The evolutionary change of flash visual evoked potentials in preterm infants with periventricular leukomalacia

doi:10.1016/j.clinph.2004.09.025

Clinical Neurophysiology

Volume 116, Issue 3, March 2005, Pages 690-695

https://doi.org/10.1016/j.clinph.2004.09.025 Get rights and content

Abstract

Objective

The aim of this study was to prospectively investigate flash visual evoked potential (VEP) findings and their chronological changes in preterm infants with cystic periventricular leukomalacia (PVL) during the early neonatal period.

Methods

The subjects of this study were 14 preterm infants with cystic PVL. The patients underwent serial cranial ultrasonography and diagnosed as having cystic PVL. Flash VEPs were diagnosed at least twice within the first 3 weeks of life.

Results

All infants had at least one or more flash VEP abnormalities. The most common finding was ‘absent VEP’, which was seen in 13 infants (93%). ‘Delayed latency’ was seen in two infants and ‘abnormal waveform’ was seen in one infant. Concerning the chronological changes, all records were abnormal in 4 infants, and the other 10 had transient normal VEP findings. Among them, flash VEPs changed from normal to abnormal within 10 days after birth in most cases.

Conclusions

Almost all infants with cystic PVL had abnormal flash VEPs within the first 3 weeks of life, but chronological changes of flash VEP findings were seen during the period.

Significance

This manuscript may be useful as a reference to the flash VEPs in preterm infants with cystic PVL.

Introduction

Periventricular leukomalacia (PVL) is even now a major cause of neurological impairment in preterm infants (Okumura et al., 1997, Allan et al., 1994). Ultrasonography is very useful to detect cystic PVL during the neonatal period (Dubowitz et al., 1985, Rodriguez et al., 1990). Multiple echolucent cyst formation in the periventricular white matter is characteristic. Magnetic resonance imaging is superior to detecting subtle white matter lesions (Debillon et al., 2003). Although visual evoked potentials (VEPs) are highly accurate in predicting abnormal outcome in asphyxiated term infants (Whyte, 1993, Watanabe, 1978), their predictive value for neurodevelopmental outcome in preterm infants is controversial (Beverley et al., 1990, Ekert et al., 1997, Shepherd et al., 1999, Pike and Marlow, 2000). In several studies, abnormal VEPs have been reported in preterm infants with PVL (Ekert et al., 1997, De Vries et al., 1987, Pike et al., 1994, Eken et al., 1994). But their evolutionary changes during the early postnatal period have not been fully evaluated. Neonatal EEG is a powerful tool in the assessment of brain damage in preterm infants and its evolutionary changes in PVL infants have been reported (Watanabe et al., 1999, Hayakawa et al., 1987, Maruyama et al., 2002, Kubota et al., 2002, Okumura et al., 1999, Okumura et al., 2003, Sofue et al., 2003). This study is a prospective study to investigate the flash VEP findings and its evolutionary changes in infants with cystic PVL during the early neonatal period.

Section snippets

Patients

One hundred and seventy-three infants with a gestational age between 27 and 32 weeks were admitted to the Neonatal Intensive Care Unit of Anjo Kosei Hospital during September 1996 through September 2000. Among them, 11 infants died of fatal neonatal complications. Serial cranial ultrasonography was performed routinely in the surviving 162 infants. Bilateral cystic PVL was detected in 15 infants. We excluded one infant with periventricular hemorrhagic infarction from this study in order to avoid

Flash VEP

Flash VEPs were performed in 135 infants of 162 surviving infants, including all 14 subjects of this study with cystic PVL and all 4 infants who had other abnormal ultrasonographic findings. Among 121 infants except the subjects, only 6 infants had abnormal flash VEP findings. One infant had absent VEP and the other 5 infants had abnormal waveform. All of them had normal ultrasonographic findings, but 3 of them developed non-cystic PVL confirmed by MRI during late infancy. Concerning a

Discussion

De Vries et al., 1987, Pike et al., 1994 reported that preterm infants with extensive cystic PVL often manifested abnormal flash VEPs between 36 and 41 weeks postmenstrual age. Ekert et al. (1997) recorded flash VEPs of 123 infants less than 32 weeks gestation in the first 3 weeks of life and reported that only 5 (31%) of 16 infants with PVL had abnormal VEPs. Thus, false-negative tests were twice as frequent as true-positive ones. They concluded that early VEPs were not predictive of abnormal

References (25)

K. Deguchi et al.
Characteristic neuropathology of leukomalacia in extremely low birth weight infants
Pediatr Neurol
(1997)
T. Kubota et al.
Combination of neonatal electroencephalography and ultrasonography: sensive means in early diagnosis of periventricular leukomalacia
Brain Dev
(2002)
A. Okumura et al.
Abnromal sharp transients on electroencephalograms in preterm infants with periventricular leukomalacia
J Pediatr
(2003)
A.A. Pike et al.
The role of cortical evoked responses in predicting neuromotor outcome in very preterm infants
Early Hum Dev
(2000)
A. Sofue et al.
Sharp waves in preterm infants with periventricular leukomalacia
Pediatr Neurol
(2003)
M.J. Taylor et al.
VEPs in normal full-term and premature neonates: longitudinal versus cross-sectional data
Electroencephalogr Clin Neurophysiol
(1987)
S. Tsuneishi et al.
Establishment of normal values of flash visual evoked potentials (VEPs) in preterm infants: a longitudinal study with special reference to two components of the N1 wave
Electroencephalogr Clin Neurophysiol
(1995)
K. Watanabe et al.
Neonatal EEG a powerful tool in the assessment of brain damage in preterm infants
Brain Dev
(1999)
H. Whyte
Visual evoked potentials in neonates following asphyxia
Clin Perinatol
(1993)
W.S. Allan et al.
Cerebral palsy in preterm infants
Lancet
(1994)

D.W. Beverley et al.

Relationship of cranial ultrasonography, visual and auditory evoked responses with neurodevelopmental outcome

Dev Med Child Neurol

(1990)

T. Debillon et al.

Limitations of ultrasonography for diagnosing white matter damage in preterm infants

Arch Dis Child Fetal Neonatol Ed

(2003)

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Eighty infants were enrolled. Morphine was the predictor of N2 (R² = 0.09, p = 0.006), P2 (R² = 0.11, p = 0.002), and N3 (R² = 0.13, p = 0.003) latencies. Younger GA was associated with lower amplitude (R² = 0.05, p = 0.029). None of the independent variables predicted the presence of N4 component, nor VEP morphology in the logistic analysis. VEP morphology was not associated with cognitive and motor scores at 2 years.
Morphine treatment and prematurity were risk factors for altered VEPs parameters at TEA. In our cohort VEP morphology did not predict neurological outcome.
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Periventricular leukomalacia (PVL) is a common magnetic resonance imaging (MRI) finding in cases of hypoxic ischemic encephalopathy. PVL, in MRI, is identified by the increased signal intensity of periventricular white matter on T2-weighted sequences which is more conspicuous in the posterior cortex. It occurs because of perinatal damage to the cerebral cortex. This insult is in the form of hypoxia, metabolic insults, prematurity, seizures, or infection. Periventricular area is most prone to damage owing to its immaturity and vascular supply. PVL is proven to affect vision in children. Depending on the area and cause of affection, PVL is associated with variable ophthalmic manifestations. It is known that visual function is closely linked to the overall neurodevelopment of a child.
A multidisciplinary approach is required to promote the growth and development of these children, and in the midst of multiple disabilities, visual function should not be overlooked. A comprehensive knowledge of the ophthalmological presentation in the developing world can aid us in an early and accurate diagnosis and in intervention for better therapeutic recovery and rehabilitation of these children.
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Several studies have reported the development of various aspects of visual function in infancy and early childhood in both preterm and term-born infants, but only a few studies have focused on the predictive power of neonatal visual findings in infants with brain lesions.
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Cranial ultrasound scans (US) were classified in normal, mild or major abnormalities. One-hundred and forty-five infants were assessed with age specific tests for visual function at term age, and at 3 and 12 months. Neurodevelopmental assessment (Griffiths' Scales) was performed at 12 months.
A good correlation was found between early and late visual assessment and neurodevelopment outcome. Of the 121 infants with normal neonatal visual assessment, 119 were also normal at 12 months and 116 had normal developmental quotient. Of the 24 infants with abnormal neonatal visual assessment, 12 were also abnormal at 12 months. All the false positives had normalised by 3 months. Of the 35 infants with major US abnormalities, 20 had normal and 15 abnormal scores on the neonatal assessment. At 1 year 17 had normal and 18 abnormal scores.
A normal visual assessment at term age is a good predictor of normal visual and neurodevelopmental outcome at 12 months. An abnormal visual examination in the neonatal period was a less reliable prognostic indicator, infant should be reassessed at 3 months.
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This association between gaze and magnetic resonance imaging-detected white-matter injury is in keeping with past studies that indicated a relationship between visual abnormalities and white-matter injury in premature infants. Several studies found that visual-evoked potentials performed before term-adjusted age may be absent or abnormal in premature infants with cystic periventricular leukomalacia [5,23-25]. Furthermore, there is a strong association between periventricular leukomalacia detected by ultrasound or magnetic resonance imaging and childhood visual and oculomotor abnormalities (reviewed by Jacobson and Dutton [7]).
Periventricular leukomalacia is a risk factor for visual impairment in children born prematurely. The impact of diffuse white-matter injury, as detected on magnetic resonance imaging, on early visual function is unknown. We developed two 5-point visual-gaze scores to analyze the association between this clinical assessment and white-matter injury in 93 premature neonates <34 weeks of gestational age at birth. Older postmenstrual age was associated with higher values of the two gaze scores. Infants with moderate or severe white-matter injury had lower scores than their peers without white-matter injury (0.41 points, 95% confidence interval of 0.13-0.69 for visual fixation score; and 0.70 points, 95% confidence interval of 0.30-1.10 for conjugate score, P < 0.005). Using the results from both scales, a score of ≥9 in an infant examined at ≥36 weeks postmenstrual age predicted normal white matter on magnetic resonance examination, with a sensitivity of 84% and a specificity of 100%. These preliminary findings suggest that white-matter injury affects visual function even before term equivalent postmenstrual age.
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We have recently investigated the correlation of flash VEPs with neurodevelopmental outcome in 60 preterm infants with gestational ages between 27 and 32 weeks.16 The VEPs were recorded more than once during the first 2 weeks of life and estimated as previously reported.11 The mean age at follow-up was 15.3 months.
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