Disorders of Consciousness: Practical Management in an Emergency Room

Lowering of the level of consciousness is a very common presentation at the emergency room, often without any history that helps finding an etiology. This emergency requires quick empirical measures to reduce neuronal mortality, with additional protection against sequelae. According to the Advanced Cardiac Life Support (ACLS) guidelines, there are current emergency neurological support protocols, such as the Emergency Neurological Life Support (ENLS) created by the Neurocritical Care Society. The present paper shows how to approach unconscious patients, highlighting possible etiologies and proposed treatments.

Alucinosis peduncular: descripción de un caso y revisión del tema / Peduncular hallucinosis: a case report and topic review / Alucinose peduncular: descrição de um caso e revisão do assunto

La alucinosis peduncular es el término utilizado para describir una forma rara de alucinaciones visuales complejas, vívidas, coloridas y generalmente recurrentes que ocurren en relación a lesiones del tronco encefálico y el tálamo. Es una patología infrecuente y su fisiopatología es controvertida. Describimos el caso de una mujer de 38 años con alucinosis peduncular asociada a compresión extrínseca del tronco encefálico secundaria a un schwannoma vestibular. Analizamos las características clínicas y los mecanismos fisiopatológicos subyacentes.

Peduncular hallucinosis is a clinical condition characterized by vivid, colorful, complex visual hallucinations that often recur in time and are described in association with midbrain and thalamic lesions. It is a rare phenomenon and its precise pathophysiology is unknown. We describe the case of a 38-year-old woman who developed peduncular hallucinosis in relation to extrinsic compression of the midbrain secondary to a vestibular schwannoma. Clinical features and underlying pathophysiological mechanisms are discussed.

A alucinose peduncular é o termo usado para descrever uma forma rara de alucinações visuais complexas, vívidas, coloridas e geralmente recorrentes que ocorrem em relação às lesões do tronco encefálico e do tálamo. É uma patologia infreqüente e sua fisiopatologia é controversa. Descrevemos o caso de uma mulher de 38 anos de idade com alucinose peduncular associada à compressão extrínseca do tronco encefálico secundária ao schwannoma vestibular. Analisamos as características clínicas e os mecanismos fisiopatológicos subjacentes.

The blink reflex test does not show abnormalities in a large group of patients with chronic migraine / O teste do reflexo do piscamento nao mostra alteracoes em um grande grupo de pacientes com enxaqueca cronica

The blink reflex – a simple, non-invasive and inexpensive test – may be indicative of lesions or dysfunctions of the brainstem, and particularly assesses the trigeminal-facial arch. Results from alterations of the blink reflex in patients with headaches have provided controversial data. Method Registration of the waves R1 and R2 (ipsilateral to the stimulus) and R2c (contralateral to the stimulus) by electroneuromyography. Results A large number of controls (n=160) and patients with chronic migraine (n=160) were studied. No significant differences were observed between the two groups. Conclusion It is possible that this relatively simple and primitive reflex is not affected unless there is significant damage to the brainstem. .

O reflexo do piscamento é um teste simples, não invasivo de baixo custo que pode direcionar o raciocínio para lesões ou disfunções do traonco cerebral, avaliando particularmente o arco trigêmeo-facial. Resultados de reflexo do piscamento em pacientes com cefaleias têm mostrado dados controversos. Método Registro das ondas R1 e R2 (ipsilaterais ao estímulo) e R2c (contralateral ao estímulo) por eletroneuromiografia. Resultados Um grande número de controles (n=160) e pacientes com enxaqueca crônica (n=160) foi avaliado. Não foram encontradas diferenças significativas no reflexo do piscamento entre os dois grupos. Conclusão É possível que este reflexo, por ser relativamente simples e primitivo, não esteja alterado a menos que ocorram danos significativos no tronco cerebral. .

Potenciais evocados auditivos de tronco encefálico em frentistas / Auditory brainstem response in gas station attendants

A ototoxidade dos solventes orgânicos pode atingir o sistema auditivo a nível coclear e retrococlear. OBJETIVO: Avaliar a integridade neurofisiológica do sistema auditivo até tronco cerebral por meio do PEATE. MÉTODO: Estudo prospectivo. Estudados frentistas de três postos de gasolina da cidade de Santa Maria/RS. A amostra ficou composta por 21 sujeitos, que foram avaliados por meio de potenciais evocados auditivos de tronco encefálico. RESULTADOS: Alteração nas latências absolutas das ondas I e III e em todas as latências interpicos, na orelha direita. Na orelha esquerda houve alteração na latência absoluta de todas as ondas, e em todos os intervalos interpicos. Alteração na diferença interaural da onda V foi verificada em 19% dos sujeitos. No grupo exposto há mais de cinco anos, foram estatisticamente significantes o número de sujeitos com alteração: no intervalo interpico I-V da orelha direita; na latência absoluta da onda I e no intervalo interpico III-V da orelha esquerda. CONCLUSÃO: A exposição a combustíveis pode causar alterações no sistema auditivo central.

Ototoxicity of organic solvents can affect the hearing system up to the cochlea level and the central structures of hearing. OBJECTIVE: To evaluate the neurophysiological integrity of the hearing system in subjects exposed to fuels using ABR. METHOD: Prospective study. We evaluated attendants from three gas stations in Santa Maria/RS. The sample had 21 subjects, who were evaluated by auditory brainstem response. RESULTS: We found an alteration in the absolute latencies of Waves I and III and in all the interpeak latencies, in the right ear. In the left ear there was a change in the absolute latencies of all Waves, and in all the interpeak intervals. A change in the interaural difference of Wave V was found in 19% of the individuals. In the group exposed for more than five years, there were subjects with a statistically significant changes: in the I-V interpeak of the right ear; in the absolute latency of Wave I and in the III-V interpeak of the left year. CONCLUSION: Exposure to fuels can cause alterations in the central hearing system.

Heart rate variability and QT dispersion study in brain death patients and comatose patients with normal brainstem function

To compare heart rate variability [HRV] and QT dispersion in comatose patients with normal brainstem function and with brain death. Cross-sectional comparative study. The Intensive Care Unit of Ali-Ebn-Abitaleb Hospital, Rafsanjan Medical University from September 2007 to June 2009. Fourteen brain death patients with clinical signs of imminent brain death and 15 comatose patients were examined by neurologist in intensive care unit. HRV, RR interval and QT dispersion on ECG were assessed for 24 hours in both groups. Independent t-test and chi-square test were for statistical analysis to determine significance which was set at p< 0.05. According to Holter Findings, mean of standard deviation of RR-interval in the comatose and brain death groups was 48.33 and 35 respectively [p= 0.045]. Mean of covariance coefficient of RR-interval was 0.065 in the comatose group and 0.043 in the brain deaths [p= 0.006]. QT dispersion was not significant difference in two groups. HRV and RR-interval analysis appeared as an early finding for the diagnosis of brainstem death in comparison to comatose patients with normal brainstem function. QT dispersion had not significant in this regard

Participación del óxido nítrico, proteína Fos y el tallo cerebral en la retención de glucosa encefálica durante la hipoxia / Involvement of the nitric oxide, Fos protein and brain stem in the retention of brain glucose during hypoxia

Se ha descrito que el núcleo del tracto solitario (NTS), estructura del tallo cerebral y vía de relevo de las aferencias del los quimiorreceptores del senocuerpo carotídeo (RSCC), participa en el aumento en la retención de glucosa por el cerebro (RGC) ante una hipoxia. Es probable que en esta respuesta participe el óxido nítrico (NO) y la proteína Fos. En este trabajo se analiza el papel del NO en el NTS sobre la modificación de la RGC y la expresión de la proteína inmunorreactiva Fos (Fos-ir) en ratas in vivo. La inyección de un donador del NO como es el nitroprusiato de sodio (NPS) en el NTS, 4 min antes de la estimulación de los RSCC, disminuyó la RGC, pero incrementó la expresión de Fos-ir en un mayor número de neuronas en el NTS con respecto a las ratas control, que sólo recibieron líquido cefalorraquídeo artificial (LCRa) antes de la estimulación RSCC. En contraste, un inhibidor selectivo del NO como el N?-nitro-L-arginina metil éster (L-NAME) en el NTS 4 min antes de la estimulación RSCC con NaCN, aumentó la RGC, pero disminuyó el número de neuronas Fos-ir comparados con el control o con NPS. La detección inmunohistoquímica de la expresión de Fos-ir en las células del tallo cerebral indica que la estimulación RSCC activa vías dependientes de NO en el NTS, para regular la RGC. El estudio de esta población de células en el NTS, serß importante para definir su caracterización.

It has been said that the nucleus tractus solitarii (NTS), one structure of the brain stem and path of apherences of chemoreceptors of carotid sinus-body, is involved in the increased glucose retention by the brain in case of hypoxia. It is likely that nitric oxide and Fos protein also take part in this response. This paper analyzes the role of nitric oxide in the NTS on the change of glucose retention by the brain and the expression of inmunoreactive protein Fos (ir-Fos) in rats in vivo. The injection of a NO donor such as sodium nitroprusiate in the NTS four minutes before the stimulation of carotid sinus-body chemoreceptors decreased glucose retention by the brain but increased the expression of ir-Fos in a higher number of neurons in NTS with respect to control group rats which only received artificial cerebrospinal fluid before the stimulation. In contrast, the use of a selective NO inhibitor such as NO-nitro-L-arginine methyl ester (L-NAME) in the NTS four minutes before the stimulation of the chemoreceptors with NaCN, increased the glucose retention by the brain but reduced the number of neurons with ir-Fos expression when compared with the control group or the sodium nitroprusiate injection. The immunohistochemical detection of ir-Fos expression in the brain stem cells indicated that stimulation of carotid sinus-body chemoreceptors activated NO-dependent paths in the NTS to regulate glucose retention by the brain. The study of this cell population in the NTS will be important to define its characterization.

Sleep apnea and REM sleep behavior disorder in patients with Chiari malformations / Apnéia do sono e distúrbio do comportamento da fase do sono com REM em pacientes com malformações de Chiari

BACKGROUND: Chiari malformations (CM) may result in the appearance of REM sleep behavior disorder (RBD) and sleep apnea syndrome (SAS) that can be considered markers of brain stem dysfunction. PURPOSE: To evaluate the frequency of RBD and SAS in patients with CM type I and II. METHOD: Were evaluated 103 patients with CM by means of full night polysomnography. Were scoring different sleep stages, frequency of abnormal movements (through video monitoring) and abnormal respiratory events. RESULTS: Of the 103 patients, 36 showed CM type I and 67 CM type II. Episodes of RBD were observed in 23 patients. Abnormal apnea-hypopnea index (AHI) was observed in 65 patients. CONCLUSION: The high rate of RBD suggests that this parassomnia and the increased frequency of central sleep apnea episodes, may be considered as a marker of progressive brain stem dysfunction.

INTRODUÇÃO: Malformações de Chiari (MC) podem gerar o aparecimento de distúrbio comportamental da fase do sono com REM (DCR) e síndrome da apnéia do sono (SAS), sugerindo a ocorrência de disfunção do tronco cerebral. OBJETIVO: Avaliar a freqüência de DCR e SAS em pacientes com MC I ou II. MÉTODO: Utilizou-se a polissonografia de noite inteira para a avaliação de 103 pacientes. Classificaram-se as diferentes fases do sono e analisou-se a freqüência de movimentos anormais (monitorada por vídeo) e de eventos respiratórios anormais. RESULTADOS: Dos 103 pacientes analisados, 36 eram portadores de MC I e 67 de MC II. Episódios de DCR foram observados em 23 pacientes. O índice de apnéia/hipopnéia foi considerado anormal em 65 pacientes. CONCLUSÃO: A alta freqüência de DCR e o aumento da freqüência de episódios de apnéia central do sono podem ser considerados manifestação de disfunção progressiva do tronco cerebral.

Patrones normales de potenciales evocados auditivos del tallo cerebral (PEATC) en recién nacidos sanos / Normal patterns of auditory evoked potentials brain stem (PEATC) in healthy newborns

El presente trabajo tiene como finalidad el estudio de los patrones normales de los Potenciales Evocados Auditivos del Tallo Cerebral (PEATC) en recién nacidos hospitalizados en el Servicio de Neonatología, Unidad de Recién Nacidos del Hospital Central de San Cristóbal, en número de 30, en el período comprendido entre los meses de mayo a octubre del año 2007. El objetivo general es el de valorar la conducción nerviosa en la vía auditiva del tallo cerebral en recién nacidos sanos. Además del estudio de la respuesta auditiva tronco encefálica en los recién nacidos a término sanos, para tener como marco de referencia estos valores en el Hospital Central de San Cristóbal, el establecer los valores de normalidad para la latencia de las Ondas I, III, V de los PEATC en recién nacidos sanos y estimar la utilidad de los PEATC como técnica de investigación auditiva en el período neonatal, para diseñar a futuro un protocolo que determine precozmente la hipoacusia. Es una investigación prospectiva, transversal, analítica, no experimental, observacional. Los parámetros de estimulación son: tipo: Click; Duración: 100 ms; Ratio: 19/seg; Polaridad: alternante; Intensidad: 90 dB nHL; Auriculares: Beyerdynamic DT48. Los parámetros de registro son: Electrodos: Cz Fz M1 M2, Filtro de paso alto: 160 Hz; Filtro de paso bajo: 3.2 kHz; Sensibilidad: 50 mV; n° de promediaciones: 2000. Los resultados se presentan en valores de medias en milisegundos y desviaciones típicas para latencias de la onda I, III y V del total de sujetos estudiados n=30 para oído izquierdo a 80 dB y n=80 para oído derecho. Se incluyen los valores de ± 2,5 desviaciones típicas a 80 dB. También se presentaron las diferencias interaurales entre ambos oídos registradas en este estudio y una comparación de los valores PEATC de este estudio con los valores normales en pediatría. En conclusión se consiguieron una serie de patrones locales de los PEATC que sirven como guía para los futuros estudios.

Hipoacusia en recién nacidos con factores de riesgo perinatal / Hypoacusia in newborns with perinatal risk factors

Estimar la incidencia de hipoacusia en recién nacidos ingresados en la Unidad de Terapia Intensiva Neonatal del Hospital de Niños J.M de Los Ríos, con factores de riesgo perinatal, entre marzo a septiembre de 2005. Se diseño una investigación prospectiva, transversal, analítica, no experimental, no aleatoria. La medición de Potenciales Auditivos Evocados de Tronco Cerebral se realizó en 31 pacientes (62 oídos): 17 del sexo femenino y 14 del sexo masculino, con edad de 34.09 ± 18.39 días. Del total de los pacientes 87,10 por ciento presentaron algún grado de hipoacusia, de los cuales el 92,6 por ciento presentaron afección bilateral y el 7,4 por ciento unilateral, el 12,9 por ciento presento audición normal. Encontrándose entre los factores de riesgo más importantes para hipoacusia: exposición a medicamentos ototóxicos (Amikacina) 45,16 por ciento, sepsis neonatal y meningitis 25.80 por ciento cada uno, y otros 3,24 por ciento. En cuanto a la evaluación del umbral auditivo de los 62 oídos se encontró: 10 audición normal (16,12 por ciento), 22 hipoacusia leve (35.48 por ciento), 11 moderada (17.74 por ciento), 10 severa (16.12 por ciento), 9 profunda (14.51 por ciento). No se hallaron diferencias significativas relacionadas con el sexo o con el número de factores de riesgo. Todo paciente con antecedente de exposición a medicamentos ototóxicos, sepsis o meningitis tiene alta probabilidad de adquirir algún grado de hipoacusia.

To estimate the incidence of hypoacusia in newborns at the Neonatal Intensive Therapy Unit of the J.M de Los Ríos Children Hospital, with perinatal risk factors, between March and September 2005. A prospective, transversal, analytical, no experimental and no aleatory investigation was designed. A measurement of evoke auditive potential of cerebral torso was performed in 31 patients (62 ears): 17 females and 14 males, betwenn 34.09 ± 18.39 days old. The 87.10% patients presented some degree of hypoacusia. From them, 92.6% had bilateral affection, the 7,4% had unilateral affection and 12.9% had normal audition. The most important risk found for hypoacusia were: 45.16% was exposure to ear toxic medicines (Amikacin), 25.8% to neonatal sepsis and meningitis, and 3.24% for other factors . According to the auditive threshold evaluation of 62 ears: 10 had normal audition (16.12%), 22 had mild hypoacusia (35.48%), 11 had medium hypoacusia (17.74%), 10 had severe hypoacusia (16.12%) and 9 had very severe hypoacusia (14.51%). There were not significative differences related to gender or the number of risk factor.

Aporte clínico en la patología cráneo cervico mandibular / Clinical contribution in cranio-cervical-mandibular pathology

Introducción: El objetivo de este trabajo es valorar las alteraciones biomecánicas que conllevan a desequilibrios musculares, causadas principalmente por hipoactividad o hiperactividad muscular y movilidad articular limitada. Material y método: Se realiza una propuesta de evaluación que involucra tres aspectos relacionados, que son: Una modificación de la pauta original hecha para pacientes con trastornos temporomandibulares, desarrollada por el Dr. Prof. Mariano Rocabado. Aspectos de la evaluación orofacial, que es un segmento perteneciente al curso básico de Evaluación y tratamiento de la hemiplejia del adulto, Bobath, y la Evaluación muscular de Daniels-Worthingham's para músculos mandibulares y cervico-torácicos. Se evaluaron 13 pacientes adultos, secuelados de Parálisis Cerebral Espástica (PCE), Accidente Cerebrovascular (ACV), Traumatismo Encefalocraneano (TEC), Esclerosis Lateral Amiotrófica (ELA) y Enfermedad de Parkinson (EP), pertenecientes a Centros de neurorehabilitación especializados (Fundación Alterego/Centro Los Coihues). Conclusiones: El grupo de pacientes con mayor compromiso neurológico (ELA, ACV hemorrágico y PCE) son los más comprometidos, en cuanto a debilidad de grupos musculares estabilizadores cervicales (principalmenete Esternocleidomasteoideo), grado funcional moderado de pterigoideos interno y externo, aumento de tono en masetero y temporal (no mensurable aún, pero inferido por la menor apertura bucal), y alteraciones posturales cervicotoracicas, de preferencia.

Brain stem auditory evoked responses and visual evoked responses in children with tubercular meningitis.

Thirty two patients between 6 months and 14 years of age with tubercular meningitis were evaluated for brain stem auditory evoked response (BAER) and Visual evoked responses (VER), within 7 days of admission. Absolute latencies and interpeak latencies were compared with values obtained from normal children. BAER abnormality was found in 56.25% and VER in 28%children, respectively. BAER abnormality correlated with Glasgow Coma Scale at admission and discharge, stage of meningitis, raised intracranial pressure, seizure activity, and poor outcome. VER abnormality correlated with abnormal fundus findings only.

Avaliação da atividade locomotora após indução local de desmielinização tóxica no tronco encefálico de ratos Wistar / Evaluation of locomotor activity after a local induction of toxic demyelination in the brainstem of Wistar rats

Lesões desmielinizantes induzidas pelo gliotóxico brometo de etídio (BE) têm sido estudadas com o objetivo de permitir a compreensão do limitado processo de reparo mielínico no sistema nervoso central, bem como avaliar estratégias terapêuticas no sentido de acelerar a reconstrução das bainhas de mielina perdidas. Muito embora estudos eletrofisiológicos correlacionando situações de desmielinização e remielinização experimental sejam bem estabelecidos, os efeitos comportamentais não têm sido adequadamente investigados. Neste estudo, foram analisadas ultra-estruturalmente as lesões desmielinizantes e a atividade locomotora de ratos submetidos à indução focal de desmielinização pelo modelo do BE na superfície ventral do tronco encefálico, mediante observação de sua movimentação e controle motor durante a travessia de uma trave elevada de madeira (beam walking test). Foi observada a ocorrência de deficiências locomotoras até 31 dias pós-injeção de BE, constatando-se ainda que a subseqüente remielinização estava relacionada com o retorno da função perdida.

Coma anóxico-isquémico en 46 pacientes: Evolución a treinta días y su relación con los reflejos de tronco / The absence of brainstem reflexes does not predict short term mortality in anoxic ischemic coma

Background: Anoxic-ischemic coma has a poor outcome with a high rate of mortality and morbidity. Therefore, clinical predictors of prognosis are needed for therapeutic decision-making. Patients and methods: Prospective analysis of 46 patients, 31 male, age range 19-85 years, with anoxic-ischemic coma following cardiac arrest. All the patients included in our study remained comatose with a Glasgow Coma Scale (GCS) score of six or less points, after their stabilization in the Intensive Care Unit. They were evaluated clinically using the pupillary light reflex, corneal reflex and vestibulo-ocular reflex testing, induced by caloric stimulation with cold water. Survival was evaluated using life tables. All patients were followed until the thirtieth day after the anoxic-ischemic event. Results: Thirty five patients (76%) died within the next twenty-nine days, 8 patients (18%) reached the vegetative state, 2 patients (4%) achieved a recovery with disability, and only 1 patient (2%) was discharged without sequelae. One day, five and 30 days survival rates were 89, 53 and 29%, respectively. The abolition of all brainstem reflexes was not a predictor of mortality. Conclusion: Thirty day survival in this group of patients was 29% and the absence of brainstem reflexes was not a predictor of mortality.

Dynamic observation of brainstem auditory evoked potential and pathological changes of the brain after closed brain injuries in rats / 法医学杂志

OBJECTIVE@#To investigate the dynamic experiences of pathological changes in brain and the injured role of brainstem auditory evoked potential (BAEP) after closed Mild Traumatic Brain Injury (MTBI) in rat.@*METHODS@#A closed diffuse brain injury model was successfully produced in rat by hit the parietal bone with a spring-droved steel stick. The auditory brainstem response evoked by click at 50Hz stimulating frequency were recorded at pre-trauma, 15 min and 1, 3, 6, 12 h and 1, 2, 4, 7, 10, 14, 21 d after brain injury. The pathological changes of brain were observed under light microscope and the brain edema was detected by wet weight/dry weight rations.@*RESULTS@#The I-V, III-V of BAEP wave inter peak latency (IPL) in MTBI group increased immediately in 15 minutes after injury. The III, V wave peak latency (PL) and I-V, III-V wave IPL became longer than the pre-trauma level in 6, 12 h post-injury (P<0.05). The III, V wave PL and I - III, I - V, III - V wave IPL became longer than the pre-trauma level in 1, 2 d after injury (P < 0.001), the BAEP retuned to normal level in 14 d after brain injury. At 15 minutes after injury, the water content in brain increased and met its peak in 1 d, decreased gradually in 4 d, then decreased slowly and returned to normal level in 10 d after injury.@*CONCLUSION@#The regular changes of BAEP could be an objective tool for evaluating hearing dysfunction after closed mild diffuse traumatic brain injury.

The influence of age in peripheral facial palsy on brainstem reflex excitability.

BACKGROUND: Neuronal plasticity is expected to be different at different ages and adaptive changes developing after peripheral facial palsy (PFP) may provide a clue in this respect. AIMS: To investigate the difference in the reorganization developing after facial nerve damage between patients who developed PFP at childhood-youth and middle-old age. PATIENTS AND METHODS: Twenty-two patients were divided into two groups according to the age-at-onset of PFP; young (PFP 1), and elderly (PFP 2). Two age-matched control groups (C 1 and C 2) comprised of 32 healthy subjects were included in the study. The latency, R(2) area, and recovery of the R(2) area of the blink reflex were investigated. STATISTICAL ANALYSIS: ANOVA and Bonferroni tests were used. RESULTS: The R(2) areas were significantly greater on the intact side of the PFP 1 group as compared to that in the control group ( P =0.012). The recovery of R2 component was significantly enhanced on the symptomatic (P = 0.027), and intact (P = 0.041) sides in PFP 1 as compared to that in the C 2 group at the stimulus interval of 600 ms. Significant enhanced recovery was noted at 200 ms stimulus interval on the symptomatic side of the two PFP groups (PFP 1, P = 0.05 and PFP 2, P = 0.025) and on the intact side of the PFP 1 group (P =0.035) as compared to that in the control groups. CONCLUSION: Young age-at-onset of PFP is associated with more prominent excitability changes developing at the neuronal and interneuronal level.

Cortical, brainstem and autonomic nervous system dysfunction in infants with post-hemorrhagic hydrocephalus

OBJECTIVE: The aim of this study was to evaluate the degree of central and autonomic dysfunction by means of electroencephalographic (EEG) and cardio-pneumographic recording (CPGR) in infants with Post-Hemorrhagic Hydrocephalus (PHH). METHODS: Nineteen infants with PHH were studied, born from October 1998 to January 2000. Clinical diagnosis was confirmed by cephalic perimeter measurement and ultrasonographic study. Eight channel bipolar EEG and CPGR were performed after sleep deprivation, EEG features studied were: Temporal organization, symmetry, synchrony, frequency of normal and abnormal patterns. CPGR features studied were: Frequency of apnea and temporal organization by means of beat to beat variability. RESULTS: Averages of birth's age and weight, Apgar scores at one and five minutes, and cephalic perimeter showed lower values in PHH infants. PHH infants showed abnormalities in EEG and CPGR such as: Higher discontinuous activity (63), asymmetry (73), asynchrony (89), abnormal EEG patterns (89), apnea (26) and absence of heart rate variability (63). CONCLUSIONS: EEG and CPGR recordings are a useful tools in the examination of infants with PHH. These findings suggest cortical-subcortical, and brainstem dysfunction with severe encephalopathy and autonomic nervous dysfunction related to ventricular dilatation in infants with PHH.