (t-test). Lactate was demonstrated in all 7 grade III neonates, but not in any of the other infants.

CONCLUSION

Cerebral 1H-MRS was related to neurodevelopmental outcome of neonates with HIE. A low NAA/Cho ratio and presence of a lactate resonance predicted an adverse outcome.

The effect of asphyxia on the pharmacokinetics of ceftazidime in the term newborn

The multiple-dose pharmacokinetics of ceftazidime (CAZ) (administered twice daily in a 50 mg/kg of body weight i.v. dose) were studied in 10 severely asphyxiated term infants with suspected septicemia on d 3 of life. Nine term infants with suspected septicemia but without asphyxia served as controls. Blood samples were collected from an arterial catheter at 0, 0.5, 1, 2, 4, 8, and 12 h after an i.v. bolus injection. A high performance liquid chromatography method was used to determine CAZ concentrations from serum. CAZ pharmacokinetics followed a one-compartment open model. The GFRs of all infants were simultaneously studied by means of the 24-h continuous inulin infusion technique. Elimination serum half-life (5.86 +/- 1.13 h versus 3.85 +/- 0.40 h) and serum trough concentrations (46 +/- 14 mg/L versus 23 +/- 7 mg/L) of CAZ were significantly (p < 0.001) increased in the asphyxiated newborn, whereas total body clearance of CAZ (128.4 +/- 25.1 mL/h versus 205.7 +/- 55.4 mL/h), CAZ clearance per kg (40.9 +/- 6.1 mL/h/kg versus 60.8 +/- 8.3 mL/h/kg), and the GFR expressed in mL/min (3.14 +/- 0.43 versus 4.73 +/- 0.89) were significantly (p < 0.001) decreased in the asphyxiated newborn. We conclude that twice daily administration of 50 mg/kg of body weight CAZ given to asphyxiated term newborns in the first days of life results in significantly higher serum trough levels in comparison with control infants. The impaired CAZ clearance is a result of a significantly decreased GFR.

Multiple nuchal cord entanglements and intrapartum complications

OBJECTIVE

Our purpose was to evaluate the outcomes of pregnancies complicated by a multiple (double, triple, or quadruple) nuchal cord entanglement.

STUDY DESIGN

Computerized data from our University Hospital perinatal database were reviewed between 1990 and 1994. Only singleton, vertex, and term pregnancies undergoing labor were analyzed. Patients with active perinatal complications were eliminated to reduce bias. Pregnancies with infants with either a single or no nuchal cord entanglement served as comparison groups. A comparison of frequencies in the three groups was by chi 2 testing and a comparison of means by a two-tailed Student t test and analysis of variance.

RESULTS

Of the 8565 deliveries, the frequency of two or more cord entanglements at delivery was 3.8%. Compared with a single or no cord entanglement, pregnancies with a multiple entanglement were more likely to exhibit an abnormal fetal heart rate pattern during advanced labor (p < 0.001) and to require low or midforceps application (p < 0.001). The study infants were also more likely to have meconium (p = 0.013), a low 1-minute Apgar score (p < 0.001), and an umbilical artery pH < or = 7.10 (odds ratio 2.2, p = 0.013) than the controls. Rates of abruptio placentae, cesarean delivery, and 5-minute Apgar scores < 7 were no more common in the multiple entanglement than the control groups.

CONCLUSION

A multiple nuchal cord entanglement was associated with a greater risk of meconium, an abnormal fetal heart rate pattern during advanced labor, the need for operative vaginal delivery, and mild umbilical artery acidosis at birth; however, there was no added risk of an adverse neonatal outcome.

Nicotine treatment counteracts perinatal asphyxia-induced changes in the mesostriatal/limbic dopamine systems and in motor behaviour in the four-week-old male rat

In the present study, the effects of nicotine treatment on the changes induced by perinatal asphyxia in exploratory and D-amphetamine-induced behaviour, and in the number of brain tyrosine hydroxylase-immunoreactive nerve cell bodies were investigated in four-week-old male rats. Asphyxia was induced in pups by placing the fetuses, still in their uterus horns removed by hysterectomy from full-term pregnant rats, in a 37 degrees C water bath for 15-16 min or 19-20 min. Surviving male pups were treated with nicotine via suckling from surrogate mothers implanted subcutaneously with Alzet minipumps containing nicotine (0.2 mumol/kg per h) for four weeks. The minipumps implanted in the mothers of sham-treated animals contained saline only. After treatment, exploratory behaviour and D-amphetamine-induced behaviour was analysed in a computerized "activity" box. After the behavioural experiments, the rats were taken for tyrosine hydroxylase immunohistochemistry, and the total number of tyrosine hydroxylase immunoreactive cell bodies were counted in the A9 and A10 regions of the substantia nigra and the ventral tegmental area, respectively. Nicotine serum levels were measured using gas chromatography in selected asphyctic and control pups at different periods after delivery. During the exploratory phase, in saline-nurtured rats, 15-16 min of asphyxia slightly increased (approximately 25%) locomotion, motility and rearing. In contrast, 19-20 min of asphyxia reduced the locomotion and rearing by approximately 50%, as compared to controls. An increase in amphetamine-induced behaviours was observed after 15-16 min, but not after 19-20 min of asphyxia, as compared to controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuronal death after perinatal asphyxia

During perinatal asphyxia several mechanisms aim to limit cerebral damage. However, when the degree of asphyxia passes beyond a certain threshold, brain damage is inevitable. This review focuses on the various factors determining the final cerebral outcome. Metabolic and biochemical events, such as the intracellular level of calcium, the formation of oxygen derived free radicals, the release of excitotoxic neurotransmitters and the interrelationship of these parameters are discussed. Furthermore, steps possibly useful to pharmacologic intervention aiming to reduce cerebral damage are presented.

Application of the accurate assessment of intracellular magnesium and pH from the 31P shifts of ATP to cerebral hypoxia-ischemia in neonatal rat

The authors present a high field in vivo demonstration of our 2-dimensional calibration methods for determining magnesium ion concentration ([Mg]), under conditions of fluctuating pH, from the three 31P NMR chemical shift differences of ATP. The effect of 3 h of hypoxic-ischemic insult (HI) on intracellular brain [Mg] was evaluated by using a well established 7-day-old rat model of cerebral HI. During the final hour of HI, there was a significant increase (P < 0.001) in free magnesium as well as in the ratio of total [Mg]/[ATP]. The normal, HI, and early (1-2 h) recovery values of free [Mg] were 0.336 +/- 0.015, 0.519 +/- 0.104, and 0.337 +/- 0.071 mM, respectively. These results are consistent with the temporal changes in [ATP]. Our assessment of [Mg] and pH for this high error measurement is general for most in vivo applications and may be routinely implemented.

Animal models of perinatal asphyxia: contributions, contradictions, clinical relevance

Animal models have contributed immensely to our understanding of hypoxic ischemic encephalopathy in the newborn. A number of animal models have been used, including both primate and subprimate species. Although the Rhesus monkey model has a dramatically similar pathological distribution of brain injury when compared with the human, other pathologic processes secondary to asphyxia may be more appropriately assessed in other species. The maxim that because primates are closer on the phylogenetic tree to humans than are subprimates all observations in the primate are applicable to the human is simply not true. Understanding of the neurochemical consequences of asphyxia in the past decade have arisen from experiments primarily in the neonatal rat. We have come to understand that not only is the hypoxic event of major significance, but that, once reperfused, reoxygenation causes further injury. Free-radical generation following reperfusion may be massive and may further contribute to cell membrane injury. These observations have lead to rational theoretic approaches to the treatment of hypoxic ischemic brain injury. On the other hand, previously used treatments such as osmotic agents and glucocorticoids would appear to be not only inefficacious but hazardous in the treatment of hypoxic ischemic brain injury. The role of nitric oxide (NO) in the pathogenesis of brain injury is yet uncertain, but there is little doubt that it plays a significant role. Although survival of the immature animal subjected to hypoxic environment is longer than in the mature animal, the central nervous system of the immature animal is more sensitive to glutamate and N-Methyl-D-aspartate (NMDA) receptor-mediated injury.

Short-term effects of perinatal asphyxia studied with Fos-immunocytochemistry and in vivo microdialysis in the rat

In the present study, the short-term consequences of various perinatal asphyctic periods were studied at the peripheral and CNS levels in the rat. Perinatal asphyxia was induced in rat pups delivered by caesarean section within the last day of gestation, by placing the uterus horns including the fetuses in a water bath at 37 degrees C for various periods of time (0-23 min). Following asphyxia, the uterus horns were opened. The pups were then removed and stimulated to breathe. Subcutaneous levels of pyruvate (Pyr), lactate (Lact), glutamate (Glu), and aspartate (Asp) were monitored with microdialysis 40 min after delivery. In parallel experiments, the pups were sacrificed 80 min after delivery. The brains were removed, fixed, cut, and processed for Fos immunocytochemistry. The number of Fos-immunoreactive (IR) cells in different brain structures was counted under light microscopy. Subcutaneous levels of Pyr, Lact, Glu, and Asp increased following perinatal asphyxia, as compared to caesarean-delivered pups or to spontaneously delivered controls. A maximum increase in Pyr levels (approximately threefold) was observed with 2-3 min of asphyxia, while Lact levels increased along with the length of asphyxia. A maximum increase in Glu and Asp levels (approximately threefold) was observed with 10-11 min of asphyxia. Fos-IR nuclei were predominantly found in the piriform cortex, and in the cortical amygdaloid complex. In some cases, mainly in pups exposed to asphyxia, Fos-positive cells were also seen in other tele-diencephalic structures.