Early Identification of Neurological Abnormalities in the NICU Infant

1. Early Identification of Neurological Abnormalities in the NICU Infant Max Wiznitzer, M.D. Division of Pediatric Neurology Rainbow Babies and Children’s Hospital Cleveland, Ohio

2. Common Problems in the NICU • Prematurity • IVH=Intraventricular Hemorrhage • PVL=Perventricular Leukomalacia • Neonatal encephalopathy • Hypoxic-Ischemic • Infarction • Seizures

3. Intraventricular Hemorrhage • Causation • Preterm • Term • Presentation • Catastrophic- Fortunately rare • Saltatory-More common; stuttering evolution • Silent-Most common • Grading severity

4. *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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7. *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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11. *Clinical Features • Catastrophic Syndrome • Evolves in minutes to hours • Deep stupor or coma • Respiratory arrhythmia, hypoventilation, apnea • Generalized tonic seizures, “Decerebrate” posturing • Eyes- Pupils fixed, no Doll’s eye • Flaccid quadriparesis

12. *Clinical Features • Catastrophic Syndrome (cont.) • Falling Hematocrit • Bulging Anterior Fontanelle • Hypotension, Bradycardia • Temperature derangements • Metabolic acidosis, DIC, Jaundice • Abnormalities of glucose and water homeostasis (Hyperglycemia, SIADH)

13. *Clinical Features • Saltatory syndrome • Stuttering evolution : hours to day • Altered level of consciousness • Altered motility (usually decreased ) • Hypotonia • Abnormally tight popliteal angle (84% if IVH, 10% if no IVH) • Abnormal eye position / movement • Respiratory disturbance

14. *Clinical Features • Clinically silent syndrome: • Careful, serial clinical assessments will miss 25-50% of infants with IVH • Most valuable sign is unexplained fall of Hematocrit or failure of Hematocrit to rise after a transfusion • More common with smaller bleeds (with associated better prognosis )

15. Intraventricular Hemorrhage • Consequences • Hydrocephalus • Germinal matrix damage • Hemorrhagic infarction • Assessment • Ultrasound • MRI • Evoked potentials

16. Neonatal Encephalopathy • Periventricular Leukomalacia • Hypoxic-ischemic encephalopathy • Near total/profound asphyxia • Prolonged partial asphyxia • Infarction (stroke) • Arterial • Venous

17. Hypoxic-ischemia Encephalopathy • Diagnosis • Clinical evolution • Impact and timing of cell death • Necrosis • Apoptosis • Radiologic assessment • Ultrasound • CT scan • MRI • Use of EEG

19. Use of Technology for Early Identification of Problems • MRI • Evoked potentials • EEG • Near Infrared Spectroscopy • Examination • Analysis of Angles (Amiel-Tison) • Assessment of general movements (Prechtl)