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)