Cyclical fluctuations in blood pressure, heart rate and cerebral blood volume in preterm infants

Low frequency cerebral arterial and venous flow oscillations in healthy neonates measured by NeoDoppler

BACKGROUND

A cerebroprotective effect of low frequency oscillations (LFO) in cerebral blood flow (CBF) has been suggested in adults, but its significance in neonates is not known. This observational study evaluates normal arterial and venous cerebral blood flow in healthy neonates using NeoDoppler, a novel Doppler ultrasound system which can measure cerebral hemodynamics continuously.

METHOD

Ultrasound Doppler data was collected for 2 h on the first and second day of life in 36 healthy term born neonates. LFO (0.04-0.15 Hz) were extracted from the velocity curve by a bandpass filter. An angle independent LFO index was calculated as the coefficient of variation of the filtered curve. Separate analyses were done for arterial and venous signals, and results were related to postnatal age and behavioral state (asleep or awake).

RESULTS

The paper describes normal physiologic variations of arterial and venous cerebral hemodynamics. Mean (SD) arterial and venous LFO indices (%) were 6.52 (2.55) and 3.91 (2.54) on day one, and 5.60 (1.86) and 3.32 (2.03) on day two. After adjusting for possible confounding factors, the arterial LFO index was estimated to decrease by 0.92 percent points per postnatal day (p < 0.001). The venous LFO index did not change significantly with postnatal age (p = 0.539). Arterial and venous LFO were not notably influenced by behavioral state.

CONCLUSION

The results indicate that arterial LFO decrease during the first 2 days of life in healthy neonates. This decrease most likely represents normal physiological changes related to the transitional period. A similar decrease for venous LFO was not found.

Current Status and Issues Regarding Pre-processing of fNIRS Neuroimaging Data: An Investigation of Diverse Signal Filtering Methods Within a General Linear Model Framework

Functional near-infrared spectroscopy (fNIRS) research articles show a large heterogeneity in the analysis approaches and pre-processing procedures. Additionally, there is often a lack of a complete description of the methods applied, necessary for study replication or for results comparison. The aims of this paper were (i) to review and investigate which information is generally included in published fNIRS papers, and (ii) to define a signal pre-processing procedure to set a common ground for standardization guidelines. To this goal, we have reviewed 110 fNIRS articles published in 2016 in the field of cognitive neuroscience, and performed a simulation analysis with synthetic fNIRS data to optimize the signal filtering step before applying the GLM method for statistical inference. Our results highlight the fact that many papers lack important information, and there is a large variability in the filtering methods used. Our simulations demonstrated that the optimal approach to remove noise and recover the hemodynamic response from fNIRS data in a GLM framework is to use a 1000th order band-pass Finite Impulse Response filter. Based on these results, we give preliminary recommendations as to the first step toward improving the analysis of fNIRS data and dissemination of the results.

Design of multichannel functional near-infrared spectroscopy system with application to propofol and sevoflurane anesthesia monitoring

Monitoring the changes of cerebral hemodynamics and the state of consciousness during general anesthesia (GA) is clinically important. There is a great need for developing advanced detectors to investigate the physiological processes of the brain during GA. We developed a multichanneled, functional near-infrared spectroscopy (fNIRS) system device and applied it to GA operation monitoring. The cerebral hemodynamic data from the forehead of 11 patients undergoing propofol and sevoflurane anesthesia were analyzed. The concentration changes of oxygenated hemoglobin, deoxygenated hemoglobin, total hemoglobin, and cerebral tissue heart rate were determined from the raw optical information based on the discrete stationary wavelet transform. This custom-made device provides an easy-to-build solution for continuous wave-fNIRS system, with customized specifications. The developed device has a potential value in cerebral monitoring in clinical settings.

Can the Assessment of Spontaneous Oscillations by Near Infrared Spectrophotometry Predict Neurological Outcome of Preterm Infants?

The aim was to assess the correlation between cerebral autoregulation and outcome. Included were 31 preterm infants, gestational age 26 1/7 to 32 2/7 and <24 h life. Coherence between cerebral total haemoglobin (tHb) or oxygenation index (OI) measured by near-infrared spectrophotometry (NIRS) and systemic heart rate (HR) or arterial blood pressure (MAP) was calculated as a measure of autoregulation. In contrast to previous studies, low coherences in the first 24 h were significantly associated with intraventricular haemorrhage, death or abnormal neurodevelopmental outcome at 18 months or later. We suggest that our results can be explained by the concept of a multi-oscillatory-functions-order.

Extrauterine environment influences spontaneous low-frequency oscillations in the preterm brain

Low-frequency oscillations in cerebral blood flow that are suggestive of resting-state brain activity have recently been reported, but no study on the development of resting-state brain activity in preterm infants has been performed. The objective of this study was to measure the cerebral blood flow oscillations, which are assumed to represent brain function in the resting state, in preterm and term infants of the same postconceptional age. The subjects were 9 preterm infants who had reached full term (gestational age (GA): 23-34 weeks, postconceptional age: 37-46 weeks) and 10 term infants (GA: 37-40 weeks, postconceptional age: 37-41 weeks). Their changes in concentration of oxyhemoglobin ([oxyHb]) and deoxyhemoglobin ([deoxyHb]) were measured in the parieto-temporal region during quiet sleep using multi-channel near-infrared spectroscopy, and the power spectral densities (PSD) of the oscillations in the concentrations of these molecules were analyzed and compared. The preterm infants displayed a higher proportion of 0.06-0.10 Hz low frequency oscillations of [oxyHb] and [deoxyHb] than the term infants, and the gestational age and the proportion of low frequency oscillations were inversely correlated. These findings suggest that resting-state cerebral blood flow oscillations differ between preterm and term infants, and that the development of circulatory regulation and nerve activity in preterm infants are influenced by the extrauterine environment.

Assessment of cardio-respiratory interactions in preterm infants by bivariate autoregressive modeling and surrogate data analysis

BACKGROUND

Cardio-respiratory interactions are weak at the earliest stages of human development, suggesting that assessment of their presence and integrity may be an important indicator of development in infants. Despite the valuable research devoted to infant development, there is still a need for specifically targeted standards and methods to assess cardiopulmonary functions in the early stages of life. We present a new methodological framework for the analysis of cardiovascular variables in preterm infants. Our approach is based on a set of mathematical tools that have been successful in quantifying important cardiovascular control mechanisms in adult humans, here specifically adapted to reflect the physiology of the developing cardiovascular system.

METHODS

We applied our methodology in a study of cardio-respiratory responses for 11 preterm infants. We quantified cardio-respiratory interactions using specifically tailored multivariate autoregressive analysis and calculated the coherence as well as gain using causal approaches. The significance of the interactions in each subject was determined by surrogate data analysis. The method was tested in control conditions as well as in two different experimental conditions; with and without use of mild mechanosensory intervention.

RESULTS

Our multivariate analysis revealed a significantly higher coherence, as confirmed by surrogate data analysis, in the frequency range associated with eupneic breathing compared to the other ranges.

CONCLUSIONS

Our analysis validates the models behind our new approaches, and our results confirm the presence of cardio-respiratory coupling in early stages of development, particularly during periods of mild mechanosensory intervention, thus encouraging further application of our approach.

Cerebral tissue oxygenation and regional oxygen saturation can be used to study cerebral autoregulation in prematurely born infants

The coupling of cerebral intravascular oxygenation (dHbD) with mean arterial blood pressure (MABP) was taken as a reflection of autoregulation assuming constant arterial oxygen content. However, this method is sensitive to movement artifacts. We examined whether the cerebral tissue oxygenation index (cTOI) and regional oxygen saturation (rScO2) may replace dHbD and changes in total Hb (dHbT), respectively. Correlation (COR) and coherence (COH) were used to measure the agreement of MABP with rScO2/dHbT and cTOI/dHbD. dHbD/cTOI and dHbT/rScO2 recordings of, respectively, 34 and 20 preterm infants in need for intensive care were studied during the first days of life. dHbD and cTOI were obtained with the NIRO300 and rScO2 and dHbT with the INVOS4100. Invasive MABP was measured continuously. COR and COH scores of MABP versus dHbD/dHbT were compared with the corresponding ones by replacing dHbD/dHbT by cTOI/rScO2, respectively. Generally, no significant score differences were found for dHbD/cTOI. Differences for dHbT/rScO2 were slightly larger but still within the normal variation of the parameters. Differences become insignificant when restricting calculations to epochs of larger variation in MABP (>10 mm Hg). Hence, we suggest that cTOI and rScO2 can be used to study cerebral autoregulation in newborns.

The role of systemic hemodynamic disturbances in prematurity-related brain injury

Premature infants who experience cerebrovascular injury frequently have acute and long-term neurologic complications. In this article, we explore the relationship between systemic hemodynamic insults and brain injury in this patient population and the mechanisms that might be at play.

HomER: a review of time-series analysis methods for near-infrared spectroscopy of the brain

Near-infrared spectroscopy (NIRS) is a noninvasive neuroimaging tool for studying evoked hemodynamic changes within the brain. By this technique, changes in the optical absorption of light are recorded over time and are used to estimate the functionally evoked changes in cerebral oxyhemoglobin and deoxyhemoglobin concentrations that result from local cerebral vascular and oxygen metabolic effects during brain activity. Over the past three decades this technology has continued to grow, and today NIRS studies have found many niche applications in the fields of psychology, physiology, and cerebral pathology. The growing popularity of this technique is in part associated with a lower cost and increased portability of NIRS equipment when compared with other imaging modalities, such as functional magnetic resonance imaging and positron emission tomography. With this increasing number of applications, new techniques for the processing, analysis, and interpretation of NIRS data are continually being developed. We review some of the time-series and functional analysis techniques that are currently used in NIRS studies, we describe the practical implementation of various signal processing techniques for removing physiological, instrumental, and motion-artifact noise from optical data, and we discuss the unique aspects of NIRS analysis in comparison with other brain imaging modalities. These methods are described within the context of the MATLAB-based graphical user interface program, HomER, which we have developed and distributed to facilitate the processing of optical functional brain data.

Cerebrovascular injury in premature infants: current understanding and challenges for future prevention

Cerebrovascular insults are a leading cause of brain injury in premature infants, contributing to the high prevalence of motor, cognitive, and behavioral deficits. Understanding the complex pathways linking circulatory immaturity to brain injury in premature infants remains incomplete. These mechanisms are significantly different from those causing injury in the mature brain. The gaps in knowledge of normal and disturbed cerebral vasoregulation need to be addressed. This article reviews current understanding of cerebral perfusion, in the sick premature infant in particular, and discusses challenges that lie ahead.

Quantitative evaluation of interrelations between spontaneous low-frequency oscillations in cerebral hemodynamics and systemic cardiovascular dynamics

A common issue in blood-related brain-function measurements, such as optical topography, is that the observed signals are usually corrupted with strong noise that is primarily spontaneous low-frequency oscillations (LFOs) in cerebral hemodynamics, which are difficult to separate from the signals due to functional brain activity because of their common spectral range. We discuss the analysis of information transfer between LFOs around 0.1 Hz in the hemoglobin concentration change (HbCC) in the cerebral cortex, the heart rate (HR), and the mean arterial blood pressure (ABP) to understand the origin of spontaneous LFOs in cerebral hemodynamics. As measures of information transfer, we used transfer entropy (TE) for two-variable system analysis and introduced intrinsic transfer entropy for further analysis of three-variable systems by extending the original TE. Data for analysis were obtained from simultaneous measurements with optical topography and infrared finger plethysmography under rest conditions. The analysis revealed that the LFOs in oxy HbCC, a parameter of cerebral hemodynamics, mainly stem from HR, but its contribution is only about 20%. In addition, the intrinsic contribution of ABP is about 5% and the common contribution of HR and ABP is about 10%. From these, HR and ABP cannot account for more than the half the information carried with variable oxy HbCC, which suggests the origin of LFOs in cerebral hemodynamics may lie in the regulation of regional cerebral blood flow change and energetic metabolism rather than due to the systemic regulation of the cardiovascular system.

Relationship between slow-wave EEG bursts and heart rate changes in preterm infants

The objective of the study is to explore interactions between cortical and autonomic functions in the first weeks of postnatal life. We investigated the behaviour of one-channel electroencephalogram (EEG) patterns and heart rate (HR) dynamics in preterm infants. In a group of 15 healthy preterm infants with a mean conceptional age (CA) of 36 weeks and a mean postnatal age of 17.5 days simultaneous registration of amplitude integrated EEG (aEEG) and HR pattern was performed during interfeeding intervals. Periods with a discontinuous EEG activity and a low heart-rate variability (HRV) were selected for further processing and averaging. It was found that spontaneous activity transients (SATs) or slow wave EEG bursts during "Tracé alternant" (TA) can be accompanied by an HR acceleration of 1-2% (mean: 1.9, range: 0.6-3.5 beats/min) lasting approximately 5s (mean, range: 3.6-7.1s). The aim of the study is to give evidence of a coherent behaviour of EEG bursts and HR in the developing nervous system of preterm infants.

A new multichannel near infrared spectrophotometry system for functional studies of the brain in adults and neonates

We have designed a versatile, multi-channel near-infrared spectrophotometry (NIRS) instrument for the purpose of mapping neuronal activation in the neonatal and adult brain in response to motor, tactile, and visual stimulation. The optical linearity, stability, and high signal to noise ratio (>70 dB) of the instrument were demonstrated using an in vitro validation procedure. In vivo measurements on the adult forearm were also performed. Changes in oxygenation, induced by arterial occlusion of the forearm, were recorded and were shown to compare well with measurements acquired using a conventional NIRS instrument. To demonstrate the capabilities of the instrument, functional measurements in adults and neonates were performed. The instrument exhibited the capability to differentiate with a spatial resolution in the order of cm, local activation patterns associated with a finger tapping sequence.

Identification of pressure passive cerebral perfusion and its mediators after infant cardiac surgery

Cerebrovascular pressure autoregulation (CPA) regulates cerebral blood flow (CBF) in relation to changes in mean arterial blood pressure (MAP). Identification of a pressure-passive cerebral perfusion and the potentially modifiable physiologic factors underlying it has been difficult to achieve in sick infants. We previously validated the near-infrared spectroscopy-derived hemoglobin difference (HbD) signal (cerebral oxyhemoglobin - deoxyhemoglobin) as a reliable measure of changes in CBF in animal models. We now sought to determine whether continuous measurements of DeltaHbD would correlate to middle cerebral artery flow velocity (CBFV), allow identification and quantification of pressure-passive state, and help to delineate potentially modifiable factors. We enrolled 43 infants (2 d to 7 mo old) who were undergoing open cardiac surgery and cardiopulmonary bypass. At 6 and 20 h after surgery, we measured changes in HbD, CBFV (by transcranial Doppler), and MAP at different end-tidal CO(2) levels. We assigned a pressure-passive index (PPI) to each study on the basis of the relative duration of significant coherence between DeltaMAP and DeltaHbD. We found a significant relationship between DeltaHbD and DeltaCBFV at both time points. At 6 h after surgery, we showed high concordance (coherence > 0.5; PPI > or = 41%) between DeltaMAP and DeltaHbD, consistent with disturbed CPA in 13% of infants. End-tidal CO(2) values > or = 40 mm Hg and higher MAP variability both were associated with increased odds (p < 0.001) of autoregulatory failure. This approach provides a means to identify and quantify disturbances of CPA. High CO(2) levels and fluctuating MAP are two important preventable factors associated with disturbed CPA.

Closed versus partially ventilated endotracheal suction in extremely preterm neonates: physiologic consequences

This randomized cross over study aimed to compare the severity and incidences of desaturation and bradycardia between the partially ventilated endotracheal suction method (PVETS) and closed tracheal suction system (CTSS) in extremely preterm neonates. Fifteen intubated and ventilated extremely low birth weight preterm infants (mean birth weight 689g) randomly underwent both suction techniques within a 12-h period to obtain a paired reading group. The process was repeated 24-48h apart until three pairs of reading groups were collected. Changes in oxygen saturation measured with pulse oximetry and heart rate changes measured with electrocardiogram were recorded using Hewlett-Packard m240A monitor trending software. The mean of each parameter's variation from baseline was obtained using SPSS descriptive statistics and analyzed using SPSS repeated measures ANOVA. Fisher Exact Test was used to analyze the incidence of desaturation and bradycardia. The closed tracheal suction system reported a significantly smaller degree of oxygen saturation fall (P<0.005) and significantly fewer incidences of desaturation. There was also a significantly smaller degree of heart rate reduction although episodes of bradycardia were not significantly different between the two methods. Oxygen saturation and heart rate were significantly more stable during the use of CTSS compared to PVETS in the extremely low birth weight preterm population.

In vivo near-infrared spectroscopy

Interrogation of tissue with light offers the potential for noninvasive chemical measurement, and penetration with near-infrared wavelengths (750-1000 nm) is greater than with visible light. Specific absorption by clinically relevant compounds such as oxy- and deoxyhemoglobin and the intracellular respiratory enzyme cytochrome oxidase enable in vivo measurement of these to be performed safely and conveniently. This is the basis of in vivo near-infrared spectroscopy (ivNIRS). Multiple scattering of the interrogating beam by tissues leads to an optical path that is considerably longer than the simple physical pathlength and this complicates the analysis. Modeling of photon propagation through tissues with, for example, finite element and Monte Carlo methods, is assisting in improving the ivNIRS methodology. Instrumentation has advanced from simple continuous wave approaches, through time-resolved methods based on either time-domain or frequency-domain approaches, to spatially resolved measurement based on diffuse reflectance. Initial clinical applications were for monitoring the brain in the neonate and fetus and muscle in adults. Currently, use in adults and children for neurological assessments are of growing interest.

Tissue oxygen saturation measured by near infrared spectrophotometry correlates with arterial oxygen saturation during induced oxygenation changes in neonates

The aim of this study was to compare quantitatively the changes in tissue oxygen saturation (TOS), determined by two algorithms (TOSc and TOSa) based on near-infrared spectrophotometry, to the changes in arterial oxygen saturation (SaO2) measured by pulse oximetry. TOSc is an algorithm derived by the manufacturer (Critikon) based on a modified Beer-Lambert law; TOSa, our own algorithm, uses the diffusion approximation of light transport for the semi-infinite boundary condition. Slow changes of more than 3% in SaO2 were carried out in 20 mechanically ventilated neonates by altering the inspired oxygen fraction. For each change the regression lines of TOSc versus SaO2, TOSa versus SaO2 and TOSc versus TOSa were calculatcd. For each infant the mcan slope, intercept and r2 of these lines were determined. In 18 preterm infants we obtained median 9.5 (range one to 13) measurements corresponding to a total of 166 measurements. The mean SaO2 was 91.6 (SD 2.3)%, TOSc was 64.7 (SD 7.2)% and TOSa was 71.4 (SD 11.0)%. Changes in TOSc and TOSa were strongly correlated to changes in SaO2 (r2 = 0.86 and r2 = 0.87). TOSc considerably but systematically underestimated the size of the change: delta TOSc = 0.49 delta SaO2. TOSa quantified changes reasonably correctly: delta TOSa = 0.90 delta SaO2. Changes in TOSc and TOSa were highly correlated (r2 = 0.98). These results are promising, but the large inter-individual variation requires further work.

Cerebral intravascular oxygenation correlates with mean arterial pressure in critically ill premature infants

OBJECTIVES

Premature infants experience brain injury, ie, germinal matrix-intraventricular hemorrhage (GMH-IVH) and periventricular leukomalacia (PVL), in considerable part because of disturbances in cerebral blood flow (CBF). Because such infants are susceptible to major fluctuations in mean arterial blood pressure (MAP), impaired cerebrovascular autoregulation would increase the likelihood for the changes in CBF that could result in GMH-IVH and PVL. The objectives of this study were to determine whether a state of impaired cerebrovascular autoregulation could be identified reliably and conveniently at the bedside, the frequency of any such impairment, and the relation of the impairment to the subsequent occurrence of severe GMH-IVH and PVL.

PATIENTS AND METHODS

To monitor the cerebral circulation continuously and noninvasively, we used near-infrared spectroscopy (NIRS) to determine quantitative changes in cerebral concentrations of oxygenated hemoglobin (HbO(2)) and deoxygenated hemoglobin (Hb) from the first hours of life. Our previous experimental study showed a strong correlation between a measure of cerebral intravascular oxygenation (HbD), ie, HbD = HbO(2) - Hb, determined by NIRS, and volemic CBF, determined by radioactive microspheres. We studied 32 very low birth weight premature infants (gestational age: 23-31 weeks; birth weight: 605-1870 g) requiring mechanical ventilation, supplemental oxygen, and invasive blood pressure monitoring by NIRS from 1 to 3 days of age. MAP measured by arterial catheter pressure transducer and arterial oxygen saturation measured by pulse oximetry were recorded simultaneously. The relationship of MAP to HbD was quantitated by coherence analysis.

RESULTS

Concordant changes (coherence scores >. 5) in HbD and MAP, consistent with impaired cerebrovascular autoregulation, were observed in 17 of the 32 infants (53%). Eight of the 17 infants (47%) developed severe GMH-IVH or PVL or both. Of the 15 infants with apparently intact autoregulation, ie, coherence scores <.5, only 2 (13%) developed severe ultrasonographic lesions. Thus, for the entire study population of 32 infants, 8 of the 10 with severe lesions exhibited coherence scores >.5.

CONCLUSIONS

We conclude that NIRS can be used in a noninvasive manner at the bedside to identify premature infants with impaired cerebrovascular autoregulation, that this impairment is relatively common in such infants, and that the presence of this impairment is associated with a high likelihood of occurrence of severe GMH-IVH/PVL.