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Wu BA, Chand KK, Bell A, Miller SL, Colditz PB, Malhotra A, Wixey JA. Effects of fetal growth restriction on the perinatal neurovascular unit and possible treatment targets. Pediatr Res 2024; 95:59-69. [PMID: 37674023 PMCID: PMC10798895 DOI: 10.1038/s41390-023-02805-w] [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: 03/01/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
The neurovascular unit (NVU) within the brain is a multicellular unit that synergistically acts to maintain blood-brain barrier function and meet cerebral metabolic demand. Recent studies have indicated disruption to the NVU is associated with neuropathology in the perinatal brain. Infants with fetal growth restriction (FGR) are known to be at increased risk of neurodevelopmental conditions including motor, learning, and behavioural deficits. There are currently no neuroprotective treatments for these conditions. In this review, we analyse large animal studies examining the effects of FGR on the perinatal NVU. These studies show altered vascularity in the FGR brain as well as blood-brain barrier dysfunction due to underlying cellular changes, mediated by neuroinflammation. Neuroinflammation is a key mechanism associated with pathological effects in the FGR brain. Hence, targeting inflammation may be key to preserving the multicellular NVU and providing neuroprotection in FGR. A number of maternal and postnatal therapies with anti-inflammatory components have been investigated in FGR animal models examining targets for amelioration of NVU disruption. Each therapy showed promise by uniquely ameliorating the adverse effects of FGR on multiple aspects of the NVU. The successful implementation of a clinically viable neuroprotective treatment has the potential to improve outcomes for neonates affected by FGR. IMPACT: Disruption to the neurovascular unit is associated with neuropathology in fetal growth restriction. Inflammation is a key mechanism associated with neurovascular unit disruption in the growth-restricted brain. Anti-inflammatory treatments ameliorate adverse effects on the neurovascular unit and may provide neuroprotection.
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Affiliation(s)
- Bing Anthony Wu
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Kirat K Chand
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Alexander Bell
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Suzanne L Miller
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Paul B Colditz
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Perinatal Research Centre, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Atul Malhotra
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Julie A Wixey
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
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Chan KYY, Miller SL, Schmölzer GM, Stojanovska V, Polglase GR. Respiratory Support of the Preterm Neonate: Lessons About Ventilation-Induced Brain Injury From Large Animal Models. Front Neurol 2020; 11:862. [PMID: 32922358 PMCID: PMC7456830 DOI: 10.3389/fneur.2020.00862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
Many preterm neonates require mechanical ventilation which increases the risk of cerebral inflammation and white matter injury in the immature brain. In this review, we discuss the links between ventilation and brain injury with a focus on the immediate period after birth, incorporating respiratory support in the delivery room and subsequent mechanical ventilation in the neonatal intensive care unit. This review collates insight from large animal models in which acute injurious ventilation and prolonged periods of ventilation have been used to create clinically relevant brain injury patterns. These models are valuable resources in investigating the pathophysiology of ventilation-induced brain injury and have important translational implications. We discuss the challenges of reconciling lung and brain maturation in commonly used large animal models. A comprehensive understanding of ventilation-induced brain injury is necessary to guide the way we care for preterm neonates, with the goal to improve their neurodevelopmental outcomes.
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Affiliation(s)
- Kyra Y Y Chan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
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Malhotra A, Castillo-Melendez M, Allison BJ, Sutherland AE, Nitsos I, Pham Y, McDonald CA, Fahey MC, Polglase GR, Jenkin G, Miller SL. Neurovascular effects of umbilical cord blood-derived stem cells in growth-restricted newborn lambs : UCBCs for perinatal brain injury. Stem Cell Res Ther 2020; 11:17. [PMID: 31915068 PMCID: PMC6947982 DOI: 10.1186/s13287-019-1526-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/28/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background Neonatal ventilation exacerbates brain injury in lambs with fetal growth restriction (FGR), characterized by neuroinflammation and reduced blood-brain barrier integrity, which is normally maintained by the neurovascular unit. We examined whether umbilical cord blood stem cell (UCBC) treatment stabilized the neurovascular unit and reduced brain injury in preterm ventilated FGR lambs. Methods Surgery was performed in twin-bearing pregnant ewes at 88 days’ gestation to induce FGR in one fetus. At 127 days, FGR and appropriate for gestational age (AGA) lambs were delivered, carotid artery flow probes and umbilical lines inserted, lambs intubated and commenced on gentle ventilation. Allogeneic ovine UCBCs (25 × 106 cells/kg) were administered intravenously to lambs at 1 h of life. Lambs were ventilated for 24 h and then euthanized. Results FGR (n = 6) and FGR+UCBC (n = 6) lambs were growth restricted compared to AGA (n = 6) and AGA+UCBC (n = 6) lambs (combined weight, FGR 2.3 ± 0.4 vs. AGA 3.0 ± 0.3 kg; p = 0.0002). UCBC therapy did not alter mean arterial blood pressure or carotid blood flow but decreased cerebrovascular resistance in FGR+UCBC lambs. Circulating TNF-α cytokine levels were lower in FGR+UCBC vs. FGR lambs (p < 0.05). Brain histopathology showed decreased neuroinflammation and oxidative stress, increased endothelial cell proliferation, pericyte stability, and greater integrity of the neurovascular unit in FGR+UCBC vs. FGR lambs. Conclusions Umbilical cord blood stem cell therapy mitigates perinatal brain injury due to FGR and ventilation, and the neuroprotective benefits may be mediated by stabilization of the neurovascular unit.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia. .,Department of Paediatrics, Monash University, Melbourne, Australia. .,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Courtney A McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Michael C Fahey
- Department of Paediatrics, Monash University, Melbourne, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
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Malhotra A, Allison BJ, Castillo-Melendez M, Jenkin G, Polglase GR, Miller SL. Neonatal Morbidities of Fetal Growth Restriction: Pathophysiology and Impact. Front Endocrinol (Lausanne) 2019; 10:55. [PMID: 30792696 PMCID: PMC6374308 DOI: 10.3389/fendo.2019.00055] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/22/2019] [Indexed: 12/11/2022] Open
Abstract
Being born small lays the foundation for short-term and long-term implications for life. Intrauterine or fetal growth restriction describes the pregnancy complication of pathological reduced fetal growth, leading to significant perinatal mortality and morbidity, and subsequent long-term deficits. Placental insufficiency is the principal cause of FGR, which in turn underlies a chronic undersupply of oxygen and nutrients to the fetus. The neonatal morbidities associated with FGR depend on the timing of onset of placental dysfunction and growth restriction, its severity, and the gestation at birth of the infant. In this review, we explore the pathophysiological mechanisms involved in the development of major neonatal morbidities in FGR, and their impact on the health of the infant. Fetal cardiovascular adaptation and altered organ development during gestation are principal contributors to postnatal consequences of FGR. Clinical presentation, diagnostic tools and management strategies of neonatal morbidities are presented. We also present information on the current status of targeted therapies. A better understanding of neonatal morbidities associated with FGR will enable early neonatal detection, monitoring and management of potential adverse outcomes in the newborn period and beyond.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- *Correspondence: Atul Malhotra
| | - Beth J. Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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Malhotra A, Castillo-Melendez M, Allison BJ, Sutherland AE, Nitsos I, Pham Y, Alves de Alencar Rocha AK, Fahey MC, Polglase GR, Jenkin G, Miller SL. Neuropathology as a consequence of neonatal ventilation in premature growth-restricted lambs. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1183-R1194. [PMID: 30230932 DOI: 10.1152/ajpregu.00171.2018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fetal growth restriction (FGR) and prematurity are associated with high risk of brain injury and long-term neurological deficits. FGR infants born preterm are commonly exposed to mechanical ventilation, but it is not known whether ventilation differentially induces brain pathology in FGR infants compared with appropriate for gestational age (AGA) infants. We investigated markers of neuropathology in moderate- to late-preterm FGR lambs, compared with AGA lambs, delivered by caesarean birth and ventilated under standard neonatal conditions for 24 h. FGR was induced by single umbilical artery ligation in fetal sheep at 88-day gestation (term, 150 days). At 125-day gestation, FGR and AGA lambs were delivered, dried, intubated, and commenced on noninjurious ventilation, with surfactant administration at 10 min. A group of unventilated FGR and AGA lambs at the same gestation was also examined. Over 24 h, circulating pH, Po2, and lactate levels were similar between groups. Ventilated FGR lambs had lower cerebral blood flow compared with AGA lambs ( P = 0.01). The brain of ventilated FGR lambs showed neuropathology compared with unventilated FGR, and unventilated and ventilated AGA lambs, with increased apoptosis (caspase-3), blood-brain barrier dysfunction (albumin extravasation), activated microglia (Iba-1), and increased expression of cellular oxidative stress (4-hydroxynonenal). The neuropathologies seen in the ventilated FGR brain were most pronounced in the periventricular and subcortical white matter but also evident in the subventricular zone, cortical gray matter, and hippocampus. Ventilation of preterm FGR lambs increased brain injury compared with AGA preterm lambs and unventilated FGR lambs, mediated via increased vascular permeability, neuroinflammation and oxidative stress.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital , Melbourne , Australia.,Department of Paediatrics, Monash University , Melbourne , Australia.,The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia.,Department of Obstetrics and Gynaecology, Monash University , Melbourne , Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia.,Department of Obstetrics and Gynaecology, Monash University , Melbourne , Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia
| | | | - Michael C Fahey
- Department of Paediatrics, Monash University , Melbourne , Australia.,The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia.,Department of Obstetrics and Gynaecology, Monash University , Melbourne , Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia.,Department of Obstetrics and Gynaecology, Monash University , Melbourne , Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne , Australia.,Department of Obstetrics and Gynaecology, Monash University , Melbourne , Australia
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Sriram S, Schreiber MD, Msall ME, Kuban KCK, Joseph RM, O' Shea TM, Allred EN, Leviton A. Cognitive Development and Quality of Life Associated With BPD in 10-Year-Olds Born Preterm. Pediatrics 2018; 141:e20172719. [PMID: 29773664 PMCID: PMC6317639 DOI: 10.1542/peds.2017-2719] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To compare neurocognitive, language, executive function, academic achievement, neurologic and behavioral outcomes, and quality of life at age 10 years in children born extremely preterm who developed bronchopulmonary dysplasia (BPD) to children who did not develop BPD. METHODS The Extremely Low Gestational Age Newborns study population included 863 children born extremely preterm whose BPD status before discharge was known had an IQ (Differential Ability Scales II [DAS II]) assessment at 10 years. We evaluated the association of BPD with any cognitive (DAS II), executive function (NEuroPSYchological Assessment II), academic achievement (Wechsler Individual Achievement Test-III and Oral and Written Language Scales [OWLS]) as well as social dysfunctions (Social Responsiveness Scale). We used logistic regression models, adjusting for potential confounding factors, to assess the strength of association between the severity of BPD and each outcomes. RESULTS Three hundred and seventy-two (43%) children were oxygen-dependent at 36 weeks postconception age, whereas an additional 78 (9%) were also oxygen- and ventilator-dependent. IQ scores 2 or more SDs below the expected mean (ie, z scores ≤-2) occurred twice as commonly among children who had BPD as among those who did not. Children with severe BPD consistently had the lowest scores on DAS II, OWLS, Wechsler Individual Achievement Test-III, NEuroPSYchological Assessment II, and Social Responsiveness Scale assessments. CONCLUSIONS Among 10-year-old children born extremely preterm, those who had BPD were at increased risk of cognitive, language, and executive dysfunctions; academic achievement limitations; social skill deficits; and low scores on assessments of health-related quality of life.
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Affiliation(s)
- Sudhir Sriram
- Department of Pediatrics, Section of Neonatology, and
| | | | - Michael E Msall
- Section of Developmental and Behavioral Pediatrics, Kennedy Research Center on Intellectual and Developmental Disabilities, The University of Chicago, Chicago, Illinois
| | - Karl C K Kuban
- Division of Pediatric Neurology, Departments of Pediatrics and
| | - Robert M Joseph
- Anatomy and Neurobiology, School of Medicine, Boston University, Boston, Massachusetts
| | - T Michael O' Shea
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Elizabeth N Allred
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Alan Leviton
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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Australian Perspectives: Outcomes from the 2016 ANZ DOHaD Scientific Meeting. J Dev Orig Health Dis 2017. [DOI: 10.1017/s2040174417000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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