1
|
Chalak LF, Kang S, Kota S, Liu H, Liu Y, Juul SE, Wu YW. Evaluation of neurovascular coupling during neuroprotective therapies: A single site HEAL ancillary study. Early Hum Dev 2023; 183:105815. [PMID: 37419079 PMCID: PMC10824020 DOI: 10.1016/j.earlhumdev.2023.105815] [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] [Received: 05/05/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND There is a critical need for development of physiological biomarkers in infants with birth asphyxia to identify the physiologic response to therapies in real time. This is an ancillary single site study of the High-Dose Erythropoietin for Asphyxia and Encephalopathy (Wu et al., 2022 [1]) to measure neurovascular coupling (NVC) non-invasively during an ongoing blinded randomized trial. METHODS Neonates who randomized in the HEAL enrolled at a single-center Level III Neonatal Intensive Care Unit were recruited between 2017 and 2019. Neurodevelopmental impairment was blinded and defined as any of the following: cognitive score <90 on Bayley Scales of Infant Toddler Development, third edition (BSID-III), Gross Motor Function Classification Score (GMFCS) ≥1. RESULTS All twenty-seven neonates enrolled in HEAL were recruited and 3 died before complete recording. The rank-based analysis of covariance models demonstrated lack of difference in NVC between the two groups (Epo versus Placebo) that was consistent with the observed lack of effect on neurodevelopmental outcomes. CONCLUSION We demonstrate no difference in neurovascular coupling after Epo administration. These findings are consistent with overall negative trial results. Physiological biomarkers can help elucidate mechanisms of neuroprotective therapies in real time in future trials.
Collapse
Affiliation(s)
- Lina F Chalak
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States of America.
| | - Shu Kang
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, United States of America
| | - Srinivas Kota
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, United States of America
| | - Yulun Liu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America
| |
Collapse
|
2
|
Munster CB, El-Shibiny H, Szakmar E, Yang E, Walsh BH, Inder TE, El-Dib M. Magnetic resonance venography to evaluate cerebral sinovenous thrombosis in infants receiving therapeutic hypothermia. Pediatr Res 2023; 93:985-989. [PMID: 35854084 DOI: 10.1038/s41390-022-02195-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/14/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The incidence of cerebral sinovenous thrombosis (CSVT) in infants receiving therapeutic hypothermia for neonatal encephalopathy remains controversial. The aim of this study was to identify if the routine use of magnetic resonance venography (MRV) in term-born infants receiving hypothermia is associated with diagnostic identification of CSVT. METHODS We performed a retrospective review of 291 infants who received therapeutic hypothermia from January 2014 to March 2020. Demographic and clinical data, as well as the incidence of CSVT, were compared between infants born before and after adding routine MRV to post-rewarming magnetic resonance imaging (MRI). RESULTS Before routine inclusion of MRV, 209 babies were cooled, and 25 (12%) underwent MRV. Only one baby (0.5%) was diagnosed with CSVT in that period, and it was detected by structural MRI, then confirmed with MRV. After the inclusion of routine MRV, 82 infants were cooled. Of these, 74 (90%) had MRV and none were diagnosed with CSVT. CONCLUSION CSVT is uncommon in our cohort of infants receiving therapeutic hypothermia for neonatal encephalopathy. Inclusion of routine MRV in the post-rewarming imaging protocol was not associated with increased detection of CSVT in this population. IMPACT Cerebral sinovenous thrombosis (CSVT) in infants with NE receiving TH may not be as common as previously indicated. The addition of MRV to routine post-rewarming imaging protocol did not lead to increased detection of CSVT in infants with NE. Asymmetry on MRV of the transverse sinus is a common anatomic variant. MRI alone may be sufficient in indicating the presence of CSVT.
Collapse
Affiliation(s)
- Chelsea B Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hoda El-Shibiny
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
3
|
Li R, Lee JK, Govindan RB, Graham EM, Everett AD, Perin J, Vezina G, Tekes A, Chen MW, Northington F, Parkinson C, O’Kane A, McGowan M, Krein C, Al-Shargabi T, Chang T, Massaro AN. Plasma Biomarkers of Evolving Encephalopathy and Brain Injury in Neonates with Hypoxic-Ischemic Encephalopathy. J Pediatr 2023; 252:146-153.e2. [PMID: 35944723 PMCID: PMC9828943 DOI: 10.1016/j.jpeds.2022.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the relationship between a panel of candidate plasma biomarkers and (1) death or severe brain injury on magnetic resonance imaging (MRI) and (2) dysfunctional cerebral pressure autoregulation as a measure of evolving encephalopathy. STUDY DESIGN Neonates with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) at 2 level IV neonatal intensive care units were enrolled into this observational study. Patients were treated with therapeutic hypothermia (TH) and monitored with continuous blood pressure monitoring and near-infrared spectroscopy. Cerebral pressure autoregulation was measured by the hemoglobin volume phase (HVP) index; a higher HVP index indicates poorer autoregulation. Serial blood samples were collected during TH and assayed for Tau, glial fibrillary acidic protein, and neurogranin. MRIs were assessed using National Institutes of Child Health and Human Development scores. The relationships between the candidate biomarkers and (1) death or severe brain injury on MRI (defined as a National Institutes of Child Health and Human Development score of ≥ 2B) and (2) autoregulation were evaluated using bivariate and adjusted logistic regression models. RESULTS Sixty-two patients were included. Elevated Tau levels on days 2-3 of TH were associated with death or severe injury on MRI (aOR: 1.06, 95% CI: 1.03-1.09; aOR: 1.04, 95% CI: 1.01-1.06, respectively). Higher Tau was also associated with poorer autoregulation (higher HVP index) on the same day (P = .022). CONCLUSIONS Elevated plasma levels of Tau are associated with death or severe brain injury by MRI and dysfunctional cerebral autoregulation in neonates with HIE. Larger-scale validation of Tau as a biomarker of brain injury in neonates with HIE is warranted.
Collapse
Affiliation(s)
- Ruoying Li
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Ernest M. Graham
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allen D. Everett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra O’Kane
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Meaghan McGowan
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, Washington, DC;,Department of Pediatrics, The George Washington University School of Medicine, Washington, DC
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Neonatology, Children’s National Hospital, Washington, DC
| |
Collapse
|
4
|
Comparative evaluation of approach to cardiovascular care in neonatal encephalopathy undergoing therapeutic hypothermia. J Perinatol 2022; 42:1637-1643. [PMID: 35859183 DOI: 10.1038/s41372-022-01459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To analyze the association between cardiovascular care and adverse outcome in infants undergoing therapeutic hypothermia for neonatal encephalopathy (NE). STUDY DESIGN This was a retrospective cohort study of 176 infants with NE and hypotension, admitted to the SickKids Hospital (Center A, n = 86) or Semmelweis University (Center B, n = 90). RESULT The lowest systolic/diastolic blood pressures were comparable amongst centers; however, proportion of cardiovascular support was lower in Center A (51% vs 97% in Center B). Overall rate of death or abnormal MRI (adverse outcome) were comparable between centers, although pattern differed with more basal ganglia injury in Center B. A 24-hour longer duration of cardiovascular support increased the odds for adverse outcome by 14%. CONCLUSION We demonstrated that management of hemodynamic instability in infants with NE was markedly different in two high-volume NICUs and showed that longer duration of cardiovascular medication is an independent risk factor for adverse outcome.
Collapse
|
5
|
Wang Z, Zhang P, Zhou W, Zhou X, Shi Y, Cheng X, Lin Z, Xia S, Zhou W, Cheng G. Electroencephalography monitoring in the neonatal intensive care unit: a Chinese perspective. Transl Pediatr 2021; 10:552-559. [PMID: 33850813 PMCID: PMC8039787 DOI: 10.21037/tp-20-340] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Electroencephalography (EEG) is an accessible technique for bedside monitoring of the cerebral function in the neonatal intensive care unit (NICU). The popularization of EEG in the field of newborns in China is relatively late compared with western countries. To learn more about current practices and improvement of EEG monitoring, we conducted a survey to describe current utilization of EEG in NICU in China. METHODS A cross-sectional electronic survey with 21-items about EEG using in NICU was administered for pediatricians in China on the official website of "Questionnaire Star". RESULTS A total of 251 participants were involved, in which 64% of them reported using EEG. EEG was employed in NICUs of Children's hospitals (97%), and grade III, class A hospitals (69%). Besides, neonatal encephalopathy and suspected seizures were the most common indications for use. In clinical practice, the vast majority of physicians managed their patients on the basis of EEG (93%). Pediatricians prefer to use conventional video-EEG (cEEG) to detect seizures and make the diagnosis of encephalopathy. Both amplitude integrated EEG (aEEG) (78%) and cEEG (56%) were mainly interpreted by neonatologists. However, only 56% of respondents had ever taken a formal EEG training course. Overall, 96% of the respondents reported that they would be interested in attending an education session on EEG in the NICU. aEEG interpretation was the most interesting part to learn (81%). For those who were not using EEG, cost (43%) and difficulty interpretation (30%) were reported as barriers to use. CONCLUSIONS The utilization rate of EEG in NICU in China is significantly lower than the international level. There is an urgent need for standardized training and financial support for neonatologists in the use of EEG and interpretation of aEEG results.
Collapse
Affiliation(s)
- Zheng Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Peng Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xiaoyu Zhou
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuyong Cheng
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenlang Lin
- Department of Neonatology, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shiwen Xia
- Department of Neonatology, Maternal and Child Hospital of Hubei Province, Wuhan, China
| | - Wei Zhou
- Department of Neonatology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| |
Collapse
|
6
|
Association between cerebral oxygen saturation and brain injury in neonates receiving therapeutic hypothermia for neonatal encephalopathy. J Perinatol 2021; 41:269-277. [PMID: 33462339 DOI: 10.1038/s41372-020-00910-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/16/2020] [Accepted: 12/01/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the association of cerebral oxygen saturation (CrSO2) collected by near infrared spectroscopy (NIRS) during therapeutic hypothermia (TH) and rewarming with evidence of brain injury on post-rewarming MRI. STUDY DESIGN This retrospective cohort study included 49 infants, who received TH for mild to severe neonatal encephalopathy. Of those, 26 presented with brain injury assessed by a novel MRI grading system, whereas 23 had normal MRI scans. RESULTS CrSO2 increased significantly from the first to the second day of TH in infants with brain injury, whereas it remained stable in patients with normal MRI. Increasing mean CrSO2 values during rewarming was associated with brain injury (aOR 1.14; 95% CI 1.00-1.28), specifically with gray matter (GM) injury (aOR 1.23; 95% CI 1.02-1.49). The area under the ROC curve showed an excellent discrimination for GM involvement. CONCLUSION Clinically applied NIRS during TH and rewarming can assist in identifying the risk for brain injury.
Collapse
|
7
|
Leon RL, Ortigoza EB, Ali N, Angelis D, Wolovits JS, Chalak LF. Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations. Front Pediatr 2021; 9:748345. [PMID: 35087771 PMCID: PMC8787287 DOI: 10.3389/fped.2021.748345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/15/2021] [Indexed: 12/18/2022] Open
Abstract
Cerebrovascular pressure autoregulation promotes stable cerebral blood flow (CBF) across a range of arterial blood pressures. Cerebral autoregulation (CA) is a developmental process that reaches maturity around term gestation and can be monitored prenatally with both Doppler ultrasound and magnetic resonance imaging (MRI) techniques. Postnatally, there are key advantages and limitations to assessing CA with Doppler ultrasound, MRI, and near-infrared spectroscopy. Here we review these CBF monitoring techniques as well as their application to both fetal and neonatal populations at risk of perturbations in CBF. Specifically, we discuss CBF monitoring in fetuses with intrauterine growth restriction, anemia, congenital heart disease, neonates born preterm and those with hypoxic-ischemic encephalopathy. We conclude the review with insights into the future directions in this field with an emphasis on collaborative science and precision medicine approaches.
Collapse
Affiliation(s)
- Rachel L Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Eric B Ortigoza
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Noorjahan Ali
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Dimitrios Angelis
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joshua S Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
8
|
Benninger KL, Inder TE, Goodman AM, Cotten CM, Nordli DR, Shah TA, Slaughter JC, Maitre NL. Perspectives from the Society for Pediatric Research. Neonatal encephalopathy clinical trials: developing the future. Pediatr Res 2021; 89:74-84. [PMID: 32221474 PMCID: PMC7529683 DOI: 10.1038/s41390-020-0859-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
Abstract
The next phase of clinical trials in neonatal encephalopathy (NE) focuses on hypothermia adjuvant therapies targeting alternative recovery mechanisms during the process of hypoxic brain injury. Identifying infants eligible for neuroprotective therapies begins with the clinical detection of brain injury and classification of severity. Combining a variety of biomarkers (serum, clinical exam, EEG, movement patterns) with innovative clinical trial design and analyses will help target infants with the most appropriate and timely treatments. The timing of magnetic resonance imaging (MRI) and MR spectroscopy after NE both assists in identifying the acute perinatal nature of the injury (days 3-7) and evaluates the full extent and evolution of the injury (days 10-21). Early, intermediate outcome of neuroprotective interventions may be best defined by the 21-day neuroimaging, with recognition that the full neurodevelopmental trajectory is not yet defined. An initial evaluation of each new therapy at this time point may allow higher-throughput selection of promising therapies for more extensive investigation. Functional recovery can be assessed using a trajectory of neurodevelopmental evaluations targeted to a prespecified and mechanistically derived hypothesis of drug action. As precision medicine revolutionizes healthcare, it should also include the redesign of NE clinical trials to allow safe, efficient, and targeted therapeutics. IMPACT: As precision medicine revolutionizes healthcare, it should also include the redesign of NE clinical trials to allow faster development of safe, effective, and targeted therapeutics. This article provides a multidisciplinary perspective on the future of clinical trials in NE; novel trial design; study management and oversight; biostatistical methods; and a combination of serum, imaging, and neurodevelopmental biomarkers can advance the field and improve outcomes for infants affected by NE. Innovative clinical trial designs, new intermediate trial end points, and a trajectory of neurodevelopmental evaluations targeted to a prespecified and mechanistically derived hypothesis of drug action can help address common challenges in NE clinical trials and allow for faster selection and validation of promising therapies for more extensive investigation.
Collapse
MESH Headings
- Biomarkers/blood
- Biomedical Research/trends
- Brain Diseases/diagnostic imaging
- Brain Diseases/etiology
- Brain Diseases/physiopathology
- Brain Diseases/therapy
- Clinical Trials as Topic
- Consensus
- Delphi Technique
- Diffusion of Innovation
- Forecasting
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/physiopathology
- Infant, Newborn, Diseases/therapy
- Neonatology/trends
- Neuroimaging
- Research Design/trends
- Societies, Medical
- Societies, Scientific
- Time Factors
- Treatment Outcome
Collapse
Affiliation(s)
- Kristen L Benninger
- Division of Neonatology and Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Amy M Goodman
- Division of Child Neurology, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas R Nordli
- Section of Child Neurology, Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Tushar A Shah
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk, VA, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathalie L Maitre
- Division of Neonatology and Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| |
Collapse
|
9
|
Abstract
Cerebrovascular autoregulation is the ability to maintain stable cerebral blood flow within a range of cerebral perfusion pressures. When cerebral perfusion pressure is outside the limits of effective autoregulation, the brain is subjected to hypoperfusion or hyperperfusion, which may cause vascular injury, hemorrhage, and/or hypoxic white matter injury. Infants born preterm, after fetal growth restriction, with congenital heart disease, or with hypoxic-ischemic encephalopathy are susceptible to a failure of cerebral autoregulation. Bedside assessment of cerebrovascular autoregulation would offer the opportunity to prevent brain injury. Clinicians need to know which patient populations and circumstances are associated with impaired/absent cerebral autoregulation.
Collapse
Affiliation(s)
- Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands.
| | - Anne E Richter
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands
| |
Collapse
|
10
|
Xu EH, Claveau M, Yoon EW, Barrington KJ, Mohammad K, Shah PS, Wintermark P. Neonates with hypoxic-ischemic encephalopathy treated with hypothermia: Observations in a large Canadian population and determinants of death and/or brain injury. J Neonatal Perinatal Med 2020; 13:449-458. [PMID: 32310192 DOI: 10.3233/npm-190368] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Birth asphyxia in term neonates remains a serious condition that causes significant mortality and long-term neurodevelopmental sequelae despite hypothermia treatment. The objective of this study was to review therapeutic hypothermia practices in a large population of neonates with hypoxic-ischemic encephalopathy (HIE) across Canada and to identify determinants of adverse outcome. METHODS Our retrospective observational cohort study examined neonates≥36 weeks, admitted to the Canadian Neonatal Network NICUs between 2010 and 2014, diagnosed with HIE, and treated with hypothermia. Adverse outcome was defined as death and/or brain injury. Maternal, birth, and postnatal characteristics were compared between neonates with adverse outcome and those without. The association between the variables which were significantly different (p < 0.05) between the two groups and adverse outcome were further tested, while adjusting for gestational age, birth weight, gender, and initial severity of encephalopathy. RESULTS A total of 2187 neonates were admitted for HIE; 52% were treated with hypothermia and 40% developed adverse outcome. Initial severity of encephalopathy (moderate, p = 0.006; severe, p < 0.0001), hypotension treated with inotropes (p = 0.001), and renal failure (p = 0.007) were significantly associated with an increased risk of death and/or brain injury. CONCLUSIONS In asphyxiated neonates treated with hypothermia, not only their initial severity of encephalopathy on admission, but also their cardiac and renal complications during the first days after birth were significantly associated with risk of death and/or brain injury. Careful monitoring and cautious management of these complications is warranted.
Collapse
Affiliation(s)
- E H Xu
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, Québec, Canada
| | - M Claveau
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, Québec, Canada
| | - E W Yoon
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - K J Barrington
- Department of Pediatrics, Division of Neonate Medicine, University of Montreal, Montreal, Québec, Canada
| | - K Mohammad
- Department of Pediatrics, Division of Neonatology, University of Calgary, Calgary, Canada
| | - P S Shah
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - P Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, Québec, Canada
| |
Collapse
|
11
|
Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
Collapse
|
12
|
Continuous Electroencephalography Monitoring for Critically Ill Neonates: A Canadian Perspective. Neurol Sci 2019; 46:394-402. [PMID: 31030685 DOI: 10.1017/cjn.2019.36] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Continuous EEG monitoring, in the form of amplitude-integrated (aEEG) or conventional EEG (cEEG), is used in the neonatal intensive care unit (NICU) to detect subclinical central nervous system pathologies, inform management, and prognosticate neurodevelopmental outcomes. To learn more about provider attitudes and current practices in Canada, we evaluated neurologist and neonatologist opinions regarding NICU EEG monitoring. METHODS A 15-item electronic questionnaire was distributed to 114 pediatric neurologists and 176 neonatologists working across 25 sites. RESULTS The survey was completed by 87 of 290 physicians. Continuous EEG monitoring is utilized by 97% of pediatric neurologists and 92% of neonatologists. Neurologists and neonatologists differ in their EEG monitoring preferences. For seizure detection and diagnosis of encephalopathy, significantly more neonatologists favor aEEG alone or in combination with cEEG, whereas most neurologists prefer cEEG (p = 0.047, 0.001). There is a significant difference in the perceived gaps in monitoring patients with cEEG between neonatologists (13% would monitor more) and neurologists (41% would monitor more) (p = 0.007). Half of all respondents (53%) reported that they would be interested in attending an education session on neonatal EEG monitoring. CONCLUSIONS Canadian neurologists and neonatologists do not agree on the best monitoring approach for critically ill neonates. Furthermore, neonatologists perceive a smaller cEEG monitoring gap as compared with neurologists. However, many participants from both specialties would like to increase long-term EEG monitoring in the NICU setting. Facilitating access to EEG monitoring and enhancing education may help to address these needs.
Collapse
|
13
|
Badurdeen S, Roberts C, Blank D, Miller S, Stojanovska V, Davis P, Hooper S, Polglase G. Haemodynamic Instability and Brain Injury in Neonates Exposed to Hypoxia⁻Ischaemia. Brain Sci 2019; 9:E49. [PMID: 30818842 PMCID: PMC6468566 DOI: 10.3390/brainsci9030049] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/24/2019] [Accepted: 02/26/2019] [Indexed: 11/23/2022] Open
Abstract
Brain injury in the asphyxic newborn infant may be exacerbated by delayed restoration of cardiac output and oxygen delivery. With increasing severity of asphyxia, cerebral autoregulatory responses are compromised. Further brain injury may occur in association with high arterial pressures and cerebral blood flows following the restoration of cardiac output. Initial resuscitation aims to rapidly restore cardiac output and oxygenation whilst mitigating the impact of impaired cerebral autoregulation. Recent animal studies have indicated that the current standard practice of immediate umbilical cord clamping prior to resuscitation may exacerbate injury. Resuscitation prior to umbilical cord clamping confers several haemodynamic advantages. In particular, it retains the low-resistance placental circuit that mitigates the rebound hypertension and cerebrovascular injury. Prolonged cerebral hypoxia⁻ischaemia is likely to contribute to further perinatal brain injury, while, at the same time, tissue hyperoxia is associated with oxidative stress. Efforts to monitor and target cerebral flow and oxygen kinetics, for example, using near-infrared spectroscopy, are currently being evaluated and may facilitate development of novel resuscitation approaches.
Collapse
Affiliation(s)
- Shiraz Badurdeen
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
- Newborn Research Centre, The Royal Women's Hospital, Melbourne 3052, Australia.
| | - Calum Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Douglas Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Suzanne Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Peter Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne 3052, Australia.
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Graeme Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| |
Collapse
|
14
|
Kouri I, Mathews K, Joshi C. Facial Weakness and Ophthalmoplegia in a 4-Day-Old Infant. Semin Pediatr Neurol 2018; 26:63-66. [PMID: 29961523 DOI: 10.1016/j.spen.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We present a neonate with neurologic deficits recognized at 4 days of age. A male infant was born at term via emergency cesarian section due to failure to progress and fetal decelerations. He underwent therapeutic hypothermia for hypoxic ischemic encephalopathy. Upon completion of rewarming, he was noted to have left facial palsy, abduction deficit on the left eye past the midline, and nystagmus involving the right eye. Brain magnetic resonance imaging showed a pontine stroke, and computed tomography angiogram revealed basilar artery thrombosis. He was treated with enoxaparin for 3 months, followed by low-dose aspirin. The mechanism of the stroke remains unclear, and there is limited evidence to guide management.
Collapse
Affiliation(s)
- Ioanna Kouri
- Department of Pediatrics and Neurology, University of Iowa Stead Family Children's Hospital, Iowa City, IA.
| | - Katherine Mathews
- Department of Pediatrics and Neurology, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Charuta Joshi
- Department of Pediatrics and Neurology, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| |
Collapse
|
15
|
Thewissen L, Caicedo A, Lemmers P, Van Bel F, Van Huffel S, Naulaers G. Measuring Near-Infrared Spectroscopy Derived Cerebral Autoregulation in Neonates: From Research Tool Toward Bedside Multimodal Monitoring. Front Pediatr 2018; 6:117. [PMID: 29868521 PMCID: PMC5960703 DOI: 10.3389/fped.2018.00117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cerebral autoregulation (CAR), the ability of the human body to maintain cerebral blood flow (CBF) in a wide range of perfusion pressures, can be calculated by describing the relation between arterial blood pressure (ABP) and cerebral oxygen saturation measured by near-infrared spectroscopy (NIRS). In literature, disturbed CAR is described in different patient groups, using multiple measurement techniques and mathematical models. Furthermore, it is unclear to what extent cerebral pathology and outcome can be explained by impaired CAR. Aim and methods: In order to summarize CAR studies using NIRS in neonates, a systematic review was performed in the PUBMED and EMBASE database. To provide a general overview of the clinical framework used to study CAR, the different preprocessing methods and mathematical models are described and explained. Furthermore, patient characteristics, definition of impaired CAR and the outcome according to this definition is described organized for the different patient groups. Results: Forty-six articles were included in this review. Four patient groups were established: preterm infants during the transitional period, neonates receiving specific medication/treatment, neonates with congenital heart disease and neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Correlation, coherence and transfer function (TF) gain are the mathematical models most frequently used to describe CAR. The definition of impaired CAR is depending on the mathematical model used. The incidence of intraventricular hemorrhage in preterm infants is the outcome variable most frequently correlated with impaired CAR. Hypotension, disease severity, dopamine treatment, injury on magnetic resonance imaging (MRI) and long term outcome are associated with impaired CAR. Prospective interventional studies are lacking in all research areas. Discussion and conclusion: NIRS derived CAR measurement is an important research tool to improve knowledge about central hemodynamic fluctuations during the transitional period, cerebral pharmacodynamics of frequently used medication (sedatives-inotropes) and cerebral effects of specific therapies in neonatology. Uniformity regarding measurement techniques and mathematical models is needed. Multimodal monitoring databases of neonatal intensive care patients of multiple centers, together with identical outcome parameters are needed to compare different techniques and make progress in this field. Real-time bedside monitoring of CAR, together with conventional monitoring, seems a promising technique to improve individual patient care.
Collapse
Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Petra Lemmers
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| |
Collapse
|
16
|
Children born at 32 to 35 weeks with birth asphyxia and later cerebral palsy are different from those born after 35 weeks. J Perinatol 2017; 37:963-968. [PMID: 28300820 DOI: 10.1038/jp.2017.23] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/19/2017] [Accepted: 02/07/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The objectives of this study were to (1) establish the proportion of cerebral palsy (CP) that occurs with a history suggestive of birth asphyxia in children born at 32 to 35 weeks and (2) evaluate their characteristics in comparison with children with CP born at ⩾36 weeks with such a history. STUDY DESIGN Using the Canadian CP Registry, children born at 32 to 35 weeks of gestation with CP with a history suggestive of birth asphyxia were compared with corresponding ⩾36 weeks of gestation children. RESULTS Of the 163 children with CP born at 32 to 35 weeks and 738 born at ⩾36 weeks, 26 (16%) and 105 (14%) had a history suggestive of birth asphyxia, respectively. The children born at 32 to 35 weeks had more frequent abruptio placenta (35% vs 12%; odds ratio (OR) 4.1, 95% confidence interval (CI) 1.5 to 11.2), less frequent neonatal seizures (35% vs 72%; OR 0.20, 95% CI 0.08 to 0.52), more frequent white matter injury (47% vs 17%; OR 4.3, 95% CI 1.3 to 14.0), more frequent intraventricular hemorrhage (IVH) (40% vs 6%; OR 11.2, 95% CI 3.4 to 37.4) and more frequent spastic diplegia (24% vs 8%; OR 1.8, 95% CI 1.2 to 12.2) than the corresponding ⩾36 weeks of gestation children. CONCLUSIONS Approximately 1 in 7 children with CP born at 32 to 35 weeks had a history suggestive of birth asphyxia. They had different magnetic resonance imaging patterns of injury from those born at ⩾36 weeks and a higher frequency of IVH. Importantly, when considering hypothermia in preterm neonates with suspected birth asphyxia, prospective surveillance for IVH will be essential.
Collapse
|
17
|
Chalak LF, Zhang R. New Wavelet Neurovascular Bundle for Bedside Evaluation of Cerebral Autoregulation and Neurovascular Coupling in Newborns with Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2017; 39:89-96. [PMID: 28355608 DOI: 10.1159/000457833] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/23/2017] [Indexed: 12/25/2022] Open
Abstract
Neonatal encephalopathy (NE) resulting from birth asphyxia constitutes a major global public health burden for millions of infants every year, and despite therapeutic hypothermia, half of these neonates have poor neurological outcomes. As new neuroprotective interventions are being studied in clinical trials, there is a critical need to establish physiological surrogate markers of therapeutic efficacy, to guide patient selection and/or to modify the therapeutic intervention. The challenge in the field of neonatal brain injury has been the difficulty of clinically discerning NE severity within the short therapeutic window after birth or of analyzing the dynamic aspects of the cerebral circulation in sick NE newborns. To address this roadblock, we have recently developed a new "wavelet neurovascular bundle" analytical system that can measure cerebral autoregulation (CA) and neurovascular coupling (NVC) at multiple time scales under dynamic, nonstationary clinical conditions. This wavelet analysis may allow noninvasive quantification at the bedside of (1) CA (combining metrics of blood pressure and cerebral near-infrared spectroscopy, NIRS) and (2) NVC (combining metrics obtained from NIRS and EEG) in newborns with encephalopathy without mathematical assumptions of linear and stationary systems. In this concept paper, we present case examples of NE using the proposed physiological wavelet metrics of CA and NVC. The new approach, once validated in large NE studies, has the potential to optimize the selection of candidates for therapeutic decision-making, and the prediction of neurocognitive outcomes.
Collapse
Affiliation(s)
- Lina F Chalak
- Department of Pediatrics and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | |
Collapse
|
18
|
Al Balushi A, Guilbault MP, Wintermark P. Secondary Increase of Lactate Levels in Asphyxiated Newborns during Hypothermia Treatment: Reflect of Suboptimal Hemodynamics (A Case Series and Review of the Literature). AJP Rep 2016; 6:e48-58. [PMID: 26929870 PMCID: PMC4737629 DOI: 10.1055/s-0035-1565921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 09/02/2015] [Indexed: 12/02/2022] Open
Abstract
Objective To evaluate whether a secondary increase of serum lactate levels in asphyxiated newborns during hypothermia treatment may reflect suboptimal dynamics. Methods-Retrospective case series and review of the literature. We present the clinical course of four asphyxiated newborns treated with hypothermia who presented with hypotension requiring inotropic support, and who displayed a secondary increase of serum lactate levels during hypothermia treatment. Serial serum lactate levels are correlated with blood pressure and inotropic support within the first 96 hours of life. Results Lactate levels initially decreased in the four patients. However, each of them started to present lower blood pressure, and lactate levels started to increase again. Inotropic support was started to raise blood pressure. The introduction of an epinephrine drip consistently worsened the increase of lactate levels in these newborns, whereas dopamine and dobutamine enabled the clearance of lactate in addition to raising the blood pressure. Rewarming was associated with hemodynamics perturbations (a decrease of blood pressure and/or an increase of lactate levels) in the three newborns who survived. Conclusions Lactate levels during the first 4 days of life should be followed as a potential marker for suboptimal hemodynamic status in term asphyxiated newborns treated with hypothermia, for whom the maintenance of homeostasis during hypothermia treatment is of utmost importance to alleviate brain injury.
Collapse
Affiliation(s)
- Asim Al Balushi
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Marie-Pier Guilbault
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| |
Collapse
|
19
|
Tian F, Tarumi T, Liu H, Zhang R, Chalak L. Wavelet coherence analysis of dynamic cerebral autoregulation in neonatal hypoxic-ischemic encephalopathy. NEUROIMAGE-CLINICAL 2016; 11:124-132. [PMID: 26937380 PMCID: PMC4753811 DOI: 10.1016/j.nicl.2016.01.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/16/2016] [Accepted: 01/23/2016] [Indexed: 12/02/2022]
Abstract
Cerebral autoregulation represents the physiological mechanisms that keep brain perfusion relatively constant in the face of changes in blood pressure and thus plays an essential role in normal brain function. This study assessed cerebral autoregulation in nine newborns with moderate-to-severe hypoxic–ischemic encephalopathy (HIE). These neonates received hypothermic therapy during the first 72 h of life while mean arterial pressure (MAP) and cerebral tissue oxygenation saturation (SctO2) were continuously recorded. Wavelet coherence analysis, which is a time-frequency domain approach, was used to characterize the dynamic relationship between spontaneous oscillations in MAP and SctO2. Wavelet-based metrics of phase, coherence and gain were derived for quantitative evaluation of cerebral autoregulation. We found cerebral autoregulation in neonates with HIE was time-scale-dependent in nature. Specifically, the spontaneous changes in MAP and SctO2 had in-phase coherence at time scales of less than 80 min (< 0.0002 Hz in frequency), whereas they showed anti-phase coherence at time scales of around 2.5 h (~ 0.0001 Hz in frequency). Both the in-phase and anti-phase coherence appeared to be related to worse clinical outcomes. These findings suggest the potential clinical use of wavelet coherence analysis to assess dynamic cerebral autoregulation in neonatal HIE during hypothermia. Cerebral hemodynamics in HIE neonates were continuously recorded in hypothermia. Wavelet coherence can be used to assess dynamic autoregulation in HIE neonates. Wavelet-derived metrics have about 88.9% accuracy in predicting clinical outcomes. Wavelet phase, coherence, and gain are validated against transfer function analysis. Cerebral autoregulation in HIE neonates is time-scale-dependent in a wide range.
Collapse
Affiliation(s)
- Fenghua Tian
- Department of Bioengineering, University of Texas at Arlington, United States
| | - Takashi Tarumi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, United States; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, United States
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, United States
| | - Rong Zhang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, United States; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, United States
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, United States.
| |
Collapse
|
20
|
Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015; 15:209. [PMID: 26486728 PMCID: PMC4618147 DOI: 10.1186/s12883-015-0464-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Abstract
Background Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. Methods In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21–32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. Results Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21–32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. Conclusion In this pilot cohort, motor and cognitive impairments at 21–32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates’ MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE. Electronic supplementary material The online version of this article (doi:10.1186/s12883-015-0464-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
21
|
Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883-015-0464-410.1186/s12883-015-0464-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
Collapse
Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
22
|
Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883‐015‐0464‐4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
Collapse
Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|