Ultrasound diagnosis and neurodevelopmental outcome of localised and extensive cystic periventricular leucomalacia.

AIMS: To compare the ultrasound (US) evolution and neurodevelopmental outcome of infants with localised (grade II) and extensive (grade III) cystic periventricular leucomalacia (c-PVL). METHODS: Over a nine year period, c-PVL was diagnosed in 96/3451 (2.8%) infants in two hospital cohorts. Eighteen were excluded from the study. Thirty nine infants with grade II PVL were compared with 39 infants with grade III PVL. RESULTS: The two populations were comparable for gestational age and birth weight. In infants with grade II PVL, cysts were noted to develop more often after the first month of life (53%) in contrast with grade III PVL (22%) (odds ratio (OR) 3.81 (95% confidence interval (CI) 1.19 to 12.63)). Cysts were also more often unilateral in grade II (54%) than in grade III PVL (0%) (OR indefinite; RR 3.17 (95% CI 2.16 to 4.64)). At 40 weeks postmenstrual age (PMA), cysts were no longer seen on US in 13/38 infants with grade II PVL, with ventriculomegaly being the only visible sequel in nine cases. In grade III PVL, cysts were still present in 25 of the 27 surviving infants. Nine infants with grade II PVL were free of motor sequelae at follow up compared with one infant with grade III PVL (OR 8.07 (95% CI 0.92 to 181.66)). Twenty two out of 29 children with grade II PVL who developed cerebral palsy achieved independent walking compared with 3/26 with grade III PVL (OR 75 (95% CI 11.4 to 662)). CONCLUSIONS: In the cohort studied, 50% of the infants with c-PVL had a more localised form (grade II). In grade II PVL, the cysts developed beyond the first month of life in more than half of the cases and were often no longer visible, on US, at 40 weeks PMA. In order not to miss this diagnosis, sequential US should also be performed beyond the first month of life. Mild ventriculomegaly noted at term can sometimes be due to grade II c-PVL. Cerebral palsy was slightly less common and tended to be less severe in infants with grade II PVL than in those with grade III PVL.

Somatosensory evoked potentials in preterm infants with intrauterine growth retardation.

In order to further evaluate both the maturation as well as the prognostic value of the somatosensory evoked potentials (SEPs) with regard to neurodevelopmental outcome, SEPs were performed after the first week of life in 56 small-for-gestational age (SGA) preterm neonates. Twenty-five had a prolonged N1 latency while 30 had a normal N1 latency around discharge. One child had an accelerated N1 latency. No correlation was found between the severity of intrauterine growth retardation in relation to birthweight, head circumference or birthweight ratio. None of the children developed cerebral palsy (CP) at follow-up. Developmental quotient (DQ) was calculated in 42 children. The mean DQ of the 21 neonates with an abnormal SEP at discharge was 79.24 +/- 18.56 while the mean DQ of the 21 children with a normal SEP at discharge was 92.52 +/- 11.31. Among the children with a normal N1 latency at discharge the number of breast-fed children was significantly higher than the number of formula-fed neonates (P < 0.05). We conclude that an abnormal SEP around term age in SGA preterm neonates does not imply an increased risk of developing CP. Breast-milk appears to have a beneficial effect on the development of the SEPs in children with intrauterine growth retardation.

[Hypoxic-ischemic encephalopathy of the full term newborn. Contribution of the electroencephalogram and trans-fontanelle echography to the prognostic evaluation. Report of 29 cases]. / Encéphalopathie anoxo-ischémique du nouveau-né à terme. Apport de l'électroencéphalogramme et de l'échographie transfontanellaire à l'évaluation pronostique. A propos de 29 observations.

This study was aimed at assessing by EEG recording and cranial imaging the cerebral function of 29 full term newborns presenting with hypoxic-ischemic encephalopathy and at establishing a correlation between the results and the neurological outcome. A correlation between the Sarnar's classification and the neurological outcome was observed, except for the intermediate grade. In this case, impairment of the EEG was variable and neurological prognosis was sometimes evidenced by cranial imaging. Unfavorable neurological outcome occurred when thalamic lesions were present, independently of clinical signs and EEG abnormalities.

[Contribution to the definition of high-risk groups of low birth weight infants]. / Contribution à la définition des groupes à haut risque d'enfants de faible poids de naissance.

Follow-up studies of low birth weight infants concern usually infants selected on the basis of either the birthweight--inferior or equal to 1500 g--or the gestational age: the upper limit is 31 or 32 weeks. To determine the most pertinent criterium, mortality and neurodevelopmental outcome at two years were compared in 3 groups, selected on the above criteria from a cohort of 369 infants with a birthweight below 2,000 grams admitted in 1983 in the neonatal unit of the University hospital of Lille. Under 1501 grams the rate of small for gestational age infants is high: it could be a part of the explanation for the high rate of minor sequelae. When cohorts are selected on the basis of gestational age, it appears that mortality is low at 32 weeks but the rate of major and moderate sequelae is still high: that fact must be considered when premature induced delivery comes in discussion. Because these criteria select different high risk populations, mortality and neurodevelopmental follow-up studies should include all infants with gestational age inferior or equal to 32 weeks and/or birthweight inferior or equal to 1,500 grams.

[Cerebral infarction: ultrasonic diagnosis and semeiologic peculiarities in premature newborn infants]. / Infarctus artériel cérébral: diagnostic échographique et particularités sémiologiques chez le nouveau-né prématuré.

BACKGROUND: Cerebral infarction in the preterm neonate is rarely associated with focal seizures. Its diagnosis is usually made on a routinely performed ultrasound scan. CASE REPORTS: Case no 1: A wedge-shaped area of increased echogenicity in the left parietal region suggesting a localized cerebral infarction was diagnosed on ultrasound scan performed in a preterm neonate born at 33 weeks of gestational age (GA) in whom electrical activity showed bilateral spiked theta-waves. The diagnosis was confirmed by CT scan and MRI. At 3 years of age, neurological and psychological evaluation was normal. Case no 2: This patient with intrauterine growth retardation was born at 31 weeks of GA after elective cesaerean section for Rhesus incompatibility. Two exchange-transfusions had been performed in utero. At day one an increased area of echogenicity lining a hypoechogenic parenchyma was noted in the parietal region suggesting its antenatal origin. The child died on day 8. CONCLUSIONS: Against other causes of parenchymal hyperechogenicity diagnosed on ultrasound scan such as periventricular leucomalacia or venous infarction--the long term prognosis of cerebral infarction, if the child survives, is usually good in the premature neonate.

[Incidence, evolution and prognosis of posthemorrhagic ventriculomegaly in a population of newborns of less than 33 weeks gestational age]. / Incidence, évolution et pronostic des dilatations ventriculaires post-hémorragiques dans une population de nouveau-nés de moins de 33 semaines d'âge gestationnel.

BACKGROUND: Posthemorrhagic ventriculomegaly is one of the most important neurological problems encountered in the premature new-born. The aim of this study was to evaluate its incidence in a tertiary neonatal unit at Lille, France, to study its evolution, the risk of ventriculoperitoneal shunt and the neurodevelopmental outcome. PATIENTS AND METHODS: Ninety-one neonates with posthemorrhagic ventriculomegaly, born before 33 weeks of gestational age (GA) and admitted in this unit between January 1989 and December 1995 were retrospectively studied. Clinical data, evolution of ventriculomegaly and outcome at 2 years were extracted from the files. RESULTS: Incidence of ventriculomegaly was stable along the study period, around 6.1% of the admissions of neonates with the same GA; 44 had moderate ventriculomegaly and 47 severe. The mean GA was 28.7 +/- 1.9 weeks. Fifteen percent of the newborns had received corticosteroids before delivery. Spontaneous delivery (P = 0.04) and infection (P = 0.002) were more frequent in case of severe ventriculomegaly. Ventriculoperitoneal shunt was inserted in 19.1% (9/47) of infants with severe ventriculomegaly. Outcome in this population was poor. Forty-nine (54%) died before the end of the first year of life. Thirteen (30.9%) of the survivors developed cerebral palsy. In 12 out of these 13 cases, cerebral palsy was associated with parenchymal involvement in the neonatal period. CONCLUSION: Long-term prognosis of ventriculomegaly is poor. In front of new therapeutic approach, an active policy towards prevention with large use of antenatal corticosteroids would allow to reduce incidence, mortality and morbidity in the neonatal period.

[Respiratory syncytial virus infections and apnea in low birth-weight infants]. / Infections à virus respiratoire syncytial et apnées chez le nourrisson de faible poids de naissance.

Respiratory syncytial virus infection was observed in 20 infants of less than 6 months of age who had a low weight at birth, were premature and/or presented with intra-uterine growth retardation. Except for rhinitis, which was present in all cases, the symptoms were closely correlated to the gestational age: beyond 48 weeks they were those of a common lower respiratory tract infection, but below 48 weeks attacks of apnea predominated, associated or not with signs of bronchitis. The apnea was of central origin, although there was no meningo-encephalitis; it regressed completely and without sequelae within a few days. In spite of similarities (notably of terrain) with disorders of respiratory command regarded as predictive of the sudden infant death syndrome risk, such children must be considered definitely cured after the initial episode. Including them in a long-term monitoring programme does not seem to be justified.

[Neonatal systemic candidiasis]. / Candidoses systémiques néo-natales.

An immature cellular immunity, the prolonged use of intravascular catheters and the administration of broad-spectrum antibiotics are the principal factors responsible for systemic Candida infections in premature babies. Six infants born at less than 33 weeks and weighing 1500 grams presented with signs of non-specific septicaemia; blood cultures were positive for Candida. All were cured with a treatment consisting of 5-fluorocytosine in 5 cases; amphotericin B was required in one case. This experience authorizes us to recommend 5-fluorocytosine as first-choice treatment of systemic candidiasis in premature babies. We also believe that priority should be given to a policy of eradication of Candida in all neonatology units.

Early treatment of posthemorrhagic hydrocephalus in low-birth-weight infants with valveless ventriculoperitoneal shunts.

The surgical treatment of posthemorrhagic hydrocephalus (PHH) in low-birth-weight infants (LBWI) is debated. In a few cases, hydrocephalus progresses rapidly and requires early drainage, but valves and ventriculostomy have a high rate of complications in the early phase. Temporary valveless shunt (VLS) is proposed as an alternative treatment of acute PHH in LBWI. Thirteen infants with PHH, weighing less than 2,000 g at birth, were treated with VLS, which was systematically converted into a valve-regulated shunt (VRS) after a few weeks; during the same period, 27 others were treated with VRS initially. The use of VLS presented significantly more shunt obstructions, but not more shunt infections, than VRS. Although placement of VLS was performed earlier, and in smaller babies than VRS, the outcome after a mean 9.1-year follow-up period was comparable in both groups, and only shunt infection was correlated with a poor outcome. We conclude that VLS is a valuable treatment of rapidly evolving PHH in LBWI.

Prognostic value of early somatosensory evoked potentials in neonates with cystic leukomalacia.

Somatosensory evoked potentials (SEPs) were performed between 31 and 49 weeks postmenstrual age on 33 neonates with extensive cystic leukomalacia. 27 had periventricular leukomalacia (PVL), while six had deep white matter lesions. All but two of the 27 infants with PVL had a reproducible potential at discharge, being delayed in 11 and within the normal range in 14. No potentials could be obtained in any of the infants with cysts in the deep white matter. All surviving infants developed severe neurological sequelae, irrespective of the N1 being delayed or within normal range. These data suggest that in infants with an ultrasound diagnosis of cystic leukomalacia, little additional information with regard to neurodevelopmental outcome is provided by performing median nerve SEPs, especially for those infants in whom the cystic lesions are restricted to the occipital periventricular white matter.

[Ultrasonic diagnosis of periventricular leukomalacia in premature infants]. / Le diagnostic échographique des leucomalacies périventriculaires du prématuré.

The ultrasonographic study through the fontanelle of 192 children below 33 weeks of age and surviving after the neonatal period led to the diagnosis of leukomalacia by identifying anechogenic cavities in the periventricular area in 7 cases. Clinical pictures were not characteristic. Important electro-encephalographic changes were constantly found, even before the occurrence of sonographic signs. Although non specific they are still suggestive when associated hemorrhage is not present. With these criteria, diagnosis seems to be correlated with severe neurologic prognosis. Its interest and chronology warrant the extension of the ultrasonographic supervision of severely immature infants up to the end of the second month.

[Discharge to the family milieu of low birth weight children. Analysis of an experience with "early discharge" in a neonatology unit]. / Le retour en milieu familial des enfants de faible poids de naissance. Analyse d'une expérience de "sortie précoce" d'un service de néonatologie.

A retrospective study of 182 children with birth weights less than or equal to 2,000 gms was undertaken. Its analysis showed that heterogeneity in discharge weights (1,580 to 3,400 gms) corresponded to an homogeneous average gestational age, around 39 weeks. Low discharge weights were neither correlated with the pathology of the first days, nor with the socio-economic status of the family. The majority were children born with intra-uterine growth retardation, who mature more rapidly and who might be given to their families earlier, with lower weights. There was no correlation between discharge weight and a second hospitalization during the first year. A policy of "early" discharge did not seem to have disadvantages, while its advantages are unquestionable.