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Cerebral infarction complicating umbilical vein catheterization.

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Cerebral Infarction
Complicating Umbilical
Vein-Catheterization
R. L. Ruff, MD, PhD, C.-M. Shaw, MD,
J. B. Beckwith, MD, and R. V. Iozzo, M D
Reported complications of umbilical vein catheterization
include: portal vein thrombosis [ 1, 3, 51, portal hypertension 11, 31, hepatic abscess 111, sepsis 111, umbilical vein
perforation 111, thrombotic embolism 11, 51, septic embolism 111, air embolism 11, 31, hepatic calcification 131,
colonic perforation 11, 31, pericardial effusion 141, and infective and nonbacterial endocarditis 121. Cerebral infarction has occurred in infants with umbilical vein catheters
and endocarditis [2], but cerebral embolism as a direct
complication of umbilical vein catheterization has not previously been reported. The following note indicates that
umbilical vein catheterization in the infants with a patent
foramen ovale can be complicated by stroke.
A 3,900 gm infant was delivered by cesarean section at 44 weeks' gestation when fetal heart tones indicated impending fetal distress. The infant had bilateral
pneumothorax and meconium aspiration and was cyanotic,
with rapid, labored respirations. There was slight improvement in respiratory status following bilateral chest
tube insertion, but she remained hypoxic with a clinical
picture of persistent fetal circulation. An arterial line was
passed via the right femoral artery into the aorta, and an
umbilical vein catheter was inserted in the inferior vena
cava. During the second day of life the infant was hypotensive and required pressors, administered via the umbilical
vein catheter. The following day she developed massive
upper gastrointestinal bleeding necessitating blood transfusion, which was done via the umbilical vein catheter. Later
that day the child developed clonic seizures starting in the
right arm and leg and then spreading to the entire body.
The seizure activity was stopped by phenobarbital delivered via a peripheral vein. Several hours later the child
developed irregular gasping respirations and died.
At autopsy the umbilical vein catheter was found to be
located in the inferior vena cava just below the level of the
right atrium. The arterial catheter was situated in the abdominal aorta with its tip at the level of the celiac ostium.
Organized thrombus covered the umbilical vein catheter
and occluded the ductus venoms as well as the umbilical
and hepatic veins. T h e foramen ovale and ductus arteriosus
were patent. The cardiac chambers and valves and the
thoracic aorta were free of vegetations and mural thrombi.
The left middle cerebral artery was occluded by a thrombus
beginning just distal to the internal carotid artery bifurcation and extending into two distal branches to form a saddle
embolus. Serial sectioning of the left middle cerebral artery
demonstrated that the lumen was occluded and distended
by an organized thrombus mixed with more recent propagating thrombi. In addition, multiple small areas of necrotizing arteritis were observed in the distended wall of the
artery. T h e necrotizing arteritis tended to be limited to the
intima, but the media was also occasionally destroyed.
The left cerebral hemisphere was infarcred in the distribution of the middle cerebral artery, involving the left
frontal and parietal lobes, corpus striatum, and internal
capsule, with the left superior frontal and cingulate gyri and
globus pallidus spared. Microscopically these areas showed
acute ischemic changes.
In various autopsy studies the incidence of thrombotic
complications in infants with umbilical venous catheters has
varied from 3 to 33% 11, 51. The most frequently involved
blood vessels are the umbilical, portal, and hepatic veins
and the ductus venosus. T h e most likely source for the left
middle cerebral artery embolus was the thrombosed hepatic vein, with the embolus passing through the foramen
ovale to enter the arterial system. It is unlikely that an
embolus from the arterial catheter could have traveled retrograde up the aorta. The multiple dlscrete areas of endarteritis in the occluded portion of the left middle cerebral
artery suggest that the embolus was infected, septic thrombosis being a known complication of umbilical vein
catheterization 111. This case illustrates that venous thrombosis, catheter induced o r otherwise, can result in stroke in
infants with a patent foramen ovale.
References
1. Kitterman JA, Phibbs RH, Tooley WH: Catheterization of
umbilical vessels in newborn infants. Pediatr Clin North Am
17:895-912, 1970
2. Symchych PS, Krauss AN, Winchester P: Endocarditis following intracardiac placement of umbilical venous catheters in
neonates. J Pediatr 90:287-289, 1977
3. Taber P, Lackey DA, Mikity V: Roentgenographic findings of
complications with neonatal umbilical vascular catheterization.
Am J Roentgenol Radium Ther Nucl Med 118:47-57, 1973
4. Walker D , Pellett JR: Pericardial tamponade secondary to umbilical vein catheters. J Pediatr Surg 7:79-80, 1972
5. Wigger HJ, Bransliver BR, Blanc WA: Thromboses due to
catheterization in infants and children. J Pediatr 76:l-11, 1970
From the Department of Neurology, Cornell University Medical
Center, New York, NY, the Laboratory of Neuropathology, University of Washington School of Medicine, Seattle, and the Department of Pathology, Children's Orthopedic Hospital and Medical Center, Seattle, WA.
Accepted for publication Mar 12, 1979
Address reprint requests to Dr Ruff, Department of Neurology,
Corneii University Medical College, 1300 York Ave, New York,
NY 10021.
Notes and Letters
85
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