Cranial ultrasound findings in preterm germinal matrix haemorrhage, sequelae and outcome

Germinal matrix-intraventricular haemorrhage (GMH-IVH), periventricular haemorrhagic infarction (PHI) and its complication, post-haemorrhagic ventricular dilatation (PHVD), are still common neonatal morbidities in preterm infants that are highly associated with adverse neurodevelopmental outcome. Typical cranial ultrasound (CUS) findings of GMH-IVH, PHI and PHVD, their anatomical substrates and underlying mechanisms are discussed in this paper. Furthermore, we propose a detailed descriptive classification of GMH-IVH and PHI that may improve quality of CUS reporting and prediction of outcome in infants suffering from GMH-IVH/PHI

Clinical application of 3D ultrasound in neonatal intraventricular hemorrhage

Preterm neonates are at risk for intraventricular hemorrhage (IVH) and subsequent post-hemorrhagic hydrocephalus (PHH). A well-accepted interventional therapy for PHH is ventricular tap (VT). Permanent treatment, ventriculo peritoneal shunt surgery (VPS) is required in the case of some neonates under some conditions (weight, immunological status, CSF protein level) who receive multiple interventions. The objective of this study was to apply a 3D ultrasound system clinically to determine CSF volume within the ventricle, to guide the neurosurgeon regarding the amount of CSF should be removed during every intervention, which lateral ventricle is better to intervene and to predict the possibilities of the requirement of the shunt. After ethics approval and parental consent, this 3D US system was used in a clinical study where data of 70 neonates having IVH were analyzed retrospectively and 22 preterm neonates were recruited prospectively. 3D US system was used to measure the ventricle volume of the neonates. In addition, we have changed the posture of some neonates to find the volume variation in two lateral postures. We found that 3D US ventricle volume had a higher correlation (Pearson correlation 0.739) with the amount of CSF removed in each tap than other parameters (weight, age, head circumference). After changing the posture of the neonates, we did not find any significant volume change of two lateral ventricle volumes (P-value was 0.353 in case of the right ventricle in two different postures and 0.473 in case of the left ventricle in two different postures). We also found more volume change after VT in those patients who required VPS than who did not need a VPS (volume change was18.70 ± 10.98 cm3 in shunt treated patients and 7.52 ± 3.35 cm3 in patients with no shunt where P- value was 0.0001). Therefore, our study suggests that a volumetric measurement of total lateral ventricles by the 3D US could be used concurrently with other physical parameters for better management of the neonates having PHH

3D Ultrasound in the Management of Post Hemorrhagic Ventricle Dilatation

Enlargement of the cerebral ventricles is relatively common among extremely preterm neonates born before 28 weeks gestational age. One common cause of ventricle dilatation is post hemorrhagic ventricle dilatation following a bleed in the cerebral ventricles. While many neonates with PHVD will have spontaneous resolution of the condition, severe, persistent PHVD is associated with a greater risk of brain injury and morbidity later in life and left untreated can cause death. The current clinical management strategy consists of daily measurements of head circumference and qualitative interpretation of two-dimensional US images to detect ventricular enlargement and monitoring vital signs for indications increased intracranial pressure (i.e. apnea, bradycardia). Despite the widespread clinical use of these indicators, they do not have the specificity to reliably indicate when an intervention to remove some CSF is required to prevent brain damage. Early recognition of interventional necessity using quantitative measurements could help with the management of the disease, and could lead to better care in the future. Our objective was to develop and validate a three-dimensional ultrasound system for use within an incubator of neonates with PHVD in order to accurately measure the cerebral ventricle volume. This system was validated against known geometric phantoms as well as a custom ventricle-like phantom. Once validated, the system was used in a clinical study of 70 neonates with PHVD to measure the ventricle size. In addition to three-dimensional ultrasound, clinical ultrasound images, and MRIs were attained. Clinical measurements of the ventricles and three-dimensional ultrasound ventricle volumes were used to determine thresholds between neonates with PHVD who did and did not receive interventions based on current clinical management. We determined image based thresholds for intervention for both neonates who will receive an initial intervention, as well as those who will receive multiple interventions. Three-dimensional ultrasound based ventricle volume measurements had high sensitivity and specificity as patients with persistent PHVD have ventricles that increase in size faster than those who undergo resolution. This allowed for delineation between interventional and non-interventional patients within the first week of life. While this is still a small sample size study, these results can give rise to larger studies that would be able to determine if earlier intervention can result in better neurodevelopmental outcomes later in life

Neurosonogram in Critically Ill Neonates in Neonatal Intensive Care Unit in Government Mohan Kumaramangalam Medical College Hospital, Salem

INTRODUCTION: Of the late due to many developments in modern neonatal intensive care, the survival of the crirically ill neonates has greatly improved. Neurosonogram is the most common and easily repeatable imaging technique for the neonatal brain showing brain development and the most frequently occurring forms of cerebral injury in the preterms and terms. This study is to assess the importance of cranial ultrasound as a investigatory modality for critically ill neonates. To find out the morphology of various cerebral lesions and to correlate neurosonogram finding with the clinical findings. AIMS AND OBJECTIVES: 1. To know the importance of neurosonogram as an investigatory modality for critically ill neonates. 2. To detect morphological changes occurring in various cerebral lesions. 3. To relate cranial ultrasound finding with the clinical findings and factors causing such brain lesions. METHODS: An Observational clinical study conducted at Government Mohan Kumaramangalam Medical College and Hospital, Salem involving 100 critically ill neonates admitted neonatal intensive care unit were subjected to neurosonography. Perinatal details were recorded and clinical examination with appropriate investigations was done. CUS was done and morphology of various findings was studied and recorded. Clinical correlation with CUS findings and follow up was done. RESULTS: On cranial ultrasound, 37% of all neonates had abnormal findings. Of the all neonates with term gestation having abnormal findings on Neurosonogram, 60% had cerebral edema, 35% showed periventricular flare and 15% had periventricular leucomalacia. Correlation between Neurosonogram findings of neonates with sepsis, birth trauma, seizures and prematurity was not statistically significant. There was statistically significant correlation between various findings on Neurosonogram and clinical outcome of the neonate. Most of neonates died had abnormal cranial ultrasound. CONCLUSION: High efficacy of Neurosonogram in identifying incidence of brain damage and its evolution on regular follow up guides clinical decisions and prognosis. This is particularly important in the expectation of potential preventive, protective, and rehabilitative strategies for the management of critically ill newborn infants.This study concludes cranial ultrasound is critical as an investigatory modality in NICU and effectively documents morphology of brain damage

Intraventricular Hemorrhage Sequelae in Low Birthweight Infants: A Meta-Analysis

Technological advances in neonatal care have dramatically improved the survival and disability rates among low birthweight infants (LBW). One common factor associated with later problems among these babies is intraventricular hemorrhage (IVH). A meta-analysis was conducted among LBW infants with and without IVH to determine developmental outcome. More than 450 studies were located. Only 125 studies met inclusion criteria. Mean effect sizes were computed by comparing the LBW group to either a fullterm children, LBW children scored worse in all areas except gross motor skills. Cognitive assessment was done commonly up to 6 years of age. LBW infants scored about 1/2 standard deviation below their comparison group. A positive linear trend was found for severity of IVH: those children without an IVH scored comparably to fullterm children, while those with severe bleeds were about one standard deviation behind. Assessment of academic skills was done with the 8- to 11-year olds. There was no information given on presence/severity of IVH. Very few assessments were done. On general academic measures, the LBW children scored about 1/2 standard deviation behind the comparison group. Over 80% of the language assessments were done at 15- to 38-months of age. LBW children tended to score 1/2 to 3/4 of a standard deviation below the comparison group. The severity of hemorrhage did not mediate these results. Fine motor assessments were performed on children 9 months to 11 years old. LBW children were about 2/3 of a standard deviation behind the comparison group. These skills were not affected by severity of IVH. Gross motor abilities were typically measured before the children were 24 months old. LBW children showed more deficits in this area than in any other: almost 90% of a standard deviation behind. Gross motor skills appear to be strongly impacted both by being low birthweight and by the severity of IVH. Results indicate that IVH is a mediating factor in outcome among LBW infants. More research needs to be conducted on these children when they are school age, so long-term effects of low birthweight can be determined

State-of-the-art neonatal cerebral ultrasound: technique and reporting

In the past three decades, cerebral ultrasound (CUS) has become a trusted technique to study the neonatal brain. It is a relatively cheap, non-invasive, bedside neuroimaging method available in nearly every hospital. Traditionally, CUS was used to detect major abnormalities, such as intraventricular hemorrhage (IVH), periventricular hemorrhagic infarction, post-hemorrhagic ventricular dilatation, and (cystic) periventricular leukomalacia (cPVL). The use of different acoustic windows, such as the mastoid and posterior fontanel, and ongoing technological developments, allows for recognizing other lesion patterns (e.g., cerebellar hemorrhage, perforator stroke, developmental venous anomaly). The CUS technique is still being improved with the use of higher transducer frequencies (7.5-18\u2009MHz), 3D applications, advances in vascular imaging (e.g. ultrafast plane wave imaging), and improved B-mode image processing. Nevertheless, the helpfulness of CUS still highly depends on observer skills, knowledge, and experience. In this special article, we discuss how to perform a dedicated state-of-the-art neonatal CUS, and we provide suggestions for structured reporting and quality assessment

Neuromonitoring in neonatal critical care part II: extremely premature infants and critically ill neonates

Abstract: Neonatal intensive care has expanded from cardiorespiratory care to a holistic approach emphasizing brain health. To best understand and monitor brain function and physiology in the neonatal intensive care unit (NICU), the most commonly used tools are amplitude-integrated EEG, full multichannel continuous EEG, and near-infrared spectroscopy. Each of these modalities has unique characteristics and functions. While some of these tools have been the subject of expert consensus statements or guidelines, there is no overarching agreement on the optimal approach to neuromonitoring in the NICU. This work reviews current evidence to assist decision making for the best utilization of these neuromonitoring tools to promote neuroprotective care in extremely premature infants and in critically ill neonates. Neuromonitoring approaches in neonatal encephalopathy and neonates with possible seizures are discussed separately in the companion paper. Impact: For extremely premature infants, NIRS monitoring has a potential role in individualized brain-oriented care, and selective use of aEEG and cEEG can assist in seizure detection and prognostication.For critically ill neonates, NIRS can monitor cerebral perfusion, oxygen delivery, and extraction associated with disease processes as well as respiratory and hypodynamic management. Selective use of aEEG and cEEG is important in those with a high risk of seizures and brain injury.Continuous multimodal monitoring as well as monitoring of sleep, sleep–wake cycling, and autonomic nervous system have a promising role in neonatal neurocritical care

Role of the advanced MRI sequences in predicting the outcome of preterm neonates

AIM The aim of the project is to evaluate the role of advanced MRI sequences (susceptibility weight imaging (SWI), diffusion tensor imaging (DTI), and arterial spin labeling (ASL) perfusion) in detecting early changes that affect preterm neonatal brain, especially in those patients without lesions at conventional MRI or with small brain injuries (i.e. low grade germinal matrix-intraventricular hemorrhage (GMHIVH)), and to correlate these subtle brain abnormalities with neurodevelopmental outcome at 24 months. METHODS Since November 2015 until June 2017, 287 preterm neonates and 108 term neonates underwent a 3T or 1.5T MRI study at term corrected age (40\ub11 weeks). SWI, DTI and ASL sequences were performed in all neonates. SWI sequences were evaluated using both a qualitative (SWI venography) and quantitative (Quantitative Susceptibility Map analysis (SWI-QSM)) approach. DTI data were analyzed using a Tract-Based Spatial Statistics analysis (TBSS). ASL studies were processed to estimate Cerebral Blood Flow (CBF) maps. Perinatal clinical data were collected for all neonates. Neurodevelopmental data were evaluated at 24 months in 175 neonates using 0-2 Griffiths Developmental Scales. RESULTS The analysis performed on SWI-venography revealed differences in subependymal veins morphology between preterm and term neonates with normal brain MRI, with a higher variability from the typical anatomical pattern in preterm neonates. The same analysis performed in preterm neonates with GMH-IVH revealed that the anatomical features of subependymal veins may play a potential role as predisposing factor for GMH-IVH. Moreover, the SWI-QSM analysis revealed a greater paramagnetic susceptibility in several periventricular white matter (WM) regions in preterm neonates with GMH-IVH than in healthy controls. This finding is likely related to the accumulation of hemosiderin/ferritin following the diffusion of large amounts of intraventricular blood products into the WM, and it is also supposed to trigger the cascade of lipid peroxidation and free radical formation that promote oxidative and inflammatory injury of the WM in neonatal brain after GMH-IVH. The TBSS analysis confirmed that microstructural WM injury can occur in preterm neonates with low grade GMH-IVH even in the absence of overt signal changes on conventional MRI, with different patterns of WM involvement depending on gestational age. Moreover, the distribution of these WM microstructural alterations after GMH-IVH correlates with specific neurodevelopmental impairments at 24 months of age. Finally, the analysis of brain perfusion at term-corrected age revealed lower CBF in preterms with sub-optimal neuromotor development, reinforcing the hypothesis that impaired autoregulation of CBF may contribute to the development of brain damage in preterm neonates. CONCLUSION Advanced MRI sequences can assist the standard perinatal brain imaging in the early diagnosis of preterm neonatal brain lesions and can provide new insights for predicting the neurodevelopmental trajectory. However, detailed and serial imaging of carefully chosen cohorts of neonates coupled with longer clinical follow-up are essential to ensure the clinical significance of these novel findings