AN ETIOLOGIC AND DIAGNOSTIC STUDY OF CEREBRAL PALSY. A PRELIMINARY REPORT

Delayed development of sensorineural hearing loss after neonatal hyperbilirubinemia: a case report with brain magnetic resonance imaging

Sensorineural hearing loss has long been known to be a clinical consequence of kernicterus. Brainstem auditory evoked potentials (BAEPs) that occur in hyperbilirubinemic infants, can be reversed in the neonatal period by exchange transfusion. The case was reported in an infant with neonatal hyperbilirubinemia from hemolysis due to glucose-6-phosphate dehydrogenase (G6PD) deficiency and napthalene exposure. BAEPs showed that the baby had normal hearing at 30 decibels at 13 days of age, after exchange transfusions, but had developed profound bilateral sensorineural hearing loss by 7 months of age. The brain magnetic resonance imaging (MRI) findings at 7 months are also presented.

Prenatal brain damage and placental infarction--an autopsy study

The histopathological abnormalities seen at autopsy in the brains and corresponding placentas of a consecutive four-year series of stillborn infants are presented. After excluding stillbirths with major cerebral malformations, the brains of 175 cases and the corresponding placentas in 165 cases were available for assessment. 70 of the 175 brains (40 per cent) showed microscopic evidence of ischaemic cerebral injury, using a combination of haematoxylin-eosin and glial fibrillary acid protein stains. In 62 of these 70 brains, the periventricular white matter was the main site of damage. 46 (28 per cent) of the corresponding 165 placentas showed macroscopic and microscopic evidence of infarction, 39 of which were associated with ischaemic cerebral lesions. It was concluded that placental infarcts are commonly associated with prenatal cerebral ischaemic lesions.

Imaging of perinatal hypoxic-ischemic brain injury

This article reviews some physiological parameters that influence the location and degree of injury from hypoxia-ischemia. The ability of various imaging tests, particularly magnetic resonance imaging, to detect tissue changes after hypoxia-ischemia is discussed. Most importantly, we evaluate the extent of our knowledge regarding the correlations between imaging, pathophysiological processes, and clinical medicine.

Magnetic resonance imaging in athetotic cerebral palsied children

The magnetic resonance findings in 22 children with athetotic cerebral palsy were studied. Sixteen had perinatal asphyxia, two had neonatal jaundice, and four had no association with predisposing conditions. In six of the children, symmetrical high intensity areas were found in both the thalamus and putamen in T2-weighted images. In five children they were seen only in the thalamus, and in another one only in the putamen. In six children, symmetrical periventricular high intensity areas were seen. In seven of the subjects, no abnormal magnetic resonance findings were seen. Magnetic resonance lesions, possibly caused by asphyxia, were found in the basal ganglia, thalamus and/or cerebral white matter in 14 of 16 children. Three children with lesions only in the cerebral white matter had mild motor abnormality, and six children with lesions in both the thalamus and putamen did not have mild abnormality.

Clinical and neuropathological findings in severe athetoid cerebral palsy: a comparative study of globo-Luysian and thalamo-putaminal groups

We divided cases of severe athetoid cerebral palsy originating perinatally into two groups neuropathologically, the "globo-Luysian group" (GL) and the "thalamo-putaminal group" (TP). The major abnormal sites in GL were the pallidum and subthalamic nucleus, and in TP the thalamus and putamen. The lesions in TP were more widespread and frequently accompanied by fibrillary gliosis in the central gray matter of the midbrain, and subthalamic nuclei were dominantly devastated. Concerning the etiology, GL and TP were related to perinatal severe jaundice and neonatal asphyxia, respectively. The patients in TP showed lower mental ability and suffered from more intractable convulsions than those in GL. In GL, rigidospasticity was frequently demonstrated with fluctuation of athetoid movements, while in TP various abnormalities of muscle tone were observed, with rather restricted athetosis.

Obstetric malpractice litigation: the pathologist's view

In obstetric malpractice litigation, there are two main bases of defense: the clinical basis and the pathogenesis basis. The malpractice suit in most cases involves an infant delivered at term that later develops cerebral palsy. Despite the fact that much information has been elucidated about the pathogenesis of cerebral palsy, the defense is often jeopardized by an inadequate presentation of relevant causal mechanisms, pathogenesis. Studies in recent years with correlated clinical and pathologic investigations have provided evidence that the occurrence of cerebral palsy is a time marker, reflecting cerebral damage incurred during the premature period, and does not result from the events of labor and delivery at term. There is broad need generally and in legal situations for clinicians and pathologists to become knowledgeable in comprehensively correlating obstetric factors with fetal-neonatal systemic pathologic conditions and with neuropathologic effects.

Temporal evolution of hypoxic-ischaemic brain lesions in asphyxiated full-term newborns as assessed by computerized tomography

Hypoxic-ischaemic brain lesions may be detected as low density (LD) areas by means of computerized tomography (CT), but the clinical significance of such LD areas has been controversial. Since timing might be a critical factor, we studied the temporal evolution of LD areas in 9 asphyxiated term babies who had had two or more CT, and compared the changes to the neurodevelopmental outcome. Scans were classified according to the elapsed time after asphyxia as early (day 1-7, n = 6), intermediate (week 2-4, n = 7; week 4-7, n = 3) and late CT (3 months or more, n = 7). In early scans, no, or only ill defined, LD areas were seen in the periventricular region. In intermediate CT's, LD-zones were further diminished in those babies who later were normal. Sharply accentuated LD areas, however, appeared in those who later suffered from neurodevelopmental disorders. These LD areas, probably representing hypoxic-ischaemic lesions, were located periventricularly, extending into the subcortical white matter and the cortex, and usually involved both hemispheres symmetrically. They began to disappear at 4 to 7 weeks in some regions, possibly because of glial proliferation. LD persisting more than 4-7 weeks tended to transform into cyst-like lesions, or marked atrophy. We conclude (1) that hypoxic-ischaemic lesions appear as zones of low density on CT scans performed after the first week and (2) that the extent of such lesions can best be assessed between 9 to 23 days after asphyxia.

Dyskinetic cerebral palsy. I. Clinical categories, associated neurological abnormalities and incidences

An unselected series of 116 dyskinetic cerebral palsy cases born 1959-70 was delineated and subgrouped according to neurological criteria into 35 hyperkinetic (30%) and 81 dystonic (70%) cases. Of the hyperkinetics, 80% had a mild motor disability, while 90% of the dystonics had moderate or severe disability. Subordinated spastic signs were found in 9% of the hyperkinetic and in 44% of the dystonic cases. IQ was greater than 90 in 69% of the hyperkinetics and 25% of the dystonics and less than 50 in 11% and 41%, respectively. Two or more additional neurological abnormalities (spasticity, mental retardation, epilepsy, anarthria, dysarthria, hearing deficit) were detected in 46% hyperkinetic and 81% dystonic cases. A heavy multihandicap complex was present predominantly in the dystonic subgroup. The 5-19 year mortality rate was 6% and was confined to the most severely handicapped dystonic cases. The twin rate was 5%. A total of 9% had birth weights less than or equal to 1500 g, and 31% had less than or equal to 2500 g. The weight- and age-specific incidences increased rapidly with decreasing birth weights and gestational ages. The crude incidence of hyperkinetic cerebral palsy was 0.07 and dystonic cerebral palsy 0.17 per thousand live births.

Computed tomography of cerebral palsy: evaluation of brain damage by volume index of CSF space

Between 1976 and 1978, we examined 110 Japanese children with cerebral palsy using a CT 1000 and a CT 1010 (EMI). In 92% of all patients, there were abnormal findings. Cortical atrophy was seen in 51%, ventricular dilatation in 86%, localized low density areas in 22%, brain anomalies in 10% and asymmetry of cerebral hemisphere in 31%. In spastic hemiplegia, the characteristic CT revealed asymmetrical ventricular dilatation without cortical atrophy and localized low density areas in the cerebral hemisphere contralateral to the palsy. In spastic tetraplegia, CT revealed moderate to marked diffuse cerebral atrophy or brain anomalies. In athetosis, CT revealed normal or slight cerebral atrophy. In 60 cases where a CT 1010 was used, we calculated the volume index of CSF space by computer, Eclipse S/200, and analyzed the relationship between the clinical features of cerebral palsy and the volume index of CSF space.

[An autopsy case of olivocerebellar and thalamic degeneration, diffuse sclerosis and hypertrophic neuropathy: infantile system degeneration? (author's transl)]

The brain of a 21-year-old man with imbecility and spastic tetraplegia since early childhood showed a diffuse sclerosis of the cerebral white matter and symmetrical degeneration of the thalamus and olivocerebellar system. The spinal nerve roots as well as proximal branches of the spinal nerves were hypertrophic and there was seen a marked fibrosis with some onion-bulb formations of Schwann cells. In spite of a possible relation to an unknown infection at the age of 3 months this case could preferably be regarded as a peculiar form of the combined system degeneration in the early childhood, including the cerebral white matter and peripheral nerves. An uncle of the patient had died of a similar nervous disease at the age of 20 years.

Neuropathological observations in a patient with carbamylphosphate-synthetase deficiency and in two sibs

Neuropathological findings are described in a child who suffered from carbamylphosphate-synthetase deficiency and died at the age of 7 months. The brain showed ulegyria of the cerebral and cerebellar cortex and hypomyelination of the centrum semiovale and the central part of the brainstem. Two sibs, who had died at the age of 4 weeks after a comparable illness, showed brain damage that seemed to represent an earlier stage of that observed in the first patient. These two children also showed bilateral symmetrical necrotizing lesions in certain brainstem areas (in one, kernicterus was observed macroscopically). The absence of further neuropathological observations in this disease makes it as yet impossible to reach any definite conclusion as to the aetiology of the brain lesions.