Cerebellar haemorrhage in the extremely preterm infant

Neurodevelopmental outcomes and volumetric analysis of brain in preterm infants with isolated cerebellar hemorrhage

Background

Cerebellar hemorrhage (CBH) is a major form of cerebellar injury in preterm infants. We aimed to investigate the risk factors and neurodevelopmental outcomes of isolated CBH and performed volumetric analysis at term-equivalent age.

Methods

This single-centered nested case-control study included 26 preterm infants with isolated CBH and 52 infants without isolated CBH and any significant supratentorial injury.

Results

Isolated CBH was associated with PCO2 fluctuation within 72 h after birth (adjusted odds ratio 1.007, 95% confidence interval 1.000–1.014). The composite score in the motor domain of the Bayley Scales of Infant and Toddler Development at 24 month of corrected age was lower in the punctate isolated CBH group than that in the control group (85.3 vs. 94.5, P = 0.023). Preterm infants with isolated CBH had smaller cerebellum and pons at term-equivalent age compared to the control group. Isolated CBH with adverse neurodevelopment had a smaller ventral diencephalon and midbrain compared to isolated CBH without adverse neurodevelopmental outcomes.

Conclusions

In preterm infants, isolated CBH with punctate lesions were associated with abnormal motor development at 24 months of corrected age. Isolated CBH accompanied by a smaller ventral diencephalon and midbrain at term equivalent had adverse neurodevelopmental outcomes.

Cranial Ultrasound Screening Protocols for Very Preterm Infants

Cranial ultrasound examinations are routinely performed in very preterm neonates. There is no widespread agreement on the optimal timing of these examinations. This review examines screening protocols and recommendations available for the timing of cranial ultrasound examinations in preterm neonates born before 32 wk of gestation. A systematic search was performed to find published screening protocols, and 18 articles were included in the final review. The protocols varied in their recommendations on timing, although at least one examination in the first week of life was universally recommended. The recommended timing for a "late" or final ultrasound examination was variable, and included at 6 wks of postnatal age, term-equivalent age or hospital discharge. There was no agreement as to whether weekly or fortnightly sequential ultrasound imaging should be performed after the first week of life. Further studies are required to establish an optimal protocol for these very preterm neonates to improve detection and monitoring of brain injuries.

Early high-dose caffeine citrate for extremely preterm infants: Neonatal and neurodevelopmental outcomes

AIM

To examine neonatal morbidities, including the incidence of cerebellar haemorrhage (CBH), and neurodevelopmental outcomes following the administration of high loading dose caffeine citrate compared to standard loading dose caffeine citrate.

METHODS

This was a retrospective study of 218 preterm infants <28 weeks' gestation who received a loading dose of caffeine citrate within the first 36 h of life at the Mater Mothers' Hospital over a 3-year period (2011-2013). Two groups were compared, with 158 neonates in the high-dose cohort receiving a median dose of caffeine citrate of 80 mg/kg and 60 neonates in the standard dose cohort receiving a median dose of 20 mg/kg. Routine cranial ultrasound, including mastoid views, was performed during the neonatal period. At 2 years of age, infants presented for follow-up and were assessed with the Neurosensory Motor Developmental Assessment (NSMDA) and the Bayley Scales of Infant and Toddler Development-III (Bayley-III).

RESULTS

There was no difference in the incidence of neonatal morbidities, including CBH, between the two groups. The incidence of CBH in the high-dose group was 2.5% compared to 1.7% in the standard-dose group. There was no difference in the neurodevelopmental follow-up scores as evaluated with the NSMDA and the Bayley-III.

CONCLUSIONS

The use of early high loading dose caffeine citrate in extremely preterm infants was not shown to be associated with CBH or abnormal long-term neurodevelopmental outcomes. The overall incidence of CBH, however, was much lower than in studies using magnetic resonance imaging techniques. It is suggested that a large randomised clinical trial is needed to determine the optimal dose of caffeine citrate when given early to very preterm infants.

Neurodevelopmental Consequences of Preterm Isolated Cerebellar Hemorrhage: A Systematic Review

CONTEXT

The effect of neonatal cerebellar hemorrhage on neurodevelopmental outcome (NDO) in the absence of supratentorial injury is still largely unknown.

OBJECTIVE

To evaluate the influence of isolated neonatal cerebellar hemorrhage on cognitive, motor, language, and behavioral NDOs and assess the effect of location and size on outcome.

DATA SOURCES

Embase, Medline, and Scopus were searched from inception to September 30, 2017.

STUDY SELECTION

Studies in which a diagnosis of isolated cerebellar hemorrhage was reported in preterm infants (<32 weeks' gestation) with a standardized NDO at ≥12 months of age were included.

DATA EXTRACTION

Patient characteristics, location, and size of bleeding and NDO (defined as severe [yes or no] on the basis of given cutoff points) in 4 domains were extracted.

RESULTS

Of the 1519 studies identified, 8 were included in final analyses. Of infants with isolated cerebellar hemorrhage, 128 were described (cumulative incidence: 2.3%). The incidence of severe delay in cognition, motor, language, and behavioral development was 38%, 39%, 41%, and 38%, respectively. The overall incidence of severe neurodevelopmental delay in ≥1 domain ranged from 43% to 75% and was most seen in infants with vermis involvement (87%-93%) and with large bleeds (46%-82%).

LIMITATIONS

Different neurodevelopmental scales lead to data heterogeneity, and reporting of data on a group level limited possibilities for an outcome description on an individual level.

CONCLUSIONS

Of infants with isolated cerebellar hemorrhage, 43% to 75% were severely delayed in cognition, motor, language, and/or behavioral development, with the highest incidence with vermis involvement and with large bleeds.

Systemic inflammation combined with neonatal cerebellar haemorrhage aggravates long-term structural and functional outcomes in a mouse model

BACKGROUND

Despite the increased recognition of cerebellar injury in survivors of preterm birth, the neurodevelopmental consequences of isolated cerebellar injury have been largely unexplored and our current understanding of the functional deficits requires further attention in order to translate knowledge to best practices. Preterm infants are exposed to multiple stressors during their postnatal development including perinatal cerebellar haemorrhage (CBH) and postnatal infection, two major risk factors for neurodevelopmental impairments.

METHODS

We developed a translational mouse model of CBH and/or inflammation to measure the short- and long-term outcomes in cerebellar structure and function.

RESULTS

Mice exposed to early combined insults of CBH and early inflammatory state (EIS) have a delay in grasping acquisition, neonatal motor deficits and deficient long-term memory. CBH combined with late inflammatory state (LIS) does not induce neonatal motor problems but leads to poor fine motor function and long-term memory deficits at adulthood. Early combined insults result in poor cerebellar growth from postnatal day 15 until adulthood shown by MRI, which are reflected in diminished volumes of cerebellar structures. There are also decreases in volumes of gray matter and hippocampus. Cerebellar microgliosis appears 24h after the combined insults and persists until postnatal day 15 in the cerebellar molecular layer and cerebellar nuclei in association with a disrupted patterning of myelin deposition, a delay of oligodendrocyte maturation and reduced white matter cerebellar volume.

CONCLUSIONS

Together, these findings reveal poor outcomes in developing brains exposed to combined cerebellar perinatal insults in association with cerebellar hypoplasia, persistence of microgliosis and alterations of cerebellar white matter maturation and growth.

Screening for autism spectrum disorder in very preterm infants during early childhood

AIM

The aim of the study was to screen very preterm infants for autism spectrum disorder (ASD) with comparisons to a group of term controls. The study also aimed to identify maternal and neonatal risk factors, development and behaviour associated with a positive screen in the preterm group.

METHOD

Preterm infants born ≤ 30 weeks gestation and term infants were recruited at two years of age. The mothers were posted the questionnaires and completed the Modified Checklist for Autism in Toddlers (M-CHAT), the Child Behaviour Checklist (CBCL) and the Depression, Anxiety and Stress Scales (DASS). Previously collected data from the mothers at 12 months--the Edinburgh Postnatal Depression Scales (EPDS) were analysed. The children had neurodevelopmental assessment including the Bayley-III. Infants positive on M-CHAT screen had an M-CHAT follow-up interview by phone and then were assessed by a developmental paediatrician as indicated with a diagnosis of autism being made on clinical judgement.

RESULTS

13 (13.4%) of the 97 preterm infants screened positive on the M-CHAT compared to three (3.9%) of the 77 term infants (p = 0.036). On follow-up interview, three of the preterm infants remained positive (one was diagnosed with autism) compared to none of the term infants. The preterm infants who screened positive were born to younger, non-Caucasian mothers and were of lower birth weight and had a higher incidence of being small for gestational age (SGA). The infants had lower composite scores on Bayley-III and had more internalising and externalising behaviours on the CBCL. The mothers had more emotional problems on the DASS and higher scores on the EPDS. On multivariate analysis, SGA, greater internalising behaviours and higher EPDS scores remained statistically significant.

CONCLUSIONS

A positive screen on the M-CHAT occurs more commonly in very preterm infants than those born at term. Internalising behaviours and maternal mental health are associated with a positive screen in the preterm cohort.

Cerebellar hemorrhagic injury in premature infants occurs during a vulnerable developmental period and is associated with wider neuropathology

BACKGROUND

Cerebellar hemorrhagic injury (CHI) is being recognized more frequently in premature infants. However, much of what we know about CHI neuropathology is from autopsy studies that date back to a prior era of neonatal intensive care. To update and expand our knowledge of CHI we reviewed autopsy materials and medical records of all live-born preterm infants (<37 weeks gestation) autopsied at our institution from 1999-2010 who had destructive hemorrhagic injury to cerebellar parenchyma (n = 19) and compared them to matched non-CHI controls (n = 26).

RESULTS

CHI occurred at a mean gestational age of 25 weeks and involved the ventral aspect of the posterior lobe in almost all cases. CHI arose as a large hemorrhage or as multiple smaller hemorrhages in the emerging internal granule cell layer of the developing cortex or in the nearby white matter. Supratentorial germinal matrix hemorrhage occurred in 95% (18/19) of CHI cases compared to 54% (14/26) of control cases (p = 0.003). The cerebellar cortex frequently showed focal neuronal loss and gliosis (both 15/19, 79%) in CHI cases compared to control cases (both 1/26, 4% p < 0.0001). The cerebellar dentate had more neuronal loss (8/15, 53%) and gliosis (9/15, 60%) in CHI cases than controls (both 0/23, 0%; p < 0.0001). The inferior olivary nuclei showed significantly more neuronal loss in CHI (10/17, 59%) than in control cases (5/26, 19%) (p = 0.0077). All other gray matter sites examined showed no significant difference in the incidence of neuronal loss or gliosis between CHI and controls.

CONCLUSIONS

We favor the possibility that CHI represents a primary hemorrhage arising due to the effects of impaired autoregulation in a delicate vascular bed. The incidences of neuronal loss and gliosis in the inferior olivary and dentate nuclei, critical cerebellar input and output structures, respectively were higher in CHI compared to control cases and may represent a transsynpatic degenerative process. CHI occurs during a critical developmental period and may render the cerebellum vulnerable to additional deficits if cerebellar growth and neuronal connectivity are not established as expected. Therefore, CHI has the potential to significantly impact neurodevelopmental outcome in survivors.