PubMed · 14700021
QUESTION: Nurses in the Pediatric ICU requested an ethics consultation asking "Is it fair to this child to continue painful experimental surgical procedures?"
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Robert D Orr. 2002. Clinical ethics case consultation.. https://pubmed.ncbi.nlm.nih.gov/14700021/
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BACKGROUND: After perinatal brain injury, clinico-anatomic correlations of functional deficits and brain plasticity remain difficult to evaluate clinically in the young infant. Thus, new non-invasive methods capable of early functional diagnosis are needed in young infants. CASE PRESENTATION: The visual system recovery in an infant with perinatal stroke is assessed by combining diffusion tensor imaging (DTI) and event-related functional MRI (ER-fMRI). All experiments were done at 1.5T. A first DTI experiment was performed at 12 months of age. At 20 months of age, a second DTI experiment was performed and combined with an ER-fMRI experiment with visual stimuli (2 Hz visual flash). At 20 months of age, ER-fMRI showed significant negative activation in the visual cortex of the injured left hemisphere that was not previously observed in the same infant. DTI maps suggest recovery of the optic radiation in the vicinity of the lesion. Optic radiations in the injured hemisphere are more prominent in DTI at 20 months of age than in DTI at 12 months of age. CONCLUSION: Our data indicate that functional cortical recovery is supported by structural modifications that concern major pathways of the visual system. These neuroimaging findings might contribute to elaborate a pertinent strategy in terms of diagnosis and rehabilitation.
The role of cytokines in the pathogenesis of brain injury and their relation to neurological outcomes of asphyxiated neonates is not fully defined. We hypothesize that interleukin-1 beta (IL-1beta), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) in cerebrospinal fluid (CSF) correlate with the severity of brain injury and can predict neurological deficits in infants who suffered from hypoxic ischemic encephalopathy (HIE). A prospective study was conducted on 24 term infants diagnosed with HIE and 13 controls. HIE was clinically classified into mild, moderate and severe according to Sarnat and Sarnat grading. Blood and CSF samples were obtained from all infants in the first 24h of life as part of routine investigations for suspected meningitis and/or sepsis. Neurological examination and Denver Developmental Screening Test II (DDST II) were performed at 6 and 12 months of life. IL-1beta, IL-6 and TNF-alpha were all significantly increased in HIE infants when compared to control. IL-1beta in the CSF correlated with the severity of HIE (r=0.61, P=0.001) more than IL-6 (r=0.45, P=0.004) or TNF-alpha (r=0.47, P=0.003). IL-1beta exhibited the highest CSF/serum ratio among the three studied cytokines suggesting its local release in the brain after the initial hypoxic injury. Abnormal neurological findings and/or abnormal DDST II at 6 and 12 months were best predicted by IL-1beta in the CSF (sensitivity=88% and specificity=80%). This study confirms the role of IL-1beta in the ongoing neuronal injury that occurs in the latent phase following the original HIE insult.
AIM: To assess the predictive value of early MRI and proton MR spectroscopy ((1)H-MRS), 11 full-term neonates with severe perinatal asphyxia were studied within 48 h after birth. METHODS: T(1)- and T(2)-weighted MRI, diffusion-weighted MRI (DW-MRI), apparent diffusion coefficient of water (ADC) of the basal ganglia and parietal white matter, as well as (1)H-MRS of the basal ganglia were performed in a 1.5-Tesla magnetic field. Neurodevelopment was assessed in the survivors for at least 24 months. RESULTS: Nine of the 11 neonates had a poor outcome (7 died, 2 developed cerebral palsy). All examinations were normal in the 2 neonates with a good outcome. T(1)- and T(2)-weighted MRI were abnormal in 7, DWI was abnormal in 7, ADC was abnormal in 5, and elevated lactate/N-acetylaspartate ratios using (1)H-MRS were seen in 7 of the 9 neonates with a poor outcome. None of these 9 had completely normal MRI or (1)H-MRS findings. CONCLUSIONS: Using a combination of T(1)- and T(2)-weighted MRI, DW-MRI, ADC measurements and (1)H-MRS within 48 h after severe perinatal asphyxia, no abnormalities were seen with any of these techniques in both neonates with a good outcome.