Resection of the lesion in patients with hypothalamic hamartomas and catastrophic epilepsy

BACKGROUND

Patients with hypothalamic hamartomas (HH) often have severe refractory epilepsy, incapacitating behavioral abnormalities, and cognitive decline. Attempts to control the seizure disorder by resection of apparently epileptogenic mesial temporal or other cortical structures have failed consistently.

OBJECTIVE

To report a series of 13 patients in whom the hamartoma itself was resected.

METHODS

All patients underwent preoperative evaluation between ages 2 and 33 years and had subtotal or complete resection of the hamartoma. Follow-up ranged from 1 to 5.5 years (mean: 2.8 y).

RESULTS

Preoperatively, all patients had variable combinations of gelastic, complex partial, and generalized seizures. Eight had drop attacks. In addition, all had marked behavior abnormalities and cognitive impairment. Postoperatively, two patients are completely seizure-free and 11 are either seizure-free or have achieved a greater than 90% reduction of drop attacks and generalized tonic-clonic seizures. However, minor gelastic, complex partial, and atypical absence seizures have persisted in 11 patients, although at significantly reduced rates. In addition, there has been a dramatic improvement in behavior and cognition. Three patients had an anterior thalamic and one a capsular infarct, which left only minimal long-term deficits. Exact location of the lesion in relation to the interpeduncular fossa and the walls of the third ventricle correlated with extent of excision, seizure control, and complication rate.

CONCLUSION

Resection can alleviate both the seizures and the behavioral and cognitive abnormalities of hypothalamic hamartomas, but complications are frequent.

Functional limitations in young children with congenital heart defects after cardiac surgery

With the recent dramatic decline in mortality rates of infants undergoing open-heart surgery (OHS), there is growing concern regarding neurodevelopmental sequelae. Outcome studies have primarily focused on delineating developmental impairments; however, the impact on function and family burden has not been investigated. The objective of this study was to determine the prevalence of functional limitations and burden of care of young children with congenital heart defects (CHD) after OHS.

STUDY DESIGN

One hundred thirty-one eligible infants with CHD undergoing their first OHS were recruited prospectively. Patients were assessed pre- and postoperatively, and again 12 to 18 months after surgery. Functional assessments included the WeeFIM (Functional Independence Measure) and the Vineland Adaptive Behavior Scale.

RESULTS

For the WeeFIM, mean quotients were 84.3 +/- 23.8 (self-care), 77.2 +/- 30.0 (mobility), and 92.4 +/- 27.8 (cognition), with an overall quotient of 83.8 +/- 23.4. Only 21% of the cohort was functioning within their expected age range. Moderate disability was noted in 37%, while only 6% demonstrated a severe disability. For the Vineland scale, mean score for daily living skills was 84.4 +/- 17.6, and 80.3 +/- 15.9 for socialization. Functional difficulties in daily living skills were documented in 40%, whereas >1/2 had poor socialization skills. Factors enhancing risk for functional disabilities included perioperative neurodevelopmental status, microcephaly, length of deep hypothermic circulatory arrest, length of stay in the intensive care unit, age at surgery, and maternal education.

CONCLUSIONS

The high prevalence of functional limitations and dependence in activities of daily living is currently underappreciated in the clinical setting, and deserves additional attention by pediatricians and developmental specialists.

Automation bias and errors: are crews better than individuals?

The availability of automated decision aids can sometimes feed into the general human tendency to travel the road of least cognitive effort. Is this tendency toward "automation bias" (the use of automation as a heuristic replacement for vigilant information seeking and processing) ameliorated when more than one decision maker is monitoring system events? This study examined automation bias in two-person crews versus solo performers under varying instruction conditions. Training that focused on automation bias and associated errors successfully reduced commission, but not omission, errors. Teams and solo performers were equally likely to fail to respond to system irregularities or events when automated devices failed to indicate them, and to incorrectly follow automated directives when the contradicted other system information.

Association between electroencephalographic findings and neurologic status in infants with congenital heart defects

Neurologic status is of concern in infants with congenital heart defects undergoing open heart surgery. The association between perioperative electroencephalography (EEG) with acute neurologic status and subsequent outcome was examined in a cohort of 60 infants. Preoperative EEG and neurologic examinations were performed within 1 to 2 days prior to surgery (n = 27) and postoperatively (n = 47). Prior to surgery, 15 of 27 infants had normal EEG, whereas 5 had epileptiform activity and 9 had disturbances in background activity that were primarily moderate (8/9) and diffuse (7/9). Postoperatively, only 17 of 47 infants had normal recordings. Newborns (<1 month) were more likely (P< .001) to demonstrate EEG abnormalities than infants. Epileptiform activity was documented in 15, whereas 28 had background abnormalities that were moderate-severe (22/28) and diffuse (20/28) in most. Epileptiform activity prior to surgery was always associated with an abnormal neurologic examination, and this association persisted postoperatively (86%). Moderate to severe background abnormalities in the postoperative EEG was also strongly associated with acute neurologic abnormalities (93%). Severe background abnormalities (n = 5) were 100% predictive of death or severe disability. Long-term follow-up revealed that all children with normal postoperative EEGs had positive neurologic outcomes (P = .04); however, there were many false positives. Perioperative EEG abnormalities increased the likelihood for acute neurologic findings, whereas normal recordings following surgery were reassuring with regard to a favorable outcome.

Intractable epilepsy after a functional hemispherectomy: important lessons from an unusual case. Case report

Residual seizures after functional hemispherectomy occur in approximately 20% of patients with catastrophic epilepsy. These episodes are traditionally attributed to incomplete disconnection, persistent epileptogenic activity in the ipsilateral insular cortex, or bilateral independent epileptogenic activity. The authors report on the case of an 8-year-old boy with an intractable seizure disorder who had classic frontal adversive seizures related to extensive unilateral left hemispheric cortical dysplasia. The initial intervention consisted of extensive removal of the epileptic frontal and precentral dysplastic tissue and multiple subpial transections of the dysplastic motor strip, guided by intraoperative electrocorticography, Subsequently, functional hemispherectomy including insular cortex resection was performed for persistent attacks. After a seizure-free period of 6 months, a new pattern ensued, consisting of an aura of fear, dystonic posturing of the right arm, and unusual postictal hyperphagia coupled with an interictal diencephalic-like syndrome. Electroencephalography and ictal/interictal single-photon emission computerized tomography were used to localize the residual epileptic discharges to deep ipsilateral structures. Results of magnetic resonance imaging indicated a complete disconnection except for a strip of residual frontobasal tissue. Therefore, a volumetric resection of the epileptogenic frontal basal tissue up to the anterior commissure was completed. The child has remained free of seizures during 21 months of follow-up review. Standard hemispherectomy methods provide extensive disconnection, despite the presence of residual frontal basal cortex. However, rarely, and especially if it is dysplastic, this tissue can represent a focus for refractory seizures. This is an important consideration in determining the source of ongoing seizures posthemispherectomy in patients with extensive cortical dysplasia. It remains important to assess them fully before considering their disease refractory to surgical treatment.

Neurodevelopmental status of newborns and infants with congenital heart defects before and after open heart surgery

BACKGROUND

Neurodevelopmental disabilities in children with congenital heart defects (CHDs) have been primarily attributed to intraoperative events without consideration of preoperative and postoperative factors.

OBJECTIVE

To describe the preoperative and postoperative neurodevelopmental status of newborns and infants with CHDs.

STUDY DESIGN

One hundred thirty-one children (56 newborns and 75 infants) were evaluated before and after surgery by using standardized neurobehavioral (newborn) and motor assessments (infant) and neurologic examinations.

RESULTS

In newborns, neurobehavioral abnormalities were documented in >50% before surgery, with abnormalities persisting in most after surgery. In infants, neurodevelopmental abnormalities were observed in 38% before surgery. There was a significant association between preoperative and postoperative neurodevelopmental status, with status remaining unchanged in most. Newborns with acyanotic heart lesions were more likely to demonstrate neurologic compromise than those with cyanotic defects. For infants, arterial oxygen saturations <85% were significantly associated with an abnormality. There was a trend for a longer circulatory arrest time to be associated with greater risk for neurologic sequelae in newborns, whereas prolonged cardiopulmonary bypass was an important risk factor for infants.

CONCLUSIONS

Neurodevelopmental abnormalities are common in young infants with CHDs and are often present before open heart surgery. These developmental concerns are clinically underappreciated. Early systematic developmental screening may be warranted in this population of interest.

Prediction of outcome at school age in neonatal intensive care unit graduates using neonatal neurologic tools

Prediction of outcome for neonatal intensive care unit graduates is clinically useful to counsel families effectively and target those who may benefit from early interventions. Evoked potentials have proven prognostic value of neurologic outcomes in early childhood; however, their long-term predictive validity remains to be determined. The objective of this prospective study was to determine the long-term predictive value of three neonatal neurologic assessments: brainstem auditory evoked potentials, somatosensory evoked potentials, and the Einstein Neonatal Neurobehavioral Assessment Scale. Seventy-eight high-risk newborns and 28 healthy controls were recruited and were assessed in the newborn period using these tests. At 8 to 9 years of age, 42 subjects and 13 controls were re-evaluated for developmental progress using a range of psychologic, sensorimotor, and neurologic measures. Findings indicated that the somatosensory evoked potential was most accurate at predicting outcome at school age, with high specificity (83-100%) across all domains tested and good sensitivity (80-100%) for intellectual performance and sensorimotor abilities. The brainstem auditory evoked potential was limited by false-negatives, whereas the neonatal neurobehavioral assessment yielded many false-positives. This study provides new evidence that associations between neonatal somatosensory evoked potentials and developmental sequelae continue to be significant at school age.

Neuronal dysfunction in children with newly diagnosed temporal lobe epilepsy

We sought to determine whether neuronal dysfunction throughout the temporal lobes of children with temporal lobe epilepsy (TLE) is already as severe at the time of diagnosis as it is in patients with long-standing intractable TLE (INT-TLE). Proton magnetic resonance spectroscopic imaging was used to measure N-acetylaspartate/creatine (NAA/Cr) ratios in the temporal lobes of five consecutive children with newly diagnosed TLE (ND-TLE), five with INT-TLE, and 30 normal control subjects. The median age of those with ND-TLE and those with INT-TLE did not significantly differ (P = 0.92). All five patients with ND-TLE had bilateral reductions in the NAA/Cr ratio. Two of the five patients with INT-TLE had bilateral reductions in the NAA/Cr ratio; three had unilateral reductions in the NAA/Cr ratio. In the three patients with lesions the NAA/Cr ratio decrease extended outside these lesions. No significant differences were detected in any temporal lobe region between the ND-TLE and INT-TLE groups. The severity of the neuronal dysfunction in the children with ND-TLE was at least as severe as in those with INT-TLE and was not restricted to one temporal lobe, implying that the neuronal abnormalities observed in patients with TLE occur before the clinical manifestations.

Multimodality evoked potential findings in infants with congenital heart defects

Evoked potentials are sensitive prognostic tools in young infants at risk for developmental disability. The objective of this prospective study was to determine whether infants with congenital heart defects demonstrate evoked potential abnormalities prior to or following open heart surgery, and to examine the association between these abnormalities and developmental status 1 year following surgery. A consecutive series of newborns (less than 1 month old) and infants (1 month to 2 years old) were recruited. Somatosensory and brain stem auditory evoked potentials were carried out before or after cardiac surgery, or both. One year later, neurologic examination and standardized measures of motor performance and functional independence were carried out. Twenty-seven newborns and 31 infants underwent perioperative somatosensory evoked potential recordings. Results indicate that perioperative somatosensory evoked potential abnormalities were common in newborns (41%) but not in infants (13%) with congenital heart defects. Brainstem conduction times were within normal limits in all subjects; however, 32% presented with mild elevations in hearing thresholds. All newborns with abnormal somatosensory evoked potentials had abnormal neurologic examinations both perioperatively and again 1 year after open heart surgery. Moreover, standardized developmental assessments 1 year following surgery indicate that all newborns with somatosensory evoked potential abnormalities had developmental deficits in one or more domains. Somatosensory evoked potential abnormalities in the perioperative period are common in newborns with congenital heart defects, and are strongly predictive of persistent developmental delay later.

Computerized EEG monitoring

Monitoring of central nervous system function in the intensive care unit is becoming more widely accepted as an integral part of critical care. The history of developments in electroencephalogram (EEG) technology is reviewed to better appreciate the rate of technological developments and their application to clinical practice. Basic concepts of digital EEG are reviewed. Principals of intensive care unit monitoring as they apply to clinical neurophysiological techniques are examined to better understand the goals for an "ideal central nervous system monitor." Some current advances and directions for future development in computerized EEG monitoring are discussed.

Unusual presentation of spinal cord compression related to misplaced pedicle screws in thoracic scoliosis

Utilization of thoracic pedicle screws is controversial, especially in the treatment of scoliosis. We present a case of a 15-year-old girl seen 6 months after her initial surgery for scoliosis done elsewhere. She complained of persistent epigastric pain, tremor of the right foot at rest, and abnormal feelings in her legs. Clinical examination revealed mild weakness in the right lower extremity, a loss of thermoalgic discrimination, and a forward imbalance. A CT scan revealed at T8 and T10 that the right pedicle screws were misplaced by 4 mm in the spinal canal. At the time of the revision surgery the somatosensory evoked potentials (SSEP) returned to normal after screw removal. The clinical symptoms resolved 1 month after the revision. The authors conclude that after pedicle instrumentation at the thoracic level a spinal cord compression should be looked for in case of subtle neurologic findings such as persistent abdominal pain, mild lower extremity weakness, tremor at rest, thermoalgic discrimination loss, or unexplained imbalance.

Monitoring the central nervous system in children with congenital heart defects: clinical neurophysiological techniques

The neurological sequelae following surgery for complex cardiac malformations is being increasingly recognized. The electroencephalogram (EEG) and evoked potentials may be used as monitors of neurological integrity. Criteria for a successful intensive care unit monitoring system have been proposed. EEG findings in the preoperative, perioperative, and postoperative periods are reviewed and may aid in the prediction of neurological sequelae. Recent advances in the development of a computerized neurophysiological monitor at the Montreal Children's Hospital are reviewed. Evoked potentials, auditory, somatosensory, and visual can be used to monitor children with complex cardiac lesions and evaluate them for potential neurological sequelae.

Neurologic status of newborns with congenital heart defects before open heart surgery

Controversy exists regarding the integrity of the nervous system in the newborn with a congenital heart defect who must undergo corrective or palliative open heart surgery. Neurodevelopmental sequelae have been primarily attributed to surgical procedures without standardized evaluation of the preoperative neurologic status.

OBJECTIVE

To determine whether newborns with congenital heart defects demonstrate abnormalities in neurobehavioral status before surgery.

STUDY DESIGN

In this prospective study, a standardized neonatal neurobehavioral assessment and a neurologic examination were conducted independently in a consecutive series of 56 neonates referred to our hospital for investigation of open heart surgery.

RESULTS

Neurobehavioral and neurologic abnormalities were documented in greater than half of the cohort and included hypotonia, hypertonia, jitteriness, motor asymmetries, and absent suck. Poor state regulation (62%) and feeding difficulties (34%) also were commonly observed. Furthermore, 3 subjects had seizures, 35.7% were microcephalic, and 12.5% were macrocephalic. The overall likelihood of neurobehavioral abnormalities was not enhanced by indicators of cardiorespiratory compromise. Interestingly, newborns with acyanotic congenital heart defects were more likely to demonstrate neurologic compromise than were those with cyanotic defects.

CONCLUSIONS

Findings suggest that the prevalence of neurobehavioral abnormalities before surgery in newborns with congenital heart defects has been underappreciated and would indicate that factors other than intraoperative procedures should be considered in the genesis of brain injury in this population.congenital heart defects, neurologic examination, newborn.

Hypothalamic hamartomas and gelastic epilepsy: a spectroscopic study

BACKGROUND

Patients with hypothalamic hamartomas present with epileptic attacks of laughter and later experience multiple seizure types and cognitive decline, suggestive of secondary generalized epilepsy. It has been suggested in the past that gelastic seizures originate in the temporal lobes rather than in the hamartoma, but temporal resections have been ineffective. Recent electrophysiologic evidence suggests that the epileptogenic discharges may originate in the hamartoma itself.

METHODS

We used proton magnetic resonance spectroscopic imaging to quantify the amount of neuronal damage in the temporal lobes and hamartomas of patients with hypothalamic hamartomas and gelastic seizures. Five patients were studied and the relative intensity of N-acetylaspartate to creatine (NAA/Cr) was determined for both temporal lobes as well as for the hamartoma. These values were compared with signals from the temporal lobes and hypothalami of normal control subjects.

RESULTS

NAA/Cr was not significantly different from normal control subjects for either temporal lobe, nor was there a significant asymmetry between the two temporal lobes for any of the patients. NAA resonance signals were present in the hamartomas, and the ratio of NAA to Cr was decreased in the hamartomas compared with the hypothalami of normal control subjects (t = 4.5, p = 0.005).

CONCLUSIONS

We found no detectable neuronal damage in the temporal lobes of patients with hypothalamic hamartomas and gelastic epilepsy. This is further evidence that gelastic seizures do not originate in the temporal lobes of these patients.

Continuous unilateral epileptiform discharge and language delay: effect of functional hemispherectomy on language acquisition

PURPOSE

To assess the efficacy of functional hemispherectomy in promoting language acquisition in a child with severe language delay and continuous left hemispheric epileptiform discharge in the absence of clinical seizures. We report a 6-month-old girl who initially presented with a right hemiparesis secondary to a lesion of probable prenatal origin in the distribution of the left middle cerebral artery. Weeks later, she developed infantile spasms. At 1.5 years of age, because of intractable seizures, the patient had fenestration of the left porencephalic cyst and anterior temporal lobectomy. The seizures ceased; however, language development remained limited to 35 words at 3.5 years of age. The EEG showed almost continuous epileptiform activity over the left hemisphere with no independent epileptiform potentials contralaterally. She underwent a functional left hemispherectomy.

METHODS

Imaging, electroencephalographic investigation, pre- and postoperative psychological and speech assessment were carried out.

RESULTS

Considerable language, speech, and behavior improvement was noted within 2 months of surgery.

CONCLUSIONS

Interictal epileptiform discharges can interfere with the development of contralateral hemispheric function in the absence of clinical seizures. Early functional hemispherectomy may have a role in promoting optimal language development in appropriately selected patients. Although the primary indication for functional hemispherectomy is to control intractable seizures, a secondary proposed indication is to reduce functional impairment of the other hemisphere by electrical interference.

Automatic EEG analysis during long-term monitoring in the ICU

To assist in the reviewing of prolonged EEGs, we have developed an automatic EEG analysis method that can be used to compress the prolonged EEG into two pages. The proposed approach of Automatic Analysis of Segmented-EEG (AAS-EEG) consists of 4 basic steps: (1) segmentation; (2) feature extraction; (3) classification; and (4) presentation. The idea is to break down the EEG into stationary segments and extract features that can be used to classify the segments into groups of like patterns. The final step involves the presentation of the processed data in a compressed form. This is done by providing the EEGer with a representative sample from each group of EEG patterns and a compressed time profile of the complete EEG. To verify the above approach, 41 6 h EEG records were assessed for normality via the AAS-EEG and conventional EEG approaches. The difference between the overall assessment via compressed and conventional EEG was within one abnormality level 100% of the time, and within one-half level for 73.6% of the records. We demonstrated the feasibility and reliability of automatically segmenting and clustering the EEG, thus allowing the reduction of a 6 h tracing to a few representative segments and their time sequence. This should facilitate review of long recordings during monitoring in the ICU.

Congenital bilateral perisylvian polymicrogyria presenting as congenital hemiplegia

We report three children with pure congenital hemiplegia found to have congenital bilateral perisylvian polymicrogyria (CBPP). None of our patients had the seizures, oromotor dysfunction, or cognitive impairment usually associated with CBPP. CBPP may be more common and heterogeneous than previously thought, is easily recognized by MRI, and should be included in the differential diagnosis of the young child presenting with congenital hemiplegia.

An expert system for EEG monitoring in the pediatric intensive care unit

OBJECTIVES

was to design a warning system for the pediatric intensive care unit (PICU). The system should be able to make statements at regular intervals about the level of abnormality of the EEG. The warnings are aimed at alerting an expert that the EEG may be abnormal and needs to be examined.

METHODS

A total of 188 EEG sections lasting 6 h each were obtained from 74 patients in the PICU. Features were extracted from these EEGs, and with the use of fuzzy logic and neural networks, we designed an expert system capable of imitating a trained EEGer in providing an overall judgment of abnormality about the EEG. The 188 sections were used in training and testing the system using the rotation method, thus separating training and testing data.

RESULTS

The EEGer and the expert system classified the EEGs in 7 levels of abnormality. There was concordance between the two in 45% of cases. The expert system was within one abnormality level of the EEGer in 91% of cases and within two levels in 97%.

CONCLUSIONS

We were therefore able to design a system capable of providing reliably an assessment of the level of abnormality of a 6 h section of EEG. This system was validated with a large data set, and could prove useful as a warning device during long-term ICU monitoring to alert a neurophysiologist that an EEG requires attention.

Automatic seizure detection in the newborn: methods and initial evaluation

Seizures are most common in the newborn period, but at that age seizures can be very difficult to identify by clinical observation. Therefore the EEG plays an even greater role in newborns than in older children and adults. The electrographic features of seizures and EEG background in the newborn are, however, very different to those found in adults. We present a set of methods for the automatic detection of seizures in the newborn. The methods are aimed at detecting a wide range of patterns, including rhythmic paroxysmal discharges at a wide range of frequencies, as well as repetitive spike patterns, even when they are not very rhythmic. The methods were developed using EEGs obtained from 55 newborns, recorded at 3 hospitals that used differing monitoring protocols. A total of 281 h of recordings containing 679 seizures were analyzed. An initial evaluation indicated that 71% of the seizures and 78% of seizure clusters (group of seizures separated by less than 90 s) were detected, with a false detection rate of 1.7/h. The methods were developed so that they can be implemented to operate in real time.

Evaluation of an automatic seizure detection method for the newborn EEG

In another publication, we described a set of methods for automatic detection of EEG seizures in the newborn. We describe here the evaluation of these methods using a completely new set of data, which were not used in developing the method. This testing data set consisted of recording from 54 patients, lasting an average of 4.4 h. Recordings had 8-16 channels and were obtained, in approximately equal numbers, from 3 institutions in Canada, the USA and Australia. Recording conditions varied from short recordings fully attended by a technologist to overnight recordings largely unattended. The average seizure detection rate was 69% (77%, 53%, 84% in the 3 institutions). False detections occurred at the average rate of 2.3/h (4.1, 1.0, 2.7 in the 3 institutions), with fluctuations that reflected largely the technical quality and level of supervision of the recordings. The results are similar to those obtained in the commonly used method of epilepsy monitoring in adults and allow us to envisage clinical application.

Agreement between the neonatal neurological examination and a standardized assessment of neurobehavioural performance in a group of high-risk newborns

The degree of agreement between the neonatal neurological examination and a standardized neurobehavioural assessment was investigated in a group of 32 newborns with congenital heart defects. A paediatric neurologist performed a neurological examination, and an occupational therapist administered the Einstein Neonatal Neurobehavioural Assessment Scale on all subjects. Both examiners independently evaluated each subject, and were blinded to the diagnosis, to perinatal status and to each other's clinical findings. Statistical analysis demonstrated a significant association between the overall impression between both examiners (p < .0001), with a crude agreement of 96.9%. Sixteen neonates were determined to be normal and 15 abnormal by both examiners, with disagreement in only one subject. Although two distinct approaches were employed in the neurological assessment of high-risk newborns, both assessments evaluate the maturity and integrity of the immature central nervous system. The results demonstrate a strong agreement between these two approaches, suggesting that the neonatal neurological examination is consistent and valid.

Progressive encephalopathy with edema, hypsarrhythmia, and optic atrophy (PEHO syndrome)

Progressive encephalopathy with edema, hypsarrhythmia, and optic atrophy syndrome is a recently described rare disorder of infantile regression, intractable seizures, and cerebellar atrophy that occurs almost exclusively in the Finnish population. We report the first North American child with this condition.

Evoked potentials as predictors of outcome in neonatal intensive care unit survivors: review of the literature

Neonatal intensive care unit survivors are at substantial risk for a range of neurodevelopmental sequelae, and therefore a variety of clinical diagnostic techniques have been evaluated as predictors of outcome. We summarize the prognostic value of evoked potentials in newborns at risk. A review of the literature reveals that brainstem conduction abnormalities in auditory brainstem evoked potentials are associated with neuromotor impairment; however, there are many false negative studies. Visual evoked potentials are highly accurate in predicting neurologic deficits in early childhood in asphyxiated term neonates. Sensitivity and specificity are consistently high for somatosensory evoked potentials in term newborns; however, correlations with outcome in premature infants is controversial. Several studies have compared neonatal findings on neuroimaging studies and evoked potentials, and concordant results between these two tests are highly predictive. However, neurologic sequelae often can most accurately be predicted by visual or somatosensory evoked potentials. Evoked potentials may therefore be a useful adjunct to the clinical investigation and prognostication of outcome in the high risk newborn.

Cauda equina histiocytosis X

A young child was admitted with a cauda equina syndrome believed to be progressive, but unrelated to a congenital anomaly. Magnetic resonance imaging studies revealed the presence of an intradural tumor in the cauda equina. A yellow pasty tumor with nerve root infiltration was identified at surgery. Histologic features were pathognomonic for histiocytosis X. The patient's management and review of the literature are discussed.

"Pseudo-BECRS": intracranial focal lesions suggestive of a primary partial epilepsy syndrome

Benign epilepsy of childhood with rolandic spikes (BECRS) is an electroclinical entity that is the most common primary partial epilepsy syndrome of childhood. Typically presenting between the ages of 3 and 13 years, it is characterized by a well-recognized seizure pattern arising in a normal child with EEG findings restricted to rolandic/centrotemporal regions. Seizure control is usually easily achieved and prognosis is believed to be uniformly good. Some authors have suggested that individuals fitting the electroclinical parameters of this entity need not undergo neuroimaging due to the benign evolution of this disorder. Five patients presenting over a 13-year period with peribuccal seizures, normal neurologic examinations, and EEG data initially suggestive of BECRS found to have focal lesions on neuroimaging are summarized. Independent bilateral centrotemporal epileptiform abnormalities were seen in 3 patients. Imaging studies (CT, MRI, or both) documented a mass lesion in all in variable locations. Histologic examination documented a low-grade astrocytoma in 3 patients and a cavernous angioma in another. The fifth patient refused treatment or biopsy. Careful retrospective review of the clinical features of these patients reveals variable atypical features in each. Therefore, despite an electroclinical phenotype initially suggestive of the BECRS presentation, the presence of atypical clinical features raises the possibility of an underlying structural lesion and thus a negative neuroimaging study may in some patients be essential to the definitive accurate diagnosis of BECRS.

Prediction of outcome at school entry in neonatal intensive care unit survivors, with use of clinical and electrophysiologic techniques

OBJECTIVE

To determine the predictive value of multimodality evoked potentials as well as the neonatal neurobehavioral assessment in neonatal intensive care unit survivors at school entry.

STUDY DESIGN

In this prospective study, healthy (n = 24) and high-risk newborn infants (n = 78) were assessed in the newborn period with auditory brain-stem responses (ABRs) and somatosensory evoked potentials (SEPs), as well as the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS). Healthy and high-risk newborn infants were assessed in a blind fashion at 1, 3, and 5 years of age by a psychologist and a pediatric neurologist. Of those healthy (all 24) and high-risk newborn infants (72/78) with a neonatal ABR, SEP, or both, 62.5% were assessed at 5 years of age with the Wechsler Preschool and Primary Scale of intelligence, the Beery-Buktenica Test of Visual-Motor Integration, the Griffiths Locomotor Subscale, and neurologic examination. Chi-square analyses were carried out on neonatal and outcome measures, and sensitivity, specificity, and predictive values for each of the neonatal tests were ascertained.

RESULTS

The ENNAS and the ABR had good negative predictive value for cognitive (85.7% to 93.3%), locomotor (83.3%), and visual-motor (91.4% to 100%) performance. The ABR had good specificity, whereas the ENNAS was more sensitive. The SEP was an excellent prognostic tool, with high sensitivity (100%) and specificity (80% to 81.3%) for motor as well as cognitive domains. All infants with normal SEPs had favorable outcomes, whereas those with absent potentials did poorly. The SEP abnormalities were associated with findings on neurologic examination in all cases.

CONCLUSIONS

Normal neonatal evoked potentials and ENNAS are associated with favorable outcomes. The SEP most accurately predicts neurodevelopmental status at school entry.

The determination of sensory deficits in children with hemiplegic cerebral palsy

Therapeutic intervention for children with cerebral palsy begins with accurate appraisal of abilities and disabilities. Currently, treatment focuses on the identified motor deficits, with any underlying sensory deficits often being overlooked. Sensory input is an essential component of motor function and motor control. Therefore, the objective of this study was to determine the presence and extent of sensory deficits in school-aged hemiplegic children using a formal clinical sensory battery, as well as somatosensory evoked potentials. A cross-sectional comparative study was performed comparing sensory function in hemiplegic children and healthy controls. Nine hemiplegic children and 41 healthy controls between 4 and 19 years of age were assessed. Hemiplegic children were included if they had a minimum level of receptive language function of 30 to 33 months and expressive language ability of 24 to 27 months, and no severe limitation of joint range of the hand. Significant bilateral sensory deficits (88.8%) were ascertained in hemiplegic children (P < .05), when compared to the performance of the healthy controls. Stereognosis and proprioception were the chief modalities affected bilaterally. The extent of sensory loss did not mirror the severity of motor deficit. Conversely, findings on somatosensory evoked potentials were closely related to motor function. Thus, a clinical sensory evaluation should be an integral part of the assessment of children with cerebral palsy. The likelihood of sensory impairment in one or more modalities on the hemiplegic or nonhemiplegic side is underappreciated and needs to be identified by rehabilitation specialists to maximize the functional potential of these children.

Lesionectomy of MRI detected lesions in children with epilepsy

The results of complete excision of cerebral lesions detected by MRI in 18 children presenting with epilepsy were analyzed. There were 14 boys and 4 girls with a mean age of 9.2 years. The average age of onset of seizures was 6.8 years. The mean time from onset of seizures to surgery was 2.3 years. Often, CT scans suggested that the lesions were indolent. MRI was better in differentiating neoplastic from developmental lesions. Angiography was non-contributory in this series. Interictal EEGs showed epileptiform activity correlating with imaging studies in 54% of children. The lesion was completely surgically excised in all patients. This was confirmed by intra-operative ultrasound and postoperative imaging. Electrocorticography was performed prior to and after the resection, but residual spiking did not lead to further resection. The average postoperative follow-up was 5.7 years. Five patients had low grade astrocytomas, 4 had gangliogliomas, 1 a mixed astrocytoma-oligodendroglioma, 3 had cortical dysplasia, 2 infantile desmoplastic gangliogliomas, 2 hamartomata, and 1 cavernous angioma. Sixteen patients have been seizure-free since surgery. Only 2 have partial seizures. Thus, all patients benefited from the resection, with respect to seizure control. In those with temporal lobe lesions, improvement in IQ was seen postoperatively. Early consideration of surgery in patients with epilepsy and lesions demonstrated by MRI is suggested.

Predicting outcome in high-risk newborns with a neonatal neurobehavioral assessment

OBJECTIVES

Effective medical management and rehabilitation efforts in neonates at risk depend on early identification of underlying brain injury. The aim of this study was to determine the prognostic value of the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS) in high-risk neonates, and to compare its predictive validity at two stages in development (i.e., 1 and 3 years of age).

METHOD

Twenty-three healthy neonates (control group) and 51 high-risk neonates (high-risk group) were assessed at term and were followed longitudinally. At 1 and 3 years, subjects in both groups were evaluated in a blind fashion by a psychologist and a pediatric neurologist.

RESULTS

Developmental delays became more apparent as high-risk newborns matured; the percentage of subjects with an abnormal Griffiths general quotient increased from 1 year (13.7%) to 3 years (39%). Analysis revealed that a normal neonatal performance on the ENNAS in high-risk subjects accurately predicted a favorable outcome at 1 year and 3 years of age. Although an abnormal ENNAS was not consistently associated with a poor outcome, the positive predictive value improved markedly from 1 year to 3 years of age.

CONCLUSION

The findings indicate that a normal neonatal neurobehavioral assessment is reassuring, as most of these children are free of neurodevelopmental sequelae at 3 years of age. For many persons, the ENNAS may provide early evidence of a pattern of brain injury that is manifested only as the child is challenged by more complex skill acquisition such as language, memory, and perceptual-motor tasks. The ability of this assessment to predict behavioral and academic skills at school age remains to be determined. Early identification of developmental deficits enables occupational therapists to direct infants to appropriate early intervention programs, thus optimizing their functional potential.

Reliability of parental recall of developmental milestones

The developmental history is a key element of the pediatric evaluation. Precise determination of a child's milestones depends on the parent's recollection of developmental events. As part of a prospective study examining neonatal predictors of outcome, healthy and high-risk newborns were assessed by a neurologist at 1, 3, and 5 years of age. The consistency of a parent's recall of two milestones (i.e., first steps and first meaningful word) was examined at 3 and 5 years. The answers provided by the parent(s) at the first visit (mean/S.D.: 12.67/1.19 months) provided the comparison standard. Twenty-five healthy and 50 high-risk infants had acquired 1 or both developmental skills by the first visit. Of 75, 63 were reexamined at 3 and/or 5 years by the same neurologist. For first steps, excellent correlations were obtained at 3 years (r = 0.74) and modest correlations were determined at 5 years (r = 0.41). The mean difference in age reported between 1 and 3 years was 0.36 +/- 1.81 months, and 0.33 +/- 2.46 months between 1 and 5 years. For first word, correlations were poor at 3 and 5 years (r = 0.27 and r = -0.11, respectively), with mean discrepancies in recall of 2.43 +/- 4.37 months (3-year visit) and 2.74 +/- 5.56 months (5-year visit). Twenty percent (n = 13) of parents reported discrepancies of 6 or more months (mean: 9.4; range: 6-25 months). Furthermore, this error in reporting of first word was later than the correct age in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Encephaloduroarteriosynangiosis (EDAS) for the treatment of childhood moyamoya disease

Moyamoya disease is defined by the angiographic demonstration of stenosis or occlusion of the vessels of the anterior circulation at the base of the brain and the concomitant development of collateral blood supply. Untreated, the disease is often clinically progressive, resulting in significant neurologic sequelae. Encephaloduroarteriosynangiosis (EDAS), which involves the transposition of a segment of a scalp artery onto the surface of the brain, is a surgical treatment aimed at improving collateral blood flow. Six children underwent 8 EDAS procedures and were followed from 6 months to 9 years after surgery. No patient experienced further deterioration in neurologic status. Postoperative angiography demonstrated cerebral revascularization from the donor scalp artery on 3 of the 6 EDASs that were studied. The 2 patients who did not revascularize after EDAS demonstrated angiographic regression of their disease. The data suggest that EDAS is a safe procedure for the treatment of childhood moyamoya disease. Given the potential severity of the sequelae, early operative intervention is recommended in all children with this disease.

Inflammatory myopathy and Walker-Warburg syndrome: etiologic implications

Walker-Warburg syndrome is a well delineated clinical entity with characteristic brain and eye anomalies. Recent diagnostic surveys have revealed that muscular dystrophy is an obligatory feature of this syndrome. We report a patient with an inflammatory myopathy that preceded dystrophic changes. While reports of parental consanguinity and multiple affected sibships strongly suggest an autosomal recessive genetic basis for this syndrome, previous pathological analyses of the CNS have suggested an inflammatory process. Our case supports both the notion of an aberrant inflammatory process that is likely under genetic control or etiologic heterogeneity (phenocopies) underlying this syndrome.

Transient oculosympathetic paresis (group II Raeder paratrigeminal neuralgia) of childhood: migraine variant

Although a recognized migrainous phenomenon in adults, transient oculosympathetic paresis in childhood has been rarely observed. Six pediatric patients are reported with transient oculosympathetic paresis occurring within the context of characteristic vascular headaches. The clinical profiles of the patients suggest transient dysfunction of third-order ocular sympathetic pathways and represent most likely a benign, self-limited variant of pediatric migrainous neuralgia.

Influence of gestational age, birth weight, and asphyxia on neonatal neurobehavioral performance

The objectives of this study were to determine the influence of birth weight, gestational age, and asphyxia on neurobehavioral performance at 40 weeks conceptional age, and to demonstrate that this performance may differ in preterm high-risk infants when using low-risk preterm rather than healthy term infant norms. A cross-sectional comparative design was used to compare neurologic behavior in healthy and high-risk newborns at 40 weeks conceptional age using the Einstein Neonatal Neurobehavioral Assessment Scale. Seventy-four high-risk newborns were selected from a consecutive sample of asphyxiated, very-low-birth-weight, and small-for-gestational-age neonates. Controls did not fulfill any of the high-risk criteria and had no pre- or perinatal complications. There were 37 healthy term and 17 low-risk preterm controls. Statistically significant differences occurred between high-risk newborns and term controls for the total score (P < .001) as well as for most individual items (P < .05). Analysis of high-risk subgroups revealed that small-for-gestational-age and term asphyxiated newborns had the most abnormal responses. When comparing test performance between preterm high-risk and term controls, the majority of test items achieved significance (P < .05); however, when compared to low-risk preterm controls, fewer items were abnormal, and the probability level on abnormal items was less significant than expected. This disparity in interpretation of neurobehavioral status in preterm high-risk neonates using a preterm versus term reference sample warrants further investigation. Appropriate normative standards for preterm infants require definition because it may increase the utility of the neonatal neurologic examination and its prognostic value.

Functional interhemispheric asymmetries at birth as demonstrated by somatosensory evoked potentials

Functional cerebral hemispheric asymmetries detectable at birth have been suggested by a number of neuroanatomic, neuroradiologic, and clinical neurophysiologic modalities. The aim of this study was to determine whether functional interhemispheric asymmetries can be identified using electrophysiologic measures. As part of a prospective study, somatosensory evoked potentials following median nerve stimulation were recorded in nine healthy full-term newborns on day 2 or 3 of life, and somatosensory evoked potentials were repeated at 2 and 6 months of age. These children were subsequently examined at 1 and 3 years of age by a pediatric neurologist and all had normal examinations. Handedness was determined at 3 years by questioning the parent and by clinical observation. Three of nine were left-handers. All three left-handers had clearly identifiable neonatal N19 parietal potentials over the right hemisphere. Following right median nerve stimulation, contralateral parietal potentials were absent on two of the three and questionable in the third. Asymmetries were not clearly present in right-handers although only one showed an increased maturation of the right hemisphere relative to the left. At 2 months of age, interhemispheric differences were no longer clearly evident. This data suggests that preferential hemispheric asymmetries are masked by 2 months of age. This differential rate of development demonstrated by neonatal somatosensory evoked potentials may be an early indicator of ultimate handedness.

Ring chromosome 20 and possible assignment of the structural gene encoding human carboxypeptidase-L to the distal segment of the long arm of chromosome 20

We report on a 14-year-old boy with ring chromosome 20. Clinical manifestations included postnatal growth retardation, epilepsy, microcephaly, behaviour disorder, minor facial anomalies, small sella turcica, possible partial growth hormone deficiency, and mental retardation. A decreased activity of enzyme carboxypeptidase-L/protective protein (CP/PP) in cultured fibroblasts was demonstrated in our patient and a patient with a karyotype 46,XY,-14, + der(14)t(14;20)(14pter----14q32.3::20q13.1----20qter)m at. This suggests possible assignment of the CP/PP gene to the distal segment of 20q.

3-Methylglutaconic aciduria: a marker for as yet unspecified disorders and the relevance of prenatal diagnosis in a 'new' type ('type 4')

The Mendelian disorder known as 3-methylgutaconic aciduria (McKusick 250950) gives evidence of allelic and locus heterogeneity. Type 1 has a mild clinical phenotype and confirmed 3-methylgutaconyl-CoA hydratase deficiency; inheritance is autosomal recessive. Other forms have major clinical manifestations and subdivide into X-linked (type 2), a form in Iraqi Jews with optic atrophy (so-called type 3); and untyped (putative autosomal recessive) forms without identified enzyme defects. In the latter, 3-methylglutaconic aciduria may simply be a marker for another metabolic disorder. We describe a male proband with 3-methylglutaconic aciduria designated here as 'type 4' (autosomal recessive, with severe psychomotor phenotype and cerebellar dysgenesis). He is the offspring of Italian consanguineous parents. Born with congenital malformations, he has been followed for 18 years, showing profound developmental delay and cerebellar dysgenesis. Measures of hydratase activity in cultured fibroblasts from the proband and 11 additional patients (two with type 1 disease, 9 with either type 2 or an unspecified form) revealed deficient enzyme activity in type 1 cases and normal activity in the proband and the other 11 cases. Two of the untyped cases probably have 3-methylglutaconic aciduria of the type described here. Prenatal diagnosis in the form described here may be feasible by analysis of amniotic fluid metabolites in pregnancies at risk if the mother does not entirely remove elevated concentrations. A female sibling of the proband had normal metabolite values in amniotic fluid. Postnatal follow-up confirmed absence of the disease. We give the normal values for amniotic fluid and results on these additional fetuses at risk (none affected).

Prognostic significance of multimodality evoked response testing in high-risk newborns

Exposure to hypoxic-ischemic events in fetal or neonatal life may lead to permanent brain damage and subsequent neurodevelopmental deficits. Clinical and diagnostic tools have been somewhat helpful in identifying an at-risk group, particularly those patients sustaining significant neurologic sequelae. In this prospective study, the prognostic significance of multimodality evoked responses in high-risk newborns was examined. A group of 44 high-risk newborns, as well as 14 healthy newborns, were tested during the newborn period with auditory brainstem responses and somatosensory evoked responses; these tests were repeated at 2 and 6 months corrected age. A neonatal neurologic examination, the Einstein Neonatal Neurobehavioral Assessment Scale, was also conducted. At 1 year corrected age, both groups were assessed in a blind fashion by a pediatric neurologist and a psychologist to determine neurodevelopmental outcome. Results indicated that somatosensory evoked response abnormalities in particular predict an abnormal neurologic status at 1 year of age. Abnormalities that persisted or worsened correlated with severe neurologic impairment, whereas an abnormal somatosensory evoked response that improved or normalized in infancy was associated with mild to moderate neurologic sequelae. Increased brainstem conduction in the auditory brainstem responses was also associated with neurologic sequelae. Normal findings from auditory brainstem responses and somatosensory evoked responses predicted normal developmental scores in all areas, as well as a normal neurologic outcome at 1 year with negative predictive powers ranging from 85-100%. Evoked response testing appears to be an important adjunct to the neurologic investigation of high-risk newborns.

The effect of gestational age at birth on somatosensory-evoked potentials performed at term

Multimodality-evoked potentials are widely used in newborns to assess the maturation and integrity of the sensory pathways. Reliable normative data are needed to maximize the utility of this technique as a diagnostic and research tool. Several electrophysiologic studies on the maturational changes of the auditory brain-stem response have demonstrated that latency measurements decrease as a function of increasing conceptional age. However, maturational studies of the somatosensory-evoked potential, particularly in low-risk premature infants, are limited. The existing evoked potential literature in healthy newborns proposes that maturation of the central nervous system occurs at a predictable rate, irrespective of a given gestational age at birth. Behavioral studies of premature infants suggest that neurologic development may be altered by early extrauterine exposure. The purpose of this study was to determine whether brain-stem auditory- or somatosensory-evoked potential conduction times were comparable in premature and full-term infants matched for conceptional age. The results of this study suggest that myelination is determined by conceptional age, independent of premature birth.

Congenital inflammatory myopathy

We present 3 patients with congenital inflammatory myopathy and summarize the literature. CNS involvement (microcephaly/intellectual delay) may or may not be present. Serum creatine kinase activity is elevated, the EMG is myopathic, and the muscle biopsy reveals inflammatory infiltrates, muscle fiber damage, and class I major histocompatibility complex products in muscle sarcolemma. Possible etiologies include intrauterine viral infection or an autoimmune process. Treatment with steroids may result in some motor improvement but has no effect on the CNS involvement. Despite a common time of presentation, these patients have a heterogeneous clinical profile, often suggesting a congenital muscular dystrophy syndrome.

A longitudinal study of short latency somatosensory evoked responses in healthy newborns and infants

Maturational changes in short latency somatosensory evoked responses (SERs) were studied in 18 healthy full-term newborns in the first week of life and consequently repeated at 2-3 and 6-7 months of age. Both median nerves were electrically stimulated individually and evoked responses were recorded at 3 levels: Erb's point (EP), second cervical vertebra (CII), and contralateral parietal scalp (C'c). In the neonatal period, results of 32 stimulated nerves were obtained in all cases at the EP and CII levels. At the parietal level, potentials were present in 85% of cases, absent in 9% and questionable in 6%. Parietal potentials were occasionally noted on one side only. Repeat examinations at 2-3 and 6-7 months of age demonstrated significant maturational changes in the SERs. These changes were most prominent in the neonatal period and 2 months of age. They included decreased interpeak latencies, increased amplitude and markedly diminished dispersion of parietal potentials. Minimal changes in wave form configuration and latency were noted at the EP and CII level. These findings most likely reflect myelination and increased synaptic efficiency predominantly in the central sensory pathway. The purpose of this investigation was to delineate a reliable technique for SERs in newborns and infants that could be applied both to research and clinical settings. Normative data were established in newborns and infants as this will help us in accurately differentiating a normal from an abnormal group of neonates and infants.

Prognostic significance of the auditory brainstem evoked response in high-risk neonates

The prognostic significance of the auditory brainstem evoked response (ABR) was examined in this prospective study of neonates at risk for neurodevelopmental sequelae. ABR testing was performed in the neonatal period (37 to 45 weeks conceptional age) and at two and/or six months corrected age. 34 high-risk newborns and 14 controls were followed to one year of age, when they received neurological and developmental assessments. Increased I to III and I to V interwave latencies predicted gross motor delay at one year, with a positive predictive power of 83 per cent and a specificity of 94.7 per cent. Increased brainstem conduction, dispersal of waves III to V and V/I amplitude ratio abnormalities predicted abnormal neurological findings at one year, with positive predictive values of 100, 100 and 80 per cent, respectively. A standard clinical examination of the newborn, performed on the at-risk and control infants at 40 weeks conceptional age, was not found to be strongly predictive of neurodevelopmental deficits at one year.

Somatosensory evoked response abnormalities in high-risk newborns

In a previous study from our laboratory, the prognostic significance of the auditory brainstem evoked response was assessed in high-risk neonates. An abnormal auditory brainstem evoked response predicted neurologic deficits at age 1 year; however, a normal result did not predict a normal outcome. In order to evaluate the prognostic utility of examining other sensory pathways, somatosensory evoked responses were elicited following median nerve stimulation. Testing was performed at 37-44 weeks conceptional age (defined as gestational age plus chronologic age) and at 2 and 6 months conceptional ages. Those patients studied included 34 high-risk neonates and 18 healthy, term infants as controls. Ten of the 34 patients had abnormal somatosensory evoked responses. Abnormalities included increased absolute (N19, P22) and interwave (N13-N19, N19-P22) latencies and flat potentials, alone or in combination. Three children with flat potentials demonstrated a persistence of this abnormality on subsequent examination and they later presented clinically with spastic quadriparesis. Four infants with increased latencies manifested normal responses on subsequent examination. Recently, these 4 patients exhibited tone abnormalities and mild developmental deficits; developmental outcome, however, will be assessed in a blind study at 1 year of age as part of this ongoing prospective study. Preliminary results suggest that somatosensory evoked responses may be valuable as an electrophysiologic predictor of outcome.

Benign occipital epilepsy: a family study

Benign occipital epilepsy is a newly recognized form of partial epilepsy in children. It is characterized by motor seizures preceded in some cases by visual symptoms and a relatively benign course. We present three siblings with this condition and a fourth with the EEG abnormalities. A family study including 25 relatives demonstrated a typical EEG abnormality in 26% of relatives. These EEG changes were more evident in younger members. These findings suggest an autosomal dominant pattern for the EEG abnormalities with age-dependent expression and variable penetrance of the seizure disorder.

Subacute necrotizing encephalomyelopathy (Leigh disease): CT study

Leigh disease, or subacute necrotizing encephalomyelopathy (SNE), is a familial, degenerative disorder characterized by lesions of the gray and white matter in the brain and spinal cord. Low attenuation in the putamina on computed tomography (CT) scans is considered to be characteristic of the disease. The authors used CT to study five patients, in three of whom the disease was confirmed histologically. In one of the patients with documented SNE, there was extensive gray matter lucency with normal basal ganglia. CT scans obtained in a second patient showed diffuse, diseased white matter with focal cortical extension and bilateral caudate involvement. In the other three cases, CT scans revealed the usual changes that occur in the basal ganglia. The appearance of SNE on CT scans thus reflects the variable and widespread distribution of the disease. The absence of radiologically detectable abnormalities in the basal ganglia should not deter one from the diagnosis of Leigh disease given in the appropriate clinical context.

Giant axonal neuropathy: central abnormalities demonstrated by evoked potentials

Previous studies of giant axonal neuropathy have reported clinical and pathological findings that indicate involvement of the central nervous system. We studied 3 boys with giant axonal neuropathy, who were 14 to 16 years of age, using auditory, visual, and somatosensory evoked potentials. Absence of waveforms and prolongation of peak and interwave latencies were found. Abnormalities were noted in all modalities. The auditory brainstem evoked response in particular indicated a significant increase in brainstem conduction time. These studies add clinical neurophysiological confirmation of the central nervous system involvement in this disorder and may also provide a means of quantitative evaluation of its progression.

A distinctive facial appearance in neurofibromatosis von Recklinghausen

Three children with neurofibromatosis from two unrelated families have unusual facial appearance due to telecanthus, antimongoloid slant of the palpebral fissures, broad nose, and tapering chin. The two boys have large hands and feet, and one is very tall. There were some facial and dermatoglyphic similarities to individuals with the Noonan syndrome, but the manifestations in the children reported here are sufficiently different to suggest the presence of a different type of neurocristopathy in these individuals.