Brain single photon emission computed tomography at term age for predicting cerebral palsy after preterm birth

In order to assess the predictive value of neonatal brain perfusion with single photon emission computed tomography (SPET) with regard to neuromotor outcome at a corrected age of 18 months, 34 infants with birth weight <1,500 g and gestation age <34 weeks underwent brain technetium-99m ethylcysteinate dimer (99Tc(m)-ECD) SPET at term age. The perfusion defects were estimated by visual interpretation. Consecutive semiquantitative assessment was made in 26 cases and reference values for the tracer were collected from images of 17 preterm infants with normal outcome after the follow-up period. Relative regional cortical (frontal, sensorimotor, parietal and occipital), cerebellar and thalamic perfusion levels were evaluated in middle sagittal slices and hemispheric asymmetries in transaxial slices. Perfusion defects predicted cerebral palsy (CP) (n = 11) with 82% sensitivity, 70% specificity and 74% accuracy, the corresponding figures for ultrasound (US) being 73, 83 and 79%, respectively. The sensitivity of SPET in predicting moderate or severe CP (n = 7) was 100% and the specificity 67%, the corresponding figures for US being 71% and 74%, respectively. Brain SPET seems to identify the most severe forms of CP in preterm infants very well at term age, but cannot identify all mild ones. In addition to a low specificity, the radiation exposure restricts usefulness of the method for clinical purposes.     

Brain imaging findings in very preterm infants throughout the neonatal period: Part I. Incidences and evolution of lesions, comparison between ultrasound and MRI

This study describes the incidence and evolution of brain imaging findings in very preterm infants (GA < 32 weeks), assessed with sequential cranial ultrasound (cUS) throughout the neonatal period and MRI around term age. The accuracy of both tools is compared for findings obtained around term.Periventricular echodensities and intraventricular haemorrhage were the most frequent cUS findings during admission. Frequent findings on both cUS and MRI around term included ventricular dilatation, widened extracerebral spaces, and decreased cortical complexity. MRI additionally showed punctate white matter lesions and diffuse and excessive high signal intensity, but did not depict lenticulostriate vasculopathy and calcifications, and was less reliable for germinolytic and plexus cysts.cUS detected most abnormalities that have been associated with abnormal neurodevelopmental outcome.     

Structure and evolution of echo dense lesions in the neonatal brain. A combined ultrasound and necropsy study.

Sixty seven of 216 infants weighing less than 2 kg at birth had cerebral lesions on ultrasonic scanning. Eight of 17 who had periventricular leukomalacia, with or without subependymal or intraventricular haemorrhage, or both, died. These and one larger baby were the subject of a combined ultrasound, and where appropriate, necropsy study. There was excellent correlation between the ultrasound and necropsy findings, only some of the earlier lesions of periventricular leukomalacia being missed by ultrasound. The data suggest it is now possible to distinguish periventricular leukomalacia and subependymal/intraventricular haemorrhage by ultrasound, that both lesions may be present in the same brain, that apparent parenchymal extension of an intraventricular haemorrhage is more probably the result of haemorrhage into ischaemic periventricular tissue, and that the term ''periventricular haemorrhage'' should be abandoned since it confuses two lesions of differing aetiology and differing clinical importance. Future advances in neonatal brain ultrasound depend on accurate assessment of both the nature and site of lesions within the cerebral hemispheres and ventricular system since the interpretation of these parameters is of critical importance.     

Status at Two Years in 121 Very Low Birth Weight Survivors Related to Neonatal Intraventricular Haemorrhage and Mode of Delivery

ABSTRACT. All 121 infants with birthweight 1500 g (VLBW) discharged from our department through an 18-month period were followed up at two years of age. All but 10 infants were examined by cranial ultrasound scanning in the neonatal period. Six had died after discharge; and of these two had severe brain damage following neonatal intraventricular haemorrhage. Twelve children had definite neuromotor abnormality; of these, the nine children with spastic types of cerebral palsy had all been delivered vaginally. Of the remaining children, one half had at least one neurodevelopmental symptom suggesting perinatal brain damage. Outcome was associated to neonatal intraventricular/subependymal haemorrhage when complicated by ventricular dilatation. Outcome in children with simple haemorrhage was similar to that in children without haemorrhage. The association between outcome and haemorrhage was considerably reduced by simultaneously considering the associations of gestational age at birth and the use of mechanical ventilation in the neonatal period. Head circumference at follow-up was greatest in those children with haemorrhage complicated by ventricular dilatation, when adjusted for actual body weight, birth weight, and gestational age at birth.     

Status at two years in 121 very low birth weight survivors related to neonatal intraventricular haemorrhage and mode of delivery

All 121 infants with birthweight less than or equal to 1500 g (VLBW) discharged from our department through an 18-month period were followed up at two years of age. All but 10 infants were examined by cranial ultrasound scanning in the neonatal period. Six had died after discharge; and of these two had severe brain damage following neonatal intraventricular haemorrhage. Twelve children had definite neuromotor abnormality; of these, the nine children with spastic types of cerebral palsy had all been delivered vaginally. Of the remaining children, one half had at least one neurodevelopmental symptom suggesting perinatal brain damage. Outcome was associated to neonatal intraventricular/subependymal haemorrhage when complicated by ventricular dilatation. Outcome in children with simple haemorrhage was similar to that in children without haemorrhage. The association between outcome and haemorrhage was considerably reduced by simultaneously considering the associations of gestational age at birth and the use of mechanical ventilation in the neonatal period. Head circumference at follow-up was greatest in those children with haemorrhage complicated by ventricular dilatation, when adjusted for actual body weight, birth weight, and gestational age at birth.     

Limitations of ultrasonography for diagnosing white matter damage in preterm infants

OBJECTIVES: To compare the accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) in diagnosing white matter abnormalities in preterm infants and to determine the specific indications for MRI. DESIGN: Prospective cohort study. SETTING: A neonatal intensive care unit in France. PATIENTS: All preterm infants (相似文献   

Brain imaging findings in very preterm infants throughout the neonatal period: Part II. Relation with perinatal clinical data

This study describes the relation between frequent and clinically relevant brain imaging findings in very preterm infants (GA < 32 weeks), assessed with sequential cranial ultrasonography throughout the neonatal period and MRI around term age, and several potential perinatal risk factors.For ultrasound findings during admission the following independent risk factors were identified: male gender for periventricular echodensities and intraventricular haemorrhage, postnatal corticosteroid treatment for cystic white matter lesions, and lower gestational age for post-haemorrhagic ventricular dilatation. For MRI findings around term age, including punctate white matter lesions, ventricular dilatation, decreased cortical complexity, and diffuse and excessive high signal intensity, no independent risk factors were found.In very preterm infants, the risk factors for frequently found changes on cranial ultrasound have largely remained unchanged over the last decades, while no risk factors could be identified for subtle and diffuse white matter injury as seen on MRI around term age.     

Periventricular haemorrhagic infarction associated with subependymal germinal matrix haemorrhage in the premature newborn. Report of two cases

Two cases of unilateral subependymal germinal matrix haemorrhage associated with homolateral periventricular haemorrhagic infarction (PVHI) are reported in two premature newborns. This association is rather rare. Indeed, PVHI occurs generally with large intraventricular haemorrhage. Diagnosis is made by brain imaging (ultrasound, MRI) scans and single photon emission computed tomography. PVHI is probably caused by obstruction of periventricular venous drainage by large intraventricular haemorrhage leading to a haemorrhagic venous infarction. From our cases, we conclude that extraventricular haemorrhage leading to a large subependymal haematoma can result in obstruction of periventricular venous drainage, subsequent PVHI and abnormal neuromotor development.     

Magnetic resonance imaging of the brain in a cohort of extremely preterm infants.

To define magnetic resonance imaging (MRI) appearances of the brain in extremely preterm infants between birth and term, a sequential cohort of infants born at a gestational age <30 weeks was studied with a dedicated neonatal magnetic resonance scanner. Images of infants (n = 41) with a median gestational age of 27 weeks (range 23 to 29 weeks) were initially obtained at a median age of 2 days (range 1 to 20 days) and then repeatedly studied; 29 (71%) infants had MRI at a median gestational age of 43 weeks (range 38 to 52 weeks) (term MRI). On the initial MRI scan 28 of 41 infants had abnormalities: either intraventricular hemorrhage, germinal layer hemorrhage, ventricular dilatation, or diffuse and excessive high signal intensity in the white matter on T(2)-weighted images. When magnetic resonance images for preterm infants at term gestation were compared with those of infants in the control group born at term, 22 of 29 infants had dilatation of the lateral ventricles, 24 of 29 had squaring of the anterior or posterior horns of the lateral ventricles, 11 of 29 had a widened interhemispheric fissure or extracerebral space, and 22 of 29 had diffuse and excessive high signal intensity in the white matter. There were no cases of cystic periventricular leukomalacia. We conclude that MRI abnormalities are commonly seen in the brain of preterm infants on whom images are obtained within 48 hours of birth and that further abnormalities develop between birth and term. A characteristic appearance of diffuse and excessive high signal intensity in the white matter on T(2)-weighted images is associated with the development of cerebral atrophy and may be a sign of white matter disease. These MRI appearances may help account for the high incidence of neurodevelopmental impairment in extremely preterm infants.     

Impact of cerebral palsy in patients discharged from neonatal intensive care units

AIM: The aim of this study was to assess the impact and the peculiarities of cerebral palsy (CP) in children discharged from our neonatal intensive care unit (NICU) from January 1998 to April 2004. METHODS: A total of 2 303 children were discharged from our NICU during this period and 1 912 were followed up for 1 year through neurological examination (traditional, Brazelton, general movements) and cranial ultrasound (US); high-risk newborns were evaluated with brain magnetic resonance imaging (MRI) too. RESULTS: In 65 children (3.4% of the follow-up group) were diagnosed CP, and classified as follows: 21 (32%) diplegia, 19 (29%) quadriplegia, 20 (31%) hemiplegia, 4 (6%) double hemiplegia, 1 (2%) dyskinetic form. In diplegia and quadriplegia prevailed low birth weight infants (less than or equal to 2,500 g) and preterm infants, while in hemiplegia prevailed normal birthweight infants (greater than 2,500 g) and infants at term. The main MRI findings were: in diplegia 82% periventricular white matter lesions; in quadriplegia 94% periventricular and/or subcortical white matter lesions; in hemiplegia 95% bilateral periventricular or subcortical white matter lesions, predominating on contralateral cerebral hemisphere; in double hemiplegia 100% periventricular and/or subcortical white matter lesions, 100% enlargement of subarachnoid spaces; in dyskinetic form 100% basal ganglia lesions. CONCLUSIONS: The impact of CP in children discharged from our NICU, in agreement with the literature, is higher than in the total population of newborns, thus it is very important to evaluate carefully high-risk newborns during hospitalization and follow-up, through neurological examination and radiologic imaging (US, MRI), for an accurate and early treatment.     

Magnetic resonance imaging of preterm brain injury

Magnetic resonance imaging (MRI) has proved to be a valuable tool for monitoring development and pathology in the preterm brain. This imaging modality is useful for assessing numerous pathologies including periventricular leukomalacia, intraventricular haemorrhage/germinal layer haemorrhage, and periventricular haemorrhagic infarction, and can help to predict outcome in these infants. MRI has also allowed the detection of posterior fossa lesions, which are not easily seen with ultrasound. Additionally, and perhaps most relevant, quantitative MR studies have shown differences between the normal appearing preterm brain at term equivalent age and term born infants, confirming that the brain develops differently in the ex utero environment. Further studies using quantifiable MR techniques will improve our understanding of the effects of the ex utero environment, including aspects of neonatal intensive care on the developing brain.     

Intracranial haemorrhage: an incidental finding at magnetic resonance imaging in a cohort of late preterm and term infants

Background

Intracranial haemorrhage (ICH) in term newborns has been increasingly recognised but the occurrence in late preterm infants and the clinical presentation are still unclear.

Objective

To investigate the appearance of intracranial haemorrhage at MRI in a cohort of infants born at 34 weeks’ gestation or more and to correlate MRI findings with neonatal symptoms.

Materials and methods

We retrospectively reviewed neonatal brain MRI scans performed during a 3-year period. We included neonates ≥34 weeks’ gestation with intracranial haemorrhage and compared findings with those in babies without intracranial haemorrhage. Babies were classified into three groups according to haemorrhage location: (1) infratentorial, (2) infra- and supratentorial, (3) infra- and supratentorial + parenchymal involvement.

Results

Intracranial haemorrhage was observed in 36/240 babies (15%). All of these 36 had subdural haemorrhage. Sixteen babies were included in group 1; 16 in group 2; 4 in group 3. All infants in groups 1 and 2 were asymptomatic except one who was affected by intraventricular haemorrhage grade 3. Among the infants in group 3, who had intracranial haemorrhage with parenchymal involvement, three of the four (75%) presented with acute neurological symptoms. Uncomplicated spontaneous vaginal delivery was reported in 20/36 neonates (56%), vacuum extraction in 4 (11%) and caesarean section in 12 (33%). Babies with intracranial haemorrhage had significantly higher gestational age (38?±?2 weeks vs. 37?±?2 weeks) and birth weight (3,097?±?485 g vs. 2,803 ± 741 g) compared to babies without intracranial haemorrhage and were more likely to be delivered vaginally than by caesarian section.

Conclusion

Mild intracranial haemorrhage (groups 1 and 2) is relatively common in late preterm and term infants, although it mostly represents an incidental finding in clinically asymptomatic babies; early neurological symptoms appear to be related to parenchymal involvement.     

Predictability of cerebral palsy and its characteristics through neonatal cranial ultrasound in a high-risk NICU population

The aim of the study is to evaluate the predictive value of various types of brain injury detected by ultrasound in the neonatal period for the occurrence of cerebral palsy and its characteristics in a large cohort of high-risk infants. Thousand twenty-one consecutively NICU-admitted high-risk infants were assessed up to the corrected age of at least 2 years. Cerebral palsy (CP) was categorised into spastic or non-spastic, bilateral or unilateral and mild, moderate or severe CP. Different types of brain injury were identified by serial cranial ultrasound (US) during the NICU stay: white matter disease (WMD), haemorrhage, cerebral infarction, deep grey matter and parasagittal cerebral injury. There is a significant overall association between different types of brain injury and gestational age. Only 4% of the children with normal US develop CP. In the presence of any abnormal US image, the likeliness to develop CP is at least seven times higher. Within the group of infants with WMD and haemorrhage, the degree of brain involvement has a clear impact on the occurrence of CP. Concerning the characteristics of CP, deep grey matter lesion predict non-spastic CP versus spastic CP (OR = 31, P < 0.001). Cerebral infarction and haemorrhage grade IV are strong predictors of unilateral spastic CP versus bilateral spastic CP (OR = 49 and 24, respectively, P < 0.001). Deep grey matter lesion is a significant predictor for severe versus mild and moderate CP (OR = 6). In conclusion, neonatal cranial US is a useful tool in predicting CP and its characteristics.     

脑性瘫痪儿童的MRI特征

目的 探讨脑性瘫痪(脑瘫)患儿脑MR／的表现及其与出生胎龄和脑瘫类型的关系。方法 回顾性分析104例脑瘫患儿的病史、l临床与MR／表现。结果 早产与足月儿脑瘫类型构成显著不同,早产儿以痉挛性双瘫多见(占66．O％),而足月儿偏瘫和失调型高于早产儿。104例脑瘫患儿MR／异常率为84．7％,早产和足月儿组MHI异常率差异无显著性。痉挛型双瘫、四肢瘫、偏瘫、手足徐动型和失调型脑瘫MR／异常率分别为89．4％、100％、100％、54．5％和90．O％。31／42例痉挛性双瘫表现为脑室周围白质软化症(PVL),而以早产儿双瘫更多见(90％);各类型脑瘫的MR／异常表现不同,双瘫以PVL为主,徐动型表现为基底节病变或．PVL失调型绝大部分存在先天性小脑发育不全,偏瘫型突出表现为单侧脑损伤。出生胎龄与MRI特点有关,早产儿组以PVL为特征,见于除失调型外的其他脑瘫类型;足月儿脑瘫MR／异常表现变化多且病变广泛。结论MR／有助于评价各型脑瘫的病理特点及其与出生胎龄的关系．对脑瘫病因的推测有帮助。     

Apnoea in relation to neonatal temporal lobe haemorrhage

BackgroundSix term newborns presented with apnoea and temporal lobe haemorrhage.AimIn this observational study, we described involvement of the limbic system in apnoeic term newborns with temporal lobe injury.MethodsSix term newborns presented to the neonatal care unit with apnoea within the first 2 days of life. Ultrasound (US) and MRI of the brain were obtained in the first week of life.ResultsApnoea was related to temporal lobe haemorrhage in all. During apnoeic periods four had focal epileptic activity on EEG. All lesions were detected first with US. On MRI, haemorrhages were located in the parenchyma, the subdural and/or subarachnoid space. Three haemorrhages were surrounded by infarction in the temporal lobe. In three infants hippocampus and mesial temporal cortex were affected. In two basal temporal cortex only was involved. Vascular anomalies were excluded by MRA, serial MRI or serial US with Doppler imaging.ConclusionTerm infants with seizure associated apnoea may present with haemorrhage and/or infarction to hippocampus, mesial and basal temporal cortex. This study supports the existence and possible disruption of descending influences from the temporal cortex and/or amygdala on brainstem breathing centres in the term newborn.     

Neurodevelopmental outcome in very-low-birth-weight infants with or without periventricular haemorrhage and/or leucomalacia

The aim of the study was to verify the predictive value of ultrasound performed in the neonatal period for short-term neurodevelopmental prognosis in 122 preterm very-low-birth-weight infants followed-up at 36 months. Neuromotor development was favourable in 53 (87%) subjects with normal ultrasound findings and in 21 (81%) subjects presenting uncomplicated haemorrhage. However, sensory and/or cognitive sequelae developed in 13% and 19% of the two groups, respectively. Outcome was unfavourable in 14 (50%) of 28 patients with ultrasound findings of complicated cerebral haemorrhages and in 5 (71%) of those (7) with ultrasound findings of parenchymal lesions without haemorrhage. Neonatal ultrasound examination seems to be fundamental in predicting neuromotor, but not cognitive, outcome in very-low-birth-weight infants.     

Brainstem size and function at term age in relation to later neurosensory disability in high-risk, preterm infants

The aim of this study was to measure brainstem size on magnetic resonance imaging (MRI) scans of high-risk, preterm infants, to assess brainstem function by brainstem auditory-evoked potentials (BAEP) and to determine the predictive value of these measures for the neurosensory outcome. A total of 51 preterm infants (gestational age <34 wk, birthweight <1500 g) underwent examinations at term age; neuromotor outcome and hearing were followed up until a corrected age of 18 mo. Fourteen (27%) infants had neurosensory disability. Those with a later neurosensory disability had a significantly smaller brain stem than those with a normal outcome. The preterm infants had significantly longer peak latency (L) V and interpeak latency (IPL) III–V than the full-term control infants. Most of the preterm infants with severe cerebral palsy or hearing loss had abnormal BAEP. Sensitivity of morphometric dimensions for predicting neurosensory disability was only 20–31%, but specificity was 97–100%. Abnormal L I and IPL III–V in BAEP predicted disability with a sensitivity of 93% and a specificity of 57–59%.
Conclusion: We conclude that adverse events during the perinatal period may lead to morpho-functional changes in the brain stem in high-risk, preterm infants, and it seems that functional changes are accurate in predicting neurosensory disability in such patients.     

Spontaneous intraventricular haemorrhage in utero

The authors report three cases of unexplained prenatal intraventricular haemorrhage (IVH) in three term infants. In the first two cases the suspected diagnosis of prenatal IVH was made a few hours after delivery, in accordance with the ultrasonographic feature of clots in the ventricles, whereas in the third case prenatal ultrasonography was suggestive of hydrocephalus with intraventricular clots.Abbreviations IVH intraventricular haemorrhage - SEH subependymal haemorrhage - CT computed tomography - US ultrasonography     

Periventricular leucomalacia and intraventricular haemorrhage in the preterm neonate.

Two hundred very low birthweight infants were prospectively scanned to ascertain the incidence of periventricular leucomalacia (PVL) and haemorrhage. Before collection of data, clear definitions of ultrasound abnormalities believed to represent PVL and intraventricular haemorrhage were described. These referred to small and moderate intraventricular haemorrhage, paenchymal haemorrhage, and PVL, including prolonged flare (echoes in the periventricular region lasting for two weeks or more and not becoming cystic). Sixty nine infants (34%) had no abnormality on ultrasound scans. Intraventricular haemorrhage occurred in 107 babies (37 grade I and 62 grade II), and only eight infants were thought to have true parenchymal haemorrhage. Ultrasound appearances of PVL were seen in 27 infants, 19 of whom developed cysts and eight died in the precystic stage. Prolonged flare occurred in another 25 babies. Unilateral parenchymal haemorrhage occurred in four infants who subsequently developed cystic PVL in the contralateral hemisphere. Twenty one infants developed ventricular dilatation, 12 of whom had associated parenchymal lesions. Haemorrhage, PVL, and flare occurred commonly in infants of 30 weeks'' gestation and below and became markedly less common in more mature infants. We believe prolonged flare represents a form of PVL, and in this study a total of 52 (26%) infants had an ultrasound appearance of periventricular leucomalacia, an incidence considerably higher than previously reported.     

Myth: cerebral palsy cannot be predicted by neonatal brain imaging

There is controversy in the literature about the value of brain imaging in neonates regarding the prediction of cerebral palsy (CP). The aim of this review was to unravel the myth that CP cannot be predicted by neuroimaging in neonates. Major intracranial lesions in the preterm infant should be recognized with sequential cranial ultrasound and will predict those with non-ambulatory CP. Magnetic resonance imaging (MRI) at term-equivalent age will refine the prediction by assessment of myelination of the posterior limb of the internal capsule. Prediction of motor outcome in preterm infants with subtle white matter injury remains difficult, even with conventional MRI. MRI is a better tool to predict outcome in the term infant with hypoxic-ischaemic encephalopathy or neonatal stroke. The use of diffusion-weighted imaging as an additional sequence adds to the predictive value for motor outcome. Sequential and dedicated neuroimaging should enable us to predict motor outcome in high risk newborns infants.