RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS

OBJECTIVE

To provide the best clinical practice guidance for surfactant use in preterm neonates with respiratory distress syndrome (RDS). The RDS-Neonatal Expert Taskforce (RDS-NExT) initiative was intended to add to existing evidence and clinical guidelines, where evidence is lacking, with input from an expert panel.

STUDY DESIGN

An expert panel of healthcare providers specializing in neonatal intensive care was convened and administered a survey questionnaire, followed by 3 virtual workshops. A modified Delphi method was used to obtain consensus around topics in surfactant use in neonatal RDS.

RESULT

Statements focused on establishing RDS diagnosis and indicators for surfactant administration, surfactant administration methods and techniques, and other considerations. After discussion and voting, consensus was achieved on 20 statements.

CONCLUSION

These consensus statements provide practical guidance for surfactant administration in preterm neonates with RDS, with a goal to contribute to improving the care of neonates and providing a stimulus for further investigation to bridge existing knowledge gaps.

Birthweight and gestational age as modifiers of rehospitalization after NICU admission

OBJECTIVE

To assess interaction effects between gestational age and birth weight on 30-day unplanned hospital readmission following discharge from the neonatal intensive care unit (NICU). To assess the relationship between gestational age and day of life (DOL) on neonatal intensive care unit (NICU) admission and the risk for 30-day unplanned hospital readmission (UHR).

METHODS

Retrospective study using the study site's Children's Hospitals Neonatal Database (CHND) and electronic health records were used. Population included patients discharged from a NICU between January 2017 and March 2020. Variables encompassing demographics, gestational age, birth weight, medications, maternal data, and surgical procedures were controlled for. A statistical interaction between gestational age and DOL birth weight was tested for statistical significance.

RESULTS

2,307 neonates were included, with 7.2% readmitted within 30 days of discharge. Statistical interaction between birth weight and gestational age was statistically significant, indicating that the odds of readmission amongst low-birth-weight premature patients increases with increasing gestational age, while it decreases with increasing gestational age amongst their normal or high birth weight peers.

CONCLUSIONS

The effect of gestational age on odds of hospital readmission is dependent on birth weight.

Misdiagnosis of Total Parental Nutrition-Related Riboflavin Deficiency: Three Case Reports of Diagnostic Error

Total parental nutrition (TPN) is a critical component of neonatal intensive care. Supply shortages leading to deficiencies in TPN constituents can have devastating consequences for critically ill patients in the neonatal intensive care unit (NICU), who may be initially misdiagnosed as potential inborn errors of metabolism. Here, we present three cases of patients with prolonged TPN dependence due to intra-abdominal pathology who presented with signs and symptoms concerning for metabolic disorders and who were ultimately determined to be a result of vitamin deficiencies in the TPN after unnecessary testing and interventions had occurred. These diagnostic errors highlight the need for clinicians to maintain a high index of suspicion for nutritional deficiencies when treating patients in the NICU with potential metabolic disorders during times when TPN constituents are not available, as well as advocating to ensure that adequate supplies are maintained for this vulnerable population.

Health Economics of Selective Early Rescue Surfactant Administration and Standard Surfactant Administration for Newborns With Respiratory Distress Syndrome

OBJECTIVE

To quantify the effect of early rescue surfactant administration techniques for preterm infants with respiratory distress syndrome (RDS) from a health care delivery system perspective.

METHODS

A cost-consequence model was developed based on previously published literature to compare the health economic impact of implementing early surfactant administration strategies vs standard surfactant administration via endotracheal intubation and mechanical ventilation (MV).

RESULTS

Early rescue surfactant treatment strategies are associated with a decrease in the number of patients requiring MV, cumulative MV days, and rate of neonatal complications. Total annual surfactant costs are higher than standard surfactant administration, but this is offset by savings in total hospital and complication costs.

CONCLUSIONS

This cost-consequence analysis suggests selective early rescue surfactant administration strategies are associated with a lower health care burden in premature infants with RDS.

Epidemiology of Neonatal COVID-19 in the United States

OBJECTIVES

Data on coronavirus disease 2019 (COVID-19) infections in neonates are limited. We aimed to identify and describe the incidence, presentation, and clinical outcomes of neonatal COVID-19.

METHODS

Over 1 million neonatal encounters at 109 United States health systems, from March 2020 to February 2021, were extracted from the Cerner Real World Database. COVID-19 diagnosis was assessed using severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) laboratory tests and diagnosis codes. Incidence of COVID-19 per 100 000 encounters was estimated.

RESULTS

COVID-19 was diagnosed in 918 (0.1%) neonates (91.1 per 100 000 encounters [95% confidence interval 85.3-97.2]). Of these, 71 (7.7%) had severe infection (7 per 100 000 [95% confidence interval 5.5-8.9]). Median time to diagnosis was 14.5 days from birth (interquartile range 3.1-24.2). Common signs of infection were tachypnea and fever. Those with severe infection were more likely to receive respiratory support (50.7% vs 5.2%, P < .001). Severely ill neonates received analgesia (38%), antibiotics (33.8%), anticoagulants (32.4%), corticosteroids (26.8%), remdesivir (2.8%), and COVID-19 convalescent plasma (1.4%). A total of 93.6% neonates were discharged home after care, 1.1% were transferred to another hospital, and discharge disposition was unknown for 5.2%. One neonate (0.1%) with presentation suggestive of multisystem inflammatory syndrome in children died after 11 days of hospitalization.

CONCLUSIONS

Most neonates infected with SARS-CoV-2 were asymptomatic or developed mild illness without need for respiratory support. Some had severe illness requiring treatment of COVID-19 with remdesivir and COVID-19 convalescent plasma. SARS-CoV-2 infection in neonates, though rare, may result in severe disease.

Chronic lung disease in full-term infants: Characteristics and neonatal intensive care outcomes in infants referred to children's hospitals

OBJECTIVE

To describe characteristics, outcomes, and risk factors for death or tracheostomy with home mechanical ventilation in full-term infants with chronic lung disease (CLD) admitted to regional neonatal intensive care units.

STUDY DESIGN

This was a multicenter, retrospective cohort study of infants born ≥37 weeks of gestation in the Children's Hospitals Neonatal Consortium.

RESULTS

Out of 67,367 full-term infants admitted in 2010-2016, 4886 (7%) had CLD based on receiving respiratory support at either 28 days of life or discharge. 3286 (67%) were still hospitalized at 28 days receiving respiratory support, with higher mortality risk than those without CLD (10% vs. 2%, p < 0.001). A higher proportion received tracheostomy (13% vs. 0.3% vs. 0.4%, p < 0.001) and gastrostomy (30% vs. 1.7% vs. 3.7%, p < 0.001) compared to infants with CLD discharged home before 28 days and infants without CLD, respectively. The diagnoses and surgical procedures differed significantly between the two CLD subgroups. Small for gestational age, congenital pulmonary, airway, and cardiac anomalies and bloodstream infections were more common among infants with CLD who died or required tracheostomy with home ventilation (p < 0.001). Invasive ventilation at 28 days was independently associated with death or tracheostomy and home mechanical ventilation (odds ratio 7.6, 95% confidence interval 5.9-9.6, p < 0.0001).

CONCLUSION

Full-term infants with CLD are at increased risk for morbidity and mortality. We propose a severity-based classification for CLD in full-term infants. Future work to validate this classification and its association with early childhood outcomes is necessary.

Osteogenesis Imperfecta: Multidisciplinary and Goal-Centered Care

We describe a case of osteogenesis imperfecta (OI) in a late preterm female of 35-week gestation. The mother did have a history of substance abuse, poor prenatal care, and hypertension. On the day of delivery, an ultrasound revealed skeletal dysplasia and breech with nonreassuring fetal tracing, leading to an emergency cesarean. The clinical exam was concerning for OI, and postnatal care was focused on optimizing respiratory status and minimizing pain and discomfort during routine care. Genetics, endocrine, orthopaedics, and palliative care were all involved to diagnose and educate the family. Support and education were needed for bedside staff to minimize angst at performing routine care, given the high risk of fractures. While initially stable on minimal oxygen, once the diagnosis of type III OI was made, a progressively deforming condition with respiratory status decompensation, the family wished to minimize suffering, limited aggressive medical care, and focused on comfort. The infant eventually died from respiratory failure in the neonatal intensive care unit. We present this case to demonstrate the need for an interdisciplinary team approach to support both family and staff in cases of OI.

Osteogenesis Imperfecta: Multidisciplinary and Goal-Centered Care

We describe a case of osteogenesis imperfecta (OI) in a late preterm female of 35-week gestation. The mother did have a history of substance abuse, poor prenatal care, and hypertension. On the day of delivery, an ultrasound revealed skeletal dysplasia and breech with nonreassuring fetal tracing, leading to an emergency cesarean. The clinical exam was concerning for OI, and postnatal care was focused on optimizing respiratory status and minimizing pain and discomfort during routine care. Genetics, endocrine, orthopaedics, and palliative care were all involved to diagnose and educate the family. Support and education were needed for bedside staff to minimize angst at performing routine care, given the high risk of fractures. While initially stable on minimal oxygen, once the diagnosis of type III OI was made, a progressively deforming condition with respiratory status decompensation, the family wished to minimize suffering, limited aggressive medical care, and focused on comfort. The infant eventually died from respiratory failure in the neonatal intensive care unit. We present this case to demonstrate the need for an interdisciplinary team approach to support both family and staff in cases of OI.

Birth Tourism Is Associated with Fewer Neonatal Intensive Care Unit Admissions: A Healthy Migrant Effect?

OBJECTIVE

This work aimed to study perinatal, maternal, and neonatal characteristics of birth tourism (BT) mother-baby dyads and the rate of neonatal intensive care unit (NICU) admissions of BT infants.

STUDY DESIGN

Retrospective study at a regional perinatal center comparing BT mother-baby dyads to all dyads. BT infants admitted to the NICU were compared with a randomly selected group of infants admitted to the NICU during the same time period.

RESULTS

A total of 1,755 BT dyads were identified over 4 years. BT mothers were older (32 vs. 28 years, p < 0.0001), more likely to carry multiples (5.5 vs. 1.4%, p < 0.0001), deliver via cesarean section (40 vs. 34%, p < 0.0001), and require postpartum intensive care (0.6 vs. 0.1%, p < 0.0001). BT infants had significantly fewer NICU admissions 96 (5.5%) versus 3,213 (11.3%; p < 0.0001). There were no statistically significant differences in NICU course and outcome between BT and non-BT control infants.

CONCLUSION

Birth tourism is associated with unique determinants of health. In our study, there were fewer NICU admissions, potentially explained by the healthy migrant effect.

KEY POINTS

· Birthright citizenship attracts foreigners to give birth in the United States.. · BT is associated with unique social determinants of health.. · Fewer NICU admissions in our study are possibly explained by the healthy migrant effect..

A comparison of newer classifications of bronchopulmonary dysplasia: findings from the Children's Hospitals Neonatal Consortium Severe BPD Group

OBJECTIVE

To compare three bronchopulmonary dysplasia (BPD) definitions against hospital outcomes in a referral-based population.

STUDY DESIGN

Data from the Children's Hospitals Neonatal Consortium were classified by 2018 NICHD, 2019 NRN, and Canadian Neonatal Network (CNN) BPD definitions. Multivariable models evaluated the associations between BPD severity and death, tracheostomy, or length of stay, relative to No BPD references.

RESULTS

Mortality was highest in 2019 NRN Grade 3 infants (aOR 225), followed by 2018 NICHD Grade 3 (aOR 145). Infants with lower BPD grades rarely died (<1%), but Grade 2 infants had aOR 7-21-fold higher for death and 23-56-fold higher for tracheostomy.

CONCLUSIONS

Definitions with 3 BPD grades had better discrimination and Grade 3 2019 NRN had the strongest association with outcomes. No/Grade 1 infants rarely had severe outcomes, but Grade 2 infants were at risk. These data may be useful for counseling families and determining therapies for infants with BPD.

Association of time of first corticosteroid treatment with bronchopulmonary dysplasia in preterm infants

OBJECTIVE

To evaluate the association between the time of first systemic corticosteroid initiation and bronchopulmonary dysplasia (BPD) in preterm infants.

STUDY DESIGN

A multi-center retrospective cohort study from January 2010 to December 2016 using the Children's Hospitals Neonatal Database and Pediatric Health Information System database was conducted. The study population included preterm infants <32 weeks' gestation treated with systemic corticosteroids after 7 days of age and before 34 weeks' postmenstrual age. Stepwise multivariable logistic regression was used to assess the association between timing of corticosteroid initiation and the development of Grade 2 or 3 BPD as defined by the 2019 Neonatal Research Network criteria.

RESULTS

We identified 598 corticosteroid-treated infants (median gestational age 25 weeks, median birth weight 760 g). Of these, 47% (280 of 598) were first treated at 8-21 days, 25% (148 of 598) were first treated at 22-35 days, 14% (86 of 598) were first treated at 36-49 days, and 14% (84 of 598) were first treated at >50 days. Infants first treated at 36-49 days (aOR 2.0, 95% CI 1.1-3.7) and >50 days (aOR 1.9, 95% CI 1.04-3.3) had higher independent odds of developing Grade 2 or 3 BPD when compared to infants treated at 8-21 days after adjusting for birth characteristics, admission characteristics, center, and co-morbidities.

CONCLUSIONS

Among preterm infants treated with systemic corticosteroids in routine clinical practice, later initiation of treatment was associated with a higher likelihood to develop Grade 2 or 3 BPD when compared to earlier treatment.

A Case of an Extremely Low Birth Weight Infant with Morganella morganii Bacteremia and Peritonitis

We describe a case of late onset Morganella morganii sepsis in an extremely low birth weight male neonate born at 23 and 4/7 weeks gestational age to a 30-year-old primigravid mother due to preterm labor. The mother was otherwise healthy with an unremarkable prenatal course. She received steroids and ampicillin prior to delivery. While initial blood cultures were negative, at day of life 4, the neonate developed signs of sepsis with leukocytosis and bandemia, and subsequent blood culture demonstrated growth of M. morganii . The patient then had spontaneous intestinal perforation on day of life 8 with peritoneal cultures growing M. morganii . The infant responded to standard therapy and survived to discharge, with few mild developmental delays upon outpatient follow-up. While M. morganii has been demonstrated in the neonatal population, it generally causes early onset sepsis and is associated with high mortality in preterm neonates. Here, we present this case of late onset neonatal sepsis with M. morganii complicated by spontaneous intestinal perforation, with survival in a 23 weeks gestation infant.

Newer bronchopulmonary dysplasia definitions and prediction of health economics impacts in very preterm infants

OBJECTIVE

To compare the abilities of bronchopulmonary dysplasia (BPD) definitions to predict hospital charges as a surrogate of disease complexity.

METHODS

Retrospective study of infants admitted to the neonatal intensive care unit (NICU) less than 32 weeks gestational age. Subjects were classified according to the Canadian Neonatal Network (CNN), the National Institute of Child Health and Human Development (NICHD) (2018), and Jensen BPD definitions as none, mild (1), moderate (2), or severe (3) BPD. Spearman's correlation was performed to evaluate the association of BPD definitions with health economics outcomes.

RESULTS

One hundred and sixty-eight infants were included with mean birth weight of 1197 g and mean gestational age of 28.4 weeks. More infants were classified as no BPD according to CNN definition (79%) in comparison to NICHD 2018 (64.3%) and Jensen (59.5%) definitions. There were fewer infants as the grade of severity increased for all definitions, this was most linear for Jensen definition with Grade 1 present in 25%, Grade 2 in 12.5%, and Grade 3 in 3%. A stronger correlation with NICU length of stay, NICU hospital charges, NICU charges per day, and first year of life hospital charges was detected for Jensen definition (correlation coefficient of 0.58, 0.66, 0.64, 0.67, respectively) in comparison to CNN and NICHD 2018 definitions (p < .0001).

CONCLUSION

Jensen BPD definition had the strongest correlation with first year health economics outcomes in our study. Validating recent BPD definitions using population-based data is imperative to improve family counseling and enhance the designs of quality improvement initiatives and therapeutic research studies targeting patient-centric outcomes.

Perinatal Management of Bart's Hemoglobinopathy: Paradoxical Effects of Intrauterine, Transplacental, and Partial Exchange Transfusions

We describe a fetus at 24 ^3/7 weeks' gestation that showed ultrasound evidence of anemia, hydrops, and severe growth restriction. Both parents were known to be cis heterozygous carriers for SEA α-thalassemia deletion (αα/-). Cordocentesis confirmed fetal anemia and homozygous α-thalassemia (-/-) in the fetus. Fetal intrauterine transfusions corrected the anemia, treated the hydrops, and improved fetal growth. The postnatal course was complicated by hypoxic respiratory failure and persistent pulmonary hypertension of the newborn, which resolved only after partial volume exchange transfusion. This case report is presented to point out the potential unintended outcomes with transplacental transfusion via delayed cord clamping and cord milking at delivery in the setting of congenital Bart's hemoglobinopathy, and demonstrates that partial exchange transfusion of the newborn may optimize oxygen delivery due to the more favorable oxygen affinity of transfused adult hemoglobin compared with the Bart's hemoglobin.

Three-hourly feeding intervals are associated with faster advancement in very preterm infants

OBJECTIVE

To compare the effect of two-hourly (Q2H) vs. three-hourly (Q3H) feeding on time to achieve full enteral feeding, growth metrics and respiratory tolerance in very preterm infants with birth weight ≤ 1250 g.

STUDY DESIGN

Retrospective study review of 18 months before and after a change in our feeding guideline from Q3H to Q2H feedings.

RESULTS

113 infants were included, 59 in Q3H and 54 in Q2H groups. Q2H infants required 10% more days to achieve full enteral feeding, however it was not statistically significant (P = 0.054). Q2H feeding was associated with 16% more central catheter days (P = 0.02) and 17% more parenteral nutrition days (P = 0.019). There were no differences in respiratory outcomes or growth metrics between the groups.

CONCLUSION

Very preterm infants fed Q3H had less central catheter and parenteral nutrition days when compared to those fed Q2H, without significant differences in growth or respiratory outcomes.

Lack of Evidence for Time or Dose Relationship between Antenatal Magnesium Sulfate and Intestinal Injury in Extremely Preterm Neonates

BACKGROUND

Recent studies reported conflicting results on the relationship between antenatal magnesium sulfate (MgSO4) exposure and neonatal intestinal injury. Most studies have not assessed MgSO4 exposure quantitatively and none reported the exposure timing.

OBJECTIVES

The aim of this work was to assess whether there is a temporal or dose-dependent relationship between antenatal MgSO4 exposure and intestinal injury in extremely preterm neonates.

METHODS

A retrospective study was made of inborn neonates with gestational age ≤28 weeks and/or birth weights ≤1,000 g. Primary outcomes included necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), and/or death prior to discharge or in the first 2 weeks of life. Outcome comparisons were made based on the timing of MgSO4 exposure, within 7 days (Mg7D) or within 3 days (Mg3D) of birth. Total cumulative doses for the Mg3D group were also computed.

RESULTS

A total of 302 neonates were included, 210 in the Mg7D group, out of whom 179 (85.2%) constituted the Mg3D group. There were no differences noted when comparing MgSO4 exposure timing and the likelihood of NEC, SIP, and/or death. This remained the same for subgroup analysis of neonates < 26 weeks' gestation. Each 10-g increase in MgSO4 cumulative dose correlated with a decrease in SIP/NEC/death by 18.9% prior to discharge and by 21.9% in the first 2 weeks of life. Small for gestational age (SGA) was a potential effect modifier by a likelihood ratio test with p = 0.07.

CONCLUSIONS

Antenatal MgSO4 exposure in extremely preterm neonates was not associated with an increased risk of intestinal injury or death, and might have reduced these complications in a dose-dependent manner in our study. This protective effect was more noticeable in SGA neonates.

Birth Tourism and Neonatal Intensive Care: A Children's Hospital Experience

Objective The aim of this article is to examine characteristics of birth tourism (BT) neonates admitted to a neonatal intensive care unit (NICU). Methods This was a retrospective review over 3 years; BT cases were identified, and relevant perinatal, medical, social, and financial data were collected and compared with 100 randomly selected non-birth tourism neonates. Results A total of 46 BT neonates were identified. They were more likely to be born to older women (34 vs. 29 years; p < 0.001), via cesarean delivery (72 vs. 48%; p = 0.007), and at a referral facility (80 vs. 32%; p < 0.001). BT group had longer hospital stay (15 vs. 7 days; p = 0.02), more surgical intervention (50 vs. 21%; p < 0.001), and higher hospital charges (median $287,501 vs. $103,105; p = 0.003). One-third of BT neonates were enrolled in public health insurance program and four BT neonates (10%) were placed for adoption. Conclusion Families of BT neonates admitted to the NICU face significant challenges. Larger studies are needed to better define impacts on families, health care system, and society.

Serial neutrophil values facilitate predicting the absence of neonatal early-onset sepsis

OBJECTIVE

To validate established neonatal neutrophil reference ranges (RRs) and determine the utility of serial measurements of neutrophil values in the first 24 hours to predict the absence of neonatal early-onset sepsis (EOS).

STUDY DESIGN

Retrospective study of 2073 admissions to the neonatal intensive care unit (2009-2011). Neonates were classified as blood culture-positive, proven EOS (n = 9), blood culture-negative but clinically suspect EOS (n = 292), and not infected (n = 1292). Neutrophil values from 745 not-infected neonates without perinatal complications were selected to validate RR distributions. Positive and negative predictive values were calculated; area under receiver operating characteristic curves (AUCs) were constructed to predict the presence or absence of EOS. Neutrophil value scores were established to determine whether serial neutrophil values predict the absence of EOS.

RESULTS

Seventy-seven percent of admissions to the neonatal intensive care unit were evaluated for EOS: 9 (0.56%) had proven EOS with positive blood culture ≤ 37 hours; 18% had clinically suspect EOS. Neutropenia occurred in preterm neonates, and nonspecific neutrophilia was common in uninfected neonates. The distribution of neutrophil values differed significantly between study groups. The specificity for absolute total immature neutrophils and immature to total neutrophil proportions was 91% and 94%, respectively, with negative predictive value of 99% for proven and 78% for proven plus suspect EOS. Absolute total immature neutrophils and immature to total neutrophil proportions had the best predictability for EOS >6 hours postnatal with an AUC ∼ 0.8. Neutrophil value scores predicted the absence of EOS with AUC of 0.9 and 0.81 for proven and proven plus suspect EOS, respectively.

CONCLUSION

Age-dependent neutrophil RRs remain valid. Serial neutrophil values at 0, 12, and 24 hours plus blood culture and clinical evaluation can be used to discontinue antimicrobial therapy at 36-48 hours.

Effects of ventilation on hearing loss in preterm neonates: Nasal continuous positive pressure does not increase the risk of hearing loss in ventilated neonates

INTRODUCTION

There is increased risk of hearing loss in preterm neonates. This risk is further increased by environmental noise exposure especially from life support equipment such as ventilation. Nasal continuous positive airway pressure (NCPAP) used for respiratory support of preterm neonates is known to be associated with prolonged exposure to high levels of noise. However, there is paucity of information on the effect of NCPAP as compared to mechanical ventilation on hearing loss among preterm neonates.

METHODS

A retrospective chart review was performed on neonates with birth weight (BW) <1500g. Association of clinical factors including the use of NCPAP and mechanical ventilation with failure of hearing screen were studied. Those who failed hearing screen were followed for 2 years to observe long term effects of NCPAP on the hearing loss.

RESULTS

Of 344 neonates included in the study, 61 failed hearing screen. Gestational age (p=0.008), BW (p=0.03), ventilation (p=0.02), intrauterine growth retardation (p=0.02), necrotizing enterocolitis (NEC) (p=0.02), apnea (p<0.001), use of vancomycin (p=0.01) and furosemide (p=0.01) were associated with failure of hearing screen. On multivariate analysis, ventilation (OR 4.56, p=0.02), apnea (OR 2.2, p<0.001) and NEC (OR 2.4, p=0.02) were predictors of failed hearing screen. As compared to those not ventilated, the odds of failing hearing screen was 4.53 (p<0.01) and 4.59 (p<0.01) for those treated with NCPAP and mechanical ventilation respectively, with there being no difference between these two ventilatory modalities. Of the 61 neonates, 42 were followed for 2 years, of which 19 had confirmed hearing loss. Among these 19 neonates, there was no difference (p=0.12) between those who were treated with NCPAP or with mechanical ventilation.

CONCLUSION

There is no increase in the hearing loss in preterm neonates treated with NCPAP as compared to mechanical ventilation despite being exposed to higher environmental noise generated by the NCPAP.

Operative confirmation of three-dimensional computed tomographic and magnetic resonance imaging of cerebrovascular pathology

The conventional neuroradiological evaluation of aneurysms and arteriovenous malformations employs computed tomography (CT), magnetic resonance imaging (MRI), and detailed cerebral angiography. These techniques may be inadequate to define fully the cerebrovascular anatomy in patients with giant aneurysms or with arteriovenous malformations (AVMs) located near so-called eloquent brain structures. Therefore, we examined the usefulness of three-dimensional (3-D) MRI and CT images of the brain and cerebral vessels for predicting operative anatomical findings in selected cases of complex cerebrovascular pathology. In six of nine (67%) patients with giant aneurysms undergoing direct surgical treatment, the 3-D images were confirmed to be accurate, and they furnished information that is not available by conventional imaging. In three of these nine (33%) patients, failure of the 3-D images to predict operative findings accurately could be directly related to inappropriate imaging technique or to anatomical findings below the limit of resolution for CT or MRI. In 13 of 19 (68%) patients with an AVM, the 3-D images were considered helpful for treatment selection or planning, primarily because they enhanced the understanding of the relationship of the AVM nidus to brain structures of known functional significance. The results of our initial experience with 3-D imaging of cerebrovascular pathology are described in this report.

Kirschner wire migration through the jugular foramen

Kirschner wires commonly are used to provide interosseous fixation. Although they usually retain their intended position, migration of these sharply pointed metal pins has been reported.

Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas

Thirty-one patients operated upon for supratentorial glioblastomas or anaplastic astrocytomas were studied to evaluate the effect of the extent of surgical resection on the length and quality of survival. The median age was 50 years and the median preoperative Karnofsky rate was 80. Twenty-one patients (68%) had glioblastoma multiforme, and 10 patients (32%) had anaplastic astrocytoma. Early postoperative enhanced computed tomography was used to determine the extent of tumor resection. Gross total tumor resection was accomplished in 19 patients (61%), and subtotal resection was performed in 12 patients (39%). The two groups were comparable regarding age, sex, pathological condition, preoperative Karnofsky rating, tumor location, postoperative radiation therapy, and postoperative chemotherapy (P greater than 0.05). The gross total resection group lived longer than the subtotal resection group by life table analysis (P less than 0.001; median survival of 90 and 43 weeks, respectively). Postoperatively, the mean functional ability measured by the Karnofsky rating was significantly increased in the gross total resection group (P = 0.006), but not in the subtotal resection group (P greater than 0.05). The difference in degree of change between preoperative and postoperative Karnofsky rating in the two groups was statistically significant (P = 0.002). The gross total resection group spent significantly more time after the operation in an independent status (Karnofsky rating greater than or equal to 80) compared to the subtotal resection group (P = 0.007; median time of 185 and 12.5 weeks, respectively). Gross total resection of supratentorial glioblastomas and anaplastic astrocytomas is feasible and is directly associated with longer and better survival when compared to subtotal resection.

Supratentorial gliomas: surgical considerations and immediate postoperative results. Gross total resection versus partial resection

Forty-two patients with supratentorial gliomas not involving the basal ganglia (extraganglionic) were studied pre- and postoperatively with computed tomographic (CT) scans to evaluate the effect of the extent of surgical resection on the immediate postoperative results. Thirty-three patients (79%) had malignant astrocytic gliomas (glioblastoma or anaplastic astrocytoma), 4 patients (10%) had well-differentiated astrocytomas, and 5 (12%) had oligodendrogliomas. The median age was 58 years, and the median Karnofsky rating was 70. There was no operative mortality. Six patients (14%) had surgical complications. A gross total resection was defined as the absence of any abnormal enhancement on the postoperative CT scan. A nearly gross total resection had been accomplished when less than 10% of the preoperatively enhancing mass was still seen. A partial resection was indicated by the presence of more than 10% of the enhancing lesion on the postoperative CT scan. A gross total or nearly gross total resection was accomplished in 36 patients (86%), and an improved or stable postoperative neurological status was present in 35 of these patients (97%). In contrast, the rate of neurological morbidity after a partial resection was 40%. Supratentorial extraganglionic gliomas, regardless of their histological type, generally were well-circumscribed lesions except at the level of the ventricular wall, where glioblastomas and anaplastic astrocytomas blended with the subependymal white matter from which they seemed to arise.

Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results

The authors have reported on 108 patients with pituitary macroadenomas (measuring 2 cm in at least one diameter) who underwent 117 transsphenoidal operations and five craniotomies, and were followed for periods ranging from 6 months to 14 years. Vision improved in 90% of the patients. Gross total tumor removal with no evidence of residual tumor tissue demonstrable on the postoperative computerized tomography scan was accomplished in 41% of cases. However, gross total tumor removal is not synonymous with complete tumor removal. Endocrine cure was possible in 25% of prolactin-secreting and 20% of growth hormone-secreting adenomas. The incidence of recurrence was 12%, with the majority occurring from 4 to 8 years postoperatively. Both the tumors with suprasellar extension of more than 2 cm and the hard fibrotic tumors had a higher recurrence rate. Postoperative administration of radiation therapy has been associated with a significantly lower recurrence rate than when this therapy was withheld. Transsphenoidal surgery of pituitary macroadenomas confined to the extra-arachnoid space is associated with a relatively small number of complications. The operative technique used in this series is described.

Absence of cerebral atrophy in chronic cannabis users. Evaluation by computerized transaxial tomography

Computerized transaxial tomography (CTT) studies of 12 young men having histories of heavy cannabis smoking revealed no evidence of cerebral atrophy.

Optimal utilization of computerized cranial tomography and radionuclide brain imaging

The results of computerized cranial tomography and radionuclide brain imaging in 490 patients were compared in relationship to the patients' clinical presentation. In 195 patients with focal neurologic abnormalities, both tests detected most lesions, but computerized cranial tomography was slightly more accurate overall. Results of both studies were normal in 69 percent of 295 patients with nonfocal neurologic presentations, and radionuclide imaging failed to detect lesions in only five patients with nonfocal presentations. These results suggest that radionuclide imaging can be used to accurately screen most patients with nonfocal neurologic presentations. An exception is the patient presenting with dementia, in whom computerized cranial tomography provides details of the anatomy of the ventricular cavities and cerebral cortex. This study demonstrates a continuing role of importance for radionuclide imaging in the evaluation of patients with neurologic disease and provides data to allow a rational approach to the optimum use of both techniques.

Value of routine cerebral radionuclide angiography in pediatric brain imaging

In addition to static brain images, cerebral radionuclide angiograms (CRAGs) were performed in 1,051 children to determine the value of routine radionuclide angiography. The CRAG resulted in a statistically significant increase in detection of abnormalities (p less than 0.01), as it provided the only evidence of confirmed abnormalities in 60 children (5.7%). The CRAG helped detect subdural fluid collections, cerebrovascular disease, and cerebral cysts, but it was of little value in detecting hydrocephalus. For maximum diagnostic yield, a CRAG should be performed with all pediatric brain-imaging studies.