Early clinical signs in Coffin-Lowry syndrome

Two unrelated patients with Coffin-Lowry syndrome are described. The main characteristics of a typical face, thick hands with tapering fingers and a transverse hypothenar crease, general hypotonia with extensible joints made diagnosis possible before the age of 6 months. A persistent large anterior fontanel beyond the age of two years may be another associated finding. Retarded bone age, coarsity of the face and skeletal malformations considered characteristic in adult patients were not present. Early recognition of Coffin-Lowry syndrome is important for genetic counseling and prevention of severe skeletal malformations.

Expanded motor and psychiatric phenotype in autosomal dominant Segawa syndrome due to GTP cyclohydrolase deficiency

BACKGROUND

Segawa syndrome due to GTP cyclohydrolase deficiency is an autosomal dominant disorder with variable expression, that is clinically characterised by l-dopa responsive, diurnally fluctuating dystonia and parkinsonian symptoms.

OBJECTIVE

To delineate the neurological and psychiatric phenotype in all affected individuals of three extended families.

METHODS

GTP cyclohydrolase deficiency was documented by biochemical analyses, enzymatic measurements in fibroblasts, and molecular investigations. All affected individuals were examined neurologically, and psychiatric data were systematically reviewed.

RESULTS

Eighteen affected patients from three families with proven GTP cyclohydrolase deficiency were identified. Eight patients presenting at less than 20 years of age had typical motor symptoms of dystonia with diurnal variation. Five family members had late-presenting mild dopa-responsive symptoms of rigidity, frequent falls, and tendonitis. Among mutation carriers older than 20 years of age, major depressive disorder, often recurrent, and obsessive-compulsive disorder were strikingly more frequent than observed in the general population. Patients responded well to medication increasing serotonergic neurotransmission and to l-dopa substitution. Sleep disorders including difficulty in sleep onset and maintenance, excessive sleepiness, and frequent disturbing nightmares were present in 55% of patients.

CONCLUSION

Physicians should be aware of this expanded phenotype in affected members of families with GTP cyclohydrolase deficiency.

Repeated bilateral retrobulbar injection of botulinum toxin in a blind patient with retinitis pigmentosa and incapacitating nystagmus

Pronounced visual loss can lead to nystagmus, provoking oscillopsia and distressing ocular sensations. The treatment of acquired nystagmus remains difficult and various therapeutic options are attempted with limited results. We report the case of a man with acquired nystagmus and excessive ocular discomfort, successfully treated with repeated retrobulbar injections with botulinum toxin.

House dust mite-specific T cells in healthy non-atopic children

BACKGROUND

T-helper type 2 (Th2) cells play an important role in the pathogenesis of allergic diseases. Recent studies have demonstrated that allergen-specific T cells can also be found in the blood of healthy individuals. Both IL-10 and IFN-gamma might modulate the induction and maintenance of allergen-specific tolerance.

AIM

To study the phenotype and functional characteristics of allergen-specific T cells in healthy non-atopic children.

METHODS

Peripheral blood mononuclear cells (PBMC) from 13 symptomatic house dust mite (HDM)-allergic children and from nine matched healthy control children were stimulated with recombinant (r)Der p 2, a major allergen from HDMs.

RESULTS

Stimulation with rDer p 2 resulted in Th2 cytokine production in cultures of PBMC from allergic but not from healthy children. In contrast, IL-10 and IFN-gamma were induced in PBMC cultures from both healthy and HDM-allergic children. Intracellular staining revealed that IL-10 and IFN-gamma are largely produced by the same T cells. Stimulation of T cells from healthy children with rDer p 2 also induced expression of inducible costimulator (ICOS) on a small T cell subset.

CONCLUSION

Allergen-specific memory T cells from healthy non-atopic children produce IL-10 and IFN-gamma (but not Th2 cytokines) and express ICOS upon stimulation. These cells might be responsible for a normal immune balance after allergen encounter in non-atopics.

Continuous measurement of cerebral blood volume and oxygenation during rewarming of neonates

AIM

To investigate the effect of rewarming in preterm infants presenting with hypothermia at admission.

METHODS

The tissue oxygenation index (TOI), changes in cerebral blood volume (DeltaCBV) and changes in intravascular oxygenation (DeltaHbD) were measured in eight preterm infants, presenting with a temperature less than 35 degrees C at admission.

RESULTS

A significant increase in HbD and TOI was seen in four patients (group A), while a significant increase in CBV and a decrease in HbD was seen in four other patients (group B). Retrospective analysis showed that group A had important signs of peripartal asphyxia.

CONCLUSION

While infants with peripartal asphyxia showed an important increase in oxygenation during rewarming, no significant changes were seen in the non-asphyxiated infants.

Rett syndrome in females with CTS hot spot deletions: A disorder profile

From a series of 107 females with Rett syndrome (RTT), we describe the long-term history of ten females with a deletion in the C-terminus of the MECP2 gene. We observed that their disorder profile is clinically recognizable with time and different from other atypical and milder RTT phenotypes. In females with hot spot deletions in the C-terminus, dystonia is present from childhood and results in a serious spine deformation in spite of preventive measures. Their adaptive behavior is surprisingly better preserved and in contrast with the typical decline in motor functioning. The delineation of disorder profiles by long-term clinical observation can teach us about genotype/phenotype relationships and eventually about the effect of epigenetic phenomena on the final phenotype.

Surgical treatment outcomes of congenital and juvenile cataracts

PURPOSE

Evaluation of visual outcome after lens aspiration with or without intraocular lens implantation for isolated congenital and juvenile cataract in children aged 6 years and younger.

MATERIAL AND METHODS

Retrospective review of 48 children with isolated congenital and juvenile cataract who were surgically treated between January 1993 and December 2002 and had a minimal follow-up of 12 months.

RESULTS

In the group of children with unilateral cataract, 33% (3 out of 9 children) of aphakic children and 45.5% (5 out of 11 children) of pseudophakic children attained a final best corrected visual acuity of 20/200 and 20/60 respectively. In the group of children with bilateral involvement, 35% (6 out of 17 children) of aphakic children have a final best corrected visual acuity of 20/30 and 63.7% (7 out of 11 children) of pseudophakic children have a final best corrected visual acuity of 20/25 or more.

CONCLUSION

The results of this study emphasize the need for early surgery and good organisation of postsurgical care in patients with pediatric cataract to optimise visual outcome. Furthermore patients with isolated unilateral congenital cataract surgically treated at an average age of 15 months without primary lens implantation and with variable and low compliance have suboptimal results. The effect of early surgery with primary lens implantation on the long term visual outcome in pediatric cataract needs to be further evaluated.

Ibuprofen and cerebral oxygenation and circulation

The effect of prophylactic administration of ibuprofen on the cerebral circulation in preterm babies was measured with near infrared spectroscopy. No significant difference in the change in cerebral blood volume, change in cerebral blood flow, or tissue oxygenation index was found between administration of ibuprofen or placebo.

The value of fast MR imaging as an adjunct to ultrasound in prenatal diagnosis

The aim of this study was to evaluate the role of MR imaging of the fetus to improve sonographic prenatal diagnosis of congenital anomalies. In 40 fetuses (not consecutive cases) with an abnormality diagnosed with ultrasound, additional MR imaging was performed. The basic sequence was a T2-weighted single-shot half Fourier (HASTE) technique. Head, neck, spinal, thoracic, urogenital, and abdominal fetal pathologies were found. This retrospective, observational study compared MR imaging findings with ultrasonographic findings regarding detection, topography, and etiology of the pathology. The MR findings were evaluated as superior, equal to, or inferior compared with US, in consent with the referring gynecologists. The role of these findings in relation to pregnancy management was studied and compared with postnatal follow-up in 30 of 40 babies. Fetal MRI technique was successful in 36 of 39 examinations and provided additional information in 21 of 40 fetuses (one twin pregnancy with two members to evaluate). More precise anatomy and location of fetal pathology (20 of 40 cases) and additional etiologic information (8 of 40 cases) were substantial advantages in cerebrospinal abnormalities [ventriculomegaly, encephalocele, vein of Galen malformation, callosal malformations, meningo(myelo)cele], in retroperitoneal abnormalities (lymphangioma, renal agenesis, multicystic renal dysplasia), and in neck/thoracic pathology [cervical cystic teratoma, congenital hernia diaphragmatica, congenital cystic adenomatoid lung malformation (CCAM)]. This improved parental counseling and pregnancy management in 15 pregnancies. In 3 cases, prenatal MRI findings did not correlate with prenatal ultrasonographic findings or neonatal diagnosis. The MRI provided a more detailed description and insight into fetal anatomy, pathology, and etiology in the vast majority of these selected cases. This improved prenatal parental counseling and postnatal therapeutic planning.

Long chain polyunsaturated fatty acid supplementation in infant formula and blood pressure in later childhood: follow up of a randomised controlled trial

OBJECTIVE

To determine whether supplementation of infant formula milk with long chain polyunsaturated fatty acids (LCPUFAs) influences blood pressure in later childhood.

DESIGN

Follow up of a multicentre, randomised controlled trial.

SETTING

Four study centres in Europe.

PARTICIPANTS

147 formula fed children, with a reference group of 88 breastfed children.

INTERVENTION

In the original trial newborn infants were randomised to be fed with a formula supplemented with LCPUFAs (n=111) or a formula without LCPUFAs but otherwise nutritionally similar (n=126). In the present follow up study the blood pressure of the children at age 6 years was measured.

MAIN OUTCOME MEASURES

Systolic, diastolic, and mean blood pressure.

RESULTS

71 children in the LCPUFA supplementation group (64% of the original group) and 76 children in the non-supplementation group (60%) were enrolled into the follow up study. The LCPUFA group had significantly lower mean blood pressure (mean difference -3.0 mm Hg (95% confidence interval -5.4 mm Hg to -0.5 mm Hg)) and diastolic blood pressure (mean difference -3.6 mm Hg (-6.5 mm Hg to -0.6 mm Hg)) than the non-supplementation group. The diastolic pressure of the breastfed children (n=88 (63%)) was significantly lower than that of the non-supplemented formula group but did not differ from the LCPUFA formula group.

CONCLUSIONS

Dietary supplementation with LCPUFAs during infancy is associated with lower blood pressure in later childhood. Blood pressure tends to track from childhood into adult life, so early exposure to dietary LCPUFAs may reduce cardiovascular risk in adulthood.

Cerebral tissue oxygenation index in very premature infants

AIM

To describe normal values of the cerebral tissue oxygenation index (TOI) in premature infants.

METHODS

TOI was measured by spatially resolved spectroscopy in preterm infants on the first 3 days of life. Infants with an abnormal cranial ultrasound were excluded. Other simultaneously measured variables were PaO(2), PaCO(2), pH, mean arterial blood pressure, heart rate, haemoglobin, glycaemia, and peripheral oxygen saturation.

RESULTS

Fifteen patients with a median postmenstrual age of 28 weeks were measured. There was a significant increase in median TOI over the first 3 days of life: 57% on day 1, 66.1% on day 2, and 76.1% on day 3. Multiple regression analysis showed no correlation between TOI and postmenstrual age, peripheral oxygen saturation, mean arterial blood pressure, PaO(2), PaCO(2), and haemoglobin concentration.

CONCLUSION

Cerebral TOI increases significantly in the first 3 days of life in premature babies. This increase probably reflects the increase in cerebral blood flow at this time.

Effects of non-nutritive sucking on heart rate, respiration and oxygenation: a model-based signal processing approach

Several studies support the idea that the use of pacifiers can reduce the risk of Sudden Infant Death Syndrome. To investigate the effect of non-nutritive sucking (NNS), we measured heart rate, abdominal respiration, EMG and arterial oxygen saturation of 20 neonates. Also, in 10 of these neonates, changes in cerebral hemoglobin concentrations were acquired by means of near-infrared spectroscopy. Using a parametric technique to model the heart rate as a sum of exponentially damped sinusoids, two main frequency components were found in the heart rate during NNS: a frequency of approximately 0.08 Hz due to the alternation of sucking bursts and pauses, and a frequency of approximately 0.8 Hz that reflects the influence of the respiration. Our analysis shows that it is the alternation of bursts and pauses itself that causes the increased heart rate variability, and that this is not due to increased effort. This suggests that the neuronal mechanism regulating NNS also stimulates the heart rate. From our measurements, no effect of NNS on cerebral or peripheral oxygenation could be found. Furthermore, we show that our model-based signal processing technique is well suited for the analysis of non-stationary biomedical signals.

Effects of preterm extrauterine visual experience on the development of the human visual system: a flash VEP study

To compare the functional maturation of the human visual system between intra- and extrauterine course flash visual evoked potentials (VEPs) in preterm infants (gestational age 24 to 36 weeks). Previously established normal values, with special reference to the two components of the N1 wave, were employed (Tsuneishi 1995). A cross-sectional analysis of 124 infants at 36 weeks postmenstrual age (PMA), showed that there are no differences in the absolute values of VEP peak latencies depending on the postnatal age (PNA). Conversely, the N1 wave form changes with increasing PNA from a wave in which the early peak (N1a) has a higher amplitude than the late peak (N1b) into the reverse situation with a higher amplitude of the N1b as compared to N1a. This observation may correlate with the maturation of the neuronal networks in the visual cortex. In a longitudinal analysis of 50 infants followed for more than 5 sessions of weekly recordings, we found that the individual rapid decrease in the N1a latency, which may reflect the initiation of myelination in the optic radiation, most frequently occurs at around 37 weeks PMA, regardless of PNA. Preterm extrauterine visual experience has little effect on the myelination process in the visual pathway, but has a marked effect on the developmental changes in VEP wave form which reflect the developmental changes of the neuronal networks in the visual cortex.

Long-term external drainage for subdural collections in infants

The treatment of subdural collections in infants remains controversial. In order to evaluate the treatment guidelines that we developed on the basis of our earlier experience, we have reviewed the results obtained in 31 consecutive infants with symptomatic chronic and subacute subdural collections treated with external drainage. Using our guidelines for removal of the drains, there was only a very low rate of permanent shunting (4/31), with a low complication rate and good clinical results. However, the long period of external drainage, and therefore of hospitalization, might make if general application of these guidelines problematic.

Septo-optic dysplasia in combination with a pigmented skin lesion: a case report with nosological discussion

In this case report a patient with bilateral optic nerve hypoplasia, schizencephaly and a pigmented skin lesion is described. The diagnosis of de Morsier syndrome or septo-optic dysplasia is put forward on the basis of the diagnosis of optic nerve hypoplasia. The differential diagnosis with Jadassohn's naevus phakomatosis is discussed. The importance of direct ophthalmoscopy of optic nerve abnormalities is stressed, as well as of magnetic resonance imaging, which has become a guideline in the classification of this syndrome.

Acquired microcephaly after low Apgar score in Zimbabwe

Serial head circumference measurements were made on 165 African babies born with a 5 min Apgar score of 5 or less. Measurements were taken at birth and at 4, 9, and 12 months of age. In the majority of infants the onset of microcephaly could be diagnosed as early as 4 months of age. Twenty-five of the 142 infants were microcephalic at 1 year. Neurological development was impaired in 19 of the 25 (76 per cent) microcephalic infants and in 18 of the 117 (15 per cent) normocephalic infants. Fourteen of the 16 (88 per cent) infants with severe quadriplegia developed microcephaly before the age of 4 months. A decreased rate of head growth during the first 4 months of life in African infants born with a low Apgar score correlates closely with the development of microcephaly. Infants with an acquired microcephaly have a high probability of developing neurologic impairment by the age of 1 year. Serial head circumference measurement in low Apgar score babies in developing countries is an easy, simple, and inexpensive method to detect microcephaly.

Results after surgery for lumbosacral lipoma: the significance of early and late worsening

We retrospectively reviewed 32 patients operated on for lipoma of the conus and lipomyeloschisis, the two main anatomical subtypes of congenital lumbosacral lipomas associated with tethered cord syndrome. Surgery was proposed to patients when they were symptomatic, and in most cases for progressive symptoms. The evolution of the different symptoms was studied separately. In most patients, symptoms improved or stabilized after surgery; in some, however, postoperative worsening, at least of some of the symptoms, was seen. This postoperative worsening became apparent either early or late after the operation, and was not associated with surgical trauma or postoperative complications. We suggest it was caused mainly by the natural course of the disease (especially in the case of the orthopedic deformities), and in some cases by retethering. Our series is not large enough to detect statistical significance for the different symptoms or for the anatomical subgroups. Importantly, according to our analysis by the different symptoms, the operation did not seem to protect the patients from later development of new deficits. This can be interpreted as an argument against prophylactic surgery in asymptomatic patients.

Treatment of a symptomatic posterior fossa subdural effusion in a child

We describe the first observation of a child with a posterior fossa subdural effusion with secondary hydrocephalus and tonsillar herniation. We diagnosed this entity in a 14-month-old girl with no history of trauma or coagulation disorder. The patient presented in our emergency department with opisthotonus and raised intracranial pressure resulting from supratentorial hydrocephalus. An emergency ventriculo-peritoneal shunt was placed, which resolved the symptoms only temporarily. Eventually external drainage of the subdural fluid was performed. The collection gradually disappeared, and both the external subdural shunt and the ventriculo-peritoneal shunt were removed. The patient made a complete neurological recovery. We review the physiopathology and treatment of subdural effusions in general, and propose some guidelines for the management of symptomatic effusions occurring in the posterior fossa in particular.

Neurodevelopmental outcome at 1 year in Zimbabwean neonates with extreme hyperbilirubinaemia

The study concentrates on estimating the magnitude of the effect of a single risk factor, maximum total serum bilirubin (TSB) in excess of 400 micromol/l (23.4 mg/dl), on the neurodevelopmental outcome of 50, singleton, Zimbabwean neonates at 1 year of age. At 1 year corrected age the Bayley Scales of Infant Development (BSID) was administered. Two infants died and five were lost to follow up. TSB was neither associated with birth weight nor with gestational age. Of 43 infants with a TSB > 400 micromol/l (23.4 mg/dl),11(26%) scored abnormal on the BSID at 1 year of age and 5 (12%) infants developed the choreoathetoid type of cerebral palsy.

CONCLUSION

Infants with bilirubin levels between 400 and 500 micromol/l (23.4 and 29.2 mg/dl) who scored abnormal or suspect on the Bayley Scales of Infant Development were preterm or had haemolytic disease. All term infants without haemolysis and with bilirubin levels between 400 and 500 micromol/l (23.4 mg/dl-29.2 mg/dl) were normal at 1 year of age.

Intravesical application of a stable oxybutynin solution improves therapeutic compliance and acceptance in children with neurogenic bladder dysfunction

PURPOSE

To improve patient compliance with and acceptance of intravesical oxybutynin therapy for neurogenic bladder dysfunction we developed a stable oxybutynin solution that eliminates the complicated crushing procedure.

MATERIALS AND METHODS

From January 1995 to January 1997 we prospectively evaluated 15 children with a mean age of 6.1 years with persistent detrusor hyperactivity or significant side effects on oral oxybutynin therapy who received intravesically 0.2 mg./kg. (maximum 5 mg.) of a stable oxybutynin solution (5 mg./5 ml., pH 5.85) twice daily.

RESULTS

The oxybutynin solution remained stable up to 24 months. In 13 of the 15 children therapeutic compliance was excellent. Detrusor hyperactivity decreased and systemic side effects were absent or minimal. After 4 and 24 months mean cystometric bladder capacity plus or minus standard error of mean increased from 114+/-15.2 to 161+/-26.6 and 214+/-21.7 ml. (p <0.01), mean ratio of cystometric-to-expected bladder capacity increased from 0.88+/-0.12 to 1.18+/-0.14 and 1.24+/-0.16 (p <0.01), and end filling bladder pressure decreased from 57.0+/-7.1 to 25.6+/-4.4 and 30.8+/-4.4 cm. water (p <0.01), respectively.

CONCLUSIONS

Intravesical instillation of a specially prepared oxybutynin solution is safe and reliable in children with persistent detrusor hyperactivity or side effects on oral oxybutynin therapy. Eliminating the complex crushing preparation of the solution by the child or parent has made this therapy easy to use and acceptable in the long term.

Intravesical oxybutynin for neurogenic bladder dysfunction: less systemic side effects due to reduced first pass metabolism

PURPOSE

To unravel why intravesical oxybutynin is more effective and causes significantly fewer systemic side effects than oral oxybutynin in the treatment of neurogenic bladder dysfunction, we tested the hypothesis that the absorption and metabolism of oxybutynin are changed after intravesical instillation.

MATERIALS AND METHODS

A high-performance liquid chromatography assay was developed for both oxybutynin and its active metabolite, N-desethyl-oxybutynin. Plasma concentrations were quantified after intravesical (n = 11) and oral (n = 5) administration of oxybutynin in children under steady-state conditions. Pharmacokinetic parameters were calculated.

RESULTS

Oral administration of oxybutynin (0.2 mg./kg./dose) resulted in peak plasma concentrations for N-desethyl-oxybutynin which were 7.4 +/- 1.3 times higher than corresponding values for oxybutynin (n = 5). Also the AUC (area under the plasma concentration time curve) values were higher for N-desethyl-oxybutynin compared with those of oxybutynin, the ratio being 10.8 +/- 1.0 (n = 5). Intravesical instillation (0.2 mg./kg./dose), on the other hand, resulted in reduced metabolite generation and peak plasma concentrations for N-desethyl-oxybutynin which were in the same range as those for oxybutynin, the ratio being 1.2 +/- 0.1 (n = 11). The ratio for the AUC values for N-desethyl-oxybutynin and oxybutynin was 2.1 +/- 0.2 (n = 11).

CONCLUSIONS

The significantly lower AUC ratio of the N-desethyl metabolite over the mother compound, due to a reduced first pass metabolism, may explain the clinically relevant reduction of side effects that characterizes intravesical compared with oral oxybutynin therapy.

Intravesical oxybutynin for neurogenic bladder dysfunction: less systemic side effects due to reduced first pass metabolism

PURPOSE

To unravel why intravesical oxybutynin is more effective and causes significantly fewer systemic side effects than oral oxybutynin in the treatment of neurogenic bladder dysfunction, we tested the hypothesis that the absorption and metabolism of oxybutynin are changed after intravesical instillation.

MATERIALS AND METHODS

A high-performance liquid chromatography assay was developed for both oxybutynin and its active metabolite, N-desethyl-oxybutynin. Plasma concentrations were quantified after intravesical (n = 11) and oral (n = 5) administration of oxybutynin in children under steady-state conditions. Pharmacokinetic parameters were calculated.

RESULTS

Oral administration of oxybutynin (0.2 mg./kg./dose) resulted in peak plasma concentrations for N-desethyl-oxybutynin which were 7.4 +/- 1.3 times higher than corresponding values for oxybutynin (n = 5). Also the AUC (area under the plasma concentration time curve) values were higher for N-desethyl-oxybutynin compared with those of oxybutynin, the ratio being 10.8 +/- 1.0 (n = 5). Intravesical instillation (0.2 mg./kg./dose), on the other hand, resulted in reduced metabolite generation and peak plasma concentrations for N-desethyl-oxybutynin which were in the same range as those for oxybutynin, the ratio being 1.2 +/- 0.1 (n = 11). The ratio for the AUC values for N-desethyl-oxybutynin and oxybutynin was 2.1 +/- 0.2 (n = 11).

CONCLUSIONS

The significantly lower AUC ratio of the N-desethyl metabolite over the mother compound, due to a reduced first pass metabolism, may explain the clinically relevant reduction of side effects that characterizes intravesical compared with oral oxybutynin therapy.

Neuropathological findings in Moebius syndrome

Pathological findings in two patients with Moebius syndrome and lethal fetal akinesia sequence are described. In both patients a congenital brain stem malformation with neuronal loss in the cranial nerve nuclei and tegmental microcalcifications was observed. In one patient, the association with splenogonadal fusion was observed, whilst in the second patient, the association with tetraperomelia was present. As the association of peromelia and splenogonadal fusion is a well-known association, the different combination of splenogonadal fusion, peromelia and Moebius syndrome due to congenital brain stem anomalies with necrosis might be the result of a disruptive phenomenon during a prolonged vulnerable critical period in the 5th and 6th week of embryonic life. The finding of olivary dysplasia in one case, reminiscent of olivary dysplasia in Zellweger syndrome and in Miller Dieker syndrome, might suggest a primary malformation underlying Moebius syndrome due to brain stem defects.

Tethered cord syndrome in occult spinal dysraphism: timing and outcome of surgical release

OBJECTIVE

To investigate the influence of neurosurgical intervention on the appearance of upper motor neuron (UMN) signs in newborns diagnosed with occult spinal dysraphism and tethered cord (TC) during the first month of life.

METHODS

A prospective study (1990 to 1996) of 22 consecutive newborns with occult spinal dysraphism monitored for the appearance of UMN signs. Untethering was performed when neurologic or urodynamic investigation indicated the presence of UMN dysfunction.

RESULTS

Of 22 patients, 10 remained free of UMN symptoms during follow-up (mean, 67+/-22 months). Untethering was performed in 12 of 22 patients because of the presence of UMN symptoms. In 7 of these 12 patients, there was a documented asymptomatic period of 13+/-11 months before the onset of UMN symptoms. Untethering at a mean age of 18+/-17 months restored normal neurologic and urinary function in all patients (mean postoperative follow-up, 25+/-16 months). Of the 12 children, 5 presented with UMN signs at birth. In these children, untethering was performed at a mean age of 9+/-5 months. In two of these five patients, UMN symptoms did not resolve after surgery, and ongoing conservative bladder treatment was required (mean follow-up, 37+/-14 months). In none of the 12 operated children did signs of retethering occur.

CONCLUSIONS

A significant number (10/22) of children born with occult spinal dysraphism and TC did not develop UMN symptoms during follow-up; neurosurgical correction after the appearance of an UMN sign restored normal neurologic and urinary function in all children; and untethering in children presenting at birth with UMN symptoms resulted in poorer outcome.

Neurological status in severely jaundiced Zimbabwean neonates

Neurological status was studied in 50 jaundiced infants with a total serum bilirubin of > 400 mumol/l (23.4 mg/dl). Infants were assessed in the neonatal period with the Neonatal Neurological Examination and 4 months of age with the Infant Motor Screen. Twenty-six (52 per cent) infants were premature. Analysis of variance did not show a significant difference between gestational age, birth weight, and maximum total serum bilirubin or between gestational age, birth weight, and neurological optimality score. Based on the presence of abnormal neurological syndromes the infants were classified as normal (n = 27), suspect (n = 11), or abnormal (n = 12). Serum bilirubin levels were higher (p < 0.0001) and the neonatal neurological examination scores lower (p < 0.0001) in the seven (14 per cent) infants who received an exchange transfusion. In the transfused group four out of seven infants and in the non-transfused group seven out of 43 infants were classified as abnormal (p < 0.03). The Neonatal Neurological Examination was shown to be sensitive in detecting neurodevelopmental abnormalities in the neonatal period, with a sensitivity of 83 per cent, specificity of 88 per cent, positive predictive value of 62 per cent, and negative predictive value of 96 per cent.

The predictive value of developmental testing of extremely jaundiced African infants

The predictive value of the Neonatal Neurological Examination (NNE) adapted from Prechtl (1977) and the Infant Motor Screen (IMS) from Nickel (1989) at 4 months was studied in severely jaundiced infants in Zimbabwe. Fifty infants were examined with the NNE, 41 with the IMS and 43 with the Bayley Scales of Infant Development (BSID) (Bayley 1969). Five infants had choreoathetosis and six had a motor delay at age 1 year. The NNE and IMS proved to be sensitive instruments particularly when two infants who became malnourished after the neonatal period were excluded. Logistic regression was used to investigate the relation between the BSID and five selected predictors from the NNE. This resulted in a correct classification of 93%. By using only the predictors acoustic blink and traction response, 80% of the infants were correctly classified but the number of false negatives was reduced from three to one.

Neonatal neurological examination as a predictor of neuromotor outcome at 4 months in term low-Apgar-score babies in Zimbabwe

The predictive value of the neonatal neurological examination (NNE) adapted from Prechtl, was investigated in 139 term Zimbabwean infants born with an Apgar score of five or less at 5 min. At 4 months, seven infants had died and 13 were lost to follow-up, leaving 119 infants to undergo the Infant Motor Screen (IMS). Eighty-eight infants were diagnosed as normal, six as suspect and 25 as abnormal at screening. The sensitivity, specificity, positive predictive value and negative predictive value of the NNE were 94%, 55%, 42% and 96%, respectively. Seventeen (14%) infants had developed microcephaly at 4 months and 13 (77%) of them scored abnormal on the IMS. Twenty-three of the 48 (48%) infants who had convulsions within 48 h of birth, were diagnosed as abnormal (P < 0.0001). The NNE proved to be very sensitive in detecting neurodevelopmental abnormalities in the neonatal period and the five abnormal syndromes derived from the NNE were able to correctly identify 94% of the abnormal infants.

MR of cerebellar cortical dysplasia

MR imaging findings are described in four patients with cerebellar cortical dysplasia. Typically, cerebellar disorganized folia were seen as an irregular bumpy gray-white matter interface. In addition, cystlike cortical abnormalities were observed in two patients and associated supratentorial developmental abnormalities were seen in three patients. To our knowledge, cerebellar cortical dysplasia without supratentorial abnormalities, as seen in one patient, has not been reported before. We suggest that cerebellar cortical dysplasia represents a spectrum of abnormalities ranging from mild to extensive in severity.

Epidermoid tumours associated with lumbar punctures performed in early neonatal life

Three children (ages 5, 7, and 12 years) with epidermoid tumours in the spinal canal, all of whom had a lumbar puncture during the early neonatal period, are reported. A considerable delay occurred from the first symptoms until the diagnosis was made. MRI of the lumbar spine was the method of choice in the diagnostic work-up. All three cases were successfully surgically treated. The link between lumbar punctures and epidermoid tumours and the possible risk factors involved are explored. Because of the variable clinical presentation, the possibility of the existence of these tumours should be considered in the differential diagnosis.

Closed spinal dysraphism: a review on diagnosis and treatment in infancy

This article reviews the clinical presentation, pathophysiology, diagnostic strategies, and therapeutic management of closed spinal dysraphism in infancy. Four groups of symptoms are distinguished: (1) cutaneous abnormalities, (2) lower motor neuron dysfunction due to congenital spinal and nerve root abnormalities, (3) upper motor neuron dysfunction due to tethering of the spinal cord, and (4) symptoms caused by associated malformations. Guidelines are proposed concerning timing and type of diagnostic investigations in infancy. This essentially encompasses a neurological assessment, including spinal ultrasonography and nuclear magnetic resonance imaging of the spine and the brain, and a urological assessment, including ultrasonography of kidneys and bladder, cystourethrography and a urodynamic study. As to the tethered cord syndrome it is concluded that first, already in infancy, a progressive neurological dysfunction can be detected; second, surgical untethering should be performed only upon appearance of upper motor neuron signs or upon progression of lower motor neuron signs. Despite its frequently asymptomatic course, the diagnosis of a congenital lumbosacral lipoma, and in the more general sense, of a closed spinal dysraphism, implies a periodic, multidisciplinary follow-up for life.

Neurodevelopmental outcome in babies with a low Apgar score from Zimbabwe

The early identification of neurological dysfunction in the neonatal period, the predictive value of single items of the neonatal neurological examination (NNE) adapted from Prechtl and the developmental outcome at 1 year of age in infants with a low Apgar score in Zimbabwe were studied. One hundred and sixty-five infants were examined with the NNE and 142 with the Bayley Scale of Infant Development (BSID) at 1 year of age. Twenty-three infants had cerebral palsy, ten had a motor delay or developmental delay, and four were mentally retarded. The NNE proved to be a sensitive instrument for detecting neurodevelopmental abnormality. Logistic regression analysis was used to investigate the relationship between the BSID and nine selected predictors from the NNE. This resulted in a correct classification of 94%. However, the number of false negatives was high. By using only the variability of movements and fixation as predictors the number of false negatives was reduced to one.

Stepwise decrease in VEP latencies and the process of myelination in the human visual pathway

To assess the progress in myelination in the developing human brain, a prospective longitudinal study of flash visual evoked potentials (VEPs) was performed in 22 healthy preterm infants with the same gestational age at birth (between 30 weeks 0 day and 31 weeks 0 day). The individual curves of the changes in the N1a peak latency (the early peak of the N1 wave) decrease not linearly but in a stepwise pattern in the preterm period. Twenty-one infants out of the 22 have one or more 'acceleration week(s)' in which the latency decreases at a rate of more than 6 ms per week. These stepwise decreases in the latency may reflect a synchronized progress in myelination in several parts of the visual pathway. A detailed analysis of the 'acceleration weeks' in relation to postmenstrual age (PMA) indicates that they most prominently occur at 37 weeks PMA. At 37 weeks an initiation of myelination in the optic radiation has been demonstrated in post-mortem studies. We propose that a longitudinal follow-up study of VEPs can be accepted as a functional in vivo evaluation of myelination in the developing human brain.

Extreme hyperbilirubinaemia in Zimbabwean neonates: neurodevelopmental outcome at 4 months

As part of a prospective study of severely jaundiced Zimbabwean infants, the relationship between maximum total serum bilirubin (TSB) concentration in the neonatal period and neurodevelopmental outcome at the corrected age of 4 months was studied. Fifty infants with a TSB of > 400 micromol/l (23.4 mg/dl) were enrolled and screened with a neonatal neurological examination (NNE). The cause of jaundice was low birth weight in 22 (44%), ABO incompatability in 8 (16%), sepsis in 8 (16%) and congenital syphilis (6%) in 3 infants. In 9 infants a cause could not be determined. At 4 months, 2 infants had died and 3 were lost to follow up, leaving 45 infants for the infant motor screen (IMS) at 4 months of age. Mean TSB in the neonatal period was 485 micromol/l (28.2 mg/dl), and 7 infants received an exchange transfusion. Mean TSB of the infants with an exchange transfusion was 637 micromol/l (37.2 mg/dl) (range 429-865 micromol/l (25-50.3 mg/dl)) and of the infants without transfusion 459 micromol/l (26.8 mg/dl) (range 400 740 micromol/l (23.4-43 mg/dl)) (P < 0.0001). The TSB was not associated with birth weight, gestational age, gender or head circumference of the baby. On the IMS, 6 of 45 (13.3%) infants scored abnormal, 6 (13.3%) suspect and 33 (73%) scored normal. Three of the six (50%) remaining infants who received an exchange transfusion scored abnormal on the IMS while only 3 of the 39 (8%) infants without exchange transfusion were abnormal.

CONCLUSION

More than 25% of infants with a TSB of > 400 micromol/l (23.4 mg/dl) scored abnormal or suspect at 4 months of age and half of these infants already showed irreversible neurological symptoms. All infants who scored abnormal or suspect on the IMS with bilirubin levels between 400 and 500 micromol/l (23.4 and 29.2 mg/dl) had haemolytic disease or were premature.

The X-linked infantile spasms syndrome (MIM 308350) maps to Xp11.4-Xpter in two pedigrees

We report 2 families with X-linked infantile spasms syndrome (X-linked West syndrome). Data from clinical examination, biochemical analysis, neuroimaging, and neuropathology are discussed. In these families, genetic linkage analysis was able to locate the disease gene to the distal part of the short arm of the X chromosome, between Xpter and Xp11.4. This is the first report of linkage with genetic markers in this disorder. Although most cases are sporadic, further unraveling of the genetic background of the familial cases might greatly improve our understanding of infantile spasms.

Cortical visual impairment following perinatal hypoxia: clinicoradiologic correlation using magnetic resonance imaging

PURPOSE

To evaluate the value of magnetic resonance imaging (MRI) in the visual prognosis of cortical visual impairment following perinatal hypoxia.

METHODS

MRI findings of 19 babies with the diagnosis of a perinatal hypoxic-ischemic insult and cortical visual impairment (CVI) were reviewed. Two groups of patients based on gestational age were compared. Babies with a gestational age > or = 34 weeks were included in group 1(n = 8). Infants < 34 weeks' gestation were included in group 2(n = 11). All 19 children underwent MRI.

RESULTS

Normal MRI always correlated with better visual outcome, regardless of the gestational age at which the insult occurred. Among infants born at or later than 34 weeks' gestation, a favorable visual recovery occurred in two with normal MRI findings. The presence of infarcts or periventricular leukomalacia indicated that full visual recovery would not occur. Among infants born before 34 weeks' gestation, the MRI findings were normal in two who had a favorable visual outcome. A normal visual cortex and the absence of periventricular leukomalacia were helpful in prognosticating the visual outcome. A general delay in the myelination-particularly in the myelination of the optic radiation-was a common finding and until now has not been described in children with CVI routinely.

CONCLUSION

MRI's ability to follow the process of myelination may be of predictive value. MRI, therefore, should be obtained in a child with CVI following perinatal hypoxia.

Normal brain perfusion pattern of technetium-99m-ethylcysteinate dimer in children

The purpose of this study was to assess the normal perfusion pattern of the pediatric brain with 99mTc-ethylcysteinate dimer (99mTc-ECD).

METHODS

Tomographic imaging was performed with a dedicated system with high sensitivity and resolution. Sixteen children, referred for brain imaging in the workup of seizure disorder, were included since they turned out negative after a 1-yr follow-up. A standardized brain presentation was obtained after reslicing and reorienting of the three-dimensional volumetric dataset.

RESULTS

Quantitative analysis did not reveal significant left-right uptake differences per patient. Three age clusters were investigated that showed differences in regional uptake, mainly a relatively increased uptake in basal ganglia, visual and motor cortex. An uptake ratio or perfusion index was calculated after normalization. Normal limits were established for the children in the three groups.

CONCLUSION

Technetium-99m-ECD is a safe agent for children and should be the radiopharmaceutical of choice for brain perfusion studies because of favorable radiation dosimetry and stability. The age dependence of perfusion necessitates a database comparison before concluding that the observed perfusion pattern is normal.

Use of external drainage for posthemorrhagic hydrocephalus in very low birth weight premature infants

To treat progressive posthemorrhagic hydrocephalus we used early external ventricular drainage (EVD) in 14 premature infants. We think it is important that the catheters in these critically ill infants be inserted in the neonatal intensive care unit, allowing us to keep the infants in an extremely stable environment. Only after prolonged external ventricular drainage (on average 38.4 days) is a ventriculoperitoneal shunt considered, preferably when the child has reached a body weight of 2000 g. There were no infections or other severe drainage-related problems. We report mean daily EVD volumes (which are related to body weight) and EVD duration. The 14 patients included 9 who required permanent shunting. Comparing the mortality, morbidity and follow-up data to at least 3 months of age in this group with similar data for an earlier cohort treated with lumbar punctures and late permanent shunting, we demonstrate the safety of the policy we have recently adopted.

Neurological findings in neonates with low Apgar in Zimbabwe

OBJECTIVES

Document neurological condition of African neonates with a low apgar score.

SETTING

Mpilo Hospital, Bulawayo, Zimbabwe.

SUBJECTS

165 babies with an Apgar score of 5 or less at 5 min.

METHODS

Neurological examination at term age according to Prechtl. Babies were classified as normal, suspect or abnormal and compared with two reference groups, one from Groningen, the Netherlands and one from Grenada in the Caribbean.

RESULTS

A higher number of Zimbabwean babies were delivered by Caesarean section compared to the Groningen group (P < 0.001). Babies delivered by vacuum extraction scored significantly lower compared to babies delivered by Caesarean section (P < 0.003). Twenty abnormal signs derived from the neonatal neurological examination proved to be predictive on the total optimality score (P < 0.001). The number of infants who were classified as abnormal was higher in the Zimbabwean population (P < 0.01).

CONCLUSION

The selected abnormal signs derived from the neonatal neurological examination proved to be highly predictive on the neurological condition. The neonatal morbidity in Zimbabwean neonates with a low Apgar score was higher when compared with two reference groups from Groningen and Grenada.

The effect of behavioural states on cerebral oxygenation during endotracheal suctioning of preterm babies

Near infrared spectroscopy (NIRS) was used to investigate the effect of behavioural states on changes of oxygenated (O2Hb), deoxygenated haemoglobin (HHb) and total haemoglobin (tHb), during endotracheal suctioning. In an open prospective design, NIRS measurements have been done during 20 suctioning episodes in 13 preterm neonates. Heart rate, arterial oxygen saturation, and carbon dioxide tension were monitored continuously. Behavioural state (BS) observations were made and documented as well. The statistical analysis showed that in patients who were active, with crying periods during suctioning (behavioural states 4-5), changes of oxygenated (p < 0.005) and deoxygenated haemoglobin (p < 0.05), as well as of arterial oxygen saturation (p < 0.05) and heart rate (p < 0.05) were significantly greater than in patients who were quiet with predominant behavioural state 1, 2 and 3. These results underline the influence of behavioural states on the physiological answers to endotracheal suctioning. NIRS proved to be a valuable tool to evaluate possible harmful effects of different suctioning techniques.

Empty sella, growth hormone deficiency and pseudotumour cerebri: effect of initiation, withdrawal and resumption of growth hormone therapy

An 11-year-old boy with normal visus and eye fundus, but with empty sella, growth hormone (GH) deficiency and central diabetes insipidus was found to have intracranial hypertension with papilloedema after 6 months of catch-up growth under recombinant human GH (rhGH) replacement therapy. Withdrawal of rhGH therapy was associated with normalisation of intracranial pressure within 1 week. Three months later, resumption of rhGH therapy at a lower dose was again followed by pronounced growth acceleration, but now without papilloedema.

CONCLUSION

Children with empty sella and GH deficiency may be prone to rhGH-induced pseudotumour cerebri which appears to be rapidly reversible and dose-dependent.

Leber congenital amaurosis--differential diagnosis, ophthalmological and neuroradiological report of 18 patients

Between 1985 and 1995 eighteen babies, presenting to our department with absent visual contact and roving eye movements, showed a non-recordable flash electroretinogram (fERG). This was confirmed when repeated after a one-year interval. In four patients with developmental delay an underlying systemic disorder was diagnosed after a thorough pediatric neurological evaluation: Senior Loken syndrome, neuroaxonal dystrophy, ceroid lipofuscinosis and a yet unclear metabolic disorder were the revised diagnoses. The fourteen remaining patients were diagnosed as having primary idiopathic Leber Congenital Amaurosis (LCA). Three of them showed developmental delay. In all three cerebellar abnormalities were visualized on brain computed tomography (CT) and/or magnetic resonance imaging (MRI). Brain CT of the other eleven patients with age appropriate development was normal. We conclude that LCA is a diagnosis of exclusion and a cautious approach with a thorough history and pediatric neurological examination is necessary to exclude a more global pediatric neurological disorder.

Add-on therapy of fenfluramine in intractable self-induced epilepsy

Eleven institutionalized children (7 girls, 4 boys) with refractory epilepsy received fenfluramine as add-on therapy. Besides therapy resistance, the patients manifested self-induction of seizures. Eight patients were photosensitive and/or pattern sensitive. All antiepileptic drugs of doubtful efficacy were withdrawn. During withdrawal, patients did neither improve nor show an increase in seizure frequency. Fenfluramine was then added and administered once to three times daily at dosages between 0.5 and 1 mg/kg.day. Side effects were mild and transient. Of the 11 patients, 7 became seizure-free and in 4 patients a more than 75% decrease of all seizures was obtained.