Cerebral dysfunctions related to perinatal organic damage: Clinical–neuropathologic correlations

Multifocal haemorrhagic brain damage following hypoxia and blood pressure lability: case report and rat model

AIMS

Haemorrhagic brain damage is frequently encountered as a complication of premature birth. Much less frequently, multifocal petechial haemorrhage is identified in asphyxiated term newborns. Our goal was to develop an experimental rat model to reproduce this pattern of brain damage.

METHODS

Neonatal rat pups were exposed to a 24-h period of 10% or 8% hypoxia followed by a single dose of phenylephrine. Acute and subacute changes, as well as long-term outcomes, were investigated by histology, brain magnetic resonance imaging and behavioural assessment. Immunostaining for vascular endothelial growth factor and caveolin-1 was performed in the rat brains as well as in a 17-day human case.

RESULTS

Small foci of haemorrhage were identified in almost all regions of the rat brain subjected to hypoxia plus phenylephrine, but not hypoxia alone. Exposure to 8% hypoxia was associated with more haemorrhagic foci than 10% hypoxia. With rare exceptions, the blood deposits were too small to be detected by magnetic resonance imaging. Altered immunohistochemical detection of vascular endothelial growth factor and caveolin-1 in the child and the rat model suggests a role for blood-brain barrier compromise. There were no clear behavioural changes and no residual morphological abnormalities in the 78-day follow-up of the rats.

CONCLUSIONS

We conclude that transient hypoxia, in a dose-dependent manner, can weaken the vasculature and predispose to brain haemorrhage in the situation of labile blood pressure. Persistent hypoxia is likely to be important in the genesis of permanent severe brain damage.

Low Apgar scores and birth asphyxia. Misconceptions that promote undeserved negligence suits

The temptation to specify cause-and-effect relationships in cases of neurologic handicap has created a number of misconceptions that have stimulated irresponsible malpractice litigation focusing on childbirth. Paradoxically, the number of such lawsuits is on the increase, even though obstetric and neonatal care has improved dramatically since Virginia Apgar introduced her scoring system in 1953. Nowadays, no evidence of intrapartum hypoxia is found in the majority of newborns who require resuscitation. Consequently, the value of using the Apgar score as an index for assessing asphyxia should be vigorously questioned. It should also be stressed that asphyxial damage may occur without respiratory depression. The recent proliferation of articles linking fetal scalp or cord blood evidence of metabolic acidosis to birth asphyxia threatens to create another legal booby trap. Although the development of fetal metabolic acidosis reflects oxygen deprivation, this fact should not be misconstrued to mean that any degree of oxygen deprivation can damage the brain. Available data make it quite clear that the fetus can sustain transient episodes of hypoxemia without ill effects. In those neonates born with low Apgar scores, cord blood gases should be measured to exclude hypoxemia. Securing such data can protect practitioners from subsequent legal inquiry. Routine determination of cord blood gases is not recommended, however, because a substantial number of newborns who are born acidotic have normal Apgar scores.(ABSTRACT TRUNCATED AT 250 WORDS)

Persisting subsensitivity of the striatal dopamine system after fetal exposure to beta-endorphin

Fetal exposure of rats to beta-endorphin during the third trimester, either alone or with alpha-MSH, resulted in mild developmental delay and significant decreases in striatal dopamine receptor density (subsensitivity) persisting through maturity. The apparent paradoxical down-regulation of dopamine receptors in the presence of beta-endorphin was consistent with fetal exposure to dopamine receptor antagonists and synthesis inhibitors. These findings suggest biophysical properties of receptors which are unique to fetal development including loss of plasticity after exposure to antagonists. Permanent, down-regulation of the striatal dopamine system may be one mechanism underlying delayed development after fetal exposure to beta-endorphin which may accompany hypoxia. Even though there were no statistically significant differences between males and females in density of the dopamine receptor, the behavioral profile after peptide treatment was sexually demorphic. Behaviorally, female rats appeared sensitized to perinatal alpha-MSH and males to alpha-endorphin.

Cognitive, perceptual, and personal-social development of prematurely born preschoolers

This study was designed to determine possible differences in the cognitive, perceptual, and personal-social development of prematurely and maturely born 3-yr.-olds which might foreshadow later learning problems. The subjects were 40 prematurely born graduates of a neonatal intensive care unit (birth weight less than 2,500 gm, less than 37 wk. gestation) matched on the pair-level with full-term controls on sex, race, post-conceptual age, and socioeconomic background. All subjects were singletons and parity was matched at the group level. No differences were found between the groups on tests of higher mental processes including the General Cognitive, Verbal, Quantitative, and Memory Scales of the McCarthy Scales of Children's Abilities, and researcher-devised measures of problem-solving competence. No differences in parental reports of personal-social development were noted. Prematures did not perform as well as controls on perceptual performance tasks, and this difference was interpreted as reflecting relatively impaired visual-motor coordination.

Perceptual-motor deficiency in autistic children

15 autistic children were matched with normals on the Beery-Buktenica Developmental Test of Visual-motor Integration. The two groups were subsequently compared on ability to (1) increase geometric figure-copying performance using additional information provided during subsequent trials, (2) make figure-ground resolutions, (3) perform a fine motor integration task, and (4) cope with background interference while responding on the Developmental Test of Visual-motor Integration. The primary deficit observed in the autistic subjects appeared to be defective monitoring of the motor response.