4 - Schneider et al. (1975)
Schneider et al. (1975) described predominantly brain
stem damage in seven cases of neonatal death. Four
of these cases appeared to have been born without
complications and had Apgar scores of 9 to 10 one
and five minutes after birth, but then suffered
unexpected circulatory arrest 3 to 26 hours later.
Although birth trauma had not been evident,
aspiration of amniotic fluid was demonstrated in two of
these infants and small tentorial tears were found
postmortem in two of the brains. The tentorium is part
of the “dura mater” connective tissue envelope of the
brain that separates the cerebellum from the occipital
and parietal lobes. Its anterior border, the tentorial
incisure, surrounds the brainstem between the pons
and midbrain at the level of the inferior colliculi, which
are therefore also vulnerable to tentorial trauma.
Textbooks on neuroanatomy such as those by Nolte
and Angevine (1995) or Truex and Carpenter (1969)
can be consulted for more detail on the structures in
close contact with the tentorium [2, 3]. Denny-Brown
(1962) described damage of the tectum in a young
girl thrown from a horse, which he attributed to
tentorial impact [4]. Gellner (1959) also proposed
tentorial impact as the mechanism for damage to the
inferior and superior colliculi caused during a
traumatic birth [5].
Symmetrical necroses were visible in the brainstem of
all seven cases examined by Schneider et al;
microscopically these were associated with incomplete
necroses surrounding abnormally enlarged congested
blood vessels. The nucleus ruber, substantia nigra,
inferior colliculi, pontine gray and inferior olives,
hypothalamus, and thalamus were all severely
affected. In the cerebellum, necrosis of Purkinje cells
was most prominent.
Two of the cases (5 and 6) described by Schneider et
al. were premature infants who appeared to have
been compromised in utero before birth. The other
five cases illustrate that problems may go
unrecognized during the birth of a healthy full term
baby; Apgar scores do not completely reflect safe
passage. Following are summaries of the information
Schneider et al. provided for each full-term case:
Case 1: Maternal edema during pregnancy,
premature rupture of membranes, gestational age 39
weeks, birthweight 3420 grams (about 7 pounds 9
ounces), Apgar scores 9/10 (at 1 and 5 minutes after
birth). Circulatory arrest 12 hours after birth,
resuscitation, transient gasping, later respiratory
paralysis, anisocoria (unequal pupils), tonic-clonic
convulsions, flat EEG, hypotonia, loss of brainstem
and spinal reflexes, survival time 6 days.
Case 2: Normal pregnancy, spontaneous rupture of
the membranes, gestational age 42 weeks,
birthweight 3600 grams (7 pounds 15 ounces), Apgar
scores 9/10. Circulatory arrest 26 hours after birth,
resuscitation, restoration of cardiac function within 15
minutes, permanent respiratory paralysis, flat EEG,
hypotonia, loss of brainstem and spinal reflexes,
survival time 4 days. Aspiration of amniotic fluid
demonstrated. Small tentorial tears found
postmortem.
Case 3: Normal pregnancy, spontaneous birth in
occipito-posterior presentation (a malpresentation
that often prolongs labor), gestational age 39 weeks,
birthweight 3580 grams (about 7 pounds 14 ounces),
Apgar scores 9/10. Circulatory arrest 9 hous after
birth, resuscitation, transient gasping, later permanent
respiratory paralysis, flat EEG, loss of brainstem and
spinal reflexes, hypotonia, survival time 14 days.
Aspiration of amniotic fluid demonstrated.
Case 4: Normal pregnancy, premature rupture of the
membranes, gestational age 38 weeks, 2980 grams
(6 pound 9 ounces), Apgar scores 9/10. Circulatory
arrest 3 hours after birth, resuscitation, permanent
respiratory paralysis, hypotonia, complete loss of
brainstem and spinal functions, survival time 5 days.
Small tentorial tears found postmortem
Case 7: Spontaneous rupture of the membranes,
gestational age 40 weeks, breech presentation,
Cesarean section after unsuccessful extraction,
birthweight 3960 grams (about 8 pounds twelve
ounces), Apgar scores 0/2, cardiac arrest and
respiratory paralysis during birth, resuscitation.
Restoration of system circulation within 30 minutes,
permanent respiratory paralysis, hypotonia, coma,
generalized tonic-clonic spasms. Finally weak
respiratory activity, myoclonic jerks, progressive
spasticity, survival time 22 days. Cortical as well as
subcortical abnormalities were found in the brain of
this infant postmortem.
- Schneider H et al. (1975)
Anoxic fcencephalopathy
with predominant
involvement of basal
ganglia, brain stem, and
spinal cord in the perinatal
period.
- Nolte J, Angevine JB (1995)
The Human Brain, in
Photographs and Diagrams.
- Truex RC, Carpenter MB
(1969) Human
Neuroanatomy, Sixth Edition.
- Denny-Brown D (1962) The
midbrain and motor
integration.
- Gellner L (1959) A
Neurophysiological Concept
of Mental Retardation and Its
Educational Implications.
- Schneider H, Ballowitz L, Schachinger H, Hanefield F, Droeszus J-U (1975) Anoxic
fcencephalopathy with predominant involvement of basal ganglia, brain stem, and spinal
cord in the perinatal period. Acta Neuropathologica (Berlin) 32:287-298.
- Nolte J and Angevine JB (1995) The Human Brain, in Photographs and Diagrams.
Mosby, St. Louis.
- Truex RC and Carpenter MB (1969) Human Neuroanatomy, Sixth Edition. Williams &
Wilkins, Baltimore.
- Denny-Brown D (1962) The midbrain and motor integration. Proceedings of the Royal
Society of Medicine 55:527-538.
- Gellner L (1959) A Neurophysiological Concept of Mental Retardation and Its Educational
Implications. Chicago, IL: The Dr. Julian D. Levinson Research Foundation for Mentally
Retarded Children, Cook County Hospital.
Gellner, Lise
A neurophysiological concept of mental retardation and its educational
implications; a series of five lectures, given under the auspices of and published
by the Dr. Julian D. Levinson Research Foundation for Mentally Retarded
Children. Chicago, 1959. Mugar Library call #RJ499 .G38