Biomedical subjects
Publications and source records attributed to P H Ellison.
Neonatal intensive care units may choose to selectively withdraw support in some neonates with severe brain damage. We offer suggestions for criteria for such withdrawal, and a review of 20 cases in which such a decision-making process occurred in our neonatal intensive care unit.
In adults, cerebrospinal fluid (CSF) acid-base balance is an important determinant of cerebral blood flow, ventilatory drive, and state of consciousness. Sixteen lumbar punctures were performed on newborns (mean gestational age, 33.8 weeks; range, 26 to 44 weeks). The mean CSF pH was 7.366 units, 0.036 less than the mean capillary blood pH (NS). The mean CSF arterial carbon dioxide tension (PCO2) was 40.3 mm Hg, 6.7 greater than the mean blood PCO2 (p less than 0.01). The mean bicarbonate ion concentration in CSF was 21.8 mEq/L, 1.2 greater than that in blood (NS). Acid-base determinations in CSF of neonates with intraventricular hemorrhage did not differ significantly from those of neonates with otherwise normal CSF. These acid-base values are similar to those found in adults and did not vary with gestational age, suggesting that mechanisms to establish this acid-base gradient are developed by 26 weeks' gestation.
Neonatal mortality for 285 infants and developmental outcome for 158 infants with birth weights of 751 to 1,500 gm, born in the Capital Regional Perinatal Center between July 1975 and December 1979, were compared with the findings in 1952, in 1965 to 1967, and in 1968 to 1970. In the 1,001- to 1,500-gm group, mortality decreased and there was an 18% incidence of major neuropsychiatric disability compared to the 48% found in 1952 when the same examination techniques and diagnostic criteria were used. More 751- to 1,000-gm infants survive now also, but 40% have a major handicap. There is a high incidence of preconceptional, prenatal, perinatal, and postnatal abnormalities in this group of very low-birth-weight infants, but the incidence is significantly higher in those with major disabilities. The infants who die and those who have subsequent major neuropsychiatric abnormalities require the sophisticated techniques of neonatal intensive care, whereas these procedures are not needed or are used only briefly for the infants who are normal. In upper New York State, the demographic shifts in race, age, parity, education, and induced abortions account for 13% of the drop in neonatal mortality in the 1,001- to 1,500-gm group. These demographic as well as social and medical care changes must be taken into account in any evaluation of the decreasing mortality and morbidity that has occurred. Improvements in prenatal, obstetric, and neonatal care appear to be doing for the 751- to 1,000-gm group now what the then high-level care in 1952 did for the 1,001- to 1,500-gm group, when mortality decreased but only half of those who survived were normal.
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Ninety-six newborn infants with seizures were scored during the initial hospitalization on abnormality of EEG, neurologic examination, etiology of seizures, length of seizure, type of seizure, and birth weight under or over 1,500 gm. At 3 months, corrected for gestational age, the 80 surviving infants were scored on abnormality of current EEG, neurologic examination, etiology of seizure, presence or absence of seizure since hospital discharge, and birth weight under or over 1,500 gm. At age 10 months, 76 of 77 surviving infants were evaluated with the Gesell Developmental Inventory, physical examination, and neurologic examination. Chi square analysis documented that the scoring system was an accurate predictor of those infants with seizure disorders, mental retardation, and motor dysfunction. The score may assist the clinician in making decisions in regard to anticonvulsant therapy during initial hospitalization or at age 3 months.
Increased transcephalic impedance readings (greater than 3 SD) were recorded in 13 asphyxiated infants 35 weeks or more in gestation, and in 13 preterm infants 34 weeks or less in gestation and with intracranial hemorrhage (greater than 2 SD). Six infants had decreased TCZ recordings in the weeks following intracranial hemorrhage, without ultrasound evidence of ventricular enlargement. TCZ provides quick, inexpensive, noninvasive indication of tissue necrosis, moderate-to-severe intracranial hemorrhage, and delayed brain maturation.
Two preterm infants had serum ammonia levels of 2400 and 2800 micrograms per deciliter and profound neurologic depression with seizures and coma. Both responded to treatment by exchange transfusion and peritoneal dialysis. All previously reported survivors of transient hyperammonemia of the preterm infant have had normal neurologic and developmental examinations on follow-up.
Fifteen premature infants with severe chronic lung disease of prematurity were treated with ventilatory assistance and continuous positive airway pressure for at least 28 days. Fourteen developed progressive central nervous system deterioration following right heart failure and pulmonary hypertension. Two patterns of deterioration were observed: (1) cerebral, with loss of developmental milestones, increasing a hypotonia, and eventual EEG deterioration and death; and (2) brainstem, with progressive apnea, bradycardia, or both, and sudden death or irreversible apnea.
A 7-year-old girl presented with progressive dementia. 99-mTechnetium pertechnetate brain imaging and flow, cerebral angiograms, and a pneumoencephalogram revealed a large, bilateral frontal lesion that crossed the corpus callosum. At surgery, the consistency of affected brain tissue was soft. The histologic diagnosis was Schilder disease. Postoperatively, prednisone therapy was initiated because of clinical evidence of increased intracranial pressure, including funduscopic change. Within 4 months, the prednisone was discontinued, and the child completed the school year at the top of her class. Three years later she continued to function as a superior student, without demonstrable clinical neurologic abnormality.
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Computerized axial tomography is a safe, non-invasive technique for measurement of ventricular size. A review of 44 children without myelodysplasia who were evaluated for inappropriately enlarging heads, documented a group of 20 children presenting at five months to two years of age with megalencephaly or mild communicating hydrocephalus. Of these, only two required shunts. At their most recent examination, the great majority of these children are developmentally normal. Serial neurological examination, developmental evaluation and head-circumference measurements, in association with computerized axial tomography, have proved effective in the assessment and management of this particular group of children with large heads.
Two children developed persistent, incapacitating, upper extremity tremor following severe head injury from bicycle-automobile collision accidents. Both responded well to treatment with the beta blocking agent, propranolol, improving motor control in school and self-care tasks.
Cerebral contusion is considered to be the lesion leading to neurological sequelae of mental retardation and cerebral palsy in abused children. This has been difficult to document other than at autopsy or craniotomy by previously available techniques. Acute contusion or hemorrhage presumably secondary to contusion is readily documented by computed tomography (CT). We are reporting the cases of four children with alleged or suspected abuse and CT evidence of cerebral contusion. The contusion has been found both with and without external evidence of head injury.
Many children and their families have experienced "hard times" because of the current economic conditions. Five cases are presented in which neurologic illness in children was related to changes in the family's economic circumstances. Pediatricians are encouraged to look carefully at the impact of changing economic conditions upon child health.
Herpes simplex virus was isolated from the tracheal aspirate of a 10-year-old boy presenting with acute onset of multiple cranial nerve palsies and a mild right hemiparesis. There was also an elevated herpes complement-fixation titer with decrease in the following weeks infection by herpes virus have been debated, we propose that this represents a case of brain-stem encephalitis due to herpes simplex infection. The importance of early diagnosis and evaluation of therapy are emphasized by this case in which the patient recovered completely.