Constantly discontinuous EEG patterns in full-term neonates with hypoxic-ischaemic encephalopathy.

OBJECTIVES: Selected EEG features were evaluated in 21 constantly discontinuous tracings recorded on the same number of full-term neonates with hypoxic-ischaemic encephalopathy. METHODS: The tracings were examined without using interval amplitude as the basis for distinguishing between burst-suppression and nonburst-suppression patterns. RESULTS: The results were related to outcomes and other clinical parameters (severity of hypoxic-ischaemic encephalopathy, pO2 levels and drug intake). CONCLUSIONS: Features defining the grade of EEG discontinuity (i.e. maximum interval duration, minimum burst duration and interval amplitude) significantly related to outcome and, in most cases, to the grade of hypoxic-ischaemic encephalopathy. Other features (amplitude of slow waves within the burst and incidence of abnormal EEG transients) related to PO2 levels. The consumption of anticonvulsant drugs increased EEG discontinuity, but this effect did not seem dose-related. Finally, the persistence of a constantly discontinuous EEG pattern after the first week of life is a sign of unfavourable prognosis. In full-term neonates with hypoxic-ischaemic encephalopathy quantitative analysis of all constantly discontinuous EEGs seems more useful than only describing burst-suppression patterns on the basis of interval amplitude.     

Predictive value of sequential electroencephalogram (EEG) in neonates with seizures and its relation to neurological outcome

The aim of this study was to evaluate the relationship of sequential neonatal electroencephalography (EEG) and neurological outcome in neonates with seizures to identify polysomnographic features predictive of outcome. Sequential EEGs recordings of 58 neonates that belonged to 2 historical cohorts of newborns with seizures from the same neonatal intensive care unit and who had follow-up at the Neurodevelopment Clinic of the Hospital S?o Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) in Porto Alegre, Brazil, were analyzed and classified into 4 groups: normal-normal, abnormal-normal, abnormal-abnormal, normal-abnormal. In patients with more than 2 recordings, during the neonatal period, the first EEG was compared with the following more abnormal. A total of 58 pairs of 2 sequential EEGs were analyzed. Considering the first EEG, a statistically significant difference was observed between the relationship of the result of this exam, if it was abnormal, with developmental delay (P = .030) and postnatal death (P = .030). Abnormal background activity was also related to neurodevelopment delay (P = .041). EEG sequences abnormal-abnormal and normal-abnormal significantly correlated to the outcome epilepsy ( P = .015). Abnormal sequential background activity was associated with neurodevelopment delay (P = .006) and epilepsy (P = .041). The burst suppression pattern when present in any EEG correlated with epilepsy (P = .013) and postnatal death (P = .034). Sequential abnormal background patterns in the first and second EEG increased the risk for epilepsy (relative risk [RR] = 1.8; 95% confidence interval [CI] = 1.03-3.0) and neurodevelopment delay (RR = 2.20; 95% CI = 1.3-3.0). Abnormal background activity only in the second electroencephalogram increased the risk for neurodevelopment delay (RR = 2.20; 95% CI = 1.3-3.0). All the neonates (n = 33) with seizures related to probable hypoxic ischemic encephalopathy had abnormalities in the first EEG (P = .030). Postnatal epilepsy was diagnosed in 24 infants (41.4%). Five (20.8%) presented West syndrome, 7 (29.2%) focal symptomatic epilepsy, 6 (25%) generalized symptomatic epilepsy, 2 (8.3%) early myoclonic encephalopathy, 1 (4.2%) early infantile epileptic encephalopathy, and in 3, the epileptic syndrome was undefined (12.5%). All infants (n = 5) with West syndrome had some degree of neurodevelopment delay. In conclusion, our findings suggest that sequential EEG in neonates with seizures has more predictive value to estimate the outcomes of neurodevelopment delay, epilepsy, and postnatal death than a single EEG recording. The abnormal background activity in even 1 EEG of the sequential recordings was more significant to determine neurological outcome than abnormal ictal activity or abnormalities in the organization of sleep state.     

Effect of erythropoietin combined with hypothermia on serum tau protein levels and neurodevelopmental outcome in neonates with hypoxic-ischemic encephalopathy

Although hypothermia therapy is effective to treat neonatal hypoxic-ischemic encephalopathy, many neonatal patients die or suffer from severe neurological dysfunction. Erythropoietin is considered one of the most promising neuroprotective agents. We hypothesized that erythropoietin combined with hypothermia will improve efficacy of neonatal hypoxic-ischemic encephalopathy treatment. In this study, 41 neonates with moderate/severe hypoxic-ischemic encephalopathy were randomly divided into a control group (hypothermia alone for 72 hours, n = 20) and erythropoietin group (hypothermia + erythropoietin 200 IU/kg for 10 days, n = 21). Our results show that compared with the control group, serum tau protein levels were lower and neonatal behavioral neurological assessment scores higher in the eryth-ropoietin group at 8 and 12 days. However, neurodevelopmental outcome was similar between the two groups at 9 months of age. Thesefindings suggest that erythropoietin combined with hypothermia reduces serum tau protein levels and improves neonatal behavioral neu-rology outcome but does not affect long-term neurodevelopmental outcome.     

新生儿行为神经测定对足月窒息儿预后的评价

目的 探讨新生儿行为神经测定(NBNA)对新生儿重症监护室(Mcu)足月窒息儿预后的预测意义.方法 对NICU住院治疗的326例足月窒息儿分别在12～14d龄、25～28d龄行NBNA测定,并随访至24月龄,行婴幼儿智能发育测定(CDCC)评估.结果 12～14d龄、25～28d龄NBNA评分异常(≤35分)组患儿在24月龄时行CDCC发育评估,智力发育落后[智力发育指数(MDI)≤69]发生率分别为61.54%、75.81%;运动发育落后[精神运动发育指数(PDI)≤69]发生率分别为65.38%、79.03%,与NBNA评分>35分组相比,差异均有统计学意义(P<0.05).且行为能力中的视听定向项目以及主动肌张力是NBNA的敏感指标.结论 NBNA评分对足月窒息儿的预后有较好的预测意义,对于12～14d龄后NBNA≤35分患儿,特别是视听定向及主动肌张力反应差的患儿需特别注意,要尽早对这些患儿行早期干预治疗.     

EPO联合亚低温治疗新生儿缺氧缺血性脑病 的疗效分析

目的 探讨促红细胞生成素（EPO）联合亚低温治疗新生儿缺氧缺血性脑病（HIE）的疗效。方法 选取2014年2月至2017年4月收治的HIE患 儿98例,依据治疗方案分为联合组（n=34）、亚低温组（n=30）和EPO组（n=34）;亚低温组患儿采用亚低温治疗,EPO组患儿采用EPO治疗,联合组 患儿采用EPO联合亚低温治疗。治疗前和治疗后2、7、14、28 d,采用新生儿神经行为（NBNA）评分评估神经行为发育,采用酶联免疫吸附试验法检 测血清Tau蛋白水平。结果 治疗后7、14、28 d,三组NBNA评分较治疗前均明显增高（P<0.05）,血清Tau蛋白水平均明显下降（P<0.05）;而且,联 合组明显优于亚低温组和EPO组（P<0.05）。Spearman相关性分析显示,治疗后7、14、28 d,患儿NBNA评分与血清Tau蛋白水平均呈明显负相关 （P<0.05）。结论 EPO联合亚低温治疗有效改善新生儿神经发育,血清Tau蛋白水平测定可作为协助评价神经发育结局的临床指标。     

Prediction of outcome in severe head injury based on recognition of sleep related activity in the polygraphic electroencephalogram.

This study shows that the continuing presence of activity similar to normal sleep in the EEG in conjunction with the EEG polygraph (EEGP) can be used to determine the severity of brain damage after head injury. Recordings were taken within seven days of head injury from 154 unselected patients after resuscitation and emergency surgery. Sixteen patients with ongoing seizures were excluded. In the remaining 138 patients the presence of activity in the EEG, EEGP, or both, which can also be recognised in normal alertness and sleep, was noted. Particular attention was paid to the presence or absence of arousal related phasic activity involving EEG, motor, and autonomic changes. The traces were allocated to one of five groups: group 1, wakeful traces with normal alpha in at least one hemisphere; group 2, sleep-like traces with K complexes responsive to stimulation; group 3, traces with phasic activity related to abnormal spontaneous arousal including EEG changes; group 4, traces with abnormal spontaneous arousal activity without EEG changes; group 5, traces with no spontaneous arousal activity. The mean follow up was 21.5 months. Groups 2 and 3 were significantly associated with a good outcome and group 5 with death or a vegetative state. Comparison between the EEG/EEGP findings and the Glasgow coma scale at the time of the recording showed the EEG/EEGP to be the better predictor of outcome, particularly for individual patients.     

Amplitude-integrated EEG is useful in predicting neurodevelopmental outcome in full-term infants with hypoxic-ischemic encephalopathy: a meta-analysis

Hypoxic ischemic encephalopathy is a common cause of neurological complications resulting in chronic handicapping conditions, such as cerebral palsy. Amplitude-integrated electroencephalography (EEG) has been used in many European countries for more than a decade in the evaluation of infants with hypoxic ischemic encephalopathy but has not been widely used in the United States. The objective of this study was to evaluate the evidence supporting use of amplitude-integrated EEG as a quantitative predictor of neurodevelopmental outcome in full-term infants with hypoxic ischemic encephalopathy. To assess efficacy, the authors performed a meta-analysis of the literature evaluating the use of the amplitude-integrated EEG or cerebral function monitor in full-term infants with hypoxic ischemic encephalopathy and their neurodevelopmental outcome. A total of 8 studies were eligible for the primary meta-analysis. There was an overall sensitivity of 91% (95% CI 87-95) and a negative likelihood ratio of 0.09 (95% CI .06-.15) for amplitude-integrated EEG tracings to accurately predict poor outcome. Amplitude-integrated EEG is a valuable bedside tool for predicting long-term neurodevelopmental outcome in term infants with hypoxic ischemic encephalopathy. This information is useful in structuring communication and care plans for physicians and parents. Early assessment techniques such as amplitude-integrated EEG provide objective means for determining inclusion in clinical studies evaluating therapies for hypoxic ischemic encephalopathy and for predicting which patients are most likely to respond to treatment.     

EEG patterns in 10 extreme premature neonates with normal neurological outcome: qualitative and quantitative data

The aim of this prospective study was to describe and quantify EEG patterns in 10 very premature infants (24 weeks 2 days- 26 weeks 4 days GA) without neonatal neurological pathology and with a normal outcome at 3 years of age for nine of them. EEG and eye movements were recorded in the first 5 days of life. All tracings were discontinuous; EEG inactivity (<15 microV) never exceeded 1 min, representing 45.3% of total recording time. The EEG bursts, mainly synchronous, could last up to 83 s when >50 microV and to 197 s when >15 microV. High voltage delta waves (0.5 Hz; up to 330 microV), either smooth or superimposed with 7-12 Hz rhythms, were the most typical and frequent figures, mainly in temporal (mean number 257.2 +/- 73.3) and occipital (237.7 +/- 65.8 per hour recording) areas. In temporal areas, they appeared mainly in clusters; more often unilateral than bilateral (P < 0.05). Occipital delta waves were as often bilateral and synchronous as unilateral. The two distinct frontal delta waves were significantly less numerous than other delta waves (P < 0.05). Bursts of hypersynchronous high voltage delta waves and of diffuse sharp theta waves were less numerous than other waves (P < 0.01). Considering periods with or without eye movements, the mean percentage and the mean longest period of EEG activity (< or =50 microV) were significantly greater (P < 0.01) when eye movements were present, indicating a rough sleep state differentiation as early as 25 weeks CA. These EEG patterns are qualitatively and quantitatively reproducible. They constitute standards of normality and a basis for the determination of neurological prognosis.     

尼莫地平治疗新生儿缺氧缺血性脑病疗效与随访

目的 :观察尼莫地平治疗中、重度新生儿缺氧缺血性脑病 (HIE)疗效及预后。方法 :75例HIE患儿给予支持及对症治疗 ,随机分为两组 ,4 0例加用尼莫地平 3～ 5mg/ (kg ,d) (治疗组 ) ,与 35例不用尼莫地平组对照 (对照组 )。观察两组患儿治疗前后新生儿神经行为评分 (NBNA) ,随访 12个月。结果 :治疗组NBNA≥ 35分 :第 7、14d分别 2 2 (5 5 % )、32 (80 % )例 ;对照组 11(31 4 % )、2 0 (5 7 1% )例 ,两组分别比较差异有显著性 (P均 <0 0 5 )。随访12个月 ,预后不良率治疗组 7 5 % ,显著低于对照组 2 5 7% (χ2 =4 6 0 8,P <0 0 5 ) ,治疗组发育商明显高于对照组(P均 <0 0 5 )。结论 :尼莫地平治疗中、重度新生儿缺氧缺血性脑病 ,能减少后遗症的发生 ,改善其预后     

Damage of thalamus and basal ganglia in asphyxiated full-term neonates

Thalamic-striatal damage of symmetric bilateral distribution was found in four severely asphyxiated neonates born at term. Two patients showed evidence of bilateral thalamic-striatal necrosis and two showed hemorrhage of the same distribution. The four patients had a common history of prolonged asphyxia in the neonatal period combined with severe acidosis and respiratory insufficiency. The outcome was lethal in all children. Three patients survived for some time and showed additional evidence of generalized brain damage including cortical necrosis and subcortical leucomalacia and one patient was found to have intravital calcification of the putamen at 14 days of age. The appearance of thalamic-striatal damage in US, CCT and NMR imaging is discussed. Thalamic-striatal damage may not be detectable by US until several days after the initial insult. US does not permit a distinction between necrosis and hemorrhage, but CCT and NMR imaging may be successful. Only five infants with a comparable pattern of brain damage due to asphyxia have been described so far. Our own studies seem to indicate that thalamic-striatal damage is the hallmark of more widespread brain damage, and that it will be found more frequently if carefully looked for in asphyxiated neonates born at term.     

Impact of anticoagulation on the short-term outcome in a population of neonates with cerebral sinovenous thrombosis: a retrospective study

To investigate the impact of anticoagulation on short-term outcome (1 month) in neonates with cerebral sinovenous thrombosis, the authors conducted a retrospective chart review of neonates admitted to 2 tertiary hospitals over a 5- and 8-year period, respectively. Neonates with confirmed radiographic evidence of cerebral sinovenous thrombosis were included. Eighteen total patients treated with hydration only were identified. Approximately 50% of these neonates showed clot extension or other complications on follow-up imaging that were obtained within 72 hours with either magnetic resonance imaging or computed topography. Five neonates were treated with anticoagulation, and none of these patients developed new infarcts or hemorrhages. The results of this retrospective study suggest that anticoagulation is safe in neonates with cerebral sinovenous thrombosis. Early follow-up scans can help treatment decision. Larger studies are needed to develop standardized guidelines for the evaluation and treatment of neonatal cerebral sinovenous thrombosis.     

Computer interpreted fetal electroencephalogram: sharp wave detection and classification of infants for one year neurological outcome.

The presence of visually discernible sharp waves (SWs) in the fetal electroencephalogram (FEEG) has been found to be associated with abnormal neurological infant outcome, but no method of programmed SW detection for FEEG was available. In order to develop an algorithm for SW detection, the first and second derivatives for visually identified SWs and non-SWs were examined and five random variables chosen for discriminant function analysis (DFA). The resulting equation, incorporated into program logic along with logic for artifact rejection, produced classifications from 85% to 89% consistent with visual identifications, suggesting that the number of SWs/epoch (NSW) corresponds with visually identified SWs. In addition, in 61 cases using a threshold for NSW derived by DFA, computer recognized SWs were found to be significantly related to the overall visual interpretation of the tracings (P less than 0.005). Finally, NSW alone produced correct classification of 65.5% of infants for 1 year neurological outcome. The overall consistency was increased to as high as 80% using additional FEEG and neonatal data. These findings imply that some forms of brain damage are present before birth and can be detected during labor using FEEG.     

新生儿缺氧缺血性脑病血清IL-18变化的临床意义

目的研究新生儿缺氧缺血性脑病发病过程中血清(白介素-18)IL-18水平变化,探讨IL-18在判断新生儿缺氧缺血性脑损伤的程度和预后的临床价值。方法采用酶联免疫吸附试验检测42例足月HIE患儿(轻度24例,中度10例,重度8例)及20例正常足月新生儿生后第1天、第7天血清IL-18水平,并于生后第7天做新生儿行为神经测定(NBNA),比较各组间各指标的差异;建立受试者工作曲线(ROC曲线),确定血清IL-18 ROC曲线下的面积(AUC),同时分析不同截断值的敏感度、特异度、阳性和阴性预测值。结果 (1)轻度HIE组与中、重度HIE组患儿的IL-18水平较对照组显著升高,P0.01;(2)不同程度HIE组IL-18水平随脑损伤程度加重而增加,各组间差异显著,P0.01;(3)各组HIE患儿恢复期(生后7d)血清IL-18水平较急性期(生后1 d)均有明显下降,各组间有显著性差异,P0.01;(4)IL-18的AUC为89.8%,当IL-18600.36 ng/L时,其敏感度、特异度、阳性及阴性预测值分别为89.2%、86.8%、87.1%、89.2%。结论动态监测IL-18水平变化可以作为HIE患儿早期预后判断的辅助性指标。     

Acute necrotizing encephalopathy: combined therapy and favorable outcome in a new case

BACKGROUND: Acute necrotizing encephalopathy (ANE) is a rare disease characterized by multiple, symmetrical brain lesions, affecting thalami, brainstem tegmentum, and cerebellar medulla; more inconstantly, other structures are involved, i.e., internal capsules, posterolateral putamen, and deep periventricular white matter. FEATURES: The clinical picture consists of rapidly deteriorating acute monophasic encephalopathy preceded by prodromal febrile illness; the symptoms include hyperpyrexia, convulsions, recurrent vomiting, and coma within 24 h. PROGNOSIS: The outcome is usually poor and approximately 70% of the patients die within a few days from the onset of fever. There is no specific therapy for ANE but, in some patients, the clinical status improved with steroid treatment.     

Physiological correlates of sleep development in premature and full-term neonates.

Differentiation of motor and automatic function control during different sleep states appears early in human ontogeny. Time of first appearance, magnitude of between-state differences and modifications with age depend on which particular parameters are considered. For some parameters, significant between-state differences appear at 31 weeks conceptional age (wk CA). For nearly all parameters, this difference is clear from 35 wk CA onwards. The analysis presented herein is based on studies of body movements, spontaneous skin potential responses, respiratory characteristics, heart rate and heart rate variability, and correlations between different functions. It examines clinically and neurologically normal premature and full-term neonates of 28-41 wk CA.     

Prediction of outcome in multiple sclerosis based on multivariate models

An incidence cohort of 308 multiple sclerosis patients was followed up repeatedly during at least 25 years of disease. In the patients with acute onset, multivariate survival analyses were performed and predictive models created. The endpoints DSS 6 and start of progressive disease were used. A number of variables were tested. The most important of these for prediction and therefore included in these models were: age at onset, sex, degree of remission after relapse, mono- or polyregional symptoms, type of affected nerve fibres, number of affected neurological systems. The relapse rate did not correlate with prognosis. In the predictive models, coefficients and risk ratios are provided that can be used for calculating the risk of progression and DSS 6 or to predict the median time for these endpoints in individual patients. It was also found that the risk of progression is not constant, but has a maximum a certain time after disease onset. For a patient with early onset, the risk is low in the beginning, but reaches a maximum level, which is several times higher, after about 15 years. The patient with a late onset has a much higher risk of endpoint immediately after onset, but reaches the maximum in a few years, and after that the risk decreases