Frequency of linear hyperechogenicity over the basal ganglia in young infants with congenital rubella syndrome

Parenchymal calcification is associated with the neurological prognosis in patients with congenital rubella syndrome

Congenital rubella syndrome (CRS) results from maternal rubella virus infection in early pregnancy. Abnormal neuroimaging findings have been analyzed in a small number of CRS patients in the past; however, their clinical significance has been poorly addressed. Therefore, we have investigated the neuroimaging findings of 31 patients with CRS from previous studies. The most common finding was parenchymal calcification, which was observed in 18 of 31 patients (58.1%). A multivariable logistic regression model showed that it was associated with psychomotor or mental retardation (p = 0.018), suggesting that parenchymal calcification in CRS could be a prognostic factor.

Lenticulostriate vasculopathy in neonates: Is it a marker of cerebral insult? Critical review of the literature

Although lenticulostriate vasculopathy (LSV) was recognized nearly 30 years ago, neonatologists and radiologists still question its clinical significance. The diagnosis of LSV may be highly subjective, resulting in many false negatives when the radiologist is not familiar with the lesion or false positive if over-read by those with special interest in this finding. There has been an increase in incidence of LSV since its recognition in 1985 which might reflect nothing more than a growing awareness of this finding on neonatal cranial ultrasound. On the other hand, improved ultrasound imaging technology may have enhanced identification of LSV. Prospective studies evaluating the presence, significance and diagnosis of LSV are limited and have produced conflicting results. Therefore, the associated risk factors and clinical relevance of LSV on cranial ultrasound remain unclear. This review will examine the existing literature.

The etiology of lenticulostriate vasculopathy and the role of congenital infections

Lenticulostriate vasculopathy (LSV) refers to increased echogenicity of the penetrating vessels that supply the basal ganglia and segments of the internal capsule seen on cranial ultrasound. Initially identified in infants with congenital infection, LSV has now been associated with a variety of infectious and non-infectious conditions. Although robust epidemiologic studies are lacking, the available evidence does not support broad evaluation for multiple congenital infections when LSV is identified. We propose screening infants with LSV for congenital cytomegalovirus infection and ensuring that prenatal screening included appropriate testing for syphilis, human immunodeficiency virus, and rubella-immune status. Large, prospective observational studies are needed to determine the incidence of LSV and the relative contribution of infectious and non-infectious conditions to LSV in the neonate.

Lenticulostriate vasculopathy in extremely low gestational age newborns: Inter-rater variability of cranial ultrasound readings, antecedents and postnatal characteristics

Although lenticulostriate vasculopathy (LSV) was first detected on a cranial ultrasound nearly 30 years ago, its clinical implications and significance remain unknown. The objective of this study was to evaluate the inter-rater reliability of cranial ultrasound readings of LSV, and to explore relationships with potential antecedents and developmental correlates in extremely low gestational age newborns. Of the 1506 infants enrolled during the years 2002-2004, 1450 had at least one set of ultrasound scans evaluated for LSV and 939 had all three sets. To evaluate the inter-rater agreement for identifying LSV, we compared readings from two independent radiologists on days 1-4, 5-14, and on or after day 15. We then evaluated the relationships between LSV and maternal, antenatal, and postnatal characteristics. Our results showed that kappa values were 0.18, 0.33, and 0.36 on days 1-4, days 5-14, and day 15 or greater. Infants who were identified as LSV positive by two readers had higher Score for Neonatal Acute Physiology-II (an illness severity indicator), higher rates of tracheal infection and bacteremia, lower partial pressure of arterial oxygen and pH levels on 2 of the first 3 postnatal days, and they were more likely to have a lower psycho-motor development index at age 2 years. Positive agreement on the presence of LSV was low, as was the kappa value, an index of inter-rater reliability. Infants with high illness severity scores and their correlates were at increased risk of developing LSV, while those who develop LSV appear to be at increased risk of motor dysfunction.

Identification of monoclinic calcium pyrophosphate dihydrate and hydroxyapatite in human sclera using Raman microspectroscopy

Raman microspectroscopy was first used to determine the composition of a calcified plaque located at the pterygium-excision site of a 51-year-old female patient's left nasal sclera after surgery. It was unexpectedly found that the Raman spectrum of the calcified sample at 1149, 1108, 1049, 756, 517, 376 and 352/cm was similar to the Raman spectrum of monoclinic form of calcium pyrophosphate dihydrate (CPPD) crystal, but differed from the Raman spectrum of triclinic form of CPPD. An additional peak at 958/cm was also observed in the Raman spectrum of the calcified plaque, which was identical to the characteristic peak at 958/cm of hydroxyapatite (HA). This is the first study to report the spectral biodiagnosis of both monoclinic CPPD and HA co-deposited in the calcified plaque of a patient with sclera dystrophic calcification using Raman microspectroscopy.

Rubella

Maternal rubella is now rare in many developed countries that have rubella vaccination programmes. However, in many developing countries congenital rubella syndrome (CRS) remains a major cause of developmental anomalies, particularly blindness and deafness. WHO have provided recommendations for prevention of CRS, and, encouragingly, the number of countries introducing rubella vaccination programmes has risen. However, declining uptake rates due to concerns about the measles-mumps-rubella vaccine in the UK, and increasing numbers of cases in some European countries coupled with poor uptake rates might jeopardise this progress. Surveillance of postnatally and congenitally acquired infection is an essential component of CRS prevention since rubella is difficult to diagnose on clinical grounds alone. Laboratory differentiation of rubella from other rash-causing infections, such as measles, parvovirus B19, human herpesvirus 6, and enteroviruses in developed countries, and various endemic arboviruses is essential. Reverse transcriptase PCR and sequencing for diagnosis and molecular epidemiological investigation and detection of rubella-specific IgG and IgM salivary antibody responses in oral fluid are now available.

Sonographic lenticulostriate vasculopathy in infancy with tic and other neuropsychiatric disorders developed after 7 to 9 years of follow-up

On gray-scale transfontanel sonography, the small arteries supplying the basal ganglia are indistinct from the brain parenchyma in normal infants. Bright linear 'branched candlestick' stripes in these regions, suggesting sonographic lenticulostriate vasculopathy, were reported in more than 200 infants in the English literature; including 34 our own patients. To identify its long-term outcome, a prospective study was accomplished on our 34 infants with sonographic lenticulostriate vasculopathy which included 13 cryptogenic cases and 21 with distinct etiologies. At the age of 7 to 9 years in the cryptogenic group, 7 in 13 patients developed tics, attention deficits, hyperactivity, and/or obsession/compulsion; while in the symptomatic group only 2 of 21 patients had tics. The rate of mortality (33% vs. 0%), developmental delay (24% vs. 8%), mental retardation (24% vs. 0%), and neurologic deficits (29% vs. 0%) were significantly higher in the symptomatic group than the cryptogenic group. Comparatively, the occurrence rate of attention deficit-hyperactivity disorder (10% vs. 54%), tics (10% vs. 38%), and obsessive-compulsive disorder (5% vs. 13%) were significantly lower in the symptomatic group than the cryptogenic group. The rates of these neuropsychiatric disorders were 10% in the symptomatic group and 54% in the cryptogenic group. We concluded that idiopathic sonographic lenticulostriate vasculopathy in infancy may predict development of neuropsychiatric disorders later in childhood.

Neonatal lenticulostriate vasculopathy: further characterisation

BACKGROUND

Lenticulostriate vasculopathy (LSV) is sometimes detected on routine brain ultrasonography in neonates, and is often associated with various perinatal and neonatal abnormalities. However, most reports on LSV are retrospective with no controls.

OBJECTIVES

To compare the perinatal and neonatal clinical characteristics of neonates with LSV with matched controls and to summarise all published reports of LSV.

DESIGN

A prospective study that summarises the clinical, laboratory, and neurosonographic data of neonates with LSV.

METHODS

Of 1184 neonates admitted to the neonatal intensive care unit (NICU) during a three year period, 857 had a routine head ultrasound examination. Twenty one had LSV, and were compared with 42 matched controls with regard to gestational, perinatal, neonatal, laboratory, and neurosonographic characteristics.

RESULTS

LSV was detected in 21 of the 857 (2.45%) neonates. It was bilateral in 10 of the 21 cases and located in the thalamus (n = 14) and basal ganglia (n = 7). Infants with LSV were not significantly different from matched controls in most tested variables. However, compared with the control group, the LSV group included significantly more multiple births and more disturbances in amniotic fluid volume, but less meconial amniotic fluid. In addition, the patients with LSV required fewer blood transfusions and less phototherapy.

CONCLUSIONS

Except for more multiple births, neonates with LSV did not display more adverse findings than their matched controls.

Teratogen update: congenital rubella

It is apparent that there are many unanswered questions about the pathogenesis of CRS. For instance, the chance of embryonic infection decreases in the second semester only to increase again in the third trimester. This is presumably due to unspecified changes in the placenta. When the embryo is infected early in the first trimester it does not appear to have any conventional immunological response to prevent spread of the virus. Yet it has been suggested that only 1 in 10(3) to 10(5) of its cells become infected. If this is true, what controls the spread of the virus in the early embryo? Why does the virus not affect major morphogenetic processes? There is considerable evidence that the virus spreads through the vascular system of the infected fetus and the observed cardiovascular, CNS, and hearing defects may be primarily due to focal cytopathic damage to the walls of blood vessels and lining of the heart; subsequent organ infection and/or ischemia may lead to further damage. Damage to blood vessels is probably extensive throughout the fetus and may be the cause of the generalized growth retardation. The effects in the eye appear to be due to a direct cytopathic effect, particularly on the lens. The short susceptible period for cataract formation is consistent with the protective effect of the lens capsule. Deafness, cardiovascular and neurological damage, and retinopathy all occur when infection takes place in the first 16 weeks of gestation and are rare after this time, despite the absence of any obvious morphological or functional changes in the susceptible structures. This termination of susceptibility in the second trimester is consistent with development of the fetal immune response and increased transfer of maternal IgG. The effect on blood vessels in particular may be limited by antibody production, although existing endothelial infection and damage may be progressive. The fetus seems unable to rid itself of established intracellular virus. The causes of the well-established late manifestations remain unknown. If these serious late-appearing effects are due to prenatal damage, then it is possible that other human teratogens may also cause unexpected late symptoms. This should also be a concern in the area of animal reproductive toxicology testing.