Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea

OBJECTIVE

To determine the utility of pulse oximetry for diagnosis of obstructive sleep apnea (OSA) in children.

METHODS

We performed a cross-sectional study of 349 patients referred to a pediatric sleep laboratory for possible OSA. A mixed/obstructive apnea/hypopnea index (MOAHI) greater than or equal to 1 on nocturnal polysomnography (PSG) defined OSA. A sleep laboratory physician read nocturnal oximetry trend and event graphs, blinded to clinical and polysomnographic results. Likelihood ratios were used to determine the change in probability of having OSA before and after oximetry results were known.

RESULTS

Of 349 patients, 210 (60%) had OSA as defined polysomnographically. Oximetry trend graphs were classified as positive for OSA in 93 and negative or inconclusive in 256 patients. Of the 93 oximetry results read as positive, PSG confirmed OSA in 90 patients. A positive oximetry trend graph had a likelihood ratio of 19.4, increasing the probability of having OSA from 60% to 97%. The median MOAHI of children with a positive oximetry result was 16.4 (7.5, 30.2). The 3 false-positive oximetry results were all in the subgroup of 92 children who had diagnoses other than adenotonsillar hypertrophy that might have affected breathing during sleep. A negative or inconclusive oximetry result had a likelihood ratio of.58, decreasing the probability of having OSA from 60% to 47%. Interobserver reliability for oximetry readings was very good to excellent (kappa =.80).

CONCLUSIONS

In the setting of a child suspected of having OSA, a positive nocturnal oximetry trend graph has at least a 97% positive predictive value. Oximetry could: 1) be the definitive diagnostic test for straightforward OSA attributable to adenotonsillar hypertrophy in children older than 12 months of age, or 2) quickly and inexpensively identify children with a history suggesting sleep-disordered breathing who would require PSG to elucidate the type and severity. A negative oximetry result cannot be used to rule out OSA.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median), and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median) and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

Perceptual-motor, visual and cognitive ability in very low birthweight preschool children without neonatal ultrasound abnormalities

Thirty-six children born preterm with very low birth weight without neonatal brain disorders and normal cerebral ultrasound findings were examined at pre-school age: visual, perceptual motor, attention, behaviour and cognitive assessments were performed in the study group as well as in a control group of term children matched for age, sex and parental educational and occupational status. The results showed a significant lower scoring in perceptual motor skills in the study group, associated with a defect of accuracy in spatial attention and a higher incidence of stereopsis impairment related with perceptual motor disabilities. Behavioural disorders, in terms of emotional maturation and hyperactivity, were significantly more frequent in the study group. To prevent behavioural and learning problems at school, a complete longitudinal assessment including visual functions and perceptual motor abilities seems mandatory in preterm born children, even in the absence of neonatal brain disorders including abnormal cerebral ultrasound findings.

Effects of prophylactic ibuprofen on cerebral and renal hemodynamics in very preterm neonates

OBJECTIVE

To evaluate the effects on cerebral and renal blood flow velocities of ibuprofen when used as prophylaxis for patent ductus arteriosus in preterm neonates (gestational age <30 weeks).

METHODS

Blood flow velocities in the anterior cerebral artery and the renal artery were measured with Doppler ultrasonography in 17 neonates before, during, and 10, 30, and 60 minutes after administration of 10 mg/kg ibuprofen lysine.

RESULTS

In four (23.6%) neonates without echocardiographic patency of the ductus, no significant modifications in blood flow velocities and Doppler indexes were found either in the anterior cerebral artery or in the renal artery. In 13 (76.4%) neonates, cardiac echocardiographic Doppler showed patency of the ductus and left-to-right shunt. In these neonates diastolic and mean blood velocities rapidly increased both in the anterior cerebral artery and the renal artery (P < .0001). Resistance and pulsatility index decreased during the study period (P < .0001 and P < .001, respectively, in the anterior cerebral artery; P < .0001 in the renal artery).

CONCLUSIONS

Data suggest that ibuprofen does not determine any direct effect on cerebral and renal blood flow velocities; hemodynamic modifications observed in neonates with patency of ductus can be related to closure of the ductus induced by the drug.

A three year follow up of preterm infants after moderately early treatment with dexamethasone

OBJECTIVE

To assess the effect of moderately early postnatal dexamethasone treatment on growth and neurodevelopmental outcome in preterm infants.

METHODS

Thirty preterm infants enrolled in a randomised clinical trial to investigate the effectiveness of moderately early dexamethasone administration in the treatment of chronic lung disease were routinely followed up. Fifteen babies received a total dose of 4.75 mg/kg over 14 days from the 10th day of life, and 15 babies were untreated. Five infants in each group received open label steroids to facilitate extubation later in their clinical course. Growth and neurodevelopmental outcome are reported.

RESULTS

The mean body weight, height, and head circumference as well as the number of babies with anthropometric measurements within normal range were similar in treated and untreated babies. There was no significant difference between treated and control groups with respect to incidence of cerebral palsy, major neurosensory impairment, mean intelligence quotient scores, and behavioural abnormalities.

CONCLUSIONS

Postnatal dexamethasone treatment with the schedule used in this study did not impair growth and neurodevelopmental outcome in preterm infants. Data from larger trials have raised major concern that postnatal steroid treatment may increase neurodevelopmental impairment. The full extent of the risk will only be known when more trials have reported follow up data.

40-Hz steady-state responses in newborns and in children

The authors investigated the 40-Hz steady-state responses (SSR) in 32 full-term newborns and in 10 normal children (5-8 years old), using 500-Hz tone bursts. The 40-Hz SSR threshold is located at about 50 and 30 dB nHL in newborns and older children, respectively. The latencies of both P1 and N1 waves decreased significantly with age, while the amplitudes increased. No significant latency and amplitude intersex differences have been observed. Moreover, with age, the 40-Hz SSR became more stable, their test-retest replicability improved, and P1-N1 wave occurrence increased. The authors finally discuss the possible underlying mechanisms of these findings and conclude that the 40-Hz SSR are difficult to obtain and are scarcely reliable in defining the low-frequency threshold in newborns. The stability and reliability of the responses increase with age, and the electrophysiological and behavioral thresholds to low-frequency stimuli tend to overlap.

Failure of fibrinolytic endoventricular treatment to prevent neonatal post-haemorrhagic hydrocephalus. A case-control trial

Post-haemorrhagic hydrocephalus is assumed to result from obstruction of the cerebrospinal fluid (CSF) pathways by blood clots and subsequent chronic infiltration with collagen. The aim of this work was to evaluate the possibility of preventing permanent shunt dependence by enhancing the endoventricular fibrinolysis by means of an endoventricular streptokinase infusion in babies affected by posthaemorrhagic ventricular dilation. A case-control trial was carried out in 12 neonates affected by intraventricular haemorrhage and subsequent progressive ventriculomegaly. Six of them were treated with 20,000 U/day of streptokinase infused over 96 h through a percutaneous ventricular catheter. Our results show that the percentage of shunted babies was identical in treated and control patients despite the enhancement of endoventricular fibrinolysis obtained in all treated patients. On the basis of our results we do not recommend intraventricular streptokinase infusion for routine use in post-haemorrhagic ventricular dilatation.

Fetal encephalopathy after maternal anaphylaxis. Case report

Fetal hypoxic-ischemic encephalopathy can be diagnosed at birth by means of cerebral ultrasound scanning. The morphological appearance of the lesions depends on the time elapsed between the insult and examination of the brain. We report a case of a neonate affected by multicystic encephalomalacia and corpus callosum atrophy attributable to an episode of maternal anaphylactic shock which occurred at 27 weeks of gestation following intravenous iron injection. The diagnosis was made by means of a cerebral ultrasound scan performed at birth and confirmed by magnetic resonance. This case demonstrates that maternal severe acute hypotension during pregnancy can cause fetal cerebral damage similar to the hypoxicischemic injuries occurring in the perinatal period.

Neurological examination at 6 to 9 months in infants with cystic periventricular leukomalacia

The Hammersmith Infant Neurological Examination was performed in 24 infants with cystic periventricular leukomalacia whose gestational age ranged between 26-38 weeks. The infants were examined between 6 and 9.5 months corrected age. The aim of the study was to establish the different patterns of neurological abnormality as well as the optimality scores that predict the severity of motor sequelae at 2 years. Increased neck and trunk extensor tone, and a posture of flexed arms and extended legs between 6 and 9 months were always associated with the inability to sit unsupported at 2 years, whilst truncal hypotonia and extended arms and legs were associated with unsupported sitting but not walking. Optimality scores between 41 and 60 were generally associated with sitting but not walking at 2 years whilst scores below 40 were always associated with the inability to sit independently at 2 years. All infants who did not develop cerebral palsy at 2 years had scores > 60. Our results suggest that the pattern of findings on neurological examination performed between 6 and 9 months as well as the calculated optimality score helps to predict motor impairment in infants with PVL.

Prenatal cerebral Doppler ultrasonography and neonatal neurologic outcome

The significance of fetal cerebral blood flow analysis in the prediction of neonatal neurologic outcome was investigated on 87 fetuses at risk for chronic hypoxia. Blood flow velocity waveforms were recorded from the fetal internal carotid artery immediately before cesarean section; newborns underwent neurologic follow-up until discharged from the neonatal division. Neonatal outcome was considered abnormal in presence of a postasphyxial encephalopathy. Receiver operating characteristic curves were used to demonstrate the efficacy of fetal cerebral blood flow velocity waveform analysis as a predictor of neonatal outcome. A value of the pulsatility index from the internal carotid artery below the second standard deviation of our range of normality was found to be a powerful indicator of the development of neonatal neurologic abnormalities (Cohen's Kappa index = .58). These results were particularly evident in fetuses with a birthweight above 2500 g in which a specificity of 93.7%, a sensitivity of 75%, and an accuracy of 89.7% were achieved.

Periodic lateralized epileptiform discharges (PLEDs) as early indicator of stroke in full-term newborns

We report on periodic lateralized epileptiform discharges (PLEDs) on EEG in two infants with neonatal convulsions. In both neonates, the EEG abnormalities were seen soon after the onset of seizures, at a time when cranial ultrasound scans were thought to be normal. Subsequent Magnetic Resonance Imaging scans demonstrated cerebral infarction in both patients. In one case, the localisation of the lesion on MRI was concordant with that of the EEG abnormalities, as usually observed in adults with focal lesions. The other infant showed similar EEG abnormalities, but her MRI showed a localised lesion in the basal ganglia, which has also been reported to be involved in the genesis of these abnormalities.

Cerebral ultrasound findings in neonatal lupus syndrome

A prospective study was performed enrolling 11 newborns with neonatal lupus syndrome (NLS) and 22 control newborns to investigate cerebral ultrasound (US) anomalies and their relationship with clinical neurological signs and laboratory findings. Cerebral US detected a significantly higher incidence in the study group of both subependymal pseudocysts (SEPC) and subependymal hemorrhage (SEH), neither of which correlated to autoantibody levels. All infants had completely normal neurological examinations both at birth and follow-up. The etiopathogenesis of central nervous system findings in NLS is discussed. US evaluation identified minimal anomalies compatible with favorable outcome: further studies are necessary to investigate the possible long-term sequelae, pathogenesis and spectrum of cerebral US findings.

Doppler evaluation of renal blood flow velocity as a predictive index of acute renal failure in perinatal asphyxia

Aim of our study was to evaluate Doppler renal blood flow velocity in asphyxiated neonates and to correlate renal function to Doppler findings. Doppler renal blood flow velocity was evaluated in 23 severely asphyxiated neonates born at a gestational age > 32 weeks and compared to our standard Doppler data obtained in 25 healthy neonates comparable for gestational age and birth weight. Renal Doppler ultrasound was performed on the 1st and 3rd days of life. Renal function was investigated in the first 2 weeks of life. Asphyxiated neonates showed mean values of systolic velocity and mean velocity significantly reduced (P < 0.001) compared with our standard Doppler values on the 1st day of life. Seven out of the 23 asphyxiated neonates were affected by acute renal failure and 14 showed no renal involvement. Two neonates were oliguric but did not develop acute renal failure. On the 1st day of life, neonates with acute renal failure had significantly lower mean values of systolic velocity and mean velocity than the asphyxiated neonates without renal involvement (P < 0.01). All 7 neonates affected by acute renal failure showed a systolic velocity more than 2SD below the mean standard value, while only 4 of the 16 asphyxiated neonates (25%) without acute renal failure had low systolic velocity values on the 1st day of life. Doppler velocities in asphyxiated neonates were similar to standard values on the 3rd day of life. Renal failure recovered before the 11th day of life in all cases.

CONCLUSION

Our findings indicate that decreased Doppler renal flow systolic velocity observed in asphyxiated neonates on the st day of life is a useful predictive index for subsequent development of acute renal failure, with 100% sensitivity and 63.6% specificity.

Antenatal phenobarbital in preventing intraventricular hemorrhage in premature newborns

In a randomized prospective study, we investigated the effect of antenatal phenobarbital on neonatal intraventricular hemorrhage in 39 women destined to deliver babies of less than 32 weeks of gestation. The treatment group received an intravenous loading dose of 700 mg of phenobarbital, followed by a daily maintenance dose until delivery. The newborns were treated with phenobarbital for the first 96 h. Ultrasound examinations of the infants' heads were performed. Intraventricular hemorrhage was significantly less frequent in the treated group: 2 of 21 (9.5%) versus 9 of 18 (50%; p less than 0.006). Moreover no severe hemorrhage (grade 3-4) occurred in the treated babies: 0 of 21 versus 5 of 18 (27.7%; p less than 0.01).

Metabolic syndrome and cardiovascular risk prediction in peripheral arterial disease

BACKGROUND AND AIMS

Metabolic syndrome (MetS) was reported to be associated with increased cardiovascular risk in various settings, however its prognostic impact in peripheral arterial disease (PAD) is scanty.

METHODS AND RESULTS

We prospectively studied 173 patients with intermittent claudication and ankle/brachial index (ABI)<0.90, in whom MetS was defined using the criteria of both the revised version of the Adults Treatment Panel III (rATP III) and the International Diabetes Federation (IDF). Of these patients, 52.6% met the rATP III and 54.9% the IDF criteria for MetS. During a median follow-up of 31 months, 54 cardiovascular events occurred. Kaplan-Meier curves showed a greater incidence of ischemic events in patients with MetS than in those without. However, adjusted Cox analyses revealed that only IDF-MetS was independently associated with increased cardiovascular risk (HR=1.91, 95% CI 1.03-3.51, p=0.038). Kaplan-Meier curves for the four groups of patients delineated according to the bootstrapped ABI cut-off value (0.73) and the presence or absence of IDF-MetS revealed that the syndrome improved the predictive power of ABI alone. Actually, among patients with an ABI≤0.73, those with IDF-MetS had a higher cardiovascular risk than those without the syndrome (HR=2.55, 95% CI 1.22-5.12, p=0.012). This was confirmed by c-statistic, which was 0.56 for ABI alone and increased to 0.65 (p=0.046) when IDF-Mets was added to the pressure index.

CONCLUSION

In PAD, IDF-MetS, but not rATP III-MetS, is associated with an increased risk of cardiovascular events. Furthermore, IDF-MetS adds to the prognostic value of ABI, currently the most powerful prognostic indicator in PAD.

Antenatal post-hemorrhagic ventriculomegaly: a prospective follow-up study

OBJECTIVE

The aim of this study was to evaluate the presence and the severity of neurological and cognitive impairment at 2 years of age in 16 infants (9 term born, 7 preterm of mean gestation 33.6 weeks) with cerebral ventriculomegaly of antenatal onset associated with intraventricular haemorrhage.

METHODS

Ventricular dilatation, with or without associated lesions, was, with one exception, not identified on the antenatal routine scan at approximately 22 weeks but was obvious on the scans performed between weeks 27 and 33. In 8 of the 16 cases there were signs of parenchymal involvement or of abnormalities of the corpus callosum or cerebellum. In all patients the diagnosis of antenatal IVH was confirmed by early neonatal imaging. Outcome was measured using the Hammersmith infant neurological examination and the Griffiths developmental scales at 2 years.

RESULTS AND CONCLUSIONS

At 2 years, 8 infants had normal motor outcome and 8 had cerebral palsy. The presence and severity of cerebral palsy or neurodevelopmental delay was not always related to the magnitude or symmetry of the ventricular dilatation per se. The presence of associated lesions was a negative prognostic marker. The early development of epilepsy was also associated with an abnormal outcome.

Intraventricular hemorrhage: past, present and future, focusing on classification, pathogenesis and prevention

The improvement in the survival rate of infants born at the limit of viability, i.e. < 26 weeks of gestational age, raises concern about the risk of neurodevelopmental disabilities. The relevance of intraventricular hemorrhage (IVH), which is the most frequent cerebral lesion diagnosed in extremely low birth weight neonates, cannot then be underestimated. Pharmacological interventions designed to prevent the occurrence of IVH and its complications have not been entirely conclusive. The understanding of pathogenetic factors involved in the genesis of IVH is the key to planning of new strategies and meanwhile of implementing care guidelines aimed at its prevention.

Bioinformatics design and experimental validation of influenza A virus multi-epitopes that induce neutralizing antibodies

Pandemics caused by influenza A virus (IAV) are responsible for the deaths of millions of humans around the world. One of these pandemics occurred in Mexico in 2009. Despite the impact of IAV on human health, there is no effective vaccine. Gene mutations and translocation of genome segments of different IAV subtypes infecting a single host cell make the development of a universal vaccine difficult. The design of immunogenic peptides using bioinformatics tools could be an interesting strategy to increase the success of vaccines. In this work, we used the predicted amino acid sequences of the neuraminidase (NA) and hemagglutinin (HA) proteins of different IAV subtypes to perform multiple alignments, epitope predictions, molecular dynamics simulations, and experimental validation. Peptide selection was based on the following criteria: promiscuity, protein surface exposure, and the degree of conservation among different medically relevant IAV strains. These peptides were tested using immunological assays to test their ability to induce production of antibodies against IAV. We immunized rabbits and mice and measured the levels of IgG and IgA antibodies in serum samples and nasal washes. Rabbit antibodies against the peptides P11 and P14 (both of which are hybrids of NA and HA) recognized HA from both group 1 (H1, H2, and H5) and group 2 (H3 and H7) IAV and also recognized the purified NA protein from the viral stock (influenza A Puerto Rico/916/34). IgG antibodies from rabbits immunized with P11 and P14 were capable of recognizing viral particles and inhibited virus hemagglutination. Additionally, intranasal immunization of mice with P11 and P14 induced specific IgG and IgA antibodies in serum and nasal mucosa, respectively. Interestingly, the IgG antibodies were found to have neutralizing capability. In conclusion, the peptides designed through in silico studies were validated in experimental assays.

Doppler ultrasound of blood flow velocities in ophthalmic and central retinal arteries during the early neonatal period

PURPOSE

To obtain standard values of blood flow velocity in the ophthalmic artery and central retinal artery in the neonatal period and to compare blood flow velocity of orbital vessels with that of the anterior cerebral artery and middle cerebral artery.

METHODS

Forty-five healthy neonates (gestational age, 39.2 +/- 1.2 weeks; birth weight, 3,210 +/- 567 g) on the first and third postnatal days (90 eyes each time) and on the fifth day of life (34 eyes) were included in a clinical trial. A duplex scanner with mechanical sector probe was used for measuring blood flow velocity in the ophthalmic artery, central retinal artery, anterior cerebral artery, and middle cerebral artery. A nominal imaging frequency of 7.5 MHz, a transmitted Doppler frequency of 5 MHz, and a wall filter setting of 50 Hz were used in each case. Systolic, end-diastolic, and mean-enveloped velocities were measured for the studied vessels and the resistance and pulsatility indices were calculated.

RESULTS

On the first postnatal day, blood flow velocities and indices in the ophthalmic artery were systolic 14 +/- 2.4 cm/sec, end-diastolic 3.8 +/- 0.6 cm/sec, mean-enveloped 7.3 +/- 1.3 cm/sec, resistance index 0.73 +/- 0.03, and pulsatility index 1.5 +/- 0.2. Central retinal artery blood flow velocities and indices were systolic 8.7 +/- 1.8 cm/sec, end-diastolic 2.7 +/- 0.7 cm/sec, mean-enveloped 5.0 +/- 1.1 cm/sec, resistance index 0.70 +/- 0.04, and pulsatility index 1.3 +/- 0.1. There were no significant differences in ophthalmic artery and central retinal artery flow velocities between right and left eyes. Doppler values of the central retinal artery were significantly lower (P = .0005) than those of the ophthalmic artery for each day studied. The Doppler data for the central retinal artery and ophthalmic artery were significantly lower (from P = .005 to .0001) than those observed in the anterior cerebral artery and middle cerebral artery at the same postnatal age. No significant differences in flow variables were found in the central retinal artery and ophthalmic artery from the first to third day, whereas blood flow velocities in the anterior cerebral artery and middle cerebral artery increased significantly (P = .01 to .0001) from day 1 to day 3. On the fifth day of life a significant increase in blood flow velocities and indices was observed in the ophthalmic artery, whereas only systolic velocity significantly increased in the central retinal artery.

CONCLUSIONS

We report blood flow data of the ophthalmic artery and central retinal artery in healthy neonates and suggest that a delay of arterial blood flow changes occurs for the ophthalmic artery and central retinal artery with respect to the anterior cerebral artery and middle cerebral artery in the early prenatal period.

Crossed cerebellar atrophy of prenatal onset

BACKGROUND

Crossed cerebellar atrophy after hemorrhagic-ischemic injury in the contralateral cerebral hemisphere was reported in adults with stroke and in children with acquired lesions. It was also reported in preterm infants after perinatal or postnatal contralateral supratentorial lesions.

CASE REPORT

We report crossed-cerebellar atrophy in a preterm neonate with prenatal posthemorrhagic ventriculomegaly and periventricular ischemic lesion in whom contralateral cerebellar involvement was detected on antenatal scans.

DISCUSSION

The result of our study suggests that in the developing brain, cross cerebellar atrophy may occur antenatally and that fetal MRI may help to identify such cases.

Intraventricular streptokinase infusion in acute post-haemorrhagic hydrocephalus

Neonatal post-haemorrhagic hydrocephalus is a clinical condition with a high mortality and long-term morbidity. Its clinical management is difficult and not well standardized. We describe the case of a term baby suffering from acute intracranial hypertension caused by an intraventricular and thalamic haemorrhage. In this case, the external ventricular drain inserted to control intracranial pressure was ineffective because of repeated obstructions due to blood clots. Continuous intraventricular infusion of streptokinase of 20,000 U/day allowed quick lysis of the clots, drainage of the cerebrospinal fluid and relief from the coma. Although it did not prevent a permanent ventriculoperitoneal shunt, we obtained reabsorption of the intraventricular haemorrhage without rebleeding complications. We suggest the use of low-dose fibrinolytic infusion through an external drain for the treatment of acute intracranial hypertension following intraventricular haemorrhage in term infants.

Cranial ultrasound evaluation in term neonates

BACKGROUND

Term neonates (TN) are not routinely submitted to cranial ultrasound scan (CUS), since they are not considered at high risk for developing cerebral lesions.

AIMS

To investigate the prevalence of cerebral abnormal findings in term neonates (TN), to identify the associated clinical features and to better target neonatal CUS investigations.

STUDY DESIGN

Prospective observational study.

SUBJECTS

A total number of 1805 healthy TN underwent CUS. 1181 neonates had clinical features supposed to increase the risk for cerebral abnormal findings (study cohort), 624 were controls.

OUTCOME MEASURES

Prevalence of minimal, minor, and major cerebral abnormal findings was analyzed in six different categories of low-risk TN and compared to controls.

RESULTS

Variations from normality at the neonatal CUS were observed in 402 TN (22.27%). In half of the cases the ultrasound findings were minimal abnormal findings, while minor abnormal findings were found in 179 TN (9.92%). About 1% of the studied neonates showed major cerebral abnormal findings potentially compromising neurodevelopmental outcome. The prevalence of the observed abnormal findings varied significantly in the different low-risk categories.

CONCLUSIONS

The clinical features significantly increasing the risk for cerebral anomalies in healthy TN were microcrania, macrocrania, mild neurologic signs, and the detection of mild variations from normal cerebral aspect at the antenatal ultrasound evaluation.

Vitamin D-binding protein in the perinatal period

The molecular polymorphism and quantitative levels of serum vitamin D-binding protein (DBP) were ascertained in a group of preterm, full-term and hypocalcaemic full-term newborn infants. The serum concentration of DBP is not influenced by phenotype and increases with fetal age from the 32nd-33rd week of gestation until the 35th week of gestation. Neither different DBP allele distribution nor abnormal quantitative levels found among 29 hypocalcaemic full-term newborn infants.