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Watershed infarcts, or parasagittal cerebral injury, were demonstrated in the asphyxiated neonatal brain the late 1970s with the use of technetium scans,1–3 but were extremely difficult to visualise in the acute phase in vivo.2,4,5
Recently, a full term boy was born after a caesarean section because of mild fetal distress. A cephalic version was performed at 38 weeks, but the pregnancy was otherwise uneventful. Umbilical arterial pH was 7.31, and Apgar scores were 8 and 9 at one and five minutes respectively. Birth weight was 3160 g. Twenty three hours after birth the baby developed left sided seizures with secondary generalisation. Seizures were treated effectively with phenobarbital, lidocaine, and midazolam. No infection, anaemia, or hypotension were demonstrated. Fifty six hours after birth, magnetic resonance imaging (MRI) was performed, which showed parasagittal changes (watershed infarcts) with diffusion weighted MRI. The apparent diffusion coefficient of water of these areas was 0.70 × 10−3/mm2/s. T1 and T2 weighted MRI showed subtle changes of the white matter.
On the 8th day of life the patient was discharged home being fully breast fed. MRI at 3 months showed a slight increase in the frontal cerebrospinal fluid space, with minimal loss of differentiation between grey and white matter (fig 1). Clinical examination at 6 months showed a normal early development.
We conclude that diffusion weighted MRI is an excellent technique for detection of watershed infarcts in vivo in neonates. These lesions may be partly reversible, as in our patient, although we expect to see gliosis in these areas in the second year of life. Further use of these MRI techniques and neurodevelopmental follow up will show the functional consequences of these brain lesions.
Competing interests: none declared
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