The Frontal and Temporal Horn Ratio to Assess Dimension of Paediatric Hydrocephalus: A Comparative Volumetric Study

Prediction of short- and long-term outcomes using pre-operative ventricular size in infants with post-hemorrhagic ventricular dilation

PURPOSE

Post-hemorrhagic ventricular dilation (PHVD) leads to developmental delays in premature infants, yet the optimal timing of neurosurgical interventions is unknown. Neuroimaging modalities have emerged to delineate injury and follow the progression of PHVD. Fronto-temporal horn ratio (FTHR) is used as a marker of ventricular dilation and can be a standardized tool to direct the timing of neurosurgical intervention. Our study determined a pre-operative FTHR measurement threshold to predict short- and long-term outcomes.

METHODS

This is a retrospective cohort study of premature infants with severe intraventricular hemorrhage (IVH) who developed PHVD requiring neurosurgical intervention and were treated in a level IV NICU between 2012 and 2019. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were performed to evaluate the accuracy of pre-operative FTHR for predicting developmental delay. In-hospital outcomes and developmental assessments were analyzed.

RESULTS

We reviewed 121 charts of infants with IVH and identified 43 infants with PHVD who required neurosurgical intervention. We found FTHR measurements were an excellent predictor of cognitive and motor delay with an AUC of 0.89 and 0.88, respectively. An average pre-operative FTHR of ≥ 0.67 was also associated with worse lung and feeding outcomes. There was excellent inter-observer reliability of individual components of FTHR measurements.

CONCLUSIONS

Early intervention for PHVD is ideal but not always practical. Identification of ventricular size thresholds associated with better outcomes is needed to direct timing of neurosurgical intervention.

Training in neonatal neurocritical care: A case-based interdisciplinary approach

Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.

Temporal Horn Enlargements Predict Secondary Hydrocephalus Diagnosis Earlier than Evans' Index

The aim of this study was to identify early radiological signs of secondary hydrocephalus. We retrieved neuroradiological data from scans performed at various times in patients who underwent surgery for secondary hydrocephalus due to severe traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), or brain tumour (BT). Baseline measurements, performed on the earliest images acquired after the neurological event (T0), included Evans’ index, the distance between frontal horns, and the widths of both temporal horns. The next neuroimage that showed an increase in at least one of these four parameters—and that lead the surgeon to act—was selected as an indication of ventricular enlargement (T1). Comparisons of T0 and T1 neuroimages showed increases in Evans’ index, in the mean frontal horn distance, and in the mean right and left temporal horn widths. Interestingly, in T1 scans, mean Evans’ index scores > 0.30 were only observed in patients with BT. However, the temporal horn widths increased up to ten-fold in most patients, independent of Evans’ index scores. In conclusion temporal horn enlargements were the earliest, most sensitive findings in predicting ventricular enlargement secondary to TBI, SAH, or BT. To anticipate a secondary hydrocephalus radiological diagnosis, clinicians should measure both Evans’ index and the temporal horn widths, to avoid severe disability and poor outcome related to temporal lobe damage.

Hemodynamic Quality Improvement Bundle to Reduce the Use of Inotropes in Extreme Preterm Neonates

BACKGROUND

We evaluated the effect of the quality improvement (QI) bundle on the rate of inotrope use and associated morbidities.

METHODS

We included inborn preterm neonates born at < 29 weeks admitted to level III NICU. We implemented a QI bundle focusing on the first 72 h from birth which included delayed cord clamping, avoidance of routine echocardiography, the addition of clinical criteria to the definition of hypotension, factoring iatrogenic causes of hypotension, and standardization of respiratory management. The rate of inotropes use was compared before and after implementing the care bundle. Incidence of cystic periventricular leukomalacia (cPVL) was used as a balancing measure.

RESULTS

QI bundle implementation was associated with significant reduction in overall use of inotropes (24 vs 7%, p < 0.001), dopamine (18 vs 5%, p < 0.001), and dobutamine (17 vs 4%, p < 0.001). Rate of acute brain injury decreased significantly: acute brain injury of any grade (34 vs 20%, p < 0.001) and severe brain injury (15 vs 6%, p < 0.001). There was no difference in the incidence of cPVL (0.8 vs 1.4%, p = 0.66). Associations remained significant after adjusting for confounding factors.

CONCLUSIONS

A quality improvement bundled approach resulted in a reduction in inotropes use and associated brain morbidities in premature babies.

Validation of Sonographic Fronto-Occipital Ratio Based on Anatomical Landmarks Compared to MR/CT-Derived Indexes in Children with Chiari II and Ventriculomegaly

INTRODUCTION

Ultrasound (US)-based indexes such as fronto-occipital ratio (FOR) can be used to obtain an acceptable estimation of ventricular volume. Patients with colpocephaly present a unique challenge due to the shape of their ventricles. In the present study, we aimed to evaluate the validity and reproducibility of the modified US-FOR index in children with Chiari II-related ventriculomegaly.

METHODS

In this retrospective study, we evaluated Chiari II patients younger than 1 year who underwent head US and MR or CT scans for ventriculomegaly evaluation. MR/CT-based FOR was measured in the axial plane by identifying the widest diameter of frontal horns, occipital horns, and the interparietal diameter (IPD). US-based FOR (US-FOR) was measured using the largest diameter based on the following landmarks: frontal horn and IPD in the coronal plane at the level of the foramen of Monro, IPD just superior to the Sylvian fissures, and occipital horn posterior to the thalami and inferior to the superior margins of the thalami. Intraclass correlation coefficients (ICCs) were used to evaluate inter-rater reliability, and Pearson correlation coefficients and Bland-Altman plots were applied to assess agreement between US and other two modalities.

RESULTS

Sixty-three paired US and MR/CT exams were assessed for agreement between US-FOR and MR/CT-FOR measurements. ICC showed an excellent inter-rater reliability for US-FOR (ICC = 0.99, p < 0.001) and MR/CT-FOR (ICC = 0.99, p < 0.001) measurements. The mean (range) values based on US-FOR showed a slight overestimation in comparison with MR/CT-FOR (0.51 [0.36-0.68] vs. 0.46 [0.34-0.64]). The Pearson correlation coefficient showed high cross-modality agreement for the FOR index (r = 0.83, p < 0.001). The Bland-Altman plot showed excellent concordance between US-FOR and MR/CT-FOR with a bias of 0.05 (95% CI: -0.03 to 0.13).

CONCLUSION

US-FOR in the coronal plane is a comparable tool for evaluating ventriculomegaly in Chiari II patients when compared with MR/CT-FOR, even in the context of colpocephaly.

The utility of the fronto-temporal horn ratio on cranial ultrasound in premature newborns: a ventriculomegaly marker

BACKGROUND

The aims of this study were to find the normal value of fronto-temporal horn ratio (FTHR) as a marker of ventriculomegaly on cranial ultrasound (CUS) in premature newborns and the relation to white matter injury (WMI) and cerebral palsy (CP).

METHODS

This is a retrospective study of newborns admitted between 2011 and 2014. Inclusion criteria were: (1) gestation <29 weeks, (2) birth weight ≤1500 g, (3) referred within 7 days of life, (4) at least two CUS preformed, (5) brain magnetic resonance imaging (MRI) at term age-equivalent. Intraventricular hemorrhage (IVH) grade was identified and FTHR was measured on all CUS. WMI on MRI was evaluated through (1) injury score (Kidokoro 2013) and (2) fractional anisotropy (FA) on the MRI diffusion tensor imaging. CP was estimated using the gross motor function classification system (GMFCS).

RESULTS

One hundred neonates met the inclusion criteria: 37 with no IVH, 36 with IVH grade 1-2, and 27 with IVH grade 3-4. The FTHR cut-point of 0.51 had the highest sensitivity and specificity for moderate-to-severe WMI. In the IVH grade 3-4 group, the elevated FTHR correlated with lower FA and higher GMFCS.

CONCLUSIONS

FTHR is a useful quantitative biomarker of ventriculomegaly in preterm newborns. It may help standardize ventricular measurement and direct intervention.

IMPACT

The fronto-temporal horn ratio has the potential to become a standardized tool that can provide an actionable measure to direct intervention for post-hemorrhagic ventricular dilation. This current study will provide the basis of a future clinical trial to optimize intervention timing to decrease the risk of white matter injury in this vulnerable population.

Standardizing treatment of preterm infants with post-hemorrhagic hydrocephalus at a single institution with a multidisciplinary team

BACKGROUND

Preterm infants with post-hemorrhagic hydrocephalus (PHH) are often treated with temporizing measures such as ventricular access devices (VADs) in order to drain cerebrospinal fluid (CSF) prior to permanent diversion with ventriculoperitoneal shunt (VPS) placement.

LOCAL PROBLEM

There is little consensus on the timing and management of VADs and VPSs. This leads to marked practice variations among treating services that can adversely affect patient outcomes.

METHODS

This is a quality improvement study evaluating practices from February 2011 to September 2017 including infants with PHH in a single level IV NICU.

INTERVENTIONS

A multidisciplinary team created a local clinical pathway modified from the Hydrocephalus Clinical Research Network's Shunting Outcomes in Post-Hemorrhagic Hydrocephalus protocol to manage infants with PHH. Methods of CSF diversion and shunt timing were based on weight. Neonatal care providers performed VAD aspiration; timing was guided by imaging and clinical exam criteria. Surgical procedures were performed in the NICU.

RESULTS

There were 78 patients eligible for the study. Prior to pathway implementation, infections occurred in 4% of VAD and 3% of VPS patients. There have been no infections since inception of the pathway. With pathway implementation, treatment compliance improved from 55 to 86% while conversion compliance rate improved from 89 to 100%.

CONCLUSIONS

Standardization of care for PHH infants leads to improvement in patient outcomes such as a decrease in time to VAD placement. Reservoir aspirations by the neonatology team did not result in an increase in infection rate.

Ultrasound-Based Phenotyping of Lateral Ventricles to Predict Hydrocephalus Outcome in Premature Neonates

OBJECTIVE

Prediction of post-hemorrhagic hydrocephalus (PHH) outcome-i.e., whether it requires intervention or not-in premature neonates using cranial ultrasound (CUS) images is challenging. In this paper, we present a novel fully-automatic method to perform phenotyping of the brain lateral ventricles and predict PHH outcome from CUS.

METHODS

Our method consists of two parts: ventricle quantification followed by prediction of PHH outcome. First, cranial bounding box and brain interhemispheric fissure are detected to determine the anatomical position of ventricles and correct the cranium rotation. Then, lateral ventricles are extracted using a new deep learning-based method by incorporating the convolutional neural network into a probabilistic atlas-based weighted loss function and an image-specific adaption. PHH outcome is predicted using a support vector machine classifier trained using ventricular morphological phenotypes and clinical information.

RESULTS

Experiments demonstrated that our method achieves accurate ventricle segmentation results with an average Dice similarity coefficient of 0.86, as well as very good PHH outcome prediction with accuracy of 0.91.

CONCLUSION

Automatic CUS-based ventricular phenotyping in premature newborns could objectively and accurately predict the progression to severe PHH.

SIGNIFICANCE

Early prediction of severe PHH development in premature newborns could potentially advance criteria for diagnosis and offer an opportunity for early interventions to improve outcome.

Cranial ultrasound-based prediction of post hemorrhagic hydrocephalus outcome in premature neonates with intraventricular hemorrhage

Premature neonates with intraventricular hemorrhage (IVH) followed by post hemorrhagic hydrocephalus (PHH) are at high risk for brain injury. Cranial ultrasound (CUS) is used for monitoring of premature neonates during the first weeks after birth to identify IVH and follow the progression to PHH. However, the lack of a standardized method for CUS evaluation has led to significant variability in decision making regarding treatment. We propose a quantitative imaging tool for the evaluation of PHH on CUS for premature neonates based on morphological features of the cerebral ventricles. We retrospectively studied 64 extremely premature neonates born less than 29 weeks gestational age, less than 1,500 grams weight at birth, admitted to our center within two weeks of life, and diagnosed with different grades of IVH. We extracted morphological features of the lateral ventricles from CUS imaging using image analysis techniques to compare neonates who needed a temporizing intervention to treat PHH to the ones who did not. From the original set of features, an optimal ranking was obtained based on linear support vector machine. A subset of features was subsequently selected that maximizes the overall accuracy level. Regarding whether or not there was a need for temporizing intervention, we predicted the outcome of PHH with an improved accuracy level of 84%, compared to the 76% rate obtained by linear manual measurement. The proposed imaging tool allowed us to establish a quantitative method for PHH evaluation on CUS in extremely premature neonates with IVH. Further studies will help standardize the evaluation of CUS in those neonates to institute treatments earlier and improve outcomes.