Neonatal lenticulostriate vasculopathy: further characterisation

Lenticulostriate Vasculopathy in Very-Low-Birth-Weight Preterm Infants: A Longitudinal Cohort Study

Background: The pathogenesis and clinical significance of lenticulostriate vasculopathy (LSV) are unclear. Our study aimed to determine the prevalence, presentation, and evolution of LSV, and the perinatal risk factors associated with LSV among very-low-birth-weight (VLBW) preterm infants. Methods: One-hundred-and-thirty VLBW preterm infants were retrospectively enrolled in this study. Serial cranial ultrasound examinations were performed regularly from birth until a corrected age of 1 year. Infants with LSV were assigned to early-onset (≤10 postnatal days) and late-onset (>10 postnatal days) groups. Data describing the infants’ perinatal characteristics, placental histopathology, and neonatal morbidities were collected, and the groups were compared. Results: Of the VLBW infants, 39.2% had LSV before they were 1 year old. Linear-type LSV was the most common presentation, and >50% of the infants had bilateral involvement. LSV was first detected at 112 ± 83 postnatal days, and its detection timing correlated negatively with gestational age (GA) (R² = 0.153, p = 0.005) and persisted for 6 months on average. The infants with and without LSV had similar perinatal characteristics, placental pathologies, cytomegalovirus infection rates, and clinical morbidities. The late-onset LSV group comprised 45 (88.2%) infants who had a significantly higher rate of being small for gestational age (SGA) and used oxygen for longer than the infants without LSV. After adjusting a multivariable regression model for GA and SGA, analysis showed that the duration of oxygen usage was an independent risk factor for late-onset LSV development in VLBW infants (odds ratio: 1.030, p = 0.032). Conclusion: LSV may be a nonspecific marker of perinatal insult to the developing brains of preterm infants. Prolonged postnatal oxygen usage may predispose VLBW preterm infants to late-onset LSV development. The long-term clinical impacts of LSV should be clarified.

Cranial US in Infants Exposed to Zika Virus: The NATZIG Cohort

Background Studies addressing neuroimaging findings as primary outcomes of congenital Zika virus infection are variable regarding inclusion criteria and confirmatory laboratory testing. Purpose To investigate cranial US signs of prenatal Zika virus exposure and to describe frequencies of cranial US findings in infants exposed to Zika virus compared to those in control infants. Materials and Methods In this single-center prospective cohort study, participants were enrolled during the December 2015-July 2016 outbreak of Zika virus infection in southeast Brazil (Natural History of Zika Virus Infection in Gestation cohort). Eligibility criteria were available cranial US and laboratory findings of maternal Zika virus infection during pregnancy confirmed with RNA polymerase chain reaction testing (ie, Zika virus-exposed infants). The control group was derived from the Zika in Infants and Pregnancy cohort and consisted of infants born to asymptomatic pregnant women who tested negative for Zika virus infection during pregnancy. Two radiologists who were blinded to the maternal Zika virus infection status independently reviewed cranial US scans from both groups and categorized them as normal findings, Zika virus-like pattern, or mild findings. Associations between cranial US findings and prenatal Zika virus exposure were assessed with univariable analysis. Results Two hundred twenty Zika virus-exposed infants (mean age, 53.3 days ± 71.1 [standard deviation]; 113 boys) and born to 219 mothers infected with Zika virus were included in this study and compared with 170 control infants (mean age, 45.6 days ± 45.8; 102 boys). Eleven of the 220 Zika virus-exposed infants (5%), but no control infants, had a Zika virus-like pattern at cranial US. No difference in frequency of mild findings was observed between the groups (50 of 220 infants [23%] vs 44 of 170 infants [26%], respectively; P = .35). The mild finding of lenticulostriate vasculopathy, however, was nine times more frequent in Zika virus-exposed infants (12 of 220 infants, 6%) than in control infants (one of 170 infants, 1%) (P = .01). Conclusion Lenticulostriate vasculopathy was more common after prenatal exposure to Zika virus, even in infants with normal head size, despite otherwise overall similar frequency of mild cranial US findings in Zika virus-exposed infants and in control infants. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Benson in this issue.

Cerebrovascular Complications of Pediatric Blunt Trauma

Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.

Lenticulostriate vasculopathy in preterm infants: a new classification, clinical associations and neurodevelopmental outcome

OBJECTIVE

To examine the inter-rater reliability for the diagnosis of LSV on cranial ultrasound (cUS), determine the risk factors associated with LSV and its progression, and examine neurodevelopmental outcome.

STUDY DESIGN

Prospective case-control study of neonates ≤32wks of gestation assessed for LSV by serial cUS (n = 1351) between 2012 and 2014 and their neurodevelopment at 18-36mon-corrected age compared to controls.

RESULTS

Agreement for LSV on cUS improved from Κappa 0.4-0.7 after establishing definitive criteria and guidelines. BPD was the only variable associated with the occurrence and the progression of LSV. Cytomegalovirus (CMV) infection occurred in one neonate (1.5%). Neurodevelopmental outcome of neonates with LSV did not differ from controls.

CONCLUSIONS

Establishment of well-defined stages of LSV improves the reliability of the diagnosis and allows identification of neonates with progression of LSV. Although LSV was associated with BPD, it was not associated with congenital CMV infection.

Stroke After Minor Head Trauma in Infants and Young Children With Basal Ganglia Calcification: A Lenticulostriate Vasculopathy?

The authors retrospectively reviewed charts of the children with basal ganglia stroke who either had preceding minor head injury or showed basal ganglia calcification on computed tomography (CT) scan. Twenty children, 14 boys and 6 girls were identified. Eighteen were aged between 7 months to 17 months. Presentation was with hemiparesis in 17 and seizures in 3. Preceding minor head trauma was noted in 18. Family history was positive in 1 case. Bilateral basal ganglia calcification on CT scan was noted in 18. Brain magnetic resonance imaging done in 18 infants showed acute or chronic infarcts in basal ganglia. Results of other laboratory and radiological investigations were normal. Four infants were lost to follow-up, 9 achieved complete or nearly completely recovery, and 7 had persistent neurological deficits. Basal ganglia calcification likely represents mineralized lenticulostriate arteries, a marker of lenticulostriate vasculopathy. Abnormal lenticulostriate vessels are vulnerable to injury and thrombosis after minor head trauma resulting in stroke.

Mineralizing Angiopathy with Basal Ganglia Stroke after Minor Trauma: Case Series Including Two Familial Cases

Introduction:

Basal ganglia stroke following trauma has been known to occur and described in previous case studies. But exact etiology is unknown.

Aim:

To study the clinical characteristics, imaging features, and neurodevelopmental outcomes of children presented with basal ganglia stroke associated with mineralization in the lenticulostriate arteries in our center from January 2013 to June 2016.

Subjects and Methods:

Children with subcortical stroke during the study period were identified retrospectively, and those presented with basal ganglia stroke with mineralization of lenticulostriate vessels were analyzed for clinical profile, imaging features, and outcomes. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS) software, version 17 (IBM, New York).

Results:

Of 38 children with basal ganglia stroke (20 boys, 18 girls, and mean age at presentation 14.026±5.8470 months), 27 had history of trauma preceding the stroke. Thirty-seven children presented with hemiparesis and one presented with hemidystonia. The mean follow-up time was 8 months, three children developed recurrence during that period. Five children with recurrence of stroke, initial episodes were not evaluated as they presented to us for the first time. A total of 17 of 30 infants who did not have stroke recurrence were normal on follow-up, whereas 9 infants showed persistent mild hemiparesis, 2 had motor delay, and 2 others had mild residual distal weakness. No identifiable causes were observed for vascular calcification. Two familial cases were also noted.

Conclusion:

Most common cause for acute basal ganglia stroke in toddlers was mineralizing angiopathy of lenticulostriate vessels. It was preceded by minor trauma in most cases.

Is lenticulostriated vasculopathy an unfavorable prognostic finding in infants with congenital cytomegalovirus infection?

BACKGROUND

Lenticulostriated vasculopathy (LSV) detected in head ultrasound (HUS) has been related to neurological and hearing sequelae in infants with congenital cytomegalovirus (cCMV) infection.

OBJECTIVE

To assess the role of LSV in predicting neurodevelopmental and hearing outcomes in infants with cCMV infection.

STUDY DESIGN

We enrolled consecutive infants who were affected by cCMV infection and underwent HUS within the first month of life. Data on clinical onset and course, laboratory findings, visual/hearing functions and neurodevelopmental outcome were collected. As controls, infants with suspected intrauterine exposure to Toxoplasma and with no confirmed congenital toxoplasmosis were considered.

RESULTS

Data from 161 infants with cCMV infection (105 symptomatic) and 133 controls were analyzed. HUS was normal in 66 (41%) cCMV patients. Among these, 28 (42.4%) were symptomatic and 38 (57.6%) asymptomatic infants. The percentage of patients with no HUS abnormalities was higher in asymptomatic (38/56, 67.9%) than in symptomatic infants (28/105, 26.7%) (p<0.05). LSV, as isolated or associated with other brain abnormalities, was diagnosed in 64/161 (39.7%) patients with cCMV compared to 24/133 (18%) controls (p<0.05). In cCMV group, LSV was found in 51 (48.6%) symptomatic infants and in 13 (72.2%) asymptomatic patients (p>0.05). Overall, in the whole population of 95 patients with cCMV and abnormal HUS results, LSV (alone or with other findings) did not represent a risk factor for unfavorable neurological and hearing outcome. Similar results were obtained when we limited the analysis to the group of symptomatic cCMV patients.

CONCLUSIONS

Although LSV is a common HUS finding in infants with cCMV infection, its presence is not predictive of an adverse outcome. Our data suggest that HUS as a single neuroimaging investigation is unreliable in selecting candidates to antiviral therapy, mainly in presence of LSV as isolated finding.

Sleep-wake cycle on amplitude-integrated EEG and neuroimage outcomes in newborns

BACKGROUND

The aim of this study was to evaluate the results of sleep-wake cycle monitoring using amplitude-integrated EEG (aEEG) and neuroimaging in newborn infants with a possible perinatal hypoxic insult, investigate the correlation between the findings, and determine the relevance of the findings to reasonably predict neurological outcome.

METHODS

aEEG was recorded among newborn infants suspected of perinatal asphyxia between November, 2014 and June, 2015 in one neonatal intensive care unit facility. Brain imaging with serial ultrasonography and MRI when available were performed, and the infants were divided into two groups according to findings and potential neurological outcome: Group I (favorable findings) and Group II (severe findings such as high grade intraventricular hemorrhage, cerebral infarction or white matter injury). Established sleep-wake cycle times after birth was compared between the two groups.

RESULTS

Among 107 newborn infants, 85 subjects were classified as Group I and the remaining 22 subjects as Group II. The total number of aEEG sessions was 207 and recording time was 2,796 h with a mean of 14.43 ± 13.40 h per study. Estimated times of cyclicity were earlier in Group I (113.34 h, 95 % CI 82.31-144.37) as compared to Group II (504.39 h, 95 % CI 319.91-688.88; p < 0.001).

CONCLUSIONS

Delayed cyclicity on aEEG has a strong correlation with unfavorable brain neuroimages in newborns with possible perinatal asphyxia. If sleep-wake cycles do not appear during initial period after birth, follow-up aEEG studies are recommended.

TRIAL REGISTRATION

Retrospectively registered Registration number: BD 2015-148 Name of registry: amplitude integrated EEG in neonate Date of registration: September 9, 2015.

Risk factors and associated diseases among preterm infants with isolated lenticulostriate vasculopathy

OBJECTIVE

To determine the prevalence, risk factors and diseases associated with isolated lenticulostriate vasculopathy (LSV) among preterm infants.

STUDY DESIGN

Medical records of 84 preterm infants (gestational age (GA) 25 to 34 weeks) with isolated LSV in a case-control retrospective study over a period of 6.5 years were reviewed and compared with matched control infants. LSV was defined as 'early' if it was documented in head ultrasound (HUS) before or on the fifth day of life and 'late' if it was not present in the first HUS and recorded later during neonatal hospitalization.

RESULTS

A 3.9% prevalence of LSV was recorded among preterm infants (GA⩽34 weeks). Study and control groups were similar for all maternal parameters, neonatal outcomes and length of hospitalization. Infants with late LSV had more neonatal complications than control infants and were born with younger GA and lower birth weight in comparison to infants with early LSV. More infants with late LSV needed mechanical ventilation, were diagnosed with bronchopulmonary dysplasia and were hospitalized longer in comparison to infants with early LSV. Urine cytomegalovirus was negative in the entire study group.

CONCLUSIONS

No risk factors or specific associated morbidities were identified among preterm infants with early isolated LSV. Infants with late isolated LSV were younger and had overall increased associated morbidities. Long-term outcome studies are needed to determine LSV impact.

Lenticulostriate Vasculopathy in Brain Ultrasonography is Associated with Cytomegalovirus Infection in Newborns

BACKGROUND

Lenticulostriate vasculopathy is associated with various disorders, in particular cytomegalovirus infection, which can cause neurological consequences. We wanted to evaluate the association of lenticulostriate vasculopathy and cytomegalovirus infection. We retrospectively collected data on lenticulostriate vasculopathy from 858 neonatal ultrasonography scans.

METHODS

Fifty-five patients with lenticulostriate vasculopathy were diagnosed. Lenticulostriate vasculopathy was classified as severe and mild according to the ultrasonographic findings. We analyzed gender, unilateral and bilateral lenticulostriate vasculopathy, mild and severe lenticulostriate vasculopathy, intrauterine growth retardation, and lenticulostriate vasculopathy associated with other brain malformations to determine whether they were correlated with cytomegalovirus infection.

RESULTS

Neonatal cytomegalovirus infections correlated primarily with lenticulostriate vasculopathy that was associated with brain structure anomalies p < 0.0001, followed by severe lenticulostriate vasculopathy (p = 0.029). Cytomegalovirus urine polymerase chain reaction ratios were 69% for severe and 23% for mild lenticulostriate vasculopathy (p = 0.002; odds ratio = 7.33). Of 72 newborns with intrauterine growth retardation without lenticulostriate vasculopathy, 33 were analyzed for cytomegalovirus, of whom only one was positive, which was significantly different from the newborns with lenticulostriate vasculopathy (p = 0.003; odds ratio = 11.64).

CONCLUSION

Lenticulostriate vasculopathy on neonatal ultrasonography is useful for predicting cytomegalovirus infection, particularly in severe lenticulostriate vasculopathy. When severe lenticulostriate vasculopathy is associated with a brain structure anomaly, cytomegalovirus infection should be considered. The outcomes for the cases in which cytomegalovirus infection was associated with other brain structure anomalies were significantly worse than the outcomes in cases associated with lenticulostriate vasculopathy only.

Lenticulostriated vasculopathy is a high-risk marker for hearing loss in congenital cytomegalovirus infections

AIM

This study investigated the relationship between lenticulostriated vasculopathy (LSV) and hearing loss in 141 infants with congenital cytomegalovirus (cCMV) infection.

METHODS

We included all infants with cCMV infection who were followed in our clinic for more than a year with only LSV signs of brain involvement on initial brain ultrasound. Group one comprised 13 infants with no hearing impairment at birth who were not treated with gan/valganciclovir during 2006-2009. Group two was 51 infants with LSV and no hearing impairment who had been treated since mid-2009. Group three was 25 infants born with LSV and hearing loss, who had been treated from birth. Group four was 52 control infants born during the same period with asymptomatic cCMV. Hearing tests were performed during the neonatal period and every four to six months until four years of age.

RESULTS

Hearing deterioration was more extensive in group one (85%) than in group two (0%, p < 0.001) and the asymptomatic group (10%, p < 0.001) and occurred more often in group four (10%) than in group two (0%, p = 0.008).

CONCLUSION

Lenticulostriated vasculopathy was common in infants with cCMV infection and may serve as a sign of central nervous system involvement and further hearing deterioration. Antiviral treatment may be prudent in such infants.

Lenticulostriate vasculopathy in neonates: Is it a marker of cerebral insult? Critical review of the literature

Although lenticulostriate vasculopathy (LSV) was recognized nearly 30 years ago, neonatologists and radiologists still question its clinical significance. The diagnosis of LSV may be highly subjective, resulting in many false negatives when the radiologist is not familiar with the lesion or false positive if over-read by those with special interest in this finding. There has been an increase in incidence of LSV since its recognition in 1985 which might reflect nothing more than a growing awareness of this finding on neonatal cranial ultrasound. On the other hand, improved ultrasound imaging technology may have enhanced identification of LSV. Prospective studies evaluating the presence, significance and diagnosis of LSV are limited and have produced conflicting results. Therefore, the associated risk factors and clinical relevance of LSV on cranial ultrasound remain unclear. This review will examine the existing literature.

Lenticulostriate vasculopathy in neonates: Perspective of the radiologist

Lenticulostriate vasculopathy (LSV) is a diagnosis dependent on neonatal cranial ultrasound (US). The diagnosis of LSV requires the presence of linear or branching echogenicities in the area of the basal ganglia and/or thalamus on gray scale cranial US. Although the diagnosis of LSV is dependent on cranial US, there are no convincing correlates observed on either computerized tomography or magnetic resonance imaging. Moreover, the radiographic criteria for LSV on cranial US remain vague, and intra-observer correlations are generally reported to be poor. The purpose of this review is to examine the issues associated with the use of cranial US and the diagnosis of LSV, including alternative imaging, clinical abnormalities and the significance of LSV on cranial US.

The etiology of lenticulostriate vasculopathy and the role of congenital infections

Lenticulostriate vasculopathy (LSV) refers to increased echogenicity of the penetrating vessels that supply the basal ganglia and segments of the internal capsule seen on cranial ultrasound. Initially identified in infants with congenital infection, LSV has now been associated with a variety of infectious and non-infectious conditions. Although robust epidemiologic studies are lacking, the available evidence does not support broad evaluation for multiple congenital infections when LSV is identified. We propose screening infants with LSV for congenital cytomegalovirus infection and ensuring that prenatal screening included appropriate testing for syphilis, human immunodeficiency virus, and rubella-immune status. Large, prospective observational studies are needed to determine the incidence of LSV and the relative contribution of infectious and non-infectious conditions to LSV in the neonate.

Imaging patterns of sonographic lenticulostriate vasculopathy and correlation with clinical and neurodevelopmental outcome

PURPOSE

To evaluate the relationship between the imaging patterns of lenticulostriate vasculopathy (LSV) and clinical outcomes.

METHODS

We performed cranial sonography (US) in 110 neonates and evaluated the patterns of visible lenticulostriate vessels with three grades: 0: no vessel seen; 1 (low grade): one or two thin branches seen; and 2 (high grade): more than three prominent branches seen. Color Doppler US was performed on these vessels to evaluate the presence of flow. Associated underlying diseases and the presence of neurodevelopmental delay on follow-up were reviewed retrospectively.

RESULTS

There were 51 neonates with associated underlying diseases, including congenital heart diseases (CHD) (n = 34) and neonatal hypoxia (n = 13). Sonographic LSV was detected in 29.1% cases (22 low- and 10 high-grade cases). Doppler flow was not detected in three patients with CHD (p = 0.028). CHD (odds ratio [OR], 25.73; p < 0.001), neonatal hypoxia (OR, 7.00; p = 0.020), two underlying diseases (OR, 73.232; p < 0.001), high-grade LSV (OR, 16.29; p = 0.005), and absent color Doppler flow (OR, 40.80; p = 0.046) were significantly associated with neurodevelopmental delay in univariate analysis. In multivariate analysis, underlying diseases and absent color Doppler flow were associated with neurodevelopmental delay. Both high LSV grade (area under the receiver operating characteristic curves of 0.901; 95% confidence interval, 0.823-0.979) and absent color Doppler flow (area under the receiver operating characteristic curves of 0.874; 95% confidence interval, 0.803-0.945) had a high predictive power for neurodevelopmental delay.

CONCLUSIONS

High-grade sonographic LSV and absent color Doppler flow on lenticulostriate vessels were significantly associated with neurodevelopmental delay.

Miller-dieker syndrome associated with congenital lobar emphysema

Miller-Dieker syndrome (MDS) is a rare genetic syndrome associated with lissencephaly, developmental delay, and high mortality. We describe a patient who was diagnosed postnatally with both MDS and congenital lobar emphysema. We believe that this is the first reported case of the two conditions presenting in the same patient.

Lenticulostriate vasculopathy in extremely low gestational age newborns: Inter-rater variability of cranial ultrasound readings, antecedents and postnatal characteristics

Although lenticulostriate vasculopathy (LSV) was first detected on a cranial ultrasound nearly 30 years ago, its clinical implications and significance remain unknown. The objective of this study was to evaluate the inter-rater reliability of cranial ultrasound readings of LSV, and to explore relationships with potential antecedents and developmental correlates in extremely low gestational age newborns. Of the 1506 infants enrolled during the years 2002-2004, 1450 had at least one set of ultrasound scans evaluated for LSV and 939 had all three sets. To evaluate the inter-rater agreement for identifying LSV, we compared readings from two independent radiologists on days 1-4, 5-14, and on or after day 15. We then evaluated the relationships between LSV and maternal, antenatal, and postnatal characteristics. Our results showed that kappa values were 0.18, 0.33, and 0.36 on days 1-4, days 5-14, and day 15 or greater. Infants who were identified as LSV positive by two readers had higher Score for Neonatal Acute Physiology-II (an illness severity indicator), higher rates of tracheal infection and bacteremia, lower partial pressure of arterial oxygen and pH levels on 2 of the first 3 postnatal days, and they were more likely to have a lower psycho-motor development index at age 2 years. Positive agreement on the presence of LSV was low, as was the kappa value, an index of inter-rater reliability. Infants with high illness severity scores and their correlates were at increased risk of developing LSV, while those who develop LSV appear to be at increased risk of motor dysfunction.

Mineralizing angiopathy with infantile basal ganglia stroke after minor trauma

AIMS

The objective of this study was to describe a cohort of infants with basal ganglia stroke associated with mineralization in the lenticulostriate arteries and their clinical outcomes.

METHOD

Subcortical strokes occurring in infants during the study period were categorized as arterial ischaemic, venous, or haemorrhagic. A cohort of infants with basal ganglia infarcts and associated mineralization of lenticulostriate arteries were identified. This group was analysed for possible aetiological factors, clinical course, and recurrence rate of the stroke.

RESULTS

Of 23 infants with basal ganglia arterial ischaemic stroke, 22 (16 males, six females; mean age 11mo [±SD 4.8mo]) were found to have lenticulostriate artery mineralization. Twenty infants presented with hemiparesis and two presented with recurrent episodes of hemidystonia. Eighteen infants had a history of minor trauma before onset of stroke. No other predisposing factors were identified in this cohort. There were no demonstrable causes for vascular and soft tissue calcification. The mean follow-up was 11 months, during which five infants experienced stroke recurrence. Of the 17 infants who did not experience a recurrent stroke, eight exhibited complete neurological recovery, and nine had mild residual hemiparesis.

INTERPRETATION

Acute basal ganglia stroke after minor trauma associated with mineralization of lenticulostriate arteries in infants is a distinct clinicoradiological entity. Investigations for prothrombotic states and vasculopathies are normal. Although neurological outcomes in most children are good, trauma is a risk factor for recurrence of stroke.

Does lenticulostriate vasculopathy predipose to ischemic brain infarct? A case report

Lenticulostriate vasculopathy (LSV) is a sonographic finding in infancy with obscure etiology and variable diagnostic and prognostic significance. Ischemic infarct in the territory of the lenticulostriate vessels after mild head trauma is a rare pathology. There are no publications on LSV followed by ischemic infarct. We present the case of an 8-month-old boy who suffered mild head trauma and developed an ischemic brain infarct in the territory of preexisting LSV. It is speculated that LSV might be a predisposing factor for ischemic brain infarct after mild head trauma in infants.

State-of-the-art cranial sonography: Part 2, pitfalls and variants

OBJECTIVE

In the first part of this article, modern cranial sonography techniques and interpretation were discussed, emphasizing ways in which the application of modern imaging technology and techniques are able to enhance detection of pathologic abnormalities on cranial sonography.

CONCLUSION

In this part of the article, we will describe pitfalls and variants that may be confused with pathologic abnormalities. Emphasis will be placed on recognizing normal variations and distinguishing them from pathologic abnormalities that may require additional imaging or clinical follow-up.

Infant craniospinal ultrasonography: beyond hemorrhage and hydrocephalus

Ultrasonography is widely used for screening for neonatal intracranial hemorrhage, hydrocephalus, and cord tethering in young infants. Proper interpretation of infant cranial and spinal ultrasound examinations requires not only familiarity with the appearances of these disorders, but also recognition of imaging artifacts capable of mimicking pathology and awareness of developmental variants and conditions that occupy a borderline position along the spectrum from normal to abnormal. This article will review the current understanding of the ultrasonographic characteristics and clinical relevance of these imaging artifacts, developmental variants, and quasi-pathologic conditions to avoid diagnostic pitfalls and guide appropriate patient management.

Association between X-linked lissencephaly with ambiguous genitalia syndrome and lenticulostriate vasculopathy in neonate

X-linked lissencephaly with ambiguous genitalia syndrome (XLAG) (OMIM #3000215) is a rare, severe malformation of the brain cortex with abnormal neuronal migration caused by mutations of the ARX gene. All the reported patients with lissencephaly are males who presented with a posterior-to-anterior gradient, moderately increased thickness of the brain cortex, agenesis of corpus callosum, micropenis, and cryptorchidism. We describe the neurosonographic findings associated with the XLAG syndrome. To our knowledge, the association between XLAG and lenticulostriate vasculopathy has not been reported before.

Lenticulostriate vasculopathy in twin-to-twin transfusion syndrome

Intracranial pathology is a common and important complication in extremely low birth weight babies. Lenticulostriate vasculopathy (LSV) is an abnormal finding on cranial ultrasounds of sick babies and has been associated with congenital infection, chromosomal aberration and twin-to-twin transfusion. We describe a previously unreported situation of LSV being detected in both donor and recipient twin. This pair of monochorionic, diamniotic twins was admitted to the Neonatal Intensive Care Unit at 28 weeks of gestation. The mother underwent an emergency caesarean section because ultrasound and Doppler studies showed stage III twin-to-twin transfusion syndrome. The first twin weighed 998 g and second twin weighed 600 g. The first twin had an uneventful stay, whereas the second twin needed prolonged continuous positive airway pressure and indomethacin for patent ductus arteriosus. Both of them developed LSV. The clinical significance of this condition on the neuro-developmental outcome of a neonate has not yet been fully determined.

Diffuse basal ganglia or thalamus hyperechogenicity in preterm infants

OBJECTIVE

To determine the incidence and factors associated with diffuse basal ganglia or thalamus hyperechogenicity (BGTH) in preterm infants.

STUDY DESIGN

(1) Review of serial neurosonograms among neonates with gestational age (GA) <34 weeks born at Weiler Hospital during a 21-month period; (2) Color Doppler flow imaging; (3) Case-control study using GA group-matched controls; and (4) Blind reading of CT scans or MRIs in patients with BGTH.

RESULTS

Among 289 infants, 24 (8.3%) had diffuse BGTH. Color Doppler flow imaging was normal in nine patients. The incidence of diffuse BGTH was inversely related to GA (P<0.01). Logistic regression (n=96) showed that diffuse BGTH was significantly associated with requirement of high-frequency oscillation (HFO) (P=0.031), severe intraventricular hemorrhage (IVH) (P=0.004), hypotension requiring vasopressors (P=0.040), hypoglycemia (P=0.031) and male gender (P=0.014). Most patients with diffuse BGTH had normal basal ganglia and thalamus on CT/MRI, one had a hemorrhage, and one had an ischemic infarction.

CONCLUSIONS

In our series, diffuse BGTH occurred in 8.3%, and was associated with factors similar to those previously reported. In contrast, several series have reported almost exclusively linear or punctuate hyperechoic foci, corresponding to hyperechogenicity of the lenticulostriate vessels. Our data provide further evidence to suggest that diffuse BGTH and hyperechogenicity of the lenticulostriate vessels are two different entities. Additional studies are required to determine the long-term significance of diffuse BGTH.

Preoperative cranial ultrasound findings in infants with major congenital heart disease

BACKGROUND

Advances in diagnostic testing and surgical techniques have resulted in reduced mortality in neonates with congenital heart disease (CHD) and a major concern for neurological morbidity in the presence of preoperative neurological injury.

OBJECTIVES

To determine the incidence and nature of preoperative cerebral ultrasound abnormalities in neonates with major CHD and to examine the relationship between cerebral abnormalities and the type of CHD.

METHODS

Retrospective study; inclusion criteria: (1) neonates with major CHD admitted to the NICU over a 3-y period, (2) gestational age >35 wk, (3) documented preoperative cranial ultrasound available; exclusion criteria: (1) small for gestational age, (2) other congenital anomalies and/or chromosomal abnormalities, (3) a 5-min Apgar score <7, (4) congenital infection. Cranial ultrasounds (CUS) were reviewed without knowledge of the cardiac defect. CHDs were categorized.

RESULTS

Fifty of 108 neonates with CHD met the inclusion criteria. Twenty-one patients (42%) had abnormalities on CUS. Thirteen of these (26%) had widened ventricular and/or subarachnoid spaces, three (6%) lenticulostriate vasculopathy, one (2%) calcification in the basal nuclei, and four (8%) had acute ischaemic changes. Cerebral abnormalities occurred more frequently in patients with coarctation or hypoplastic left heart syndrome (HLHS) than transposition of the great arteries (TGA) (63% vs 14%; n.s.).

CONCLUSION

There is a high incidence of preoperative cerebral ultrasound abnormalities in this group of neonates with major CHD.

Antenatal risk factors associated with the development of lenticulostriate vasculopathy (LSV) in neonates

OBJECTIVE

To determine the antenatal risk factors associated with neonatal lenticulostriate vasculopathy (LSV).

STUDY DESIGN

Women in preterm labor were randomized to magnesium sulfate (MgSO4), other tocolytic, or saline control. The surviving babies underwent head ultrasounds (HUS) (weeks of life 1, 2, and 4) and periodic developmental examinations (months 4, 8, 12, and 18).

RESULTS

Of 140 infants, 17.1% (24) had neonatal intraventricular hemorrhage (IVH), and 10.0% (14) had LSV (half of the latter (7 of 14) had both IVH and LSV). In a regression model in which other risk factors were controlled for, the association between antenatal exposures to tocolytic MgSO4 >or=50 g and LSV were significant (adjusted odds ratio (OR), 8.3; 95% confidence interval (CI), 1.5 to 45.0; p=0.01).

CONCLUSION

Based on our data and their analyses, we infer that antenatal exposure to high-dosage, tocolytic MgSO4 may be associated with LSV.

Association between lenticulostriate vasculopathy (LSV) and neonatal intraventricular hemorrhage (IVH)

OBJECTIVES

To determine whether there is an unconfounded association between neonatal intraventricular hemorrhage (IVH) and lenticulostriate vasculopathy (LSV (also known as thalamostriate or mineralizing vasculopathy)).

STUDY DESIGN

During the conduct of the Magnesium and Neurologic Endpoints Trial (MagNET), a randomized controlled trial involving maternal, hence fetal, exposure to antenatal magnesium sulfate in the context of preterm labor, head ultrasounds were obtained for each of the surviving neonates. Because of our previous experience in the diagnosis of LSV, when ascertaining the presence of IVH, as called for by the research protocol of our study, the presence or absence of LSV was also determined.

RESULTS

We found LSV to be relatively prevalent (10% (14 of 140) among surviving babies). More importantly, it was significantly associated with the occurrence of neonatal IVH, even when controlled for possible confounding (adjusted OR 9.8, 95% confidence interval 1.3 to 73.1; p=0.03).

CONCLUSION

Given the known relationships between IVH and neonatal morbidity and mortality, the finding of a statistically significant association between neonatal IVH and LSV may suggest more substantial implications for the latter than previously believed.