1
|
Calixto C, Taymourtash A, Karimi D, Snoussi H, Velasco-Annis C, Jaimes C, Gholipour A. Advances in Fetal Brain Imaging. Magn Reson Imaging Clin N Am 2024; 32:459-478. [PMID: 38944434 PMCID: PMC11216711 DOI: 10.1016/j.mric.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Over the last 20 years, there have been remarkable developments in fetal brain MR imaging analysis methods. This article delves into the specifics of structural imaging, diffusion imaging, functional MR imaging, and spectroscopy, highlighting the latest advancements in motion correction, fetal brain development atlases, and the challenges and innovations. Furthermore, this article explores the clinical applications of these advanced imaging techniques in comprehending and diagnosing fetal brain development and abnormalities.
Collapse
Affiliation(s)
- Camilo Calixto
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, 401 Park Dr, 7th Floor West, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Athena Taymourtash
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Spitalgasse 23, Wien 1090, Austria
| | - Davood Karimi
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, 401 Park Dr, 7th Floor West, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Haykel Snoussi
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, 401 Park Dr, 7th Floor West, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Clemente Velasco-Annis
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, 401 Park Dr, 7th Floor West, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Camilo Jaimes
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02215, USA
| | - Ali Gholipour
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, 401 Park Dr, 7th Floor West, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| |
Collapse
|
2
|
Ergui I, Griffith N, Salama J, Ebner B, Dangl M, Vincent L, Razuk V, Marzouka G, Colombo R. In-Hospital Outcomes in Patients With Non-ST Segment Elevation Myocardial Infarction and Concomitant Neurodevelopmental Disorders in the United States: Insights From the National Inpatient Sample 2011-2020. Cureus 2024; 16:e60289. [PMID: 38746481 PMCID: PMC11093150 DOI: 10.7759/cureus.60289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 05/16/2024] Open
Abstract
Patients with neurodevelopmental disorders (NDDs) encounter significant barriers to receiving quality health care, particularly for acute conditions such as non-ST segment elevation myocardial infarction (NSTEMI). This study addresses the critical gap in knowledge regarding in-hospital outcomes and the use of invasive therapies in this demographic. By analyzing data from the National Inpatient Sample database from 2011 to 2020 using the International Classification of Diseases, Ninth Edition (ICD-9) and Tenth Edition (ICD-10) codes, we identified patients with NSTEMI, both with and without NDDs, and compared baseline characteristics, in-hospital outcomes, and the application of invasive treatments. The analysis involved a weighted sample of 7,482,216 NSTEMI hospitalizations, of which 30,168 (0.40%) patients had NDDs. There were significantly higher comorbidity-adjusted odds of in-hospital mortality, cardiac arrest, endotracheal intubation, infectious complications, ventricular arrhythmias, and restraint use among the NDD cohort. Conversely, this group exhibited lower adjusted odds of undergoing left heart catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery. These findings underscore the disparities faced by patients with NDDs in accessing invasive cardiac interventions, highlighting the need for further research to address these barriers and improve care quality for this vulnerable population.
Collapse
Affiliation(s)
- Ian Ergui
- Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Nayrana Griffith
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Joshua Salama
- Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Bertrand Ebner
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Michael Dangl
- Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Louis Vincent
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Victor Razuk
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - George Marzouka
- Cardiology, Miami Department of Veterans Affairs, Miami, USA
| | - Rosario Colombo
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| |
Collapse
|
3
|
O’Brien MP, Pryzhkova MV, Lake EMR, Mandino F, Shen X, Karnik R, Atkins A, Xu MJ, Ji W, Konstantino M, Brueckner M, Ment LR, Khokha MK, Jordan PW. SMC5 Plays Independent Roles in Congenital Heart Disease and Neurodevelopmental Disability. Int J Mol Sci 2023; 25:430. [PMID: 38203602 PMCID: PMC10779392 DOI: 10.3390/ijms25010430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Up to 50% of patients with severe congenital heart disease (CHD) develop life-altering neurodevelopmental disability (NDD). It has been presumed that NDD arises in CHD cases because of hypoxia before, during, or after cardiac surgery. Recent studies detected an enrichment in de novo mutations in CHD and NDD, as well as significant overlap between CHD and NDD candidate genes. However, there is limited evidence demonstrating that genes causing CHD can produce NDD independent of hypoxia. A patient with hypoplastic left heart syndrome and gross motor delay presented with a de novo mutation in SMC5. Modeling mutation of smc5 in Xenopus tropicalis embryos resulted in reduced heart size, decreased brain length, and disrupted pax6 patterning. To evaluate the cardiac development, we induced the conditional knockout (cKO) of Smc5 in mouse cardiomyocytes, which led to the depletion of mature cardiomyocytes and abnormal contractility. To test a role for Smc5 specifically in the brain, we induced cKO in the mouse central nervous system, which resulted in decreased brain volume, and diminished connectivity between areas related to motor function but did not affect vascular or brain ventricular volume. We propose that genetic factors, rather than hypoxia alone, can contribute when NDD and CHD cases occur concurrently.
Collapse
Affiliation(s)
- Matthew P. O’Brien
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Marina V. Pryzhkova
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
- Department of Biochemistry and Molecular Biology, Uniformed Services, University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
| | - Evelyn M. R. Lake
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Francesca Mandino
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Xilin Shen
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Ruchika Karnik
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Alisa Atkins
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Michelle J. Xu
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Weizhen Ji
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Pediatric Genomics Discovery Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Monica Konstantino
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Pediatric Genomics Discovery Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Martina Brueckner
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Department of Genetics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Laura R. Ment
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Mustafa K. Khokha
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Pediatric Genomics Discovery Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Department of Genetics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Philip W. Jordan
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
- Department of Biochemistry and Molecular Biology, Uniformed Services, University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
| |
Collapse
|
4
|
Karimi D, Rollins CK, Velasco-Annis C, Ouaalam A, Gholipour A. Learning to segment fetal brain tissue from noisy annotations. Med Image Anal 2023; 85:102731. [PMID: 36608414 PMCID: PMC9974964 DOI: 10.1016/j.media.2022.102731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/17/2022] [Accepted: 12/23/2022] [Indexed: 01/03/2023]
Abstract
Automatic fetal brain tissue segmentation can enhance the quantitative assessment of brain development at this critical stage. Deep learning methods represent the state of the art in medical image segmentation and have also achieved impressive results in brain segmentation. However, effective training of a deep learning model to perform this task requires a large number of training images to represent the rapid development of the transient fetal brain structures. On the other hand, manual multi-label segmentation of a large number of 3D images is prohibitive. To address this challenge, we segmented 272 training images, covering 19-39 gestational weeks, using an automatic multi-atlas segmentation strategy based on deformable registration and probabilistic atlas fusion, and manually corrected large errors in those segmentations. Since this process generated a large training dataset with noisy segmentations, we developed a novel label smoothing procedure and a loss function to train a deep learning model with smoothed noisy segmentations. Our proposed methods properly account for the uncertainty in tissue boundaries. We evaluated our method on 23 manually-segmented test images of a separate set of fetuses. Results show that our method achieves an average Dice similarity coefficient of 0.893 and 0.916 for the transient structures of younger and older fetuses, respectively. Our method generated results that were significantly more accurate than several state-of-the-art methods including nnU-Net that achieved the closest results to our method. Our trained model can serve as a valuable tool to enhance the accuracy and reproducibility of fetal brain analysis in MRI.
Collapse
Affiliation(s)
- Davood Karimi
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Clemente Velasco-Annis
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abdelhakim Ouaalam
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Gholipour
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Structural Racism, Social Determinants of Health, and Provider Bias: Impact on Brain Development in Critical Congenital Heart Disease. Can J Cardiol 2023; 39:133-143. [PMID: 36368561 DOI: 10.1016/j.cjca.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/17/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Critical congenital heart disease (cCHD) has neurodevelopmental sequelae that can carry into adulthood, which may be due to aberrant brain development or brain injury in the prenatal and perinatal/neonatal periods and beyond. Health disparities based on the intersection of sex, geography, race, and ethnicity have been identified for poorer pre- and postnatal outcomes in the general population, as well as those with cCHD. These disparities are likely driven by structural racism, disparities in social determinants of health, and provider bias, which further compound negative brain development outcomes. This review discusses how aberrant brain development in cCHD early in life is affected by reduced access to quality care (ie, prenatal care and testing, postnatal care) due to divestment in non-White neighbourhoods (eg, redlining) and food insecurity, differences in insurance status, location of residence, and perceived interpersonal racism and bias that disproportionately affects pregnant people of colour who have fewer economic resources. Suggestions are discussed for moving forward with implementing strategies in medical education, clinical care, research, and gaining insight into the communities served to combat disparities and bias while promoting cultural humility.
Collapse
|
6
|
Moerdijk AS, Claessens NH, van Ooijen IM, van Ooij P, Alderliesten T, Grotenhuis HB, Benders MJNL, Bohte AE, Breur JMPJ, Charisopoulou D, Clur SA, Cornette JMJ, Fejzic Z, Franssen MTM, Frerich S, Geerdink LM, Go ATJI, Gommers S, Helbing WA, Hirsch A, Holtackers RJ, Klein WM, Krings GJ, Lamb HJ, Nijman M, Pajkrt E, Planken RN, Schrauben EM, Steenhuis TJ, ter Heide H, Vanagt WYR, van Beynum IM, van Gaalen MD, van Iperen GG, van Schuppen J, Willems TP, Witters I. Fetal MRI of the heart and brain in congenital heart disease. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:59-68. [PMID: 36343660 DOI: 10.1016/s2352-4642(22)00249-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/12/2022] [Accepted: 08/22/2022] [Indexed: 11/06/2022]
Abstract
Antenatal assessment of congenital heart disease and associated anomalies by ultrasound has improved perinatal care. Fetal cardiovascular MRI and fetal brain MRI are rapidly evolving for fetal diagnostic testing of congenital heart disease. We give an overview on the use of fetal cardiovascular MRI and fetal brain MRI in congenital heart disease, focusing on the current applications and diagnostic yield of structural and functional imaging during pregnancy. Fetal cardiovascular MRI in congenital heart disease is a promising supplementary imaging method to echocardiography for the diagnosis of antenatal congenital heart disease in weeks 30-40 of pregnancy. Concomitant fetal brain MRI is superior to brain ultrasound to show the complex relationship between fetal haemodynamics in congenital heart disease and brain development.
Collapse
Affiliation(s)
- Anouk S Moerdijk
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nathalie Hp Claessens
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands; Department of Neonatology, Division of Woman and Baby, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Inge M van Ooijen
- Department of Neonatology, Division of Woman and Baby, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Pim van Ooij
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Thomas Alderliesten
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands; Department of Neonatology, Division of Woman and Baby, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Heynric B Grotenhuis
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Goncalves LF, Lindblade CL, Cornejo P, Patel MC, McLaughlin ES, Bardo DME. Contribution of fetal magnetic resonance imaging in fetuses with congenital heart disease. Pediatr Radiol 2022; 52:513-526. [PMID: 34842935 DOI: 10.1007/s00247-021-05234-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 09/18/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing evidence supports an association among congenital heart disease (CHD), structural brain lesions on neuroimaging, and increased risk of neurodevelopmental delay and other structural anomalies. Fetal MRI has been found to be effective in demonstrating fetal structural and developmental abnormalities. OBJECTIVE To determine the contribution of fetal MRI to identifying cardiovascular and non-cardiovascular anomalies in fetuses with CHD compared to prenatal US and fetal echocardiography. MATERIALS AND METHODS We performed a retrospective study of fetuses with CHD identified by fetal echocardiography. Exams were performed on 1.5-tesla (T) or 3-T magnets using a balanced turbo field echo sequence triggered by an external electrocardiogram simulator with a fixed heart rate of 140 beats per minute (bpm). Fetal echocardiography was performed by pediatric cardiologists and detailed obstetrical US by maternal-fetal medicine specialists prior to referral to MRI. We compared the sensitivity of fetal MRI and fetal echocardiography for the diagnosis of cardiovascular anomalies, as well as the sensitivity of fetal MRI and referral US for the diagnosis of non-cardiac anomalies. We performed statistical analysis using the McNemar test. RESULTS We identified 121 anomalies in 31 fetuses. Of these, 73 (60.3%) were cardiovascular and 48 (39.7%) involved other organ systems. Fetal echocardiography was more sensitive for diagnosing cardiovascular anomalies compared to fetal MRI, but the difference was not statistically significant (85.9%, 95% confidence interval [CI] 77.8-94.0% vs. 77.5%, 95% CI 67.7-87.2%, respectively; McNemar test 2.29; P=0.13). The sensitivity of fetal MRI was higher for diagnosing extracardiac anomalies when compared to referral US (84.1%, 95% CI 73.3-94.9% vs. 31.8%, 95% CI 18.1-45.6%, respectively; McNemar test 12.9; P<0.001). The additional information provided by fetal MRI changed prognosis, counseling or management for 10/31 fetuses (32.2%), all in the group of 19 fetuses with anomalies in other organs and systems besides CHD. CONCLUSION Fetal MRI performed in a population of fetuses with CHD provided additional information that altered prognosis, counseling or management in approximately one-third of the fetuses, mainly by identifying previously unknown anomalies in other organs and systems.
Collapse
Affiliation(s)
- Luis F Goncalves
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA.
- University of Arizona College of Medicine, Phoenix, AZ, USA.
- Department of Radiology, Creighton University, Phoenix, AZ, USA.
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA.
| | - Christopher L Lindblade
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Patricia Cornejo
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Mittun C Patel
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Ericka Scheller McLaughlin
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Dianna M E Bardo
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
8
|
Dovjak GO, Zalewski T, Seidl-Mlczoch E, Ulm PA, Berger-Kulemann V, Weber M, Prayer D, Kasprian GJ, Ulm B. Abnormal Extracardiac Development in Fetuses With Congenital Heart Disease. J Am Coll Cardiol 2021; 78:2312-2322. [PMID: 34857093 DOI: 10.1016/j.jacc.2021.09.1358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/26/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Knowledge about extracardiac anomalies (ECA) in fetal congenital heart disease (CHD) can improve our understanding of the developmental origins of various outcomes in these infants. The prevalence and spectrum of ECA, including structural brain anomalies (SBA), on magnetic resonance imaging (MRI) in fetuses with different types of CHD and at different gestational ages, is unknown. OBJECTIVES The purpose of this study was to evaluate ECA rates and types on MRI in fetuses with different types of CHD and across gestation. METHODS A total of 429 consecutive fetuses with CHD and MRI between 17 and 38 gestational weeks were evaluated. ECA and SBA rates were assessed for each type of CHD and classified by gestational age (<25 or ≥25 weeks) at MRI. RESULTS Of all 429 fetuses with CHD, 243 (56.6%) had ECA on MRI, and 109 (25.4%) had SBA. Among the 191 fetuses with normal genetic testing results, the ECA rate was 54.5% and the SBA rate 19.4%. Besides SBA, extrafetal (21.2%) and urogenital anomalies (10.7%) were the most prevalent ECA on MRI in all types of CHD. Predominant SBA were anomalies of hindbrain-midbrain (11.0% of all CHD), dorsal prosencephalon (10.0%) development, and abnormal cerebrospinal fluid spaces (10.5%). There was no difference in the prevalence or pattern of ECA between early (<25 weeks; 45.7%) and late (≥25 weeks; 54.3%) fetal MRI. CONCLUSIONS ECA and SBA rates on fetal MRI are high across all types of CHD studied, and ECA as well as SBA are already present from midgestation onward.
Collapse
Affiliation(s)
- Gregor O Dovjak
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Tim Zalewski
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Seidl-Mlczoch
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Medical University of Vienna, Vienna, Austria
| | - Patricia A Ulm
- Department of Chromosome Biology, University of Vienna, Vienna, Austria
| | - Vanessa Berger-Kulemann
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Daniela Prayer
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Gregor J Kasprian
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Ulm
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
9
|
Everwijn SM, van Bohemen JF, van Geloven N, Jansen FA, Teunissen AK, Rozendaal L, Blom N, van Lith JM, Haak MC. Serial neurosonography in fetuses with congenital heart defects shows mild delays in cortical development. Prenat Diagn 2021; 41:1649-1657. [PMID: 34474501 PMCID: PMC9293037 DOI: 10.1002/pd.6038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/28/2021] [Accepted: 08/23/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Neurodevelopmental delay is more common in children born with congenital heart defects (CHD), even with optimal perinatal and peri-operative care. It is hypothesized that fetuses with CHD are prone to neurological impairment in utero due to their cardiac defect, possibly leading to delayed cortical development. METHODS Cerebral cortical maturation was assessed with advanced neurosonographic examinations every 4 weeks in fetuses with CHD and compared to control fetuses. Five different primary fissures and four areas were scored (ranging 0-5) by blinded examiners using a cortical maturation scheme. RESULTS Cortical staging was assessed in 574 ultrasound examinations in 85 CHD fetuses and 61 controls. Small differences in grading were seen in Sylvian and cingulate fissures. (Sylvian fissure: -0.12 grade, 95% CI (-0.23; -0.01) p = 0.05, cingulate fissure: -0.24 grade, 95% CI (-0.38; -0.10) p = <0.001. Other cortical areas showed normal maturation as compared to control fetuses. CONCLUSION Small differences were seen in three of the nine analyzed cortical areas in CHD fetuses, in contrast to previous reports on progressive third-trimester delay. The clinical implications of the small differences however, remain unknown.
Collapse
Affiliation(s)
- Sheila M Everwijn
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Jiska F van Bohemen
- Department of Obstetrics and Gynecology, HAGA Hospital, The Hague, The Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Fenna A Jansen
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Aalbertine K Teunissen
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieke Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M van Lith
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
10
|
Lee FT, Seed M, Sun L, Marini D. Fetal brain issues in congenital heart disease. Transl Pediatr 2021; 10:2182-2196. [PMID: 34584890 PMCID: PMC8429876 DOI: 10.21037/tp-20-224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022] Open
Abstract
Following the improvements in the clinical management of patients with congenital heart disease (CHD) and their increased survival, neurodevelopmental outcome has become an emerging priority in pediatric cardiology. Large-scale efforts have been made to protect the brain during the postnatal, surgical, and postoperative period; however, the presence of brain immaturity and injury at birth suggests in utero and peripartum disturbances. Over the past decade, there has been considerable interest and investigations on fetal brain growth in the setting of CHD. Advancements in fetal brain imaging have identified abnormal brain development in fetuses with CHD from the macrostructural (brain volumes and cortical folding) down to the microstructural (biochemistry and water diffusivity) scale, with more severe forms of CHD showing worse disturbances and brain abnormalities starting as early as the first trimester. Anomalies in common genetic developmental pathways and diminished cerebral substrate delivery secondary to altered cardiovascular physiology are the forefront hypotheses, but other factors such as impaired placental function and maternal psychological stress have surfaced as important contributors to fetal brain immaturity in CHD. The characterization and timing of fetal brain disturbances and their associated mechanisms are important steps for determining preventative prenatal interventions, which may provide a stronger foundation for the developing brain during childhood.
Collapse
Affiliation(s)
- Fu-Tsuen Lee
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mike Seed
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.,Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Liqun Sun
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Davide Marini
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| |
Collapse
|
11
|
Payette K, de Dumast P, Kebiri H, Ezhov I, Paetzold JC, Shit S, Iqbal A, Khan R, Kottke R, Grehten P, Ji H, Lanczi L, Nagy M, Beresova M, Nguyen TD, Natalucci G, Karayannis T, Menze B, Bach Cuadra M, Jakab A. An automatic multi-tissue human fetal brain segmentation benchmark using the Fetal Tissue Annotation Dataset. Sci Data 2021; 8:167. [PMID: 34230489 PMCID: PMC8260784 DOI: 10.1038/s41597-021-00946-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/13/2021] [Indexed: 11/09/2022] Open
Abstract
It is critical to quantitatively analyse the developing human fetal brain in order to fully understand neurodevelopment in both normal fetuses and those with congenital disorders. To facilitate this analysis, automatic multi-tissue fetal brain segmentation algorithms are needed, which in turn requires open datasets of segmented fetal brains. Here we introduce a publicly available dataset of 50 manually segmented pathological and non-pathological fetal magnetic resonance brain volume reconstructions across a range of gestational ages (20 to 33 weeks) into 7 different tissue categories (external cerebrospinal fluid, grey matter, white matter, ventricles, cerebellum, deep grey matter, brainstem/spinal cord). In addition, we quantitatively evaluate the accuracy of several automatic multi-tissue segmentation algorithms of the developing human fetal brain. Four research groups participated, submitting a total of 10 algorithms, demonstrating the benefits the dataset for the development of automatic algorithms.
Collapse
Affiliation(s)
- Kelly Payette
- Center for MR Research, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland.
- Neuroscience Center Zurich, University of Zurich/ETH Zurich, Zurich, Switzerland.
| | - Priscille de Dumast
- CIBM, Center for Biomedical Imaging, Lausanne, Switzerland
- Medical Image Analysis Laboratory, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Hamza Kebiri
- CIBM, Center for Biomedical Imaging, Lausanne, Switzerland
- Medical Image Analysis Laboratory, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ivan Ezhov
- Image-Based Biomedical Imaging Group, Technical University of Munich, München, Germany
| | - Johannes C Paetzold
- Image-Based Biomedical Imaging Group, Technical University of Munich, München, Germany
| | - Suprosanna Shit
- Image-Based Biomedical Imaging Group, Technical University of Munich, München, Germany
| | - Asim Iqbal
- Neuroscience Center Zurich, University of Zurich/ETH Zurich, Zurich, Switzerland
- Brain Research Institute, University of Zurich, Zurich, Switzerland
- Center for Intelligent Systems & Brain Mind Institute, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Romesa Khan
- Neuroscience Center Zurich, University of Zurich/ETH Zurich, Zurich, Switzerland
- Institute for Biomedical Engineering, UZH/ETH Zurich, Zurich, Switzerland
| | - Raimund Kottke
- Department of Diagnostic Imaging, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Patrice Grehten
- Department of Diagnostic Imaging, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hui Ji
- Center for MR Research, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Levente Lanczi
- Faculty of Medicine, Department of Medical Imaging, University of Debrecen, Debrecen, Hajdú-Bihar, Hungary
| | - Marianna Nagy
- Faculty of Medicine, Department of Medical Imaging, University of Debrecen, Debrecen, Hajdú-Bihar, Hungary
| | - Monika Beresova
- Faculty of Medicine, Department of Medical Imaging, University of Debrecen, Debrecen, Hajdú-Bihar, Hungary
| | - Thi Dao Nguyen
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Giancarlo Natalucci
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
- Larsson-Rosenquist Center for Neurodevelopment, Growth and Nutrition of the Newborn, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | | | - Bjoern Menze
- Image-Based Biomedical Imaging Group, Technical University of Munich, München, Germany
| | - Meritxell Bach Cuadra
- CIBM, Center for Biomedical Imaging, Lausanne, Switzerland
- Medical Image Analysis Laboratory, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andras Jakab
- Center for MR Research, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich/ETH Zurich, Zurich, Switzerland
| |
Collapse
|
12
|
Ren JY, Zhu M, Dong SZ. Three-Dimensional Volumetric Magnetic Resonance Imaging Detects Early Alterations of the Brain Growth in Fetuses With Congenital Heart Disease. J Magn Reson Imaging 2021; 54:263-272. [PMID: 33559371 DOI: 10.1002/jmri.27526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Several published studies have shown alterations of brain development in third-trimester fetuses with congenital heart disease (CHD). However, little is known about the timing and pattern of altered brain development in fetuses with CHD. PURPOSE To investigate the changes in the volume of intracranial structures in fetuses with CHD by three-dimensional (3D) volumetric magnetic resonance imaging (MRI) in the earlier stages of pregnancy (median gestational age [GA], 26 weeks). STUDY TYPE Retrospective. POPULATION Forty women carrying a fetus with CHD (including 20 fetuses with GA <26 weeks) and 120 pregnant women carrying a healthy fetus (including 50 fetuses with GA <26 weeks). FIELD STRENGTH/SEQUENCE Two-dimensional single-shot turbo spin echo sequence at 1.5 -T. ASSESSMENT Three-dimensional volumetric parameters from slice-to-volume registered images, including cortical gray matter volume (GMV), subcortical brain tissue volume (SBV), intracranial cavity volume (ICV), lateral ventricles volume (VV), cerebellum, brainstem, and extra-cerebrospinal fluid (e-CSF) were quantified by manual segmentation from one primary and two secondary observers. STATISTICAL TESTS Volumes were presented graphically with quadratic curve fitting. Scatterplots were produced mapping volumes against GA in normal and CHD fetuses. For GA <26 weeks, Z scores were calculated and Student's t-tests were conducted to compare volumes between the normal and CHD fetuses. RESULTS In fetuses with CHD GMV, SBV, cerebellum, and brainstem were significantly reduced (all P < 0.05) in early stages of pregnancy (GA <26 weeks), with differences becoming progressively greater with increasing GA. Compared with normal fetuses, e-CSF, e-CSF to ICV ratio, and VV were higher in fetuses with CHD (all P < 0.05). However, ICV volume and the GMV to SBV ratio were not significantly reduced in the CHD group (P = 0.94 and P = 0.13, respectively) during the middle gestation (GA <26 weeks). DATA CONCLUSION There appear to be alterations of brain development trajectory in CHD fetuses that can be detected by 3D volumetric MRI in the earlier stages of pregnancy. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 3.
Collapse
Affiliation(s)
- Jing-Ya Ren
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming Zhu
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Su-Zhen Dong
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
13
|
Everwijn SMP, Namburete AIL, van Geloven N, Jansen FAR, Papageorghiou AT, Teunissen AK, Rozendaal L, Blom N, van Lith JM, Haak MC. The association between flow and oxygenation and cortical development in fetuses with congenital heart defects using a brain-age prediction algorithm. Prenat Diagn 2020; 41:43-51. [PMID: 33448406 PMCID: PMC7891604 DOI: 10.1002/pd.5813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 12/18/2022]
Abstract
Objectives Presumably, changes in fetal circulation contribute to the delay in maturation of the cortex in fetuses with congenital heart defect (CHD). The aim of the current study is to analyze fetal brain development based on hemodynamic differences, using novel brain‐age prediction software. Methods We have performed detailed neurosonography, including acquiring 3D volumes, prospectively in cases with isolated CHD from 20 weeks onwards. An algorithm that assesses the degree of fetal brain‐age automatically was used to compare CHD cases to controls. We stratified CHD cases according to flow and oxygenation profiles by lesion physiology and performed subgroup analyses. Results A total of 616 ultrasound volumes of 162 CHD cases and 75 controls were analyzed. Significant differences in maturation of the cortex were observed in cases with normal blood flow toward the brain (−3.8 days, 95%CI [−5.5; −2.0], P = <.001) and low (−4.0 days, 95% CI [−6.7; −1.2] P = <.05; hypoplastic left heart syndrome[HLHS]) and mixed (−4.4 days, 95%CI [−6.4; −2.5] p = <.001) oxygen saturation in the ascending aorta (TGA) and in cardiac mixing (eg, Fallot) cases. Conclusion The current study shows significant delay in brain‐age in TGA and Fallot cases as compared to control cases. However, the small differences found in this study questions the clinical relevance.
Collapse
Affiliation(s)
- Sheila M P Everwijn
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ana I L Namburete
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Section Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Fenna A R Jansen
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aalbertine K Teunissen
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieke Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M van Lith
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
14
|
Ji W, Ferdman D, Copel J, Scheinost D, Shabanova V, Brueckner M, Khokha MK, Ment LR. De novo damaging variants associated with congenital heart diseases contribute to the connectome. Sci Rep 2020; 10:7046. [PMID: 32341405 PMCID: PMC7184603 DOI: 10.1038/s41598-020-63928-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/08/2020] [Indexed: 12/15/2022] Open
Abstract
Congenital heart disease (CHD) survivors are at risk for neurodevelopmental disability (NDD), and recent studies identify genes associated with both disorders, suggesting that NDD in CHD survivors may be of genetic origin. Genes contributing to neurogenesis, dendritic development and synaptogenesis organize neural elements into networks known as the connectome. We hypothesized that NDD in CHD may be attributable to genes altering both neural connectivity and cardiac patterning. To assess the contribution of de novo variants (DNVs) in connectome genes, we annotated 229 published NDD genes for connectome status and analyzed data from 3,684 CHD subjects and 1,789 controls for connectome gene mutations. CHD cases had more protein truncating and deleterious missense DNVs among connectome genes compared to controls (OR = 5.08, 95%CI:2.81-9.20, Fisher's exact test P = 6.30E-11). When removing three known syndromic CHD genes, the findings remained significant (OR = 3.69, 95%CI:2.02-6.73, Fisher's exact test P = 1.06E-06). In CHD subjects, the top 12 NDD genes with damaging DNVs that met statistical significance after Bonferroni correction (PTPN11, CHD7, CHD4, KMT2A, NOTCH1, ADNP, SMAD2, KDM5B, NSD2, FOXP1, MED13L, DYRK1A; one-tailed binomial test P ≤ 4.08E-05) contributed to the connectome. These data suggest that NDD in CHD patients may be attributable to genes that alter both cardiac patterning and the connectome.
Collapse
Affiliation(s)
- Weizhen Ji
- Departments of Pediatrics, New Haven, CT, USA
| | | | - Joshua Copel
- Departments of Pediatrics, New Haven, CT, USA
- Obstetrics, Gynecology and Reproductive Sciences, New Haven, CT, USA
| | | | | | - Martina Brueckner
- Departments of Pediatrics, New Haven, CT, USA
- Genetics, New Haven, CT, USA
- Yale Combined Program in Biological and Biomedical Sciences, New Haven, CT, USA
| | - Mustafa K Khokha
- Departments of Pediatrics, New Haven, CT, USA
- Genetics, New Haven, CT, USA
| | - Laura R Ment
- Departments of Pediatrics, New Haven, CT, USA.
- Neurology, Yale School of Medicine, 333 Cedar Street, New Haven, CT, USA.
| |
Collapse
|
15
|
Howell HB, Zaccario M, Kazmi SH, Desai P, Sklamberg FE, Mally P. Neurodevelopmental outcomes of children with congenital heart disease: A review. Curr Probl Pediatr Adolesc Health Care 2019; 49:100685. [PMID: 31708366 DOI: 10.1016/j.cppeds.2019.100685] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Congenital heart defects are the most common birth anomaly affecting approximately 1% of births. With improved survival in this population, there is enhanced ability to assess long-term morbidities including neurodevelopment. There is a wide range of congenital heart defects, from those with minimal physiologic consequence that do not require medical or surgical intervention, to complex structural anomalies requiring highly specialized medical management and intricate surgical repair or palliation. The impact of congenital heart disease on neurodevelopment is multifactorial. Susceptibility for adverse neurodevelopment increases with advancing severity of the defect with initial risk factors originating during gestation. Complex structural heart anomalies may pre-dispose the fetus to abnormal circulatory patterns in utero that ultimately impact delivery of oxygen rich blood to the fetal brain. Thus, the brain of a neonate born with complex congenital heart disease may be particularly vulnerable from the outset. That vulnerability is compounded during the newborn period and through childhood, as this population endures a myriad of medical and surgical interventions. For each individual patient, these factors are likely cumulative and synergistic with progression from fetal life through childhood. This review discusses the spectrum of risk factors that may impact neurodevelopment in children with congenital heart disease, describes current recommendations and practices for neurodevelopmental follow-up of children with congenital heart disease and reviews important neurodevelopmental trends in this high risk population.
Collapse
Affiliation(s)
- Heather B Howell
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA.
| | - Michele Zaccario
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA; Pace University, Department of Psychology, 41 Park Row, New York, NY 10038 USA
| | - Sadaf H Kazmi
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| | - Purnahamsi Desai
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| | - Felice E Sklamberg
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| | - Pradeep Mally
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| |
Collapse
|
16
|
Everwijn SMP, Namburete AIL, van Geloven N, Jansen FAR, Papageorghiou AT, Noble AJ, Teunissen AKK, Rozendaal L, Blom NA, van Lith JMM, Haak MC. Cortical development in fetuses with congenital heart defects using an automated brain-age prediction algorithm. Acta Obstet Gynecol Scand 2019; 98:1595-1602. [PMID: 31322290 DOI: 10.1111/aogs.13687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/14/2019] [Accepted: 07/03/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Congenital heart defects are associated with neurodevelopmental delay. It is hypothesized that fetuses affected by congenital heart defect have altered cerebral oxygen perfusion and are therefore prone to delay in cortical maturation. The aim of this study was to determine the difference in fetal brain age between consecutive congenital heart defect cases and controls in the second and third trimester using ultrasound. MATERIAL AND METHODS Since 2014, we have included 90 isolated severe congenital heart defect cases in the Heart And Neurodevelopment (HAND)-study. Every 4 weeks, detailed neurosonography was performed in these fetuses, including the recording of a 3D volume of the fetal brain, from 20 weeks onwards. In all, 75 healthy fetuses underwent the same protocol to serve as a control group. The volumes were analyzed by automated age prediction software which determines gestational age by the assessment of cortical maturation. RESULTS In total, 477 volumes were analyzed using the age prediction software (199 volumes of 90 congenital heart defect cases; 278 volumes of 75 controls). Of these, 16 (3.2%) volume recordings were excluded because of imaging quality. The age distribution was 19-33 weeks. Mixed model analysis showed that the age predicted by brain maturation was 3 days delayed compared with the control group (P = .002). CONCLUSIONS This study shows that fetuses with isolated cases of congenital heart defects show some delay in cortical maturation as compared with healthy control cases. The clinical relevance of this small difference is debatable. This finding was consistent throughout pregnancy and did not progress during the third trimester.
Collapse
Affiliation(s)
- Sheila M P Everwijn
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ana I L Namburete
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Section Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Fenna A R Jansen
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics and Gynecology, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Alison J Noble
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Aalbertine K K Teunissen
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieke Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M M van Lith
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
17
|
Griffiths PD, Mousa HA, Finney C, Mooney C, Mandefield L, Chico TJA, Jarvis D. An integrated in utero MR method for assessing structural brain abnormalities and measuring intracranial volumes in fetuses with congenital heart disease: results of a prospective case-control feasibility study. Neuroradiology 2019; 61:603-611. [PMID: 30796469 PMCID: PMC6477996 DOI: 10.1007/s00234-019-02184-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/04/2019] [Indexed: 11/30/2022]
Abstract
Purpose To refine methods that assess structural brain abnormalities and calculate intracranial volumes in fetuses with congenital heart diseases (CHD) using in utero MR (iuMR) imaging. Our secondary objective was to assess the prevalence of brain abnormalities in this high-risk cohort and compare the brain volumes with normative values. Methods We performed iuMR on 16 pregnant women carrying a fetus with CHD and gestational age ≥ 28-week gestation and no brain abnormality on ultrasonography. All cases had fetal echocardiography by a pediatric cardiologist. Structural brain abnormalities on iuMR were recorded. Intracranial volumes were made from 3D FIESTA acquisitions following manual segmentation and the use of 3D Slicer software and were compared with normal fetuses. Z scores were calculated, and regression analyses were performed to look for differences between the normal and CHD fetuses. Results Successful 2D and 3D volume imaging was obtained in all 16 cases within a 30-min scan. Despite normal ultrasonography, 5/16 fetuses (31%) had structural brain abnormalities detected by iuMR (3 with ventriculomegaly, 2 with vermian hypoplasia). Brain volume, extra-axial volume, and total intracranial volume were statistically significantly reduced, while ventricular volumes were increased in the CHD cohort. Conclusion We have shown that it is possible to perform detailed 2D and 3D studies using iuMR that allow thorough investigation of all intracranial compartments in fetuses with CHD in a clinically appropriate scan time. Those fetuses have a high risk of structural brain abnormalities and smaller brain volumes even when brain ultrasonography is normal.
Collapse
Affiliation(s)
- Paul D Griffiths
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
| | - Hatem A Mousa
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Chloe Finney
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Cara Mooney
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Laura Mandefield
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Timothy J A Chico
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Deborah Jarvis
- Academic Unit of Radiology, University of Sheffield, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| |
Collapse
|
18
|
Jansen FAR, van Zwet EW, Everwijn SMP, Teunissen AKK, Rozendaal L, van Lith JMM, Blom NA, Haak MC. Fetuses with Isolated Congenital Heart Defects Show Normal Cerebral and Extracerebral Fluid Volume Growth: A 3D Sonographic Study in the Second and Third Trimester. Fetal Diagn Ther 2019; 45:212-220. [PMID: 30654359 DOI: 10.1159/000488674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/07/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim of our study is to explore whether the cerebral growth is delayed in fetuses with congenital heart defects (CHD) in the second and early third trimester. METHODS A prospective cohort study was conducted in 77 CHD cases, with 75 healthy controls. 3D cerebral volume acquisition was performed sequentially. The volumes of the fetal hemicerebrum and extracerebral fluid were compared by linear regression analysis, and the Sylvian fissure was measured. RESULTS Between 19 and 32 weeks of gestation, 158 measurements in cases and 183 measurements in controls were performed (mean 2.2/subject). The volume growth of the hemicerebrum (R2 = 0.95 vs. 0.95; p = 0.9) and the extracerebral fluid (R2 = 0.84 vs. 0.82, p = 0.9) were similar. Fetuses with abnormal oxygen delivery to the brain have a slightly smaller brain at 20 weeks of gestation (p = 0.02), but this difference disappeared with advancing gestation. CHD cases demonstrated a slightly shallower Sylvian fissure (mean ratio 0.146 vs. 0.153; p = 0.004). CONCLUSIONS Our study shows no differences in cerebral growth, studied in an unselected cohort, with successive cases of isolated CHD. Even in the severest CHD cases, cerebral size is similar in the early third trimester. The cause and meaning of a shallower Sylvian fissure is unclear; possibly, it is a marker for delayed cerebral maturation or it might be an expression of decreasing amount of extracerebral fluid.
Collapse
Affiliation(s)
- F A R Jansen
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands,
| | - E W van Zwet
- Leiden University Medical Centre, Department of Medical Statistics, Leiden, The Netherlands
| | - S M P Everwijn
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - A K K Teunissen
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - L Rozendaal
- Leiden University Medical Centre, Department of Paediatric Cardiology, Leiden, The Netherlands
| | - J M M van Lith
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - N A Blom
- Leiden University Medical Centre, Department of Paediatric Cardiology, Leiden, The Netherlands
| | - M C Haak
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| |
Collapse
|
19
|
Glass TJ, Seed M, Chau V. Congenital Heart Disease. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
20
|
Robinson AJ, Ederies MA. Fetal neuroimaging: an update on technical advances and clinical findings. Pediatr Radiol 2018; 48:471-485. [PMID: 29550864 DOI: 10.1007/s00247-017-3965-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/14/2017] [Accepted: 08/09/2017] [Indexed: 10/17/2022]
Abstract
This paper is based on a literature review from 2011 to 2016. The paper is divided into two main sections. The first section relates to technical advances in fetal imaging techniques, including fetal motion compensation, imaging at 3.0 T, 3-D T2-weighted MRI, susceptibility-weighted imaging, computed tomography, morphometric analysis, diffusion tensor imaging, spectroscopy and fetal behavioral assessment. The second section relates to clinical updates, including cerebral lamination, migrational anomalies, midline anomalies, neural tube defects, posterior fossa anomalies, sulcation/gyration and hypoxic-ischemic insults.
Collapse
Affiliation(s)
- Ashley J Robinson
- Sidra Medical and Research Center, Qatar Foundation, Education City North, Al Luqta Street, Doha, 26999, Qatar. .,Clinical Radiology, Weill-Cornell Medical College, New York, NY, USA.
| | - M Ashraf Ederies
- Sidra Medical and Research Center, Qatar Foundation, Education City North, Al Luqta Street, Doha, 26999, Qatar.,Clinical Radiology, Weill-Cornell Medical College, New York, NY, USA
| |
Collapse
|
21
|
Heye KN, Knirsch W, Latal B, Scheer I, Wetterling K, Hahn A, Akintürk H, Schranz D, Beck I, O´Gorman Tuura R, Reich B. Reduction of brain volumes after neonatal cardiopulmonary bypass surgery in single-ventricle congenital heart disease before Fontan completion. Pediatr Res 2018; 83:63-70. [PMID: 29278641 DOI: 10.1038/pr.2017.203] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 08/10/2017] [Indexed: 11/09/2022]
Abstract
BackgroundLittle is known about the relationship between brain volumes and neurodevelopmental outcome at 2 years of age in children with single-ventricle congenital heart disease (CHD). We hypothesized that reduced brain volumes may be associated with adverse neurodevelopmental outcome.MethodsVolumetric segmentation of cerebral magnetic resonance imaging (MRI) scans was carried out in 44 patients without genetic comorbidities and in 8 controls. Neurodevelopmental outcome was assessed with the Bayley-III scales.ResultsGray matter (GM), deep GM, white matter (WM), and cerebrospinal fluid (CSF) volumes were 611±59, 43±4.5, 277±30, and 16.4 ml, respectively (interquartile range (IQR) 13.1, 23.3 ml). Children undergoing neonatal cardiopulmonary bypass surgery showed smaller deep GM (P=0.005) and WM (P=0.021) volumes. Brain volumes were smaller in patients compared with controls (GM: P=0.017, deep GM: P=0.012, and WM: P=0.015), whereas CSF volumes were greater (P=0.014). Of all intracranial volumes, only CSF volume was associated with neurodevelopmental outcome, accounting for 21% (P=0.011) of variability in the cognitive composite score when combined with common risk factors in a multivariable analysis.ConclusionIncreased CSF volume represents a significant risk factor for neurodevelopmental impairment in children with single-ventricle CHD. Later assessments are warranted to determine the prognostic role of intracranial volumes for long-term outcome.
Collapse
Affiliation(s)
- Kristina N Heye
- Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Walter Knirsch
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital, Zurich, Switzerland
| | - Ianina Scheer
- Department of Diagnostic Imaging, MR-Center, University Children's Hospital, Zurich, Switzerland
| | | | - Andreas Hahn
- Department of Pediatric Neurology, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Hakan Akintürk
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Ingrid Beck
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Zurich, Switzerland
| | - Ruth O´Gorman Tuura
- Department of Diagnostic Imaging, MR-Center, University Children's Hospital, Zurich, Switzerland
| | - Bettina Reich
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| |
Collapse
|
22
|
Mebius MJ, Kooi EMW, Bilardo CM, Bos AF. Brain Injury and Neurodevelopmental Outcome in Congenital Heart Disease: A Systematic Review. Pediatrics 2017; 140:peds.2016-4055. [PMID: 28607205 DOI: 10.1542/peds.2016-4055] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Brain injury during prenatal and preoperative postnatal life might play a major role in neurodevelopmental impairment in infants with congenital heart disease (CHD) who require corrective or palliative surgery during infancy. A systematic review of cerebral findings during this period in relation to neurodevelopmental outcome (NDO), however, is lacking. OBJECTIVE To assess the association between prenatal and postnatal preoperative cerebral findings and NDO in infants with CHD who require corrective or palliative surgery during infancy. DATA SOURCES PubMed, Embase, reference lists. STUDY SELECTION We conducted 3 different searches for English literature between 2000 and 2016; 1 for prenatal cerebral findings, 1 for postnatal preoperative cerebral findings, and 1 for the association between brain injury and NDO. DATA EXTRACTION Two reviewers independently screened sources and extracted data on cerebral findings and neurodevelopmental outcome. Quality of studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. RESULTS Abnormal cerebral findings are common during the prenatal and postnatal preoperative periods. Prenatally, a delay of cerebral development was most common; postnatally, white matter injury, periventricular leukomalacia, and stroke were frequently observed. Abnormal Doppler measurements, brain immaturity, cerebral oxygenation, and abnormal EEG or amplitude-integrated EEG were all associated with NDO. LIMITATIONS Observational studies, different types of CHD with different pathophysiological effects, and different reference values. CONCLUSIONS Prenatal and postnatal preoperative abnormal cerebral findings might play an important role in neurodevelopmental impairment in infants with CHD. Increased awareness of the vulnerability of the young developing brain of an infant with CHD among caregivers is essential.
Collapse
Affiliation(s)
- Mirthe J Mebius
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, Netherlands; and
| | - Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, Netherlands; and
| | - Catherina M Bilardo
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Arend F Bos
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, Netherlands; and
| |
Collapse
|
23
|
Koning IV, Roelants JA, Groenenberg IAL, Vermeulen MJ, Willemsen SP, Reiss IKM, Govaert PP, Steegers-Theunissen RPM, Dudink J. New Ultrasound Measurements to Bridge the Gap between Prenatal and Neonatal Brain Growth Assessment. AJNR Am J Neuroradiol 2017; 38:1807-1813. [PMID: 28663264 DOI: 10.3174/ajnr.a5278] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/24/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Most ultrasound markers for monitoring brain growth can only be used in either the prenatal or the postnatal period. We investigated whether corpus callosum length and corpus callosum-fastigium length could be used as markers for both prenatal and postnatal brain growth. MATERIALS AND METHODS A 3D ultrasound study embedded in the prospective Rotterdam Periconception Cohort was performed at 22, 26 and 32 weeks' gestational age in fetuses with fetal growth restriction, congenital heart defects, and controls. Postnatally, cranial ultrasound was performed at 42 weeks' postmenstrual age. First, reliability was evaluated. Second, associations between prenatal and postnatal corpus callosum and corpus callosum-fastigium length were investigated. Third, we created reference curves and compared corpus callosum and corpus callosum-fastigium length growth trajectories of controls with growth trajectories of fetuses with fetal growth retardation and congenital heart defects. RESULTS We included 199 fetuses; 22 with fetal growth retardation, 20 with congenital heart defects, and 157 controls. Reliability of both measurements was excellent (intraclass correlation coefficient ≥ 0.97). Corpus callosum growth trajectories were significantly decreased in fetuses with fetal growth restriction and congenital heart defects (β = -2.295; 95% CI, -3.320-1.270; P < .01; β = -1.267; 95% CI, -0.972-0.562; P < .01, respectively) compared with growth trajectories of controls. Corpus callosum-fastigium growth trajectories were decreased in fetuses with fetal growth restriction (β = -1.295; 95% CI, -2.595-0.003; P = .05). CONCLUSIONS Corpus callosum and corpus callosum-fastigium length may serve as reliable markers for monitoring brain growth from the prenatal into the postnatal period. The clinical applicability of these markers was established by the significantly different corpus callosum and corpus callosum-fastigium growth trajectories in fetuses at risk for abnormal brain growth compared with those of controls.
Collapse
Affiliation(s)
- I V Koning
- From the Department of Obstetrics and Gynecology (I.V.K., J.A.R., I.A.L.G., S.P.W., R.P.M.S.-T.), Division of Obstetrics and Prenatal Medicine.,Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - J A Roelants
- From the Department of Obstetrics and Gynecology (I.V.K., J.A.R., I.A.L.G., S.P.W., R.P.M.S.-T.), Division of Obstetrics and Prenatal Medicine.,Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - I A L Groenenberg
- From the Department of Obstetrics and Gynecology (I.V.K., J.A.R., I.A.L.G., S.P.W., R.P.M.S.-T.), Division of Obstetrics and Prenatal Medicine
| | - M J Vermeulen
- Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - S P Willemsen
- From the Department of Obstetrics and Gynecology (I.V.K., J.A.R., I.A.L.G., S.P.W., R.P.M.S.-T.), Division of Obstetrics and Prenatal Medicine.,Department of Biostatistics (S.P.W.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - I K M Reiss
- Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - P P Govaert
- Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Neonatology (P.P.G.), ZNA Koningin Paola Ziekenhuis, Antwerp, Belgium
| | - R P M Steegers-Theunissen
- From the Department of Obstetrics and Gynecology (I.V.K., J.A.R., I.A.L.G., S.P.W., R.P.M.S.-T.), Division of Obstetrics and Prenatal Medicine.,Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - J Dudink
- Department of Pediatrics (I.V.K., J.A.R., M.J.V., I.K.M.R., P.P.G., R.P.M.S.-T., J.D.), Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands .,Department of Neonatology (J.D.), Wilhelmina's Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
24
|
Benkarim OM, Sanroma G, Zimmer VA, Muñoz-Moreno E, Hahner N, Eixarch E, Camara O, González Ballester MA, Piella G. Toward the automatic quantification of in utero brain development in 3D structural MRI: A review. Hum Brain Mapp 2017; 38:2772-2787. [PMID: 28195417 DOI: 10.1002/hbm.23536] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/13/2017] [Accepted: 01/25/2017] [Indexed: 11/08/2022] Open
Abstract
Investigating the human brain in utero is important for researchers and clinicians seeking to understand early neurodevelopmental processes. With the advent of fast magnetic resonance imaging (MRI) techniques and the development of motion correction algorithms to obtain high-quality 3D images of the fetal brain, it is now possible to gain more insight into the ongoing maturational processes in the brain. In this article, we present a review of the major building blocks of the pipeline toward performing quantitative analysis of in vivo MRI of the developing brain and its potential applications in clinical settings. The review focuses on T1- and T2-weighted modalities, and covers state of the art methodologies involved in each step of the pipeline, in particular, 3D volume reconstruction, spatio-temporal modeling of the developing brain, segmentation, quantification techniques, and clinical applications. Hum Brain Mapp 38:2772-2787, 2017. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
| | | | | | - Emma Muñoz-Moreno
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Spain.,Experimental 7T MRI Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Nadine Hahner
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Spain
| | - Elisenda Eixarch
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Spain
| | - Oscar Camara
- DTIC, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Gemma Piella
- DTIC, Universitat Pompeu Fabra, Barcelona, Spain
| |
Collapse
|
25
|
Paladini D, Alfirevic Z, Carvalho JS, Khalil A, Malinger G, Martinez JM, Rychik J, Ville Y, Gardiner H. ISUOG consensus statement on current understanding of the association of neurodevelopmental delay and congenital heart disease: impact on prenatal counseling. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:287-288. [PMID: 27891680 DOI: 10.1002/uog.17324] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 06/06/2023]
Affiliation(s)
- D Paladini
- Fetal Medicine & Surgery Unit, Istituto G.Gaslini, Genoa, Italy
| | - Z Alfirevic
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - J S Carvalho
- Fetal Medicine Unit, St George's Hospital and St George's University of London, London, UK
- Centre for Fetal Cardiology, Royal Brompton Hospital, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's Hospital and St George's University of London, London, UK
| | - G Malinger
- OB-GYN Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J M Martinez
- Fetal Medicine, Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Clínic and Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - J Rychik
- Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Y Ville
- Maternité, Hôpital Universitaire Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - H Gardiner
- The Fetal Center, University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
26
|
Delayed cortical gray matter development in neonates with severe congenital heart disease. Pediatr Res 2016; 80:668-674. [PMID: 27434120 DOI: 10.1038/pr.2016.145] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/15/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND This study aimed to assess cortical gray matter growth and maturation in neonates with congenital heart disease (CHD). METHODS Thirty-one (near) term neonates with severe CHD (8 univentricular heart malformation (UVH), 21 d-transposition of great arteries (d-TGA) and 2 aortic coarctation) underwent cerebral MRI before (postnatal-day 7) and after (postnatal-day 24) surgery. Eighteen controls with similar gestational age had one MRI (postnatal-day 23). Cortical gray matter volume (CGM), inner cortical surface (iCS), and median cortical thickness were extracted as measures of volumetric growth, and gyrification index (GI) as measure of maturation. RESULTS Over a median of 18 d, CGM increased by 21%, iCS by 17%, thickness and GI both by 9%. Decreased postoperative CGM and iCS were seen for CHD compared to controls (P values < 0.01), however with similar thickness and GI. UVH showed lower postoperative iCS, thickness (P values < 0.05) and GI (P value < 0.01) than d-TGA and controls. Infants requiring preoperative balloon-atrioseptostomy (BAS, 61%) had reduced postoperative CGM, iCS, and GI (P values < 0.05). CONCLUSION Infants with severe CHD show reduced cortical volumes compared to controls with gyrification being delayed in UVH, but not in d-TGA. Infants requiring BAS show higher risk of impaired cortical volume and gyrification.
Collapse
|
27
|
Khalil A, Thilaganathan B, Carvalho JS. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:539-540. [PMID: 27704671 DOI: 10.1002/uog.16023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's Hospital London, London, UK.
| | - B Thilaganathan
- Fetal Medicine Unit, St George's Hospital London, London, UK
| | - J S Carvalho
- Fetal Medicine Unit, St George's Hospital London, London, UK
| |
Collapse
|
28
|
Khalil A, Bennet S, Thilaganathan B, Paladini D, Griffiths P, Carvalho JS. Prevalence of prenatal brain abnormalities in fetuses with congenital heart disease: a systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:296-307. [PMID: 27062519 DOI: 10.1002/uog.15932] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Studies have shown an association between congenital heart defects (CHDs) and postnatal brain abnormalities and neurodevelopmental delay. Recent evidence suggests that some of these brain abnormalities are present before birth. The primary aim of this study was to perform a systematic review to quantify the prevalence of prenatal brain abnormalities in fetuses with CHDs. METHODS MEDLINE, EMBASE and The Cochrane Library were searched electronically. Reference lists within each article were hand-searched for additional reports. The outcomes observed included structural brain abnormalities (on magnetic resonance imaging (MRI)) and changes in brain volume (on MRI, three-dimensional (3D) volumetric MRI, 3D ultrasound and phase-contrast MRI), brain metabolism or maturation (on magnetic resonance spectroscopy and phase-contrast MRI) and brain blood flow (on Doppler ultrasound, phase-contrast MRI and 3D power Doppler ultrasound) in fetuses with CHDs. Cohort and case-control studies were included and cases of chromosomal or genetic abnormalities, case reports and editorials were excluded. Proportion meta-analysis was used for analysis. Between-study heterogeneity was assessed using the I(2) test. RESULTS The search yielded 1943 citations, and 20 studies (n = 1175 cases) were included in the review. Three studies reported data on structural brain abnormalities, while data on altered brain volume, metabolism and blood flow were reported in seven, three and 14 studies, respectively. The three studies (221 cases) reporting on structural brain abnormalities were suitable for inclusion in a meta-analysis. The prevalence of prenatal structural brain abnormalities in fetuses with CHD was 28% (95% CI, 18-40%), with a similar prevalence (25% (95% CI, 14-39%)) when tetralogy of Fallot was considered alone. These abnormalities included ventriculomegaly (most common), agenesis of the corpus callosum, ventricular bleeding, increased extra-axial space, vermian hypoplasia, white-matter abnormalities and delayed brain development. Fetuses with CHD were more likely than those without CHD to have reduced brain volume, delay in brain maturation and altered brain circulation, most commonly in the form of reduced middle cerebral artery pulsatility index and cerebroplacental ratio. These changes were usually evident in the third trimester, but some studies reported them from as early as the second trimester. CONCLUSION In the absence of known major aneuploidy or genetic syndromes, fetuses with CHD are at increased risk of brain abnormalities, which are discernible prenatally. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University of London, London, UK
| | - S Bennet
- Fetal Medicine Unit, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University of London, London, UK
| | - D Paladini
- Fetal Medicine & Surgery Unit - Istituto G.Gaslini, Genoa, Italy
| | - P Griffiths
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - J S Carvalho
- Fetal Medicine Unit, St George's University of London, London, UK
- Brompton Centre for Fetal Cardiology, Royal Brompton Hospital, London, UK
| |
Collapse
|
29
|
Brossard-Racine M, du Plessis A, Vezina G, Robertson R, Donofrio M, Tworetzky W, Limperopoulos C. Brain Injury in Neonates with Complex Congenital Heart Disease: What Is the Predictive Value of MRI in the Fetal Period? AJNR Am J Neuroradiol 2016; 37:1338-46. [PMID: 26988809 DOI: 10.3174/ajnr.a4716] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/05/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Brain injury in neonates with congenital heart disease is an important predictor of adverse neurodevelopmental outcome. Impaired brain development in congenital heart disease may have a prenatal origin, but the sensitivity and specificity of fetal brain MR imaging for predicting neonatal brain lesions are currently unknown. We sought to determine the value of conventional fetal MR imaging for predicting abnormal findings on neonatal preoperative MR imaging in neonates with complex congenital heart disease. MATERIALS AND METHODS MR imaging studies were performed in 103 fetuses with confirmed congenital heart disease (mean gestational age, 31.57 ± 3.86 weeks) and were repeated postnatally before cardiac surgery (mean age, 6.8 ± 12.2 days). Each MR imaging study was read by a pediatric neuroradiologist. RESULTS Brain abnormalities were detected in 17/103 (16%) fetuses by fetal MR imaging and in 33/103 (32%) neonates by neonatal MR imaging. Only 9/33 studies with abnormal neonatal findings were preceded by abnormal findings on fetal MR imaging. The sensitivity and specificity of conventional fetal brain MR imaging for predicting neonatal brain abnormalities were 27% and 89%, respectively. CONCLUSIONS Brain abnormalities detected by in utero MR imaging in fetuses with congenital heart disease are associated with higher risk of postnatal preoperative brain injury. However, a substantial proportion of anomalies on postnatal MR imaging were not present on fetal MR imaging; this result is likely due to the limitations of conventional fetal MR imaging and the emergence of new lesions that occurred after the fetal studies. Postnatal brain MR imaging studies are needed to confirm the presence of injury before open heart surgery.
Collapse
Affiliation(s)
- M Brossard-Racine
- From the Advanced Pediatric Brain Imaging Research Laboratory (M.B.-R., C.L.) Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., C.L.) Fetal and Transitional Medicine (M.B.-R., A.d.P., C.L.)
| | - A du Plessis
- Fetal and Transitional Medicine (M.B.-R., A.d.P., C.L.)
| | - G Vezina
- Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., C.L.)
| | | | - M Donofrio
- Division of Cardiology (M.D.), Children's National Health System, Washington DC
| | - W Tworetzky
- Cardiology (W.T.), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - C Limperopoulos
- From the Advanced Pediatric Brain Imaging Research Laboratory (M.B.-R., C.L.) Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., C.L.) Fetal and Transitional Medicine (M.B.-R., A.d.P., C.L.)
| |
Collapse
|
30
|
Jansen FAR, Everwijn SMP, Scheepjens R, Stijnen T, Peeters-Scholte CMPCD, van Lith JMM, Haak MC. Fetal brain imaging in isolated congenital heart defects - a systematic review and meta-analysis. Prenat Diagn 2016; 36:601-13. [DOI: 10.1002/pd.4842] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 01/29/2023]
Affiliation(s)
- Fenna A. R. Jansen
- Department of Obstetrics and Fetal Medicine; Leiden University Medical Center; Leiden The Netherlands
| | - Sheila M. P. Everwijn
- Department of Obstetrics and Fetal Medicine; Leiden University Medical Center; Leiden The Netherlands
| | - Robert Scheepjens
- Department of Medical Statistics; Leiden University Medical Center; Leiden The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics; Leiden University Medical Center; Leiden The Netherlands
| | | | - Jan M. M. van Lith
- Department of Obstetrics and Fetal Medicine; Leiden University Medical Center; Leiden The Netherlands
| | - Monique C. Haak
- Department of Obstetrics and Fetal Medicine; Leiden University Medical Center; Leiden The Netherlands
| |
Collapse
|
31
|
Paladini D, Alfirevic Z, Carvalho JS, Khalil A, Malinger G, Martinez JM, Rychik J, Gardiner H. Prenatal counseling for neurodevelopmental delay in congenital heart disease: results of a worldwide survey of experts' attitudes advise caution. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:667-671. [PMID: 26749377 DOI: 10.1002/uog.15852] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 11/21/2015] [Accepted: 12/29/2015] [Indexed: 06/05/2023]
Affiliation(s)
- D Paladini
- Fetal Medicine and Surgery Unit- Istituto G.Gaslini, Genoa, Italy
| | - Z Alfirevic
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - J S Carvalho
- Fetal Medicine Unit, St George's University of London
- Brompton Centre for Fetal Cardiology, Royal Brompton Hospital, London, UK
| | - A Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's Hospital, London, UK
| | - G Malinger
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J M Martinez
- Fetal Medicine, Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Clínic and Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - J Rychik
- Fetal Heart Program, Children's Hospital of Philadelphia, PA, USA
| | - H Gardiner
- The Fetal Center, University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
32
|
Morton PD, Ishibashi N, Jonas RA, Gallo V. Congenital cardiac anomalies and white matter injury. Trends Neurosci 2015; 38:353-63. [PMID: 25939892 PMCID: PMC4461528 DOI: 10.1016/j.tins.2015.04.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/01/2015] [Accepted: 04/02/2015] [Indexed: 12/17/2022]
Abstract
Cardiac abnormalities are the most common birth defects. Derangement of circulatory flow affects many vital organs; without proper supply of oxygenated blood, the brain is particularly vulnerable. Although surgical interventions have greatly reduced mortality rates, patients often suffer an array of neurological deficits throughout life. Neuroimaging provides a macroscopic assessment of brain injury and has shown that white matter (WM) is at risk. Oligodendrocytes and myelinated axons have been identified as major targets of WM injury, but still little is known about how congenital heart anomalies affect the brain at the cellular level. Further integration of animal model studies and clinical research will define novel therapeutic targets and new standards of care to prevent developmental delay associated with cardiac abnormalities.
Collapse
Affiliation(s)
- Paul D Morton
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA
| | - Richard A Jonas
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA
| | - Vittorio Gallo
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA.
| |
Collapse
|
33
|
Brossard-Racine M, du Plessis AJ, Vezina G, Robertson R, Bulas D, Evangelou IE, Donofrio M, Freeman D, Limperopoulos C. Prevalence and spectrum of in utero structural brain abnormalities in fetuses with complex congenital heart disease. AJNR Am J Neuroradiol 2014; 35:1593-9. [PMID: 24651820 DOI: 10.3174/ajnr.a3903] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Brain injury is a major complication in neonates with complex congenital heart disease. Preliminary evidence suggests that fetuses with congenital heart disease are at greater risk for brain abnormalities. However, the nature and frequency of these brain abnormalities detected by conventional fetal MR imaging has not been examined prospectively. Our primary objective was to determine the prevalence and spectrum of brain abnormalities detected on conventional clinical MR imaging in fetuses with complex congenital heart disease and, second, to compare the congenital heart disease cohort with a control group of fetuses from healthy pregnancies. MATERIALS AND METHODS We prospectively recruited pregnant women with a confirmed fetal congenital heart disease diagnosis and healthy volunteers with normal fetal echocardiogram findings who underwent a fetal MR imaging between 18 and 39 weeks gestational age. RESULTS A total of 338 fetuses (194 controls; 144 with congenital heart disease) were studied at a mean gestational age of 30.61 ± 4.67 weeks. Brain abnormalities were present in 23% of the congenital heart disease group compared with 1.5% in the control group (P < .001). The most common abnormalities in the congenital heart disease group were mild unilateral ventriculomegaly in 12/33 (36.4%) and increased extra-axial spaces in 10/33 (30.3%). Subgroup analyses comparing the type and frequency of brain abnormalities based on cardiac physiology did not reveal significant associations, suggesting that the brain abnormalities were not limited to those with the most severe congenital heart disease. CONCLUSIONS This is the first large prospective study reporting conventional MR imaging findings in fetuses with congenital heart disease. Our results suggest that brain abnormalities are prevalent but relatively mild antenatally in fetuses with congenital heart disease. The long-term predictive value of these findings awaits further study.
Collapse
Affiliation(s)
- M Brossard-Racine
- From the Advanced Pediatric Brain Imaging Research Laboratory (M.B.-R., I.E.E., D.F., C.L.)Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., D.B., I.E.E., D.F., C.L.)Fetal and Transitional Medicine (M.B.-R., A.d.P., M.D., C.L.)
| | - A J du Plessis
- Fetal and Transitional Medicine (M.B.-R., A.d.P., M.D., C.L.)
| | - G Vezina
- Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., D.B., I.E.E., D.F., C.L.)
| | - R Robertson
- Department of Radiology (R.R.), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - D Bulas
- Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., D.B., I.E.E., D.F., C.L.)
| | - I E Evangelou
- From the Advanced Pediatric Brain Imaging Research Laboratory (M.B.-R., I.E.E., D.F., C.L.)Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., D.B., I.E.E., D.F., C.L.)
| | - M Donofrio
- Fetal and Transitional Medicine (M.B.-R., A.d.P., M.D., C.L.)Division of Cardiology (M.D.), Children's National Medical Center, Washington DC
| | - D Freeman
- From the Advanced Pediatric Brain Imaging Research Laboratory (M.B.-R., I.E.E., D.F., C.L.)Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., D.B., I.E.E., D.F., C.L.)
| | - C Limperopoulos
- From the Advanced Pediatric Brain Imaging Research Laboratory (M.B.-R., I.E.E., D.F., C.L.)Division of Diagnostic Imaging and Radiology (M.B.-R., G.V., D.B., I.E.E., D.F., C.L.)Fetal and Transitional Medicine (M.B.-R., A.d.P., M.D., C.L.)
| |
Collapse
|