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Machie M, de Vries LS, Inder T. Advances in Neuroimaging Biomarkers and Scoring. Clin Perinatol 2024; 51:629-647. [PMID: 39095101 DOI: 10.1016/j.clp.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
MRI of the brain is a critical tool in the diagnosis, evaluation, and management of neonatal encephalopathy (NE). More than simply a diagnostic and prognostic tool, MRI informs the biology, nature, and timing of the disease process resulting in NE, of which the largest single etiology is hypoxic-ischemic encephalopathy (HIE). Historically, 2 major patterns of injury were seen in HIE: a basal ganglia/thalamus predominant pattern and a watershed pattern of injury. The advent of therapeutic hypothermia for NE/HIE, alongside improvements in the application of imaging technology in newborn infants, has resulted in progressively more advanced MRI scoring systems.
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Affiliation(s)
- Michelle Machie
- Division of Pediatric Neurology, Department of Pediatrics, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
| | - Linda S de Vries
- Department of Neonatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Womens Hospital; Children's Hospital of Orange County, University of California Irvine, 1201 W. La Veta, Orange, CA 92868, USA
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Turner MJ, Rumpel JA, Spray BJ, Stence N, Neuberger I, Frymoyer A, Chock VY, Courtney S, Gist K. Urine biomarkers of acute kidney injury and association with brain MRI abnormalities in neonatal hypoxic-ischemic encephalopathy. J Perinatol 2024; 44:1203-1207. [PMID: 38509202 DOI: 10.1038/s41372-024-01937-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE Determine whether urine biomarkers NGAL (neutrophil gelatinase-associated lipocalin), KIM-1 (kidney injury molecule 1) and IL-18 (interleukin-18) are associated with abnormal MRI findings in neonates with hypoxic-ischemic encephalopathy (HIE) who underwent therapeutic hypothermia (TH). STUDY DESIGN Secondary analysis of a multicenter, prospective study of neonates with HIE requiring TH. Urine biomarkers were obtained at 12 and 24 h of life (HOL). Brain MRI was scored per NICHD criteria. Association between biomarkers and MRI stage was determined. RESULTS In 57 neonates with HIE, only IL-18 at 24 HOL was significantly increased in neonates with MRI Stage 2B or greater, compared to Stage 2A or less (mean 398.7 vs. 182.9 pg/mL, p = 0.024.) A multivariate model including IL-18 at 24 HOL and 5-min Apgar performed best, with an AUC of 0.84 (SE = 0.07, p = 0.02). CONCLUSIONS Elevated urine IL-18 at 24 HOL was associated with more severe brain MRI abnormalities among neonates with HIE.
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Affiliation(s)
- Megan J Turner
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Pediatrics, Denver Health Medical Center, Denver, CO, USA.
| | | | - Beverly J Spray
- Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Nicholas Stence
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ilana Neuberger
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam Frymoyer
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sherry Courtney
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Katja Gist
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Damien J, Vannasing P, Tremblay J, Petitpas L, Marandyuk B, Balasingam T, El Jalbout R, Paquette N, Donofrio G, Birca A, Gallagher A, Pinchefsky EF. Relationship between EEG spectral power and dysglycemia with neurodevelopmental outcomes after neonatal encephalopathy. Clin Neurophysiol 2024; 163:160-173. [PMID: 38754181 DOI: 10.1016/j.clinph.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/28/2024] [Accepted: 03/23/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE We investigated how electroencephalography (EEG) quantitative measures and dysglycemia relate to neurodevelopmental outcomes following neonatal encephalopathy (NE). METHODS This retrospective study included 90 neonates with encephalopathy who received therapeutic hypothermia. EEG absolute spectral power was calculated during post-rewarming and 2-month follow-up. Measures of dysglycemia (hypoglycemia, hyperglycemia, and glycemic lability) and glucose variability were computed for the first 48 h of life. We evaluated the ability of EEG and glucose measures to predict neurodevelopmental outcomes at ≥ 18 months, using logistic regressions (with area under the receiver operating characteristic [AUROC] curves). RESULTS The post-rewarming global delta power (average all electrodes), hyperglycemia and glycemic lability predicted moderate/severe neurodevelopmental outcome separately (AUROC = 0.8, 95%CI [0.7,0.9], p < .001) and even more so when combined (AUROC = 0.9, 95%CI [0.8,0.9], p < .001). After adjusting for NE severity and magnetic resonance imaging (MRI) brain injury, only global delta power remained significantly associated with moderate/severe neurodevelopmental outcome (odds ratio [OR] = 0.9, 95%CI [0.8,1.0], p = .04), gross motor delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), global developmental delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), and auditory deficits (OR = 0.9, 95%CI [0.8,1.0], p = .03). CONCLUSIONS In NE, global delta power post-rewarming was predictive of outcomes at ≥ 18 months. SIGNIFICANCE EEG markers post-rewarming can aid prediction of neurodevelopmental outcomes following NE.
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Affiliation(s)
- Janie Damien
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Phetsamone Vannasing
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Julie Tremblay
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Laurence Petitpas
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Bohdana Marandyuk
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Thameya Balasingam
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Ramy El Jalbout
- Department of Radiology, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Natacha Paquette
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Gianluca Donofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Ala Birca
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Anne Gallagher
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Elana F Pinchefsky
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
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Cascant-Vilaplana MM, Piñeiro-Ramos JD, Soláz-García Á, Lara-Cantón I, Izquierdo I, Llorens R, Marin P, Torres-Martínez E, Molitor C, Mohareb F, Boronat N, Quintás G, Kuligowski J, Vento M. Searching molecular biomarkers correlating with BSID-III at 24 months in infants with neonatal hypoxic-ischemic encephalopathy. Eur J Pediatr 2024:10.1007/s00431-024-05652-x. [PMID: 38916739 DOI: 10.1007/s00431-024-05652-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/06/2024] [Accepted: 06/12/2024] [Indexed: 06/26/2024]
Abstract
An early prediction of outcomes of neonatal hypoxic-ischemic encephalopathy (NE) is of key importance in reducing neonatal mortality and morbidity. The objectives were (i) to analyze the characteristics of miRNA expression and metabolic patterns of neonates with NE and (ii) to assess their predictive performance for neurodevelopmental outcomes. Plasma samples from moderate/severe NE patients (N = 92) of the HYPOTOP study were collected before, during, and after therapeutic hypothermia (TH) and compared to a control group (healthy term infants). The expression of miRNAs and concentrations of metabolites (hypoxia-related and energy, steroid, and tryptophan metabolisms) were analyzed. Neurodevelopmental outcomes were evaluated at 24 months postnatal age using Bayley Scales of Infant Development, ed. III, BSID-III. Differences in miRNA and metabolic profiles were found between NE vs. control infants, abnormal (i.e., mildly and moderately abnormal and severe) vs. normal, and severe vs. non-severe (i.e., normal and mildly and moderately abnormal) BSID-III. 4-Androstene-3,17-dione, testosterone, betaine, xanthine, and lactate were suitable for BSID-III outcome prediction (receiver operating characteristic areas under the curve (AUCs) ≥ 0.6), as well as 68 miRNAs (AUCs of 0.5-0.9). Significant partial correlations of xanthine and betaine levels and the expression of several miRNAs with BSID-III sub-scales were found. Conclusion: We have identified metabolites/miRNAs that might be useful to support the prediction of middle-term neurodevelopmental outcomes of NE. What is known and what is new: • The early prediction of outcomes of neonatal hypoxic-ischemic encephalopathy (NE) is of key importance in reducing neonatal mortality and morbidity. • Alterations of the metabolome and miRNAs had been observed in NE. • We performed miRNA sequencing and quantified selected metabolites (i.e., lactate, pyruvate, ketone bodies, Krebs cycle intermediates, tryptophan pathway, hypoxia-related metabolites, and steroids) by GC- and LC-MS. • Specific miRNAs and metabolites that allow prediction of middle-term neurodevelopmental outcomes of newborns with NE undergoing hypothermia treatment were identified.
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Affiliation(s)
| | | | - Álvaro Soláz-García
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
- Division of Neonatology, University & Polytechnic Hospital La Fe, Valencia, Spain
| | | | - Isabel Izquierdo
- Division of Neonatology, University & Polytechnic Hospital La Fe, Valencia, Spain
| | - Roberto Llorens
- Division of Radiology and Imaging, University & Polytechnic Hospital La Fe, Valencia, Spain
| | - Purificación Marin
- Division of Neonatology, University & Polytechnic Hospital La Fe, Valencia, Spain
| | | | - Corentin Molitor
- The Bioinformatics Group, School of Water, Energy and Environment, Cranfield University, Bedford, UK
| | - Fady Mohareb
- The Bioinformatics Group, School of Water, Energy and Environment, Cranfield University, Bedford, UK
| | - Nuria Boronat
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
- Division of Neonatology, University & Polytechnic Hospital La Fe, Valencia, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS-SAMID) (RD21/0012/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Quintás
- Health and Biomedicine, Leitat Technological Center, Valencia, Spain
| | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain.
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS-SAMID) (RD21/0012/0001), Instituto de Salud Carlos III, Madrid, Spain.
| | - Máximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
- Division of Neonatology, University & Polytechnic Hospital La Fe, Valencia, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS-SAMID) (RD21/0012/0001), Instituto de Salud Carlos III, Madrid, Spain
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Hung SC, Tu YF, Hunter SE, Guimaraes C. MRI predictors of long-term outcomes of neonatal hypoxic ischaemic encephalopathy: a primer for radiologists. Br J Radiol 2024; 97:1067-1077. [PMID: 38407350 DOI: 10.1093/bjr/tqae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024] Open
Abstract
This review aims to serve as a foundational resource for general radiologists, enhancing their understanding of the role of Magnetic Resonance Imaging (MRI) in early prognostication for newborns diagnosed with hypoxic ischaemic encephalopathy (HIE). The article explores the application of MRI as a predictive instrument for determining long-term outcomes in newborns affected by HIE. With HIE constituting a leading cause of neonatal mortality and severe long-term neurodevelopmental impairments, early identification of prognostic indicators is crucial for timely intervention and optimal clinical management. We examine current literature and recent advancements to provide an in-depth overview of MRI predictors, encompassing brain injury patterns, injury scoring systems, spectroscopy, and diffusion imaging. The potential of these MRI biomarkers in predicting long-term neurodevelopmental outcomes and the probability of epilepsy is also discussed.
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Affiliation(s)
- Sheng-Che Hung
- Department of Radiology, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, United States
| | - Yi-Fang Tu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Senyene E Hunter
- Department of Neurology, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC 27599-7025, United States
| | - Carolina Guimaraes
- Department of Radiology, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, United States
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Zhao H, Cai H, Liu M. Transformer based multi-modal MRI fusion for prediction of post-menstrual age and neonatal brain development analysis. Med Image Anal 2024; 94:103140. [PMID: 38461655 DOI: 10.1016/j.media.2024.103140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/23/2023] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
The brain development during the perinatal period is characterized by rapid changes in both structure and function, which have significant impact on the cognitive and behavioral abilities later in life. Accurate assessment of brain age is a crucial indicator for brain development maturity and can help predict the risk of neonatal pathology. However, evaluating neonatal brains using magnetic resonance imaging (MRI) is challenging due to its complexity, multi-dimension, and noise with subtle alterations. In this paper, we propose a multi-modal deep learning framework based on transformers for precise post-menstrual age (PMA) estimation and brain development analysis using T2-weighted structural MRI (T2-sMRI) and diffusion MRI (dMRI) data. First, we build a two-stream dense network to learn modality-specific features from T2-sMRI and dMRI of brain individually. Then, a transformer module based on self-attention mechanism integrates these features for PMA prediction and preterm/term classification. Finally, saliency maps on brain templates are used to enhance the interpretability of results. Our method is evaluated on the multi-modal MRI dataset of the developing Human Connectome Project (dHCP), which contains 592 neonates, including 478 term-born and 114 preterm-born subjects. The results demonstrate that our method achieves a 0.5-week mean absolute error (MAE) in PMA estimation for term-born subjects. Notably, preterm-born subjects exhibit delayed brain development, worsening with increasing prematurity. Our method also achieves 95% accuracy in classification of term-born and preterm-born subjects, revealing significant group differences.
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Affiliation(s)
- Haiyan Zhao
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Hongjie Cai
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Manhua Liu
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China; MoE Key Lab of Artificial Intelligence, AI Institute, Shanghai, China.
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Sakpichaisakul K, El-Dib M, Munster C, Supapannachart KJ, Yang E, Walsh BH, Volpe JJ, Inder TE. Amplitude-Integrated Electroencephalography Evolution and Magnetic Resonance Imaging Injury in Mild and Moderate to Severe Neonatal Encephalopathy. Am J Perinatol 2024; 41:e2463-e2473. [PMID: 37369240 DOI: 10.1055/a-2118-2953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVE This study aimed to describe the evolution of amplitude-integrated electroencephalography (aEEG) in neonatal encephalopathy (NE) during therapeutic hypothermia (TH) and evaluate the association between aEEG parameters and magnetic resonance imaging (MRI) injury. STUDY DESIGN aEEG data of infants who underwent TH were reviewed for background, sleep wake cycling (SWC), and seizures. Conventional electroencephalography (cEEG) background was assessed from the reports. Discordance of background on aEEG and cEEG was defined if there was a difference in the severity of the background. MRI injury (total score ≥ 5) was assessed by using the Weeke scoring system. RESULTS A total of 46 infants were included; 23 (50%) with mild NE and 23 (50%) with moderate to severe NE. Comparing mild NE with moderate to severe NE, the initial aEEG background differed with more mild being continuous (70 vs. 52%), with fewer being discontinuous (0 vs. 22%) and flat tracing (0 vs. 4%), whereas burst suppression (4 vs. 4%) and low voltage (26 vs. 18%) did not differ. There was a notably common discordance between the background assessment on cEEG with aEEG in 82% with continuous and 40% low voltage aEEG background. MRI abnormalities were identified in four infants with mild NE and seven infants with moderate to severe NE. MRI injury was associated with aEEG seizures in infants with moderate to severe NE. CONCLUSION aEEG seizures are useful to predict MRI injury in moderate to severe NE infants. There is a large discrepancy between aEEG, cEEG, and MRI in neonates treated by TH. KEY POINTS · MRI injury was identified in 29% of moderate NE infants and in 50% of severe NE infants.. · aEEG seizures were associated with MRI injury in the moderate to severe NE infants.. · MRI injury was identified in 16% infants with mild NE.. · Mild NE infants with normal aEEG were unlikely to have MRI injury.. · There was a large discrepancy between aEEG, cEEG, and MRI in infants treated by TH..
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Affiliation(s)
- Kullasate Sakpichaisakul
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Division of Neurology, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chelsea Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Krittin J Supapannachart
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brain H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Joseph J Volpe
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Christensen R, de Vries LS, Cizmeci MN. Neuroimaging to guide neuroprognostication in the neonatal intensive care unit. Curr Opin Pediatr 2024; 36:190-197. [PMID: 37800448 DOI: 10.1097/mop.0000000000001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW Neurological problems are common in infants admitted to the neonatal intensive care unit (NICU). Various neuroimaging modalities are available for neonatal brain imaging and are selected based on presenting problem, timing and patient stability. RECENT FINDINGS Neuroimaging findings, taken together with clinical factors and serial neurological examination can be used to predict future neurodevelopmental outcomes. In this narrative review, we discuss neonatal neuroimaging modalities, and how these can be optimally utilized to assess infants in the NICU. We will review common patterns of brain injury and neurodevelopmental outcomes in hypoxic-ischemic encephalopathy, perinatal arterial ischemic stroke and preterm brain injury. SUMMARY Timely and accurate neuroprognostication can identify infants at risk for neurodevelopmental impairment and allow for early intervention and targeted therapies to improve outcomes.
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Affiliation(s)
- Rhandi Christensen
- Division of Neurology, The Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Linda S de Vries
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mehmet N Cizmeci
- Division of Neonatology, The Hospital for Sick Children and the University of Toronto, Toronto, Canada
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Jackson W, Gonzalez D, Greenberg RG, Lee YZ, Laughon MM. A phase I trial of caffeine to evaluate safety in infants with hypoxic-ischemic encephalopathy. J Perinatol 2024; 44:508-512. [PMID: 37587184 PMCID: PMC10869636 DOI: 10.1038/s41372-023-01752-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Caffeine provides neuroprotection following hypoxic-ischemic injury in animals. We characterized the safety of escalating doses of caffeine in infants with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia. STUDY DESIGN Phase I trial of infants undergoing therapeutic hypothermia for HIE receiving IV caffeine 20 mg/kg followed by up to two daily doses of 5 mg/kg (n = 9) or 10 mg/kg (n = 8). Safety was evaluated based on adverse events and frequency of pre-specified outcomes compared to data from the Whole-Body Hypothermia for HIE trial (Shankaran, 2005). RESULTS Twelve of 17 (71%) infants had ≥1 adverse event during the study period. The frequency of clinical outcomes related to HIE were not statistically different from outcomes in infants receiving hypothermia in the Whole-Body Hypothermia for HIE trial. CONCLUSION Caffeine administration was well tolerated. A larger study is required to determine the optimal dose and evaluate drug safety and efficacy. CLINICAL TRIAL ClinicalTrials.gov Identifier: NCT03913221.
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Affiliation(s)
- Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Yueh Z Lee
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew M Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Im SA, Tomita E, Oh MY, Kim SY, Kang HM, Youn YA. Volumetric changes in brain MRI of infants with hypoxic-ischemic encephalopathy and abnormal neurodevelopment who underwent therapeutic hypothermia. Brain Res 2024; 1825:148703. [PMID: 38101694 DOI: 10.1016/j.brainres.2023.148703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) is a severe neonatal complication that can result in 40-60 % of long-term morbidity. Magnetic Resonance Imaging (MRI) is a noninvasive method which is usually performed before discharge to visually assess acquired cerebral lesions associated with HIE and severity of lesions possibly providing a guide for detecting adverse outcomes. This study aims to evaluate the impact of HIE on brain volume changes observed in MRI scans performed at a mean 10 days of life, which can serve as a prognostic indicator for abnormal neurodevelopmental (ND) outcomes at 18-24 months among HIE infants. METHODS We retrospectively identified a cohort of HIE patients between June 2013 and March 2017. The inclusion criteria for therapeutic hypothermia (TH) were a gestational age ≥35 weeks, a birth weight ≥1800 g, and the presence of ≥ moderate HIE. Brain MRI was performed at a mean 10 days of life and brain volumes (total brain volume, cerebral volume, cerebellar volume, brain stem volume, and ventricle volume) were measured for quantitative assessment. At 18-24 months, the infants returned for follow-up evaluations, during which their cognitive, language, and motor skills were assessed using the Bayley Scales of Infant and Toddler Development III. RESULTS The study recruited a total of 240 infants between 2013 and 2017 for volumetric brain MRI evaluation. Among these, 83 were normal control infants, 107 were TH-treated HIE infants and 37 were HIE infants who did not receive TH due to contraindications. Clinical evaluation was further proceeded. We compared the brain volumes between the normal control infants (n = 83) with normal ND but TH-treated HIE infants (n = 76), abnormal ND TH-treated HIE infants (n = 31), and the severe HIE MRI group with no TH (n = 37). The abnormal ND TH-treated HIE infants demonstrated a significant decrease in brainstem volume and an increase in ventricle size (p < 0.001) (Table 4). Lastly, the severe brain MRI group who did not receive TH showed significantly smaller brain stem (p = 0.006), cerebellar (p = 0.006) and cerebrum volumes (p = 0.027), accompanied by larger ventricular size (p = 0.013) compared to the normal control group (Table 5). CONCLUSION In addition to assessing the location of brain injuries in MRI scans, the reduction in brain stem volume coupled with an increase in ventricular volume in HIE infants may serve as a biomarker indicating severe HIE and adverse long-term ND outcomes among HIE infants who either received therapeutic hypothermia (TH) treatment or not.
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Affiliation(s)
- Soo-Ah Im
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Emi Tomita
- Artificial Intelligence Research Center, JLK Inc, Republic of Korea
| | - Moon Yeon Oh
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sae Yun Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Mi Kang
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Ah Youn
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Shevtsova Y, Starodubtseva N, Tokareva A, Goryunov K, Sadekova A, Vedikhina I, Ivanetz T, Ionov O, Frankevich V, Plotnikov E, Sukhikh G, Zorov D, Silachev D. Metabolite Biomarkers for Early Ischemic-Hypoxic Encephalopathy: An Experimental Study Using the NeoBase 2 MSMS Kit in a Rat Model. Int J Mol Sci 2024; 25:2035. [PMID: 38396712 PMCID: PMC10888647 DOI: 10.3390/ijms25042035] [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: 12/04/2023] [Revised: 02/01/2024] [Accepted: 02/03/2024] [Indexed: 02/25/2024] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is one of the most common causes of childhood disability. Hypothermic therapy is currently the only approved neuroprotective approach. However, early diagnosis of HIE can be challenging, especially in the first hours after birth when the decision to use hypothermic therapy is critical. Distinguishing HIE from other neonatal conditions, such as sepsis, becomes a significant problem in diagnosis. This study explored the utility of a metabolomic-based approach employing the NeoBase 2 MSMS kit to diagnose HIE using dry blood stains in a Rice-Vannucci model of HIE in rats. We evaluated the diagnostic fidelity of this approach in a range between 3 and 6 h after the onset of HIE, including in the context of systemic inflammation and concomitant hypothermic therapy. Discriminant analysis revealed several metabolite patterns associated with HIE. A logistic regression model using glycine levels achieved high diagnostic fidelity with areas under the receiver operating characteristic curve of 0.94 at 3 h and 0.96 at 6 h after the onset of HIE. In addition, orthogonal partial least squares discriminant analysis, which included five metabolites, achieved 100% sensitivity and 80% specificity within 3 h of HIE. These results highlight the significant potential of the NeoBase 2 MSMS kit for the early diagnosis of HIE and could improve patient management and outcomes in this serious illness.
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Affiliation(s)
- Yulia Shevtsova
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Natalia Starodubtseva
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- Moscow Institute of Physics and Technology, 141700 Moscow, Russia
| | - Alisa Tokareva
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Kirill Goryunov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Alsu Sadekova
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Irina Vedikhina
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Tatiana Ivanetz
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Oleg Ionov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Vladimir Frankevich
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Egor Plotnikov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Gennady Sukhikh
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Dmitry Zorov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Denis Silachev
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
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12
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Russ JB, Ostrem BEL. Acquired Brain Injuries Across the Perinatal Spectrum: Pathophysiology and Emerging Therapies. Pediatr Neurol 2023; 148:206-214. [PMID: 37625929 DOI: 10.1016/j.pediatrneurol.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/29/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
The development of the central nervous system can be directly disrupted by a variety of acquired factors, including infectious, inflammatory, hypoxic-ischemic, and toxic insults. Influences external to the fetus also impact neurodevelopment, including placental health, maternal comorbidities, adverse experiences, environmental exposures, and social determinants of health. Acquired perinatal brain insults tend to affect the developing brain in a stage-specific manner that reflects the susceptible cell types, developmental processes, and risk factors present at the time of the insult. In this review, we discuss the pathophysiology, neurodevelopmental outcomes, and management of common acquired perinatal brain conditions. In the fetal brain, we divide insults based on trimester, and in the postnatal brain, we focus on common pathologies that have a presentation dependent on gestational age at birth: white matter injury and germinal matrix hemorrhage/intraventricular hemorrhage in preterm infants and hypoxic-ischemic encephalopathy in term infants. Although specific treatments for fetal and newborn brain disorders are currently limited, we emphasize therapies in preclinical or early clinical phases of the development pipeline. The growing number of novel cell type- and stage-specific emerging therapies suggests that in the near future we may have a dramatically improved ability to treat acquired perinatal brain disorders and to mitigate the associated neurodevelopmental consequences.
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Affiliation(s)
- Jeffrey B Russ
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Bridget E L Ostrem
- Department of Neurology, University of California, San Francisco, San Francisco, California.
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13
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Cawley P, Padormo F, Cromb D, Almalbis J, Marenzana M, Teixeira R, Uus A, O’Muircheartaigh J, Williams SC, Counsell SJ, Arichi T, Rutherford MA, Hajnal JV, Edwards AD. Development of neonatal-specific sequences for portable ultralow field magnetic resonance brain imaging: a prospective, single-centre, cohort study. EClinicalMedicine 2023; 65:102253. [PMID: 38106560 PMCID: PMC10725077 DOI: 10.1016/j.eclinm.2023.102253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 12/19/2023] Open
Abstract
Background Magnetic Resonance (MR) imaging is key for investigation of suspected newborn brain abnormalities. Access is limited in low-resource settings and challenging in infants needing intensive care. Portable ultralow field (ULF) MRI is showing promise in bedside adult brain imaging. Use in infants and children has been limited as brain-tissue composition differences necessitate sequence modification. The aim of this study was to develop neonatal-specific ULF structural sequences and test these across a range of gestational maturities and pathologies to inform future validation studies. Methods Prospective cohort study within a UK neonatal specialist referral centre. Infants undergoing 3T MRI were recruited for paired ULF (64mT) portable MRI by convenience sampling from the neonatal unit and post-natal ward. Key inclusion criteria: 1) Infants with risk or suspicion of brain abnormality, or 2) preterm and term infants without suspicion of major genetic, chromosomal or neurological abnormality. Exclusions: presence of contra-indication for MR scanning. ULF sequence parameters were optimised for neonatal brain-tissues by iterative and explorative design. Neuroanatomic and pathologic features were compared by unblinded review, informing optimisation of subsequent sequence generations in a step-wise manner. Main outcome: visual identification of healthy and abnormal brain tissues/structures. ULF MR spectroscopy, diffusion, susceptibility weighted imaging, arteriography, and venography require pre-clinical technical development and have not been tested. Findings Between September 23, 2021 and October 25, 2022, 102 paired scans were acquired in 87 infants; 1.17 paired scans per infant. Median age 9 days, median postmenstrual age 40+2 weeks (range: 31+3-53+4). Infants had a range of intensive care requirements. No adverse events observed. Optimised ULF sequences can visualise key neuroanatomy and brain abnormalities. In finalised neonatal sequences: T2w imaging distinguished grey and white matter (7/7 infants), ventricles (7/7), pituitary tissue (5/7), corpus callosum (7/7) and optic nerves (7/7). Signal congruence was seen within the posterior limb of the internal capsule in 10/11 infants on finalised T1w scans. In addition, brain abnormalities visualised on ULF optimised sequences have similar MR signal patterns to 3T imaging, including injury secondary to infarction (6/6 infants on T2w scans), hypoxia-ischaemia (abnormal signal in basal ganglia, thalami and white matter 2/2 infants on T2w scans, cortical highlighting 1/1 infant on T1w scan), and congenital malformations: polymicrogyria 3/3, absent corpus callosum 2/2, and vermian hypoplasia 3/3 infants on T2w scans. Sequences are susceptible to motion corruption, noise, and ULF artefact. Non-identified pathologies were small or subtle. Interpretation On unblinded review, optimised portable MR can provide sufficient contrast, signal, and resolution for neuroanatomical identification and detection of a range of clinically important abnormalities. Blinded validation studies are now warranted. Funding The Bill and Melinda Gates Foundation, the MRC, the Wellcome/EPSRC Centre for Medical Engineering, the MRC Centre for Neurodevelopmental Disorders, and the National Institute for Health Research (NIHR) Biomedical Research Centres based at Guy's and St Thomas' and South London & Maudsley NHS Foundation Trusts and King's College London.
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Affiliation(s)
- Paul Cawley
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Neonatal Intensive Care Unit, Evelina Children’s Hospital London, St Thomas’ Hospital, 6th Floor North Wing, Westminster Bridge Road, London SE1 7EH, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SE1 1UL, UK
| | - Francesco Padormo
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Medical Physics, Guy’s & St. Thomas' NHS Foundation Trust, London, UK
- Hyperfine, Inc., 351 New Whitfield St., Guilford, Connecticut 06437, USA
| | - Daniel Cromb
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Neonatal Intensive Care Unit, Evelina Children’s Hospital London, St Thomas’ Hospital, 6th Floor North Wing, Westminster Bridge Road, London SE1 7EH, UK
| | - Jennifer Almalbis
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Neonatal Intensive Care Unit, Evelina Children’s Hospital London, St Thomas’ Hospital, 6th Floor North Wing, Westminster Bridge Road, London SE1 7EH, UK
| | - Massimo Marenzana
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Rui Teixeira
- Hyperfine, Inc., 351 New Whitfield St., Guilford, Connecticut 06437, USA
| | - Alena Uus
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Jonathan O’Muircheartaigh
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SE1 1UL, UK
- Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Steven C.R. Williams
- Centre for Neuroimaging Sciences, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Serena J. Counsell
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Tomoki Arichi
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SE1 1UL, UK
- Paediatric Neurosciences, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Mary A. Rutherford
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SE1 1UL, UK
| | - Joseph V. Hajnal
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - A. David Edwards
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Neonatal Intensive Care Unit, Evelina Children’s Hospital London, St Thomas’ Hospital, 6th Floor North Wing, Westminster Bridge Road, London SE1 7EH, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SE1 1UL, UK
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14
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Wu YW, Monsell SE, Glass HC, Wisnowski JL, Mathur AM, McKinstry RC, Bluml S, Gonzalez FF, Comstock BA, Heagerty PJ, Juul SE. How well does neonatal neuroimaging correlate with neurodevelopmental outcomes in infants with hypoxic-ischemic encephalopathy? Pediatr Res 2023; 94:1018-1025. [PMID: 36859442 PMCID: PMC10444609 DOI: 10.1038/s41390-023-02510-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND In newborns with hypoxic-ischemic encephalopathy (HIE), the correlation between neonatal neuroimaging and the degree of neurodevelopmental impairment (NDI) is unclear. METHODS Infants with HIE enrolled in a randomized controlled trial underwent neonatal MRI/MR spectroscopy (MRS) using a harmonized protocol at 4-6 days of age. The severity of brain injury was measured with a validated scoring system. Using proportional odds regression, we calculated adjusted odds ratios (aOR) for the associations between MRI/MRS measures of injury and primary ordinal outcome (i.e., normal, mild NDI, moderate NDI, severe NDI, or death) at age 2 years. RESULTS Of 451 infants with MRI/MRS at a median age of 5 days (IQR 4.5-5.8), outcomes were normal (51%); mild (12%), moderate (14%), severe NDI (13%); or death (9%). MRI injury score (aOR 1.06, 95% CI 1.05, 1.07), severe brain injury (aOR 39.6, 95% CI 16.4, 95.6), and MRS lactate/n-acetylaspartate (NAA) ratio (aOR 1.6, 95% CI 1.4,1.8) were associated with worse primary outcomes. Infants with mild/moderate MRI brain injury had similar BSID-III cognitive, language, and motor scores as infants with no injury. CONCLUSION In the absence of severe injury, brain MRI/MRS does not accurately discriminate the degree of NDI. Given diagnostic uncertainty, families need to be counseled regarding a range of possible neurodevelopmental outcomes. IMPACT Half of all infants with hypoxic-ischemic encephalopathy (HIE) enrolled in a large clinical trial either died or had neurodevelopmental impairment at age 2 years despite receiving therapeutic hypothermia. Severe brain injury and a global pattern of brain injury on MRI were both strongly associated with death or neurodevelopmental impairment. Infants with mild or moderate brain injury had similar mean BSID-III cognitive, language, and motor scores as infants with no brain injury on MRI. Given the prognostic uncertainty of brain MRI among infants with less severe degrees of brain injury, families should be counseled regarding a range of possible neurodevelopmental outcomes.
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Affiliation(s)
- Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Hannah C Glass
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology, University of California San Francisco, San Francisco, CA, USA
| | - Jessica L Wisnowski
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington Univ School of Medicine, St. Louis, MO, USA
| | - Stefan Bluml
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Radiology, University of Southern CA Keck School of Medicine, Los Angeles, CA, USA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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15
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Garvey AA, El-Shibiny H, Yang E, Inder TE, El-Dib M. Differences between early and late MRI in infants with neonatal encephalopathy following therapeutic hypothermia. Pediatr Res 2023; 94:1011-1017. [PMID: 37024670 DOI: 10.1038/s41390-023-02580-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND MRI is the gold standard test to define brain injury in infants with neonatal encephalopathy(NE). As imaging findings evolve considerably over the first week, early imaging may not fully reflect the final nature of the injury. This study aimed to compare day 4 versus second week MRI in infants with NE. METHODS Retrospective cohort study including infants who received therapeutic hypothermia(TH) for NE and had two MRIs: early (≤7days) and late (>7days). MRIs were clinically reported and also reviewed by study investigators. RESULTS 94infants with NE were included (40mild,49moderate,5severe). Twenty-four infants(26%) had a normal early scan of which 3/24(13%) had injury noted on repeat MRI. Seventy infants(74%) had abnormal findings noted on early MRI, of which 4/70(6%) had further evolution of injury while 11/70(16%) had complete resolution of findings. Applying a grading system resulted in a change of grade in 7 infants. CONCLUSION In infants who received TH for NE, 19% had changes noted between their early and late MRIs. While the impact on predicting neurodevelopmental outcome was not studied, relying solely on early MRI may overestimate injury in a proportion of infants and miss injury in others. Combining early and late MRI allows for better characterization of injury. IMPACT MRI is the gold standard tool to define brain injury in infants with NE, however, imaging findings evolve considerably over the first week of life. Most centers perform a single MRI on day 4 after rewarming. In our cohort, 19% of infants had a notable change in their MRI findings between early (within the first week) and late (beyond the first week) scans. Relying solely on early MRI may overestimate injury in a proportion of infants and miss injury in others. Combining early and late MRI following hypothermia allows for better characterization of brain injury.
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Affiliation(s)
- Aisling A Garvey
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- INFANT Research Centre, Cork, Ireland
| | - Hoda El-Shibiny
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Childrens Hospital of Orange County, University of California Irvine, Irvine, CA, USA
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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16
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Korf JM, McCullough LD, Caretti V. A narrative review on treatment strategies for neonatal hypoxic ischemic encephalopathy. Transl Pediatr 2023; 12:1552-1571. [PMID: 37692539 PMCID: PMC10485647 DOI: 10.21037/tp-23-253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Objective Hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and disability worldwide. Therapeutic hypothermia (TH) represents a significant achievement in the translation of scientific research to clinical application, but it is currently the only neuroprotective treatment for HIE. This review aims to revisit the use of TH for HIE and its longitudinal impact on patient outcomes to readers new to the field of HIE. We discuss how emerging therapies address the broader pathophysiology of injury progression in the neonatal brain days to years after HIE. Methods We included full articles and book chapters published in English on PubMed with references to "hypoxic ischemic encephalopathy", "birth asphyxia", "therapeutic hypothermia", or "neonatal encephalopathy". We limited our review to outcomes on term infants and to new therapeutics that are in the second phase of clinical trials. Key Content and Findings Despite the use of TH for HIE, mortality remains high. Analysis of longitudinal studies reveals a high incidence of ongoing disability even with the implementation of TH. New therapeutics addressing the secondary phase and the less understood tertiary phase of brain injury are in clinical trials as adjunctive treatments to TH to support additional neurological repair and regeneration. Conclusions TH successfully improves outcomes after HIE, and it continues to be optimized. Larger studies are needed to understand its use in mild cases of HIE and if certain factors, such as sex, affect long term outcomes. TH primarily acts in the initial phases of injury, while new pharmaceutical therapies target additional injury pathways into the tertiary phases of injury. This may allow for more effective approaches to treatment and improvement of long-term functional outcomes after HIE.
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Affiliation(s)
- Janelle M. Korf
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Louise D. McCullough
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Viola Caretti
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
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17
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Sutin J, Vyas R, Feldman HA, Ferradal S, Hsiao CH, Zampolli L, Pierce LJ, Nelson CA, Morton SU, Hay S, El-Dib M, Soul JS, Lin PY, Grant PE. Association of cerebral metabolic rate following therapeutic hypothermia with 18-month neurodevelopmental outcomes after neonatal hypoxic ischemic encephalopathy. EBioMedicine 2023; 94:104673. [PMID: 37392599 PMCID: PMC10338207 DOI: 10.1016/j.ebiom.2023.104673] [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: 01/12/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is standard of care for moderate to severe neonatal hypoxic ischemic encephalopathy (HIE) but many survivors still suffer lifelong disabilities and benefits of TH for mild HIE are under active debate. Development of objective diagnostics, with sensitivity to mild HIE, are needed to select, guide, and assess response to treatment. The objective of this study was to determine if cerebral oxygen metabolism (CMRO2) in the days after TH is associated with 18-month neurodevelopmental outcomes as the first step in evaluating CMRO2's potential as a diagnostic for HIE. Secondary objectives were to compare associations with clinical exams and characterise the relationship between CMRO2 and temperature during TH. METHODS This was a prospective, multicentre, observational, cohort study of neonates clinically diagnosed with HIE and treated with TH recruited from the tertiary neonatal intensive care units (NICUs) of Boston Children's Hospital, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center between December 2015 and October 2019 with follow-up to 18 months. In total, 329 neonates ≥34 weeks gestational age admitted with perinatal asphyxia and suspected HIE were identified. 179 were approached, 103 enrolled, 73 received TH, and 64 were included. CMRO2 was measured at the NICU bedside by frequency-domain near-infrared and diffuse correlation spectroscopies (FDNIRS-DCS) during the late phases of hypothermia (C), rewarming (RW) and after return to normothermia (NT). Additional variables were body temperature and clinical neonatal encephalopathy (NE) scores, as well as findings from magnetic resonance imaging (MRI) and spectroscopy (MRS). Primary outcome was the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) at 18 months, normed (SD) to 100 (15). FINDINGS Data quality for 58 neonates was sufficient for analysis. CMRO2 changed by 14.4% per °C (95% CI, 14.2-14.6) relative to its baseline at NT while cerebral tissue oxygen extraction fraction (cFTOE) changed by only 2.2% per °C (95% CI, 2.1-2.4) for net changes from C to NT of 91% and 8%, respectively. Follow-up data for 2 were incomplete, 33 declined and 1 died, leaving 22 participants (mean [SD] postnatal age, 19.1 [1.2] month; 11 female) with mild to moderate HIE (median [IQR] NE score, 4 [3-6]) and 21 (95%) with BSID-III scores >85 at 18 months. CMRO2 at NT was positively associated with cognitive and motor composite scores (β (SE) = 4.49 (1.55) and 2.77 (1.00) BSID-III points per 10-10 moL/dl × mm2/s, P = 0.009 and P = 0.01 respectively; linear regression); none of the other measures were associated with the neurodevelopmental outcomes. INTERPRETATION Point of care measures of CMRO2 in the NICU during C and RW showed dramatic changes and potential to assess individual response to TH. CMRO2 following TH outperformed conventional clinical evaluations (NE score, cFTOE, and MRI/MRS) at predicting cognitive and motor outcomes at 18 months for mild to moderate HIE, providing a promising objective, physiologically-based diagnostic for HIE. FUNDING This clinical study was funded by an NIH grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, United States (R01HD076258).
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Affiliation(s)
- Jason Sutin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA.
| | - Rutvi Vyas
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Henry A Feldman
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Pediatrics, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Silvina Ferradal
- Department of Intelligent Systems Engineering, Indiana University Bloomington, 107 S Indiana Ave., Bloomington, IN 47405, USA
| | - Chuan-Heng Hsiao
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Lucca Zampolli
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Lara J Pierce
- Department of Psychology, York University, 198 York Blvd., North York, ON M3J 2S5, Canada
| | - Charles A Nelson
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Sarah U Morton
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Susanne Hay
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, USA
| | - Mohamed El-Dib
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, USA
| | - Janet S Soul
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Neurology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Pei-Yi Lin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Patricia E Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
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18
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Kang OH, Jahn P, Eichhorn JG, Dresbach T, Müller A, Sabir H. Correlation of Different MRI Scoring Systems with Long-Term Cognitive Outcome in Cooled Asphyxiated Newborns. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1295. [PMID: 37628294 PMCID: PMC10453158 DOI: 10.3390/children10081295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023]
Abstract
(1) Background: Cerebral MRI plays a significant role in assessing the extent of brain injury in neonates with neonatal encephalopathy after perinatal asphyxia. Over the last decades, several MRI scoring systems were developed to enhance the predictive accuracy of MRI. The aim of this study was to validate the correlation of four established MRI scoring systems with cognitive long-term outcomes in cooled asphyxiated newborns. (2) Methods: Forty neonates with neonatal encephalopathy treated with therapeutic hypothermia were included in this retrospective study. The MRI scans from the second week of life were scored using four existing MRI scoring systems (Barkovich, NICHD, Rutherford, and Weeke). The patients' outcome was assessed with the Bayley Scales of Infant Development (BSID-III) at the age of 2 years. To evaluate the correlation between the MRI scoring system with the cognitive scores of BSID-III, the correlation coefficient was calculated for each scoring system. (3) Results: All four MRI scoring systems showed a significant correlation with the cognitive scores of BSID-III. The strongest correlation was found between the Weeke Score (r2 = 0.43), followed by the Rutherford score (r2 = 0.39), the NICHD score (r2 = 0.22), and the Barkovich score (r2 = 0.17). (4) Conclusion: Our study confirms previously published results in an independent cohort and indicates that the Weeke and Rutherford scores have the strongest correlation with the cognitive score of BSID-III in cooled asphyxiated newborns.
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Affiliation(s)
- Ok-Hap Kang
- Children’s Hospital, Klinikum Leverkusen, 51375 Leverkusen, Germany; (O.-H.K.); (P.J.); (J.G.E.)
| | - Peter Jahn
- Children’s Hospital, Klinikum Leverkusen, 51375 Leverkusen, Germany; (O.-H.K.); (P.J.); (J.G.E.)
| | - Joachim G. Eichhorn
- Children’s Hospital, Klinikum Leverkusen, 51375 Leverkusen, Germany; (O.-H.K.); (P.J.); (J.G.E.)
| | - Till Dresbach
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany; (T.D.); (A.M.)
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany; (T.D.); (A.M.)
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany; (T.D.); (A.M.)
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19
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Catenaccio E, Smith RJ, Chavez-Valdez R, Burton VJ, Graham E, Parkinson C, Vaidya D, Tekes A, Northington FJ, Everett AD, Stafstrom CE, Ritzl EK. Evaluating Injury Severity in Neonatal Encephalopathy Using Automated Quantitative Electroencephalography Analysis: A Pilot Study. Dev Neurosci 2023; 46:136-144. [PMID: 37467736 PMCID: PMC11181340 DOI: 10.1159/000530299] [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: 09/11/2022] [Accepted: 03/03/2023] [Indexed: 07/21/2023] Open
Abstract
Quantitative analysis of electroencephalography (qEEG) is a potential source of biomarkers for neonatal encephalopathy (NE). However, prior studies using qEEG in NE were limited in their generalizability due to individualized techniques for calculating qEEG features or labor-intensive pre-selection of EEG data. We piloted a fully automated method using commercially available software to calculate the suppression ratio (SR), absolute delta power, and relative delta, theta, alpha, and beta power from EEG of neonates undergoing 72 h of therapeutic hypothermia (TH) for NE between April 20, 2018, and November 4, 2019. We investigated the association of qEEG with degree of encephalopathy (modified Sarnat score), severity of neuroimaging abnormalities following TH (National Institutes of Child Health and Development Neonatal Research Network [NICHD-NRN] score), and presence of seizures. Thirty out of 38 patients met inclusion criteria. A more severe modified Sarnat score was associated with higher SR during all phases of TH, lower absolute delta power during all phases except rewarming, and lower relative delta power during the last 24 h of TH. In 21 patients with neuroimaging data, a worse NICHD-NRN score was associated with higher SR, lower absolute delta power, and higher relative beta power during all phases. QEEG features were not significantly associated with the presence of seizures after correction for multiple comparisons. Our results are consistent with those of prior studies using qEEG in NE and support automated qEEG analysis as an accessible, generalizable method for generating biomarkers of NE and response to TH. Additionally, we found evidence of an immature relative frequency composition in neonates with more severe brain injury, suggesting that automated qEEG analysis may have a use in the assessment of brain maturity.
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Affiliation(s)
- Eva Catenaccio
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel J. Smith
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vera J. Burton
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Ernest Graham
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen D. Everett
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carl E. Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eva K. Ritzl
- Departments of Neurology and Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Raad JD, Chinnam RB, Arslanturk S, Tan S, Jeong JW, Mody S. Unsupervised abnormality detection in neonatal MRI brain scans using deep learning. Sci Rep 2023; 13:11489. [PMID: 37460615 PMCID: PMC10352269 DOI: 10.1038/s41598-023-38430-0] [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: 09/21/2022] [Accepted: 07/07/2023] [Indexed: 07/20/2023] Open
Abstract
Analysis of 3D medical imaging data has been a large topic of focus in the area of Machine Learning/Artificial Intelligence, though little work has been done in algorithmic (particularly unsupervised) analysis of neonatal brain MRI's. A myriad of conditions can manifest at an early age, including neonatal encephalopathy (NE), which can result in lifelong physical consequences. As such, there is a dire need for better biomarkers of NE and other conditions. The objective of the study is to improve identification of anomalies and prognostication of neonatal MRI brain scans. We introduce a framework designed to support the analysis and assessment of neonatal MRI brain scans, the results of which can be used as an aid to neuroradiologists. We explored the efficacy of the framework through iterations of several deep convolutional Autoencoder (AE) unsupervised modeling architectures designed to learn normalcy of the neonatal brain structure. We tested this framework on the developing human connectome project (dHCP) dataset with 97 patients that were previously categorized by severity. Our framework demonstrated the model's ability to identify and distinguish subtle morphological signatures present in brain structures. Normal and abnormal neonatal brain scans can be distinguished with reasonable accuracy, correctly categorizing them in up to 83% of cases. Most critically, new brain anomalies originally missed during the radiological reading were identified and corroborated by a neuroradiologist. This framework and our modeling approach demonstrate an ability to improve prognostication of neonatal brain conditions and are able to localize new anomalies.
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Affiliation(s)
- Jad Dino Raad
- Industrial and Systems Engineering Department, Wayne State University, Detroit, MI, 48201, USA
| | - Ratna Babu Chinnam
- Industrial and Systems Engineering Department, Wayne State University, Detroit, MI, 48201, USA
| | - Suzan Arslanturk
- Computer Science Department, Wayne State University, Detroit, MI, 48201, USA.
| | - Sidhartha Tan
- Department of Pediatrics, Wayne State University, Detroit, MI, 48201, USA
| | - Jeong-Won Jeong
- Department of Pediatrics, Wayne State University, Detroit, MI, 48201, USA
| | - Swati Mody
- Division of Pediatric Radiology, University of Michigan, Ann Arbor, MI, 48109, USA
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21
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Peralta D, Bogetz J, Lemmon ME. Seminars in Fetal & neonatal medicine: Palliative and end of life care in the NICU. Semin Fetal Neonatal Med 2023; 28:101457. [PMID: 37230860 PMCID: PMC10827319 DOI: 10.1016/j.siny.2023.101457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Dana Peralta
- Duke North Pavilion, 2400 Pratt Street, 8th Floor, DUMC 102509, Durham, NC 27710, USA.
| | - Jori Bogetz
- 1900 Ninth Ave, JMB-6, Seattle, WA 98101, USA.
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22
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Onda K, Chavez-Valdez R, Graham EM, Everett AD, Northington FJ, Oishi K. Quantification of Diffusion Magnetic Resonance Imaging for Prognostic Prediction of Neonatal Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2023; 46:55-68. [PMID: 37231858 PMCID: PMC10712961 DOI: 10.1159/000530938] [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: 10/18/2022] [Accepted: 02/20/2023] [Indexed: 05/27/2023] Open
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is the leading cause of acquired neonatal brain injury with the risk of developing serious neurological sequelae and death. An accurate and robust prediction of short- and long-term outcomes may provide clinicians and families with fundamental evidence for their decision-making, the design of treatment strategies, and the discussion of developmental intervention plans after discharge. Diffusion tensor imaging (DTI) is one of the most powerful neuroimaging tools with which to predict the prognosis of neonatal HIE by providing microscopic features that cannot be assessed by conventional magnetic resonance imaging (MRI). DTI provides various scalar measures that represent the properties of the tissue, such as fractional anisotropy (FA) and mean diffusivity (MD). Since the characteristics of the diffusion of water molecules represented by these measures are affected by the microscopic cellular and extracellular environment, such as the orientation of structural components and cell density, they are often used to study the normal developmental trajectory of the brain and as indicators of various tissue damage, including HIE-related pathologies, such as cytotoxic edema, vascular edema, inflammation, cell death, and Wallerian degeneration. Previous studies have demonstrated widespread alteration in DTI measurements in severe cases of HIE and more localized changes in neonates with mild-to-moderate HIE. In an attempt to establish cutoff values to predict the occurrence of neurological sequelae, MD and FA measurements in the corpus callosum, thalamus, basal ganglia, corticospinal tract, and frontal white matter have proven to have an excellent ability to predict severe neurological outcomes. In addition, a recent study has suggested that a data-driven, unbiased approach using machine learning techniques on features obtained from whole-brain image quantification may accurately predict the prognosis of HIE, including for mild-to-moderate cases. Further efforts are needed to overcome current challenges, such as MRI infrastructure, diffusion modeling methods, and data harmonization for clinical application. In addition, external validation of predictive models is essential for clinical application of DTI to prognostication.
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Affiliation(s)
- Kengo Onda
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raul Chavez-Valdez
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M. Graham
- Department of Gynecology & Obstetrics, Division of Maternal-Fetal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen D. Everett
- Department of Pediatrics, Division of Pediatric Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J. Northington
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenichi Oishi
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Thayyil S, Montaldo P, Krishnan V, Ivain P, Pant S, Lally PJ, Bandiya P, Benkappa N, Kamalaratnam CN, Chandramohan R, Manerkar S, Mondkar J, Jahan I, Moni SC, Shahidullah M, Rodrigo R, Sumanasena S, Sujatha R, Burgod C, Garegrat R, Mazlan M, Chettri I, Babu Peter S, Joshi AR, Swamy R, Chong K, Pressler RR, Bassett P, Shankaran S. Whole-Body Hypothermia, Cerebral Magnetic Resonance Biomarkers, and Outcomes in Neonates With Moderate or Severe Hypoxic-Ischemic Encephalopathy Born at Tertiary Care Centers vs Other Facilities: A Nested Study Within a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2312152. [PMID: 37155168 PMCID: PMC10167567 DOI: 10.1001/jamanetworkopen.2023.12152] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Importance The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. Objective To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). Design, Setting, and Participants This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. Exposure 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. Main Outcomes and Measures Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. Results Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). Conclusions and Relevance In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs. Trial Registration ClinicalTrials.gov Identifier: NCT02387385.
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Affiliation(s)
- Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
- Neonatal Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Prathik Bandiya
- Neonatal Unit, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Naveen Benkappa
- Neonatal Unit, Indira Gandhi Institute of Child Health, Bengaluru, India
| | | | | | - Swati Manerkar
- Neonatal Unit, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Jayshree Mondkar
- Neonatal Unit, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ismat Jahan
- Neonatal Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Sadeka C Moni
- Neonatal Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Ranmali Rodrigo
- Department of Pediatrics, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Radhika Sujatha
- Neonatal Unit, Sree Avittom Thirunal Hospital, Government Medical College, Thiruvananthapuram, India
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Munirah Mazlan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Ismita Chettri
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | | | - Anagha R Joshi
- Department of Radiology, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Kling Chong
- Department of Neuroradiology, Great Ormond Street Hospital, London, United Kingdom
| | - Ronit R Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, United Kingdom
| | | | - Seetha Shankaran
- Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
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24
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Akyel NG, Davutoğlu S, Bozkaya A. Adrenal congestion in perinatal hypoxia: Sonographic assessment and relationship with hypoxic ischemic encephalopathy. Early Hum Dev 2023; 181:105772. [PMID: 37043970 DOI: 10.1016/j.earlhumdev.2023.105772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/11/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND During hypoxia, blood flow to the brain, myocardium, and adrenal glands is preserved or even increased to maintain homeostasis. Adrenal congestion occurs when venous return remains insufficient. Several different ultrasound measurements of adrenal glands in neonates have been reported in the literature. However, there is no data related on adrenal gland size in neonates with perinatal hypoxia. AIMS To evaluate the adrenal congestion using by ultrasound (US) measurements in perinatal hypoxia, and to reveal the relationship of adrenal congestion with hypoxic-ischemic encephalopathy (HIE) grades and magnetic resonance imaging (MRI) findings. STUDY DESIGN Prospective cohort study. SUBJECTS Infants with perinatal hypoxia who met therapeutic hypothermia criteria and were being cooled were included in the present study. The control group was established from healthy neonates admitted to our center during the recruitment. OUTCOME MEASURES The gland area was measured by tracing, and both the corpus and crura widths were measured. RESULTS We reported adrenal gland area data of 110 newborns with HIE and compared them with 56 normal neonates. The adrenal size was significantly higher in the HIE group than in the control group (p<0,01). The frequency of adrenal congestion was 72.7% based on the selected cut-off values. The adrenal gland measurements were increased in the patients with perinatal hypoxia than those of the controls. CONCLUSIONS In the systemic evaluation of newborns with perinatal hypoxia, additional care should be taken regarding adrenal congestion. The measurement of adrenal size with 2D US will help us to diagnose or confirm adrenal congestion and possible hemorrhagic changes. The morphological data and cut-off values given in our study will be useful for neonatologists and pediatric radiologists to evaluate the patient while managing perinatal hypoxia.
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Affiliation(s)
- Nazlı Gülsüm Akyel
- Başakşehir Çam and Sakura City Hospital, Department of Pediatric Radiology, İstanbul, Turkey.
| | - Salih Davutoğlu
- Şanlıurfa Training and Research Hospital, Department of Neonatology, Şanlıurfa, Turkey
| | - Aydın Bozkaya
- Şanlıurfa Training and Research Hospital, Department of Pediatrics, Şanlıurfa, Turkey
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25
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Strizek B. Perinatal brain damage - what the obstetrician needs to know. J Perinat Med 2023:jpm-2022-0523. [PMID: 36853861 DOI: 10.1515/jpm-2022-0523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/22/2022] [Indexed: 03/01/2023]
Abstract
Perinatal brain damage is still one of the leading contributors to perinatal death and postnatal disability worldwide. However, the term perinatal brain damage encompasses very different aetiological entities that result in an insult to the developing brain and does not differentiate between the onset, cause and severity of this insult. Hypoxic-ischemic encephalopathy (HIE), intraventricular haemorrhage, periventricular leukomalacia and perinatal stroke are often listed as the major aetiologies of perinatal brain damage. They differ by type and timing of injury, neuropathological and imaging findings and their clinical picture. Along the timeline of neurodevelopment in utero, there appears to be a specific "window of vulnerability" for each type of injury, but clinical overlap does exist. In the past, peripartum acute hypoxia was believed to be the major, if not the only, cause of perinatal brain damage, but intrauterine inflammation, prematurity, chronic hypoxia/growth retardation and genetic abnormalities appear to be at least equally important contributors.
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Affiliation(s)
- Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
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26
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Spencer APC, Lee-Kelland R, Brooks JCW, Jary S, Tonks J, Cowan FM, Thoresen M, Chakkarapani E. Brain volumes and functional outcomes in children without cerebral palsy after therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy. Dev Med Child Neurol 2023; 65:367-375. [PMID: 35907252 PMCID: PMC10087533 DOI: 10.1111/dmcn.15369] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/11/2022] [Accepted: 07/12/2022] [Indexed: 02/03/2023]
Abstract
AIM To investigate whether brain volumes were reduced in children aged 6 to 8 years without cerebral palsy, who underwent therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy (patients), and matched controls, and to examine the relation between subcortical volumes and functional outcome. METHOD We measured regional brain volumes in 31 patients and 32 controls (median age 7 years and 7 years 2 months respectively) from T1-weighted magnetic resonance imaging (MRI). We assessed cognition using the Wechsler Intelligence Scales for Children, Fourth Edition and motor ability using the Movement Assessment Battery for Children, Second Edition (MABC-2). RESULTS Patients had lower volume of whole-brain grey matter, white matter, pallidi, hippocampi, and thalami than controls (false discovery rate-corrected p < 0.05). Differences in subcortical grey-matter volumes were not independent of total brain volume (TBV). In patients, hippocampal and thalamic volumes correlated with full-scale IQ (hippocampi, r = 0.477, p = 0.010; thalami, r = 0.452, p = 0.016) and MABC-2 total score (hippocampi, r = 0.526, p = 0.004; thalami, r = 0.505, p = 0.006) independent of age, sex, and TBV. No significant correlations were found in controls. In patients, cortical injury on neonatal MRI was associated with reduced volumes of hippocampi (p = 0.001), thalami (p = 0.002), grey matter (p = 0.015), and white matter (p = 0.013). INTERPRETATION Children who underwent therapeutic hypothermia have reduced whole-brain grey and white-matter volumes, with associations between hippocampal and thalamic volumes and functional outcomes.
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Affiliation(s)
- Arthur P C Spencer
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Clinical Research and Imaging Centre, University of Bristol, Bristol, UK
| | - Richard Lee-Kelland
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jonathan C W Brooks
- Clinical Research and Imaging Centre, University of Bristol, Bristol, UK.,School of Psychology, University of East Anglia, Norwich, UK
| | - Sally Jary
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - James Tonks
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,University of Exeter Medical School, Exeter, UK
| | - Frances M Cowan
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Paediatrics, Imperial College London, London, UK
| | - Marianne Thoresen
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ela Chakkarapani
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Neonatal Intensive Care Unit, St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Labat J, Brocard C, Belaroussi Y, Bar C, Gotchac J, Chateil JF, Brissaud O. Hypothermia for neonatal hypoxic-ischemic encephalopathy: Retrospective descriptive study of features associated with poor outcome. Arch Pediatr 2023; 30:93-99. [PMID: 36522220 DOI: 10.1016/j.arcped.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/24/2022] [Accepted: 08/24/2022] [Indexed: 12/15/2022]
Abstract
AIM To investigate the clinical, laboratory, electrophysiological, and imaging features associated with death or neurological impairment at 1 year of age in term neonates with hypoxic-ischemic encephalopathy (HIE) treated by therapeutic hypothermia (TH). METHODS This was a single-center retrospective and descriptive study conducted over a period of 2 years. We included consecutive term newborns with moderate or severe HIE who were treated by TH initiated within the sixth hour after birth and continued for 72 h,. For all patients, brain magnetic resonance imaging (MRI) was performed before the eighth day and a score was established; furthermore, at least two electroencephalograms were recorded. RESULTS Among the 33 patients included, 20 neonates had a favorable outcome and 13 had an unfavorable outcome. Early clinical seizures (15% vs. 53.8%, p = 0.047), the persistence of a poor prognosis according to the electroencephalogram pattern after TH (0% vs. 69.2%, p = 0.0001), and an elevated score on the early brain MRI (2 vs. 11, p < 0.001) combined with a high lactate/N-acetyl-aspartate ratio (0.52 vs. 1.33, p = 0.008) on spectroscopy were associated with death and a poor outcome. CONCLUSION A combination of tools can help the medical team to establish the most reliable prognosis for these full-term neonates, to guide care, and to inform parents most appropriately and sincerely.
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Affiliation(s)
- J Labat
- Pediatric Department, Children's University Hospital Bordeaux, France.
| | - C Brocard
- Pediatric Radiology Department, Children's University Hospital Bordeaux, France
| | - Y Belaroussi
- Inserm, Bordeaux Population Health Research Center, Epicene Team, University of Bordeaux, UMR 1219, Bordeaux F-33000, France
| | - C Bar
- Pediatric Neurology, Children's University Hospital Bordeaux, France
| | - J Gotchac
- Pediatric and Neonatal Intensive Care Unit Department, Children's University Hospital Bordeaux, France
| | - J F Chateil
- Pediatric Radiology Department, Children's University Hospital Bordeaux, France; CRMSB, UMR5536 CNRS, University of Bordeaux, Bordeaux F-33076, France
| | - O Brissaud
- Pediatric and Neonatal Intensive Care Unit Department, Children's University Hospital Bordeaux, France
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Fidelity of 3D Printed Brains from MRI Scan in Children with Pathology (Prior Hypoxic Ischemic Injury). J Digit Imaging 2023; 36:17-28. [PMID: 36280655 PMCID: PMC9984578 DOI: 10.1007/s10278-022-00723-7] [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] [Received: 06/14/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2022] Open
Abstract
Cortical injury on the surface of the brain in children with hypoxic ischemic injury (HII) can be difficult to demonstrate to non-radiologists and lay people using brain images alone. Three-dimensional (3D) printing is helpful to communicate the volume loss and pathology due to HII in children's brains. 3D printed models represent the brain to scale and can be held up against models of normal brains for appreciation of volume loss. If 3D printed brains are to be used for formal communication, e.g., with medical colleagues or in court, they should have high fidelity of reproduction of the actual size of patients' brains. Here, we evaluate the size fidelity of 3D printed models from MRI scans of the brain, in children with prior HII. Twelve 3D prints of the brain were created from MRI scans of children with HII and selected to represent a variety of cortical pathologies. Specific predetermined measures of the 3D prints were made and compared to measures in matched planes on MRI. Fronto-occipital length (FOL) and bi-temporal/bi-parietal diameters (BTD/BPD) demonstrated high interclass correlations (ICC). Correlations were moderate to weak for hemispheric height, temporal height, and pons-cerebellar thickness. The average standard error of measurement (SEM) was 0.48 cm. Our results demonstrate high correlations in overall measurements of each 3D printed model derived from brain MRI scans versus the original MRI, evidenced by high ICC values for FOL and BTD/BPD. Measures with low correlation values can be explained by variability in matching the plane of measurement to the MRI slice orientation.
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Longitudinal perturbations of plasma nuclear magnetic resonance profiles in neonatal encephalopathy. Pediatr Res 2023:10.1038/s41390-023-02464-x. [PMID: 36639516 DOI: 10.1038/s41390-023-02464-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 12/07/2022] [Accepted: 12/27/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Neonatal encephalopathy (NE) is a major cause of mortality and severe neurological disability in the neonatal period and beyond. We hypothesized that the degree of brain injury is reflected in the molecular composition of peripheral blood samples. METHODS A sub-cohort of 28 newborns included in the HYPOTOP trial was studied. Brain injury was assessed by magnetic resonance imaging (MRI) once per patient and neurodevelopment at 24 months of age was evaluated using the Bayley III Scales of Infant and Toddler Development. The nuclear magnetic resonance (NMR) profile of 60 plasma samples collected before, during, and after cooling was recorded. RESULTS In total, 249 molecular features were quantitated in plasma samples from newborns and postnatal age showed to affect detected NMR profiles. Lactate, beta-hydroxybutyrate, pyruvate, and three triglyceride biomarkers showed the ability to discern between different degrees of brain injury according to MRI scores. The prediction performance of lactate was superior as compared to other clinical and biochemical parameters. CONCLUSIONS This is the first longitudinal study of an ample compound panel recorded by NMR spectroscopy in plasma from NE infants. The serial determination of lactate confirms its solid position as reliable candidate biomarker for predicting the severity of brain injury. IMPACT The use of nuclear magnetic resonance (NMR) spectroscopy enables the simultaneous quantitation of 249 compounds in a small volume (i.e., 100 μL) of plasma. Longitudinal perturbations of plasma NMR profiles were linked to magnetic resonance imaging (MRI) outcomes of infants with neonatal encephalopathy (NE). Lactate, beta-hydroxybutyrate, pyruvate, and three triglyceride biomarkers showed the ability to discern between different degrees of brain injury according to MRI scores. Lactate is a minimally invasive candidate biomarker for early staging of MRI brain injury in NE infants that might be readily implemented in clinical guidelines for NE outcome prediction.
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Zhuang X, Lin H, Li J, Yin Y, Dong X, Jin K. Radiomics based of deep medullary veins on susceptibility-weighted imaging in infants: predicting the severity of brain injury of neonates with perinatal asphyxia. Eur J Med Res 2023; 28:9. [PMID: 36609425 PMCID: PMC9817267 DOI: 10.1186/s40001-022-00954-y] [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] [Received: 09/15/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE This study aimed to apply radiomics analysis of the change of deep medullary veins (DMV) on susceptibility-weighted imaging (SWI), and to distinguish mild hypoxic-ischemic encephalopathy (HIE) from moderate-to-severe HIE in neonates. METHODS A total of 190 neonates with HIE (24 mild HIE and 166 moderate-to-severe HIE) were included in this study. All of them were born at 37 gestational weeks or later. The DMVs were manually included in the regions of interest (ROI). For the purpose of identifying optimal radiomics features and to construct Rad-scores, 1316 features were extracted. LASSO regression was used to identify the optimal radiomics features. Using the Red-score and the clinical independent factor, a nomogram was constructed. In order to evaluate the performance of the different models, receiver operating characteristic (ROC) curve analysis was applied. Decision curve analysis (DCA) was implemented to evaluate the clinical utility. RESULTS A total of 15 potential predictors were selected and contributed to Red-score construction. Compared with the radiomics model, the nomogram combined model incorporating Red-score and urea nitrogen did not better distinguish between the mild HIE and moderate-to-severe HIE group. For the training cohort, the AUC of the radiomics model and the combined nomogram model was 0.84 and 0.84. For the validation cohort, the AUC of the radiomics model and the combined nomogram model was 0.80 and 0.79, respectively. The addition of clinical characteristics to the nomogram failed to distinguish mild HIE from moderate-to-severe HIE group. CONCLUSION We developed a radiomics model and combined nomogram model as an indicator to distinguish mild HIE from moderate-to-severe HIE group.
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Affiliation(s)
- Xiamei Zhuang
- grid.440223.30000 0004 1772 5147Department of Radiology, Hunan Children’s Hospital, 86 Ziyuan Road, Yuhua District, Changsha, China
| | - Huashan Lin
- Department of Pharmaceutical Diagnosis, GE Healthcare, Changsha, 410005 China
| | - Junwei Li
- grid.440223.30000 0004 1772 5147Department of Radiology, Hunan Children’s Hospital, 86 Ziyuan Road, Yuhua District, Changsha, China
| | - Yan Yin
- grid.440223.30000 0004 1772 5147Department of Radiology, Hunan Children’s Hospital, 86 Ziyuan Road, Yuhua District, Changsha, China
| | - Xiao Dong
- grid.440223.30000 0004 1772 5147Department of Radiology, Hunan Children’s Hospital, 86 Ziyuan Road, Yuhua District, Changsha, China
| | - Ke Jin
- grid.440223.30000 0004 1772 5147Department of Radiology, Hunan Children’s Hospital, 86 Ziyuan Road, Yuhua District, Changsha, China
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Li R, Lee JK, Govindan RB, Graham EM, Everett AD, Perin J, Vezina G, Tekes A, Chen MW, Northington F, Parkinson C, O’Kane A, McGowan M, Krein C, Al-Shargabi T, Chang T, Massaro AN. Plasma Biomarkers of Evolving Encephalopathy and Brain Injury in Neonates with Hypoxic-Ischemic Encephalopathy. J Pediatr 2023; 252:146-153.e2. [PMID: 35944723 PMCID: PMC9828943 DOI: 10.1016/j.jpeds.2022.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the relationship between a panel of candidate plasma biomarkers and (1) death or severe brain injury on magnetic resonance imaging (MRI) and (2) dysfunctional cerebral pressure autoregulation as a measure of evolving encephalopathy. STUDY DESIGN Neonates with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) at 2 level IV neonatal intensive care units were enrolled into this observational study. Patients were treated with therapeutic hypothermia (TH) and monitored with continuous blood pressure monitoring and near-infrared spectroscopy. Cerebral pressure autoregulation was measured by the hemoglobin volume phase (HVP) index; a higher HVP index indicates poorer autoregulation. Serial blood samples were collected during TH and assayed for Tau, glial fibrillary acidic protein, and neurogranin. MRIs were assessed using National Institutes of Child Health and Human Development scores. The relationships between the candidate biomarkers and (1) death or severe brain injury on MRI (defined as a National Institutes of Child Health and Human Development score of ≥ 2B) and (2) autoregulation were evaluated using bivariate and adjusted logistic regression models. RESULTS Sixty-two patients were included. Elevated Tau levels on days 2-3 of TH were associated with death or severe injury on MRI (aOR: 1.06, 95% CI: 1.03-1.09; aOR: 1.04, 95% CI: 1.01-1.06, respectively). Higher Tau was also associated with poorer autoregulation (higher HVP index) on the same day (P = .022). CONCLUSIONS Elevated plasma levels of Tau are associated with death or severe brain injury by MRI and dysfunctional cerebral autoregulation in neonates with HIE. Larger-scale validation of Tau as a biomarker of brain injury in neonates with HIE is warranted.
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Affiliation(s)
- Ruoying Li
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Ernest M. Graham
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allen D. Everett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra O’Kane
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Meaghan McGowan
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, Washington, DC;,Department of Pediatrics, The George Washington University School of Medicine, Washington, DC
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Neonatology, Children’s National Hospital, Washington, DC
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Cascio A, Ferrand A, Racine E, St-Hilaire M, Sanon PN, Gorgos A, Wintermark P. Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents. eNeurologicalSci 2022; 29:100424. [PMID: 36147866 PMCID: PMC9485039 DOI: 10.1016/j.ensci.2022.100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022] Open
Abstract
Context Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). Purpose To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents. Procedures Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively. Results Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were "usually" (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only "sometimes" accurate and only used them "sometimes" (33%) to discuss prognosis; a majority of them (66%) would "always" repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents. Conclusions Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.
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Affiliation(s)
- Ariel Cascio
- College of Medicine, Central Michigan University, Mount Pleasant, USA
| | - Amaryllis Ferrand
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada
- Division of Newborn Medicine, Department of Pediatrics, Jewish General Hospital, McGill University, Montreal, Canada
- Faculty of Medicine, Department of Biomedical Sciences, University of Montreal, Montreal, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada
- Departments of Medicine and Social and Preventive Medicine, University of Montreal, Montreal, Canada
- Departments of Neurology and Neurosurgery, Medicine, and Biomedical Ethics Unit, McGill University. Montreal, Canada
| | - Marie St-Hilaire
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Priscille-Nice Sanon
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Andreea Gorgos
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
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Shukla VV, Rysavy MA, Das A, Tyson JE, Bell EF, Ambalavanan N, Carlo WA. Outcome prediction in newborn infants: Past, present, and future. Semin Perinatol 2022; 46:151641. [PMID: 35850743 PMCID: PMC10969981 DOI: 10.1016/j.semperi.2022.151641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The perinatal and neonatal periods are the periods of considerable organ development and maturation. Perinatal and neonatal illnesses can result in mortality and morbidities that burden families and the healthcare system. Outcome prediction is essential for informing perinatal and intensive care management, prognosis, and post-discharge interventions. The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) research databases include hospital and neurodevelopment follow-up outcomes of infants with various underlying diseases and conditions receiving intensive care, providing a unique opportunity to assess outcome risk prediction. The NRN has developed outcome risk prediction tools for use in infants with various diseases and conditions that allow data-driven, transparent discussions to inform family-focused communications and clinical management. This review presents the published neonatal outcome risk prediction research from the NRN, their present clinical utility, and possible future directions for advanced individualized risk prediction.
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Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - Abhik Das
- RTI International, Research Triangle Park, NC, USA
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DeMauro SB, Merhar SL, Peralta-Carcelen M, Vohr BR, Duncan AF, Hintz SR. The critical importance of follow-up to school age: Contributions of the NICHD Neonatal Research Network. Semin Perinatol 2022; 46:151643. [PMID: 35850744 PMCID: PMC10983779 DOI: 10.1016/j.semperi.2022.151643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Follow-up studies are essential for understanding outcomes and informing the care of infants with high risk for medical and developmental consequences because of extreme prematurity or perinatal illness. Studies that extend to school age often identify sequelae that go unrecognized in neonatal or short-term follow-up studies. Many critical neurocognitive, behavioral, functional, and health outcomes are best assessed beginning at school age. The Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN) has performed comprehensive school age evaluations of several key trial cohorts. This manuscript summarizes the important contributions of school age follow-up studies in the NRN, both historically and in ongoing research. We describe in detail the clinical questions that have been answered by the completed studies and new questions about the outcomes of high-risk infants that must be addressed by ongoing and future studies.
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Affiliation(s)
- Sara B DeMauro
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, Pennsylvania 19146, United States.
| | - Stephanie L Merhar
- University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | | | - Betty R Vohr
- Warren Alpert Medical School of Brown University and Women & Infants Hospital of Rhode Island, Providence, Rhode Island, United States
| | - Andrea F Duncan
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
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Bonifacio SL, Chalak LF, Van Meurs KP, Laptook AR, Shankaran S. Neuroprotection for hypoxic-ischemic encephalopathy: Contributions from the neonatal research network. Semin Perinatol 2022; 46:151639. [PMID: 35835616 DOI: 10.1016/j.semperi.2022.151639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Therapeutic hypothermia (TH) is now well established as the standard of care treatment for moderate to severe neonatal encephalopathy secondary to perinatal hypoxic ischemic encephalopathy (HIE) in infants ≥36 weeks gestation in high income countries. The Neonatal Research Network (NRN) contributed greatly to the study of TH as a neuroprotectant with three trials now completed in infants ≥36 weeks gestation and the only large randomized-controlled trial of TH in preterm infants now in the follow-up phase. Data from the first NRN TH trial combined with data from other large trials of TH affirm the safety and neuroprotective qualities of TH and highlight the importance of providing TH to all infants who qualify. In this review we will highlight the findings of the three NRN trials of TH in the term infant population and the secondary analyses that continue to inform the care of patients with HIE.
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Affiliation(s)
- Sonia Lomeli Bonifacio
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Lina F Chalak
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Krisa P Van Meurs
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
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Cerebral injuries in neonatal encephalopathy treated with hypothermia: French LyTONEPAL cohort. Pediatr Res 2022; 92:880-887. [PMID: 34802036 DOI: 10.1038/s41390-021-01846-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/04/2021] [Accepted: 10/31/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypothermia is widely used for infants with hypoxic-ischemic neonatal encephalopathy but its impact remains poorly described at a population level. We aimed to describe brain imaging in infants born at ≥36 weeks' gestation, with moderate/severe encephalopathy treated with hypothermia. METHODS Descriptive analysis of brain MRI and discharge neurological examination for infants included in the French national multicentric prospective observational cohort LyTONEPAL. RESULTS Among 575 eligible infants, 479 (83.3%) with MRI before 12 days of life were included. MRI was normal for 48.2% (95% CI 43.7-52.8). Among infants with brain injuries, 62.5% (95% CI 56.2-68.5) had damage to more than one structure, 19.8% (95% CI 15.0-25.3) showed a pattern-associating injuries of basal ganglia/thalami (BGT), white matter (WM) and cortex. Overall, 68.4% (95% CI 62.0-74.3) of infants with normal MRI survived with a normal neurological examination. The rate of death was 15.4% (95% CI 12.3-19.0), predominantly for infants with the combined BGT, cortex, and/or WM injuries. CONCLUSIONS Among infants with neonatal encephalopathy treated with hypothermia, two-thirds of those with normal MRI survived with a normal neurological examination at discharge. When present, brain injuries often involved more than one structure. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (NCT02676063). IMPACT In this multicentric cohort of infants with neonatal encephalopathy (LYTONEPAL) two-thirds survived with normal MRI and neurological examination at discharge. In total, 10% of newborns showed a pattern associating injuries of the basal ganglia-thalami, white matter, and cortex, which was correlated with a high risk of death at discharge. The evolution of MRI techniques and sequences in the era of hypothermia calls for a revisiting of imaging protocol in neonatal encephalopathy, especially for the timing. The neurological examination did not give evidence of brain injuries, thus questioning the reproducibility of the clinical exam or the neonatal brain functionality.
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Gadde JA, Pardo AC, Bregman CS, Ryan ME. Imaging of Hypoxic-Ischemic Injury (in the Era of Cooling). Clin Perinatol 2022; 49:735-749. [PMID: 36113932 DOI: 10.1016/j.clp.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypoxic-ischemic injury (HII) is a major worldwide contributor of term neonatal mortality and long-term morbidity. At present, therapeutic hypothermia is the only therapy that has demonstrated efficacy in reducing severe disability or death in infants with moderate to severe encephalopathy. MRI and MRS performed during the first week of life are adequate to assess brain injury and offer prognosis. Patterns of injury will depend on the gestation age of the neonate, as well as the degree of hypotension.
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Affiliation(s)
- Judith A Gadde
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 9, Chicago, IL 60611, USA; Medical Imaging Department; Northwestern University Feinberg School of Medicine.
| | - Andrea C Pardo
- Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 51, Chicago, IL 60611, USA
| | - Corey S Bregman
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 9, Chicago, IL 60611, USA; Medical Imaging Department; Northwestern University Feinberg School of Medicine
| | - Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 9, Chicago, IL 60611, USA; Medical Imaging Department; Northwestern University Feinberg School of Medicine
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Early Plasma Magnesium in Near-Term and Term Infants with Neonatal Encephalopathy in the Context of Perinatal Asphyxia. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9081233. [PMID: 36010122 PMCID: PMC9406851 DOI: 10.3390/children9081233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022]
Abstract
Magnesium ions are implicated in brain functioning. The disruption of brain metabolism subsequent to a perinatal hypoxic-ischaemic insult may be reflected by plasma magnesium. Infants at 36 weeks after birth or later with neonatal encephalopathy and who were admitted to our neonatal unit from 2011 to 2019 were retrospectively included. The kinetics of plasma magnesium were investigated for the first 72 h of life and correlated to the Barkovich MRI score. Among the 125 infants who met the inclusion criteria, 45 patients (36%) had moderate to severe brain lesions on neonatal MRI. Plasma magnesium values were not strongly associated with the severity of clinical encephalopathy, initial EEG background and brain lesions. Intriguingly, higher plasma magnesium values during the 0−6 h period were linked to the presence of brain injuries that predominated within the white matter (p < 0.001) and to the requirement of cardiac resuscitation in the delivery room (p = 0.001). The occurrence of seizures was associated with a lower mean magnesium value around the 24th hour of life (p = 0.005). This study supports that neonatal encephalopathy is a complex and multifactorial condition. Plasma magnesium could help to better identify the subtypes of neonatal encephalopathy. Further studies are needed to confirm these results in this prospect.
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Onda K, Catenaccio E, Chotiyanonta J, Chavez-Valdez R, Meoded A, Soares BP, Tekes A, Spahic H, Miller SC, Parker SJ, Parkinson C, Vaidya DM, Graham EM, Stafstrom CE, Everett AD, Northington FJ, Oishi K. Development of a composite diffusion tensor imaging score correlating with short-term neurological status in neonatal hypoxic-ischemic encephalopathy. Front Neurosci 2022; 16:931360. [PMID: 35983227 PMCID: PMC9379310 DOI: 10.3389/fnins.2022.931360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is the most common cause of neonatal acquired brain injury. Although conventional MRI may predict neurodevelopmental outcomes, accurate prognostication remains difficult. As diffusion tensor imaging (DTI) may provide an additional diagnostic and prognostic value over conventional MRI, we aimed to develop a composite DTI (cDTI) score to relate to short-term neurological function. Sixty prospective neonates treated with therapeutic hypothermia (TH) for HIE were evaluated with DTI, with a voxel size of 1 × 1 × 2 mm. Fractional anisotropy (FA) and mean diffusivity (MD) from 100 neuroanatomical regions (FA/MD *100 = 200 DTI parameters in total) were quantified using an atlas-based image parcellation technique. A least absolute shrinkage and selection operator (LASSO) regression was applied to the DTI parameters to generate the cDTI score. Time to full oral nutrition [short-term oral feeding (STO) score] was used as a measure of short-term neurological function and was correlated with extracted DTI features. Seventeen DTI parameters were selected with LASSO and built into the final unbiased regression model. The selected factors included FA or MD values of the limbic structures, the corticospinal tract, and the frontotemporal cortices. While the cDTI score strongly correlated with the STO score (rho = 0.83, p = 2.8 × 10-16), it only weakly correlated with the Sarnat score (rho = 0.27, p = 0.035) and moderately with the NICHD-NRN neuroimaging score (rho = 0.43, p = 6.6 × 10-04). In contrast to the cDTI score, the NICHD-NRN score only moderately correlated with the STO score (rho = 0.37, p = 0.0037). Using a mixed-model analysis, interleukin-10 at admission to the NICU (p = 1.5 × 10-13) and tau protein at the end of TH/rewarming (p = 0.036) and after rewarming (p = 0.0015) were significantly associated with higher cDTI scores, suggesting that high cDTI scores were related to the intensity of the early inflammatory response and the severity of neuronal impairment after TH. In conclusion, a data-driven unbiased approach was applied to identify anatomical structures associated with some aspects of neurological function of HIE neonates after cooling and to build a cDTI score, which was correlated with the severity of short-term neurological functions.
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Affiliation(s)
- Kengo Onda
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eva Catenaccio
- Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jill Chotiyanonta
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Raul Chavez-Valdez
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Bruno P. Soares
- Division of Neuroradiology, Department of Radiology, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Aylin Tekes
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Harisa Spahic
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sarah C. Miller
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Charlamaine Parkinson
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Dhananjay M. Vaidya
- Department of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ernest M. Graham
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carl E. Stafstrom
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Neurology, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Allen D. Everett
- Division of Pediatric Cardiology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Frances J. Northington
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenichi Oishi
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Neonatal encephalopathy prediction of poor outcome with diffusion-weighted imaging connectome and fixel-based analysis. Pediatr Res 2022; 91:1505-1515. [PMID: 33966055 PMCID: PMC9053106 DOI: 10.1038/s41390-021-01550-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Better biomarkers of eventual outcome are needed for neonatal encephalopathy. To identify the most potent neonatal imaging marker associated with 2-year outcomes, we retrospectively performed diffusion-weighted imaging connectome (DWIC) and fixel-based analysis (FBA) on magnetic resonance imaging (MRI) obtained in the first 4 weeks of life in term neonatal encephalopathy newborns. METHODS Diffusion tractography was available in 15 out of 24 babies with MRI, five each with normal, abnormal motor outcome, or death. All 15 except one underwent hypothermia as initial treatment. In abnormal motor and death groups, DWIC found 19 white matter pathways with severely disrupted fiber orientation distributions. RESULTS Using random forest classification, these disruptions predicted the follow-up outcomes with 89-99% accuracy. These pathways showed reduced integrity in abnormal motor and death vs. normal tone groups (p < 10-6). Using ranked supervised multi-view canonical correlation and depicting just three of the five dimensions of the analysis, the abnormal motor and death were clearly differentiated from each other and the normal tone group. CONCLUSIONS This study suggests that a machine-learning model for prediction using early DWIC and FBA could be a possible way of developing biomarkers in large MRI datasets having clinical outcomes. IMPACT Early connectome and FBA of clinically acquired DWI provide a new noninvasive imaging tool to predict the long-term motor outcomes after birth, based on the severity of white matter injury. Disrupted white matter connectivity as a novel neonatal marker achieves high accuracy of 89-99% to predict 2-year motor outcomes using conventional machine-learning classification. The proposed neonatal marker may allow better prognostication that is important to elucidate neural repair mechanisms and evaluate treatment modalities in neonatal encephalopathy.
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Predictive Value of Heat-Shock Protein Gene Expression on Severe Neonatal Hypoxic-Ischemic Encephalopathy. Diagnostics (Basel) 2022; 12:diagnostics12040981. [PMID: 35454029 PMCID: PMC9030968 DOI: 10.3390/diagnostics12040981] [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: 02/12/2022] [Revised: 04/02/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022] Open
Abstract
This study aims to evaluate significant gene expression in severe hypoxic ischemic encephalopathy (HIE) in newborns, which can be used as a predictable measure for high-risk HIE infants. The study prospectively recruited 77 inborn near-term or term HIE newborns between January 2018 and December 2020. We measured six different genes within 6 h of life among the HIE infants and compared the gene levels between the mild- and severe-HIE groups. Among these, 64 HIE infants (83.1%) did not receive therapeutic hypothermia (TH) because they were categorized as mild HIE, and the 13 remaining (16.9%) infants were categorized as ≥ moderate-HIE group and received TH. More abnormal MRI findings, seizure, and use of anti-convulsant were more found in the ≥ moderate = HIE group along with longer mechanical ventilation days and hospitalization. Heat-shock protein 70 family 1 A (HSPA1A) and serpin family H member 1 (SERPINH1) genes, which encode heat-shock protein (HSP) 70 and 47, respectively, were significantly elevated in the ≥ moderate-HIE, seizure, and abnormal MRI groups. HSP 70 and 47 were significantly elevated in the severe-HIE group, possibly playing protective roles in inhibiting exacerbated neuroinflammation and maintaining a cellular homeostasis. At 18–24 months, ≥ moderate-HIE group manifested a significant language delay.
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Chalak L. New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care. Clin Perinatol 2022; 49:279-294. [PMID: 35210007 DOI: 10.1016/j.clp.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) presents clinically with a neonatal encephalopathy (NE) whereby the mild spectrum is difficult to classify immediately after birth. For decades trials have focused exclusively on infants with moderate-severe HIE s, as these infants were easier to identify after birth and had the highest risk of adverse outcomes. Twenty years after those trials, the PRIME study finally solved the first part of the conundrum by providing a definition of mild HIE in the first 6 hours. There is strong biological plausibility and preclinical evidence supporting the efficacy of therapeutic hypothermia (TH) but there is a lack of comparative clinical data to establish the risk-benefit in mild HIE. The fundamental question of how best to manage mild HIE remains unanswered. This review will summarize (1) the evidence that neonates with mild HIE are at significant risk for adverse outcomes, (2) the gaps/controversies in management, and (3) an algorithm of care is proposed to ensure standardized management of mild HIE and the direction of future trials.
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Affiliation(s)
- Lina Chalak
- Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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Flibotte J, Laptook AR, Shankaran S, McDonald SA, Baserga MC, Bell EF, Cotten CM, Das A, DeMauro SB, DuPont TL, Eichenwald EC, Heyne R, Jensen EA, Van Meurs KP, Dysart K. Blanket temperature during therapeutic hypothermia and outcomes in hypoxic ischemic encephalopathy. J Perinatol 2022; 42:348-353. [PMID: 34999716 PMCID: PMC9121861 DOI: 10.1038/s41372-021-01302-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Determine whether blanket temperatures during therapeutic hypothermia (TH) are associated with 18-22 month outcomes for infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of 181 infants with HIE who received TH in two randomized trials within the Neonatal Research Network. We defined summative blanket temperature constructs and evaluated for association with a primary composite outcome of death or moderate/ severe disability at 18-22 months. RESULTS Each 0.5 °C above 33.5 °C in the mean of the highest quartile blanket temperature was associated with a 52% increase in the adjusted odds of death/ disability (aOR 1.52, 95% CI 1.09-2.11). Having >8 consecutive blanket temperatures above 33.5 °C rendered an aOR of death/disability of 5.04 in the first 24 h (95% CI 1.54-16.6) and 6.92 in the first 48 h (95% CI 2.20-21.8) of TH. CONCLUSIONS Higher blanket temperature during TH may be an early, clinically useful biomarker of HIE outcome.
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Affiliation(s)
- John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Scott A McDonald
- Biostatistics and Epidemiology, RTI International, Research Triangle Park, NC, USA
| | - Mariana C Baserga
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Abhik Das
- Biostatistics and Epidemiology, RTI International, Rockville, MD, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tara L DuPont
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric C Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Roy Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erik A Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Krisa P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin Dysart
- Division of Neonatal and Perinatal Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
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Jackson TC, Herrmann JR, Garman RH, Kang RD, Vagni VA, Gorse K, Janesko-Feldman K, Stezoski J, Kochanek PM. Hypoxia-ischemia-mediated effects on neurodevelopmentally regulated cold-shock proteins in neonatal mice under strict temperature control. Pediatr Res 2022:10.1038/s41390-022-01990-4. [PMID: 35184138 PMCID: PMC9388702 DOI: 10.1038/s41390-022-01990-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/18/2021] [Accepted: 01/17/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neonates have high levels of cold-shock proteins (CSPs) in the normothermic brain for a limited period following birth. Hypoxic-ischemic (HI) insults in term infants produce neonatal encephalopathy (NE), and it remains unclear whether HI-induced pathology alters baseline CSP expression in the normothermic brain. METHODS Here we established a version of the Rice-Vannucci model in PND 10 mice that incorporates rigorous temperature control. RESULTS Common carotid artery (CCA)-ligation plus 25 min hypoxia (8% O2) in pups with targeted normothermia resulted in classic histopathological changes including increased hippocampal degeneration, astrogliosis, microgliosis, white matter changes, and cell signaling perturbations. Serial assessment of cortical, thalamic, and hippocampal RNA-binding motif 3 (RBM3), cold-inducible RNA binding protein (CIRBP), and reticulon-3 (RTN3) revealed a rapid age-dependent decrease in levels in sham and injured pups. CSPs were minimally affected by HI and the age point of lowest expression (PND 18) coincided with the timing at which heat-generating mechanisms mature in mice. CONCLUSIONS The findings suggest the need to determine whether optimized therapeutic hypothermia (depth and duration) can prevent the age-related decline in neuroprotective CSPs like RBM3 in the brain, and improve outcomes during critical phases of secondary injury and recovery after NE. IMPACT The rapid decrease in endogenous neuroprotective cold-shock proteins (CSPs) in the normothermic cortex, thalamus, and hippocampus from postnatal day (PND) 11-18, coincides with the timing of thermogenesis maturation in neonatal mice. Hypoxia-ischemia (HI) has a minor impact on the normal age-dependent decline in brain CSP levels in neonates maintained normothermic post-injury. HI robustly disrupts the expected correlation in RNA-binding motif 3 (RBM3) and reticulon-3 (RTN3). The potent neuroprotectant RBM3 is not increased 1-4 days after HI in a mouse model of neonatal encephalopathy (NE) in the term newborn and in which rigorous temperature control prevents the manifestation of endogenous post-insult hypothermia.
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Affiliation(s)
- Travis C Jackson
- University of South Florida Morsani College of Medicine, USF Health Heart Institute, MDD 0630, 560 Channelside Drive, Tampa, FL, 33602, USA.
- Department of Molecular Pharmacology & Physiology, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612-4799, USA.
| | - Jeremy R Herrmann
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Robert H Garman
- Division of Neuropathology, University of Pittsburgh, 3550 Terrrace Street, Pittsburgh, PA, 15261, USA
| | - Richard D Kang
- University of South Florida Morsani College of Medicine, USF Health Heart Institute, MDD 0630, 560 Channelside Drive, Tampa, FL, 33602, USA
- Department of Molecular Pharmacology & Physiology, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612-4799, USA
| | - Vincent A Vagni
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Kiersten Gorse
- University of South Florida Morsani College of Medicine, USF Health Heart Institute, MDD 0630, 560 Channelside Drive, Tampa, FL, 33602, USA
- Department of Molecular Pharmacology & Physiology, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612-4799, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Jason Stezoski
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
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Noninvasive monitoring of evolving urinary metabolic patterns in neonatal encephalopathy. Pediatr Res 2022; 91:598-605. [PMID: 33953355 DOI: 10.1038/s41390-021-01553-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 04/08/2021] [Accepted: 04/10/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Infants with moderate and severe neonatal encephalopathy (NE) frequently suffer from long-term adverse outcomes. We hypothesize that the urinary metabolome of newborns with NE reflects the evolution of injury patterns observed with magnetic resonance imaging (MRI). METHODS Eligible patients were newborn infants with perinatal asphyxia evolving to NE and qualifying for therapeutic hypothermia (TH) included in the HYPOTOP trial. MRI was employed for characterizing brain injury. Urine samples of 55 infants were collected before, during, and after TH. Metabolic profiles of samples were recorded employing three complementary mass spectrometry-based assays, and the alteration of detected metabolic features between groups was assessed. RESULTS The longitudinal assessment revealed significant perturbations of the urinary metabolome. After 24 h of TH, a stable disease pattern evolved characterized by the alterations of 4-8% of metabolic features related to lipid metabolism, metabolism of cofactors and vitamins, glycan biosynthesis and metabolism, amino acid metabolism, and nucleotide metabolism. Characteristic metabolomic fingerprints were observed for different MRI injury patterns. CONCLUSIONS This study shows the potential of urinary metabolic profiles for the noninvasive monitoring of brain injury of infants with NE during TH. IMPACT A comprehensive approach for the study of the urinary metabolome was employed involving a semi-targeted capillary electrophoresis-time-of-flight mass spectrometry (TOFMS) assay, an untargeted ultra-performance liquid chromatography (UPLC)-quadrupole TOFMS assay, and a targeted UPLC-tandem MS-based method for the quantification of amino acids. The longitudinal study of the urinary metabolome identified dynamic metabolic changes between birth and until 96 h after the initiation of TH. The identification of altered metabolic pathways in newborns with pathologic MRI outcomes might offer the possibility of developing noninvasive monitoring approaches for personalized adjustment of the treatment and for supporting early outcome prediction.
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Nanyunja C, Sadoo S, Mambule I, Mathieson SR, Nyirenda M, Webb EL, Mugalu J, Robertson NJ, Nabawanuka A, Gilbert G, Bwambale J, Martinello K, Bainbridge A, Lubowa S, Srinivasan L, Ssebombo H, Morgan C, Hagmann C, Cowan FM, Le Doare K, Wintermark P, Kawooya M, Boylan GB, Nakimuli A, Tann CJ. Protocol for the Birth Asphyxia in African Newborns (Baby BRAiN) Study: a Neonatal Encephalopathy Feasibility Cohort Study. Gates Open Res 2022; 6:10. [PMID: 35614965 PMCID: PMC9110736 DOI: 10.12688/gatesopenres.13557.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND: Neonatal encephalopathy (NE) is a leading cause of child mortality worldwide and contributes substantially to stillbirths and long-term disability. Ninety-nine percent of deaths from NE occur in low-and-middle-income countries (LMICs). Whilst therapeutic hypothermia significantly improves outcomes in high-income countries, its safety and effectiveness in diverse LMIC contexts remains debated. Important differences in the aetiology, nature and timing of neonatal brain injury likely influence the effectiveness of postnatal interventions, including therapeutic hypothermia. METHODS: This is a prospective pilot feasibility cohort study of neonates with NE conducted at Kawempe National Referral Hospital, Kampala, Uganda. Neurological investigations include continuous video electroencephalography (EEG) (days 1-4), serial cranial ultrasound imaging, and neonatal brain Magnetic Resonance Imaging and Spectroscopy (MRI/ MRS) (day 10-14). Neurodevelopmental follow-up will be continued to 18-24 months of age including Prechtl's Assessment of General Movements, Bayley Scales of Infant Development, and a formal scored neurological examination. The primary outcome will be death and moderate-severe neurodevelopmental impairment at 18-24 months. Findings will be used to inform explorative science and larger trials, aiming to develop urgently needed neuroprotective and neurorestorative interventions for NE applicable for use in diverse settings. DISCUSSION: The primary aims of the study are to assess the feasibility of establishing a facility-based cohort of children with NE in Uganda, to enhance our understanding of NE in a low-resource sub-Saharan African setting and provide infrastructure to conduct high-quality research on neuroprotective/ neurorestorative strategies to reduce death and disability from NE. Specific objectives are to establish a NE cohort, in order to 1) investigate the clinical course, aetiology, nature and timing of perinatal brain injury; 2) describe electrographic activity and quantify seizure burden and the relationship with adverse outcomes, and; 3) develop capacity for neonatal brain MRI/S and examine associations with early neurodevelopmental outcomes.
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Affiliation(s)
| | - Samantha Sadoo
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ivan Mambule
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | - Emily L Webb
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - J Mugalu
- Kawempe National Referral Hospital, Kampala, UK
| | - Nicola J Robertson
- University College London, London, UK
- University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | | | | | | | - Cathy Morgan
- Cerebral Palsy Alliance Research Institute, University of Sydney, Sydney, Australia
| | | | | | - Kirsty Le Doare
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- St George's, University of London, London, UK
| | | | - Michael Kawooya
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Kampala, Uganda
| | | | - Annettee Nakimuli
- Kawempe National Referral Hospital, Kampala, UK
- Makarere University, Kampala, Uganda
| | - Cally J Tann
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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Ní Bhroin M, Kelly L, Sweetman D, Aslam S, O'Dea MI, Hurley T, Slevin M, Murphy J, Byrne AT, Colleran G, Molloy EJ, Bokde ALW. Relationship Between MRI Scoring Systems and Neurodevelopmental Outcome at Two Years in Infants With Neonatal Encephalopathy. Pediatr Neurol 2022; 126:35-42. [PMID: 34736061 DOI: 10.1016/j.pediatrneurol.2021.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) scoring systems are used in the neonatal period to predict outcome in infants with neonatal encephalopathy. Our aim was to assess the relationship between three MRI scores and neurodevelopmental outcome assessed using Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), at two years in infants with neonatal encephalopathy. METHODS Term-born neonates with evidence of perinatal asphyxia born between 2011 and 2015 were retrospectively reviewed. MRI scanning was performed within the first two weeks of life and scored using Barkovich, National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN), and Weeke systems by a single assessor blinded to the infants clinical course. Neurodevelopmental outcome was assessed using composite scores on the Bayley-III at two years. Multiple linear regression analyses were used to assess the association between MRI scores and Bayley-III composite scores, with postmenstrual age at scan and sex included as covariates. RESULTS Of the 135 recruited infants, 90 infants underwent MRI, and of these, 66 returned for follow-up. MRI abnormalities were detected with the highest frequency using the Weeke score (Barkovich 40%, NICHD NRN 50%, Weeke 77%). The inter-rater agreement was good for the Barkovich score and excellent for NICHD NRN and Weeke scores. There was a significant association between Barkovich, NICHD NRN, and Weeke scores and Bayley-III cognitive and motor scores. Only the Weeke score was associated with Bayley-III language scores. CONCLUSIONS Our findings confirm the predictive value of existing MRI scoring systems for cognitive and motor outcome and suggest that more detailed scoring systems have predictive value for language outcome.
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Affiliation(s)
- Megan Ní Bhroin
- Cognitive Systems Group, Discipline of Psychiatry, School of Medicine, Trinity College Dublin, Dublin, Ireland; Trinity College Institute of Neuroscience (TCIN), Trinity College Dublin, Dublin, Ireland.
| | - Lynne Kelly
- Department of Paediatric and Child Health, Trinity College Dublin, Tallaght University Hospital (TUH), Dublin, Ireland
| | - Deirdre Sweetman
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland
| | - Saima Aslam
- Department of Neonatology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland
| | - Mary I O'Dea
- Department of Paediatric and Child Health, Trinity College Dublin, Tallaght University Hospital (TUH), Dublin, Ireland; Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Department of Paediatric and Child Health, Trinity College Dublin, Tallaght University Hospital (TUH), Dublin, Ireland
| | - Marie Slevin
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland
| | - John Murphy
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland
| | - Angela T Byrne
- Department of Radiology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland
| | - Gabrielle Colleran
- Department of Radiology, The National Maternity Hospital, Dublin, Ireland and Children's Hospital Ireland (CHI) at Temple Street, Dublin, Ireland; Department of Paediatrics, Trinity College Dublin, Dublin, Ireland; Women's and Children's Health, University College Dublin (UCD), School of Medicine, University College Dublin, Dublin, Ireland
| | - Eleanor J Molloy
- Department of Paediatric and Child Health, Trinity College Dublin, Tallaght University Hospital (TUH), Dublin, Ireland; Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Arun L W Bokde
- Cognitive Systems Group, Discipline of Psychiatry, School of Medicine, Trinity College Dublin, Dublin, Ireland; Trinity College Institute of Neuroscience (TCIN), Trinity College Dublin, Dublin, Ireland
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Troha Gergeli A, Škofljanec A, Neubauer D, Paro Panjan D, Kodrič J, Osredkar D. Prognostic Value of Various Diagnostic Methods for Long-Term Outcome of Newborns After Hypoxic-Ischemic Encephalopathy Treated With Hypothermia. Front Pediatr 2022; 10:856615. [PMID: 35463898 PMCID: PMC9021608 DOI: 10.3389/fped.2022.856615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Prediction of outcome in newborns with hypoxic-ischemic encephalopathy (HIE) has been modulated by hypothermia treatment (HT). We assessed the predictive value of diagnostic methods commonly used in neonates with HIE for short-term neurodevelopmental outcome and long-term neurological outcome. MATERIALS AND METHODS This longitudinal cohort study followed up 50 term newborns who underwent HT after HIE between July 2006 and August 2015, until preschool age. We estimated sensitivity and specificity for short-term neurodevelopmental outcome at 18 months and long-term neurological outcome at five years based on Amiel-Tison Neurological Assessment (ATNA), electroencephalography (EEG), and magnetic resonance imaging (MRI) performed in the neonatal period. RESULTS The accuracy of all neonatal methods tested was higher for long-term neurological outcome compared to the predictive accuracy for short-term neurodevelopmental outcome at 18-24 months. Sensitivity and specificity in predicting unfavorable long-term neurological outcome were: MRI (sensitivity 1.0 [95%CI 0.96-1.0]; specificity 0.91 [95%CI 0.86-1.0]), EEG (sensitivity 0.94 [95%CI 0.71-1.0]; specificity 1.0 [95% CI 0.89-1.0]), and ATNA (sensitivity 0.94 [95%CI 0.71-1.0]; specificity 0.91 [95%CI 0.76-0.98]). CONCLUSION MRI is a powerful predictor of long-term neurological outcome when performed in the first week after HIE in HT treated infants, as are EEG and ATNA performed in the second or third week postnatally.
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Affiliation(s)
- Anja Troha Gergeli
- Department of Child, Adolescent and Developmental Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Andreja Škofljanec
- Pediatric Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Health Institution Zdravje, Ljubljana, Slovenia
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Center for Developmental Neuroscience, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Darja Paro Panjan
- Center for Developmental Neuroscience, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Neonatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jana Kodrič
- Unit of Child Psychiatry of the University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Damjan Osredkar
- Department of Child, Adolescent and Developmental Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Center for Developmental Neuroscience, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Cascant-Vilaplana MM, Sánchez-Illana Á, Piñeiro-Ramos JD, Llorens-Salvador R, Quintás G, Oger C, Galano JM, Vigor C, Durand T, Kuligowski J, Vento M. Do Levels of Lipid Peroxidation Biomarkers Reflect the Degree of Brain Injury in Newborns? Antioxid Redox Signal 2021; 35:1467-1475. [PMID: 34409848 DOI: 10.1089/ars.2021.0168] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The pathogenesis and progression of hypoxic-ischemic encephalopathy (HIE), a major cause of severe neurological disability and mortality in the perinatal period, are shaped by the interplay of multiple processes, including inflammation, oxidative stress, and excitotoxicity. We conducted a longitudinal study to determine biomarkers of oxidative stress and inflammation in noninvasive urine samples of newborns with moderate/severe HIE (N = 51), employing liquid chromatography-mass spectrometry. We noted that levels of several biomarkers of oxidative stress increased over time, demonstrating the ongoing propagation of oxidative injury. Prostaglandins, in contrast, showed a decreasing trend in their concentration profiles over time, which probably reflects their mediation in pathogenic mechanisms, including the inflammatory response. Statistically significant differences in the levels of oxidative stress of neonates with distinct brain lesion patterns, as detected with magnetic resonance imaging (MRI), were observed, revealing an increase of lipid peroxidation biomarkers in newborns with cerebral lesions (MRI score of 1 compared with scores of 0 and 2). Moreover, a gender-dependent study showed no statistically significant differences in biomarker concentrations between male and female infants. Our observation leads to the hypothesis that monitoring of noninvasive lipid peroxidation biomarkers could aid in diagnosis and prediction of long-term outcomes as a complementary tool to standard exploration. Antioxid. Redox Signal. 35, 1467-1475.
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Affiliation(s)
| | - Ángel Sánchez-Illana
- Neonatal Research Group, Health Research Institute Hospital La Fe, Valencia, Spain
| | | | | | - Guillermo Quintás
- Health and Biomedicine, Leitat Technological Center, Valencia, Spain.,Unidad Analítica, Health Research Institute La Fe, Valencia, Spain
| | - Camille Oger
- Institut des Biomolecules Max Mousseron, UMR 5247 CNRS, ENSCM, Universite de Montpellier, Montpellier, France
| | - Jean-Marie Galano
- Institut des Biomolecules Max Mousseron, UMR 5247 CNRS, ENSCM, Universite de Montpellier, Montpellier, France
| | - Claire Vigor
- Institut des Biomolecules Max Mousseron, UMR 5247 CNRS, ENSCM, Universite de Montpellier, Montpellier, France
| | - Thierry Durand
- Institut des Biomolecules Max Mousseron, UMR 5247 CNRS, ENSCM, Universite de Montpellier, Montpellier, France
| | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute Hospital La Fe, Valencia, Spain
| | - Máximo Vento
- Neonatal Research Group, Health Research Institute Hospital La Fe, Valencia, Spain.,Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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50
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Das Y, Leon RL, Liu H, Kota S, Liu Y, Wang X, Zhang R, Chalak LF. Wavelet-based neurovascular coupling can predict brain abnormalities in neonatal encephalopathy. Neuroimage Clin 2021; 32:102856. [PMID: 34715603 PMCID: PMC8564674 DOI: 10.1016/j.nicl.2021.102856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 09/24/2021] [Accepted: 10/12/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) is a leading cause of morbidity and mortality in neonates, but quantitative methods to predict outcomes early in their course of illness remain elusive. Real-time physiologic biomarkers of neurologic injury are needed in order to predict which neonates will benefit from therapies. Neurovascular coupling (NVC) describes the correlation of neural activity with cerebral blood flow, and the degree of impairment could predict those at risk for poor outcomes. OBJECTIVE To determine if neurovascular coupling (NVC) calculated in the first 24-hours of life based on wavelet transform coherence analysis (WTC) of near-infrared spectroscopy (NIRS) and amplitude-integrated electroencephalography (aEEG) can predict abnormal brain MRI in neonatal HIE. METHODS WTC analysis was performed between dynamic oscillations of simultaneously recorded aEEG and cerebral tissue oxygen saturation (SctO2) signals for the first 24 h after birth. The squared cross-wavelet coherence, R2, of the time-frequency domain described by the WTC, is a localized correlation coefficient (ranging between 0 and 1) between these two signals in the time-frequency domain. Statistical analysis was based on Monte Carlo simulation with a 95% confidence interval to identify the time-frequency areas from the WTC scalograms. Brain MRI was performed on all neonates and classified as normal or abnormal based on an accepted classification system for HIE. Wavelet metrics of % significant SctO2-aEEG coherence was compared between the normal and abnormal MRI groups. RESULT This prospective study recruited a total of 36 neonates with HIE. A total of 10 had an abnormal brain MRI while 26 had normal MRI. The analysis showed that the SctO2-aEEG coherence between the group with normal and abnormal MRI were significantly different (p = 0.0007) in a very low-frequency (VLF) range of 0.06-0.2 mHz. Using receiver operating characteristic (ROC) curves, the use of WTC-analysis of NVC had an area under the curve (AUC) of 0.808, and with a cutoff of 10% NVC. Sensitivity was 69%, specificity was 90%, positive predictive value (PPV) was 94%, and negative predictive value (NPV) was 52% for predicting brain injury on MRI. This was superior to the clinical Total Sarnat score (TSS) where AUC was 0.442 with sensitivity 61.5%, specificity 30%, PPV 75%, and NPV 31%. CONCLUSION NVC is a promising neurophysiological biomarker in neonates with HIE, and in our prospective cohort was superior to the clinical Total Sarnat score for prediction of abnormal brain MRI.
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Affiliation(s)
- Yudhajit Das
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, USA
| | - Rachel L Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, USA
| | - Srinivas Kota
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yulun Liu
- Department of Population and Datasciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Xinlong Wang
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, USA
| | - Rong Zhang
- Departments of Neurology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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