Risk factors for intracranial hemorrhage among full-term infants: a case-control study

Cranial ultrasound screening in term and late preterm neonates born by vacuum-assisted delivery: Is it worthwhile?

BACKGROUND

Vacuum extraction is the most common choice to assist vaginal delivery, but there are still concerns regarding the neonatal injuries it may cause. This study aimed to evaluate the rate of intracranial injuries assessed by cranial ultrasound (cUS) among infants born by vacuum extraction, and the relationship with maternal and perinatal factors.

METHODS

This was a single-center retrospective study carried out in a level-3 neonatal unit. A total of 593 term and late preterm infants born by vacuum-assisted delivery were examined with a cUS scan within 3 days after birth.

RESULTS

Major head injuries were clinically silent and occurred in 2% of the infants, with a rate of intracranial haemorrhage of 1.7%. Regardless of obstetric factors, the risk of cranial injury was increased in infants requiring resuscitation at birth (p = 0.04, OR 4.1), admitted to NICU (p = 0.01, OR 5.5) or with perinatal asphyxia (p < 0.01, OR 21.3). Maternal age ≥40 years correlated both with adverse perinatal outcomes (p < 0.05) and the occurrence of major injury (p = 0.02, OR 4.6).

CONCLUSION

Overall, vacuum extraction is a safe procedure for neonates. Head injuries are usually mild and asymptomatic, and with spontaneous recovery. However, the rate of major cranial injuries in our cohort warrants further investigation to support a cUS screening, particularly for infants requiring respiratory support at birth. Also, maternal age might be taken into account when evaluating the risk for neonatal complications after vacuum application.

Neonatal Encephalopathy: Beyond Hypoxic-Ischemic Encephalopathy

Neonatal encephalopathy is a clinical syndrome of neurologic dysfunction that encompasses a broad spectrum of symptoms and severity, from mild irritability and feeding difficulties to coma and seizures. It is vital for providers to understand that the term "neonatal encephalopathy" is simply a description of the neonate's neurologic status that is agnostic to the underlying etiology. Unfortunately, hypoxic-ischemic encephalopathy (HIE) has become common vernacular to describe any neonate with encephalopathy, but this can be misleading. The term should not be used unless there is evidence of perinatal asphyxia as the primary cause of encephalopathy. HIE is a common cause of neonatal encephalopathy; the differential diagnosis also includes conditions with infectious, vascular, epileptic, genetic/congenital, metabolic, and toxic causes. Because neonatal encephalopathy is estimated to affect 2 to 6 per 1,000 term births, of which HIE accounts for approximately 1.5 per 1,000 term births, (1)(2)(3)(4)(5)(6) neonatologists and child neurologists should familiarize themselves with the evaluation, diagnosis, and treatment of the diverse causes of neonatal encephalopathy. This review begins by discussing HIE, but also helps practitioners extend the differential to consider the broad array of other causes of neonatal encephalopathy, emphasizing the epidemiology, neurologic presentations, diagnostics, imaging findings, and therapeutic strategies for each potential category.

What Isn't a Case-Control Study?

BACKGROUND

Confusion exists among neurosurgeons when choosing and implementing an appropriate study design and statistical methods when conducting research. We noticed particular difficulty with mislabeled and inappropriate case-control studies in the neurosurgical literature.

OBJECTIVE

To quantify and to rigorously review this issue for appropriateness in publication and to establish quality of the manuscripts using a rigorous technique.

METHODS

Following a literature search, pairs drawn from 5 independent reviewers evaluated a complete sample of 125 manuscripts claiming to be case-control studies with respect to basic case-control criteria. Seventy-five papers were then subjected to a more rigorous appraisal for quality using the SIGN Methodology Checklist for case-control studies.

RESULTS

Fifty publications were rejected based on basic criteria used to identify case-control design. Of the 75 subjected to quality analysis, 46 were felt to be acceptable for publication. Only 11 papers (9%) achieved the designation of high quality. Of the original 125 papers evaluated, 79 (63%) were inappropriately labeled case-control studies.

CONCLUSION

Mislabeling and use of inappropriate study design are common in the neurosurgical literature. Manuscripts should be evaluated rigorously by reviewers and readers, and neurosurgical training programs should include instruction on choice of appropriate study design and critical appraisal of the literature.

Perinatal stroke syndromes: Similarities and diversities in aetiology, outcome and management

With a birth-prevalence of 37-67/100,000 (mostly term-born), perinatal stroke encompasses distinct disease-states with diverse causality, mechanism, time of onset, mode of presentation and outcome. Neonatal primary haemorrhagic stroke and ischemic events (also divided into neonatal arterial ischemic stroke and neonatal cerebral sinus venous thrombosis) that manifest soon after birth are distinguished from presumed perinatal - ischemic or haemorrhagic - stroke. Signs of the latter become apparent only beyond the neonatal period, most often with motor asymmetry or milestones delay, and occasionally with seizures. Acute or remote MRI defines the type of stroke and is useful for prognosis. Acute care relies on homeostatic maintenance. Seizures are often self-limited and anticonvulsant agents might be discontinued before discharge. Prolonged anticoagulation for a few weeks is an option in some cases of sinovenous thrombosis. Although the risk of severe impairment is low, many children develop mild to moderate multimodal developmental issues that require a multidisciplinary approach.

Meningiomas in pregnancy: timing of surgery and clinical outcomes as observed in 104 cases and establishment of a best management strategy

BACKGROUND

There is a strong correlation between the level of circulating female sex hormones and the parturient growth of meningiomas. As a result, rapid changes in meningioma size occur during pregnancy, putting both the mother and fetus at risk. Large, symptomatic meningiomas require surgical resection, regardless of the status of pregnancy. However, the preferred timing of such complex intervention is a matter of debate. The rarity of this clinical scenario and the absence of prospective trials make it difficult to reach evidence-based conclusions. The aim of this study was to create evidence-based management guidelines for timing of surgery for pregnancy-related intracranial meningiomas.

METHOD

The English literature from 1990 to 2016 was systematically reviewed according to PRISMA guidelines for all surgical cases of pregnancy-related intracranial meningiomas. Cases were divided into two groups: patients who have had surgery during pregnancy and delivered thereafter (group A) and patients who delivered first (group B). Groups were compared for demographic, clinical and radiological features, as well as for neurosurgical, obstetrical and neonatological outcomes. Statistical analysis was performed to assess differences.

RESULTS

A total of 104 surgical cases were identified and reviewed, of which 86 were suitable for comparison and statistical analysis. Thirty-five patients (40%) underwent craniotomy for resection during pregnancy or at delivery (group A) and 51 patients (60%) underwent surgery after delivery (group B). Groups showed no significant differences in characteristics such as age at diagnosis, number of gestations, presenting symptoms, tumor site and tumor size. Despite a comparable distribution over the gestational trimesters, group A had significantly more patients diagnosed prior to the 27th gestational week (46 vs 17.5%, p = 0.0075). Group A was also associated with a significantly higher rate of both emergent craniotomies (40 vs 19.6%, p = 0.0048) and emergent Caesarian deliveries (47 vs 17.8%, p = 0.00481). The time from diagnosis to surgery was significantly longer in group B (11 weeks vs 1 week in group A, p = 0.0013). The rate of premature delivery was high but similar in both groups (∼70%). Risks of maternal mortality or fetal mortality were associated with group A (odds ratio = 14.7), but did not reach statistical significance.

CONCLUSIONS

While surgical resection of meningioma during pregnancy may be associated with increased maternal and fetal mortalities, the overall neurosurgical, obstetrical and neonatological outcomes, as well as many clinical characteristics, are similar to patients undergoing resection postpartum. We believe that fetal survival chances have a significant impact on decision-making, as patients diagnosed at a later stage in pregnancy (≥27th week of gestation) were more likely to undergo delivery first. This complicated clinical scenario requires the close cooperation of multiple disciplines. While the mother's health and well-being should always be paramount in guiding management, we hope that the overall good outcomes observed by this systematic review will encourage colleagues to aim for term pregnancies whenever possible in order to reduce prematurity-related problems.

Intracranial hemorrhage in term neonates

BACKGROUND

Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates; currently, ICH is more frequently diagnosed because of improved neuroimaging techniques.

PURPOSE

The study aims to evaluate the clinical characteristics and neuroimaging data (pattern, size, distribution) of neonatal ICH.

METHODS

We reviewed MRI data from July 2004 to June 2015 for 42 term neonates with ICH who were less than 1 month old. We recorded clinical data and manifestations, mode of delivery, Apgar score at 1 and 5 min, associated hypoxic insult, birth trauma, neurological symptoms, EEG results, extent and site of hemorrhage, neurosurgical intervention, and developmental outcomes. The clinical outcome was determined for 27 neonates. Risk factors were assessed in relation to ICH.

RESULTS

A total of 42 neonates who presented with ICH underwent MR imaging 2 to 22 days postnatally (mean age 9.3 days). The majority of clinical symptoms were present in patients within the first 24 h of life (n = 31), but symptoms appeared until day 10 postnatally (mean 4.9 days, n = 11). Seizure or seizure-like activity was the most common presenting symptom (17/42, 40.5%), with apnea seen in another seven infants (7/42, 16.7%). The majority of infants had a normal prenatal course. Two patients had antenatally detected hydrocephalus. Ten had infratentorial hemorrhage, and two had supratentorial hemorrhage. A total of 30 infants had a combination of infratentorial and supratentorial hemorrhage. Subdural hemorrhage (SDH) was the most common type of hemorrhage (40/42, 95.2%), followed by nine cases of parenchymal hemorrhage, seven of subarachnoid hemorrhage, three of germinal matrix hemorrhage (GMH), and one of epidural hemorrhage (EDH). A total of 16 infants had two or more types of hemorrhage. SDH was identified along the tentorium (n = 38) as well as over the cerebellar hemispheres (n = 39), along the interhemispheric fissure (n = 10), and over the occipital (n = 13) or parietooccipital (n = 11) lobes. Intraparenchymal hemorrhage involved either the frontal (n = 4), parietal (n = 3), or cerebellar (n = 2) lobes. Traumatic delivery was suspected in 20 patients (47.6%), and perinatal asphyxia was present in 21 patients (50.0%). A low Apgar score at 5 min and a history of perinatal asphyxia were the factors that most predicted poor clinical outcomes (n = 12/27). Logistic regression analysis revealed that a history of perinatal asphyxia resulted in poor outcomes. No patients died. One infant required burr hole drainage of a right parietal EDH, one infant needed a subcutaneous reservoir, and three infants required a ventriculoperitoneal shunt for obstructive hydrocephalus.

CONCLUSION

SDH was the most common type of ICH in term infants. Combined supratentorial and infratentorial hemorrhage was more common than isolated infratentorial hemorrhage in these infants. A total of 44.4% of patients had poor outcomes, with perinatal asphyxia the most common statistically significant cause.

Hypoxia and Neonatal Haemorrhagic Stroke: Experimental Study of Mechanisms

We studied the level of blood oxygen saturation (SpO2) in the brain in newborn rats in the pre- and post-stroke periods, as well as the changes in cerebral blood flow and beta-arrestin-1 as a marker of hypoxic stress. Our results show that mild hypoxia precedes the stroke development and is associated with venous relaxation and decrease blood outflow from the brain resulting in the elevation of synthesis of beta-arrestin-1 in the brain. The incidence of stroke is characterized by severe hypoxia, which is accompanied by the progression of pathological changes in cerebral veins and the high level of beta-arrestin-1.

The Stress and Vascular Catastrophes in Newborn Rats: Mechanisms Preceding and Accompanying the Brain Hemorrhages

In this study, we analyzed the time-depended scenario of stress response cascade preceding and accompanying brain hemorrhages in newborn rats using an interdisciplinary approach based on: a morphological analysis of brain tissues, coherent-domain optical technologies for visualization of the cerebral blood flow, monitoring of the cerebral oxygenation and the deformability of red blood cells (RBCs). Using a model of stress-induced brain hemorrhages (sound stress, 120 dB, 370 Hz), we studied changes in neonatal brain 2, 4, 6, 8 h after stress (the pre-hemorrhage, latent period) and 24 h after stress (the post-hemorrhage period). We found that latent period of brain hemorrhages is accompanied by gradual pathological changes in systemic, metabolic, and cellular levels of stress. The incidence of brain hemorrhages is characterized by a progression of these changes and the irreversible cell death in the brain areas involved in higher mental functions. These processes are realized via a time-depended reduction of cerebral venous blood flow and oxygenation that was accompanied by an increase in RBCs deformability. The significant depletion of the molecular layer of the prefrontal cortex and the pyramidal neurons, which are crucial for associative learning and attention, is developed as a consequence of homeostasis imbalance. Thus, stress-induced processes preceding and accompanying brain hemorrhages in neonatal period contribute to serious injuries of the brain blood circulation, cerebral metabolic activity and structural elements of cognitive function. These results are an informative platform for further studies of mechanisms underlying stress-induced brain hemorrhages during the first days of life that will improve the future generation's health.

The incidence of severe intraventricular hemorrhage based on retrospective analysis of 35939 full-term newborns-report of two cases and review of literature

INTRODUCTION

Intraventricular hemorrhage (IVH) is mostly documented in premature infants, and the younger the gestational age, the more often it occurs. IVH is very rarely reported in full-term neonates.

CASE REPORT

Retrospective analysis was performed in 35939 full-term neonates, who were born in the Clinical Hospital of Gynecology and Obstetrics at the University of Medical Sciences in Poznań. Clinical data were retrieved from their medical records. We report a case series of 2 term newborns, who developed severe IVH grade 3 and 4 with no evidence of asphyxia, neuroinfection, TORCH infections, coagulation disorders and trombocytopenia, metabolic disorders, arteriovenous malformations, and selected genetic abnormalities (factor V Leiden 1601G > A polymorphism and MTHFR 677C > T; 1298A > C polymorphisms). IVH in both cases was complicated by posthemorrhagic hydrocephalus treated with decompressive lumbar punctures and next ventriculoperitoneal shunt placement.

CONCLUSIONS

In conclusion, several factors influence the predisposition for severe IVH in term neonates. Perinatal period complicated by fetal distress, birth trauma, and severe asphyxia should be taken into account. However, it is possible that etiopathogenesis cannot be defined clearly as in our cases. Cranial ultrasounds in a specific group of term newborns (taking into account risk factors for IVH) should be widely recommended.

A Follow-up Study of Infants with Intracranial Hemorrhage at Full-Term

Objective:

To determine physical and cognitive outcomes of full-term infants who suffered intracranial hemorrhage (ICH) at birth.

Methods:

A retrospective hospital-based, follow-up study of infants treated in London, Ontario between 1985 and 1996. Follow-up was conducted by telephone interviews and clinic visits. Outcome was measured according to physical and cognitive scales. Perinatal risk factors and hemorrhage characteristics were correlated with final outcome.

Results:

For this study 66 infants with ICH were identified, of which seven died during the first week of life. We obtained follow-up in all but ten cases (median = 3-years; range 1.0 to 10.9 years). Overall, 57% of infants had no physical or cognitive deficits at follow-up. Death occurred most frequently among those with primarily subarachnoid hemorrhage (19%) and the most favorable outcomes occurred among those with subdural hemorrhage (80% had no disability). In univariate models, thrombocytopenia (platelet count ≤ 70 x 109/L), increasing overall hemorrhage severity, frontal location and spontaneous vaginal delivery as opposed to forceps-assisted delivery increased risk for poor outcome. In multivariate models, all these factors tended towards increased risk, but only thrombocytopenia remained significant for physical disability (OR = 7.6; 95% CI = 1.02 – 56.6); thrombocytopenia was borderline significant in similar models for cognitive disability (OR = 4.6; 95% CI = 0.9 – 23.9).

Conclusion:

Although forceps-assisted delivery may contribute to ICH occurrence, our study found better outcomes among these infants than those who had ICH following a spontaneous vaginal delivery. Hemorrhage in the frontal lobe was the most disabling hemorrhage location and if multiple compartments were involved, disability was also more likely to occur. However, in this report we found that the factor that was most likely to contribute to poor outcome was thrombocytopenia and this remained important in multivariate analysis.

Case-control studies in neurosurgery

OBJECT

Observational studies, such as cohort and case-control studies, are valuable instruments in evidence-based medicine. Case-control studies, in particular, are becoming increasingly popular in the neurosurgical literature due to their low cost and relative ease of execution; however, no one has yet systematically assessed these types of studies for quality in methodology and reporting.

METHODS

The authors performed a literature search using PubMed/MEDLINE to identify all studies that explicitly identified themselves as "case-control" and were published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Each paper was evaluated for 22 descriptive variables and then categorized as having either met or missed the basic definition of a case-control study. All studies that evaluated risk factors for a well-defined outcome were considered true case-control studies. The authors sought to identify key features or phrases that were or were not predictive of a true case-control study. Those papers that satisfied the definition were further evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

RESULTS

The search detected 67 papers that met the inclusion criteria, of which 32 (48%) represented true case-control studies. The frequency of true case-control studies has not changed with time. Use of odds ratios (ORs) and logistic regression (LR) analysis were strong positive predictors of true case-control studies (for odds ratios, OR 15.33 and 95% CI 4.52-51.97; for logistic regression analysis, OR 8.77 and 95% CI 2.69-28.56). Conversely, negative predictors included focus on a procedure/intervention (OR 0.35, 95% CI 0.13-0.998) and use of the word "outcome" in the Results section (OR 0.23, 95% CI 0.082-0.65). After exclusion of nested case-control studies, the negative correlation between focus on a procedure/intervention and true case-control studies was strengthened (OR 0.053, 95% CI 0.0064-0.44). There was a trend toward a negative association between the use of survival analysis or Kaplan-Meier curves and true case-control studies (OR 0.13, 95% CI 0.015-1.12). True case-control studies were no more likely than their counterparts to use a potential study design "expert" (OR 1.50, 95% CI 0.57-3.95). The overall average STROBE score was 72% (range 50-86%). Examples of reporting deficiencies were reporting of bias (28%), missing data (55%), and funding (44%).

CONCLUSIONS

The results of this analysis show that the majority of studies in the neurosurgical literature that identify themselves as "case-control" studies are, in fact, labeled incorrectly. Positive and negative predictors were identified. The authors provide several recommendations that may reverse the incorrect and inappropriate use of the term "case-control" and improve the quality of design and reporting of true case-control studies in neurosurgery.

Haemorrhagic stroke in term and late preterm neonates

OBJECTIVE

Few data regarding causes and outcomes of haemorrhagic stroke (HS) in term neonates are available. We characterised risk factors, mechanism and short-term outcomes in term and late preterm neonates with acute HS.

DESIGN

Prospective cohort.

SETTING

Single-centre tertiary care stroke registry.

SUBJECTS

Term and late preterm neonates (≥ 34 weeks gestation), born 2004-2010, with acute HS ≤ 28 days of life were identified, and clinical information was abstracted. Short-term outcomes were assessed via standardised neurological exam and rated using the Paediatric Stroke Outcome Measure (PSOM).

RESULTS

Among 42 neonates, median gestational age was 39.7 weeks (IQR 38-40.7 weeks). Diagnosis occurred at a median of 1 day (IQR 0-7 days) after delivery. Twenty-seven (64%) had intraparenchymal and intraventricular haemorrhage. Mechanism was haemorrhagic transformation of venous or arterial infarction in 22 (53%). Major risk factors included congenital heart disease (CHD), fetal distress and haemostatic abnormalities. Common presentations included seizure, apnoea, and poor feeding or vomiting. Acute hydrocephalus was common. Mortality was 12%. Follow-up occurred in 36/37 survivors at a median of 1 year (IQR 0.5-2.0 years). Among 17/36 survivors evaluated in stroke clinic, 47% demonstrated neurologic deficits. Deficits were mild (PSOM 0.5-1.5) in 9/36 (25%), and moderate-to-severe (PSOM ≥ 2.0) in 8/36 (22%).

CONCLUSIONS

In our cohort with acute HS, most presented with seizures, apnoea and/or poor feeding. Fetal distress and CHD were common. Nearly two-thirds had intraparenchymal with intraventricular haemorrhage. Over half were due to haemorrhagic transformation of infarction. Short-term neurologic deficits were present in 47% of survivors.

Endoscopic evacuation of cerebellar hematoma in a term newborn

Intracerebellar hemorrhage is very rare in term infants and only severe cases with massive intracranial hemorrhage, posthemorrhagic hydrocephalus and clinical deterioration due to increased intracranial pressure require neurosurgical evacuation. In recent adult studies endoscopic hematoma evacuation has been shown as a rapid, effective, and safe technique. A term newborn hospitalized for meconium aspiration syndrome showed hypertonia, jitteriness and abnormal amplitude integrated electroencephalogram findings. He was diagnosed with cerebellar hematoma which caused hydrocephalus by cranial magnetic resonance imaging (MRI). The hematoma was successfully evacuated neuroendoscopically as the first case in literature to our knowledge. Neurologic, a-EEG and MRI findings resolved.

Intrauterine grade IV intraventricular hemorrhage in a full-term infant leading to hydrocephalus

INTRODUCTION

Peri/intraventricular hemorrhage (PIVH) is more often seen in premature neonates and can lead to posthemorrhagic hydrocephalus, characterized by high mortality rate and neurodevelopmental delay.

CASE REPORT

We report a case of in utero PIVH in a full-term neonate, which led to hydrocephalus. The infant developed at 8 months of gestational age intracerebral/intraventricular hemorrhage at the regions of the left basal ganglia and thalamus with significant intraventricular extension and ventriculomegaly, which was diagnosed with fetal MR scan, and progressed post partum to active multiloculated hydrocephalus. At the age of 3 months, the infant was operated on with endoscopic fenestration of the ventricular septations at the left side and ventriculoperitoneal shunt insertion at the right side. A follow-up MR scan after 4 months showed improvement of the ventriculomegaly and the multiloculated hydrocephalus. Up to a period of 6 months follow up, there have been no shunt-related problems.

DISCUSSION

The complications of a grade IV intraventricular hemorrhage are well documented in premature infants. It is difficult to know to what extent these apply equally to full-term infants with intraventricular hemorrhage. Ventricular hemorrhage is very rarely reported in full-term neonates, and even more rarely in the intrauterine period.

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.

Birth-related injury to the head and cervical spine in neonates

Birth-related injury is defined as any traumatic or ischemic event sustained during the process of delivery. Perinatally acquired disease processes secondary to birth-related injury can be traumatic or ischemic in nature. In this article, the authors focus on traumatic/mechanical injuries. Other diseases of the perinatal time period, including germinal matrix hemorrhages and hypoxic-ischemic encephalopathy, are beyond the objective of this review.

Obstetric conditions and risk of first ever mental health contact during infancy, childhood and adolescence

OBJECTIVE

the main aim of this study was to investigate whether risk of first ever occasion of outpatient or inpatient service for a mental disorder among male children and adolescents may be associated with obstetric conditions.

DESIGN, SETTING AND PARTICIPANTS

this study was a population-based birth-cohort study of males born between 1980 and 1984 in Western Australia (WA). Males were identified using birth registry records and followed-up over a 19 year period using linked health data available through the Western Australian Data Linkage System.

MEASUREMENTS

multivariate logistic regression was employed to estimate the risk of first ever mental health contact at different stages of mental development in childhood and adolescence.

MAIN FINDINGS

vacuum and forceps assisted delivery and emergency caesarean were associated with an increased risk of first ever mental health contact. The risk of first ever mental health contact was similar for spontaneous vaginal delivery and elective caesarean. Although outcomes varied by age group, children with stillborn siblings were at increased risk of first ever mental health contact as were babies with 7-9 Apgar score at 5 mins and those born to mothers with several previous live births.

CONCLUSIONS AND IMPLICATIONS

vacuum and forceps assisted delivery and/or the pathophysiological causes that lead to these clinical procedures, as well as other obstetric conditions, which may be associated with (asymptomatic) brain injury at birth, which may increase the risk of mental disorders.

Intracranial hemorrhage in full-term newborns: a hospital-based cohort study

INTRODUCTION

In recent years, intracranial hemorrhage (ICH) with parenchymal involvement has been diagnosed more often in full-term neonates due to improved neuroimaging techniques. The aim of this study is to describe clinical and neuroimaging data in the neonatal period and relate imaging findings to outcome in a hospital-based population admitted to a level 3 neonatal intensive care unit (NICU).

METHODS

From our neuroimaging database, we retrospectively retrieved records and images of 53 term infants (1991-2008) in whom an imaging diagnosis of ICH with parenchymal involvement was made. Clinical data, including mode of delivery, clinical manifestations, neurological symptoms, extent and site of hemorrhage, neurosurgical intervention, and neurodevelopmental outcomes, were recorded.

RESULTS

Seventeen of the 53 term infants had infratentorial ICH, 20 had supratentorial ICH, and 16 had a combination of the two. Seizures were the most common presenting symptom (71.7%), another ten infants (18.9%) presented with apneic seizures, and five infants had no clinical signs but were admitted to our NICU because of perinatal asphyxia (n=2), respiratory distress (n=2), and development of posthemorrhagic ventricular dilatation (n=1). Continuous amplitude-integrated electroencephalography recordings were performed in all infants. Clinical or subclinical seizures were seen in 48/53 (90.6%) infants; all received anti-epileptic drugs. Thirteen of all 53 (24.5%) infants died. The lowest mortality rate was seen in infants with supratentorial ICH (10%). Three infants with a midline shift required craniotomy, six infants needed a subcutaneous reservoir due to outflow obstruction, and three subsequently required a ventriculoperitoneal shunt. The group with poor outcome (death or developmental quotient (DQ) <85) had a significantly lower 5-min Apgar score (p=.006). Follow-up data were available for 37/40 survivors aged at least 15 months. Patients were assessed with the Griffiths Mental Developmental Scales, and the mean DQ of all survivors was 97 (SD=12). Six infants (17%) had a DQ below 85 [two of them had cerebral palsy (CP)]. Three infants developed CP (8.6%); one had cerebellar ataxia, and two had hemiplegia.

CONCLUSION

ICH with parenchymal involvement carries a risk of adverse neurological sequelae with a mortality of 24.5% and development of CP in 8.6%. The high mortality rate could partly be explained by associated perinatal asphyxia. Infants with supratentorial ICH had a lower, although not significant, mortality rate compared with infants with infratentorial ICH and infants with a combination of supratentorial ICH and infratentorial ICH. In spite of often large intraparenchymal lesions, 30 of the 34 survivors without CP (88.2%) had normal neurodevelopmental outcome at 15 months.

Clinical manifestations of symptomatic intracranial hemorrhage in term neonates: 18 years of experience in a medical center

BACKGROUND

Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates. We conducted a retrospective analysis of the clinical characteristics and developmental outcomes of symptomatic ICH in term neonates.

METHODS

A retrospective chart review was conducted of all term neonates (less than 1 month old) diagnosed with ICH and admitted to the neonatal intensive care unit of Kaohsiung Chang Gung Hospital from December 1991 to December 2008. Demographic characteristics, mode of delivery, laboratory data, clinical presentation, and developmental status were recorded.

RESULTS

Data for 24 term neonates (17 boys and 7 girls) with a diagnosis of ICH were collected for analysis. The clinical manifestations of ICH included anemia (13/24, 54%), seizure (11/24, 46%), cyanosis (7/24, 29%), tachypnea (5/24, 21%), fever (1/24, 4%), hypothermia (1/24, 4%), and poor feeding (1/24, 4%). Age at symptom onset ranged from 2 hours to 11 days following birth. The most common type of ICH was subdural hemorrhage. All ICHs resolved, except in one infant, who died from hypoxicischemic encephalopathy at 25 days. Ten children with symptomatic ICH were reported to have normal development, while the remainder (13/23, 57%) showed developmental delays or disabilities.

CONCLUSION

Unexplained anemia, seizure, and cyanosis were the major presenting signs in infants with symptomatic ICH. A diagnosis of ICH should be considered in term neonates who present with one or more of these signs. Although the mortality in term infants with symptomatic ICH was low, more than half.

Prevalence and predictors of perinatal hemorrhagic stroke: results from the kaiser pediatric stroke study

OBJECTIVES

Predictors for perinatal arterial ischemic stroke include both maternal and intrapartum factors, but predictors of perinatal hemorrhagic stroke have not been studied. We sought to determine both the prevalence and predictors of perinatal hemorrhagic stroke within a large, multiethnic population.

PATIENTS AND METHODS

We performed a case-control study nested within the cohort of all infants born from 1993 to 2003 in the Northern California Kaiser Permanente Medical Care Program, a health maintenance organization providing care for >3 million members. Cases of symptomatic perinatal hemorrhagic stroke and perinatal arterial ischemic stroke in neonates (28 weeks' gestational age through 28 days of life) were identified through electronic searches of diagnosis and radiology databases and confirmed by medical chart review. Three controls per case were randomly selected and matched on birth year and facility. This analysis included cases of perinatal hemorrhagic stroke (intracerebral hemorrhage or subarachnoid hemorrhage, excluding pure intraventricular hemorrhage) and all controls. Predictors of perinatal hemorrhagic stroke were assessed by using logistic regression, adjusting for the matching criteria.

RESULTS

Among 323 532 live births, we identified 20 cases of perinatal hemorrhagic stroke (19 intracerebral hemorrhage and 1 subarachnoid hemorrhage), which yielded a population prevalence for perinatal hemorrhagic stroke of 6.2 in 100 000 live births. Cases presented with encephalopathy (100%) and seizures (65%). Perinatal hemorrhagic stroke was typically unifocal (74%) and unilateral (83%). Etiologies included thrombocytopenia (n = 4) and cavernous malformation (n = 1); 15 (75%) were idiopathic. Univariate predictors of perinatal hemorrhagic stroke included male gender, fetal distress, emergent cesarean delivery, prematurity, and postmaturity but not birth weight. When entered into a multivariate model, fetal distress and postmaturity continued to be independent predictors.

CONCLUSIONS

Fetal distress is an independent predictor of perinatal hemorrhagic stroke, perhaps suggesting a prenatal event. Postmaturity also predicts perinatal hemorrhagic stroke, an association not explained by large birth weight in our study.

Intracranial hemorrhage in term newborns: management and outcomes

Child neurology is frequently a late player in the management of the term newborn with intracranial hemorrhage in the first neonatal week. It is crucial, however, that the child neurologist undertake a comprehensive evaluation by investigating etiology and management of the hemorrhage. Intracranial hemorrhage is usually associated with premature newborns. The literature on intracranial hemorrhage in term newborns is largely in the form of isolated case reports or a small series of cases, and mostly nonsystematic. Presented here is an evidence-based review of the incidence, risk factors, etiologies, and clinical management of intracranial hemorrhage in the first week after birth, with discussion of the role of neuroimaging and hematologic investigation. Consideration of these investigations along with documentation of every intervention or its explanation will reduce parental anxiety and will assure the best possible neurologic as well as legal outcomes of term newborns with intracranial hemorrhage.

Severe fetal thrombocytopenia in Rhesus D alloimmunized pregnancies

OBJECTIVE

The objective of the study was to evaluate the incidence of fetal thrombocytopenia and association with hydrops in Rhesus D alloimmunization.

STUDY DESIGN

The study was a retrospective chart review of 914 intrauterine transfusions in 314 pregnancies performed between 1988 and 2005 in a single institution. The incidence of thrombocytopenia and severity of hydrops at cordocentesis were assessed and correlated with perinatal mortality.

RESULTS

Thrombocytopenia (less than 150 x 10(9)/L) was found in 241 of 914 (26%) and severe thrombocytopenia (less than 50 x 10(9)/L) in 25 of 914 (3%) cordocentesis. Twenty-three percent of severely hydropic fetuses had severe thrombocytopenia, compared with 3% and 1% of mildly hydropic and nonhydropic fetuses, respectively. Thrombocytopenia was an independent risk factor for perinatal mortality. Mortality in fetuses that were severely thrombocytopenic and severely hydropic was 67%.

CONCLUSION

Thrombocytopenia is common in hydropic anemic fetuses. Severe thrombocytopenia is associated with a poor prognosis, irrespective of the presence of hydrops. The option of platelet transfusion in severely hydropic anemic fetuses needs further study.

Head trauma after instrumental births

Instrumental vaginal delivery involves the use of the vacuum extractor or obstetric forceps to facilitate delivery of the fetus. It is associated with substantial risk of head injury, including hemorrhage, fractures, and, rarely, brain damage or fetal death. This review article describes the different types, etiology, pathophysiology, risk factors, and clinical features of head trauma after instrumental birth, along with their management and prevention strategies.

Macrocephaly, increased intracranial pressure, and hydrocephalus in the infant and young child

Macrocephaly, increased intracranial pressure, and hydrocephalus are common related conditions that lead to cross-sectional imaging of the infant and young child. Imaging plays a central role in establishing the diagnosis and guiding disposition and treatment of these patients. In this review, a general overview is provided, and the more common causes of hydrocephalus are presented, including posthemorrhage, postinfection, developmental malformations, and masses. Imaging guidelines are also outlined for initial evaluation and follow-up, along with a discussion of the imaging features of shunt malfunction.

Head injuries after instrumental vaginal deliveries

PURPOSE OF REVIEW

The types, mechanisms and clinical manifestations of head injuries (extracranial, cranial and intracranial) after instrumental delivery are described along with current evidence of their prevention and management.

RECENT FINDINGS

Asymptomatic subdural hematomas can occur in up to 6.1% of uncomplicated vaginal deliveries. Maternal nulliparity, incorrect placement of vacuum extraction cup and failed vacuum extraction are predisposing factors to subgaleal hemorrhage. Injuries associated with the vacuum devices may be minimized if the recommended limits for a safe traction force are not exceeded. There is no difference in the incidence of scalp trauma between vacuum deliveries by a rigid plastic cup (Omnicup) and the standard, silastic cup. The use of a metal cup may increase the occurrence of head injuries. Protective covers over forceps reduce the rates of neonatal facial abrasions and skin bruises. There is no difference in the incidence of cephalhematoma comparing a sequential operative vaginal delivery and a caesarean section following a failed vacuum delivery.

SUMMARY

Instrumental vaginal deliveries carry substantial risks. Only practitioners who are adequately trained or are under supervision should undertake instrumental delivery. The mode of intervention needs to be individualized after consideration of the operator's skills and experience and the clinical circumstances.

Management of birth injuries

Birth injuries are a significant cause of neonatal morbidity and mortality. Although often associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors. This article discusses the diagnosis and management of the most common birth injuries that are encountered by health care providers who care for newborns.

Neonatal thrombocytopenia

Thrombocytopenia occurs in up to a third of preterm neonates admitted to intensive care units. In these babies, thrombocytopenia typically presents in one of two patterns: early-onset thrombocytopenia occurring within 72 h of birth and late-onset thrombocytopenia which develops after 72 h. Early-onset thrombocytopenia is most commonly caused by disorders associated with placental insufficiency (e.g. maternal hypertension), is mild-moderate, self-limiting and requires no treatment; it is caused by reduced platelet production. Late-onset thrombocytopenia is usually due to bacterial sepsis or necrotising enterocolitis; it is often severe (platelets <50 x 10(9)/l), prolonged and requires treatment with platelet transfusions. In term babies, neonatal thrombocytopenia is usually severe and most commonly caused by bacterial sepsis, perinatal asphyxia or neonatal alloimmune thrombocytopenia. There is a lack of evidence-based guidelines for treatment of neonatal thrombocytopenia. The most important future developments will depend upon studies aimed at determining optimal platelet transfusion schedules for term and preterm neonates.

Management of birth injuries

Birth injuries are a significant cause of neonatal morbidity and mortality. Although they are frequently associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors. This article discusses the diagnosis and management of the most common birth injuries encountered by health care providers caring for newborns.