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Steiner M, Elis J, Giordano V, Kienast P, Ciglar L, Langs G, Vignolle GA, Olischar M, Berger A, Goeral K. Acute impact of posthemorrhagic ventricular dilatation on cerebral oxygenation in preterm infants with intraventricular haemorrhage. Acta Paediatr 2024. [PMID: 39115973 DOI: 10.1111/apa.17375] [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: 01/01/2024] [Revised: 06/13/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024]
Abstract
AIM To assess the effect of ventricular decompression on cerebral oxygenation in preterm neonates with intraventricular haemorrhage (IVH) and posthemorrhagic ventricular dilatation (PHVD) using near-infrared spectroscopy (NIRS). METHODS Fifty-three preterm neonates born <34 weeks' gestation between 2013 and 2023 with IVH and subsequent PHVD were prospectively included. Regional cerebral oxygen saturation (rScO2) as well as fractional cerebral tissue oxygen extraction (cFTOE) were analysed 2 weeks before and after ventricular decompression. RESULTS Ventricular decompression was performed at 18 ± 6 days of life. Patients with repeated lumbar punctures prior to ventricular drainage showed consistently higher rScO2 and lower cFTOE levels 2 weeks before and after intervention compared to those without. Patients who underwent direct ventricular drainage showed an immediate increase in rScO2 levels on the day of the procedure. In patients who underwent prior lumbar punctures, ventricular decompression did not yield additional acute effects on cerebral oxygenation. CONCLUSION Patients who underwent repeated lumbar punctures preceding ventricular drainage consistently maintained higher rScO2 and lower cFTOE levels during the study period. In these patients, ventricular decompression did not further affect cerebral oxygenation, as they already demonstrated improved cerebral hemodynamics, whereas an immediate improvement was observed in those without prior lumbar punctures.
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Affiliation(s)
- Mirjam Steiner
- Comprehensive Center for Pediatrics, Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Julia Elis
- Comprehensive Center for Pediatrics, Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Comprehensive Center for Pediatrics, Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Patric Kienast
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Lucia Ciglar
- Center Health & Bioresources, Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Georg Langs
- Department of Radiology, Computational Imaging Research Lab, Medical University of Vienna, Vienna, Austria
| | - Gabriel Alexander Vignolle
- Center Health & Bioresources, Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Monika Olischar
- Comprehensive Center for Pediatrics, Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Comprehensive Center for Pediatrics, Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Goeral
- Comprehensive Center for Pediatrics, Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Musiime GM, Mohammad K, Momin S, Kwong GPS, Riva-Cambrin J, Scott J, Zein H, Hendson L, Leijser LM. Prediction of post-hemorrhagic ventricular dilatation trajectory using a growth mixture model in preterm infants. Pediatr Res 2024:10.1038/s41390-024-03396-w. [PMID: 38982166 DOI: 10.1038/s41390-024-03396-w] [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: 02/25/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Early intervention for post-hemorrhagic ventricular dilatation (PHVD), guided by ventricular size measurements from cranial ultrasound (cUS), is associated with improved neurodevelopmental outcomes in preterm infants but benefits must be balanced against intervention risks. METHODS Anterior horn width (AHW) and ventricular index (VI) were measured from cUS for preterm infants (<29 weeks) with intraventricular hemorrhage admitted from 2010-2018. PHVD was defined as AHW > 6 mm or VI >97th percentile for postmenstrual age. Individual ventricular size trajectories were plotted, and a growth mixture model (GMM) used to identify latent trajectory classes and compare these to predetermined outcome of neurosurgical intervention. RESULTS Measurements were obtained from 1543 cUS in 249 infants, of whom 39 had PHVD without and 17 PHVD with neurosurgical intervention based on signs of raised intracranial pressure. The GMM predicted trajectory identified: 93.3% of infants without PHVD, 88.2% and 30.8% of infants with PHVD with and without intervention using AHW; 100% of infants without PHVD, 52.9% and 59.0% of infants with PHVD with and without intervention using VI. CONCLUSIONS The AHW GMM identified a significant proportion of infants with severe PHVD. Model refinement offers a promising approach for identifying differences in PHVD trajectory at an early stage to guide management. IMPACT It is difficult to distinguish the trajectory of PHVD in the early stage of development, in particular PHVD that spontaneously arrests from slowly progressive PHVD which eventually requires intervention. We report the first modeling-based evaluation of PHVD trajectory for the prediction of short-term outcome of PHVD progression and neurosurgical intervention. With additional clinical validation and optimization to increase accuracy, predictive modeling has the potential to identify important differences in PHVD trajectory at an early stage in the clinical course, allowing for more individualized data-driven risk-benefit assessments to guide decisions on early intervention.
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Affiliation(s)
- Grace M Musiime
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarfaraz Momin
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Grace P S Kwong
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Community Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Jay Riva-Cambrin
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - James Scott
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hussein Zein
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Leonora Hendson
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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June A, Heck T, Shah TA, Vazifedan T, Bass WT. Decreased Cerebral Oxygenation in Premature Infants with Progressive Posthemorrhagic Ventricular Dilatation May Help with Timing of Intervention. Am J Perinatol 2023; 40:1446-1453. [PMID: 34674212 DOI: 10.1055/s-0041-1736533] [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: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to determine the degree of progressive posthemorrhagic ventricular dilatation (PHVD) that is associated with a significant decrease in regional cerebral oxygen saturation (rScO2) in premature infants at risk for periventricular-intraventricular hemorrhage (PIVH). STUDY DESIGN Cranial ultrasound (US) and near-infrared spectroscopy (NIRS) measurements of rScO2 were performed on inborn infants with birth weights less than 1,250 g on admission and at 1, 4, and 8 weeks of age. Infants with severe PIVH were studied weekly. A 1-hour average of rScO2 was compared with the frontal-occipital horn ratio (FOHR) measured the same day. Generalized linear models were used to analyze the relationship between FOHR and rScO2, by severity of PIVH, and adjusted for gestational age. Cut-off points of 0.55 for FOHR and 45% for rScO2 were used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS The study cohort included 63 infants with normal US, 15 with grade-1 or -2 PIVH (mild group), and 21 with grade-3 or -4 PIVH (severe group). Increases in FOHR in the severe group were associated with decreases in rScO2 at 1 week (p = 0.036), 4 weeks (p = 0.013), and 8 weeks of life (p = 0.001) compared with the normal and mild groups. Infants with FOHR greater than 0.55 were 92% more likely to have rScO2 less than 45% when compared with infants with FOHR less than 0.55 (OR = 0.08, 95% CI: [0.04, 0.13], p < 0.001). CONCLUSION Progressive PHVD (FOHR > 0.55) is a strong predictor of compromised cerebral oxygenation. A combination of rScO2 and FOHR measurements may aid in identifying infants with PHVD that would benefit from early intervention. KEY POINTS · Earlier intervention in PHVD may improve outcomes.. · PHVD is diagnosed with US measurements of ventricular size.. · FOHR > 0.55 is associated with decreased cerebral perfusion..
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Affiliation(s)
- Angelina June
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of King's Daughters, Norfolk, Virginia
| | - Timothy Heck
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of King's Daughters, Norfolk, Virginia
| | - Tushar A Shah
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of King's Daughters, Norfolk, Virginia
| | - Turaj Vazifedan
- Division of Biostatistics, Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of King's Daughters, Norfolk, Virginia
| | - William Thomas Bass
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of King's Daughters, Norfolk, Virginia
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Kebaya LMN, Stubbs K, Lo M, Al-Saoud S, Karat B, St Lawrence K, de Ribaupierre S, Duerden EG. Three-dimensional cranial ultrasound and functional near-infrared spectroscopy for bedside monitoring of intraventricular hemorrhage in preterm neonates. Sci Rep 2023; 13:3730. [PMID: 36878952 PMCID: PMC9988970 DOI: 10.1038/s41598-023-30743-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH) remains a significant cause of adverse neurodevelopment in preterm infants. Current management relies on 2-dimensional cranial ultrasound (2D cUS) ventricular measurements. Reliable biomarkers are needed to aid in the early detection of posthemorrhagic ventricular dilatation (PHVD) and subsequent neurodevelopment. In a prospective cohort study, we incorporated 3-dimensional (3D) cUS and functional near-infrared spectroscopy (fNIRS) to monitor neonates with GMH-IVH. Preterm neonates (≤ 32 weeks' gestation) were enrolled following a GMH-IVH diagnosis. Neonates underwent sequential measurements: 3D cUS images were manually segmented using in-house software, and the ventricle volumes (VV) were extracted. Multichannel fNIRS data were acquired using a high-density system, and spontaneous functional connectivity (sFC) was calculated. Of the 30 neonates enrolled in the study, 19 (63.3%) had grade I-II and 11 (36.7%) grade III-IV GMH-IVH; of these, 7 neonates (23%) underwent surgical interventions to divert cerebrospinal fluid (CSF). In infants with severe GMH-IVH, larger VV were significantly associated with decreased |sFC|. Our findings of increased VV and reduced sFC suggest that regional disruptions of ventricular size may impact the development of the underlying white matter. Hence, 3D cUS and fNIRS are promising bedside tools for monitoring the progression of GMH-IVH in preterm neonates.
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Affiliation(s)
- Lilian M N Kebaya
- Neuroscience Program, Western University, London, ON, Canada.
- Department of Paediatrics, Division of Neonatal-Perinatal Medicine, London Health Sciences Centre, 800 Commissioner's Road East, London, ON, N6A5W9, Canada.
| | - Kevin Stubbs
- Western Institute for Neuroscience, Western University, London, ON, Canada
- BrainsCAN, Western University, London, ON, Canada
| | - Marcus Lo
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Sarah Al-Saoud
- Western Institute for Neuroscience, Western University, London, ON, Canada
| | - Bradley Karat
- Neuroscience Program, Western University, London, ON, Canada
| | - Keith St Lawrence
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Sandrine de Ribaupierre
- Neuroscience Program, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Emma G Duerden
- Neuroscience Program, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
- Applied Psychology, Faculty of Education, Western University, London, ON, Canada
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Afifi J, Leijser LM, de Vries LS, Shah PS, Mitra S, Brouwer MJ, Walling S, McNeely PD. Variability in the diagnostic and management practices of post-hemorrhagic ventricular dilatation in very preterm infants across Canadian centers and comparison with European practices. J Neonatal Perinatal Med 2022; 15:721-729. [PMID: 36463462 DOI: 10.3233/npm-221071] [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: 12/04/2022]
Abstract
OBJECTIVES To investigate the variability in diagnostic and therapeutic approaches to posthemorrhagic ventricular dilatation (PHVD) among Canadian neonatal centers, and secondary exploration of differences in approaches between Canadian and European practices. METHODS We conducted a survey among Canadian tertiary neonatal centers on their local practices for managing very preterm infants with PHVD. The survey covered questions on the diagnostic criteria, timing and type of interventions and resources utilization (transfer to neurosurgical sites and neurodevelopmental follow-up). In a secondary exploration, Canadian responses were compared with responses to the same survey from European centers. RESULTS 23/30 Canadian centers (77%) completed the survey. There was no consensus among Canadian centers on the criteria used for diagnosing PHVD or to initiate intervention. The therapeutic interventions also vary, both for temporizing procedures or permanent shunting. Compared to European practices, the Canadian approach relied less on the sole use of ultrasound criteria for diagnosing PHVD (43 vs 94%, p < 0.0001) or timing intervention (26 vs 63%, p = 0.007). Majority of European centers intervened early in the development of PHVD based on ultrasound parameters, whereas Canadian centers intervened based on clinical hydrocephalus, with fewer centers performing serial lumbar punctures prior to neurosurgical procedures (40 vs 81%, p = 0.003). CONCLUSION Considerable variability exists in diagnosis and management of PHVD in preterm infants among Canadian tertiary centers and between Canadian and European practices. Given the potential implications of the inter-center practice variability on the short- and long-term outcomes of preterm infants with PHVD, efforts towards evidence-based Canada-wide practice standardization are underway.
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Affiliation(s)
- J Afifi
- Department of Pediatrics, Neonatal Perinatal Medicine, Dalhousie University, Halifax, Canada
| | - L M Leijser
- Department of Pediatrics, Division of Neonatology, University of Calgary, Calgary, Canada
| | - L S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P S Shah
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - S Mitra
- Department of Pediatrics, Neonatal Perinatal Medicine, Dalhousie University, Halifax, Canada
| | - M J Brouwer
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S Walling
- Department of Surgery, Division of Neurosurgery, Dalhousie University, Halifax, Canada
| | - P D McNeely
- Department of Surgery, Division of Neurosurgery, Dalhousie University, Halifax, Canada
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Neuromonitoring in neonatal critical care part II: extremely premature infants and critically ill neonates. Pediatr Res 2022:10.1038/s41390-022-02392-2. [PMID: 36434203 DOI: 10.1038/s41390-022-02392-2] [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: 05/05/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022]
Abstract
Neonatal intensive care has expanded from cardiorespiratory care to a holistic approach emphasizing brain health. To best understand and monitor brain function and physiology in the neonatal intensive care unit (NICU), the most commonly used tools are amplitude-integrated EEG, full multichannel continuous EEG, and near-infrared spectroscopy. Each of these modalities has unique characteristics and functions. While some of these tools have been the subject of expert consensus statements or guidelines, there is no overarching agreement on the optimal approach to neuromonitoring in the NICU. This work reviews current evidence to assist decision making for the best utilization of these neuromonitoring tools to promote neuroprotective care in extremely premature infants and in critically ill neonates. Neuromonitoring approaches in neonatal encephalopathy and neonates with possible seizures are discussed separately in the companion paper. IMPACT: For extremely premature infants, NIRS monitoring has a potential role in individualized brain-oriented care, and selective use of aEEG and cEEG can assist in seizure detection and prognostication. For critically ill neonates, NIRS can monitor cerebral perfusion, oxygen delivery, and extraction associated with disease processes as well as respiratory and hypodynamic management. Selective use of aEEG and cEEG is important in those with a high risk of seizures and brain injury. Continuous multimodal monitoring as well as monitoring of sleep, sleep-wake cycling, and autonomic nervous system have a promising role in neonatal neurocritical care.
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Abstract
While intraventricular hemorrhage (IVH) predominantly damages the periventricular white matter, it induces substantial injury to the cerebral gray matter. IVH destroys the germinal matrix, suppresses neurogenesis, and disrupts corticogenesis, thereby reducing the number of neurons in the upper cortical layer and volume of the cerebral gray matter. The pathogenesis of gray matter injury is attributed to IVH-induced oxidative stress, inflammation, and mass effect damaging the germinal matrix as well as to post-hemorrhagic ventricular dilation (PHVD). The IVH-induced cerebral gray matter injury and PHVD contribute to cognitive deficits and neurobehavioral disorders. Neuroimaging has enhanced our understanding of cerebral gray matter injury and is a valuable predictor of neurodevelopmental outcomes. Evidence from therapies tested in preclinical models and clinical trials suggests that strategies to promote neurogenesis, reduce cerebral inflammation and oxidative stress, and remove blood clots from the ventricles might enhance the outcome of these infants. This review offers an integrated view of new insights into the mechanisms underlying gray matter injury in premature infants with IVH and highlights the imminent therapies to restore neurodevelopmental dysfunction in IVH survivors.
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Affiliation(s)
- Deep Sharma
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Alex Agyemang
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Praveen Ballabh
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY, USA.
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Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hemorrhage. Pediatr Res 2022; 91:1238-1247. [PMID: 34215837 DOI: 10.1038/s41390-021-01631-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/21/2021] [Accepted: 06/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Greater ventriculomegaly in preterm infants with intraventricular hemorrhage (IVH) has been associated with worse neurodevelopmental outcomes in infancy. We aim to explore the relationship between ventriculomegaly and school-age functional outcome. METHODS Retrospective review of preterm infants with Grade III/IV IVH from 2006 to 2020. Frontal-occipital horn ratio (FOHR) was measured on imaging throughout hospitalization and last available follow-up scan. Pediatric Cerebral Performance Category (PCPC) scale was used to assess functional outcome at ≥4 years. Ordinal logistic regression was used to determine the relationship between functional outcome and FOHR at the time of Neurosurgery consult, neurosurgical intervention, and last follow-up scan while adjusting for confounders. RESULTS One hundred and thirty-four infants had Grade III/IV IVH. FOHR at consult was 0.62 ± 0.12 and 0.75 ± 0.13 at first intervention (p < 0.001). On univariable analysis, maximum FOHR, FOHR at the last follow-up scan, and at Neurosurgery consult predicted worse functional outcome (p < 0.01). PVL, longer hospital admission, and gastrotomy/tracheostomy tube also predicted worse outcome (p < 0.05). PVL, maximum FOHR, and FOHR at consult remained significant on multivariable analysis (p < 0.05). Maximum FOHR of 0.61 is a fair predictor for moderate-severe impairment (AUC 75%, 95% CI: 62-87%). CONCLUSIONS Greater ventricular dilatation and PVL were independently associated with worse functional outcome in Grade III/IV IVH regardless of neurosurgical intervention. IMPACT Ventriculomegaly measured by frontal-occipital horn ratio (FOHR) and periventricular leukomalacia are independent correlates of school-age functional outcomes in preterm infants with intraventricular hemorrhage regardless of need for neurosurgical intervention. These findings extend the known association between ventriculomegaly and neurodevelopmental outcomes in infancy to functional outcomes at school age. FOHR is a fair predictor of school-age functional outcome, but there are likely other factors that influence functional status, which highlights the need for prospective studies to incorporate other clinical and demographic variables in predictive models.
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Variane GFT, Camargo JPV, Rodrigues DP, Magalhães M, Mimica MJ. Current Status and Future Directions of Neuromonitoring With Emerging Technologies in Neonatal Care. Front Pediatr 2022; 9:755144. [PMID: 35402367 PMCID: PMC8984110 DOI: 10.3389/fped.2021.755144] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatology has experienced a significant reduction in mortality rates of the preterm population and critically ill infants over the last few decades. Now, the emphasis is directed toward improving long-term neurodevelopmental outcomes and quality of life. Brain-focused care has emerged as a necessity. The creation of neonatal neurocritical care units, or Neuro-NICUs, provides strategies to reduce brain injury using standardized clinical protocols, methodologies, and provider education and training. Bedside neuromonitoring has dramatically improved our ability to provide assessment of newborns at high risk. Non-invasive tools, such as continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), and near-infrared spectroscopy (NIRS), allow screening for seizures and continuous evaluation of brain function and cerebral oxygenation at the bedside. Extended and combined uses of these techniques, also described as multimodal monitoring, may allow practitioners to better understand the physiology of critically ill neonates. Furthermore, the rapid growth of technology in the Neuro-NICU, along with the increasing use of telemedicine and artificial intelligence with improved data mining techniques and machine learning (ML), has the potential to vastly improve decision-making processes and positively impact outcomes. This article will cover the current applications of neuromonitoring in the Neuro-NICU, recent advances, potential pitfalls, and future perspectives in this field.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Division of Neonatology, Grupo Santa Joana, São Paulo, Brazil
| | - João Paulo Vasques Camargo
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Data Science Department, OPD Team, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maurício Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Department of Pediatrics, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Jenné Mimica
- Department of Pathology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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Suppan E, Pichler G, Binder-Heschl C, Schwaberger B, Urlesberger B. Three Physiological Components That Influence Regional Cerebral Tissue Oxygen Saturation. Front Pediatr 2022; 10:913223. [PMID: 35769216 PMCID: PMC9234387 DOI: 10.3389/fped.2022.913223] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) measurement of regional cerebral tissue oxygen saturation (rcStO2) has become a topic of high interest in neonatology. Multiple studies have demonstrated that rcStO2 measurements are feasible in the delivery room during immediate transition and resuscitation as well as after admission to the neonatal intensive care unit. Reference ranges for different gestational ages, modes of delivery, and devices have already been published. RcStO2 reflects a mixed tissue saturation, composed of arterial (A), venous (V), and capillary signals, derived from small vessels within the measurement compartment. The A:V signal ratio fluctuates based on changes in oxygen delivery and oxygen consumption, which enables a reliable trend monitoring of the balance between these two parameters. While the increasing research evidence supports its use, the interpretation of the absolute values of and trends in rcStO2 is still challenging, which halts its routine use in the delivery room and at the bedside. To visualize the influencing factors and improve the understanding of rcStO2 values, we have created a flowchart, which focuses on the three major physiological components that affect rcStO2: oxygen content, circulation, and oxygen extraction. Each of these has its defining parameters, which are discussed in detail in each section.
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Affiliation(s)
- Ena Suppan
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Corinna Binder-Heschl
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
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11
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Whittemore BA, Swift DM, M Thomas J, F Chalak L. A neonatal neuroNICU collaborative approach to neuromonitoring of posthemorrhagic ventricular dilation in preterm infants. Pediatr Res 2022; 91:27-34. [PMID: 33627823 DOI: 10.1038/s41390-021-01406-9] [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: 08/28/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/31/2023]
Abstract
Morbidity and mortality in prematurely born infants have significantly improved due to advancement in perinatal care, development of NeuroNICU collaborative multidisciplinary approaches, and evidence-based management protocols that have resulted from a better understanding of perinatal risk factors and neuroprotective treatments. In premature infants with intraventricular hemorrhage (IVH), the detrimental secondary effect of posthemorrhagic ventricular dilation (PHVD) on the neurodevelopmental outcome can be mitigated by surgical intervention, though management varies considerably across institutions. Any benefit derived from the use of neuromonitoring to optimize surgical timing and technique stands to improve neurodevelopmental outcome. In this review, we summarize (1) the approaches to surgical management of PHVD in preterm infants and outcome data; (2) neuromonitoring modalities and the effect of neurosurgical intervention on this data; (3) our resultant protocol for the monitoring and management of PHVD. In particular, our protocol incorporates cerebral near-infrared spectroscopy (NIRS) and transcranial doppler ultrasound (TCD) to better understand cerebral physiology and to enable the hypothesis-driven study of the management of PHVD. IMPACT: Review of the published literature concerning the use of near-infrared spectroscopy (NIRS) and a cerebral Doppler ultrasound to study the effect of cerebrospinal fluid drainage on infants with posthemorrhagic ventricular dilation. Presentation of our institution's evidence-based protocol for the use of NIRS and cerebral Doppler ultrasound to study the optimal neurosurgical treatment of posthemorrhagic ventricular dilation, an as yet inadequately studied area.
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Affiliation(s)
- Brett A Whittemore
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Dale M Swift
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennifer M Thomas
- Department of Neurology, 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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Levy PT, Pellicer A, Schwarz CE, Neunhoeffer F, Schuhmann MU, Breindahl M, Fumagelli M, Mintzer J, de Boode W. Near-infrared spectroscopy for perioperative assessment and neonatal interventions. Pediatr Res 2021:10.1038/s41390-021-01791-1. [PMID: 34716423 DOI: 10.1038/s41390-021-01791-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
Perioperative applications of near-infrared spectroscopy (NIRS) to monitor regional tissue oxygenation and perfusion in cardiac and noncardiac surgery are of increasing interest in neonatal care. Complex neonatal surgery can impair adequate oxygen delivery and tissue oxygen consumption and increase the risk of neurodevelopmental delay. Coupled with conventional techniques, NIRS monitoring may enable targeted hemodynamic management of the circulation in both cardiac and noncardiac surgical procedures. In this narrative review, we discuss the application of perioperative NIRS in specific neonatal interventions, including surgical intervention for congenital heart defects, definitive closure of the patent ductus arteriosus, neurological and gastrointestinal disorders, and use of extracorporeal membrane oxygenation. We identified areas for future research within disease-specific indications and offer a roadmap to aid in developing evidence-based targeted diagnostic and management strategies in neonates. IMPACT: There is growing recognition that perioperative NIRS monitoring, used in conjunction with conventional monitoring, may provide critical hemodynamic information that either complements clinical impressions or delivers novel physiologic insight into the neonatal circulatory and perfusion pathways.
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Affiliation(s)
- Philip T Levy
- Department of Pediatrics, Harvard Medical School and Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christoph E Schwarz
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
- Infant Research centre, University College Cork Ireland, Cork, Ireland
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Monica Fumagelli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Jonathan Mintzer
- Division of Newborn Medicine, Department of Pediatrics, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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13
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Flanders TM, Lang SS, Ko TS, Andersen KN, Jahnavi J, Flibotte JJ, Licht DJ, Tasian GE, Sotardi ST, Yodh AG, Lynch JM, Kennedy BC, Storm PB, White BR, Heuer GG, Baker WB. Optical Detection of Intracranial Pressure and Perfusion Changes in Neonates With Hydrocephalus. J Pediatr 2021; 236:54-61.e1. [PMID: 34004191 PMCID: PMC8403158 DOI: 10.1016/j.jpeds.2021.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To demonstrate that a novel noninvasive index of intracranial pressure (ICP) derived from diffuse optics-based techniques is associated with intracranial hypertension. STUDY DESIGN We compared noninvasive and invasive ICP measurements in infants with hydrocephalus. Infants born term and preterm were eligible for inclusion if clinically determined to require cerebrospinal fluid (CSF) diversion. Ventricular size was assessed preoperatively via ultrasound measurement of the fronto-occipital (FOR) and frontotemporal (FTHR) horn ratios. Invasive ICP was obtained at the time of surgical intervention with a manometer. Intracranial hypertension was defined as invasive ICP ≥15 mmHg. Diffuse optical measurements of cerebral perfusion, oxygen extraction, and noninvasive ICP were performed preoperatively, intraoperatively, and postoperatively. Optical and ultrasound measures were compared with invasive ICP measurements, and their change in values after CSF diversion were obtained. RESULTS We included 39 infants, 23 with intracranial hypertension. No group difference in ventricular size was found by FOR (P = .93) or FTHR (P = .76). Infants with intracranial hypertension had significantly higher noninvasive ICP (P = .02) and oxygen extraction fraction (OEF) (P = .01) compared with infants without intracranial hypertension. Increased cerebral blood flow (P = .005) and improved OEF (P < .001) after CSF diversion were observed only in infants with intracranial hypertension. CONCLUSIONS Noninvasive diffuse optical measures (including a noninvasive ICP index) were associated with intracranial hypertension. The findings suggest that impaired perfusion from intracranial hypertension was independent of ventricular size. Hemodynamic evidence of the benefits of CSF diversion was seen in infants with intracranial hypertension. Noninvasive optical techniques hold promise for aiding the assessment of CSF diversion timing.
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Affiliation(s)
- Tracy M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Tiffany S Ko
- Division of Neurology, Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Kristen N Andersen
- Division of Neurology, Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jharna Jahnavi
- Division of Neurology, Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - John J Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Daniel J Licht
- Division of Neurology, Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Gregory E Tasian
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania; Division of Urology, Children's Hospital of Philadelphia
| | - Susan T Sotardi
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania
| | | | - Benjamin C Kennedy
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Brian R White
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Gregory G Heuer
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Wesley B Baker
- Division of Neurology, Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.
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Leijser LM, Scott JN, Roychoudhury S, Zein H, Murthy P, Thomas SP, Mohammad K. Post-hemorrhagic ventricular dilatation: inter-observer reliability of ventricular size measurements in extremely preterm infants. Pediatr Res 2021; 90:403-410. [PMID: 33184496 DOI: 10.1038/s41390-020-01245-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Post-hemorrhagic ventricular dilatation (PHVD) in preterm infants can be assessed with ventricular size indices from cranial ultrasound. We explored inter-observer reliability of these indices for prediction of severe PHVD. METHODS For all 139 infants with IVH, serial neonatal ultrasound at 3 time points (days 4-7, day 14, 36 weeks PMA) were assessed independently by 3 observers with differing levels of training/experience. Ventricular index (VI), anterior horn width (AHW), and fronto-temporal horn ratio (FTHR) were measured and used to diagnose PHVD. For all, inter-observer reliability and predictive values for receipt of surgical intervention were calculated. RESULTS Inter-observer reliability for all observers varied from poor to excellent, with higher reliability for VI/AHW (ICC 0.49-0.84/0.51-0.81) than FTHR (0.41-0.82), particularly from the second week. Good-excellent inter-expertise reliability was found between observers with ample experience/training (0.65-0.99), particularly for VI and AHW, while poor-moderate when comparing with an inexperienced observer (0.28-0.88). Slightly higher predictive value for PHVD intervention (n = 12) was found for AHW (AUC 0.86-0.96) than for VI and FTHR (0.80-0.96/0.80-0.95). CONCLUSIONS AHW and VI are highly reproducible in experienced hands compared to FTHR, with AHW from the second week onwards being the strongest predictor for receiving surgical intervention for severe PHVD. AHW may aid in early PHVD diagnosis and decision-making on intervention. IMPACT While ventricular size indices from serial cUS are superior to clinical signs of increased intracranial pressure to assess PHVD, questions remained on their inter-observer reproducibility and reliability to predict severity of PHVD. AHW and VI are highly reproducible when performed by experienced clinicians. AHW from the second week of birth is the strongest predictor of PHVD onset and severity. AHW, combined with VI, may aid in early PHVD diagnosis and decision-making on need for surgical intervention. Consistent use of these indices has the potential to improve PHVD management and therewith the long-term outcomes in preterm infants.
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Affiliation(s)
- Lara M Leijser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada.
| | - James N Scott
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
| | - Smita Roychoudhury
- Department of Pediatrics, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Sumesh P Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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15
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Cizmeci MN, Groenendaal F, de Vries LS. Timing of Intervention for Posthemorrhagic Ventricular Dilatation: An Ongoing Debate. J Pediatr 2021; 234:14-16. [PMID: 33592220 DOI: 10.1016/j.jpeds.2021.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Mehmet N Cizmeci
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands.
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16
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El-Dib M, Limbrick DD, Inder T, Whitelaw A, Kulkarni AV, Warf B, Volpe JJ, de Vries LS. Management of Post-hemorrhagic Ventricular Dilatation in the Infant Born Preterm. J Pediatr 2020; 226:16-27.e3. [PMID: 32739263 PMCID: PMC8297821 DOI: 10.1016/j.jpeds.2020.07.079] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - David D Limbrick
- Department of Neurological Surgery, St Louis Children's Hospital, Washington University School of Medicine, St Louis, MO
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew Whitelaw
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Abhaya V Kulkarni
- Department of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Joseph J Volpe
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, the Netherlands; University Medical Center Utrecht, Utrecht Brain Center, the Netherlands
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17
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Hummler H. Near-Infrared spectroscopy for perfusion assessment and neonatal management. Semin Fetal Neonatal Med 2020; 25:101145. [PMID: 32830077 DOI: 10.1016/j.siny.2020.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Term and preterm infants often present with adverse conditions after birth resulting in abnormal vital functions and severe organ failure, which are associated or sometimes caused by low oxygen and/or blood supply. Brain injury may lead to substantial mortality and morbidity often affecting long-term outcome. Standard monitoring techniques in the NICU focus on arterial oxygen supply and hemodynamics and include respiratory rate, heart rate, blood pressure and arterial oxygen saturation as measured by pulse oximetry but provide only limited information on end organ oxygen delivery. Near-Infrared Spectroscopy can bridge this gap by displaying continuous measurements of tissue oxygen saturation, providing information on the balance of oxygen delivery and consumption in organs of interest. Future techniques using multi-wavelength devices may provide additional information on oxidative metabolism in real time adding important information.
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Affiliation(s)
- Helmut Hummler
- Chief Division of Neonatology, Department of Pediatrics, Sidra Medicine, Al Gharrafa Street, Ar-Rayyan, PO Box 26999, Doha, Qatar; Professor of Pediatrics, Weill Cornell Medicine Qatar, Professor of Pediatrics adj. Ulm University, Germany.
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18
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Rajaram A, Yip LCM, Milej D, Suwalski M, Kewin M, Lo M, Carson JJL, Han V, Bhattacharya S, Diop M, de Ribaupierre S, St. Lawrence K. Perfusion and Metabolic Neuromonitoring during Ventricular Taps in Infants with Post-Hemorrhagic Ventricular Dilatation. Brain Sci 2020; 10:E452. [PMID: 32679665 PMCID: PMC7407524 DOI: 10.3390/brainsci10070452] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023] Open
Abstract
Post-hemorrhagic ventricular dilatation (PHVD) is characterized by a build-up of cerebral spinal fluid (CSF) in the ventricles, which increases intracranial pressure and compresses brain tissue. Clinical interventions (i.e., ventricular taps, VT) work to mitigate these complications through CSF drainage; however, the timing of these procedures remains imprecise. This study presents Neonatal NeuroMonitor (NNeMo), a portable optical device that combines broadband near-infrared spectroscopy (B-NIRS) and diffuse correlation spectroscopy (DCS) to provide simultaneous assessments of cerebral blood flow (CBF), tissue saturation (StO2), and the oxidation state of cytochrome c oxidase (oxCCO). In this study, NNeMo was used to monitor cerebral hemodynamics and metabolism in PHVD patients selected for a VT. Across multiple VTs in four patients, no significant changes were found in any of the three parameters: CBF increased by 14.6 ± 37.6% (p = 0.09), StO2 by 1.9 ± 4.9% (p = 0.2), and oxCCO by 0.4 ± 0.6 µM (p = 0.09). However, removing outliers resulted in significant, but small, increases in CBF (6.0 ± 7.7%) and oxCCO (0.1 ± 0.1 µM). The results of this study demonstrate NNeMo's ability to provide safe, non-invasive measurements of cerebral perfusion and metabolism for neuromonitoring applications in the neonatal intensive care unit.
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Affiliation(s)
- Ajay Rajaram
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Lawrence C. M. Yip
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Daniel Milej
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Marianne Suwalski
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Matthew Kewin
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
| | - Marcus Lo
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
| | - Jeffrey J. L. Carson
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Victor Han
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, London Health Sciences Centre, London, ON N6A 3K7, Canada; (V.H.); (S.B.)
| | - Soume Bhattacharya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, London Health Sciences Centre, London, ON N6A 3K7, Canada; (V.H.); (S.B.)
| | - Mamadou Diop
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Sandrine de Ribaupierre
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
- Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Keith St. Lawrence
- Imaging Program, Lawson Health Research Institute, London, ON N6A 4V2, Canada; (L.C.M.Y.); (D.M.); (M.S.); (M.K.); (M.L.); (J.J.L.C.); (M.D.); (K.S.L.)
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
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Beijst C, Dudink J, Wientjes R, Benavente-Fernandez I, Groenendaal F, Brouwer MJ, Išgum I, de Jong HWAM, de Vries LS. Two-dimensional ultrasound measurements vs. magnetic resonance imaging-derived ventricular volume of preterm infants with germinal matrix intraventricular haemorrhage. Pediatr Radiol 2020; 50:234-241. [PMID: 31691845 PMCID: PMC6978291 DOI: 10.1007/s00247-019-04542-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 08/05/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Post-haemorrhagic ventricular dilatation can be measured accurately by MRI. However, two-dimensional (2-D) cranial US can be used at the bedside on a daily basis. OBJECTIVE To assess whether the ventricular volume can be determined accurately using US. MATERIALS AND METHODS We included 31 preterm infants with germinal matrix intraventricular haemorrhage. Two-dimensional cranial US images were acquired and the ventricular index, anterior horn width and thalamo-occipital distance were measured. In addition, cranial MRI was performed. The ventricular volume on MRI was determined using a previously validated automatic segmentation algorithm. We obtained the correlation and created a linear model between MRI-derived ventricular volume and 2-D cranial US measurements. RESULTS The ventricular index, anterior horn width and thalamo-occipital distance as measured on 2-D cranial US were significantly associated with the volume of the ventricles as determined with MRI. A general linear model fitted the data best: ∛ventricular volume (ml) = 1.096 + 0.094 × anterior horn width (mm) + 0.020 × thalamo-occipital distance (mm) with R2 = 0.831. CONCLUSION The volume of the lateral ventricles of infants with germinal matrix intraventricular haemorrhage can be estimated using 2-D cranial US images by application of a model.
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Affiliation(s)
- Casper Beijst
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rens Wientjes
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Margaretha J Brouwer
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ivana Išgum
- Image Sciences Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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20
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Bembich S, Cont G, Bua J, Paviotti G, Demarini S. Cerebral Hemodynamics During Neonatal Cerebrospinal Fluid Removal. Pediatr Neurol 2019; 94:70-73. [PMID: 30718162 DOI: 10.1016/j.pediatrneurol.2019.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/24/2018] [Accepted: 01/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Standard treatment of neonatal posthemorrhagic hydrocephalus is cerebrospinal fluid removal. The aim of this study was to assess how much cerebrospinal fluid volume removal, by ventricular reservoir taps, is needed to improve cerebral hemodynamics and oxygenation in neonatal posthemorrhagic hydrocephalus. METHODS Cerebral hemodynamics and oxygenation were continuously monitored by near-infrared spectroscopy in four newborns (one term and three preterm) during 28 ventricular reservoir taps. At each tap, 10 mL/kg of cerebrospinal fluid was removed. Near-infrared spectroscopy detected changes in the concentration of oxy-hemoglobin and total hemoglobin, considered as estimates of cerebral blood flow and volume, respectively. Cerebral tissue oxygenation index was also measured. During cerebrospinal fluid removal, variation in cerebral blood flow, volume, and oxygenation were analyzed by repeated measures analysis of variance. The associations between changes in cerebral hemodynamics and oxygenation, during cerebrospinal fluid removal and after its conclusion, were analyzed by Pearson's r correlation coefficient. RESULTS A significant increase in cerebral blood flow and volume was already evident at 50% of targeted cerebrospinal fluid volume removal (P < 0.001). Although cerebral tissue oxygenation index absolute value remained unchanged, variations in cerebral blood flow and oxygenation were positively correlated, both during cerebrospinal fluid removal and after its conclusion (r = 0.57; P = 0.002). CONCLUSIONS On the basis of the results from this small cohort, the volume of cerebrospinal fluid removal associated with an improvement in cerebral hemodynamics and perfusion seems to be less than the traditional 10 mL/kg. Further research is needed to define the potential role of near-infrared spectroscopy monitoring to individualize cerebrospinal fluid removal.
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Affiliation(s)
- Stefano Bembich
- Division of Neonatology, Institute for Maternal and Child Health, IRCSS "Burlo Garofolo", Trieste, Italy
| | - Gabriele Cont
- Division of Neonatology, Institute for Maternal and Child Health, IRCSS "Burlo Garofolo", Trieste, Italy
| | - Jenny Bua
- Division of Neonatology, Institute for Maternal and Child Health, IRCSS "Burlo Garofolo", Trieste, Italy
| | - Giulia Paviotti
- Division of Neonatology, Institute for Maternal and Child Health, IRCSS "Burlo Garofolo", Trieste, Italy
| | - Sergio Demarini
- Division of Neonatology, Institute for Maternal and Child Health, IRCSS "Burlo Garofolo", Trieste, Italy.
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21
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de Vries LS, Groenendaal F, Liem KD, Heep A, Brouwer AJ, van 't Verlaat E, Benavente-Fernández I, van Straaten HL, van Wezel-Meijler G, Smit BJ, Govaert P, Woerdeman PA, Whitelaw A. Treatment thresholds for intervention in posthaemorrhagic ventricular dilation: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2019; 104:F70-F75. [PMID: 29440132 DOI: 10.1136/archdischild-2017-314206] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare a low versus a higher threshold for intervention in preterm infants with posthaemorrhagic ventricular dilatation. DESIGN Multicentre randomised controlled trial (ISRCTN43171322). SETTING 14 neonatal intensive care units in six countries. PATIENTS 126 preterm infants ≤34 weeks gestation with ventricular dilatation after grade III-IV haemorrhage were randomised to low threshold (LT) (ventricular index (VI) >p97 and anterior horn width (AHW) >6 mm) or higher threshold (HT) (VI>p97+4 mm and AHW >10 mm). INTERVENTION Cerebrospinal fluid tapping by lumbar punctures (LPs) (max 3), followed by taps from a ventricular reservoir, to reduce VI, and eventually a ventriculoperitoneal (VP) shunt if stabilisation of the VI below the p97+4 mm did not occur. COMPOSITE MAIN OUTCOME MEASURE VP shunt or death. RESULTS 19 of 64 (30%) LT infants and 23 of 62 (37%) HT infants were shunted or died (P=0.45). A VP shunt was inserted in 12/64 (19%) in the LT and 14/62 (23%) infants in the HT group. 7/12 (58%) LT infants and 1/14 (7%) HT infants required shunt revision (P<0.01). 62 of 64 (97%) LT infants and 36 of 62 (58%) HT infants had LPs (P<0.001). Reservoirs were inserted in 40 of 64 (62%) LT infants and 27 of 62 (43%) HT infants (P<0.05). CONCLUSIONS There was no significant difference in the primary composite outcome of VP shunt placement or death in infants with posthaemorrhagic ventricular dilatation who were treated at a lower versus a higher threshold for intervention. Infants treated at the lower threshold received more invasive procedures. Assessment of neurodevelopmental outcomes will provide further important information in assessing the risks and benefits of the two treatment approaches.
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Affiliation(s)
- Linda S de Vries
- Department of Neonatology and Brain Center Rudolf Magnus, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology and Brain Center Rudolf Magnus, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kian D Liem
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Axel Heep
- Department of Neonatology, Southmead Hospital, School of Clinical Science, University of Bristol, Bristol, UK
| | - Annemieke J Brouwer
- Department of Neonatology and Brain Center Rudolf Magnus, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - Ellen van 't Verlaat
- University of Applied Sciences Utrecht, Utrecht, The Netherlands.,Department of Neonatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Gerda van Wezel-Meijler
- Isala Women and Children's Hospital, Zwolle, The Netherlands.,Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bert J Smit
- Directorate Quality & Patientcare, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul Govaert
- Department of Neonatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter A Woerdeman
- Division of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrew Whitelaw
- Department of Neonatology, Southmead Hospital, School of Clinical Science, University of Bristol, Bristol, UK
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22
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Leijser LM, de Vries LS. Preterm brain injury: Germinal matrix-intraventricular hemorrhage and post-hemorrhagic ventricular dilatation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:173-199. [PMID: 31324310 DOI: 10.1016/b978-0-444-64029-1.00008-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Germinal matrix hemorrhage and intraventricular hemorrhages (GMH-IVH) remain a common and clinically significant problem in preterm infants, particularly extremely preterm infants. A large GMH-IVH is often complicated by posthemorrhagic ventricular dilation (PHVD) or parenchymal hemorrhagic infarction and is associated with an increased risk of adverse neurologic sequelae. The widespread use of cranial ultrasonography since the early 1980s has shown a gradual decrease in the incidence of GMH-IVH and has helped with the identification of antenatal and perinatal risk factors and timing of the lesion. The increased use of magnetic resonance imaging (MRI) has contributed to more detailed visualization of the site and extent of the GMH-IVH. In addition, MRI has contributed to the awareness of associated white matter changes as well as associated cerebellar hemorrhages. Although GMH-IVH and PHVD still cannot be prevented, cerebrospinal fluid drainage initiated in the early stage of PHVD development seems to be associated with a better neurodevelopmental outcome. Further studies are underway to improve treatment strategies for PHVD and to potentially prevent and repair GMH-IVH and PHVD and associated brain injury. This chapter discusses the pathogenesis, incidence, risk factors, and management, including preventive measures, of GHM-IVH and PHVD.
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Affiliation(s)
- Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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23
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El-Dib M, Soul JS. Monitoring and management of brain hemodynamics and oxygenation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:295-314. [PMID: 31324316 DOI: 10.1016/b978-0-444-64029-1.00014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While cardiorespiratory monitoring is standard for newborns in the NICU, monitoring of brain hemodynamics and oxygenation is usually sporadic and targeted to newborns with suspected or confirmed neurologic disorders. This is unfortunate, since critically ill newborns, both preterm and term-born, are at high risk of brain injury and would benefit from improved techniques for continuous monitoring of brain hemodynamics and oxygenation, in addition to monitoring of systemic hemodynamics and oxygenation. Near-infrared spectroscopy (NIRS) and, to a lesser extent, Doppler ultrasound are techniques that have been used in research and increasingly for clinical purposes to measure and monitor brain hemodynamics and oxygenation in newborns. NIRS monitoring can be useful for detection of diverse pathologic conditions that occur frequently in very preterm newborns and in selected populations of term newborns at risk for brain injury related to disturbances of systemic hemodynamics. This chapter reviews the current state of the art with regard to brain-monitoring techniques and the research directed at this important area, and it concludes with suggestions for the use of currently available tools to manage newborns at high risk of neurologic injury from disturbances in brain hemodynamics and oxygenation.
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Affiliation(s)
- Mohamed El-Dib
- Neonatal Neurocritical Care, Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States; Department of Neurology, Harvard Medical School, Boston, MA, United States.
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24
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de Vries LS, Leijser LM. Author response: Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene? Neurology 2018; 91:488. [DOI: 10.1212/wnl.0000000000006114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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25
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Beausoleil TP, Janaillac M, Barrington KJ, Lapointe A, Dehaes M. Cerebral oxygen saturation and peripheral perfusion in the extremely premature infant with intraventricular and/or pulmonary haemorrhage early in life. Sci Rep 2018; 8:6511. [PMID: 29695729 PMCID: PMC5916916 DOI: 10.1038/s41598-018-24836-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/09/2018] [Indexed: 12/29/2022] Open
Abstract
Extremely preterm infants are at higher risk of pulmonary (PH) and intraventricular (IVH) haemorrhage during the transitioning physiology due to immature cardiovascular system. Monitoring of haemodynamics can detect early abnormal circulation that may lead to these complications. We described time-frequency relationships between near infrared spectroscopy (NIRS) cerebral regional haemoglobin oxygen saturation (CrSO2) and preductal peripheral perfusion index (PI), capillary oxygen saturation (SpO2) and heart rate (HR) in extremely preterm infants in the first 72 h of life. Patients were sub-grouped in infants with PH and/or IVH (N H = 8) and healthy controls (N C = 11). Data were decomposed in wavelets allowing the analysis of localized variations of power. This approach allowed to quantify the percentage of time of significant cross-correlation, semblance, gain (transfer function) and coherence between signals. Ultra-low frequencies (<0.28 mHz) were analyzed as slow and prolonged periods of impaired circulation are considered more detrimental than transient fluctuations. Cross-correlation between CrSO2 and oximetry (PI, SpO2 and HR) as well as in-phase semblance and gain between CrSO2 and HR were significantly lower while anti-phase semblance between CrSO2 and HR was significantly higher in PH-IVH infants compared to controls. These differences may reflect haemodynamic instability associated with cerebrovascular autoregulation and hemorrhagic complications observed during the transitioning physiology.
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Affiliation(s)
- Thierry P Beausoleil
- Institute of Biomedical Engineering, University of Montréal, Montréal, Canada.,Research Centre, CHU Sainte-Justine, Montréal, Canada
| | - Marie Janaillac
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Keith J Barrington
- Research Centre, CHU Sainte-Justine, Montréal, Canada.,Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Anie Lapointe
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Mathieu Dehaes
- Research Centre, CHU Sainte-Justine, Montréal, Canada. .,Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montréal, Montréal, Canada.
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26
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Leijser LM, Miller SP, van Wezel-Meijler G, Brouwer AJ, Traubici J, van Haastert IC, Whyte HE, Groenendaal F, Kulkarni AV, Han KS, Woerdeman PA, Church PT, Kelly EN, van Straaten HLM, Ly LG, de Vries LS. Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene? Neurology 2018; 90:e698-e706. [PMID: 29367448 DOI: 10.1212/wnl.0000000000004984] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 11/06/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare neurodevelopmental outcomes of preterm infants with and without intervention for posthemorrhagic ventricular dilatation (PHVD) managed with an "early approach" (EA), based on ventricular measurements exceeding normal (ventricular index [VI] <+2 SD/anterior horn width <6 mm) with initial temporizing procedures, followed, if needed, by permanent shunt placement, and a "late approach" (LA), based on signs of increased intracranial pressure with mostly immediate permanent intervention. METHODS Observational cohort study of 127 preterm infants (gestation <30 weeks) with PHVD managed with EA (n = 78) or LA (n = 49). Ventricular size was measured on cranial ultrasound. Outcome was assessed at 18-24 months. RESULTS Forty-nine of 78 (63%) EA and 24 of 49 (49%) LA infants received intervention. LA infants were slightly younger at birth, but did not differ from EA infants for other clinical measures. Initial intervention in the EA group occurred at younger age (29.4/33.1 week postmenstrual age; p < 0.001) with smaller ventricles (VI 2.4/14 mm >+2 SD; p < 0.01), and consisted predominantly of lumbar punctures or reservoir taps. Maximum VI in infants with/without intervention was similar in EA (3/1.5 mm >+2 SD; p = 0.3) but differed in the LA group (14/2.1 mm >+2 SD; p < 0.001). Shunt rate (20/92%; p < 0.001) and complications were lower in EA than LA group. Most EA infants had normal outcomes (>-1 SD), despite intervention. LA infants with intervention had poorer outcomes than those without (p < 0.003), with scores <-2 SD in 81%. CONCLUSION In preterm infants with PHVD, those with early intervention, even when eventually requiring a shunt, had outcomes indistinguishable from those without intervention, all being within the normal range. In contrast, in infants managed with LA, need for intervention predicted worse outcomes. Benefits of EA appear to outweigh potential risks. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for preterm infants with PHVD, an EA to management results in better neurodevelopmental outcomes than a LA.
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Affiliation(s)
- Lara M Leijser
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Steven P Miller
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Gerda van Wezel-Meijler
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Annemieke J Brouwer
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Jeffrey Traubici
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Ingrid C van Haastert
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Hilary E Whyte
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Floris Groenendaal
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Abhaya V Kulkarni
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Kuo S Han
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Peter A Woerdeman
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Paige T Church
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Edmond N Kelly
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Henrica L M van Straaten
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Linh G Ly
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada
| | - Linda S de Vries
- From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada.
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27
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McLachlan PJ, Kishimoto J, Diop M, Milej D, Lee DSC, de Ribaupierre S, St Lawrence K. Investigating the effects of cerebrospinal fluid removal on cerebral blood flow and oxidative metabolism in infants with post-hemorrhagic ventricular dilatation. Pediatr Res 2017; 82:634-641. [PMID: 28553990 DOI: 10.1038/pr.2017.131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/28/2017] [Indexed: 11/09/2022]
Abstract
BackgroundPost-hemorrhagic ventricular dilatation (PHVD) is predictive of mortality and morbidity among very-low-birth-weight preterm infants. Impaired cerebral blood flow (CBF) due to elevated intracranial pressure (ICP) is believed to be a contributing factor.MethodsA hyperspectral near-infrared spectroscopy (NIRS) method of measuring CBF and the cerebral metabolic rate of oxygen (CMRO2) was used to investigate perfusion and metabolism changes in patients receiving a ventricular tap (VT) based on clinical management. To improve measurement accuracy, the spectral analysis was modified to account for compression of the cortical mantle caused by PHVD and the possible presence of blood breakdown products.ResultsFrom nine patients (27 VTs), a significant CBF increase was measured (15.6%) following VT (14.6±4.2 to 16.9±6.6 ml/100 g/min), but with no corresponding change in CMRO2 (1.02±0.41 ml O2/100 g/min). Post-VT CBF was in good agreement with a control group of 13 patients with patent ductus arteriosus but no major cerebral pathology (16.5±7.7 ml/100 g/min), whereas tissue oxygen saturation (StO2) was significantly lower (58.9±12.1% vs. 70.5±9.1% for controls).ConclusionCBF was impeded in PHVD infants requiring a clinical intervention, but the effect is not large enough to alter CMRO2.
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Affiliation(s)
- Peter J McLachlan
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Jessica Kishimoto
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Mamadou Diop
- Imaging Division, Lawson Health Research Institute, London, Ontario, Canada
| | - Daniel Milej
- Imaging Division, Lawson Health Research Institute, London, Ontario, Canada
| | - David S C Lee
- Department of Pediatrics, Western University, London, Ontario, Canada
| | | | - Keith St Lawrence
- Imaging Division, Lawson Health Research Institute, London, Ontario, Canada
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28
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Kochan M, McPadden J, Bass WT, Shah T, Brown WT, Tye GW, Vazifedan T. Changes in Cerebral Oxygenation in Preterm Infants With Progressive Posthemorrhagic Ventricular Dilatation. Pediatr Neurol 2017; 73:57-63. [PMID: 28651978 DOI: 10.1016/j.pediatrneurol.2017.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/04/2017] [Accepted: 05/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Optimal timing of intervention in neonatal progressive posthemorrhagic hydrocephalus is often a difficult decision. Unchecked hydrocephalus can lead to irreversible brain injury through impaired perfusion, while placement of a shunt is not without long-term morbidity. The purpose of this study was to assess the use of near-infrared spectroscopy to measure changes in regional cerebral oxygen saturation as an indicator of cerebral perfusion in infants with progressive posthemorrhagic ventricular dilatation. METHODS Near-infrared spectroscopy was used to measure regional cerebral oxygen saturation for more than a one-hour period in infants within 24 hours of cranial ultrasound. Simultaneous pulse oximetry was recorded and oxygen extraction was calculated. Ventricular size was measured by ultrasound using the frontal-occipital horn ratio and compared with average oxygen saturation and oxygen extraction. Statistical analysis was done using the Spearman rank test and analysis of variance. RESULTS Ventricular measurements were made in 20 very low birth weight premature infants with periventricular-intraventricular hemorrhage and 12 infants with normal ultrasound scans. Ventricular dilatation was associated with lower cerebral oxygen saturation and higher oxygen extraction (P < 0.001). Progressive ventricular dilatation was inversely related to changes in cerebral oxygen saturation (P < 0.001). CONCLUSIONS Progressive posthemorrhagic ventricular dilatation is associated with a significant decrease in cerebral oxygenation and increase in oxygen extraction suggesting a decrease in cerebral perfusion. Near-infrared spectroscopy could potentially provide additional clinical information to assist in determining optimal timing of surgical intervention in preterm infants with progressive ventricular enlargement.
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Affiliation(s)
- Michael Kochan
- Department of Pediatrics, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jacob McPadden
- Department of Pediatrics, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia
| | - William T Bass
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia.
| | - Tushar Shah
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia
| | - Wendy T Brown
- Department of Pediatric Neuroradiology, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia
| | - Gary W Tye
- Department of Pediatric Neurosurgery, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia
| | - Turaj Vazifedan
- Division of BioStatistics, Department of Pediatrics, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia
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29
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Alderliesten T, De Vis JB, Lemmers PMA, Hendrikse J, Groenendaal F, van Bel F, Benders MJNL, Petersen ET. Brain oxygen saturation assessment in neonates using T 2-prepared blood imaging of oxygen saturation and near-infrared spectroscopy. J Cereb Blood Flow Metab 2017; 37:902-913. [PMID: 27151900 PMCID: PMC5363470 DOI: 10.1177/0271678x16647737] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although near-infrared spectroscopy is increasingly being used to monitor cerebral oxygenation in neonates, it has a limited penetration depth. The T2-prepared Blood Imaging of Oxygen Saturation (T2-BIOS) magnetic resonance sequence provides an oxygen saturation estimate on a voxel-by-voxel basis, without needing a respiratory calibration experiment. In 15 neonates, oxygen saturation measured by T2-prepared blood imaging of oxygen saturation and near-infrared spectroscopy were compared. In addition, these measures were compared to cerebral blood flow and venous oxygen saturation in the sagittal sinus. A strong linear relation was found between the oxygen saturation measured by magnetic resonance imaging and the oxygen saturation measured by near-infrared spectroscopy ( R2 = 0.64, p < 0.001). Strong linear correlations were found between near-infrared spectroscopy oxygen saturation, and magnetic resonance imaging measures of frontal cerebral blood flow, whole brain cerebral blood flow and venous oxygen saturation in the sagittal sinus ( R2 = 0.71, 0.50, 0.65; p < 0.01). The oxygen saturation obtained by T2-prepared blood imaging of oxygen saturation correlated with venous oxygen saturation in the sagittal sinus ( R2 = 0.49, p = 0.023), but no significant correlations could be demonstrated with frontal and whole brain cerebral blood flow. These results suggest that measuring oxygen saturation by T2-prepared blood imaging of oxygen saturation is feasible, even in neonates. Strong correlations between the various methods work as a cross validation for near-infrared spectroscopy and T2-prepared blood imaging of oxygen saturation, confirming the validity of using of these techniques for determining cerebral oxygenation.
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Affiliation(s)
- Thomas Alderliesten
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Thomas Alderliesten, Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Room KE04.123.1, PO Box 85090, 3584 AE Ut, The Netherlands.
| | - Jill B De Vis
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra MA Lemmers
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon JNL Benders
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Esben T Petersen
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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30
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Brouwer MJ, de Vries LS, Kersbergen KJ, van der Aa NE, Brouwer AJ, Viergever MA, Išgum I, Han KS, Groenendaal F, Benders MJNL. Effects of Posthemorrhagic Ventricular Dilatation in the Preterm Infant on Brain Volumes and White Matter Diffusion Variables at Term-Equivalent Age. J Pediatr 2016; 168:41-49.e1. [PMID: 26526364 DOI: 10.1016/j.jpeds.2015.09.083] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/21/2015] [Accepted: 09/30/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the differential impact of germinal matrix-intraventricular hemorrhage (GMH-IVH) and posthemorrhagic ventricular dilatation (PHVD) on brain and cerebrospinal fluid (CSF) volumes and diffusion variables in preterm born infants at term-equivalent age (TEA). STUDY DESIGN Nineteen infants (gestational age <31 weeks) with GMH-IVH grade II-III according to Papile et al and subsequent PHVD requiring intervention were matched against 19 controls with GMH-IVH grade II but no PHVD and 19 controls without GMH-IVH. Outcome variables on magnetic resonance imaging (MRI) including diffusion weighted imaging at TEA were volumes of white matter, cortical gray matter, deep gray matter, brainstem, cerebellum, ventricles, extracerebral CSF, total brain tissue, and intracranial volume (ICV), as well as white matter and cerebellar apparent diffusion coefficients (ADCs). Effects of GMH-IVH and PHVD on TEA-MRI measurements were evaluated using multivariable regression analysis. Brain and CSF volumes were adjusted for ICV to account for differences in bodyweight at TEA-MRI and ICV between cases and controls. RESULTS PHVD was independently associated with volumes of deep gray matter (β [95% CI]: -1.4 cc [-2.3; -.5]), cerebellum (-2.7 cc [-3.8; -1.6]), ventricles (+12.7 cc [7.9; 17.4]), and extracerebral CSF (-11.2 cc [-19.2; -3.3]), and with ADC values in occipital, parieto-occipital, and parietal white matter (β: +.066-.119×10(-3) mm(2)/s) on TEA-MRI (P < .05). No associations were found between GMH-IVH grade II-III and brain and CSF volumes or ADC values at TEA. CONCLUSIONS PHVD was negatively related to deep gray matter and cerebellar volumes and positively to white matter ADC values on TEA-MRI, despite early intervention for PHVD in the majority of the infants. These relationships were not observed for GMH-IVH.
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Affiliation(s)
- Margaretha J Brouwer
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karina J Kersbergen
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Annemieke J Brouwer
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Max A Viergever
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ivana Išgum
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kuo S Han
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
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