Watershed infarcts in the fetal and neonatal brainstem. An aetiology of central hypoventilation, dysphagia, Möibius syndrome and micrognathia

Physiopathologic Bases of Moebius Syndrome: Combining Genetic, Vascular, and Teratogenic Theories

Moebius syndrome (MBS) is a congenital cranial dysinnervation disorder (CCDD) characterized by a bilateral palsy of abducens and facial cranial nerves, which may coexist with other cranial nerves palsies, mostly those found in the dorsal pons and medulla oblongata. MBS is considered a "rare" disease, occurring in only 1:50,000 to 1:500,000 live births, with no gender predominance. Three independent theories have been described to define its etiology: the vascular theory, which talks about a transient blood flow disruption; the genetic theory, which takes place due to mutations related to the facial motor nucleus neurodevelopment; and last, the teratogenic theory, associated with the consumption of agents such as misoprostol during the first trimester of pregnancy. Since the literature has suggested the existence of these theories independently, this review proposes establishing a theory by matching the MBS molecular bases. This review aims to associate the three etiopathogenic theories at a molecular level, thus submitting a combined postulation. MBS is most likely an underdiagnosed disease due to its low prevalence and challenging diagnosis. Researching other elements that may play a key role in the pathogenesis is essential. It is common to assume the difficulty that patients with MBS have in leading an everyday social life. Research by means of PubMed and Google Scholar databases was carried out, same in which 94 articles were collected by using keywords with the likes of "Moebius syndrome," "PLXND1 mutations," "REV3L mutations," "vascular disruption AND teratogens," and "congenital facial nerve palsy." No exclusion criteria were applied.

The challenging management of Moebius syndrome using orthodontic camouflage: A case report

Moebius syndrome (MS) is a rare congenital neuromuscular disorder characterized by weakness or paralysis (palsy) of abducens and facial nerves, or other cranial nerves which may be affected. Diagnosis, treatment, and dental management of MS patients are focused on treating manifestations like malocclusion, while catering to associated extraoral (neurologic, dermatologic, ocular) complications, aiming to improve their quality of life. Here, we report the case of a 9-year-old female patient with MS who underwent orthodontic camouflage using combined orthopedic-orthodontic therapy using a high-pull chin cup and fixed orthodontic appliance to improve skeletal mal-relation and facial appearance. The outcome displayed great improvement in function and better esthetics, improving not only the patient's but also the family's quality of life. A year's follow-up showed successful maintenance of the achieved results. A multidisciplinary approach in MS not only helps in overcoming the treatment challenges but also provides great psychosocial benefits to these patients.

Neuroembryonic and fetal brain development: Relevance to fetal/neonatal neurological training

Insight into neuroembryology, developmental neuroanatomy and neurophysiology distinguish the diagnostic approaches of paediatric from adult neurologists and general paediatricians. These fundamental disciplines of basic neuroscience could be more effectively taught during paediatric neurology and most residency programmes, that will strengthen career-long learning. Interdisciplinary training of fetal-neonatal neurology within these programs requires working knowledge of neuroembryology applied to maternal reproductive health influencing the maternal-placental-fetal triad, neonate, and young child. Systematic didactic teaching of development in terms of basic neuroscience with neuropathological context would better address needed clinical skill sets to be incorporated into paediatric neurology and neonatology residencies to address brain health and diseases across childhood. Trainees need to recognize the continuity of development, established by maternal reproductive health before conception with gene -environment influences over the first 1000 days. Considerations of neuroembryology that explain earlier brain development during the first half of pregnancy enhances an understanding of effects throughout gestation through parturition and into neonatal life. Neonatal EEG training enhances these clinical descriptions by applying serial EEG-state analyses of premature neonates through early childhood to recognize evolving patterns associated with neuronal maturation and synaptogenesis. Neuroimaging studies offer comparisons of normal structural images with malformations and destructive lesions to correlate with clinical and neurophysiological findings. This analysis better assesses aberrant developmental processes in the context of neuroembryology. Time-specific developmental events and semantic precision are important for accurate phenotypic descriptions for a better understanding of etiopathogenesis with maturation. Certification of paediatric neurology training programme curricula should apply practical knowledge of basic neuroscience in the context of nervous system development and maturation from conception through postnatal time periods. Interdisciplinary fetal-neonatal neurology training constitutes an important educational component for career-long learning.

Case report: Central alveolar hypoventilation in a survivor of cardiopulmonary arrest

Introduction

Ondine's curse is a rare respiratory disorder that is characterized by central alveolar hypoventilation (CAH) during sleep. It is most commonly congenital. However, it can also be acquired very rarely. Herein, we report a young survivor who developed CAH following cardiopulmonary arrest.

Case presentation

A 35-year-old man was admitted to the Intensive Care Unit following unwitnessed cardiopulmonary arrest. Following resuscitative interventions, he remained comatose. Early diagnostic testing showed elevated neuronal specific enolase (28.7 ng/ml), absent cortical responses on evoked potential testing and MRI evidence of restricted diffusion in the cerebellum, hippocampi, juxtacortical white matter, superior cerebellar peduncles, dorsal pons, dorsolateral medulla, and upper cervical spinal cord. Ten days following admission, the patient remained comatose and underwent tracheostomy. He subsequently began to emerge from coma but had persistent unexplained hypotension and bradypnea necessitating ongoing vasopressor and respiratory support. Repeat MRI on hospital day 40 revealed residual FLAIR hyperintensities in the medulla within the nucleus tractus solitarius (NTS). After being discharged to long-term acute care facility, he was successfully liberated from mechanical ventilation 70 days post arrest.

Conclusion

We report the first survivor of cardiopulmonary arrest who was complicated by CAH and hypotension with MRI verified ischemic injury to the bilateral NTS regions. Despite this injury, ventilator and vasopressor dependency resolved over a period of 10 weeks. Our case highlighted the essential functions of NTS in regulating the respiratory and cardiovascular systems.

Moebius Syndrome: What We Know So Far

Moebius syndrome (MBS) is a rare congenital cranial nerve disorder characterized by unilateral, bilateral symmetrical, or asymmetrical facial (VII) and abducens (VI) nerve palsies. Genetics and rhombencephalon vascular disturbances from intrauterine environmental exposures have been attributed to its development. It can present with various orofacial abnormalities. Although the diagnosis is purely clinical, certain characteristic features are present in the brain's images. With no cure, it is essential to devise management on a personalized basis. We discuss etiology, presentation, diagnostic approaches, and effective management in the existing literature. This comprehensive review examines the clinic-pathological aspects of Moebius syndrome. The authors employed the PUBMED base index to identify pertinent literature and reference it according to research keywords. Findings suggest the most popular etiology is the theory of intrauterine vascular disruption to the brainstem during embryogenesis, followed by the genetic hypothesis. Intrauterine environmental exposures have been implicated as potential risk factors. Facial and abducens nerve palsies are the most common presenting features. However, clinical manifestations of lower cranial nerves (IX, X, XI, XII) may be present with orthopedic anomalies and intellectual deficiencies. The diagnosis is clinical with minimal defined diagnostic criteria. Characteristic radiological manifestations involving the brainstem and cerebellum can be observed in imaging studies. With no definitive treatment options, a multidisciplinary approach is employed to provide supportive care. Despite radiological manifestations, Moebius syndrome is diagnosed clinically. Although incurable, a multidisciplinary approach, with personalized rehabilitative measures, can manage physical and psychological deficits; however, standard guidelines need to be established.

Difficult intubation and postoperative aspiration pneumonia associated with Moebius syndrome: a case report

Background

Moebius syndrome is a rare congenital disorder characterized by non-progressive palsy of the abducens (VI) and facial (VII) cranial nerves. Its common features include dysfunctions associated with other cranial nerves, orofacial abnormalities, skeletal muscle hypotonia, and other systemic disorders of differing severities. There are several concerns in the perioperative management of patients with Moebius syndrome.

Case presentation

We present a report on the management of general anesthesia of a 14-year-old male patient with Moebius syndrome who was scheduled for mandibular cystectomy. The patient was diagnosed with Moebius syndrome at the age of 7 years based on his clinical manifestations of nerve palsy since birth and cranial nerve palsy of the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and sublingual nerves (XII). The patient’s oral morphological abnormalities made intubation difficult. He also experienced dysphagia and aspiration pneumonia on a daily basis. Oral secretions were frequently suctioned postoperatively. However, after discharge, the patient developed aspiration pneumonia and was readmitted to the hospital.

Conclusions

The main problem arising when administering general anesthesia to patients with this syndrome is difficult airway management. The oral abnormalities in these patients, such as small jaw and extreme dental stenosis, make mask ventilation and intubation difficult. Furthermore, this syndrome often involves respiratory impairment and dysphagia due to cerebral nerve palsy, so there is a high risk of postoperative respiratory complications. Since multiple organs are affected in patients with Moebius syndrome, appropriate perioperative management strategies must be prepared for these patients.

Hypothesis: By-products of vascular disruption carried in the CSF affect prenatal brain development

Prenatal CNS disruptions can be associated with physically separate findings. Examples include cognitive issues in septo-optic dysplasia and sporadic and WNT1-related unilateral cerebellar hypoplasia, and physical findings such as thinning of the corpus callosum, ventriculomegaly, hippocampal abnormalities, olfactory tract and bulb hypoplasia, and distant cortical dysplasias with schizencephaly. Similar effects to toxicities with intraventricular hemorrhage in prematurity could occur earlier in development. CSF transportation of disruption by-products would provide access to vulnerable areas through inflammatory effects on blood-brain barrier permeability. Outcomes are influenced by location and volume of byproducts in the CSF, timing, transport, and inflammatory responses. A particular association of vermis disruption with cognitive issues may be related to CSF flow distortions that avoid toxin dilutions in the third ventricle. Symmetrical contralateral cortical dysplasia with schizencephaly may reflect immunovascular field-related vulnerabilities seen in situations such as vitiligo.

Fasciculations in Children

Fasciculations are the most common form of spontaneous muscle contraction. They frequently occur in healthy individuals. However, there are a minority of situations that fasciculations are observed in association with specific neurologic disorders. Publications concerning the evaluation of pediatric patients experiencing fasciculations are limited. These children may undergo invasive or expensive diagnostic investigations that are unnecessary. Moreover, without careful consideration of differential diagnoses, rare neuromuscular disorders that present with fasciculations in the pediatric age group can be under-recognized by pediatric neurologists. This review examines the most important pediatric disorders presenting with fasciculations and other spontaneous muscle contractions to guide pediatric neurologists in evaluating these children.

Transitory and Vestigial Structures of the Developing Human Nervous System

As with many body organs, the human central nervous system contains many structures and cavities that may have had functions in embryonic and fetal life but are vestigial or atrophic at maturity. Examples are the septum pellucidum, remnants of the lamina terminalis, Cajal-Retzius neurons, induseum griseum, habenula, and accessory olfactory bulb. Other structures are transitory in fetal or early postnatal life, disappearing from the mature brain. Examples are the neural crest, subpial granular glial layer of Brun over cerebral cortex, radial glial cells, and subplate zone of cerebral cortex. At times persistent fetal structures that do not regress may cause neurological problems or indicate a pathologic condition, such as Blake pouch cyst. Transitory structures thus can become vestigial. Examples are an excessively wide cavum septi pellucidi, suprapineal recess of the third ventricle, trigeminal artery of the posterior fossa circulation, and hyaloid ocular artery. Arrested maturation might be considered another aspect of vestigial structure. An example is the persistent microcolumnar cortical architecture in focal cortical dysplasia type Ia, in cortical zones of chronic fetal ischemia, and in some metabolic/genetic congenital encephalopathies. Some transitory structures in human brain are normal adult structures in lower vertebrates. Recognition of transitory and vestigial structures by fetal or postnatal neuroimaging and neuropathologically enables better understanding of cerebral ontogenesis and avoids misinterpretations.

Brainstem hypoxic-ischemic lesions on MRI in infants treated with therapeutic cooling: effects on the length of stay and mortality

OBJECTIVE

To test the hypothesis that brainstem hypoxic-ischemic injury on magnetic resonance imaging (MRI) would be independently associated with short-term outcomes in cooled asphyxiated infants.

METHODS

A total of 90 consecutively cooled asphyxiated infants who survived to have brain MRI were reviewed. A neuroradiologist who was masked to outcomes evaluated MRI images for brainstem involvement. Outcomes were mortality and length of stay.

RESULTS

Brainstem lesions were present on post-cooling brain MRI in 20 of the 90 infants (22%). Overall, four infants died before discharge, and all four had brainstem involvement. The infants with brainstem involvement had longer hospital stay (29 days, IQR 20-47 versus 16 days, IQR 10-26; P = 0.0001), compared to infants without brainstem lesions (n = 70); and upon multivariate analysis, brainstem involvement remained independently associated with prolonged hospital stay (β = 12.4, P = 0.001).

CONCLUSION

This study demonstrates the importance of recognizing brainstem injury for the prediction of short-term outcomes in cooled asphyxiated infants.

Moebius sequence: radiological approximations to molecular disturbances: an overview

Moebius sequence is one of the rarest congenital cranial nerve abnormalities. Approximately 300 cases have been recorded in medical literature usually from single case report. Frequently characterized by either partial or complete agenesis of the VI and VII cranial nerves, Moebius sequence is also accompanied by vascular abnormalities and other alterations such as an aberrant or hypoplastic posterior fossa. We present 3 patients with Moebius sequence and their clinical and radiological features along with a discussion of their diagnostic approximations. The 3 patients (1 male and 2 females) with ages ranging from 24 days to 7 years in both outpatient and inpatient settings in a high complexity health center. Clinical and radiologic diagnosis with magnetic resonance imaging showed to be consistent with Moebius sequence. Moebius sequence initial diagnosis is based exclusively on nonunified clinical criteria, and there is an apparent genetic pattern of inheritance. Diagnostic clues include the child's inability for proper facial expressions, affectations in eye convergence, or diminished functional hearing. A radiological approach through the use of specific MRI sequences is often warranted in order to not only approximate cranial nerve abnormalities but also accompanying structural malformations.

Characterization of Hand Anomalies Associated With Möbius Syndrome

PURPOSE

To investigate the distinguishing morphological characteristics of the upper extremities in children with Möbius syndrome.

METHODS

Twenty-seven involved extremities in 14 patients with a diagnosis of Möbius syndrome were identified at 2 institutions. Medical records, radiographs, and clinical photographs were evaluated. Congenital hand differences were classified according to the Oberg, Manske, and Tonkin classification, and hands with symbrachydactyly were classified by the Blauth and Gekeler classification. The presence of other congenital anomalies was catalogued.

RESULTS

There was bilateral involvement in 93% of patients with congenital hand anomalies. Twelve patients demonstrated congenital hand anomalies and 2 patients had been diagnosed with arthrogryposis. Among the 12 patients with congenital hand anomalies, 21 hands were classifiable as symbrachydactyly by the Oberg, Manske, and Tonkin classification and could be categorized by the Blauth and Gekeler classification. Short finger type was the most common subtype of symbrachydactyly, present in 13 hands. Eleven of these 13 patients (85%) were primarily affected on the radial side of the hand. Proximal arm involvement was identified in 2 patients with symbrachydactyly, both of whom had Poland syndrome and an absent pectoralis major.

CONCLUSIONS

Symbrachydactyly in Möbius syndrome differs from the typical presentation of symbrachydactyly. Characteristically, there is a bilateral presentation with a strong predilection for radially based brachydactyly. These described characteristics may help the hand surgeon appropriately assess patients, especially those with radial-sided symbrachydactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Area Postrema: Fetal Maturation, Tumors, Vomiting Center, Growth, Role in Neuromyelitis Optica

INTRODUCTION

The area postrema in the caudal fourth ventricular floor is highly vascular without blood-brain or blood-cerebrospinal fluid barrier. In addition to its function as vomiting center, several others are part of the circumventricular organs for vasomotor/angiotensin II regulation, role in neuromyelitis optica related to aquaporin-4, and somatic growth and appetite regulation. Functions are immature at birth. The purpose was to demonstrate neuronal, synaptic, glial, or ependymal maturation in the area postrema of normal fetuses. We describe three area postrema tumors.

METHODS

Sections of caudal fourth ventricle of 12 normal human fetal brains at autopsy aged six to 40 weeks and three infants aged three to 18 months were examined. Immunocytochemical neuronal and glial markers were applied to paraffin sections. Two infants with area postrema tumors and another with neurocutaneous melanocytosis and pernicious vomiting also studied.

RESULTS

Area postrema neurons exhibited cytologic maturity and synaptic circuitry by 14 weeks'. Astrocytes coexpressed vimentin, glial fibrillary acidic protein, and S-100β protein. The ependyma is thin over area postrema, with fetal ependymocytic basal processes. A glial layer separates area postrema from medullary tegmentum. Melanocytes infiltrated area postrema in the toddler with pernicious vomiting; two children had primary area postrema pilocytic astrocytomas.

CONCLUSIONS

Although area postrema is cytologically mature by 14 weeks, growth increases and functions mature during postnatal months. We recommend neuroimaging for patients with unexplained vomiting and that area postrema neuropathology includes synaptophysin and microtubule-associated protein-2 in patients with suspected dysfunction.

Neuroimaging Findings in Moebius Sequence

BACKGROUND AND PURPOSE

Moebius sequence comprises a spectrum of brain congenital malformations predominantly affecting the function of multiple cranial nerves. Reported neuroimaging findings are heterogeneous and based on case reports or small case series. Our goal was to describe the neuroimaging findings of Moebius sequence in a large population of patients scanned with MR imaging.

MATERIALS AND METHODS

An observational cross-sectional study was performed to assess brain MR imaging findings in 38 patients with Moebius syndrome studied between 2013 and 2016.

RESULTS

Retrospective analysis of MR imaging studies showed flattening of the floor of the fourth ventricle floor secondary to a bilateral absent facial colliculus in 38 patients (100%) and unilateral absence in 1. A hypoplastic pons was found in 23 patients (60.5%). Mesencephalic malformations consisted of tectal beaking in 15 patients (39.5%) and increased anteroposterior midbrain diameter with a shallow interpeduncular cistern in 12 (31.6%). Infratentorial arachnoid cysts were found in 5 patients (13.2%), and cerebellar vermis hypoplasia, in 2 (5.3%). Supratentorial findings included the following: thalamic fusion (26.3%), periventricular nodular heterotopias (26.3%), ventriculomegaly (26.3%), callosal abnormalities (23.7%), and hippocampal malrotations (23.7%).

CONCLUSIONS

Findings seen in this large patient cohort agreed with previously published reports. Flattening of the fourth ventricle floor secondary to a bilaterally absent facial colliculus was the most frequent MR imaging finding. The presence of other brain stem and cerebellar malformations as well as supratentorial abnormalities may help explain clinical symptoms and achieve a correct diagnosis.

Möbius syndrome associated with obesity and precocious puberty

Möbius syndrome is a neurological disorder involving underdevelopment of the sixth and seventh cranial nerves. Multiple associations have been described including dysfunction of other cranial nerves, limb abnormalities and hypogonadotrophic hypogonadism causing delayed puberty. We present the second reported case of Möbius syndrome associated with obesity and with precocious puberty. These features may be secondary to dysregulation of the hypothalamic-pituitary axis. We highlight the need to consider extraocular symptoms in these patients and for close liaison with physicians in their management.

Brainstem network disruption: A pathway to sudden unexplained death in epilepsy?

Observations in witnessed Sudden Unexpected Death in Epilepsy (SUDEP) suggest that a fatal breakdown of the central autonomic control could play a major role in SUDEP. A previous MR study found volume losses in the mesencephalon in focal epilepsy that were more severe and extended into the lower brainstem in two patients who later died of SUDEP. The aims of this study were to demonstrate an association (1) between brainstem volume loss and impaired autonomic control (reduced heart rate variability [HRV]); (2) between brainstem damage and time to SUDEP in patients who later died of SUDEP. Two populations were studied: (1) Autonomic system function population (ASF, 18 patients with focal epilepsy, 11 controls) with HRV measurements and standardized 3 T MR exams. (2) SUDEP population (26 SUDEP epilepsy patients) with clinical MRI 1-10 years before SUDEP. Deformation-based morphometry of the brainstem was used to generate profile similarity maps from the resulting Jacobian determinant maps that were further characterized by graph analysis to identify regions with excessive expansion indicating significant volume loss or atrophy. The total number of regions with excessive expansion in ASF was negatively correlated with HRV (r = -.37, p = .03), excessive volume loss in periaqueductal gray/medulla oblongata autonomic nuclei explained most of the HRV associated variation (r/r²  = -.82/.67, p < .001). The total number of regions with excessive expansion in SUDEP was negatively correlated with time to SUDEP (r = -.39, p = .03), excessive volume loss in the raphe/medulla oblongata at the obex level explained most of the variation of the time between MRI to SUDEP (r/r²  = -.60/.35,p = .001). Epilepsy is associated with brainstem atrophy that impairs autonomic control and can increase the risk for SUDEP if it expands into the mesencephalon.

Central Hypoventilation: A Rare Complication of Wallenberg Syndrome

Central alveolar hypoventilation disorders denote conditions resulting from underlying neurologic disorders affecting the sensors, the central controller, or the integration of those signals leading to insufficient ventilation and reduction in partial pressures of oxygen. We report a patient who presented with a left lateral medullary ischemic stroke after aneurysm repair who subsequently developed a rare complication of CAH. Increased awareness of this condition's clinical manifestations is crucial to make an accurate diagnosis and understand its complications and prognosis.

SÍNDROME POSTERIOR DO TRONCO CEREBRAL E O USO DE VENTILAÇÃO ASSISTIDA AJUSTADA NEURALMENTE (NAVA) EM LACTENTE

Objective:

To report a rare case of dorsal brainstem syndrome in an infant after hypoxic-ischemic episode due to severe sepsis and the use of neurally adjusted ventilatory assist (NAVA) to aid in diagnosis and in the removal of mechanical ventilation.

Case description:

A 2-month-old male infant, previously healthy, presented with severe sepsis that evolved to dorsal brainstem syndrome, which usually occurs after hypoxic-ischemic injury in neonates and infants, and is related to very specific magnetic resonance images. Due to neurological lesions, thei nfant remained in mechanical ventilation. A NAVA module was installed to keep track of phrenic nerve conduction to the diaphragm, having successfully showed neural conduction and helped removing mechanical ventilation.

Comments:

Dorsal brainstem syndrome is a rare condition that should be considered after hypoxic-ischemic episode in infants.

Pre- and Postsurgical Orthodontics in Patients with Moebius Syndrome

The authors report a combined orthodontic-surgical correction of an adult patient's malocclusion affected by Moebius Syndrome (MS). The treatment was conducted at the Dentistry Unit and the Maxillofacial Surgery Unit of the University Hospital of Parma. Treatment of malocclusion was performed after the correction of facial mimic mobility with smile surgery. The postoperative stability and orthodontic results were good and the correction of the morphological problems related to the syndrome was very satisfactory.

Telencephalic Flexure and Malformations of the Lateral Cerebral (Sylvian) Fissure

After sagittal division of the prosencephalon at 4.5 weeks of gestation, the early fetal cerebral hemisphere bends or rotates posteroventrally from seven weeks of gestation. The posterior pole of the telencephalon thus becomes not the occipital but the temporal lobe as the telencephalic flexure forms the operculum and finally the lateral cerebral or Sylvian fissure. The ventral part is infolded to become the insula. The frontal and temporal lips of the Sylvian fissure, as well as the insula, all derive from the ventral margin of the primitive telencephalon, hence may be influenced by genetic mutations with a ventrodorsal gradient of expression. The telencephalic flexure also contributes to a shift of the hippocampus from a dorsal to a ventral position, the early rostral pole of the hippocampus becoming caudal and dorsal becoming ventral. The occipital horn is the most recent recess of the lateral ventricle, hence most vulnerable to anatomic variations that affect the calcarine fissure. Many major malformations include lack of telencephalic flexure (holoprosencephaly, extreme micrencephaly) or dysplastic Sylvian fissure (lissencephalies, hemimegalencephaly, schizencephaly). Although fissures and sulci are genetically programmed, mechanical forces of growth and volume expansion are proposed to be mainly extrinsic (including ventricles) for fissures and intrinsic for sulci. In fetal hydrocephalus, the telencephalic flexure is less affected because ventricular dilatation occurs later in gestation. Flexures can be detected prenatally by ultrasound and fetal magnetic resonance imaging and should be described neuropathologically in cerebral malformations.

Synaptogenesis and Myelination in the Nucleus/Tractus Solitarius: Potential Role in Apnea of Prematurity, Congenital Central Hypoventilation, and Sudden Infant Death Syndrome

Fetuses as early as 15 weeks' gestation exhibit rhythmical respiratory movements shown by real-time ultrasonography. The nucleus/tractus solitarius is the principal brainstem respiratory center; other medullary nuclei also participate. The purpose was to determine temporal maturation of synaptogenesis. Delayed synaptic maturation may explain neurogenic apnea or hypoventilation of prematurity and some cases of sudden infant death syndrome. Sections of medulla oblongata were studied from 30 human fetal and neonatal brains 9 to 41 weeks' gestation. Synaptophysin demonstrated the immunocytochemical sequence of synaptogenesis. Other neuronal markers and myelin stain also were applied. The nucleus/tractus solitarius was similarly studied in fetuses with chromosomopathies, metabolic encephalopathies, and brain malformations. Synapse formation in the nucleus solitarius begins at about 12 weeks' gestation and matures by 15 weeks; myelination initiated at 33 weeks. Synaptogenesis was delayed in 3 fetuses with different conditions, but was not specific for only nucleus solitarius. Delayed synaptogenesis or myelination in the nucleus solitarius may play a role in neonatal hypoventilation, especially in preterm infants and in some sudden infant death syndrome cases.

Transabdominal Insonation of Fetal Basilar Artery: A Feasibility Study

BACKGROUND

Fetal anterior, middle, and posterior cerebral arteries have been studied using transabdominal Doppler ultrasound. We performed a feasibility study to determine whether basilar artery can be identified and blood flow velocities measured using transabdominal fetal Doppler ultrasound.

METHODS

The basilar artery was identified in sagittal plane behind the clivus bone using directional color Doppler with 6-2 and 7-4 MHz curved array probes. The clivus was identified by hyperechoic linear signal anterior to junction of vertebral processes and occipital bone and superior to first vertebral body. The flow direction was away from the probe in the basilar artery consistent with caudo cephalic orientation. The Doppler ultrasound probe was placed at insonation angles of less than 30° at the visualized segment of the basilar artery. Peak systolic and end diastolic velocities were measured.

RESULTS

We attempted insonation of the basilar artery in 20 fetuses. The basilar artery was adequately insonated in 18 fetuses with a mean gestational age of 27 weeks (range 19 to 38 weeks). The mean value (±SD) of peak systolic velocity of the basilar artery was 22.1 ± 8.5 cm/second (range 10.4-36.7 cm/second). The mean value (±SD) of end diastolic velocity was 6.8 ± 2.8 cm/second (range 3.5-13.5 cm/second). There was an increase in peak systolic velocity values according to gestational age of fetus.

CONCLUSIONS

We demonstrate the feasibility of fetal basilar artery insonation using directional color Doppler ultrasound via transabdominal approach.

Paroxysmal nonepileptic motor phenomena in newborn

INTRODUCTION

Understanding the pathophysiological meaning of paroxysmal nonepileptic motor phenomena in newborns represents a challenge for the clinicians of the Neonatal Intensive Care Unit.

METHODS

This paper provides an extensive review of the most frequent paroxysmal nonepileptic motor phenomena in newborns, in order to improve the knowledge about this sub-topic of the neonatal pathology and to guide the diagnostic-therapeutic approach.

RESULTS

The correct identification of an epileptic form, among different motor phenomena, which may clinically mimic seizures, is essential for a correct management, avoiding overtreatment. However, it is likewise important to know and to be able to identify other rare neurological conditions, such as hyperekplexia, spinal muscular atrophy, acute bilirubin encephalopathy, that could make a first appearance with paroxysmal motor manifestations, needing specific diagnostic work-up and treatment.

CONCLUSIONS

These clinical events should not be underestimated because, even if many times they are physiological and age-related, sometimes they could be the visible signs of an underlying epileptic or nonepileptic neurological disease.

Congenital maxillomandibular syngnathia: a new management technique using distraction techniques

Complex zygomaticomandibular syngnathia is an extremely rare condition with an unknown etiology. The main goal of the surgery is to release the ankylosis, establish good functioning mandible, and prevent reankylosis, if possible. In our case, we offer a new solution to have an adequate oral opening and to prevent reankylosis. After the release of bony syngnathia, we placed a distractor between mandibular segment and maxillozygomatic complex. To our best knowledge, this is the only syngnathia case in the literature treated using distraction techniques. There is a major improvement in the patient's status. Distraction may broaden our horizons in this rare and difficult-to-treat deformity.

Clinical characteristics and outcomes of Möbius syndrome in a children's hospital

BACKGROUND

Möbius syndrome is a congenital disorder with facial and abducens palsy. Although a few case series studies have examined comorbid conditions in Möbius syndrome, follow-up and outcome data are sparse.

OBJECTIVES

To examine the clinical characteristics and outcomes of Möbius syndrome.

METHODS

Clinical data were reviewed for 10 patients. Neonatal history, neurological examination, comorbid anomalies, medical home care, outcomes, and neuroimaging were summarized.

RESULTS

The patients' mean age was 7.3 ± 6.2 years. On neurological examination, absent blink reflex, jaw ankylosis, absent gag reflex, and tongue atrophy were frequently observed. Poland anomaly and clubfoot were present in three and six patients, respectively. Specific therapies required for patients included medical home care (six patients), suction apparatus (six), tube feeding (five), gastrostomy (two), tracheostomy (three), oxygen therapy (three), and home ventilator (two). Punctate calcification in the brainstem was observed in four patients. Pontine and medulla hypoplasia were detected on the basis of anteroposterior diameter in four and seven patients, respectively. Two patients had congenital hydrocephalus with aqueductal stenosis. Global developmental delay occurred in five patients. Three patients died.

CONCLUSION

The rate of both the use of home medical devices and death was high in our patients. Möbius syndrome is extremely diverse, not only in clinical manifestation, but also outcome. Early multidisciplinary intervention is important to ensure an optimal outcome. Aqueductal stenosis is an occasional comorbid anomaly resulting from midbrain abnormality.

Unilateral Möbius syndrome: two cases and a review of the literature

IMPORTANCE

The Möbius sequence is a rare condition defined by the combination of congenital non-progressive facial and abducens nerve palsies. The etiology of the sequence is still unknown, but likely encompasses a group of heterogeneous disorders involving genetic maldevelopment of the brainstem, a fetal vascular insult and/or teratogen exposure. The clinical phenotype reported has expanded over the years, and may be associated with more extensive cranial nerve and oropharyngeal involvement, as well as limb defects.

OBSERVATIONS

We describe two cases of children presenting with unilateral Möbius syndrome associated with ipsilateral unilateral palatal weakness. Investigations failed to identified a clear underlying etiology, but both cases shared phenotypic features of other more common cranial facial disorders such as craniofacial microsomia and the velocardiofacial syndrome.

CONCLUSION AND RELEVANCE

These two cases highlight the clinical heterogeneity of the Möbius sequence. Although asymmetries are not uncommon, cases with strictly unilateral features are extremely rare, and as such these may represent a distinct subgroup that may pertain to a specific etiology. Although in many cases, evidence of an intrauterine vascular insult may be identified, a contributing genetic etiology should be considered, even in cases with strictly unilateral features. As such genes expressed in the developing rhombencephalon and its vasculature represent good candidates for future investigation.

Evidence for brainstem network disruption in temporal lobe epilepsy and sudden unexplained death in epilepsy

The symptoms witnessed in unexplained death in epilepsy (SUDEP) suggest a breakdown of central autonomic control. Since the brainstem plays a crucial role in autonomic control, the objectives of this study were 1. To investigate if temporal lobe epilepsy (TLE) is associated with brainstem atrophy and to characterize it using graph Analysis 2. To compare the findings with those in two probable TLESUDEP. T1 images were obtained from 17 controls, 30 TLE (16 with mesial-temporal-sclerosis (TLE-MTS) and 14 without (TLE-no)) and from 2 patients who died of SUDEP. The brainstem was extracted, warped onto a brainstem atlas and Jacobian determinants maps (JDM) calculated. SPM8 was used to compare the JDMs at the group level, z-score maps were calculated for single subject analysis. Brainstem regions encompassing autonomic structures were identified based on macroscopic landmarks and mean z-scores from 5 × 5 × 5 voxel cubes extracted to calculate a new measure called atrophy-similarity index (ASI) for graph analysis. TLE-MTS had volume loss in the dorsal mesencephalon. The SUDEP cases had severe and more extensive volume loss in the same region. Nodal degrees and participation coefficients were decreased and local efficiency increased in SUDEP compared to controls. TLE is associated with volume loss in brainstem regions involved in autonomic control. Structural damage in these regions might increase the risk for a fatal dysregulation during situations with increased demand such as following severe seizures.

Patients with temporal lobe epilepsy (TLE) were studied.

Two had died of Sudden Unexplained Death in Epilepsy (TLE-SUDEP)The brainstem was studied with deformation-based morphometry and graph analysis TLE has volume loss in the dorsal mesencephalon.TLE-SUDEP have more extensive brainstem damage and evidence for network breakdown.

Proposed toxic and hypoxic impairment of a brainstem locus in autism

Electrophysiological findings implicate site-specific impairment of the nucleus tractus solitarius (NTS) in autism. This invites hypothetical consideration of a large role for this small brainstem structure as the basis for seemingly disjointed behavioral and somatic features of autism. The NTS is the brain's point of entry for visceral afference, its relay for vagal reflexes, and its integration center for autonomic control of circulatory, immunological, gastrointestinal, and laryngeal function. The NTS facilitates normal cerebrovascular perfusion, and is the seminal point for an ascending noradrenergic system that modulates many complex behaviors. Microvascular configuration predisposes the NTS to focal hypoxia. A subregion--the "pNTS"--permits exposure to all blood-borne neurotoxins, including those that do not readily transit the blood-brain barrier. Impairment of acetylcholinesterase (mercury and cadmium cations, nitrates/nitrites, organophosphates, monosodium glutamate), competition for hemoglobin (carbon monoxide, nitrates/nitrites), and higher blood viscosity (net systemic oxidative stress) are suggested to potentiate microcirculatory insufficiency of the NTS, and thus autism.

Autism spectrum disorders: the quest for genetic syndromes

Autism spectrum disorders (ASD) are a heterogeneous group of neurodevelopmental disabilities with various etiologies, but with a heritability estimate of more than 90%. Although the strong correlation between autism and genetic factors has been long established, the exact genetic background of ASD remains unclear. A number of genetic syndromes manifest ASD at higher than expected frequencies compared to the general population. These syndromes account for more than 10% of all ASD cases and include tuberous sclerosis, fragile X, Down, neurofibromatosis, Angelman, Prader-Willi, Williams, Duchenne, etc. Clinicians are increasingly required to recognize genetic disorders in individuals with ASD, in terms of providing proper care and prognosis to the patient, as well as genetic counseling to the family. Vice versa, it is equally essential to identify ASD in patients with genetic syndromes, in order to ensure correct management and appropriate educational placement. During investigation of genetic syndromes, a number of issues emerge: impact of intellectual disability in ASD diagnoses, identification of autistic subphenotypes and differences from idiopathic autism, validity of assessment tools designed for idiopathic autism, possible mechanisms for the association with ASD, etc. Findings from the study of genetic syndromes are incorporated into the ongoing research on autism etiology and pathogenesis; different syndromes converge upon common biological backgrounds (such as disrupted molecular pathways and brain circuitries), which probably account for their comorbidity with autism. This review paper critically examines the prevalence and characteristics of the main genetic syndromes, as well as the possible mechanisms for their association with ASD.

Sudden infant death syndrome: an update and new perspectives of etiology

Sudden infant death syndrome (SIDS) is a condition in which an infant, usually in the early postnatal period and nearly always before 6 months of age, dies during sleep for unexplained reasons and the standard autopsy fails to disclose an etiology. Various physiological explanations of risk factors include the prone sleeping position, overheating by excessive bundling, viral upper respiratory tract infections, parental smoking at home, and birthing injury resulting in an insult to the inner ear and central chemoreceptor zone, an immaturity that involves CO2 chemoreceptors that regulate respiratory control. Neuropathological studies and theories implicate: (1) hypoplasia or defective transmitter function in the medullary arcuate nucleus, a derivative of the rhombencephalic lip of His; (2) synaptic or receptor immaturity of the nucleus of the fasciculus solitarius, the "pneumotaxic center"; and (3) functional impairment of the serotonergic raphé nuclei of the pontine and medullary ventral median septum and other serotonergic neurons of the brainstem. Additional neurological risk factors for SIDS include perinatal neuromuscular diseases, infantile epilepsies or status epilepticus, and genetic metabolic encephalopathies.

Magnetic resonance imaging in neonates with total asphyxia

Magnetic resonance (MR) findings in cases of total asphyxia, whose lesions are mainly in the brainstem and deep nuclei, have not been clarified. In this study, we investigated MR images in neonates with total asphyxia. MR images of six infants (three males and three females; gestational age, 35-39 weeks; birth weights, 1880-3572 g) with total asphyxia were examined. In all subjects, neonatal cortical MR lesions were limited to the hippocampus with highlighting on T1-weighted imaging (T1-WI). The neonatal MR lesions of the cerebral white matter were limited to the white matter between the insula and putamen in four infants, and were diffusely involved in two infants. The ventral lateral nucleus of the thalamus was hyperintense on T1-WI in all of the subjects. Other nuclei in the thalamus, the globus pallidus and the putamen were involved in neonatal MR images of all subjects. High intensity areas on T2- weighted imaging were observed at the dorsal areas in the midbrain, pons and medulla oblongata in all or most of the subjects at the neonatal period. Also, high intensity areas on T1-WI were observed in the tegmentum of the pons and the midbrain in five cases. Neonates with total asphyxia had lesions mainly in the tegmentem of the brainstem, thalamus, putamen and globus palludus. Some of the infants had extensive lesions of the white matter.

Birth defects after exposure to misoprostol in the first trimester of pregnancy: prospective follow-up study

Misoprostol during the first trimester of pregnancy is associated with a specific malformative pattern (Moebius sequence and limb defects) whose incidence remains unknown. Data originate mostly from illegal use for abortion and are mainly retrospective. The present prospective controlled study analyses outcomes of first trimester misoprostol exposures after medical prescriptions. Malformation rate was higher among 236 pregnancies exposed before 12 gestational weeks (4%) than in 255 controls (1.8%), although not statistically significant (OR=2.2 [95% CI=0.6-7.7]). Three malformations (2%) in the exposed group were consistent with the misoprostol malformative pattern. This is the largest prospective study on first trimester misoprostol exposure and the first one relying on prescriptions. A trend toward a doubling of the overall rate of malformations was observed and for the first time an estimation of the incidence of misoprostol specific spectrum is proposed (2%). Brainstem injuries including severe trismus might be added to this specific pattern.

Feeding and communication impairments in infants with central grey matter lesions following perinatal hypoxic-ischaemic injury

BACKGROUND

Basal ganglia and thalamic (BGT) injury is common after acute perinatal hypoxia-ischaemia. Cerebral palsy is the most obvious consequence of BGT injury affecting 70-75% of survivors and is predictable from neonatal magnetic resonance imaging (MRI). However there is no equivalent predictive data for other specific outcomes. Feeding and communication impairments are also common in children following hypoxic-ischaemic encephalopathy (HIE) and BGT injury.

AIMS

To describe, in infants with HIE and BGT injury, the prevalence of feeding and communication impairments; and to evaluate the accuracy of early MRI for predicting these outcomes.

METHODS

175 term infants with HIE and BGT injury were studied. Brain lesions were classified by site and severity from the MRI scans. Motor, feeding and communication impairments were documented at 2 years.

RESULTS

Feeding and communication impairments occurred in 65% and 82% of 126 survivors respectively and related strongly to the severity of motor impairment. Forty-one children had a gastrostomy or long-term nasogastric tube. Injury severity in all brain regions was significantly associated with feeding and communication impairment on univariate analysis. On logistic regression analysis BGT (OR 10.9) and mesencephalic lesions (OR 3.7) were independently associated with feeding impairment; BGT (OR 10.5) and pontine lesions (OR 3.8) were associated with gastrostomy; the severity of BGT lesions (OR 20.1) was related to the severity of communication impairment.

CONCLUSIONS

Feeding and communication impairment are very common in children with BGT and brainstem injury of neonatal origin and can be well predicted from early MRI scans.

A case of bulbar type cerebral palsy: representative symptoms of dorsal brainstem syndrome

In this study, we present the case of a 2-year-old boy who exhibited facial and bulbar paralysis since birth, severe dysphagia, signs of oculomotor disturbance, jaw jerks, pyramidal signs on both toes, intellectual disability, and severe gastroesophageal reflux. His blink reflex and auditory/somatosensory evoked potentials suggested abnormalities in the lower brainstem, and magnetic resonance imaging showed a T2 hyperintense area in the pontine tegmentum. These findings combined with the patient's symptoms suggested "dorsal brainstem syndrome" and indicated a possibility of prenatal asphyxia in this patient. Nosologic issues regarding this subgroup of cerebral palsy are discussed here.

Early sucking and swallowing problems as predictors of neurodevelopmental outcome in children with neonatal brain injury: a systematic review

AIM

Early sucking and swallowing problems may be potential markers of neonatal brain injury and assist in identifying those infants at increased risk of adverse outcomes, but the relation between early sucking and swallowing problems and neonatal brain injury has not been established. The aim of the review was, therefore, to investigate the relation between early measures of sucking and swallowing and neurodevelopmental outcomes in infants diagnosed with neonatal brain injury and in infants born very preterm (<32wks) with very low birthweight (<1500g), at risk of neonatal brain injury.

METHOD

We conducted a systematic review of English-language articles using CINAHL, EMBASE, and MEDLINE OVID (from 1980 to May 2011). Additional studies were identified through manual searches of key journals and the works of expert authors. Extraction of data informed an assessment of the level of evidence and risk of bias for each study using a predefined set of quality indicators.

RESULTS

A total of 394 abstracts were generated by the search but only nine studies met the inclusion criterion. Early sucking and swallowing problems were present in a consistent proportion of infants and were predictive of neurodevelopmental outcome in infancy in five of the six studies reviewed.

LIMITATIONS

The methodological quality of studies was variable in terms of research design, level of evidence (National Health and Medical Research Council levels II, III, and IV), populations studied, assessments used and the nature and timing of neurodevelopmental follow-up.

CONCLUSIONS

Based upon the results of this review, there is currently insufficient evidence to clearly determine the relation between early sucking and swallowing problems and neonatal brain injury. Although early sucking and swallowing problems may be related to later neurodevelopmental outcomes, further research is required to delineate their value in predicting later motor outcomes and to establish reliable measures of early sucking and swallowing function.

Moebius sequence and autism spectrum disorders--less frequently associated than formerly thought

Moebius sequence is a rare congenital disorder usually defined as a combination of facial weakness with impairment of ocular abduction. It is questionable, whether there is a strong association of the sequence with autism spectrum disorders (ASDs) as suggested in some earlier case reports and studies. Twenty-two participants with Möbius sequence aged 6-16 years followed a request of the German Moebius foundation to participate in a nationwide study. All patients had a physical examination and intelligence testing. Primary caregivers were asked to complete two screening measures of ASD (Behaviour and Communication Questionnaire, VSK; Marburger Asperger's Syndrome Rating Scale, MBAS). For those who reached the cut-off for ASD and/or showed behavioural aspects indicative of ASDs during IQ testing and/or physical examination, well standardized diagnostic instruments (Autism Diagnostic Interview-Revised, Autism Diagnostic Observation Schedule, and Kinder-DIPS) were administered. Minimal diagnostic criteria for Möbius sequence were congenital facial weakness (uni- or bilateral) and impairment of ocular abduction (uni- or bilateral). Three boys (one of them mentally retarded) out of 22 participants (12 males and 10 females) were found suspicious of ASD by screening, but none of them fulfilled diagnostic criteria of ASD on a clinical consensus conference. Therefore, ASDs seem to be not as frequent as reported in previous studies on patients with Möbius sequence.

Abnormal fetal movements, micrognathia and pulmonary hypoplasia: a case report. Abnormal fetal movements

Background

Micrognathia is a facial malformation characterized by mandibular hypoplasia and a small, receding chin that fails to maintain the tongue in a forward position. We previously reported a system of prenatal screening that we developed to identify fetuses with compromised central nervous system function by observing fetal behavior. In this paper we report the case of a preterm infant with micrognathia and pulmonary hypoplasia who presented abnormal fetal movements.

Case presentation

A 27-year-old Japanese primigravida at 33 weeks of gestation was referred to our hospital. Ultrasonographic examination revealed clinical polyhydramnios. Micrognathia was evident on midsagittal and 3 D scan. The lung area was less than the mean -2.0 standard deviations for the gestational age. The infant had mandibular hypoplasia and glossoptosis. After emergency cesarean delivery for non-reasuring fetal status, required immediate tracheostomy and cardiopulmonary resuscitation with mechanical ventilatory support. However, the infant's cardiopulmonary condition did not improve and she died 21 hours after birth.

Conclusions

The findings of our ultrasound exam are suggestive of brain dysfunction. The observation of fetal behavior appears to be effective for the prediction of prognosis of cases with micrognathia.

Dorsal brain stem syndrome: MR imaging location of brain stem tegmental lesions in neonates with oral motor dysfunction

The anatomic extent of brain stem damage may provide information about clinical outcome and prognosis in children with hypoxic-ischemic encephalopathy and oral motor dysfunction. The aim of this study was to retrospectively characterize the location and extent of brain stem lesions in children with oral motor dysfunction. From January 2005 to August 2009, 43 infants hospitalized at our institution were included in the study because of a history of hypoxic-ischemic events. Of this group, 14 patients showed oral motor dysfunction and brain stem tegmental lesions detected at MR imaging. MR imaging showed hypoxic-ischemic lesions in supra- and infratentorial areas. Six of 14 patients revealed only infratentorial lesions. Focal symmetric lesions of the tegmental brain stem were always present. The lesions appeared hyperintense on T2-weighted images and hypointense on IR images. We found a strong association (P < .0001) between oral motor dysfunction and infratentorial lesions on MR imaging. Oral motor dysfunction was associated with brain stem tegmental lesions in posthypoxic-ischemic infants. The MR imaging examination should be directed to the brain stem, especially when a condition of prolonged gavage feeding is necessary in infants.

Hypoglossal hypoplasia and hyperplasia of the area postrema following perinatal hypoxic brain damage

We report here an autopsy case of perinatal hypoxic brain damage showing hypoglossal hypoplasia and hyperplasia of the area postrema (AP) in the medulla oblongata. A 16-year-old girl who suffered from severe psychomotor developmental delay, epilepsy and tongue fasciculation, was shown by pathology to have a medullary change, as well as tongue atrophy and severe sclerotic changes in the cerebrum and cerebellum. Moderate to severe neuronal loss and gliosis were found in the brainstem. But neurons were preserved in the trigeminal nuclei, abducens nucleus and dorsal vagal nucleus. We performed a preliminary immunohistochemical analysis of sections of the medulla oblongata in our case, normal controls and disease controls with perinatal hypoxic ischemic encephalopathy (HIE). The normal and disease controls showed neither hypoglossal hypoplasia nor AP hyperplasia. The combination of hypoglossal hypoplasia and AP hyperplasia is unique and intriguing, and further analysis of the AP is required to understand developmental brain disorders.

Brainstem dysgenesis in an infant prenatally exposed to cocaine

Many authors described the effects on the fetus of maternal cocaine abuse during pregnancy. Vasoconstriction appears to be the common mechanism of action leading to a wide range of fetal anomalies. We report on an infant with multiple cranial-nerve involvement attributable to brainstem dysgenesis, born to a cocaine-addicted mother.

Is developmental neuropathology of the motor neurons the key to resolving the mystery in motor neuron diseases?

Recently, genetic analyses on motor neurons diseases have advanced leaps and bounds, but mysteries still remain in the pathogenesis of amyotrophic lateral sclerosis and spinal muscular atrophy. Three papers in this issue of Brain and Development presented intriguing topics on the developmental neuropathology of motor neurons in the spinal cord and brainstem. Neonatal asphyxia experiments in rats indicated the modification of brainstem monoaminergic neuron systems in the development and repair of spinal motor neurons. In the victims of sudden perinatal and infant death, population changes in motor neurons and interneurons in the hypoglossal nucleus were shown to be involved in the disturbed maturation of the respiratory network in the brainstem. The coexistence of hypoglossal hypoplasia and hyperplasia of the area postrema was reported in a case of perinatal hypoxic ischemic encephalopathy. These findings are likely to be a key to resolving the undetermined pathological mechanisms of motor neuron diseases.

Reflections on the brainstem dysfunction in neurologically disabled children

This article deals with the neurological basis of brainstem-related symptoms in disabled children. Synaptic interactions of respiratory and swallowing centers, which are briefly reviewed in this study, highlight the significance of the nucleus of solitary tract (NTS) in the stereotyped motor events. Coordination mechanisms between these two central pattern generators are also studied with a focus on the inhibitory action of decrementing expiratory neurons that terminate the inspiratory activity and become activated during swallowing. Dorsal brainstem lesions in hypoxic-ischemic encephalopathy (HIE) affect the area including NTS, and result in symptoms of apneusis, facial nerve paresis, dysphagia, gastroesophageal reflux, and laryngeal stridor. Leigh syndrome patients with similar distributions of medullary lesions show increased sighs, post-sigh apnea, hiccups, and vomiting in addition to the symptoms of HIE, suggesting pathologically augmented vagal reflex pathways. The present article also discusses the pathophysiology of laryngeal dystonia in xeroderma pigmentosum group A, self-mutilation in Lesch-Nyhan syndrome, and sudden unexpected death in Fukuyama congenital muscular dystrophy. Close observation and logical assessment of brainstem dysfunction symptoms should be encouraged in order to achieve better understanding and management of these symptoms in disabled children.

Autism spectrum disorders in children and adolescents with Moebius sequence

Moebius sequence is a rare congenital disorder usually defined as a combination of facial weakness with impairment of ocular abduction. A strong association of Moebius sequence with autism spectrum disorders (ASDs) has been suggested in earlier studies with heterogenous age groups. The primary caregivers of all children and adolescents with Moebius sequence aged 6-17 years known to the German Moebius foundation were anonymously asked to complete two screening measures of ASD [Behavior and Communication Questionnaire (VSK); Marburger Asperger's Syndrome Rating Scale (MBAS)]. For those who reached the cut-off for ASD, well standardized diagnostic instruments (Autism Diagnostic Interview-Revised, Autism Diagnostic Observation Schedule, WISC-III, and Kinder-DIPS) should be administered. Minimal diagnostic criteria for Moebius sequence were congenital facial weakness (uni- or bilateral) and impairment of ocular abduction (uni- or bilateral). Familiar cases should be excluded. The primary caregivers of 35/46 children and adolescents (18 males, 17 females, mean age 11.5 years) sent back completed questionnaires, but only 27 subjects met inclusion criteria. According to the primary caregivers, none of these subjects showed mental retardation. Two probands (both males 9 and 16 years old) reached the cut-off of the MBAS whereas the results of the VSK did not indicate ASDs in any of the patients. The 9 year old boy could be examined personally and did not meet diagnostic criteria of ASD. ASDs might be not as frequent as reported in previous studies on patients with Moebius sequence, at least not in patients without mental retardation.