Pediatr Radiol (1992) 22:128-130
Pediatric Radiology 9 Springer-Verlag 1992
Reverse flow in the intracranial arteries - the possible significance of comparative flow in the anterior cerebral and the basilar arteries T. Hayashi t, T. Ichiyama 1, O. Kondoh 1, H. Tanaka 1, H. Tateishi 1' 2, N. Harima 2, and T. Saitoh 2 1Department of Pediatrics, and 2 Perinatal Care Center for Mother and Child, Yamaguchi University School of Medicin e, Ube, Japan Received: 3 September 1991; accepted: 10 December 1991
Abstract. F o u r infants with reverse flow patterns of the intracranial arteries are reported. Two with severe brain damage, h a d a reverse flow pattern in the anterior cerebral artery, which was r e c o r d e d during the r e c o v e r y stage f r o m cardiac arrest. The other two patients s h o w e d a reverse flow p a t t e r n in the basilar artery and had a g o o d prognosis. Reverse flow in the anterior cerebral artery suggests severe brain damage, but that in the basilar artery does not.
D o p p l e r u l t r a s o n o g r a p h y (US) t h r o u g h the anterior fontanelle of n e w b o r n s and infants is useful for estimating the cerebral b l o o d flow velocity. T h e technique has b e e n used in the determination of brain death in 6 n e w b o r n s [1]. T h e study utilized the changes in the flow velocity pattern in the anterior cerebral ( A C A ) and c o m m o n carotid arteries. T h e sequence of deterioration of the flow velocity wave f o r m in b o t h vessels which was characteristic of brain death consisted of (1) the loss of diastolic flow, (2) the a p p e a r a n c e of retrograde flow during diastole, (3) a decrease in systolic flow in the anterior cerebral artery and, ultimately, (4) no detectable flow in the comm o n carotid artery. T h e absent or reversed diastolic flow
and early systolic spikes has b e e n detected by transcranial D o p p l e r US in adult patients with brain death [2]. R e t r o grade flow velocity during diastole has also b e e n o b s e r v e d in the A C A [3] or the basal artery [4] of p r e t e r m infants with a large patent ductus arteriosus ( P D A ) , but without overt neurological deficits.
Material and methods The clinical and echographic findings in the 4 infants are summarized in Table 1. Patient 1 suffered from intracranial bleeding due to vitamin K deficiency with severe brain edema and increased intracranial pressure. Patient 2 had the adrenogenital syndrome with hyperpotassemia. When he arrived at our hospital, he had cardiac arrest with severe brain edema, as observed on B-mode US. Patient 3 was born, weighing 1980 g, at 34 weeks gestation with neonatal asphyxia, and cranial US revealed ventricular narrowing. Patient 4, weighing 1460 g, was born after 38 weeks gestation with trisomy 18, interruption of the aorta and a large PDA. Intracranial blood flow was examined by means of a Aloka Color Doppler SSD 350 or SSD 870 with a 5-MHz convex or sector probe. Images of the ACA and the basilar artery (BA) were obtained in the sagittal plane through the anterior fontanelle. The blood flow velocities in the A1 portion of the ACA and the BA were measured by pulsed Doppler technique.
Table 1. Clinical data and flow patterns for intracranial arteries in patients with reverse flow patterns
Age Sex Clinical findings Clinical diagnosis Prognosis
Flow pattern Anterior cerebral artery Basilar artery Condition at recording
1 9 wks M
2 5 mo M
Patient 3 2h F
Intracranial bleeding
Adrenogenital syndrome
Asphyxia
Died 6 h
Severe brain damage
Mild mental retardation
Trisomy 18 Interruption of aorta Died 20 weeks later of pulmonary hypertension and pneumonia
Reverse Not detected Severely increased intracranial pressure
Reverse Reverse Post dead on arrival
Not reverse Reverse In incubator with oxygen supply
Not reverse Reverse Mechanical ventilation with oxygen supply
4 4 wks F
129
Fig. 1. The blood flow velocity patterns in patient 2. Note the reverse flow patterns in both the anterior cerebral artery (upper) and basilar artery (lower)
Fig. 2. The blood flow velocity patterns in patient 4. Note the reverse flow pattern only in the basilar artery (lower)
Results
death. While reverse flow in intracranial arteries was previously reported in preterm neonates with a large PDA, our results show that the reverse blood flow in the A C A suggests a different clinical picture from that in the BA. The results for patients i and 2 suggest that the flow pattern in the anterior cerebral artery is influenced by increased peripheral resistance due to increased intracranial pressure caused by brain edema. Patient 4 with interruption of the aorta, showed a completely different flow patterns in the A C A and the BA, and demonstrates that the flow pattern in the B A is affected by the cardiac condition. Patient 3 had reverse flow only in the B A and the absence of diastolic flow in the A C A was recorded 2 hours after birth. These conditions may be related to the asphyxia occurring with brain edema and probably a physiological PDA. These findings suggest that the flow pattern in the A C A is chiefly affected by peripheral resistance of the cerebral vessels, while that in the B A is influenced by the cardiac condition. Thus, we think that the reverse flow in the A C A reflects the fatal condition caused by severe increased intracranial pressure, but that in the B A does not. Flow velocity measurements in both the anterior cerebral artery and the basilar artery are therefore strongly recommended for evaluating patients with severe brain damage.
The blood flow patterns in A C A and B A in the four patients and the associated conditions are presented in Table 1. Reverse blood flow was observed in the anterior cerebral artery in patients i and 2 (Fig. 1), and in the basilar artery in patients 2 4 (Fig. 2). Flow in A C A in patient 3 was absent in diastole and that in patient 4 had a normal pulsating flow pattern. In particular, the reverse flow pattern in B A in patient 4 was not a spiky retrograde one, as seen in patients 1, 2 and 3, but a "to and fro" flow pattern resembling a sine curve. Patient 1 died 6 h after the ultrasonic examination, and patient 2 developed severe cerebral palsy and mental retardation. An contrast patient 3 recovered with only mild mental retardation, and patient 4 survived for 20 weeks, but eventually died of severe pulmonary hypertension and pneumonia. In the latter case autopsy revealed interruption of the aorta, type B. It thus seems that reverse blood flow in A C A is accompanied by severe brain damage, while that in B A is not.
Discussion The reverse blood flow in the intracranial arteries is known to be one of the key findings in the process of brain
130
References 1. McMenamin JB, Volpe JJ (1983) Doppler ultrasonography in the determination of neonatal brain death. A n n Neuro114: 302 2. Petty GW, M o h r JR Pedley TA, Tatemichi TK, Lennihan L, Duterte DI, Sacco R L (1990) The role of transcranial Doppler in confirming brain death: sensitivity, specificity, and suggestions for performance and interpretation. Neurology 40:300 3. Lipman B, Serwer GA, Brazy J E (1982) A b n o r m a l cerebral hemodynamics in preterm infants with patent ductus arteriosus. Pediatrics 69:778
Literature in pediatric radiology T1 and T2 in the cerebrum: correlation with age, gender, and demographic factors. Breger, R. K. et al. (Haughton, V.M., Dept. of Rad., Med. Coltege, Froedtert Memorial Lutheran Hosp., 9200 W Wisconsin Av., Milwaukee, W153226, USA) 181, 545 (1991) Color Doppler US imaging during pediatric neurosurgical and neuroradiologic procedures. Barr, L.L. et al. (Dept. of Rad. and Ped., Children's Hosp. Med. Center, Univ. College of Med., Elland and Bethesda Av., Cincinnati, OH 45229-2899, USA) 181,567 (1991) Intramedullary lesions of the pediatric spinal cord: correlation of findings from MR imaging, intraoperative sonography, surgery, and histologic study. Brunberg, J.A. et al. (Dept. of Rad., Univ. Hosp., 1500 E Med. Center Dr., Ann Arbor, M148109-0030, USA) 181, 573 (1991) Cerebellar dimensions in assessment of gestational age in neonates. Co, E. et al. (Raju, T. N. K., Dept. of Ped. (M/C 856), Univ. Hosp., 840 S Wood St., Chicago, IL 60612, USA) 181, 581 (1991) MR imaging of diffuse bone marrow replacement in pediatric patients with cancer. Ruzal-Shapiro, C. et al. (Dept. of Rad., Babies Hosp., Presbyterian Med. Center, Columbia College of Physicians and Surgeons, 3959 Broadway, New York, NY 10032, USA) 181, 587 (1991) Seminars in Roentgenology (New York) Trauma to the elbow and forearm. Karasick, D. et al. (Dept. of Rad., Jefferson Med. College and Thomas Jefferson Univ. Hosp., 111 S/llth St., Philadelphia, PA 19107, USA) 26, 318 (1991) Surgery (St. Louis) Pancreatic ductal abnormalities in children. Tagge, E. E et al. (Div. of Ped. Surg., Med. Univ., Children's Hosp., 171 Ashley Av., Charleston, SC 29425, USA) I10, 709 (1991) Archives of Disease in Childhood (London) Imaging of neonatal arterial thrombosis. Gudinchet, E et al. (Radiodiagn., CHUV-BH07, CH-1011 Lausanne, Switzerland) 66,1158 (1991) Family implications of neonatal Gorlin's syndrome. Evans, D.G.R. et al. (Dept. of Med. Genetics, StMary's Hosp., Hathersage Rd., Manchester M13 OJH, England) 66, 1162 (1991) Gastroduodenat perforation in preterm babies treated with dexamethasone for bronchopulmonary dysplasia. Ng, EC. et al. (Dear, ER.E, Dept. of Paed. and Child health, St James's Univ. Hosp., Beckett St., Leeds LS9 7TF, England) 66, 1164 (1991) Transoesophageal echocardiography: a new diagnostic method in paediatric cardiology. Stamper, O. (Dept. ofPaed. Cardiol., RoyalHosp. for Sick Children, Sciennes Rd., Edinburgh EH9 1LF, Scotland) 66,1175 (1991) Retropharyngeal abscess. Coulthard, M., Isaacs, D. (Isaacs, D., The Children's Hosp., Pyrmont Bridge Rd., Camperdown, PO Box 34, Sydney 2050, Australia) 66, 1227 (1991) Congenital neuroblastoma with paraplegia. Munro, F.D. et al. (Carachi, R., Dept. of Paed. Surg., Royal Hosp. for Sick Children, Yorkhill, Glasgow G3 8SJ, England) 66, 1246 (1991) Imaging in urinary tract infection. Gleeson, F.V., Gordon, I. (X Ray Dept., Royal Free Hosp., Pond St., London NW3 2QG, England) 66,1282 (1991) Transoral decompression and posterior stabilisation in Morquio's disease. Ashraf, J. et al. (Crockard, H. A., The NationalHosp. For Neurol. and Neurosurg., Queen Square, London WC1N 3BG, England) 66,1318 (1991)
4. Martin CG, Snider AR, Katz SM, Peabody JL, Brady JP (1982) A b n o r m a l cerebral blood flow patterns in preterm infants with a large patent ductus arteriosus. J Pediatr 101:587
T. Hayashi, MD D e p a r t m e n t of Pediatrics Yamaguchi University School of Medicine Ube, Yamaguchi 755 Japan
Continued from p. 119 Complications of splintage in congenital dislocation of the hip. Langkamer, V. G. et al. (Dept of Orthop., Directorate of Surg., Royal Infirmary, Bristol BS2 8HW, England) 66,1322 (1991) Subdural fat effusion complicating parenteral nutrition. Rushforth, A. et al. (Puntis, J.W.L., Dept. of Paed. and Child Health, Level D, Clarendon Wing, The General Infirmary, Belmont Grove, Leeds LS2 9NS, England) 66,1350 (1991) Familial infantile oesophageal achalasia. Kaar, T.K. et al. (Watson, J. B. G., Dept. of Paed., Regional Hosp., Wilton, Cork, Rep. of Ireland) 66, 1353 (1991) Clinical Radiology (Edinburgh) Case report: painless thoracic scoliosis due to dumb-bell ganglioneuroma-CT and MRI appearances. Sampson, M.A. et al. (Dept. of Rad., General Hosp., Tremona Rd., Southampton, England) 44, 359 (1991) Journal of Bone and Joint Surgery. British Volume (London) Ultrasonography in congenital dislocation of the hip. Simultaneous imaging of both hips from in front. Suzuki, S. et al. (Dept. of Orthop., Med. Center for Children, 120-6 Moriyama-cho Moriyama, Shiga 524, Japan) 73-B, 879 (1991) Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity. Kallio, R E. et al. (Dept. of Orthop. Surg, and Traumatol., Surgical Hosp., Univ, Central Hosp., Kasarminkatu 11-13, SF-00130 Helsinki, Finland) 73-B, 884 (1991) Congenital discoid lateral meniscus in children. Aichroth, R M. et al. (Westminster Hosp., Dean Ryle St., Horseferry Rd., London SWlP 2AR England) 73-B, 932 (1991) Metatarsus primus varus. Kilmartin, T. E. et al. (School of Ped., Cliftonville, Northhampton NN1 5BD, England) 73-B, 937 (1991) Calcaneus deformity in the ambulant patient with myelomeningocele. Fraser, R. K., Hoffman, E.B. (Hoffman, E. B., 7 Marne Av., Newlands 7700, Cape Town, Rep. of South Africa) 73-B, 994 (1991) Imaging of intramedullary tumour spread in osteosarcoma. O'Flanagan, S.J. et al. (12 Sion Hill Av., Harold's Cross, Dublin 6, Rep. of Ireland) 73-B, 998 (1991) Fibular hypoplasia with absent lateral rays of the foot. Maffulli, N., Fixsen, J.A. (Newham General Hosp., Glen Rd., Plaistow, London E13 8RU, England) 73-B, 1002 (1991) Pediatric Reviews and Communications (Berkshire) Cervico-medullary cord compression in achondroplasia: two case histories and a hterature review. Matthes, J.W.A., Webb, E.V.J. (Dept. of Child Health, Univ. Hosp. of Wales, Cardiff, U. K.) 6, 27 (1991) Annales de P6diatrie (Paris) Post-immunization hemiseizure-hemiplegia syndrome: report of a case. [In french]. Playds, R et al. (Roussey, M., Serv. de P6d. et G~ndtique M6d., CHRU Pontchaillou, F-35033 Rennes, cedex, France) 38,602 (1991) Cerebral arterial ischemia and neonatal seizures. [In french]. Daltroff, G. et al. (D6pt. de P6d., Centre Hosp., 14, rue de Mulhouse, F-90000 Belfort, France) 38, 607 (1991)
c o n f i n u e d o n p . 139
Pediatric Radiology 9 Springer-Verlag 1992
Reverse flow in the intracranial arteries - the possible significance of comparative flow in the anterior cerebral and the basilar arteries T. Hayashi t, T. Ichiyama 1, O. Kondoh 1, H. Tanaka 1, H. Tateishi 1' 2, N. Harima 2, and T. Saitoh 2 1Department of Pediatrics, and 2 Perinatal Care Center for Mother and Child, Yamaguchi University School of Medicin e, Ube, Japan Received: 3 September 1991; accepted: 10 December 1991
Abstract. F o u r infants with reverse flow patterns of the intracranial arteries are reported. Two with severe brain damage, h a d a reverse flow pattern in the anterior cerebral artery, which was r e c o r d e d during the r e c o v e r y stage f r o m cardiac arrest. The other two patients s h o w e d a reverse flow p a t t e r n in the basilar artery and had a g o o d prognosis. Reverse flow in the anterior cerebral artery suggests severe brain damage, but that in the basilar artery does not.
D o p p l e r u l t r a s o n o g r a p h y (US) t h r o u g h the anterior fontanelle of n e w b o r n s and infants is useful for estimating the cerebral b l o o d flow velocity. T h e technique has b e e n used in the determination of brain death in 6 n e w b o r n s [1]. T h e study utilized the changes in the flow velocity pattern in the anterior cerebral ( A C A ) and c o m m o n carotid arteries. T h e sequence of deterioration of the flow velocity wave f o r m in b o t h vessels which was characteristic of brain death consisted of (1) the loss of diastolic flow, (2) the a p p e a r a n c e of retrograde flow during diastole, (3) a decrease in systolic flow in the anterior cerebral artery and, ultimately, (4) no detectable flow in the comm o n carotid artery. T h e absent or reversed diastolic flow
and early systolic spikes has b e e n detected by transcranial D o p p l e r US in adult patients with brain death [2]. R e t r o grade flow velocity during diastole has also b e e n o b s e r v e d in the A C A [3] or the basal artery [4] of p r e t e r m infants with a large patent ductus arteriosus ( P D A ) , but without overt neurological deficits.
Material and methods The clinical and echographic findings in the 4 infants are summarized in Table 1. Patient 1 suffered from intracranial bleeding due to vitamin K deficiency with severe brain edema and increased intracranial pressure. Patient 2 had the adrenogenital syndrome with hyperpotassemia. When he arrived at our hospital, he had cardiac arrest with severe brain edema, as observed on B-mode US. Patient 3 was born, weighing 1980 g, at 34 weeks gestation with neonatal asphyxia, and cranial US revealed ventricular narrowing. Patient 4, weighing 1460 g, was born after 38 weeks gestation with trisomy 18, interruption of the aorta and a large PDA. Intracranial blood flow was examined by means of a Aloka Color Doppler SSD 350 or SSD 870 with a 5-MHz convex or sector probe. Images of the ACA and the basilar artery (BA) were obtained in the sagittal plane through the anterior fontanelle. The blood flow velocities in the A1 portion of the ACA and the BA were measured by pulsed Doppler technique.
Table 1. Clinical data and flow patterns for intracranial arteries in patients with reverse flow patterns
Age Sex Clinical findings Clinical diagnosis Prognosis
Flow pattern Anterior cerebral artery Basilar artery Condition at recording
1 9 wks M
2 5 mo M
Patient 3 2h F
Intracranial bleeding
Adrenogenital syndrome
Asphyxia
Died 6 h
Severe brain damage
Mild mental retardation
Trisomy 18 Interruption of aorta Died 20 weeks later of pulmonary hypertension and pneumonia
Reverse Not detected Severely increased intracranial pressure
Reverse Reverse Post dead on arrival
Not reverse Reverse In incubator with oxygen supply
Not reverse Reverse Mechanical ventilation with oxygen supply
4 4 wks F
129
Fig. 1. The blood flow velocity patterns in patient 2. Note the reverse flow patterns in both the anterior cerebral artery (upper) and basilar artery (lower)
Fig. 2. The blood flow velocity patterns in patient 4. Note the reverse flow pattern only in the basilar artery (lower)
Results
death. While reverse flow in intracranial arteries was previously reported in preterm neonates with a large PDA, our results show that the reverse blood flow in the A C A suggests a different clinical picture from that in the BA. The results for patients i and 2 suggest that the flow pattern in the anterior cerebral artery is influenced by increased peripheral resistance due to increased intracranial pressure caused by brain edema. Patient 4 with interruption of the aorta, showed a completely different flow patterns in the A C A and the BA, and demonstrates that the flow pattern in the B A is affected by the cardiac condition. Patient 3 had reverse flow only in the B A and the absence of diastolic flow in the A C A was recorded 2 hours after birth. These conditions may be related to the asphyxia occurring with brain edema and probably a physiological PDA. These findings suggest that the flow pattern in the A C A is chiefly affected by peripheral resistance of the cerebral vessels, while that in the B A is influenced by the cardiac condition. Thus, we think that the reverse flow in the A C A reflects the fatal condition caused by severe increased intracranial pressure, but that in the B A does not. Flow velocity measurements in both the anterior cerebral artery and the basilar artery are therefore strongly recommended for evaluating patients with severe brain damage.
The blood flow patterns in A C A and B A in the four patients and the associated conditions are presented in Table 1. Reverse blood flow was observed in the anterior cerebral artery in patients i and 2 (Fig. 1), and in the basilar artery in patients 2 4 (Fig. 2). Flow in A C A in patient 3 was absent in diastole and that in patient 4 had a normal pulsating flow pattern. In particular, the reverse flow pattern in B A in patient 4 was not a spiky retrograde one, as seen in patients 1, 2 and 3, but a "to and fro" flow pattern resembling a sine curve. Patient 1 died 6 h after the ultrasonic examination, and patient 2 developed severe cerebral palsy and mental retardation. An contrast patient 3 recovered with only mild mental retardation, and patient 4 survived for 20 weeks, but eventually died of severe pulmonary hypertension and pneumonia. In the latter case autopsy revealed interruption of the aorta, type B. It thus seems that reverse blood flow in A C A is accompanied by severe brain damage, while that in B A is not.
Discussion The reverse blood flow in the intracranial arteries is known to be one of the key findings in the process of brain
130
References 1. McMenamin JB, Volpe JJ (1983) Doppler ultrasonography in the determination of neonatal brain death. A n n Neuro114: 302 2. Petty GW, M o h r JR Pedley TA, Tatemichi TK, Lennihan L, Duterte DI, Sacco R L (1990) The role of transcranial Doppler in confirming brain death: sensitivity, specificity, and suggestions for performance and interpretation. Neurology 40:300 3. Lipman B, Serwer GA, Brazy J E (1982) A b n o r m a l cerebral hemodynamics in preterm infants with patent ductus arteriosus. Pediatrics 69:778
Literature in pediatric radiology T1 and T2 in the cerebrum: correlation with age, gender, and demographic factors. Breger, R. K. et al. (Haughton, V.M., Dept. of Rad., Med. Coltege, Froedtert Memorial Lutheran Hosp., 9200 W Wisconsin Av., Milwaukee, W153226, USA) 181, 545 (1991) Color Doppler US imaging during pediatric neurosurgical and neuroradiologic procedures. Barr, L.L. et al. (Dept. of Rad. and Ped., Children's Hosp. Med. Center, Univ. College of Med., Elland and Bethesda Av., Cincinnati, OH 45229-2899, USA) 181,567 (1991) Intramedullary lesions of the pediatric spinal cord: correlation of findings from MR imaging, intraoperative sonography, surgery, and histologic study. Brunberg, J.A. et al. (Dept. of Rad., Univ. Hosp., 1500 E Med. Center Dr., Ann Arbor, M148109-0030, USA) 181, 573 (1991) Cerebellar dimensions in assessment of gestational age in neonates. Co, E. et al. (Raju, T. N. K., Dept. of Ped. (M/C 856), Univ. Hosp., 840 S Wood St., Chicago, IL 60612, USA) 181, 581 (1991) MR imaging of diffuse bone marrow replacement in pediatric patients with cancer. Ruzal-Shapiro, C. et al. (Dept. of Rad., Babies Hosp., Presbyterian Med. Center, Columbia College of Physicians and Surgeons, 3959 Broadway, New York, NY 10032, USA) 181, 587 (1991) Seminars in Roentgenology (New York) Trauma to the elbow and forearm. Karasick, D. et al. (Dept. of Rad., Jefferson Med. College and Thomas Jefferson Univ. Hosp., 111 S/llth St., Philadelphia, PA 19107, USA) 26, 318 (1991) Surgery (St. Louis) Pancreatic ductal abnormalities in children. Tagge, E. E et al. (Div. of Ped. Surg., Med. Univ., Children's Hosp., 171 Ashley Av., Charleston, SC 29425, USA) I10, 709 (1991) Archives of Disease in Childhood (London) Imaging of neonatal arterial thrombosis. Gudinchet, E et al. (Radiodiagn., CHUV-BH07, CH-1011 Lausanne, Switzerland) 66,1158 (1991) Family implications of neonatal Gorlin's syndrome. Evans, D.G.R. et al. (Dept. of Med. Genetics, StMary's Hosp., Hathersage Rd., Manchester M13 OJH, England) 66, 1162 (1991) Gastroduodenat perforation in preterm babies treated with dexamethasone for bronchopulmonary dysplasia. Ng, EC. et al. (Dear, ER.E, Dept. of Paed. and Child health, St James's Univ. Hosp., Beckett St., Leeds LS9 7TF, England) 66, 1164 (1991) Transoesophageal echocardiography: a new diagnostic method in paediatric cardiology. Stamper, O. (Dept. ofPaed. Cardiol., RoyalHosp. for Sick Children, Sciennes Rd., Edinburgh EH9 1LF, Scotland) 66,1175 (1991) Retropharyngeal abscess. Coulthard, M., Isaacs, D. (Isaacs, D., The Children's Hosp., Pyrmont Bridge Rd., Camperdown, PO Box 34, Sydney 2050, Australia) 66, 1227 (1991) Congenital neuroblastoma with paraplegia. Munro, F.D. et al. (Carachi, R., Dept. of Paed. Surg., Royal Hosp. for Sick Children, Yorkhill, Glasgow G3 8SJ, England) 66, 1246 (1991) Imaging in urinary tract infection. Gleeson, F.V., Gordon, I. (X Ray Dept., Royal Free Hosp., Pond St., London NW3 2QG, England) 66,1282 (1991) Transoral decompression and posterior stabilisation in Morquio's disease. Ashraf, J. et al. (Crockard, H. A., The NationalHosp. For Neurol. and Neurosurg., Queen Square, London WC1N 3BG, England) 66,1318 (1991)
4. Martin CG, Snider AR, Katz SM, Peabody JL, Brady JP (1982) A b n o r m a l cerebral blood flow patterns in preterm infants with a large patent ductus arteriosus. J Pediatr 101:587
T. Hayashi, MD D e p a r t m e n t of Pediatrics Yamaguchi University School of Medicine Ube, Yamaguchi 755 Japan
Continued from p. 119 Complications of splintage in congenital dislocation of the hip. Langkamer, V. G. et al. (Dept of Orthop., Directorate of Surg., Royal Infirmary, Bristol BS2 8HW, England) 66,1322 (1991) Subdural fat effusion complicating parenteral nutrition. Rushforth, A. et al. (Puntis, J.W.L., Dept. of Paed. and Child Health, Level D, Clarendon Wing, The General Infirmary, Belmont Grove, Leeds LS2 9NS, England) 66,1350 (1991) Familial infantile oesophageal achalasia. Kaar, T.K. et al. (Watson, J. B. G., Dept. of Paed., Regional Hosp., Wilton, Cork, Rep. of Ireland) 66, 1353 (1991) Clinical Radiology (Edinburgh) Case report: painless thoracic scoliosis due to dumb-bell ganglioneuroma-CT and MRI appearances. Sampson, M.A. et al. (Dept. of Rad., General Hosp., Tremona Rd., Southampton, England) 44, 359 (1991) Journal of Bone and Joint Surgery. British Volume (London) Ultrasonography in congenital dislocation of the hip. Simultaneous imaging of both hips from in front. Suzuki, S. et al. (Dept. of Orthop., Med. Center for Children, 120-6 Moriyama-cho Moriyama, Shiga 524, Japan) 73-B, 879 (1991) Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity. Kallio, R E. et al. (Dept. of Orthop. Surg, and Traumatol., Surgical Hosp., Univ, Central Hosp., Kasarminkatu 11-13, SF-00130 Helsinki, Finland) 73-B, 884 (1991) Congenital discoid lateral meniscus in children. Aichroth, R M. et al. (Westminster Hosp., Dean Ryle St., Horseferry Rd., London SWlP 2AR England) 73-B, 932 (1991) Metatarsus primus varus. Kilmartin, T. E. et al. (School of Ped., Cliftonville, Northhampton NN1 5BD, England) 73-B, 937 (1991) Calcaneus deformity in the ambulant patient with myelomeningocele. Fraser, R. K., Hoffman, E.B. (Hoffman, E. B., 7 Marne Av., Newlands 7700, Cape Town, Rep. of South Africa) 73-B, 994 (1991) Imaging of intramedullary tumour spread in osteosarcoma. O'Flanagan, S.J. et al. (12 Sion Hill Av., Harold's Cross, Dublin 6, Rep. of Ireland) 73-B, 998 (1991) Fibular hypoplasia with absent lateral rays of the foot. Maffulli, N., Fixsen, J.A. (Newham General Hosp., Glen Rd., Plaistow, London E13 8RU, England) 73-B, 1002 (1991) Pediatric Reviews and Communications (Berkshire) Cervico-medullary cord compression in achondroplasia: two case histories and a hterature review. Matthes, J.W.A., Webb, E.V.J. (Dept. of Child Health, Univ. Hosp. of Wales, Cardiff, U. K.) 6, 27 (1991) Annales de P6diatrie (Paris) Post-immunization hemiseizure-hemiplegia syndrome: report of a case. [In french]. Playds, R et al. (Roussey, M., Serv. de P6d. et G~ndtique M6d., CHRU Pontchaillou, F-35033 Rennes, cedex, France) 38,602 (1991) Cerebral arterial ischemia and neonatal seizures. [In french]. Daltroff, G. et al. (D6pt. de P6d., Centre Hosp., 14, rue de Mulhouse, F-90000 Belfort, France) 38, 607 (1991)
c o n f i n u e d o n p . 139
