Evaluation of neurocognitive and social developments after craniosynostosis surgery

OBJECTIVE

The study focused on assessing the potential neurocognitive and social developmental issues in children with non-syndromic craniosynostosis (NSC) who received optimal surgical treatment. The primary objective was to determine whether NSC, even after optimal surgical treatment, could have negative effects on brain development.

METHODS

The study included a total of 73 pediatric patients aged between 2 and 6 years who had previously undergone surgery for NSC at the Gazi University Faculty of Medicine, Department of Neurosurgery. These patients were carefully matched with 107 healthy children who visited the outpatient clinic of the same department in terms of sociodemographic characteristics such as age, gender, and social status. To assess the neurocognitive and social development of the participants, the child psychologist administered a developmental scale to the child and his/her family via video conference. This scale was adapted from the Bayley-III Infant and Child Development Scale by the Gazi University Faculty of Medicine, Division of Pediatric Neurology.

RESULTS

The study found no social or gross motor developmental issues in patients who had undergone optimal surgical treatment for NSC. However, the risk of fine motor developmental deficiencies was 4.79 times higher than that of the normal population, and the risk of language developmental deficiencies was 5.75 times higher than that of the normal population.

CONCLUSIONS

Despite timely treatment of NSC, long-term neurocognitive and social development issues may arise in affected children. Therefore, it is crucial to monitor these patients after completing surgical treatment and thoroughly examine their development using a multidisciplinary approach.

Optic neuritis in Turkish children and adolescents: A multicenter retrospective study

BACKGROUND

Various etiologies may underlie optic neuritis, including autoantibody-mediated disorders described in the last decade. We re-examined demographic, clinical, laboratory features and prognostic factors in pediatric patients with autoimmune optic neuritis according to current knowledge.

METHODS

Cases of pediatric ON from 27 centers in Türkiye diagnosed between 2009 and 2022 were included for retrospective evaluation.

RESULTS

The study included 279 patients, 174 females and 105 males, with a female-to-male ratio of 1.65. The average age at onset was 12.8 ± 3.4 years, and mean follow-up, 2.1 years (range: 1-12.1 years). Patients <10 years old were grouped as "prepubertal" and those ≥10 years old as "others". The diagnoses made at the end of follow-up were multiple sclerosis associated optic neuritis (n = 90, 32.3 %), single isolated optic neuritis (n = 86, 31 %), clinically isolated syndrome (n = 41, 14.7 %), myelin oligodendrocyte glycoprotein antibody associated optic neuritis (n = 22, 7.9 %), and relapsing isolated optic neuritis (n = 18, 6.5 %). Predominant diagnoses were myelin oligodendrocyte glycoprotein antibody associated optic neuritis and acute disseminated encephalomyelitis associated optic neuritis in the prepubertal group and multiple sclerosis associated optic neuritis in the older group. Recurrences were observed in 67 (24 %) patients, including 28 with multiple sclerosis associated optic neuritis, 18 with relapsing isolated optic neuritis, 11 with myelin oligodendrocyte glycoprotein antibody associated optic neuritis, 8 with aquaporin-4 antibody related optic neuritis, and 2 with chronic relapsing inflammatory optic neuropathy. Recurrences were more common among female patients. Findings supporting the diagnosis of multiple sclerosis included age of onset ≥ 10 years (OR=1.24, p = 0.027), the presence of cranial MRI lesions (OR=26.92, p<0.001), and oligoclonal bands (OR=9.7, p = 0.001). Treatment in the acute phase consisted of intravenous pulse methylprednisolone (n = 46, 16.5 %), pulse methylprednisolone with an oral taper (n = 212, 76 %), and combinations of pulse methylprednisolone, plasmapheresis, or intravenous immunoglobulin (n = 21, 7.5 %). Outcome at 12 months was satisfactory, with 247 out of 279 patients (88.5 %) demonstrating complete recovery. Thirty-two patients exhibited incomplete recovery and further combination treatments were applied. Specifically, patients with relapsing isolated optic neuritis and aquaporin-4 antibody related optic neuritis displayed a less favorable prognosis.

CONCLUSION

Our results suggest optic neuritis is frequently bilateral in prepubertal and unilateral in peri‑ or postpubertal patients. Age of onset 10 or older, presence of oligoclonal bands, and brain MRI findings reliably predict the development of multiple sclerosis. The risk of developing multiple sclerosis increases mostly during the second and third years of follow-up. Relapsing isolated optic neuritis remains a separate group where the pathogenesis and outcome remain unclear. Investigation of predisposing and diagnostic biomarkers and long follow-up could help to define this group.

Effects of caffeine therapy for apnea of prematurity on sleep and neurodevelopment of preterm infants at 6 months of corrected age

STUDY OBJECTIVES

To determine the differences in sleep patterns between preterm infants who received caffeine and those who did not and to evaluate the effects of caffeine therapy on early neurodevelopment. Secondarily, actigraphy and polysomnography were compared to evaluate the sleep of preterm infants.

METHODS

Twenty-eight preterm infants ages 28-34 weeks admitted to a single-center Level III neonatal intensive care unit between May 2020 and May 2021 were included. Sleep was assessed by actigraphy for 72 hours with Respironics Mini-Mitter® Actiwatch-2 and Brief Infant Sleep Questionnaire at 6 months corrected age. On the first day of actigraphy, infants underwent polysomnography between 10:00 am and 3:00 pm. Neurodevelopment was evaluated by the Bayley Scales of Infant and Toddler Development-III, the Ages & Stages Questionnaire, and the Hammersmith Infant Neurological Examination.

RESULTS

There were no significant differences in sleep parameters measured by actigraphy, the Brief Infant Sleep Questionnaire, and polysomnography between infants in the caffeine group (n = 12) and no-caffeine group (n = 16). Sensitivity (91.07%) and agreement rate (77.21%) for the actigraphy against polysomnography were highest at the automatic threshold. No significant differences were observed in the neurodevelopment of infants in the caffeine group compared to the no-caffeine group.

CONCLUSIONS

Sleep parameters and neurodevelopmental outcomes were not different in infants at 6 months of corrected age with regard to caffeine therapy. Actigraphy at the automatic threshold can be used in infants for sleep pattern assessment.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Influence of Caffeine Therapy in Preterm Infants; URL: https://www.clinicaltrials.gov/ct2/show/NCT04376749; Identifier: NCT04376749.

CITATION

Atalah YEY, Barış HE, Akdere SK, et al. Effects of caffeine therapy for apnea of prematurity on sleep and neurodevelopment of preterm infants at 6 months of corrected age. J Clin Sleep Med. 2023;19(12):2075-2085.

Short-term effects of SAFE early intervention approach in infants born preterm: A randomized controlled single-blinded study

OBJECTIVE

Recent literature suggests that goal-oriented and family-based interventions in enriched environment have a beneficial effect on neuromotor and cognitive development. We aimed to examine the short-term effects of SAFE (Sensory strategies, Activity-based motor training, Family collaboration, and Environmental Enrichment) early intervention approach on motor, cognitive, speech and language, and sensory development in preterm infants.

METHODS

The study's sample population consisted of 24 preterm infants with corrected ages between 9 and 10 months. Infants in the control group participated in the family training program in accordance with the neurodevelopmental therapy principles (NDT). Infants in the treatment group were included in the family training program according to the principles of the SAFE Early Intervention Approach. Affordances in the Home Environment for Motor Development-Infant Scale (AHEMD-IS), Test of Sensory Functions in Infants (TSFI), Canadian Occupational Performance Measure (COPM), and Bayley Scales of Infant and Toddler Development III (Bayley III) were used to evaluate infants in both groups before and after 10 weeks of treatment (AHEMD-IS). The Depression, Anxiety, Stress Scale Short Form was used to assess the parents' mental health (DASS-SF).

RESULTS

The interaction effects (time × group) revealed significant differences for Bayley-III cognitive and language scores, TSFI total score, and AHEMD-IS total score in favor of the SAFE group (p < .05). However, there were no differences in Bayley-III motor composite score, COPM Performance score, and COPM Satisfaction score between the interaction effects (time × group) of the groups (p > .05).

CONCLUSIONS

SAFE early intervention approach improved cognitive, speech and language, sensory outcomes and provide enriched home environment in all domains when compared to NDT-based home program. SAFE is a promising novel early intervention approach for preterm infants.

ALG11-CDG: novel variant and review of the literature

OBJECTIVES

Asparagine-dependent glycosylation 11-congenital disorders of glycosylation (ALG11-CDG) is a rare autosomal recessive N-glycosylation defect with multisystem involvement particularly neurological symptoms such as epilepsy and neuromotor developmental delay.

CASE PRESENTATION

A 31-month-old male patient admitted to our center with complaints of axial hypotonia, drug-resistant myoclonic seizures, microcephaly and deafness. The electroencephalography (EEG) showed a burst-suppression pattern without hypsarrhythmia. Basal metabolic investigations were unremarkable. Progressive cerebral atrophy, hypomyelination and corpus callosum hypoplasia were striking features in brain MRI images taken during our follow-up. Compound heterozygous mutations of the ALG11 gene were found by whole exome sequencing (WES) analysis. It was determined that the c.476T>C mutation is a novel mutation. CDG type 1 pattern was detected with the examination of carbohydrate-deficient transferrin (CDT) by capillary zone electrophoresis.

CONCLUSIONS

In patients with a possible congenital defect of glycosylation, a screening test such as CDT analysis is suggested. To discover novel mutations in this rare disease group, expanded genetic analysis should be performed.

Celiac disease and catatonia: more than a coincidence?

BACKGROUND

Catatonia is a complex neuropsychiatric disorder involving stupor, waxy flexibility, and mutism lasting more than 1 hour. It has arisen mostly from mental and neurologic disorders. Organic causes are more prominent in children.

CASE

A 15-year-old female who had refused to eat and drink for 3 days, had not talked, and had stood in a fixed position for long periods was admitted to the inpatient clinic, and she was diagnosed with catatonia. Her maximum score on the Bush-Francis Catatonia Rating Scale (BFCRS) was 15/69 on day 2 of her stay. On neurologic examination, the patient`s cooperation was limited, and she was apathetic to her surroundings and stimuli and inactive. Other neurologic examination findings were normal. To investigate catatonia etiology, her biochemical parameters, thyroid hormone panel, and toxicology screening were conducted but all parameters were normal. Cerebrospinal fluid examination and autoimmune antibodies were negative. Sleep electroencephalography showed diffuse slow background activity, and brain magnetic resonance imaging was normal. As a first-line treatment for catatonia, diazepam was started. With her poor response to diazepam, we continued to evaluate the cause and found the transglutaminase levels were 153 U/mL (normal values, < 10 U/mL). The patient`s duodenal biopsies showed changes consistent with Celiac disease (CD). Catatonic symptoms did not benefit from a gluten-free diet or oral diazepam for 3 weeks. Then, diazepam was replaced with amantadine. With amantadine, the patient recovered within 48 hours, and her BFCRS retreated to 8/69.

CONCLUSIONS

Even without gastrointestinal manifestations, CD may present with neuropsychiatric symptoms. According to this case report, CD should be investigated in patients with unexplained catatonia, and that CD may only present with neuropsychiatric symptoms.

Sleep assessment in preterm infants: Use of actigraphy and aEEG

OBJECTIVE

Objective methods to monitor the sleep of preterm infants at the neonatal intensive care unit (NICU) are required to prevent potentially adverse neurodevelopmental outcomes. This study aimed to determine the concordance of actigraphy and amplitude-integrated electroencephalogram (aEEG) against gold standard direct observation (DO) in assessing sleep/wake states of typically developing preterm infants.

METHODS

This prospective observational study was conducted in a single center level III NICU. Sleep variables were measured using Philips Respironics Mini-Mitter® Actiwatch-2 for 24 h and compared with 8-h matched data of aEEG and DO. Sensitivity-specificity analysis, Cohen's kappa, prevalence-adjusted and bias-adjusted kappa (PABAK), and Bland Altman plots were generated.

RESULTS

Seventeen preterm infants were recruited. A total of 11252 epochs were studied. Sensitivity (86.4%), agreement rate (67.9%), and predictive value for wake (47.9%) for the actigraphy were highest at the automatic activity threshold whereas specificity (54.5%) and predictive value for sleep (75.5%) were highest at low threshold. The sensitivity of aEEG was 79.3% and the specificity was 54.3%. At all thresholds, the agreement was largely equivalent with low kappas (0.14-0.17) and PABAK coefficients (0.22-0.35) for actigraphy and DO. Moderate agreement was observed between aEEG and DO according to the PABAK coefficient (0.44). Mean differences in sleep parameters were not different between DO and aEEG as well as DO/aEEG and actigraphy at medium threshold (p > 0.05).

CONCLUSIONS

Actigraphy at medium threshold can be used in depicting sleep in typically developing preterm infants at NICU. aEEG may be an alternative adjunctive method to actigraphy for the evaluation of sleep/wake states in the NICU setting.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04145362.

Turkish Validity and Reliability of the Hammersmith Infant Neurological Examination (HINE) with High-Risk Infant Group: A Preliminary Study

Objective: The purpose of this study was to establish the reliability of the Turkish translation of the Hammersmith Infant Neurological Examination in infants at 8-12 months corrected age and compare Hammersmith Infant Neurological Examination scores to other predictive assessments.

Materials and Methods: Perinatal risk factors, term-age magnetic resonance imaging, general movements at 3-month corrected age, and 12-month corrected age The Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) scores were obtained in 35 high-risk infants. The Hammersmith Infant Neurological Examination was evaluated using intra-rater and inter-rater reliability. Hammersmith Infant Neurological Examination scores were compared to the findings from the three other assessments.

Results: Intra-rater and inter-rater reliability was high (intraclass correlation coefficient = 1.00; intraclass correlation coefficient = 0.969, P < .001, 95% CI = 0.939-0.984, respectively). Global Hammersmith Infant Neurological Examination scores were significantly lower in infants with magnetic resonance imaging evidence of brain injury than without (P < .05) and in infants without general movements Fidgety movements (P < .05), than with. There was a significant positive correlation between global Hammersmith Infant Neurological Examination scores and Bayley Scales-III cognitive (P < .001), language (P < .001), and motor composite scores (P < .001).

Conclusion: This study strongly supports the use of the Turkish translation of the Hammersmith Infant Neurological Examination. Users found it readily understandable and easy to use, and the scores were consistent with 3 different methods of predicting neurodevelopmental outcomes. These findings will aid the early diagnosis, management, and support for children with neurodevelopmental problems.

Psychosis: a rare onset symptom of pediatric multiple sclerosis

Neuropsychiatric symptoms are common in multiple sclerosis (MS), but it is rarely associated with psychosis as the initial manifestation. Fourteen-year-old boy admitted with auditory hallucinations. His neurological examination was normal. Brain magnetic resonance imaging (MRI) showed multiple demyelinating lesions in the mesencephalon and periventricular regions. His IgG index was high and the oligoclonal band was positive. MS was diagnosed and pulsed corticosteroids were given and his psychotic symptoms regressed. After 22months, the patient presented with hemi-hypoesthesia, and repeated MRI showed new contrast enhancing lesion detected. His complaints completely resolved with pulse corticosteroid therapy. Increasing morbidity due to delay in MS treatment underlines the need to consider MS in the differential diagnosis of pediatric cases presenting with psychosis.

The use of neuroimaging, Prechtl's general movement assessment and the Hammersmith infant neurological examination in determining the prognosis in 2-year-old infants with hypoxic ischemic encephalopathy who were treated with hypothermia

BACKGROUND

The use of neuroimaging, the General Movement Assessment (GMA), and the Hammersmith Infant Neurological Examination (HINE) to identify the risk of neurodevelopmental delay in early infancy is recommended.

AIM

The aim of this study was to examine the predictive power of neuroimaging, GMA and HINE for neurodevelopmental delay and cerebral palsy (CP) in infants with hypoxic ischemic encephalopathy (HIE) who were treated with hypothermia.

STUDY DESIGN

Retrospective cohort.

SUBJECTS AND OUTCOME MEASURES

This retrospective study included 47 (18 female and 29 male) infants who were treated with hypothermia due to HIE. Neonates with a diagnosis of HIE were followed and assessed using neuroimaging, GMA, HINE and the Bayley Scales of Infant and Toddler Development-II (Bayley II) between 3 m and 2 years of age.

RESULTS

Out of the 47 infants with HIE, no fidgety movements were observed in 5 infants. The sensitivity and specificity in determining the psychomotor developmental index (PDI) score were 97% and 100%, respectively, for MRI; 92.9% and 100% for GMA; and 91.9% and 80% for the HINE. The sensitivity and specificity in determining the mental developmental index (MDI) score were 95% and 85.7%, respectively, for MRI; 90.5% and 80% for GMA; and 91.9% and 50% for HINE. The sensitivity and specificity in determining CP diagnosis at the age of 2 years were 83.3% and 95%, respectively, for MRI; 83.3% and 100% for GMA; and 83.3% and 87.8% for HINE.

CONCLUSION

The interpretation of MRI, GMA, and HINE that are performed within the early period of life may be the gold standard for the early detection of neurodevelopmental risks in 2-year-old infants with HIE. Clinical implementation of these methods in the early period in the follow-up of these infants offers useful information for the early identification of neurodevelopmental risk and for planning early intervention.

Evaluation of state and trait anxiety levels of parents and children before electroencephalography procedures: A prospective study from a tertiary epilepsy center

BACKGROUND

Inadequate or misinformation about electroencephalography (EEG) and epilepsy may lead to anxiety in children and their parents. The purpose of this study was to make a simultaneous evaluation of the anxiety levels of children and parents before EEG procedures and to make a brief assessment of their knowledge about EEG.

METHODS AND MATERIALS

Children aged between 8 and 18 years who were referred for EEG tests at Department of Pediatric Neurology, Gazi University Faculty of Medicine, Ankara, Turkey and their parents were included in the study, prospectively. Data were collected through Personal Information Forms; an EEG questionnaire form, which questioned the knowledge of the participants about EEG; the Spielberger's State-Trait Anxiety Inventory (STAI) to determine anxiety levels of the parents; and the State-Trait Anxiety Inventory for Children-State form (STAIC) to determine the anxiety levels of the children. The following parameters were collected in a database: demographic data about children and parents (sex, age), indication of suspected diagnosis on EEG request (i.e., the referral diagnosis), history of epilepsy, number of EEG recordings, and results of previous EEG recordings. The state and trait anxiety test results of the children were compared between the girls and boys, between age groups, and their parents' results in terms of both trait and state anxiety in terms of EEG, sex, ages, educational levels, and working.

RESULTS

Eighty-five children (mean age: 13.25 ± 3.02 years) and 85 parents (mean age: 41.16 ± 7.65 years) were included in the study. The children's mean trait anxiety score was 32.51 ± 8.09, and the mean state anxiety score was 34.97 ± 7.62. Half of the children who had a trait anxiety score of ≤30 points had increased state anxiety levels because they received more than 30 points in the state anxiety evaluation score. No significant differences were found between the boys and girls in terms of the state and trait anxiety scores (p > 0.05). The parents' mean trait anxiety score was 39.16 ± 7.74, and the mean state anxiety score was 42.74 ± 6.22. Forty (47%) parents were found to have trait anxiety, and 52 (61.2%) parents had state anxiety before the EEG. The trait anxiety score of the mothers was statistically significantly higher than that of the fathers (p < 0.01). The investigation of the knowledge level of both parents and children about EEG demonstrated some misunderstandings or points of insufficiency.

CONCLUSION

The present study revealed that both parents and children had insufficient knowledge about EEG, and the procedure caused anxiety for both the parents and children. When EEG procedures are requested, parents and children should be given brief information about EEG and epilepsy. We think that in this way, the knowledge of both parents and children about this issue may be increased and their anxiety may be decreased.

Cognitive functions in pediatric multiple sclerosis: 2-years follow-up

Objective: To assess the neuropsychological status of pediatric multiple sclerosis (MS) patients and its relationship with clinical variables in a longitudinal study.Methods: Patients with MS (n = 46) and age- and gender-matched healthy control subjects (HCs, n = 53) were given tests of non-verbal reasoning, attention/concentration, visuospatial judgement and verbal fluency at baseline visit and after 2 years of follow-up. Cognitive impairment was defined as a failure on at least three of the four tests. Patients were grouped according to the age of disease onset (≤12 years as group 1 and > 12 years as group 2).Results: Cognitive impairment was detected in 22 of 46 patients at follow-up (47.8%). Patients with cognitive worsening had higher EDSS scores at follow-up compared to cognitively improved/stable group (0.68 ± 1.16 vs 0.04 ± 0.2, p = 0.01). The most affected domains were attention/concentration and non-verbal reasoning. Comparison between baseline and follow-up tests showed impairment in non-verbal reasoning over time in group 1 patients while other functions improved over time in patient and control groups as expected.Conclusion: Pediatric MS is likely to affect patients' cognition concurrently with their disability levels. This effect is significant in the non-verbal reasoning area in patients with disease onset before age 12 years. A practical method assessing this function should be part of these patients' regular follow-up for optimal treatment, prevention and rehabilitation.

Effects of robotic rehabilitation on walking and balance in pediatric patients with hemiparetic cerebral palsy

BACKGROUND

The most prominent characteristics of hemiparetic cerebral palsy (hCP) children are structural and functional asymmetries. These children have low walking speeds, endurance and poor balance. The robotic walking devices repeat and experience symmetrical stepping at the corresponding speed and angles of the lower extremities. RESEARCH QUESTION 1: Are robotic walking devices effective in the development of walking in hCP children who can walk? RESEARCH QUESTION 2: How does the aerobic exercise experience with assisted and symmetrical movement affect the walking and local muscle, peripheral oxygenation of children with hCP?

METHODS

This prospective, controlled study included 24 children with hCP. All children attended to a standard physiotherapy rehabilitation (PTR) program (three days a week for 12 weeks); those in the study group (n=12) also attended to an Robotic Gait Training (RGT) program three times a week. Evaluations performed before treatment, after treatment, and at the 3rd month after treatment included assessment of balance, functionality walking and measurements for oxygenation of vastus lateralis muscle and peripheral oxygenation.

RESULTS

The evaluations were similar for both groups before treatment. After treatment, walking speed, endurance and peripheral O2 saturation were increased and balance abilities and functional performances improved in the RGT group as compared with the pre-treatment evaluations; these improvements in balance and functional performance were generally preserved after 3 months of treatment. An increase in 6-min walking distance and a partial increase in gross motor functions and functional muscle strength were observed in the control group; however, these abilities were not preserved after the treatment.

SIGNIFICANCE

RGT can provide a faster and higher effect on the development of functional muscle strength, balance, walking speed and endurance than the standard PTR program. It improves functional walking performance. RGT can be used for aerobic exercise training in children with walking hCP.

Multiple Sclerosis with Onset Younger Than 10 Years in Turkey

OBJECTIVE

To identify the demographics, clinical characteristics, disease course, treatment patterns, and disability levels of multiple sclerosis (MS) patients with onset under the age of 10 years (early onset multiple sclerosis, EOMS).

METHODS

EOMS patients were reviewed retrospectively in detailed records from 27 child neurology centers. Patients with preschool (≤7 years) and school age (>7 years) onset were compared.

RESULTS

There were 30 children (16 girls, 14 boys) who have disease onset between 4 and 10 (mean8.1 ± 1.8) years. MS was relapsing-remitting in 29 (96.7%) and primary progressive in one (3.3%) of the patients. In patients with onset ≤7 years, motor symptoms (54.5%) and encephalopathy (45.5%) predominated, while in those with onset >7 years brainstem (42.1%), sensory (26.3%), and optic nerve (26.3%) involvement were the most frequent presentations.

CONCLUSIONS

MS starting ≤7 years differs from the 7-10-year-old group by the higher rate of motor symptoms and more attacks in the first year: the latter suggests a more inflammatory character for EOMS.

Characteristics of pediatric multiple sclerosis: The Turkish pediatric multiple sclerosis database

OBJECTIVE

To document the clinical and paraclinical features of pediatric multiple sclerosis (MS) in Turkey.

METHODS

Data of MS patients with onset before age 18 years (n = 193) were collected from 27 pediatric neurology centers throughout Turkey. Earlier-onset (<12 years) and later-onset (≥12 years) groups were compared.

RESULTS

There were 123 (63.7%) girls and 70 (36.3%) boys aged 4-17 years, median 14 years at disease onset. Family history of MS was 6.5%. The first presentation was polysymptomatic in 55.4% of patients, with brainstem syndromes (50.3%), sensory disturbances (44%), motor symptoms (33.2%), and optic neuritis (26.4%) as common initial manifestations. Nineteen children had facial paralysis and 10 had epileptic seizures at first attack; 21 (11%) were initially diagnosed with acute disseminated encephalomyelitis (ADEM). Oligoclonal bands were identified in 68% of patients. Magnetic resonance imaging revealed periventricular (96%), cortical/juxtacortical (64.2%), brainstem (63%), cerebellum (51.4%), and spinal cord (67%) involvement. Visual evoked potentials (VEP) were abnormal in 52%; serum 25-hydroxyvitamin D levels were low in 68.5% of patients. The earlier-onset group had a higher rate of infection/vaccination preceding initial attack, initial diagnosis of ADEM, longer interval between first 2 attacks, and more disability accumulating in the first 3 years of the disease.

CONCLUSION

Brainstem and cerebellum are common sites of clinical and radiological involvement in pediatric-onset MS. VEP abnormalities are frequent even in patients without history of optic neuropathy. Vitamin D status does not appear to affect the course in early disease. MS beginning before 12 years of age has certain characteristics in history and course.

Cerebellopontine angle arachnoid cyst associated with mirror movements

Arachnoid cysts are benign developmental collections of cerebrospinal fluid (CSF). They constitute approximately 1% of intracranial masses. The cerebellopontine angle (CPA) arachnoid cysts are rare and often asymptomatic. The onset of symptoms and signs is usually due to the compression of the brain, cranial nerves and obstruction of CSF circulation. The major clinical symptoms for CPA arachnoid cysts were reported as headache, ataxia and 8^th cranial nerve palsy. We report a patient with a CPA arachnoid cyst. He presented with cranial nerve palsies and mirror movements found in upper extremities. We postulated that CPA arachnoid cyst compressing the brain stem and the pyramidal decussation may lead to mirror movements. We conclude that mirror movements can be associated with CPA arachnoid cyst.

Does nephrotoxicity exist in pediatric epileptic patients on valproate or carbamazepine therapy?

The aim of this study was to investigate the effects of valproate and carbamazepine, on renal glomerular and tubular functions. The patient group comprised 54 children with new-onset epilepsy treated with valproate (n = 30) and carbamazepine (n = 24). Twenty-six healthy children were in the control group. The serum creatinine and cystatin C levels and urinary excretion of N-acetyl-β-d-glucosaminidase (NAG) levels were measured and the glomerular filtration rate (GFR) was estimated. Serum creatinine and cystatin C concentrations were not different between patients and controls. The glomerular filtration rate of the patient groups were higher than those of the control group. Thus, both drugs probably lead to glomerular hyperfiltration and toxicity for glomerular functions. However, urinary N-acetyl-β-d-glucosaminidase/creatinine levels were significantly higher in patients receiving only valproate (6.1 ± 5). The difference between carbamazepine and control groups was not significant for urinary N-acetyl-β-d-glucosaminidase/creatinine levels. Our data suggest that valproate has adverse effects on renal tubular functions.

The effect of topiramate on body weight and ghrelin, leptin, and neuropeptide-Y levels of prepubertal children with epilepsy

BACKGROUND

Weight loss is one of the most frequent side effects of topiramate treatment. The aim of our study was to investigate the effect of topiramate on body mass index, serum glucose, insulin, cortisol, leptin, and neuropeptide-Y levels and the role of these variables on the pathogenesis of weight loss in prepubertal children with epilepsy.

METHODS

Twenty prepubertal children with epilepsy who were treated with topiramate were enrolled in the study. Topiramate was used at a daily dose of 5 mg/kg. Body mass index and fasting insulin-to-glucose ratio were calculated. Serum glucose, insulin, leptin, neuropeptide-Y, ghrelin, and cortisol levels were measured for all patients before the treatment and at the third and sixth months of the treatment.

RESULTS

There were significant decreases in mean body mass index, fasting insulin-to-glucose ratio, and serum cortisol and leptin levels at the third and sixth months of the treatment compared with pretreatment levels. No significant changes were observed in serum glucose, ghrelin, neuropeptide-Y, or insulin levels.

CONCLUSIONS

The exact mechanism of topiramate on energy balance regulation is not clearly understood. Topiramate affects body mass index, fasting insulin-to-glucose ratio, and serum leptin and cortisol levels in prepubertal children. These changes may be key factors in weight loss due to topiramate.

Aromatic L-Amino acid decarboxylase deficiency: A new case from Turkey with a novel mutation

Aromatic L-amino acid decarboxylase (AADC), a vitamin B6-requiring enzyme that converts L-dopa to dopamine and 5-hydroxytryptophan to serotonin. Deficiency of this enzyme results in developmental delay, muscular hypotonia, dystonia, involuntary movements, autonomic dysfunction, and oculogyric crises. We now report a 2-year-old Turkish boy with AADC deficiency confirmed by greatly reduced AADC activity in the plasma and by genetic studies. Mutation analysis revealed a homozygous mutation c.208C > T (p. His70Tyr) in exon 3 of the AADC gene which has not been described to date.

Cerebral hemodynamic changes and pain perception during venipuncture: is glucose really effective?

Newborns are exposed to a considerable number of painful stimuli. This study is aimed to investigate the effects of 30% glucose solution and nonnutritive sucking on pain perception during venipuncture. Twenty-five term infants were randomized as receiving 30% dextrose (group 1) or sterile water (group 2). Neonatal Infant Pain Scale scores, skin conductance algesimeter recordings, and near-infrared spectroscopy measurements were recorded during the procedure. Neonatal Infant Pain Scale and skin conductance algesimeter results were decreased in both groups from that during venipuncture to after the procedure. Group 1 had lower Neonatal Infant Pain Scale scores compared with group 2 after venipuncture, different from the skin conductance algesimeter, where no difference was observed between groups. In group 1, cerebral blood volume increased after venipuncture. Glucose does not attenuate the Neonatal Infant Pain Scale score and skin conductance algesimeter index during venipuncture, but it leads to a lower Neonatal Infant Pain Scale score after venipuncture unlike the skin conductance algesimeter index, which was not lowered.

Short- and long-term effects of individualized enteral protein supplementation in preterm newborns

The aim of this retrospective study was to assess the need for additional enteral protein supplementation in preterm newborns with gestational age (GA) ≤32 weeks after full enteral feeds with either fortified breast milk (FBM) or preterm formula (PF) were reached, and to determine the effects of additional protein on physical and neurological development. After the standard early total parenteral nutrition (TPN) and reaching full enteral nutrition with 150-160 ml/kg/day, preterms were assessed for the requirement of additional protein based on serum blood urea nitrogen (BUN)/prealbumin levels. Additional enteral protein was given for BUN <5 mg/dl and/or prealbumin ≤8 mg/dl with weekly assessments as per Neonatal Intensive Care Unit (NICU) protocol. Growth in the NICU and neurodevelopmental outcome at 18 months' corrected age (CA) were determined. There were 32 newborns in the non-supplemented group (Group 1) and 33 newborns in the supplemented group (Group 2). All newborns in Group 2 were on FBM. Weight gain and head growth were better and Bayley scores at 18 months' CA were higher in Group 2. Standard preterm nutrition with FBM may not be sufficient for preterms, and additional enteral protein supplementation may improve the physical growth rate in the NICU and result in better neurodevelopmental outcome at 18 months' CA.

Matrix metalloproteinase-7 and matrix metalloproteinase-9 in pediatric multiple sclerosis

Matrix metalloproteinases and their tissue inhibitors play a key role in the pathogenesis of adult-onset multiple sclerosis, and were suggested as biomarkers of response to interferon-β, an established treatment in multiple sclerosis. However, data regarding pediatric population are scarce. We determined serum levels of matrix metalloproteinase-7, matrix metalloproteinase-9, and tissue inhibitor of matrix metalloproteinase-1 in children, and evaluated effects of interferon-β therapy on these measures. Serum samples from 14 children with relapsing, remitting multiple sclerosis at baseline and at month 12, and from 15 controls, were collected. Interferon-β treatment was initiated in eight patients. Mean serum matrix metalloproteinase-9 levels and matrix metalloproteinase-9/tissue inhibitor of matrix metalloproteinase-1 ratio were higher in patients compared with controls, and were reduced significantly in treated patients at month 12, but did not change in untreated patients. Mean matrix metalloproteinase-7 levels were lower in patients compared with controls, and increased significantly in the treated group, but did not change significantly in the untreated group. In pediatric multiple sclerosis, a shift in matrix metalloproteinase-9/tissue inhibitor of matrix metalloproteinase-1 balance toward proteolytic activity is evident, and interferon-β therapy demonstrates a beneficial effect on this disturbed balance.

Macular Retinitis as a First Sign of Subacute Sclerosing Panencephalitis: The Importance of Early Diagnosis

PURPOSE

Subacute sclerosing panencephalitis (SSPE) is a subacute inflammatory and neurodegenerative encephalitis related to the measles (rubeola) virus and usually affecting children and young adults. The overwhelming majority of cases follow a progressive downhill course leading to death, although there have been a few case reports of patients who have apparently gone into remission. Ocular changes occur in up to 50% of SSPE cases. Visual complaints, if present, generally antedate the onset of neurological symptoms by a few weeks or months. Here, we report two cases of SSPE presenting with ocular findings and their prognoses.

METHODS

Case reports. In the first case, a 17-year-old male presenting with macular retinitis, the macular findings were mistaken for a heredodegenerative disorder and diagnosis was postponed until neurological findings took place. He died six months after the appearance of his first ophthalmic symptoms despite intravenous immune globulin and isoprinosine therapy. The second case was a 14-year-old male, who presented with only ophthalmological complaints. His diagnosis was based on both ophthalmological findings and high doses of measles IgG in the cerebrospinal fluid (CSF); isoprinosine and intramuscular beta-interferon therapy was started before the onset of neurological findings and in the follow-up time of about 18 months, neurological findings consistent with SSPE did not develop.

RESULTS

The characteristic finding of macular retinitis in SSPE patients is rapid recovery in about one month without therapy. After improvement, neurological findings take place. Once suspected, the diagnosis of SSPE is easily established by the demonstration of high levels of measles antibody in the serum and CSF. Early diagnosis can be made with typical ocular findings and high IgG titers for rubeola in CSF.

CONCLUSION

We suppose that ophthalmic manifestations, especially macular retinitis, may be useful in the diagnosis and management of SSPE cases with elevated IgG titers for rubeola in CSF. The typical clinical findings must be familiar to every ophthalmologist so that diagnostic pitfalls can be prevented and early therapy started. It may be discussed if early diagnosis and therapy will be possible before neurological signs appear, the prognosis of this relentless disease may show a more favorable course.

A boy with small supernumerary marker chromosome X identified by FISH

Marker or ring X chromosomes are frequently seen in Ullrich-Turner Syndrome with 46,X,r(X) karyotype, but only 8 children were reported with an extra marker X chromosome in at least some of their cell lines, we describe a 5 years old male patient who is mosaic (17%) for a cell line with an extra ring shaped marker X chromosome in addition to a normal 46,XY cell line. He had mild motor mental retardation, a dysmorphic face, dysplastic ears, high arched palate, cryptorchidism and brachydactyly. G-banding showed 46,XY[83]/47,XY,+r?[17] karyotype. NOR banding revealed no satellite region but its centromere was intact in C-banding. By fluorescent in situ hybridization (FISH) technique, dual X/Y alpha-satellite probes were used to detect the origin of ring shaped marker chromosome and 17% of his cells had two X chromosome signals due to marker X; hybridization with X chromosome inactivation center (XIST) specific probe revealed the absence of the locus on the ring chromosome. In this report, clinical features of our patient are compared with previously reported cases and the cytogenetic and molecular cytogenetic techniques used to detect origin of marker chromosome are discussed.

Brain perfusion assessed by 99mTc-ECD SPECT imaging in pediatric patients with neurally mediated reflex syncope

BACKGROUND

The involvement of cardiogenic and neurogenic mechanisms in neurally mediated reflex syncope is well documented. In our previous studies in patients with neurally mediated reflex syncope, we have found evidence for differential regulation of the noradrenergic receptors in tilt-positive and tilt-negative patients. The present work concentrates on the observations of differences in regional brain perfusion using brain SPECT via injecting the patient at the completion of the tilt test.

METHODS AND RESULTS

The following study was designed to assess the reduction and regional differences in cerebral blood flow by means of SPECT using technetium-99m labeled V-oxo-1,2-N1ethylenedylbisl-cysteine diethylester (ECD) in patients with an injection during tilt testing. Twenty patients with NMS were included in the study with a mean age of 12.2 years (age range; 8-16 years). HUT was positive in 10 patients and negative in 10 patients. When tilt (+) and tilt (-) were evaluated together, regional cortical/cerebellum ratios were ranging from 0.85 to 1.25 in different cortical areas with highest variability of perfusion index in left frontoparietal cortex. The lowest perfusion index values were observed in the left anterior frontal region followed by the left prefrontal-frontoparietal-anterior, parietal-orbito frontal, and anterior temporal regions where perfusion is predominantly supplied via the anterior and middle cerebral arteries, while these differences did not reach statistical significance in a single dominant region compared to the other regions examined using ANOVA (P > 0.05) with this sample size. Decreases in [99mTc]ECD uptake were more widespread regionally on the left hemisphere than were decreases in right side of the brain. However when tilt- and tilt+ groups were compared, perfusion was significantly lower in the right periinsular posterior parietal and temporal regions (P < 0.05) in tilt + group.

CONCLUSION

These tilt induced regional differences in brain perfusion suggest the distinct roles of middle cerebral artery dominant territory-related vasodepressor compensation mechanisms in neurally mediated reflex syncope phenomena where cerebral lateralization of cardiac control and insular ischemia may play an important role.

Serum carnitine levels in newborns with perinatal asphyxia and relation to neurologic prognosis

Neonatal hypoxic encephalopathy is one of the major causes of permanent neurological sequel. This study was conducted to investigate serum total, free and acylcarnitine levels in asphyxiated newborns with or without encephalopathy. Serum total, free and acylcarnitine levels were investigated in 21 newborns with and seven asphyxiated newborns without signs of encephalopathy. The newborns with encephalopathy were further divided into grade 1, 2 and 3 encephalopathy groups. Serum total and acylcarnitine concentrations of the whole encephalopathy group were significantly lower than the non-encephalopathy group (p = 0.042 for both). Serum total and acylcarnitine concentrations of grade 3 encephalopathy group were significantly lower than the non-encephalopathy group (p = 0.014 and p = 0.040, respectively). No significant differences were noticed for free carnitine levels. Total carnitine levels were positively correlated with birth weight and 10th minute apgar score, whereas acylcarnitine levels were found to correlate with cord blood pH and free carnitine levels with birth weight. Cord blood pH, and total carnitine levels were found to be the most significant determinants of the neurological outcome at one year of age. It was emphasized that carnitine deficiency could occur in severely affected asphyxiated newborns and it is related to the outcome at one year of age.

Complex partial seizure mimicking psychotic reaction in an adolescent

A previously healthy 15-year-old boy initially diagnosed to have acute psychotic reaction had a history of a single generalized seizure and prolonged amnestic states of varying intensity and duration. An ictal electroencephalogram (EEG) showed bitemporal ictal discharges starting from the left side. Carbamazepine was started. A magnetic resonance imaging (MRI) obtained on the 10th day of the antiepileptic therapy showed increased signal intensity on the T2 weighted images. The patient's memory function markedly improved during 10 months' follow-up with antiepileptic treatment, although he described brief attacks of dizziness. A repeat MRI examination showed normal findings. The amnesticstates were thought to be due to frequent complex partial seizures, and transient MRI changes to hippocampal edema. This case illustrates the importance of epileptic disorders in the differential diagnosis of psychiatric conditions.

The impact of pre- and perinatal factors on attention-deficit and disruptive behavior disorders

Diagnosis of attention-deficit and disruptive behavior disorders defines a group of disorders which have common properties. This group consists of attention-deficit hyperactivity disorder, conduct disorder and oppositional defiant disorder. In order to differentiate these disorders, which share similar properties, it is important to verify the existing differences. In this respect, differences between and distribution of perinatal factors in these three disorders were investigated. The study was conducted in the Child Psychiatry and Pediatric Neurology Departments over a 20-month period. Two hundred and seventy children out of 1,556 attendant with various complaints were diagnosed to have one of the following disorders: 121 had attention-deficit hyperactivity disorder, 50 had oppositional defiant disorder and 99 had conduct disorder. The prenatal and perinatal data of the patients were evaluated retrospectively by a neonatologist. With regard to the investigated parameters, none showed any significant difference between the three groups when compared. The three disorders, which share many similarities in terms of the symptoms, also show similarities in terms of perinatal factors. Since we did not find any study similar in design, our results, although statistically not significant, are discussed in light of the little data available.

Autosomal recessive spastic ataxia of Charlevoix-Saguenay in two unrelated Turkish families

Autosomal recessive spastic ataxia of Charlevoix-Saguenay is an early onset form of hereditary spastic paraplegia with a peculiar clinical presentation. In addition to cerebellar findings which manifest first with ataxic gait in early life and spasticity, on an evolutionary basis, there is axonal neuropathy, prominent myelinated fibers in the optic fundus, and evidence of cerebellar atrophy that can be detected by cranial MRI. Intelligence is usually normal, however lower IQs have also been documented. This disorder mainly originates from the Charlevoix-Saguenay region of Quebec. Here, we report two Turkish families linked to the disease locus on chromosome 13 q12. There was homozygosity and segregation of disease haplotypes in both families. This form of spastic ataxia may be more common than originally presumed.

Why hypothermia in neonatal hypoxic ischemic encephalopathy?

The incidence of asphyxiated full-term infants is still high in both high income and developing countries. In up to 80 percent of infants, moderate to severe birth asphyxia results in long-term neurological sequelae. Many years of experimental work and a limited data on hypoxic-ischemic neonates have supported the hypothesis that hypothermia after the primary insult induces permanent neuroprotection. In this mini overview, we attempt to update pediatricians in this aspect and raise the following: Will the future treatment include hypothermia along with the conventional and or other promising drugs affecting different aspects of the hypoxia-ischemia?

Evaluation of dysrhythmia in children with muscular dystrophy

Myocardial involvement and dysrhythmia are common findings with muscular dystrophy and are among the leading causes of death. The authors evaluated rhythm and conduction abnormalities in children with muscular dystrophy by electrocardiography, signal-averaged electrocardiography, and Holter monitoring. Twenty-nine patients (mean age, 8 years) and 29 healthy control subjects were included in the study. Sixty-two percent of patients had electrocardiographic abnormalities defined as deep Q waves in V6, tall R waves in V1, and QRS axis deviation. The cardiomyopathy index was significantly greater in the patient group whereas QT and QTc dispersion values showed no significant difference. Holter monitoring revealed premature atrial and ventricular contractions more frequently than normal. However all were classified as Lown I and II. Mean heart rate was significantly higher in the patient group. The electrocardiograms of 41% of the patients showed late potentials. No relationship with these changes and cardiac function was observed. During the study, one patient died whose cardiomyopathy index was longer and had late potentials detected with signal-averaged electrocardiography. In conclusion, standard electrocardiography, cardiomyopathy index, signal-averaged electrocardiography, and Holter monitoring are valuable and reliable monitoring methods in children with muscular dystrophy.

Moyamoya syndrome after radiation therapy for optic pathway glioma: case report

We present a 4-year-old girl with neurofibromatosis-1 who developed moyamoya syndrome characterized by bilateral stenosis or occlusion of the distal internal carotid arteries and their branches, leading to the development of an abnormal vascular network. In light of a literature review, the postradiation vasculopathy of the moyamoya type and its relationship with neurofibromatosis-1 are discussed.

Urinary nitric oxide in newborns with infections

BACKGROUND

Neonatal sepsis is a major problem in newborn nurseries because of the difficulty in early diagnosis and because of the high morbidity and mortality. The objective of the present study was to investigate whether urinary nitric oxide (NO) levels could be useful for the diagnosis of infected newborns.

METHODS

Newborns with suspected infection according to previously defined criteria between ages of 1-7 days and 8-30 days were included as the study groups (p) to be compared with age-matched healthy controls (c). Urine NO levels were assayed by Sievers NOA based on chemiluminescence and expressed as corrected for urine creatinine.

RESULTS

20 newborns with suspected infection at 1-7 days of age (group 1p) were compared with 45 healthy age-matched newborns (group 1c). 16 newborns with suspected infection at 8-30 days of age (group 2p) were compared with 15 healthy age-matched newborns (group 2c). The groups were similar with regard to birth weight and gestational age; however, the urinary NO levels in newborns with suspected infection at 1-7 days of age (80.25+/-60.68 micromol/mg creatinine) were higher than in healthy newborns (25.45+/- 19.35 micromol/mg creatinine). Similarly, newborns with suspected infection at 8-30 days of age had higher urinary NO levels (81.78+/- 40.43 micromol/mg creatinine) than age-matched controls (36.99+/-24.58 micromol/mg creatinine; p < 0.05). The sensitivity of urinary NO levels to detect infection was 50% in both age groups, and the specificity was 95% for 1-7 days of age and 93% for 8-30 days of age. Groups 1p and 2p were similar with regard to NO production. Altogether 12 patients had culture-proven sepsis, 11 patients had clinical sepsis, and 13 patients had other infections. The NO levels were similar in patients with culture-proven and clinical sepsis and higher than in patients with other infections. No difference was observed among NO levels of patients with gram-positive and gram-negative sepsis.

CONCLUSIONS

Urinary NO levels which are quick and easy to measure are higher in infected newborns as compared with controls, and although the specificity is good, the sensitivity of the test is low, necessitating the use of another marker in addition to NO.

Tremor and myoclonus heralding Hashimoto's encephalopathy

We report the clinical laboratory, electroencephalography (EEG), magnetic resonance imaging (MRI) and single photon emission computerized tomography (SPECT) findings in a 15 year-old euthyroid girl with autoimmune thyroiditis and encephalopathy. She had stupor, coma and generalized tonic clonic seizure preceded by tremor and myoclonus with a previous misdiagnosis of epilepsy and encephalitis. Response to steroid after the 3rd relapse was excellent. Another four children in the literature are also discussed.

Neonatal cerebral venous thrombosis coexisting with bilateral adrenal hemorrhage

We report a case of severe perinatal asphyxia with both cerebral venous thrombosis and adrenal hemorrhage who survived with severe sequela including multicystic encephalomalasia, acquired microcephaly and blindness. Hematological investigations showed normal levels of anticardiolipin antibodies, protein C and S levels and activity, antithrombin III levels. Factor V Leiden mutation was negative. The adrenal hemorrhage resolved within three months with glucocorticoid therapy, the cerebral venous thrombosis resolved within two months without treatment. The literature on neonatal cerebral venous thrombosis is also reviewed.

Evaluation of bone mineral metabolism in children receiving carbamazepine and valproic acid

Dual energy X-ray absorptiometry (DXA) was used to assess lumbar spine (L2-4) and femoral neck bone mineral density (BMD) in 36 children taking either carbamazepine or valproic acid for longer than one year, for generalized idiopathic epilepsy. Patients were matched with controls. Biochemical parameters of bone mineral metabolism were also measured. BMD values at both the femur neck and lumbar spine in both the carbamazepine and valproic acid groups were not significantly different from that of the control group. Serum levels of calcium were subnormal and alkaline phosphatase levels were high in the carbamazepine group. Urinary calcium levels were significantly lower in both groups than in the control group (p< or =0.05) and also significantly lower in the valproic acid group than in the carbamazepine group (p< or = 0.05). There were no other significant biochemical changes in either group. In conclusion, the results suggest that valproic acid and carbamazepine monotherapies have minimal effects on bone mineral metabolism, but routine monitoring of risk and consideration of prophylactic vitamin D supplementation is important.

Methyl-prednisolone in neurologic complications of Mycoplasma pneumonia

In patients with Mycoplasma pneumonia extrapulmonary manifestations such as encephalitis, meningitis, cerebellar and brain stem involvement, cranial nerve lesions, peripheral neuropathy, polymyositis have been observed. We report a 16-year-old girl with M. pneumonia infection, acute behavioral changes and coma. Treatment with high dose methyl-prednisolone and clarithromycin led to rapid clinical improvement.

The serum nitric oxide levels in patients with Duchenne muscular dystrophy

Nitric oxide is formed in skeletal muscle by the neuronal type nitric oxide synthase and the signalling function of dystrophin and related compounds are in part mediated by nitric oxide. Duchenne muscular dystrophy, mdx mice and patients with Becker dystrophy demonstrated neuronal type nitric oxide synthase deficiency in muscle biopsy specimens. We have intended to find out whether the plasma nitric oxide levels show any abnormality in patients with Duchenne muscular dystrophy. Serum NO levels of Duchenne patients (4.191+/-2.82 micromol/l) were significantly lower than those of the control (39.53+/-19.43 micromol/l) and cerebral palsy (77.84+/-21.70 micromol/l) groups.

Cerebrospinal fluid and serum nitric oxide levels in asphyxiated newborns

Hypoxic-ischemic encephalopathy (HIE) is the result of a chain of events caused mainly by cytokines and nitric oxide (NO) release, which is later on followed by free oxygen radical injury. To investigate NO involvement in asphyxiated newborns, serum and cerebrospinal fluid (CSF) values of NO levels in 17 neonates with HIE were detected. Infants at or above 37 weeks of gestation were classified to have mild, moderate and severe HIE due to Sarnat and Sarnat. Samples obtained between 24 and 72 h of life were immediately frozen at -70 degrees C till the time of measurement by Sievers NOA. Five patients had mild, 6 patients had moderate and 6 patients had severe HIE, 4 in the severe HIE group also had multisystem involvement. The CSF NO levels were significantly higher in moderate and severe HIE groups compared to the mild HIE group (p = 0.028 and p = 0.018 respectively). Our results show that NO level increases in CSF with the severity of HIE between 24 and 72 h following asphyxia. According to the animal work, this is the time period where inducible NO synthase gets activated and could cause neurotoxicity, which might perhaps be prevented by interventions.

Excitatory amino acids and taurine levels in cerebrospinal fluid of hypoxic ischemic encephalopathy in newborn

The recent studies indicating the transiently enhanced expression of excitatory amino acid receptors in hypoxia vulnerable brain regions and the elevated concentration of aspartate and glutamate in cerebrospinal fluid of asphyxiated newborns strongly suggest the role of excitatory amino acids in hypoxic ischemic brain damage in the developing human brain. In this study, we compared the concentrations of glutamate, aspartate, taurine and glycine in the cerebrospinal fluid of asphyxiated infants with values of a healthy control group. The concentrations of aspartate (5.82 +/- 3.36), glutamate (1.76 +/- 1.0) and taurine (9.32 +/- 9.1) were significantly elevated in cerebrospinal fluid of asphyxiated infants (P < 0.05). When compared to the control group, the high levels of aspartate was correlated with the degrees of hypoxic-ischemic encephalopathy (HIE) and the varying outcome. The high levels of aspartate and glutamate in the asphyxiated patients adds further evidence to the role of excitotoxicity in hypoxic ischemic encephalopathy. The mental and motor development of the patients in asphyxiated group was followed for 3 years.

Tc-99m HMPAO brain perfusion imaging in young Down's syndrome patients

Down's syndrome (DS) is characterized by moderate mental retardation and a variety of abnormalities involving multiple organ systems. There is a high incidence of Alzheimer's disease (AD) type dementia beyond the age of 35. In this study, single photon emission computed tomography (SPECT) brain perfusion imaging of young Down's syndrome patients was performed to define the perfusion pattern. Tc-99m HMPAO brain perfusion SPECT was performed on 17 young DS patients, aged 3-24 years (mean: 10.9+/-5.9 years). None of the patients had dementia symptoms. Brain perfusion scans were acquired 15 min after i.v. injection of 12 MBq/kg of Tc-99m HMPAO using a single head rotating gamma camera. Images were analyzed visually and semiquantitatively by defining side-to-side asymmetry index. Nine DS cases showed normal brain perfusion. Eight of the 17 cases revealed mostly unilateral parieto-temporal, parieto-occipital and frontal hypoperfusions. The side-to-side asymmetry indices for these visually interpreted regional brain perfusion abnormalities ranged from 6 to 15%. These findings revealing mostly unilateral parieto-temporal and frontal hypoperfusions may not be considered as predictive patterns of dementia related Alzheimer type perfusion deficits in DS. However, such findings may connect to other functional imaging studies related to the higher cortical dysfunction in mental retardation.

D2 receptor imaging with iodine-123-iodobenzamide brain SPECT in infants with hypoxic-ischemic brain injury

The purpose of this study was to evaluate the striatal dopamine D2 receptor density in infants with perinatal hypoxic-ischemic brain injury (HIBI) using 123I-iodobenzamide (IBZM) brain SPECT and to correlate the findings with the severity of HIBI and neurologic outcome.

METHODS

Twenty infants who were diagnosed to have perinatal HIBI were included in this study. They were classified as having mild (n = 6), moderate (n = 10) or severe (n = 4) HIBI according to their neurologic findings at birth using the criteria of Sarnat and Sarnat. Neurologic outcome of these infants was determined by serial neurologic examinations and the Denver developmental screening test; 10 infants recovered without any deficit and the remaining 10 were affected to a degree varying from motor impairment to cerebral palsy. All 20 infants were examined using 123I-IBZM brain SPECT at age 7.8 +/- 2.3 mo. Transaxial slices were obtained 2 hr after intravenous injection of 300 micro ci (11.1 MBq) 123I-IBZM and the activity ratios of striatal to occipital cortex (ST/OC) were calculated.

RESULTS

The mean ST/OC ratios in patients with mild, moderate and severe HIBI (1.219 +/- 0.078, 1.097 +/- 0.069 and 0.813 +/- 0.140, respectively) were significantly different from each other (p = 0.001). The infants who recovered from HIBI without any neurologic sequelae had higher mean ST/OC ratios than the others (1.184 +/- 0.010 versus 0.969 +/- 0.160, p = 0.002).

CONCLUSION

The results of this study show that in infants with HIBI, striatal D2 receptor density decreases as the severity of injury increases. The D2 receptor density is higher in infants who recover without neurologic deficits compared to those who are affected neurologically. Dopamine D2 receptor imaging can be used to assess the severity of HIBI in children.

Role of excitatory aminoacids in neonatal hypoglycemia

BACKGROUND

In many neurological disorders, injury to neurons may be due in part to overstimulation of the receptors for the excitatory amino acids glutamate and aspartate. The same excitotoxic mechanism and high aspartate levels in experimental studies led to this study of the concentrations of glutamate and aspartate and zinc, copper, and magnesium levels in the cerebrospinal fluid (CSF) of hypoglycemic newborns.

METHODS

Aspartate and glutamate were determined by high-performance liquid chromatography, and magnesium, zinc and copper by atomic absorption spectrophotometer.

RESULTS

The CSF levels of aspartate (3.98 +/- 1.77 mumol/L) and glutamate (1.7 +/- 1.05 mumol/L) in 20 hypoglycemic newborns were significantly higher when compared with the values of aspartate (2.19 +/- 0.6 mumol/L) and glutamate (0.77 +/- 0.34 mumol/L) of 10 control newborns. In the hypoglycemic patients, the concentration of zinc (0.57 +/- 0.13 microgram/mL), but not copper (0.39 +/- 0.40 microgram/mL) was significantly lower when compared with the control values. There was no difference in the magnesium levels between the two groups.

CONCLUSIONS

The higher levels of excitatory amino acids found in the CSF of hypoglycemic infants than in controls were consistent with previous animal studies, which may indicate the role of excitatory amino acids in the late biochemical effects of hypoglycemia in newborn brain metabolism.

Clinical observations in autosomal recessive spastic paraplegia in childhood and further evidence for genetic heterogeneity

Among our 23 families (32 cases) with autosomal recessive hereditary spastic paraplegia (AR-HSP) all presenting in childhood, 9 families had the "pure" form. Occasional patients with this form had upper extremity hyperreflexia, pes cavus and sphincter disturbances, even at the early stages. Fourteen families were classified as the "complicated" types which manifested with mental retardation and cerebellar abnormalities. The evolution and severity was variable, but was generally consistent within families. Carriers (parents) did not manifest any signs. A total of 5 multiplex families with "complicated" type were used to test for a genetic heterogeneity to the region on chromosome 8p12-q13 where the "pure" AR-HSP has been mapped previously. No evidence in favor of linkage was detected in 3 of our families, thus we further supported genetic heterogeneity for AR-HSP.

A comparison between MUGA and echocardiography in patients with muscular dystrophy in the early detection of cardiac involvement

Muscular dystrophies are a group of sex-linked diseases with frequent myocardial involvement. In this study 14 patients with Duchenne Muscular Dystrophy (DMD), 7 with Becker Muscular Dystrophy (BMD), and 8 female carriers who were asymptomatic were evaluated with echocardiography and multigated radionuclide ventriculography (MUGA). All showed predominant systolic and minor diastolic left ventricular dysfunction determined both by echocardiography and MUGA when compared with healthy controls. In conclusion, it is recommended that DMD, BMD, and female carriers be evaluated and closely monitored for cardiac functions. Though MUGA and echocardiography are both effective and sensitive techniques, echocardiography is more convenient for availability and serial evaluation.