Early Identification of Neurological Abnormalities in the NICU Infant

Max Wiznitzer, M.D.

Division of Pediatric NeurologyRainbow Babies and Children’s HospitalCleveland, Ohio

Common Problems in the NICU

PrematurityIVH=Intraventricular HemorrhagePVL=Perventricular Leukomalacia

Neonatal encephalopathyHypoxic-IschemicInfarction

Seizures

Intraventricular Hemorrhage

CausationPretermTerm

PresentationCatastrophic- Fortunately rareSaltatory-More common; stuttering evolution Silent-Most common

Grading severity

*GRADING OF IVH (per J. Volpe):

-Grade I: Bleeding confined to periventricular area (germinal matrix)

-Grade II: Intraventricular bleeding (10-50% of ventricular area on sagittal view)

-Grade III: Intraventricular bleeding (>50% of ventricular area or distends ventricle)

-Intra-parenchymal echodensity (IPE) represents periventricular hemorrhagic infarction and is often referred to as Grade IV IVH.

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*OUTCOME and PROGNOSIS:

Progressive Ventricular Neurological

Severity of IVH Mortality (%) Dilatation (%) Sequelae (%)

Grade I 5 5 5

Grade II 10 20 15

Grade III 20 55 35

IPE 50 80 90

(In general, outcomes with IVH Grade I or II are similar to infants without IVH.)

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*Clinical FeaturesCatastrophic Syndrome

Evolves in minutes to hoursDeep stupor or comaRespiratory arrhythmia, hypoventilation, apneaGeneralized tonic seizures, “Decerebrate” posturingEyes- Pupils fixed, no Doll’s eyeFlaccid quadriparesis

*Clinical FeaturesCatastrophic Syndrome (cont.)

Falling Hematocrit

Bulging Anterior Fontanelle

Hypotension, Bradycardia

Temperature derangements

Metabolic acidosis, DIC, Jaundice

Abnormalities of glucose and water homeostasis (Hyperglycemia, SIADH)

*Clinical Features

Saltatory syndromeStuttering evolution : hours to dayAltered level of consciousnessAltered motility (usually decreased )HypotoniaAbnormally tight popliteal angle (84% if IVH, 10% if no IVH)Abnormal eye position / movementRespiratory disturbance

*Clinical Features

Clinically silent syndrome:Careful, serial clinical assessments will miss 25-50% of infants with IVHMost valuable sign is unexplained fall of Hematocrit or failure of Hematocrit to rise after a transfusionMore common with smaller bleeds

(with associated better prognosis )

Intraventricular Hemorrhage

ConsequencesHydrocephalusGerminal matrix damageHemorrhagic infarction

AssessmentUltrasoundMRIEvoked potentials

Neonatal EncephalopathyPeriventricular LeukomalaciaHypoxic-ischemic encephalopathy

Near total/profound asphyxiaProlonged partial asphyxia

Infarction (stroke)ArterialVenous

Hypoxic-ischemia Encephalopathy

DiagnosisClinical evolution

Impact and timing of cell deathNecrosisApoptosis

Radiologic assessmentUltrasoundCT scanMRI

Use of EEG

Use of Technology for Early Identification of ProblemsMRIEvoked potentialsEEGNear Infrared SpectroscopyExamination

Analysis of Angles (Amiel-Tison)Assessment of general movements (Prechtl)