Prognostic factors after a first attack of inflammatory CNS demyelination in children

OBJECTIVE

To identify clinical, radiologic, or CSF factors that predict conversion to multiple sclerosis (MS) after a first attack of inflammatory demyelination in children.

METHODS

In this nationwide retrospective multicenter study in the Netherlands, 117 children below age 16 were included. Fifty-four children presented with a monofocal clinically isolated syndrome (CIS) and 63 children with a polyfocal CIS (PCIS).

RESULTS

A second MS-defining attack occurred in 43% of the CIS cases, compared to 21% of the patients with PCIS onset (p < 0.006). Basal ganglia and thalamic lesions and lesions larger than 2 cm on MRI (considered typical of ADEM) were observed during PCIS, irrespective of the presence of encephalopathy. No significant difference in developing MS was found in children with PCIS with or without encephalopathy. Elevated IgG index and presence of oligoclonal CSF bands were more often observed in children who developed MS. Both Barkhof and KIDMUS MRI criteria shared a high specificity and had a high positive predictive value for conversion to MS. In children under the age of 10, the Barkhof criteria had a higher sensitivity than the KIDMUS criteria, but still lower than in older children.

CONCLUSIONS

Barkhof and KIDMUS MRI criteria share a high specificity and positive prognostic value for conversion to multiple sclerosis (MS). Sensitivity of these criteria is poor, especially in children below 10 years of age. Basal ganglia lesions can occur in patients who later develop MS. A substantial number of patients presenting with polyfocal onset and no encephalopathy remained monophasic.

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.

Child psychiatric diagnoses in a population of Dutch schoolchildren aged 6 to 8 years

OBJECTIVE

To determine the prevalence rates of child psychiatric diagnoses in a school-based population of children aged 6 to 8 years in the south of the province of Limburg (The Netherlands).

METHOD

In a two-stage design 1,317 children were screened with the Child Behavior Checklist. From 403 of these children, child psychiatric information was obtained with the Amsterdam Diagnostic Interview for Children and Adolescents (ADIKA, DSM-III-R/IV). Data were generalized to the responder group (n = 1,317) and to the entire cohort (N = 2,290). For the latter procedure, a prediction model was used to generalize ADIKA results to the nonresponders (n = 973).

RESULTS

Estimates of the prevalence of different ADIKA diagnoses in the responder group were quite comparable with those for the entire cohort. Twenty-four percent of the entire cohort met criteria for a single disorder, and 21.0% met criteria for two or more disorders. However, in only 5.7% of the cases parents did report a need for help.

CONCLUSIONS

Where other studies generalize psychiatric diagnoses to the responder group only, this report adds new information by generalizing the prevalence to a school-based cohort of children aged 6 to 8 years. These prevalence estimates are of importance with regard to the demand for care for child psychopathology.

Factors affecting the relation between parental education as well as occupation and problem behaviour in Dutch 5- to 6-year-old children

BACKGROUND

This study investigated whether problem behaviour in 5- to 6-year-old children is related to parental education and occupation. It also analysed the contribution of correlating factors to explain this association.

METHOD

The Child Behaviour Checklist was administered to a large community sample of 1317 children who were in the 1st year of normal primary school in the Netherlands. Outcome measures were total problem score, and externalising and internalising scale scores.

RESULTS

Results of the logistic regression analyses indicated that higher rates of reported behaviour problems were significantly associated with low parental education and occupation. These associations were mediated by low maternal age at delivery and single-parent families. The number of children in a family and physical illness of the parents did not contribute to these associations.

CONCLUSIONS

Parental education and occupation have a large impact on the mental health of young children. Psychosocial and biological factors are possible explanations for this phenomenon.

Neighbourhood level and individual level SES effects on child problem behaviour: a multilevel analysis

OBJECTIVE

This study examined whether neighbourhood level socioeconomic variables have an independent effect on reported child behaviour problems over and above the effect of individual level measures of socioeconomic status.

DESIGN AND SETTING

Multilevel analysis of cross sectional survey data relating individual level child behavioural problems and parental measures of socioeconomic status with neighbourhood level measures of socioeconomic deprivation in the city of Maastricht, the Netherlands.

PARTICIPANTS

Children born in the years 1990-1991 attending the second grade of normal kindergarten schools in the city of Maastricht, the Netherlands. Out of 1417 eligible 5-7 year olds, the parents of 734 children (51.8%) agreed to participate.

MAIN RESULTS

Child behaviour problems were more frequent in families of low parental occupation and education (F=14.51, df 3, 721, p<0.001; F=12.20, df 3, 721, p<0.001, respectively) and in families living in deprived neighbourhoods (F=13.26, df 2, 722, p<0.001). Multilevel random effects regression analysis showed that the effect of neighbourhood level deprivation remained after adjustment for individual level socioeconomic status (B over three levels of deprivation: 1.36; 95%CI=0.28, 2.45).

CONCLUSIONS

Living in a more deprived neighbourhood is associated with higher levels of child problem behaviour, irrespective of individual level socioeconomic status. The additional effect of the neighbourhood may be attributable to contextual variables such as the level of social cohesion among residents.

Electrocortical brain activity, cerebral haemodynamics and oxygenation during progressive hypotension in newborn piglets

OBJECTIVES

To investigate the relationships between systemic and cerebral haemodynamics and oxygenation, and electroencephalogram (EEG) amplitude and frequency analysis studied by the cerebral function analyzing monitor (CFAM) during progressive hypovolemic hypotension.

METHODS

Six piglets of 1 week of age, weighing 1.9-3.4 kg were mechanically ventilated under 1-1.5% halothane anaesthesia. After 1 h stabilization, blood was withdrawn in aliquots of 10 ml/kg over 15 min up to a total of 40-60 ml/kg. Arterial oxygenation was maintained at normal levels. Thereafter, the total blood volume previously withdrawn, was reinfused. Changes in near infrared spectroscopy (NIRS) parameters [cerebral oxidized cytochrome aa3 (Cytaa3), cerebral blood volume (CBV) or total haemoglobin (tHb: oxy- + deoxyhaemoglobin)], carotid blood flow (Q(car)), maximal EEG amplitude and EEG frequency percentages were analyzed continuously.

RESULTS

The EEG amplitude remained stable until the mean arterial blood pressure (MAP), Q(car) and tHb dropped below 30 mmHg (41% of baseline), 20 ml/min (33% of baseline) and 82% of baseline, respectively. Delta (delta) wave frequency percentage of the CFAM increased significantly at MAP below 30 mm Hg. EEG amplitude remained depressed after blood reinfusion and haemodynamic recovery. Cytaa3 changes were not statistically significant, reflecting sufficient neuronal oxygenation.

CONCLUSION

Our results show that electrocortical function is affected only by profound systemic hypotension. This occurred at a higher level of cerebral oxygen delivery than the level associated with neuronal hypoxia and secondary cell damage.

Helmet versus nonhelmet treatment in nonsynostotic positional posterior plagiocephaly

A total of 105 infants with nonsynostotic posterior plagiocephaly were treated using a helmet or by head positioning. Effect of treatment was scored using a cosmetic outcome score (0-10 points) assigned by the parents. The onset of the observed skull deformity correction was not different for the helmet vs. nonhelmet treatment. Improvement was significantly better and faster in the helmet group compared with nonhelmet treatment (p < 0.01 and p < 0.001, respectively).

Listing's law in strabismus and amblyopia: a preliminary report

We investigated whether Listing's law applies in patients with diminished or no stereopsis due to strabismus or amblyopia. Eye movements of normal subjects and patients with strabismus and/or amblyopia were recorded during monocular and binocular fixation; from these data the shape and relative orientation of displacement planes were calculated. In normal subjects, monocular or binocular fixation did not influence the thickness and relative orientation of displacement planes. No differences were found between normals and the patient with amblyopia due to anisometropia. In one patient with strabismus but without amblyopia, the orientation of displacement planes depended on the fixation conditions; a coupling between horizontal vergence effort and plane orientation was observed. Patients with amblyopia and strabismus showed abnormally shaped and/or abnormally orientated displacement planes, which depended on the fixation conditions. Differences between both eyes in the shape of the planes were also observed. These results show that normal Listing behavior can be present in subjects with diminished stereopsis. They also show that normal stereopsis does not necessarily mean normal Listing behavior, suggesting that Listing's law is mainly a result of motor strategy.

Effect of repetitive umbilical cord occlusions on neuronal brain activity measured by the cerebral function analyzing monitor and histologic outcome in immature fetal sheep

OBJECTIVE

To examine the effect of repetitive total umbilical cord occlusions on electrocortical brain activity as measured by cerebral function analyzing monitoring (CAFM) and the histologic outcome in immature sheep fetuses.

STUDY DESIGN

We performed brief repeated total umbilical cord occlusions, two every 5 minutes, in 12 immature sheep fetuses (at 90 days of gestation, term 147 days) until fetal mean arterial pressure dropped below 50% of baseline value during two successive occlusions. A pair of electrodes was inserted on the parietal dura for recording of electrocortical brain activity (ECoG). Off-line ECoG signal processing consisted of amplitude integrated analysis (CFAM) and spectral analysis. Fetal blood gas analyses were performed at regular intervals just before subsequent umbilical cord occlusions. Three days after the occlusion neuronal damage was evaluated histologically in three regions of the fetal brain.

RESULTS

CFAM amplitide parameters decreased significantly during the first occlusion and remained so during the entire repetitive occlusion period (analysis of variance [ANOVA]; P <.05). Spectral analysis of the ECoG signal demonstrated no changes in the distribution of frequency bands. Progressive acidemia and hypotension developed with ongoing occlusions. Five fetuses died at the end or shortly after the entire repetitive occlusion period. No neuronal damage or macroscopic intraventricular and/or germinal matrix hemorrhage was observed in the surviving fetuses.

CONCLUSION

Repetitive umbilical cord occlusions in immature sheep fetuses resulted in functional, not structural changes of the fetal brain in surviving fetuses. At this gestational age, amplitude analysis is more sensitive than spectral analysis of the ECoG signal to functional changes of the compromised fetal brain.

Paroxysmal non-epileptic events in children: a retrospective study over a period of 10 years

OBJECTIVE

To determine the frequency, nature and clinical characteristics of paroxysmal non-epileptic events in children diagnosed by video electroencephalogram (EEG) monitoring at a tertiary referral centre.

METHODOLOGY

A retrospective study of children with paroxysmal non-epileptic events, aged 2 weeks to 17 years inclusive was undertaken. The study group consisted of children who had video EEG monitoring during a 10-year period (1988-99). Telemetry files, medical charts, events recorded on video and record sheets were reviewed.

RESULTS

A total of 666 children were analysed, 269 had epileptic events recorded, 285 had non-epileptic events and 112 had no events recorded. In children with non-epileptic events, 43% were developmentally delayed, 25% had an abnormal neurological examination and 40% had epilepsy. In the study sample an epileptiform interictal EEG was common (24%). The major subgroups of non-epileptic events were: staring (34%), sleep phenomena - benign sleep myoclonus (15%), arousals (13%), motor tics (11%) and shuddering (7%). Developmental delay (57%) was common in children who presented with staring spells. A diagnosis of a specific non-epileptic event was reached in 96% of cases.

CONCLUSION

Paroxysmal non-epileptic events can cause diagnostic confusion, particularly in children with developmental delay, epilepsy or an epileptiform EEG. Accurate diagnosis can be reached in the majority of cases using video EEG monitoring.

Subcutaneous ventricular catheter reservoir and ventriculoperitoneal drain-related infections in preterm infants and young children

OBJECTIVE

In the period January 1990 to September 1997, 70 patients, aged under 6 years were treated for hydrocephalus with a subcutaneous ventricular catheter reservoir and/or a ventriculoperitoneal drain at the University Hospital of Maastricht.

METHODS

By means of a retrospective chart analysis, the number of shunt infections and related risk factors were analyzed.

RESULTS

Twenty-one patients (30%) developed one or more infections, with an infection rate of 15.2% per surgical event. For an implanted reservoir or drain, the infection rates were 15.9 and 16.4%, respectively. The study group consisted of 39 (55.7%) preterm infants (< 37 weeks) and 31 (44.3%) full-term infants (> or = 37 weeks), with infection rates of 33.3 and 25.8%, respectively. At the first surgical intervention 28 patients (40%) had a postmenstrual age less than 37 weeks, with an infection rate of 46.4%. At the time of surgery, 69.7% of the patients were aged less than 6 months, with an infection rate of 19.6%. The most frequent causative microorganism of the shunt infections was Staphylococcus epidermidis (42.1%).

CONCLUSIONS

Prematurity is an important risk factor for ventricular catheter reservoir and ventriculoperitoneal drain-related infections, especially for patients with a postmenstrual age of less than 37 weeks at their initial shunt placement and extreme low birth weight infants have a high risk for infection. In our opinion the use of adequate antibiotic prophylaxis and optimal infection control measures are necessary to keep the rate of infection as low as possible.

Localization and age-related changes of nitric oxide- and ANP-mediated cyclic-GMP synthesis in rat cervical spinal cord: an immunocytochemical study

An immunocytochemical technique was used to study the localization and developmental aspects of cyclic GMP (cGMP)-synthesizing structures in the cervical spinal cord of 2-week and 3-month-old Lewis rats in response to the nitric oxide (NO) donor sodium nitroprusside (SNP) and/or atrial natriuretic peptide (ANP). By using cell-specific markers, the cell structures involved were investigated. To visualize cGMP, a combined technique of low- and high-power magnification, using a confocal laser scanning microscope was used. NOS-mediated cGMP synthesis was observed in the cervical spinal cord in laminae I, II and III in 14-day-old rats, which activity was mainly absent at the age of 3 months. The involvement of NO in the NMDA-mediated increase in cGMP immunostaining (cGMP-IS) was demonstrated by the absence of cGMP-IS in slices incubated in the presence of NMDA together with the NOS inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME). This NO-mediated effect of NMDA on cGMP-IS was completely absent in the 3-month-old rats. ANP-mediated cGMP synthesis resulted in an increase in cGMP in laminae I and II, which was generally similar at both ages. Astrocytes in both white and gray matter were found to be cGMP-IS in the basal, NO- and ANP-stimulated conditions. Using confocal laser microscopy, NO-mediated cGMP synthesis was observed in large cholinergic terminals nearby motor neurons in the ventral horn. An extensive colocalization between NO-stimulated cGMP synthesis and parvalbumin-positive (GABAergic) neurons and fibers was observed in all laminae. In the ANP-stimulated condition, a colocalization with parvalbumin structures was found in laminae II and III. No NO- or ANP-mediated cGMP synthesis was found in fibers immunopositive for the presynaptic glutamate transporter, serotonin, or tyrosine hydroxylase.

Effects of hypothermia and gender on survival and behavior after perinatal asphyxia in rats

Previous studies in rats have demonstrated that perinatal asphyxia (PA) produces long-term morphological alterations, particularly affecting hippocampus. neostriatum, and cerebral cortex. These changes were prevented by applying hypothermia during the asphyctic insult. Because these cerebral areas are involved in cognitive and motor functions, the aim of the present study was to determine whether periods of PA during normothermia or hypothermia produces long-term behavioral impairments in rats of both sexes. The cognitive and motor functions were studied using the spatial Morris water maze (MWM) task at 1.5 months, and the open field at 5 months, respectively. The present study revealed that female rats had a higher survival rate than males after PA in normothermic conditions (p < 0.014). and that hypothermia drastically prolonged the time of survival in both sexes (p < 0.001). There were no differences in learning and memory functions between groups or male and female rats when tested with MWM. Rats subjected to hypothermia treatment did not show differences in the MWM compared to controls. A lower locomotor activity in the open field test was only observed in male rats that suffered 15 and 20 min of PA in normothermia (p < 0.05). Hypothermia treatment prevented this hypoactivity. PA in females, even if severe, did not affect the motor activity. The data of both behavioral tests showed differences between sexes, i.e., the female rats learned the MWM task slower, and were more active in the open field. This work lends further support for the hypothesis that hypothermia can prevent mortality as well as long-term sequelae induced by PA.

The Maastricht Cerebral Monitor (MCM) for the neonatal intensive care unit

Although long-term monitoring of cerebral activity can be important in neonatal intensive care, the complexity of multi-channel EEG makes it less suitable for this purpose. In the past, a cerebral function monitor (CFM) was developed that analyses EEG. The output parameter of the CFM is a semi-logarithmic amplitude distribution resulting from the amplification, bandpass filtering, compression, rectification and smoothing of the single-channel EEG. Drawbacks of the CFM include its inflexibility and limited single-channel processing capacity and its lack of functionality for data storage, review or re-analysis. Modern computers are powerful enough that a system can be built which does not have these drawbacks. We have developed such a system: the Maastricht Cerebral Monitor (MCM). The MCM is a flexible system that not only overcomes the CFM drawbacks but also provides advanced signal analysis. It was developed with a software system (Poly) for acquisition, high quality real-time display, on-line analysis and storage of physiological signals. The MCM processes three EEG signals in the amplitude and frequency domains. Other parameters provided by the MCM are asymmetry of absolute frequency powers, percentage suppression, mean and 90% spectral edge frequency. Electrode impedance is recorded as a measure of quality of the recording.

Sibs with Axenfeld-Rieger anomaly, hydrocephalus, and leptomeningeal calcifications: a new autosomal recessive syndrome?

The Axenfeld-Rieger anomaly is a defect of the anterior chamber of the eye affecting the angle structures. If accompanied by hypodontia, midface hypoplasia, and umbilical anomalies, the designation "Rieger syndrome" is appropriate. Both conditions are autosomal dominant traits. The Axenfeld-Rieger anomaly is also known to occur in a variety of other syndromes. We report on two sisters, born to consanguineous parents, who presented with Axenfeld-Rieger anomaly, hydrocephalus, leptomeningeal calcifications, and mild mental retardation. Their height was on and just below the 3rd centile, respectively. One of them suffered from epilepsy and the other from sensorineural hearing loss. Two of their brothers died at young ages of hydrocephalus and possibly had intracranial calcifications as well. The differential diagnosis is discussed. Of the known syndromes associated with Axenfeld-Rieger anomaly, none could be convincingly applied to the propositae. Possibly, they represent a previously unreported autosomal recessive syndrome.

Hypothermia during or after severe perinatal asphyxia prevents increase in cyclic GMP-related nitric oxide levels in the newborn rat striatum

The striatum is rich in nitric oxide synthase (NOS). It is present in a dense fiber network and in a few medium-sized non-spiny interneurons. Previous work showed chronic overexpression of NOS in the rat striatum after a severe perinatal asphyctic (SPA) insult. This was prevented by hypothermia. We investigated whether the overexpression of NOS was accompanied by increased NOS activity. As nitric oxide (NO) is a potent activator of the soluble isoform of guanylyl cyclase, we measured striatal 3',5'-cyclic monophosphate (cyclic GMP) synthesis in 10-day-old (P10) rat pups that were subjected to SPA during normothermia or hypothermia during or after the insult. Cyclic GMP levels in striatal tissue from control pups were approximately 25.8 pmol/mg protein and in the SPA group approximately 38.1 pmol/mg protein (p<0.01). Hypothermia, during as well as after insult, prevented this increase of cyclic GMP. Nomega-nitro-L-arginine (L-NAME) (0.1 mM) decreased cyclic GMP levels in control, SPA and hypothermia treated pups to similar low levels (approximately 8% of level without L-NAME). Sodium nitroprusside (SNP) stimulated cyclic GMP showed no differences between the four groups. This indicates that high cyclic GMP levels in the striatum of rats subjected to SPA are caused by increased NOS activity. Hypothermia after an asphyctic insult could be a promising treatment.

Characterization of a de novo unbalanced translocation t(14q18q) using microdissection and fluorescence in situ hybridization

We report on a patient with a de novo translocation between the long arms of chromosomes 14 and 18. The translocation was studied using microdissection in combination with fluorescence in situ hybridization (micro-FISH). Five copies of the chromosomes involved in the translocation were isolated by microdissection and amplified by means of degenerate oligonucleotide primed-polymerase chain reaction (DOP-PCR). Reverse chromosome painting with the biotin-labeled PCR product showed that part of the q-arm of chromosome 18 had no signal. The deletion was characterized further by FISH with band-specific probes and it was concluded that the rearrangement was unbalanced: 46,XY,t(14;18)(14pter-->14q22::18q21.1-->18qter) (18pter-->18q12.2::14q22-->14qter). The patient, who presented with psychomotor retardation, mild obesity, pes equinovarus, strabismus, and facial anomalies, is compared with previously reported patients with an interstitial deletion of band 18q12.

The influence of head position and head position change on spontaneous body posture and motility in full-term AGA and SGA newborn infants

No consensus exists concerning the influence of head position and head position change on body posture and motility. Especially the existence of an asymmetric tonic neck reflex (ATNR) in full-term newborns is an issue of discussion. Three-hour video recordings were made of 15 full-term appropriate for gestational age (AGA) and 15 full-term small for gestational age (SGA) infants between the third and eight postnatal day. During a playback of the video recording head position, head position change and several movement patterns of the four limbs were fed into a computer using an event-detecting program. Furthermore, spontaneous head turnings were selected and body posture just before, immediately at and 1 min after the head turning were sketched. The data were analyzed concerning: (1) influence of head position on symmetry of movement of the four limbs; (2) the existence of an ATNR and ATNR-related patterns. In both AGA and SGA infants all movement patterns except hand-face and hand-mouth contact showed a symmetrical distribution, independent of head position. Furthermore, the occurrence of an ATNR following a spontaneous head turning in both AGA and SGA infants was rare. From our results it may be concluded that the ATNR is rare in full-term AGA and SGA newborns. Furthermore, this study demonstrates that head position is not a major factor influencing quantitative aspects of spontaneous motor behaviour. The results are of clinical importance as they imply that in the examination of the neurological condition of the full-term newborn infant by means of observation of spontaneous posture and motility, head position is not of major importance.

Doppler ultrasonography in suspected intrauterine growth retardation: a randomized clinical trial

A randomized clinical trial was performed to test the hypothesis that if suspected intrauterine growth retardation (IUGR) is associated with normal umbilical artery Doppler ultrasound findings, hospitalization can safely be avoided. One hundred and fifty women with singleton pregnancies and suspected IUGR were randomized between an intervention (n = 74) and a control group (n = 76). In the intervention group, clinicians were strongly requested not to hospitalize for suspected IUGR if the Doppler findings were normal. In the control group, the Doppler results were not revealed and the participants received the standard management for suspected IUGR. Endpoints of the trial were: costs in terms of hospitalization, perinatal outcome, neurological development, and postnatal growth. Duration of hospitalization was significantly shorter in the intervention group than in the control group. Contrary to expectations, the hospitalization rate during pregnancy in the intervention group was not below that of the control group. This negative finding was partly due to the admission of patients in the intervention group despite their normal Doppler results. Moreover, the trial might have induced a more critical attitude towards hospitalization in suspected IUGR, decreasing admission in the control group. No clear differences were found in perinatal outcome, neurological development, or postnatal growth. The results suggest that normal umbilical artery Doppler findings in suspected cases of IUGR justify outpatient management.

The influence of acute hypoxemia and hypovolemic hypotension of neuronal brain activity measured by the cerebral function monitor in newborn piglets

Little is known about the cerebral electrical response to short periods of hypoxemia, hypotension and their combination. These conditions occur frequently in critically ill newborn infants; their cerebral electrical activity can be registrated easily with the Cerebral Function Monitor (CFM). Therefore we recorded on-line cortical electrical activity during hypoxemia and hypotension in 11 newborn piglets aged 13-18 days. Hypoxemia was induced by reducing inspired oxygen fraction. Hypotension was induced by withdrawal of blood. The experimental groups were: Group I: arterial oxygen saturation (SaO2) 45-85%, group II: SaO2 < 45%, group III: mean arterial pressure (MAP) 50-75 mmHg, group IV: MAP < 50 mmHG, group V: SAO2 < 85% and MAP 50-75 mmHg and group VI: SaO2 < 85% and MAP < 50 mmHg. CFM registrated normal cortical electrical activity during periods of moderate or severe hypoxemia (group I and II) and during isolated moderate hypotension (group III). The cortical activity decreased significantly due to severe hypotension alone (group IV) and combined hypotension and hypoxemia (group V and VI). Hypotension has a more potent effect on cortical electrical activity than hypoxemia in the newborn piglet. Cerebral electrical activity does not change during severe hypoxemia and moderate hypotension possibly due to cerebral flow regulation. CFM recorded decreased cerebral electrical activity during severe hypotension and hypotension with hypoxemia. CFM could provide invaluable data in severely ill newborns.

Inversion duplication of the short arm of chromosome 8: clinical data on seven patients and review of the literature

We report on clinical and cytogenetic data on 5 children and 2 adults with a de novo inverted duplication of the short arm of chromosome 8, and we give a review of 26 patients from the literature. The clinical picture in young children is characterized by minor facial anomalies, hypotonia, and severe developmental delay. In older patients the facial traits are less characteristic, spastic paraplegia develops, and severe orthopedic problems are frequent. Psychomotor retardation is always severe-to-profound. Duplication of 8p21-p22 results in a clinically recognizable multiple congenital anomalies/mental retardation (MCA/MR) syndrome. It is shown that in all patients examined, the duplication was accompanied by a deletion of the most terminal part of 8p.

Posture in low-risk pre-term infants of 30 weeks postmenstrual age

In this study we analysed the spontaneous postural behaviour of seven pre-term infants of 30 weeks postmenstrual age (PMA). Each infant was observed for a 3-h observation period and each minute a sketch of the resting-posture was made. Analysis of the postures included the complete observed posture, the distribution of adduction and abduction of the hips and shoulders and the distribution of extension and flexion of the elbows and knees. Although each infant showed a preference posture, no preference posture for the total group could be determined. A separate analysis of the positions of the limbs showed a preference for fully flexed arms and partly extended legs. Because no group preference posture at 30 weeks PMA (nor at other PMA in different studies) could be determined, it is suggested that the use of posture as a characteristic of PMA is no longer warranted.

Quality of spontaneous general movements in full-term small for gestational age and appropriate for gestational age newborn infants

Quality of spontaneous movements was studied in 15 healthy full-term appropriate for gestational age (AGA) and in 15 full-term small-for gestational age (SGA) newborn infants. All general movements with a minimal duration of 20 seconds were judged on different aspects of movement quality. From the general movements in each group (AGA: n = 106; SGA: n = 187), dominant patterns were isolated. In the AGA Group 3 dominant patterns of general movements were present. In the SGA Group 5 dominant patterns of general movements were found. Three of those were identical to the movement patterns in the AGA group, the remaining two patterns were unique for the SGA infants. Our results indicate that the three different types of general movements which constitute the major part of the normal repertoire of healthy full-term infants can be used as a reference for normal spontaneous motor behaviour. The two different types of general movements in the SGA infants might be used to discriminate between healthy and neurologically suspect newborn infants. The difference in movement pattern between AGA and SGA infants might be explained by the effect of intrauterine malnutrition on CNS development.

Lumbosacral plexopathy in the third trimester of pregnancy: a report of three cases

Lumbosacral plexopathy was diagnosed in three patients in the third part of pregnancy. Symptoms started with acute pain in the groin and/or the lower part of the back around 33 weeks amenorrhoea. Neurological symptoms were absent before pregnancy. Denervation activity occurred in the muscles innervated by the upper part of the lumbosacral plexus. The exact etiology is not known although pressure on the plexus by fetal parts may be involved. Recovery may require months but the injury is self-limiting and the prognosis is favourable.

Effects of asphyxia on the fetal lamb brain

OBJECTIVE

Our purpose was to study the effect of fetal asphyxia on the release of hypoxanthine and xanthine in cerebrospinal fluid and on brain histologic characteristics.

STUDY DESIGN

In seven fetal lambs (3 to 5 days after surgery, gestational age 124.3 +/- 2.6 days) asphyxia was induced by restriction of uterine blood flow.

RESULTS

Fetal pH and base excess were reduced to 6.99 +/- 0.02 and -17.6 +/- 0.9 mmol/L, respectively. Cerebral blood flow increased during asphyxia and returned to normal in the recovery phase. Maximum concentrations of cerebrospinal fluid hypoxanthine and xanthine were reached in the normoxemic recovery phase. This high level of substrates during normoxemia facilitates oxygen free radical formation and may thus aggravate postasphyctic brain damage. Histologic evaluation of the brain 3 days after the insult showed a variable degree of edema. Coagulative neuronal changes, characteristic of irreversible cell death, were only occasionally detected. These changes were most obvious in the Purkinje cells of the cerebellum.

CONCLUSIONS

Fetal asphyxia induced by uterine blood flow restriction is associated with high levels of cerebrospinal fluid hypoxanthine and xanthine in the recovery phase. Microscopically detectable brain damage, although not extensive, is mainly located in the cerebellum.

Possible neuroprotective properties of flunarizine infused after asphyxia in fetal lambs are not explained by effects on cerebral blood flow or systemic blood pressure

Neuroprotective properties of the calcium channel blocker flunarizine have been reported after hypoxic-ischemic insults in immature, infant, and adult rats. However, its effect on fetal regional cerebral blood flow (rCBF) and systemic blood pressure after severe asphyxia is not known. In 15 fetal lambs (3 to 5 d after surgery; gestational age at the experiment, 123.2 +/- 2.5 d), arterial oxygen content was progressively reduced to 30% by restriction of uterine blood flow with an inflatable balloon occluder around the maternal common internal iliac artery. The rCBF was measured with radioactive microspheres at baseline condition, after 1 h of severe asphyxia, and at 30 and 120 min in the recovery phase. Immediately after the end of the occlusion period, fetuses randomly received either flunarizine or its solvent (0.5 mg/kg estimated fetal weight). No differences in rCBF changes between groups were observed during and after asphyxia. Changes in arterial blood pressure or fetal heart rate due to flunarizine could not be demonstrated either. Only five fetuses (33%) survived this degree of asphyxia longer than 24 h: four of the flunarizine-treated group and one of the control group. It is unlikely that this possible protective property of the drug is caused by its influence on rCBF, arterial blood pressure, or fetal heart rate in the phase immediately after asphyxia.

Vigabatrin in the treatment of infantile spasms

The anti-epileptic effect of vigabatrin as a first choice therapy was investigated in 6 children suffering from infantile spasms (IS). All 6 children showed a reduction in seizure frequency. Three children became seizure-free within a period of 2 weeks. Because our results suggest "an all or nothing phenomenon", a period of 2 weeks may be sufficient to evaluate the efficacy of vigabatrin in untreated infants suffering from IS. We suggest to use vigabatrin as a first choice anti-epileptic drug in infants with IS.

Postural behaviour of term SGA and AGA newborn infants

The authors studied the body posture at rest of 15 healthy term infants with birthweights appropriate for gestational age (AGA) and 15 infants who were small for gestational age (SGA). In both groups, there was wide inter-individual variability in postural behaviour. Apart from a preference for a position with all limbs in abduction between 1 and 90 degrees, independent of the degree of flexion or extension and internal/external rotation, no dominant preference posture could be seen for either group. The SGA infants showed a more flexed position of the arms, compared with the AGA group. One of the factors contributing to this difference might be the influence of intra-uterine malnutrition on the development of the central nervous system.

Magnetic resonance imaging of progressive hydrosyringomyelia in two patients with meningomyelocele

Two patients who postoperatively developed extensive multiseptated hydrosyringomyelia following surgical repair of a lumbal meningomyelocele are reported. Since MRI has been available, an increasing number of reports showed that MRI is useful in the diagnosis of hydrosyringomyelia. Hydrosyringomyelia can be considered as a dysraphic lesion. Etiology and pathogenesis of hydrosyringomyelia are still not fully understood. Probably arachnoidal adhesions and cord tethering in both patients may be potential factors in producing cystic degeneration of the underlying structure secondary to ischemia.

Computed cranial tomography, magnetic resonance imaging and single photon emission computed tomography in hemorrhagic shock and encephalopathy syndrome: a report of three cases

Three different neuro-imaging studies were performed in 3 infants with hemorrhagic shock and encephalopathy syndrome (HSE). Areas of cerebral infarction were noted on CT. Single photon emission computed tomography (SPECT) showed decreased perfusion in these areas in one infant. Magnetic resonance imaging (MRI) also identified the areas of infarction, noted on CT, but provided additional information showing non-haem iron deposition in the thalami and basal ganglia.

State profile in low-risk pre-term infants: a longitudinal study of 7 infants from 32-36 weeks of postmenstrual age

Spontaneous motor behaviour was longitudinally studied in 7 low-risk preterm infants. The object of this study was to determine whether or not certain recognizable behavioural states exist between 32 and 36 weeks postmenstrual age (PMA), in order to have a well defined recognizable pattern of behaviour during which the preterm infant can be clinically examined. The criteria used to define a behavioural state were: eyes open/closed; crying present/absent; gross body movements present/absent; and respiration regular/irregular. A total of 35 videotapes were made (total time, 99 hours and 25 minutes). For analyzing the data, one second and three-minute windows were used. Our data provide convincing evidence that spontaneous behaviour of preterm infants of 32-36 weeks of PMA can be classified into behavioural states. The variables gross body movements and respiration, are not independent ones. The observed states can be used as a defined clinical condition during which the preterm infants can be clinically examined.

A new device to measure short-term growth of head circumference in newborn infants

We have developed and tested a new instrument to measure the occipitofrontal head circumference of newborn infants more accurately. The intra- and interobserver variability was determined. The results indicate that the head circumference of newborn infants can be measured with an accuracy of 1 mm.

Multiple vertebro-basilar infarctions from fibromuscular dysplasia related dissecting aneurysm of the vertebral artery in a child

A 9-year-old boy with paroxysmal headache suffered persistent, focal neurologic deficit in the vertebral-basilar artery territory. Angiography showed dissecting aneurysm and "a string of beads" lesion in the third segment of the left vertebral artery compatible with fibromuscular dysplasia.

Holocord astrocytomas in childhood

In this case report, we present a patient with a low-grade holocord astrocytoma. Therapy and its consequences are discussed.

Single photon emission computed tomography (SPECT) in seizure disorders in childhood

In 38 children with partial seizures, the EEG, CT and NMR findings were compared to the results obtained with Tc99m HMPAO single photon emission computed tomography (SPECT) in order to determine whether SPECT is a useful adjunct to EEG, CT and NMR in this age group. In 3 out of 7 patients with a normal EEG, SPECT showed focal abnormalities. Nine patients whose EEGs did not show adequate lateralization had an abnormal SPECT which revealed a focus. In 14 out of 21 patients with a normal CT, SPECT showed focal changes in 13 patients and diffuse changes in the other one. In 7 out of 12 patients with a normal NMR, SPECT showed focal abnormalities. Although clinical history and a careful description of the seizures are the most valuable information in partial seizure disorders, SPECT imagining gives valuable additional information, which might target treatment. SPECT was superior to CT and NMR with respect to the depiction of some kind of abnormality.

Spondylocostal dysostosis: an example of autosomal dominant transmission in a large family

This report gives a description of a three-generation family in which spondylocostal dysostosis associated with previously unreported neurological complaints occurred in five family members, suggesting autosomal dominant inheritance. A review of the literature is presented and previously unreported neurological complaints, e.g. neurogenic claudicatio, are emphasized.

Posture of low-risk preterm infants between 32 and 36 weeks postmenstrual age

The supine posture of 15 low-risk preterm infants was studied to establish whether they have a preferred posture and, if so, whether it changes with age. No over-all preferred posture was found. Almost always one posture was adopted most frequently, but often a great variety of other postures were adopted almost as frequently. There was no correlation between postmenstrual age and preferred posture, the number of different postures, or the duration of longest uninterrupted posture.

Posture during head turning in pre-term infants: a longitudinal study of 15 low-risk infants of 32-36 weeks of conceptional age

As part of a longitudinal study of spontaneous behaviour from 32-36 weeks of conceptional age, body posture was studied during spontaneous head movements in 15 low-risk pre-term infants. At the moment of an active head position in the midline, the most frequently observed posture was a symmetrical one in which the arms were fully flexed and the legs partly extended. With regard to the arm position no clearly developmental trend was noted. With regard to the leg position an increase of the partly flexed position of the limbs related to conceptional age was found. The observed postures during activity in our study showed a cephalocaudal acquisition of flexor tone. A symmetrical posture, when the head is in the midline, may be a sign of normality in pre-term infants.

Influence of head position and head position-change on body posture in pre-term infants (A.T.N.R.)

Although body posture in pre-term infants is generally studied to describe developmental aspects, no consensus exists in literature about the influence of head position and head position change upon body posture in pre-term infants. In a weekly assessed longitudinal study of 15 healthy pre-term infants we extensively observed and analysed the flexion and extension patterns of the limbs in relation to a "spontaneous" head position turning from 32 to 36 weeks of conceptional age. A significant flexion/extension pattern was only observed with respect to the leg: turning of the head induced extension of the chin leg and flexion of the other leg. This pattern persisted during the total 3 hours observation sessions, occurred at every age and in all states, but rapidly disappeared within maximal 20 seconds after the head-turning. No consequent significant pattern was observed with respect to the other limbs or the various other combinations of limb posture changes analysed. An Asymmetric Tonic Neck Reflex was seen after only 3 percent of the head position changes.

Head position in low-risk premature infants. Impact of nursing routines

Head position preference in 15 low-risk pre-term infants studied in relation to conceptional age and nursing routines. A head position preference to the right is evident with respect to the head position imposed by the nurse. The observed spontaneous head position preference might be ascribed to the influence of the foregoing imposed head position, the influence of which diminishes with increasing observation time. After several spontaneous head turnings the low-risk pre-term infants show no head position preference anymore.

A longitudinal study of brainstem auditory evoked potentials of preterm infants

Brainstem auditory evoked potentials (BAEPs) of nine 'healthy' preterm infants were recorded at weekly intervals between 32 and 36 weeks conceptional age to study the relationship between stimulus intensity and central transmission time through the subcortical auditory pathway (i.e. the interval latency between peak I and peak V) as a function of conceptional age. Stimulus intensities of 70, 80 and 90 dB nHTL were used. Changes in click intensity produced changes in the absolute latency of all BAEP peaks, but the interval latency I to V remained constant. The absolute latencies and interval latencies reflected maturity, but varied widely between these preterm infants. The peak V latency and the I to V interval latency decreased with increasing conceptional age. Exponential regression analysis suggested that, above 70 dB nHTL, the time-constant of the calculated exponential function most likely represents maturation and function of the central subcortical pathway, and may give an indication of the infants' development.

The value of immediate post-operative routine CT related to uncomplicated ventricle drainage in childhood hydrocephalus

Retrospectively we assessed the value of routine postoperative CT scans in 113 children shunted for hydrocephalus. Of the 165 routine CT scans 13 showed fortuitous findings (= 8%) with a change in treatment accompanied by questionable benefits in only 2 (= 1.3%). Therefore we suggest that post-operative CT should not be performed as a routine examination but only on clinical grounds.

A boy with acromesomelic dysplasia. Growth course and growth hormone release

A 2 6/12-year-old boy is reported with the typical clinical and radiological features of acromesomelic dysplasia. This rare skeletal dysplasia is inherited as an autosomal recessive trait, and differential diagnosis is to be made with pseudoachondroplasia and acrodysostosis. Endocrine investigations were performed, and their results are found to be normal. Longitudinal growth reveals a very early slowing down of growth velocity.

Neuroradiological findings in Jadassohn nevus phakomatosis: a report of four cases

Four patients with Jadassohn nevus phakomatosis (linear nevus sebaceus syndrome, Schimmelpenning-Feuerstein syndrome) are described. Neuroradiological findings consisted of skull asymmetry shown by X-rays and hemimegalencephaly with ventricular system asymmetry on CT. Three of the patients showed, in addition, a widened insula. In two patients areas of increased density suggesting calcium deposits were seen. Skull asymmetry was progressive during infancy in two of the patients. It is presumed that these findings are secondary to the progression of the underlying central nervous system disorder.

Variability of outcome in Joubert syndrome

Two children with Joubert syndrome are reported. Patient one is the first case with Joubert syndrome where CT-findings are confirmed by autopsy. Until now only three cases with necropsy findings were reported. Patient two shows a remarkable clinical outcome not previously mentioned.

Intraparenchymal meningioma in a 14-month-old infant: case report

The authors report a 14-month-old infant with an intraparenchymal meningioma. At this age, intracranial tumor is an unusual cause of hemiconvulsions, and an intraparenchymal tumor localisation is even more unusual.

Enlarged persistent anterior fontanel following head injury. A case report

A 2-year-old child is reported with an unusual large anterior fontanel. The boy sustained a head injury at the age of 10 months. Post traumatic skull X-rays showed a parietal bone fracture. At the age of 2 years a leptomeningeal cyst underlying the anterior fontanel was found on CT. A causal relation between the persistent anterior fontanel and the roentgenographic findings is discussed.