Gastrointestinal injury in polycythemic term infants.

Necrotizing enterocolitis is uncommon among term infants. In this group, necrotizing enterocolitis has been associated with two risk factors: polycythemia and umbilical catheterization. During a randomized trial of partial plasma exchange transfusion for treatment of polycythemia, an increased risk of gastrointestinal problems was noted. Eight hyperviscous patients treated with partial plasma exchange transfusion, no symptomatically treated patients, and no control infants developed typical necrotizing enterocolitis (blood in the stools, pneumatosis, and systemic signs). The incidence of necrotizing enterocolitis was significantly greater among patients treated with exchange transfusion compared with patients treated symptomatically or control subjects (P less than .001).

Role of coagulopathy in newborn intracranial hemorrhage.

Fifty newborn infants of less than 33 weeks' gestation were followed prospectively from birth with serial coagulation and real-time ultrasound studies. A significant association of hypocoagulability in the first four hours of life with subsequent onset or progression of intraventricular or other clinical hemorrhages was documented. Abnormalities included lower values for fibrinogen, platelet count, antithrombin III, and factor VIII with higher values for fibrin monomer and longer Laidlaw whole blood clotting times. These abnormalities tended to correct spontaneously in surviving infants. An association between gestational complications and incidence of hypocoagulability and intracranial hemorrhage (ICH) was noted. Babies of preeclamptic mothers had fewer abnormalities and babies born to mothers with premature rupture of membranes and suspected amnionitis manifested more hypocoagulability and more severe intracranial hemorrhages.

Timing and antecedents of intracranial hemorrhage in the newborn.

Fifty newborn infants of less than 33 weeks' gestation were followed prospectively from birth to evaluate the temporal relationships of various clinical factors to the onset and progression of intracranial hemorrhage (ICH) in an inborn population given maximal support. ICH was diagnosed and followed with bedside ultrasound every eight hours. The incidence of intraventricular hemorrhage was 30% and of any ICH was 40% with onset from less than 2 hours to 8 days of age. Grades 2, 3, and 4 ICH correlated with Apgar scores of less than 5 at five minutes, vaginal delivery, longer labors, and intrapartum hemorrhage. There was a significant correlation between ICH and both blood pressure fluctuations of greater than 100% and rapid colloid infusions. Slow transfusions of packed red cells did not appear to precipitate episodes of ICH. In a setting of optimal care, ICH appears to be more related to prenatal stresses than to specific postnatal complications.

Neonatal intracranial hemorrhage and maternal use of aspirin.

A prospective study of 108 infants born at 34 weeks' gestation or earlier or weighing 1500 g or less was carried out to determine the incidence of intracranial hemorrhage and the multiple risk factors that may cause or aggravate this hemorrhage in premature infants. On day 2 post partum, mothers were questioned regarding maternal risk factors, including the use of either aspirin or acetaminophen during the last week of pregnancy. Between days 3 and 7 post partum, computed tomographic scanning was performed on the 108 infants. Of the total, 53 (49%) developed intracranial hemorrhage. The incidence of hemorrhage in the infants whose mothers had ingested aspirin was significantly greater (P less than .05) than that seen in infants whose mothers did not take either aspirin or acetaminophen (control group). The incidence of intracranial hemorrhage among infants whose mothers ingested acetaminophen was not significantly different from that of the control group. This study indicates that aspirin is associated with an increased incidence of intracranial hemorrhage in the authors' population. The use of aspirin in the last 3 months of pregnancy is highly questionable and probably inappropriate.

Ultrasonic evaluation of the neonatal brain.

Ultrasound examination of the infant brain has been performed in selected medical centers for many years. However, the equipment necessary for obtaining satisfactory visualization of the brain has only recently become commercially available. Currently, ultrasonography is an excellent, noninvasive, inexpensive, rapid, and safe imaging modality for the evaluation of hydrocephalus and other pathologic conditions of the neonatal brain. Ventricular size can often be evaluated in infants up to two or three years of age, but a detailed image of the brain parenchyma becomes more difficult to obtain in a term infant after the first two to three months of life. With the use of the water path and high resolution, real-time systems and with the delineation of structures by multiple projections, (axial, coronal, sagittal and occipital), complex abnormalities may be delineated.

Portal venous velocity in biliary atresia.

From December 1986 to April 1989, 38 patients with biliary atresia (eight newly diagnosed) were evaluated with doppler ultrasound of the portal venous system. Peak and mean velocities were computer derived from the spectral waveform. Good velocity was greater than 15 cm/s, intermediate velocity was 8 to 14 cm/s, abnormal velocity was less than 7 cm/s or hepatofugal. Patients were grouped according to clinical status: group 1 (n = 14), normal liver function; group 2 (n = 15), recurrent cholangitis; group 3 (n = 2), established bile drainage but complicated cirrhosis; group 4 (n = 7), failed portoenterostomy. All patients with normal liver function (group 1) had good or intermediate velocities. Thirteen of 15 patients with recurrent cholangitis (group 2) had good or intermediate velocities. Both patients in this group with abnormal velocities required transplantation. In group 3 the patient with abnormal velocity is on the transplant waiting list. In group 4, abnormal velocities preceded or coincided with deterioration of liver function in five of seven patients. Doppler ultrasound provides useful anatomic information, determines direction of flow, quantitates velocity of flow, and, when performed serially, provides adjunctive information on liver status in children with biliary atresia. These preliminary results suggest that patients with abnormal or significantly decreasing velocity are destined for transplantation. Patients with good portal venous velocity warrant ongoing, aggressive surgical management.

In utero diagnosis of intracranial hemorrhage resulting in fetal hydrocephalus. A case report.

An intracranial hemorrhage resulted in fetal hydrocephalus. Antepartum fetal heart rate monitoring instituted for decreased fetal activity led to this intrauterine diagnosis. The infant had no neurologic delay at 16 months of age.

Role of computed tomography and ultrasound in neonatal brain imaging.

Neonatal brain imaging has had a tremendous impact on neonatal care with the introduction of computed tomography and ultrasound to noninvasive study of the neonatal brain. Improved obstetrical and neonatal care have saved many premature infants, resulting in an increased incidence of central nervous system hemorrhagic and hypoxic brain damage in those very-low-birthweight infants who are at greatest risk for intracranial hemorrhage. The evaluation of the neonatal brain can best be done by an understanding of the relative merits of computed tomography and ultrasound as imaging techniques. This report demonstrates the ability of each modality in specific lesions and recommends a basic approach to neonatal care based on the most likely lesion.

The decline and early fall of neonatal pulmonary hemorrhage.

Seven years' experience (1965-1972) with neonatal pulmonary hemorrhage at the University of Colorado was reviewed. Pulmonary hemorrhage still occurs frequently as a preterminal event in hyaline membrane disease. As an isolated "pure" entity, however, pulmonary hemorrhage has shown a marked decline. This phenomenon is probably related to advances in neonatal intensive care. The radiographic pattern of "pure" pulmonary hemorrhage in the newborn is most commonly a diffuse alveolar infiltrate. Since pure hemorrhage is now an uncommon entity, the radiologist can reasonably suggest this diagnosis on rare occasions only, in the clinical setting of profound hypoxia.

Ultrasound evaluation of cystic intracranial lesions in the neonate.

Ultrasound detected cystic intracranial lesions in 18 infants. Lesions included porencephaly (6 infants), hydranencephaly (1 infant), a quadrigeminal cyst (1 infant), Dandy-Walker syndrome (1 infant), and cavum septi pellucidi and Vergae (9 infants). Cystic lesions of the infant brain can be delineated accurately with ultrasound and distinguished from normal ventricular structures.

Fetal intracranial teratoma: US diagnosis of three cases and a review of the literature.

We describe three cases of fetal intracranial teratoma diagnosed by ultrasound and review the literature. Sonographic features include cranial enlargement, gross distortion of normal cerebral architecture by a hyperechoic, multicystic mass, and polyhydramnios. Despite early diagnosis, the cesarean section rate is high and the overall prognosis is dismal.

Diagnosis of brain neuropathology in utero.

The fetal brain can be evaluated very effectively with high-resolution real-time ultrasound equipment. This paper reviews normal fetal brain anatomy with specific emphasis on artifacts of ultrasound scanning of the brain. A review of the developmental abnormalities seen in utero include ventriculomegaly, anencephaly, encephalocele, meningomyelocele, Dandy-Walker syndrome, holoprosencephaly, craniosynostosis, microcephaly, and agenesis of the corpus callosum. The destructive lesions reviewed include hydranencephaly, infection, intracranial hemorrhage, and mass lesion. Identification of these abnormalities can be extremely helpful in providing the patients with management options and providing the obstetrician with information which can help in obstetric and neonatal therapy.

The fetal spine.

Ultrasonography has made it possible to evaluate the fetal spine in utero. Vertebral ossifications are demonstrable by ultrasonography in the early second trimester. Most spinal defects are apparent by 20-22 weeks menstrual age. Early detection of spinal anomalies allows for parental counseling and appropriate obstetrical management. Real-time equipment allows the fetal spine to be examined in parasagittal, transverse and coronal planes. The transverse plane provides the best view of the three ossification centers that form each fetal vertebra. Evaluation of the neural arch ossifications in the transverse view is crucial in detecting spina bifida defects. Ultrasonography of the fetal spine complements the use of alpha-fetoprotein levels in screening for neural tube defects. Examination of the fetal spine is also important in detecting vertebral ossification defects, particularly in cases of short-limbed dwarfs and infants of diabetic mothers.

Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma.

BACKGROUND: Child abuse specialists rely heavily on diagnostic neuroimaging. OBJECTIVES: Study objectives were: (1) to compare the frequencies of six specific intracranial CT abnormalities in accidental and non-accidental pediatric head trauma, and (2) to assess interobserver agreement regarding these CT findings. MATERIALS AND METHODS: Three pediatric radiologists blindly and independently reviewed cranial CT scans of pediatric patients who sustained closed head trauma between 1991 and 1994. All patients were less than 4 years of age. Study cases included thirty-nine (50 %) with non-accidental head trauma and thirty-nine (50 %) with accidental head trauma. Each scan was evaluated for the presence or absence of the following six intracranial findings: (1) interhemispheric falx hemorrhage, (2) subdural hemorrhage, (3) large (non-acute) extra-axial fluid, (4) basal ganglia edema, (5) posterior fossa hemorrhage, and (6) frontal-parietal shearing tear(s). Interobserver agreement was calculated as the percentage of total cases in which all reviewers agreed a specific CT finding was present or absent. Diagnosis required independent agreement by all three pediatric radiologists. The frequencies of these six intracranial CT abnormalities were compared between the two study groups by Chi-square analysis and Fisher's exact test. RESULTS: Interobserver agreement between radiologists was greater than 80 % for all lesions evaluated, with the exception of frontal-parietal shearing tear(s). Interhemispheric falx hemorrhage, subdural hemorrhage, large (non-acute) extra-axial fluid, and basal ganglia edema were discovered significantly more frequently in non-accidental trauma (P

B-mode echoencephalography in the normal and high risk infant.

Commercially available high resolution, contact, gray scale imaging systems can now dependably visualize the normal and abnormal ventricular system as well as some other intracranial structures in all newborns. On 25 normal infants and 41 high risk infants, 135 B-mode echoencephalograms were performed. The technique for obtaining these scans is described. The normal lateral ventricle at the midbody in term infants is 0.9--1.3 cm wide (mean, 1.1 cm). Normal ratio of lateral ventricle to hemisphere is 28% (range, 24%--30%). High risk premature infants have a ratio of 31% (range, 24%--34%). The demonstration of hydrocephalus and cystic intracranial masses is reliable and the correlation with computed tomography is excellent. Postoperative or high risk infants can be repeatedly evaluated without radiation, at a lower cost, and more rapidly with ultrasound than with computed tomography. Ventricular size can be closely monitored and shunt failure detected at any early stage.

Detection of neonatal intracranial hemorrhage utilizing real-time and static ultrasound.

Accurate assessment of neonatal brain anatomy and pathology can now be obtained with commercially available ultrasound equipment. Intracranial hemorrhage (ICH) has a 50% to 60% incidence in premature infants under 32 wk gestational age and is felt to be one of the leading causes of neonatal morbidity and mortality. Computerized tomography (CT) has been the standard for detecting ICH; this study demonstrates that ultrasound is equally accurate and sensitive. Real-time examination through the anterior fontanelle resulted in 100% accuracy when compared with CT in a prospective study. Compound axial scans through the parietal bone were not as accurate, with a sensitivity of 91% and a specificity of 85%. If available, good quality real-time, transfontanelle sector ultrasound should be the screening procedure of choice for detecting and following intracranial hemorrhage in the high-risk premature infant.

Kleeblattschadel anomaly. In utero sonographic appearance.

Four cases of Kleeblattschadel demonstrated on prenatal ultrasound examinations are reported. Five additional cases from the literature are reviewed. Sonographic features include enlarged trilobed skull, hydrocephalus, polyhydramnios, and frequent association with thanatophoric dwarfism. The most common error in diagnosis was misinterpretation of this skull anomaly as encephalocele.

Specific skeletal dysplasias in utero: sonographic diagnosis.

A retrospective study was performed of 13 short-limbed fetuses with lethal skeletal dysplasias that were evaluated with ultrasound (US) from 1981 to 1984. The specific diagnoses were thanatophoric dwarfism, achondrogenesis, osteogenesis imperfecta, and campomelic dwarfism. Death occurred in utero or within 2 weeks after delivery in all cases. US examination showed other associated abnormalities, including polyhydramnios, hydrops, shortened femurs, and CNS abnormalities. Radiographs confirmed these findings and provided more information regarding the shape of the limbs and thorax and the appearance of the spine. The probable diagnosis of lethal short-limbed dwarfism was made antenatally using US in eleven of the fetuses. Spinal appearance, thoracic shape, and associated hydrops and polyhydramnios were most helpful in determining the specific type of dysplasia present. Lethal short-limbed skeletal dysplasia may be diagnosed confidently in utero using US examination; however, obstetric plain film radiography may be required to determine the definitive type of dysplasia. In certain cases, US may be sufficient to make a definitive diagnosis.

Partial splenic embolization in children with hypersplenism.

Partial splenic embolization (PSE) was successfully accomplished in 10 of 11 children, aged 2-9, who had portal hypertension or variceal bleeding. Nine of the 11 children had undergone portoenterostomy (Kasai operation) for biliary atresia, and two had portal vein thrombosis. After embolization these children had a longer period of fever (mean = 23.7 days) and elevated white blood cell (WBC) count (above 10,000, mean = 13.6 days) than adults who have undergone the same procedure. The leukopenia and thrombocytopenia of hypersplenism were corrected by PSE in seven of eight children, and the condition of the eighth child improved. Among ten patients who had experienced episodes of variceal hemorrhage, the frequency of bleeding episodes was reduced from an average of 2.87 per year before PSE to 0.67 per year after PSE. There were no splenic abscesses and no other significant complications of the treatment. Ultrasound (US) evaluation after embolization demonstrated hypoechogenicity of the infarcted areas and tiny, linear echoes scattered throughout the spleen typical of postinfarction intravascular gas. All nine children who underwent follow-up Tc-99m sulfur colloid scanning showed evidence of splenic regeneration, though none has had recurrence of clinical symptoms. Splenic regeneration following PSE may occur more frequently in children than in adults.