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Biouss G, Antounians L, Aguet J, Kopcalic K, Fakhari N, Baranger J, Mertens L, Villemain O, Zani A. The brain of fetuses with congenital diaphragmatic hernia shows signs of hypoxic injury with loss of progenitor cells, neurons, and oligodendrocytes. Sci Rep 2024; 14:13680. [PMID: 38871804 DOI: 10.1038/s41598-024-64412-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 06/08/2024] [Indexed: 06/15/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a birth defect characterized by incomplete closure of the diaphragm, herniation of abdominal organs into the chest, and compression of the lungs and the heart. Besides complications related to pulmonary hypoplasia, 1 in 4 survivors develop neurodevelopmental impairment, whose etiology remains unclear. Using a fetal rat model of CDH, we demonstrated that the compression exerted by herniated organs on the mediastinal structures results in decreased brain perfusion on ultrafast ultrasound, cerebral hypoxia with compensatory angiogenesis, mature neuron and oligodendrocyte loss, and activated microglia. In CDH fetuses, apoptosis was prominent in the subventricular and subgranular zones, areas that are key for neurogenesis. We validated these findings in the autopsy samples of four human fetuses with CDH compared to age- and sex-matched controls. This study reveals the molecular mechanisms and cellular changes that occur in the brain of fetuses with CDH and creates opportunities for therapeutic targets.
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Affiliation(s)
- George Biouss
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Julien Aguet
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, 263 McCaul Street, Toronto, ON, M5T 1W7, Canada
| | - Katarina Kopcalic
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Nikan Fakhari
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
| | - Jerome Baranger
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Luc Mertens
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Olivier Villemain
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Surgery, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
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Maddaloni C, De Rose DU, Ronci S, Pugnaloni F, Martini L, Caoci S, Bersani I, Conforti A, Campi F, Lombardi R, Capolupo I, Tomà P, Dotta A, Calzolari F. The role of point-of-care ultrasound in the management of neonates with congenital diaphragmatic hernia. Pediatr Res 2024; 95:901-911. [PMID: 37978315 DOI: 10.1038/s41390-023-02889-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
In the last few years, current evidence has supported the use of point-of-care ultrasound (POCUS) for a number of diagnostic and procedural applications. Considering the valuable information that POCUS can give, we propose a standardized protocol for the management of neonates with a congenital diaphragmatic hernia (CDH-POCUS protocol) in the neonatal intensive care unit. Indeed, POCUS could be a valid tool for the neonatologist through the evaluation of 1) cardiac function and pulmonary hypertension; 2) lung volumes, postoperative pleural effusion or pneumothorax; 3) splanchnic and renal perfusion, malrotations, and/or signs of necrotizing enterocolitis; 4) cerebral perfusion and eventual brain lesions that could contribute to neurodevelopmental impairment. In this article, we discuss the state-of-the-art in neonatal POCUS for which concerns congenital diaphragmatic hernia (CDH), and we provide suggestions to improve its use. IMPACT: This review shows how point-of-care ultrasound (POCUS) could be a valid tool for managing neonates with congenital diaphragmatic hernia (CDH) after birth. Our manuscript underscores the importance of standardized protocols in neonates with CDH. Beyond the well-known role of echocardiography, ultrasound of lungs, splanchnic organs, and brain can be useful. The use of POCUS should be encouraged to improve ventilation strategies, systemic perfusion, and enteral feeding, and to intercept any early signs related to future neurodevelopmental impairment.
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Affiliation(s)
- Chiara Maddaloni
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
- PhD course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome "Tor Vergata", Rome, Italy.
| | - Sara Ronci
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Flaminia Pugnaloni
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Ludovica Martini
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Stefano Caoci
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Iliana Bersani
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Roberta Lombardi
- Department of Imaging, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Paolo Tomà
- Department of Imaging, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Flaminia Calzolari
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
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Johng S, Licht DJ, Hedrick HL, Rintoul N, Linn RL, Gebb JS, Xiao R, Massey SL. Prenatal Brain Maturation is Delayed in Neonates with Congenital Diaphragmatic Hernia. J Pediatr 2024; 264:113738. [PMID: 37722557 DOI: 10.1016/j.jpeds.2023.113738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To assess brain development in fetuses with congenital diaphragmatic hernia (CDH) using a fetal Total Maturation Score (fTMS). STUDY DESIGN This is a retrospective cohort study using data from a single-center clinical registry. Neonates with an antenatal diagnosis of CDH between 2014 and 2020 and prenatal brain magnetic resonance imaging (MRI) (n = 48) were included. We compared our study sample with historical healthy controls (n = 48). The relationship between fTMS and gestational age (GA), as well as the association between fTMS and key prenatal variables and placental pathologic findings, were evaluated. RESULTS Compared with healthy controls, neonates with CDH had a significant delay in fTMS (P value <.001). Within the CDH cohort, there was no significant difference in fTMS based on CDH severity, intrathoracic liver position, right vs left CDH, sex, presence of abnormal echocardiogram findings, treatment with extracorporeal membrane oxygenation (ECMO), or in-hospital mortality. Placentas of neonates with CDH had a high proportion of fetal vascular malperfusion (56%) and chronic inflammation (67%), and relatively large placentas had a protective effect on prenatal brain maturation (P value = .025). CONCLUSIONS Prenatal brain maturation in neonates with CDH is delayed. Placental pathology may influence fetal brain development. The etiology and clinical impact of prenatal brain immaturity in neonates with CDH warrant further investigation.
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Affiliation(s)
- Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca L Linn
- Division of Anatomic Pathology, Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Juliana S Gebb
- Richard D Wood, Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Shavonne L Massey
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
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Blundell M, Doktor F, Figueira RL, Khalaj K, Biouss G, Antounians L, Zani A. Anti-inflammatory effects of antenatal administration of stem cell derived extracellular vesicles in the brain of rat fetuses with congenital diaphragmatic hernia. Pediatr Surg Int 2023; 39:291. [PMID: 37955723 DOI: 10.1007/s00383-023-05578-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) survivors may experience neurodevelopmental impairment, whose etiology remains elusive. Preclinical evidence indicates that amniotic fluid stem cell extracellular vesicle (AFSC-EV) administration promotes lung development but their effects on other organs are unknown. Herein, we investigated the brain of rat fetuses with CDH for signs of inflammation and response to AFSC-EVs. METHODS CDH was induced by maternal nitrofen administration at E9.5. At E18.5, fetuses were injected intra-amniotically with saline or AFSC-EVs (isolated by ultracentrifugation, characterized as per MISEV guidelines). Fetuses from vehicle-gavaged dams served as controls. Groups were compared for: lung hypoplasia, TNFa and IL-1B brain expression, and activated microglia (Iba1) density in the subgranular zone (SGZ). RESULTS CDH lungs had fewer airspaces compared to controls, whereas AFSC-EV-treated lungs had rescued branching morphogenesis. Fluorescently labeled AFSC-EVs injected intra-amniotically into CDH fetuses had fluorescent signal in the brain. Compared to controls, the brain of CDH fetuses had higher TNFa and IL-1B levels, and increased activated microglia density. Conversely, the brain of AFSC-EV treated fetuses had inflammatory marker expression levels and microglia density similar to controls. CONCLUSION This study shows that the brain of rat fetuses with CDH has signs of inflammation that are abated by the intra-amniotic administration of AFSC-EVs.
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Affiliation(s)
- Matisse Blundell
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Fabian Doktor
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Rebeca L Figueira
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Kasra Khalaj
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - George Biouss
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada.
- Department of Surgery, University of Toronto, Toronto, M5T 1P5, Canada.
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5
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Antounians L, Zani A. Beyond the diaphragm and the lung: a multisystem approach to understanding congenital diaphragmatic hernia. Pediatr Surg Int 2023; 39:194. [PMID: 37160490 DOI: 10.1007/s00383-023-05471-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/11/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a birth defect characterized by the incomplete closure of the diaphragm and herniation of abdominal organs into the chest during gestation. This invariably leads to an impairment in fetal lung development (pulmonary hypoplasia) that involves the pulmonary vessels (vascular remodeling) leading to postnatal pulmonary hypertension. Moreover, approximately 60% of CDH survivors have long-term comorbidities, including critical cardiac anomalies, neurodevelopmental impairment, gastroesophageal reflux, and musculoskeletal malformations. While the pathophysiology of the diaphragmatic defect and pulmonary hypoplasia have been studied in detail over the decades, less is known about the other organs affected in CDH. In this review, we searched the literature for reports on other organs beyond the lung and diaphragm in human and experimental models of CDH. We found studies reporting gross morphometric changes and alterations to biological pathways in the heart, brain, liver, kidney, gastrointestinal tract, and musculoskeletal system. Given the paucity of literature and the importance that these comorbidities play in the life of patients with CDH, further studies are needed to comprehensively uncover the pathophysiology of the changes observed in these other organs.
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Affiliation(s)
- Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Department of Surgery, University of Toronto, Toronto, M5T 1P5, Canada.
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Van der Veeken L, Russo FM, Bleeser T, Basurto D, Emam D, Regin Y, Gsell W, Himmelreich U, De Catte L, Rex S, Deprest J. Brain development is altered in rabbit fetuses with congenital diaphragmatic hernia. Prenat Diagn 2023; 43:359-369. [PMID: 36627261 DOI: 10.1002/pd.6309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/28/2022] [Accepted: 01/07/2023] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Children with congenital diaphragmatic hernia (CDH) are at risk for neurodevelopmental delay. Some changes are already present prenatally. Herein, we further examined how the brain develops in fetal rabbits with surgically created DH. METHODS Two fetuses underwent surgical DH creation on day 23 (term = d31). DH pups and littermate controls were harvested at term. Ten DH pups and 11 controls underwent transcardial perfusion for brain fixation and measurement of brain volume, brain folding, neuron and synaptic density, pre-oligodendrocyte count, proliferation, and vascularization. Twelve other DH and 11 controls had echocardiographic assessment of cardiac output and aortic and cerebral blood flow, magnetic resonance imaging (9.4 T) for cerebral volumetry, and molecular assessment of vascularization markers. RESULTS DH pups had lower lung-to-body weight ratio (1.3 ± 0.3 vs. 2.4 ± 0.3%; p < 0.0001) and lower heart-to-body weight ratio (0.007 ± 0.001 vs. 0.009 ± 0.001; p = 0.0006) but comparable body weight and brain-to-body weight ratio. DH pups had a lower left ventricular ejection fraction, aortic and cerebral blood flow (39 ± 8 vs. 54 ± 15 mm/beat; p = 0.03) as compared to controls but similar left cardiac ventricular morphology. Fetal DH-brains were similar in volume but the cerebellum was less folded (perimeter/surface area: 25.5 ± 1.5 vs. 26.8 ± 1.2; p = 0.049). Furthermore, DH brains had a thinner cortex (143 ± 9 vs. 156 ± 13 μm; p = 0.02). Neuron densities in the white matter were higher in DH fetuses (124 ± 18 vs. 104 ± 14; p = 0.01) with comparable proliferation rates. Pre-oligodendrocyte count was lower, coinciding with the lower endothelial cell count. CONCLUSION Rabbits with DH had altered brain development compared to controls prenatally, indicating that brain development is already altered prenatally in CDH.
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Affiliation(s)
- Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium.,Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Clinical Department Obstetrics and Gynaecology, University Hospital Antwerp, Antwerpen, Belgium
| | - Francesca Maria Russo
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium.,Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Bleeser
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - David Basurto
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Doaa Emam
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department Obstetrics and Gynaecology, University Hospitals Tanta, Tanta, Egypt
| | - Yannick Regin
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Willy Gsell
- Biomedical MRI Unit, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Uwe Himmelreich
- Biomedical MRI Unit, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium.,Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium.,Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
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de Munck S, Otter SCMCD, Schnater JM, van Rosmalen J, Peters NCJ, van Gils-Frijters APJM, van Haren NEM, Gischler SJ, IJsselstijn H, Rietman AB. Neuropsychological outcome in survivors of congenital diaphragmatic hernia at 5 years of age, what does it tell? Eur J Pediatr 2023; 182:1057-1066. [PMID: 36565322 PMCID: PMC10023636 DOI: 10.1007/s00431-022-04696-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/24/2022] [Accepted: 11/05/2022] [Indexed: 12/25/2022]
Abstract
Previous studies have frequently reported neurocognitive deficits in children born with congenital diaphragmatic hernia (CDH) at school age, which may contribute to academic difficulties. Yet, age at onset of these deficits is currently unknown. We evaluated neurocognitive skills with possible determinants in preschool children born with CDH. Eligible 5-year-old children born with CDH (2010-2015) who participated in our prospective structural follow-up program were included. We used the WPPSI-III to assess intelligence, subtests of the Kaufman-ABC for memory, and NEPSY-II to assess inhibition and attention. We included 63 children. Their test scores generally were within or significantly above normal range: total IQ = 103.4 (15.7) (p = 0.13); Verbal memory = 10.2 (2.8) (p = 0.61); Visuospatial memory = 11.4 (2.6) (p < 0.01); Inhibition = 10.5 (2.2), (p = 0.10). In univariable analyses, length of ICU-stay was negatively associated with IQ, and maximum vasoactive inotropic score and open repair were negatively associated with inhibition skills. In multivariable regression analysis, the latter association remained (B = 5.52, p = 0.04 (CI 0.32-10.72)). Conclusions: In these tested 5-year-old children born with CDH, neuropsychological outcome was normal on average. While problems in 8-year-olds are common, we did not detect onset of these problems at age 5. Yet, we cannot rule out that this cohort had a relatively mild level of disease severity; therefore, conclusions should be interpreted with caution. However, given the growing-into-deficit hypothesis, meaning that deviant brain development in early life is revealed once higher cognitive brain functions are demanded, follow-up should be conducted up to school age, and preferably beyond. What is Known: • Children born with CDH are at risk for academic difficulties at school age. • Whether these difficulties can be detected already before school age is unknown. What is New: • At age 5 years, intelligence, inhibition, attention, and memory skills were all within normal range, or even above, in children with CDH. This is supportive of the growing-into-deficit hypothesis in this patient population. • Those who underwent open surgical correction had poorer inhibition skills than those who were corrected with minimal access surgery.
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Affiliation(s)
- Sophie de Munck
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Suzan C M Cochius-den Otter
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Foetal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Annabel P J M van Gils-Frijters
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Childrens Hospital, Rotterdam, The Netherlands
| | - Neeltje E M van Haren
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Childrens Hospital, Rotterdam, The Netherlands
| | - Saskia J Gischler
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - André B Rietman
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Childrens Hospital, Rotterdam, The Netherlands
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8
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Emam D, Aertsen M, Van der Veeken L, Fidon L, Patkee P, Kyriakopoulou V, De Catte L, Russo F, Demaerel P, Vercauteren T, Rutherford M, Deprest J. Longitudinal MRI Evaluation of Brain Development in Fetuses with Congenital Diaphragmatic Hernia around the Time of Fetal Endotracheal Occlusion. AJNR Am J Neuroradiol 2023; 44:205-211. [PMID: 36657946 PMCID: PMC9891331 DOI: 10.3174/ajnr.a7760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Congenital diaphragmatic hernia is associated with high mortality and morbidity, including evidence suggesting neurodevelopmental comorbidities after birth. The aim of this study was to document longitudinal changes in brain biometry and the cortical folding pattern in fetuses with congenital diaphragmatic hernia compared with healthy fetuses. MATERIALS AND METHODS This is a retrospective cohort study including fetuses with isolated congenital diaphragmatic hernia between January 2007 and May 2019, with at least 2 MR imaging examinations. For controls, we used images from fetuses who underwent MR imaging for an unrelated condition that did not compromise fetal brain development and fetuses from healthy pregnant women. Biometric measurements and 3D segmentations of brain structures were used as well as qualitative and quantitative grading of the supratentorial brain. Brain development was correlated with disease-severity markers. RESULTS Forty-two fetuses were included, with a mean gestational age at first MR imaging of 28.0 (SD, 2.1) weeks and 33.2 (SD, 1.3) weeks at the second imaging. The mean gestational age in controls was 30.7 (SD, 4.2) weeks. At 28 weeks, fetuses with congenital diaphragmatic hernia had abnormal qualitative and quantitative maturation, more extra-axial fluid, and larger total skull volume. By 33 weeks, qualitative grading scores were still abnormal, but quantitative scoring was in the normal range. In contrast, the extra-axial fluid volume remained abnormal with increased ventricular volume. Normal brain parenchymal volumes were found. CONCLUSIONS Brain development in fetuses with congenital diaphragmatic hernia around 28 weeks appears to be delayed. This feature is less prominent at 33 weeks. At this stage, there was also an increase in ventricular and extra-axial space volume.
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Affiliation(s)
- D Emam
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Department Obstetrics and Gynaecology (D.E., L.F.), Faculty of Medicine, Tanta University, Tanta, Egypt
| | - M Aertsen
- Department of Imaging and Pathology (M.A., P.D.), Clinical Department of Radiology, University Hospitals, KU Leuven, Leuven, Belgium
| | - L Van der Veeken
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - L Fidon
- Department Obstetrics and Gynaecology (D.E., L.F.), Faculty of Medicine, Tanta University, Tanta, Egypt
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
| | - P Patkee
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
| | | | - L De Catte
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - F Russo
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - P Demaerel
- Department of Imaging and Pathology (M.A., P.D.), Clinical Department of Radiology, University Hospitals, KU Leuven, Leuven, Belgium
| | - T Vercauteren
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
| | - M Rutherford
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
| | - J Deprest
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
- Institute for Women's Health (J.D.), University College London, London, UK
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9
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Larson AC, Didier R, Daszewska-Smith G, Chang J, Sridharan A, Agarwal D, Carreon CK, Sanders SP, Toba S, Partridge E. The fetal lamb model of congenital diaphragmatic hernia shows altered cerebral perfusion using contrast enhanced ultrasound. J Pediatr Surg 2022; 57:991-998. [PMID: 35346482 DOI: 10.1016/j.jpedsurg.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Neurodevelopmental impairment is common in survivors of congenital diaphragmatic hernia (CDH). Altered cerebral perfusion in utero may contribute to abnormal brain development in CDH patients. METHODS 5 fetal lambs with surgical left-CDH and 5 controls underwent transuterine cranial Doppler and contrast enhanced ultrasound (CEUS). Global and regional perfusion metrics were obtained. Biometric and perfusion data were compared between groups via nonparametric Mann Whitney U test and Spearman's rank order correlation. RESULTS No significant differences in cerebral Doppler measurements were identified between groups. By CEUS, CDH animals demonstrated significantly decreased global brain perfusion and increased transit time. With focal regions-of-interest (ROIs), there was a tendency towards decreased perfusion in the central/thalamic region in CDH but not in the peripheral brain parenchyma. Transit time was significantly increased in both ROIs in CDH, whereas flux rate was decreased in the central/thalamic region but not the peripheral brain parenchyma. Biometric CDH severity was correlated to perfusion deficit. There was no difference in cardiomyocyte histology. CONCLUSION The fetal lamb model of CDH shows altered cerebral perfusion as measured by CEUS, correlating to disease severity. This suggests a physiological abnormality in fetal cerebrovascular perfusion that may contribute to abnormal brain development and neurodevelopmental impairment in survivors.
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Affiliation(s)
- Abby C Larson
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Ryne Didier
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gabriela Daszewska-Smith
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Jonathan Chang
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Divyansh Agarwal
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chrystalle Katte Carreon
- Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Stephen P Sanders
- Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Shuhei Toba
- Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Emily Partridge
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA.
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10
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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