Injury and recovery in the developing brain: evidence from functional MRI studies of prematurely born children

Birth weight, verbal cognition in early adolescence, and lexical and reading skills in late adolescence: a formal mediation analysis using a potential outcomes approach

BACKGROUND

Oral and written language in late adolescence are influenced by many pre- and postnatal factors, including cognitive performance at earlier ages. We investigated whether the association between birth weight and lexical knowledge and reading comprehension in late adolescence (14-16 years) is mediated by verbal cognition during early adolescence (10-11 years).

METHODS

We conducted a mediation analysis via a potential outcomes approach to data from three United Kingdom (UK) prospective birth cohorts - The National Child Development Study (NCDS; year of birth (Y.B.) = 1,958; analytic sample size (A.N.) = 9,399; original sample size (O.N.) = 18,558), British Cohort Study (BCS70; Y.B. = 1,970; A.N. = 6,591; O.N. = 17,196), and Millennium Cohort Study (MCS; Y.B. = 2,000-2,001; A.N. = 3,950; O.N. = 18,552) - to evaluate the indirect effects of birth weight on lexical knowledge (BCS and MCS) and reading comprehension measures (NCDS) in adolescence.

RESULTS

We found an indirect effect but no statistically significant direct effects for the BCS and MCS cohorts. The proportion of the effect of birth weight on oral and written language in late adolescence mediated by early adolescence verbal cognition was 59.19% (BCS) and 8.41% (MCS) for lexical knowledge and 61.00% when the outcome was reading comprehension (NCDS). Sensitivity analyses, used to assess whether unmeasured variables could have affected our mediation estimates, showed that for reading comprehension, in NCDS, the indirect effect is robust; only unmeasured confounders highly correlated with the mediator and outcome (ρ = .68) would explain away the indirect effect. For lexical knowledge, smaller correlations with hypothetical confounders (ρ = .33 for BCS) would suffice to render the indirect effect non-significant; the indirect effect for MCS non statistical significant.

CONCLUSIONS

Birth weight affects oral and written language skills (lexical knowledge and reading comprehension) in late adolescence via verbal cognition in early adolescence in two cohorts born in 1958 and 1970, but not in a cohort born at the turn of the millennium. These indirect effects were stronger than the direct effects and are unlikely to be explained by unmeasured confounders when the outcome involves complex skills such as reading comprehension.

Trajectories of brain development in school-age children born preterm with very low birth weight

Preterm birth (gestational age < 37 weeks) with very low birth weight (VLBW, birth weight ≤ 1500 g) is associated with lifelong cognitive deficits, including in executive function, and persistent alterations in cortical and subcortical structures. However, it remains unclear whether “catch-up” growth is possible in the preterm/VLBW brain. Longitudinal structural MRI was conducted with children born preterm with VLBW (n = 41) and term-born peers participating in the Norwegian Mother and Child Cohort Study (MoBa) (n = 128) at two timepoints in early school age (mean ages 8.0 and 9.3 years). Images were analyzed with the FreeSurfer 5.3.0 longitudinal stream to assess differences in development of cortical thickness, surface area, and brain structure volumes, as well as associations with executive function development (NEPSY Statue and WMS-III Spatial Span scores) and perinatal health markers. No longitudinal group × time effects in cortical thickness, surface area, or subcortical volumes were seen, indicating similar brain growth trajectories in the groups over an approximately 16-month period in middle childhood. Higher IQ scores within the VLBW group were associated with greater surface area in left parieto-occipital and inferior temporal regions. Among VLBW preterm-born children, cortical surface area was smaller across the cortical mantle, and cortical thickness was thicker occipitally and frontally and thinner in lateral parietal and posterior temporal areas. Smaller volumes of corpus callosum, right globus pallidus, and right thalamus persisted in the VLBW group from timepoint 1 to 2. VLBW children had on average IQ 1 SD below term-born MoBa peers and significantly worse scores on WMS-III Spatial Span. Executive function scores did not show differential associations with morphometry between groups cross-sectionally or longitudinally. This study investigated divergent or “catch-up” growth in terms of cortical thickness, surface area, and volumes of subcortical gray matter structures and corpus callosum in children born preterm/VLBW and did not find group × time interactions. Greater surface area at mean age 9.3 in left parieto-occipital and inferior temporal cortex was associated with higher IQ in the VLBW group. These results suggest that preterm VLBW children may have altered cognitive networks, yet have structural growth trajectories that appear generally similar to their term-born peers in this early school age window.

Association of Gestational Age With Verbal Ability and Spatial Working Memory at Age 11

BACKGROUND

Although children born very preterm (gestation <32 weeks) have an increased risk of cognitive impairment compared with full-term children (39-41 weeks), the risk for children born moderately (32-33 weeks) to late preterm (34-36 weeks) and early term (37-38 weeks) is unclear. This study describes the relationship between gestational age and cognitive outcomes at 11 years and the trajectory of deficits in verbal ability from age 3 to 11 years.

METHODS

Cognitive ability was assessed by using the Spatial Working Memory test from the Cambridge Neuropsychological Test Automated Working Battery (n = 11 395) and British Ability Scale Verbal Similarities test (n = 11 889) in the UK Millennium Cohort Study. Each gestational group was compared with the full-term group by using differences in z scores and odds ratios for delay (scoring ≥1 SD below the mean).

RESULTS

Very and moderately preterm children demonstrated significantly lower working memory scores compared with full-term children (adjusted difference -0.2 to -0.6) and were more likely to be delayed. There was no significant relationship between late-preterm or early-term birth and working memory (adjusted differences < -0.1), or between gestational age and verbal ability at 11 years. There appears to be a general attenuation in odds ratios as the child ages.

CONCLUSIONS

Very preterm children exhibited working memory deficits at 11 years. However, the absence of delayed verbal skills at 11 years despite earlier delays could indicate "catch-up" effects.

Neuropsychological Outcomes in Extremely Preterm Preschoolers Exposed to Tiered Low Oxygen Targets: An Observational Study

An observational study of neuropsychological outcomes at preschool age of tiered lowered oxygen (O2) saturation targets in extremely preterm neonates. We studied 111 three-year-olds born <28 weeks' gestational age. Fifty-nine participants born in 2009-2010 during a time-limited quality improvement initiative each received three-tiered stratification of oxygen rates (83-93% until age 32 weeks, 85-95% until age 35 weeks, and 95% after age 35 weeks), the TieredO2 group. Comparisons were made with 52 participants born in 2007-2008 when pre-initiative saturation targets were non-tiered at 89-100%, the Non-tieredO2 group. Neuropsychological domains included general intellectual, executive, attention, language, visuoperceptual, visual-motor, and fine and gross motor functioning. Descriptive and inferential analyses were conducted. Group comparisons were not statistically significant. Descriptively, the TieredO2 group had better general intellectual, executive function, visual-motor, and motor performance and the Non-tieredO2 group had better language performance. Cohen's d and confidence intervals around d were in similar direction and magnitude across measures. A large effect size was found for recall of digits-forward in participants born at 23 and 24 weeks' gestation, d=0.99 and 1.46, respectively. Better TieredO2 outcomes in all domains except language suggests that the tiered oxygen saturation target method is not harmful and merits further investigation through further studies. Benefit in auditory attention appeared greatest in those born at 23 and 24 weeks. Participants in the tiered oxygen saturation group also had fewer ventilation days and a lower incidence of bronchopulmonary dysplasia, perhaps explanatory for these neuropsychological outcomes at age 3.

Modulation of Sox10, HIF-1α, Survivin, and YAP by Minocycline in the Treatment of Neurodevelopmental Handicaps following Hypoxic Insult

Premature infants are at an increased risk of developing cognitive and motor handicaps due to chronic hypoxia. Although the current therapies have reduced the incidence of these handicaps, untoward side effects abound. Using a murine model of sublethal hypoxia, we demonstrated reduction in several transcription factors that modulate expression of genes known to be involved in several neural functions. We demonstrate the induction of these genes by minocycline, a tetracycline antibiotic with noncanonical functions, in both in vitro and in vivo studies. Specifically, there was induction of genes, including Sox10, Hif1a, Hif2a, Birc5, Yap1, Epo, Bdnf, Notch1 (cleaved), Pcna, Mag, Mobp, Plp1, synapsin, Adgra2, Pecam1, and reduction in activation of caspase 3, all known to affect proliferation, apoptosis, synaptic transmission, and nerve transmission. Minocycline treatment of mouse pups reared under sublethal hypoxic conditions resulted in improvement in open field testing parameters. These studies demonstrate beneficial effects of minocycline treatment following hypoxic insult, document up-regulation of several genes associated with improved cognitive function, and support the possibility of minocycline as a potential therapeutic target in the treatment of neurodevelopmental handicaps observed in the very premature newborn population. Additionally, these studies may aid in further interpretation of the effects of minocycline in the treatment trials and animal model studies of fragile X syndrome and multiple sclerosis.

Use of resting-state functional MRI to study brain development and injury in neonates

Advances in methodology have led to expanded application of resting-state functional MRI (rs-fMRI) to the study of term and prematurely born infants during the first years of life, providing fresh insight into the earliest forms of functional cerebral development. In this review, we detail our evolving understanding of the use of rs-fMRI for studying neonates. We initially focus on the biological processes of cortical development related to resting-state network development. We then review technical issues principally affecting neonatal investigations, including the effects of subject motion during acquisition and image distortions related to magnetic susceptibility effects. We next summarize the literature in which rs-fMRI is used to study normal brain development during the early postnatal period, the effects of prematurity, and the effects of cerebral injury. Finally, we review potential future directions for the field, such as the use of complementary imaging modalities and advanced analysis techniques.

A crucial role for white matter alterations in interference control problems of very preterm children

BACKGROUND

Attention problems are among the most prominent behavioral deficits reported in very preterm children (below 32 wk of gestation) at school age. In this study, we aimed to elucidate the brain abnormalities underlying attention problems in very preterm children by investigating the role of abnormalities in white and gray brain matter during interference control, using functional magnetic resonance imaging (fMRI)-guided probabilistic diffusion tensor tractography.

METHODS

Twenty-nine very preterm children (mean (SD) age: 8.6 (0.3) y), and 47 term controls (mean (SD) age: 8.7 (0.5) y), performed a fMRI version of the Eriksen Flanker task measuring interference control.

RESULTS

Very preterm children showed slower reaction times than term controls when interfering stimuli were presented, indicating poorer interference control. Very preterm children and term controls did not differ in mean activation of the cortical regions involved in interference control. However, impaired fractional anisotropy (FA) was found in very preterm children in specifically those fiber tracts that innervate the cortical regions involved in interference control. Lower FA was related to poorer interference control in very preterm children.

CONCLUSION

White matter alterations have a crucial role in the interference control problems of very preterm children at school age.

GABA, resting-state connectivity and the developing brain

BACKGROUND

Preclinical data demonstrate that gamma-aminobutyric acid (GABA) interneurons initiate connectivity in the developing brain.

OBJECTIVES

The goal of this study was to compare GABA concentration and its relationship to functional connectivity in the brains of term and preterm infants at term-equivalent age.

METHODS

Infants received both magnetic resonance spectroscopy (MRS) and functional magnetic resonance imaging (fMRI) scans at term-equivalent age. Whole brain functional connectivity MRI data using intrinsic connectivity distribution maps were compared to identify areas with differences in resting-state functional connectivity between the preterm and term control groups. MRS measured concentrations of GABA, glutamate, N-acetyl-aspartate (NAA) and choline; NAA/choline was then calculated for comparison between the 2 groups.

RESULTS

Preterm infants had lower right frontal GABA and glutamate concentrations than term controls and showed a significantly different relationship between connectivity and GABA concentration in the right frontal lobe. Preterm infants had a positive correlation between GABA concentration and connectivity, while term controls demonstrated a negative correlation between these two developmentally regulated parameters.

CONCLUSION

These results suggest that regional GABA concentrations are associated with normal and altered neonatal resting-state connectivity.

Functional neuroimaging study of performances on a Go/No-go task in 6- to 7-year-old preterm children: Impact of intrauterine growth restriction

Children born preterm, and more specifically those with intrauterine growth restriction (IUGR), are prone to exhibit scholastic difficulties and behavioral problems later in development. Neuropsychological studies showed that their deficits in response inhibition and attention could be at the heart of these difficulties. Functional magnetic resonance imaging (fMRI) studies using a Go/No-go task in preterm adolescents and adults suggest their use of an alternative neuronal pathway to compensate for a possible delayed development. However, little is known about the impact of IUGR at a functional neural network level. This study used fMRI to explore brain regions activated during a Go/No-go task in 20 preterm children aged 6–7 years, 10 of which were born with IUGR. Results showed that preterm children without IUGR preferentially activated fronto-temporal regions including the inferior frontal cortex, region known to be involved in successful response inhibition. In contrast, IUGR preterm children exhibited greater activation in the putamen, in the medial frontal cortex and parietal regions, specifically involved in attention demanding tasks, some being part of the default-mode network. These findings suggest that IUGR preterm children use different brain regions and a more diffuse network to perform the task, which interfere with goal-directed activity and may reflect inefficient attentional control. The differences observed in IUGR preterm children might relate to their higher risk for neurodevelopmental and behavioral disorders.

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We investigate inhibition abilities with fMRI in 6- to 7-year-old preterm children.

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IUGR children showed different patterns of brain activation compared with controls.

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IUGR preterm children seem to rely on more posterior, parietal regions and SMA.

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Control preterm children seem to preferentially activate fronto-temporal regions.

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Results suggest more attentional control difficulties in IUGR children.

Modeling the neurovascular niche: unbiased transcriptome analysis of the murine subventricular zone in response to hypoxic insult

Premature infants often experience chronic hypoxia, resulting in cognitive & motor neurodevelopmental handicaps. These sometimes devastating handicaps are thought to be caused by compromised neural precursor cell (NPC) repair/recovery resulting in variable central nervous system (CNS) repair/recovery. We have identified differential responses of two mouse strains (C57BL/6 & CD1) to chronic hypoxia that span the range of responsiveness noted in the premature human population. We previously correlated several CNS tissue and cellular behaviors with the different behavioral parameters manifested by these two strains. In this report, we use unbiased array technology to interrogate the transcriptome of the subventricular zone (SVZ) in these strains. Our results illustrate differences in mRNA expression in the SVZ of both C57BL/6 and CD1 mice following hypoxia as well as differences between C57BL/6 and CD1 SVZ under both normoxic and hypoxic conditions. Differences in expression were found in gene sets associated with Sox10-mediated neural functions that explain, in part, the differential cognitive and motor responsiveness to hypoxic insult. This may shed additional light on our understanding of the variable responses noted in the human premature infant population and facilitate early intervention approaches. Further interrogation of the differentially expressed gene sets will provide a more complete understanding of the differential responses to, and recovery from, hypoxic insult allowing for more informed modeling of the ranges of disease severity observed in the very premature human population.

Resolving the transition from negative to positive blood oxygen level-dependent responses in the developing brain

The adult brain exhibits a local increase in cortical blood flow in response to external stimulus. However, broadly varying hemodynamic responses in the brains of newborn and young infants have been reported. Particular controversy exists over whether the "true" neonatal response to stimulation consists of a decrease or an increase in local deoxyhemoglobin, corresponding to a positive (adult-like) or negative blood oxygen level-dependent (BOLD) signal in functional magnetic resonance imaging (fMRI), respectively. A major difficulty with previous studies has been the variability in human subjects and measurement paradigms. Here, we present a systematic study in neonatal rats that charts the evolution of the cortical blood flow response during postnatal development using exposed-cortex multispectral optical imaging. We demonstrate that postnatal-day-12-13 rats (equivalent to human newborns) exhibit an "inverted" hemodynamic response (increasing deoxyhemoglobin, negative BOLD) with early signs of oxygen consumption followed by delayed, active constriction of pial arteries. We observed that the hemodynamic response then matures via development of an initial hyperemic (positive BOLD) phase that eventually masks oxygen consumption and balances vasoconstriction toward adulthood. We also observed that neonatal responses are particularly susceptible to stimulus-evoked systemic blood pressure increases, leading to cortical hyperemia that resembles adult positive BOLD responses. We propose that this confound may account for much of the variability in prior studies of neonatal cortical hemodynamics. Our results suggest that functional magnetic resonance imaging studies of infant and child development may be profoundly influenced by the maturing neurovascular and autoregulatory systems of the neonatal brain.

Oligodendrocyte regeneration after neonatal hypoxia requires FoxO1-mediated p27Kip1 expression

Diffuse white matter injury (DWMI) caused by hypoxia is associated with permanent neurodevelopmental disabilities in preterm infants. The cellular and molecular mechanisms producing DWMI are poorly defined. Using a mouse model of neonatal hypoxia, we demonstrate a biphasic effect on oligodendrocyte development, resulting in hypomyelination. Oligodendrocyte death and oligodendrocyte progenitor cell (OPC) proliferation during the week after hypoxia were followed by delayed oligodendrocyte differentiation and abnormal myelination, as demonstrated by electron microscopy. Cdk2 activation was essential for the regenerative OPC response after hypoxia and was accompanied by reduced FoxO1-dependent p27(Kip1) expression. p27(Kip1) was also reduced in OPCs in human infant white matter lesions after hypoxia. The negative effects of hypoxia on oligodendrogenesis and myelination were more pronounced in p27(Kip1)-null mice; conversely, overexpression of FoxO1 or p27(Kip1) in OPCs after hypoxia promoted oligodendrogenesis. Our studies demonstrate for the first time that neonatal hypoxia affects the Foxo1/p27(Kip1) pathway during white matter development. We also show that molecular manipulation of this pathway enhances oligodendrocyte regeneration during a critical developmental time window after DWMI. Thus, FoxO1 and p27(Kip1) may serve as promising target molecules for promoting timely oligodendrogenesis in neonatal DWMI.

Effects of glutamine on brain development in very preterm children at school age

OBJECTIVES

The amino acid glutamine has been shown to reduce the number of serious neonatal infections in very preterm children, which may benefit long-term brain development. The aims of the current follow-up study were to (1) determine the long-term effects of glutamine-enriched feeding in the first month after birth in very preterm children on measures of brain development at school age, and (2) elucidate a potential mediating role of serious neonatal infections.

METHODS

Fifty-two very preterm children who originally took part in a randomized controlled trial on enteral glutamine supplementation between day 3 and 30 after birth participated at a mean (SD) age of 8.6 (0.3) years. Measures of brain development included volumetric outcomes of major brain structures, as well as fractional anisotropy (FA) values of major white matter tracts.

RESULTS

Glutamine supplementation in the first month was associated with medium-sized increases in white matter (d = 0.54, P = .03), hippocampus (d = 0.47, P = .02), and brain stem (d = 0.54, P = .04) volumes at school age. Exploratory analyses using an uncorrected P value indicated higher FA values of the bilateral cingulum hippocampal tract in the glutamine group. All differences were either strongly associated (hippocampus volume, brain stem volume, and FA values of cingulum hippocampal tract) or completely mediated (white matter volume) by the lower number of serious neonatal infections in the glutamine group.

CONCLUSIONS

Short-term glutamine supplementation after birth increases white matter, hippocampus, and brain stem volumes in very preterm children at school age, mediated by a decrease in serious neonatal infections.

Environmental enrichment increases the GFAP+ stem cell pool and reverses hypoxia-induced cognitive deficits in juvenile mice

Premature children born with very low birth weight (VLBW) can suffer chronic hypoxic injury as a consequence of abnormal lung development and cardiovascular abnormalities, often leading to grave neurological and behavioral consequences. Emerging evidence suggests that environmental enrichment improves outcome in animal models of adult brain injury and disease; however, little is known about the impact of environmental enrichment following developmental brain injury. Intriguingly, data on socio-demographic factors from longitudinal studies that examined a number of VLBW cohorts suggest that early environment has a substantial impact on neurological and behavioral outcomes. In the current study, we demonstrate that environmental enrichment significantly enhances behavioral and neurobiological recovery from perinatal hypoxic injury. Using a genetic fate-mapping model that allows us to trace the progeny of GFAP+ astroglial cells, we show that hypoxic injury increases the proportion of astroglial cells that attain a neuronal fate. In contrast, environmental enrichment increases the stem cell pool, both through increased stem cell proliferation and stem cell survival. In mice subjected to hypoxia and subsequent enrichment there is an additive effect of both conditions on hippocampal neurogenesis from astroglia, resulting in a robust increase in the number of neurons arising from GFAP+ cells by the time these mice reach full adulthood.

Brain development of very preterm and very low-birthweight children in childhood and adolescence: a meta-analysis

AIM

The aim of this article was to clarify the impact and consequences of very preterm birth (born <32wks of gestation) and/or very low birthweight ([VLBW], weighing <1500g) on brain volume development throughout childhood and adolescence.

METHOD

The computerized databases PubMed, Web of Knowledge, and EMBASE were searched for studies that reported volumetric outcomes during childhood or adolescence using magnetic resonance imaging and included a term-born comparison group. Fifteen studies were identified, encompassing 818 very preterm/VLBW children and 450 term-born peers. Average reductions in the total brain volume, white matter volume, grey matter volume, and in the size of the cerebellum, hippocampus, and corpus callosum were investigated using meta-analytic methods.

RESULTS

Very preterm/VLBW children were found to have a significantly smaller total brain volume than the comparison group (d=-0.58; 95% confidence interval [CI] -0.43 to -0.73; p<0.001), smaller white matter volume (d=-0.53; CI -0.40 to -0.67; p<0.001), smaller grey matter volume (d=-0.62; CI -0.48 to -0.76; p<0.001), smaller cerebellum (d=-0.74; CI -0.56 to -0.92; p<0.001), smaller hippocampus (d=-0.47; CI -0.26 to -0.69; p<0.001), and smaller corpus callosum (d=-0.71; CI -0.34 to -1.07; p<0.001). Reductions have been associated with decreased general cognitive functioning, and no relations with age at assessment were found.

INTERPRETATION

  Very preterm/VLBW birth is associated with an overall reduction in brain volume, which becomes evident in equally sized reductions in white and grey matter volumes, as well as in volumes of diverse brain structures throughout childhood and adolescence.

Cortical glial fibrillary acidic protein-positive cells generate neurons after perinatal hypoxic injury

Glial fibrillary acidic protein-positive (GFAP(+)) cells give rise to new neurons in the neurogenic niches; whether they are able to generate neurons in the cortical parenchyma is not known. Here, we use genetic fate mapping to examine the progeny of GFAP(+) cells after postnatal hypoxia, a model for the brain injury observed in premature children. After hypoxia, immature cortical astroglia underwent a shift toward neuronal fate and generated cortical excitatory neurons that appeared synaptically integrated into the circuitry. Fate-mapped cortical GFAP(+) cells derived ex vivo from hypoxic, but not normoxic, mice were able to form pluripotent, long-term self-renewing neurospheres. Similarly, exposure to low oxygen conditions in vitro induced stem-cell-like potential in immature cortical GFAP(+) cells. Our data support the conclusion that hypoxia promotes pluripotency in GFAP(+) cells in the cortical parenchyma. Such plasticity possibly explains the cognitive recovery found in some preterm children.

Functional connectivity MRI in infants: exploration of the functional organization of the developing brain

Advanced neuroimaging techniques have been increasingly applied to the study of preterm and term infants in an effort to further define the functional cerebral architecture of the developing brain. Despite improved understanding of the complex relationship between structure and function obtained through these investigations, significant questions remain regarding the nature, location, and timing of the maturational changes which occur during early development. Functional connectivity magnetic resonance imaging (fcMRI) utilizes spontaneous, low frequency (< 0.1 Hz), coherent fluctuations in blood oxygen level dependent (BOLD) signal to identify networks of functional cerebral connections. Due to the intrinsic characteristics of its image acquisition and analysis, fcMRI offers a novel neuroimaging approach well suited to investigation of infants. Recently, this methodology has been successfully applied to examine neonatal populations, defining normative patterns of large-scale neural network development in the maturing brain. The resting-state networks (RSNs) identified in these studies reflect the evolving cerebral structural architecture, presumably driven by varied genetic and environmental influences. Principal features of these investigations and their role in characterization of the tenets of neural network development during this critical developmental period are highlighted in this review. Despite these successes, optimal methods for fcMRI data acquisition and analysis for this population have not yet been defined. Further, appropriate schemes for interpretation and translation of fcMRI results remain unknown, a matter of increasing importance as functional neuroimaging findings are progressively applied in the clinical arena. Notwithstanding these concerns, fcMRI provides insight into the earliest forms of cerebral connectivity and therefore holds great promise for future neurodevelopmental investigations.

Long-term outcome of preterm infants and the role of neuroimaging

Preterm birth has been defined as one of the major public health problems of this decade, preterm neonates being at high risk for neurodevelopmental disabilities. As preterm survival rates increase, the next great imperative for perinatal medicine is to understand and prevent the serious adverse neurodevelopmental outcomes of preterm birth. The challenge for neonatologists and neurologists alike is identifying early markers of outcome in the prematurely born. This article reviews current trends in prevalence, mortality, and morbidity, and the present status of outcome data for cognitive and neurosensory neurodevelopmental dysfunctions in preterm infants. New neuroimaging modalities and analysis tools are contributing to the understanding of neurologic sequelae of preterm birth by providing microstructural evidence of injury sustained by the preterm brain.

Somatosensory cortical activation identified by functional MRI in preterm and term infants

Functional MRI (fMRI) has not previously been used systematically to investigate brain function in preterm infants. We here describe statistically robust and reproducible fMRI results in this challenging subject group using a programmable somatosensory stimulus synchronized with MR image acquisition which induced well-localized positive blood oxygen level dependent (BOLD) responses contralateral to the side of the stimulation in: 11 preterm infants (median post menstrual age 33 weeks and 4 days, range 29+1 to 35+3); 6 control infants born at term gestational age; and 18 infants born preterm (median gestational age at birth 30 weeks and 5 days, range 25+4 to 36+0) but studied at term corrected gestational age. Bilateral signals were identified in 8 of the ex-preterm infants at term age. Anatomical confirmation of appropriate activations was provided with diffusion tensor imaging (DTI) based tractography which identified connecting pathways from the regions of activation through the ipsilateral corticospinal tracts and posterior limb of the internal capsule. These results demonstrate that it is possible to reliably identify positive BOLD signals in the infant brain and that fMRI techniques can also be applied in the study of preterm infants.

Strain differences in behavioral and cellular responses to perinatal hypoxia and relationships to neural stem cell survival and self-renewal: Modeling the neurovascular niche

Premature infants have chronic hypoxia, resulting in cognitive and motor neurodevelopmental handicaps caused by suboptimal neural stem cell (NSC) repair/recovery in neurogenic zones (including the subventricular and the subgranular zones). Understanding the variable central nervous system repair response is crucial to identifying "at risk" infants and to increasing survival and clinical improvement of affected infants. Using mouse strains found to span the range of responsiveness to chronic hypoxia, we correlated differential NSC survival and self-renewal with differences in behavior. We found that C57BL/6 (C57) pups displayed increased hyperactivity after hypoxic insult; CD-1 NSCs exhibited increased hypoxia-induced factor 1alpha (HIF-1alpha) mRNA and protein, increased HIF-1alpha, and decreased prolyl hydroxylase domain 2 in nuclear fractions, which denotes increased transcription/translation and decreased degradation of HIF-1alpha. C57 NSCs exhibited blunted stromal-derived factor 1-induced migratory responsiveness, decreased matrix metalloproteinase-9 activity, and increased neuronal differentiation. Adult C57 mice exposed to hypoxia from P3 to P11 exhibited learning impairment and increased anxiety. These findings support the concept that behavioral differences between C57 and CD-1 mice are a consequence of differential responsiveness to hypoxic insult, leading to differences in HIF-1alpha signaling and resulting in lower NSC proliferative/migratory and higher apoptosis rates in C57 mice. Information gained from these studies will aid in design and effective use of preventive therapies in the very low birth weight infant population.

Imaging biomarkers of outcome in the developing preterm brain

The neurodevelopmental disabilities of those who were born prematurely have been well described, yet the underlying alterations in brain development that lead to these changes remain poorly understood. Processes that are vulnerable to injury in the developing brain include maturation of oligodendrocyte precursors and genetically programmed changes in cortical connectivity; recent data have indicated that diffuse injury of the white matter accompanied by neuronal and axonal disruption is common in prematurely born infants. Recent advances in MRI include diffusion tensor imaging and sophisticated image analysis tools, such as functional connectivity, voxel-based morphometry, and mathematical morphology-based cortical folding strategies. These advanced techniques have shown that white matter structure is dependent on gestational age and have started to provide important information about the dynamic interactions between development, injury, and functional recovery in the preterm brain. Identification of early biomarkers for outcome could enable physicians and scientists to develop targeted pharmacological and behavioural therapies to restore functional connectivity.

Modeling premature brain injury and recovery

Premature birth is a growing and significant public health problem because of the large number of infants that survive with neurodevelopmental sequelae from brain injury. Recent advances in neuroimaging have shown that although some neuroanatomical structures are altered, others improve over time. This review outlines recent insights into brain structure and function in these preterm infants at school age and relevant animal models. These animal models have provided scientists with an opportunity to explore in depth the molecular and cellular mechanisms of injury as well as the potential of the brain for recovery. The endogenous potential that the brain has for neurogenesis and gliogenesis, and how environment contributes to recovery, are also outlined. These preclinical models will provide important insights into the genetic and epigenetic mechanisms responsible for variable degrees of injury and recovery, permitting the exploration of targeted therapies to facilitate recovery in the developing preterm brain.

The neural basis of response inhibition and attention allocation as mediated by gestational age

Children and adolescents born before 33 weeks of gestation, that is very preterm, may experience problems with the inhibitory control of behaviour and the allocation of attention. Previous functional magnetic resonance imaging (fMRI) studies have found preterm-born adolescents to display altered brain activation in tasks measuring inhibitory control. However, adolescence is a period during which dynamic changes are occurring in the brain, and it is not yet known whether these functional alterations will persist into adulthood, or instead reflect developmental delay. This study used an event-related fMRI Go/No-Go motor response inhibition paradigm, which included an oddball task measuring attention allocation to infrequent stimuli, to compare blood-oxygen-level-dependent (BOLD) signal between 26 preterm-born adults and 21 controls. Group differences in brain activation were observed in inhibition and attention networks during both conditions. During motor response inhibition, preterm-born participants compared to controls showed increased BOLD signal in medial and right lateral posterior brain regions, including middle temporal/occipital gyrus, posterior cingulate gyrus and precuneus. During oddball trials, preterm-born young adults displayed attenuated brain activation in a fronto-parietal-cerebellar network which is involved in mediating attention allocation. This pattern of reduced brain activation in task-relevant regions of attention allocation, and increased activation in posterior brain regions during inhibitory control, suggests adult alteration of inhibition and attention processing following very preterm birth, which may reflect a developmental delay.

Alterations in functional connectivity for language in prematurely born adolescents

Recent data suggest recovery of language systems but persistent structural abnormalities in the prematurely born. We tested the hypothesis that subjects who were born prematurely develop alternative networks for processing language. Subjects who were born prematurely (n = 22; 600–1250 g birth weight), without neonatal brain injury on neonatal cranial ultrasound, and 26 term control subjects were examined with a functional magnetic resonance imaging (fMRI) semantic association task, the Wechsler Intelligence Scale for Children-III (WISC-III) and the Clinical Evaluation of Language Fundamentals (CELF). In-magnet task accuracy and response times were calculated, and fMRI data were evaluated for the effect of group on blood oxygen level dependent (BOLD) activation, the correlation between task accuracy and activation and the functional connectivity between regions activating to task. Although there were differences in verbal IQ and CELF scores between the preterm (PT) and term control groups, there were no significant differences for either accuracy or response time for the in-magnet task. Both groups activated classic semantic processing areas including the left superior and middle temporal gyri and inferior frontal gyrus, and there was no significant difference in activation patterns between groups. Clear differences between the groups were observed in the correlation between task accuracy and activation to task at P< 0.01, corrected for multiple comparisons. Left inferior frontal gyrus correlated with accuracy only for term controls and left sensory motor areas correlated with accuracy only for PT subjects. Left middle temporal gyri correlated with task accuracy for both groups. Connectivity analyses at P< 0.001 revealed the importance of a circuit between left middle temporal gyri and inferior frontal gyrus for both groups. In addition, the PT subjects evidenced greater connectivity between traditional language areas and sensory motor areas but significantly fewer correlated areas within the frontal lobes when compared to term controls. We conclude that at 12 years of age, children born prematurely and children born at term had no difference in performance on a simple lexical semantic processing task and activated similar areas. Connectivity analyses, however, suggested that PT subjects rely upon different neural pathways for lexical semantic processing when compared to term controls. Plasticity in network connections may provide the substrate for improving language skills in the prematurely born.

Preterm infant hippocampal volumes correlate with later working memory deficits

Children born preterm exhibit working memory deficits. These deficits may be associated with structural brain changes observed in the neonatal period. In this study, the relationship between neonatal regional brain volumes and working memory deficits at age 2 years were investigated, with a particular interest in the dorsolateral prefrontal cortex, parietal cortex and the hippocampus. While the eligible sample consisted of 227 very preterm children who were born at the Royal Women's Hospital, Melbourne prior to 30 weeks gestation or weighing <1250 g, 156 children had complete data sets. Neonatal magnetic resonance images of the brain were obtained at term equivalent age and subsequently parcellated into eight sub-regions, while the hippocampus was manually segmented. The relationship between brain volumes for these regions and performance on a working memory task (delayed alternation) at 2 years of age was examined. Very preterm children who perseverated on the working memory task had significantly smaller hippocampal volumes than very preterm children who exhibited intact working memory, even after adjusting for relevant perinatal, sociodemographic and developmental factors. Preterm children appear to have altered hippocampal volumes by discharge from hospital which may have a lasting impact on working memory function.