''Intraventricular'' hemorrhage and cystic periventricular leukomalacia in preterm infants: how are they related?

Variations in neonatal mortality of preterm infants with intraparenchymal haemorrhage in Europe: the EPICE cohort

OBJECTIVE

The aim of this study was to investigate variations in mortality before neonatal intensive care unit (NICU) discharge of infants born preterm with intraparenchymal haemorrhage (IPH) in Europe with a special interest for withdrawing life-sustaining therapy (WLST).

DESIGN

Secondary analysis of the Effective Perinatal Intensive Care in Europe (EPICE) cohort, 2011-2012.

SETTING

Nineteen regions in 11 European countries.

PATIENTS

All infants born between 24+0 and 31+6 weeks' gestational age (GA) with a diagnosis of IPH.

MAIN OUTCOME MEASURES

Mortality rate with multivariable analysis after adjustment for GA, antenatal steroids and gender. WLST policies were described among NICUs and within countries.

RESULTS

Among 6828 infants born alive between 24+0 and 31+6 weeks' GA and without congenital anomalies admitted to NICUs, IPH was diagnosed in 234 infants (3.4%, 95% CI 3.3% to 3.9%) and 138 of them (59%) died. The median age at death was 6 days (3-13). Mortality rates varied significantly between countries (extremes: 30%-81%; p<0.004) and most infants (69%) died after WLST. After adjustment and with reference to the UK, mortality rates were significantly higher for France, Denmark and the Netherlands, with ORs of 8.8 (95% CI 3.3 to 23.6), 5.9 (95% CI 1.6 to 21.4) and 4.8 (95% CI 1.1 to 8.9). There were variations in WLST between European regions and countries.

CONCLUSION

In infants with IPH, rates of death before discharge and death after WLST varied between European countries. These variations in mortality impede studying reliable outcomes in infants with IPH across European countries and encourage reflection of clinical practices of WLST across European units.

Regional cerebral oxygen saturation variability and brain injury in preterm infants

Objective

To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants.

Study design

A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury.

Results

The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury.

Conclusions

In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.

The validity of hospital diagnostic and procedure codes reflecting morbidity in preterm neonates born <32 weeks gestation

OBJECTIVE

To determine the validity of diagnostic hospital billing codes for complications of prematurity in neonates <32 weeks gestation.

STUDY DESIGN

Retrospective cohort data from discharge summaries and clinical notes (n = 160) were reviewed by trained, blinded abstractors for the presence of intraventricular hemorrhage (IVH) grades 3 or 4, periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), stage 3 or higher, retinopathy of prematurity (ROP), and surgery for NEC or ROP. Data were compared to diagnostic billing codes from the neonatal electronic health record.

RESULTS

IVH, PVL, ROP and ROP surgery had strong positive predictive values (PPV > 75%) and excellent negative predictive values (NPV > 95%). The PPVs for NEC (66.7%) and NEC surgery (37.1%) were low.

CONCLUSION

Diagnostic hospital billing codes were observed to be a valid metric to evaluate preterm neonatal morbidities and surgeries except in the instance of more ambiguous diagnoses such as NEC and NEC surgery.

Case report: Bilateral damage to the immature optic radiation and secondary massive loss of retinal ganglion cells causing tunnel vision

We describe the case of a 30-year-old woman, who needed a formal report on her visual impairment to seek support from society. She was born preterm, and during her neonatal period, she suffered from bilateral intraventricular hemorrhage (IVH) grade 3, a condition that can cause cerebral visual impairment (CVI) due to damage to the retro-geniculate visual pathways. Individuals with such brain damage of this severity are often restricted by cerebral palsy (CP) and intellectual disability, and thus have a limited ability to cooperate in the assessment of visual function. However, our patient was capable of providing reliable test results, and she manifested only a small island of central vision in each eye, with additional reduced visual acuities. She cooperated well in examinations involving MRI of the brain, optical coherence tomography (OCT) of retinal ganglion cells, and multi-focal visual evoked potentials, with each test providing information about potential limitations in the structural prerequisites for visual function. What distinguishes our case is the severity of the damage to the optic radiations and the massive secondary loss of most of her retinal ganglion cells (GCs). However, there is some measurable visual function, which may be due to developmental neuroplasticity during early development, when surviving GCs prioritize the central visual field. Despite her visual difficulties, she is a keen portrait painter. Our patient may be representative of, and a spokesperson for, other individuals with extensive brain damage of the same etiology, who are unable to perform perimetric tests and therefore run the risk of not being recognized as severely visually impaired, and consequently, not being given the best conditions for habilitation. OCT may serve as a helpful diagnostic tool. Aim: This study aims to describe visual behavior and practical applications of visual function in relation to structural prerequisites for visual function.

Prevention of severe brain injury in very preterm neonates: A quality improvement initiative

OBJECTIVE

To determine the impact of neuroprotection interventions bundle on the incidence of severe brain injury or early death (intraventricular hemorrhage grade 3/4 or death by 7 days or ventriculomegaly or cystic periventricular leukomalacia on 1-month head ultrasound, primary composite outcome) in very preterm (27^0/7 to ≤ 29^6/7 weeks gestational age) infants.

STUDY DESIGN

Prospective quality improvement initiative, from April 2017-September 2019, with neuroprotection interventions bundle including cerebral NIRS, TcCO₂, and HeRO monitoring-based management algorithm, indomethacin prophylaxis, protocolized bicarbonate and inotropes use, noise reduction, and neutral positioning.

RESULT

There was a decrease in the incidence of the primary composite outcome in the intervention period on unadjusted (N = 11/99, pre-intervention to N = 0/127, intervention period, p < 0.001) and adjusted analysis (adjusted for birthweight and Apgar score <5 at 5 min, aOR = 0.042, 95% CI = 0.003-0.670, p = 0.024).

CONCLUSIONS

Neuroprotection interventions bundle was associated with significant decrease in severe brain injury or early death in very preterm infants.

Determination of Predictors of Brain Injury in Very Preterm Infants - A Retrospective Cohort Study

Background

Despite decades of research, there is inadequate evidence on the etiological factors of brain injury in preterm infants.

Objective

To study the perinatal risk factors for preterm brain injury and to assess their strength of association.

Methods

In this retrospective cohort study, we included infants born at <32 weeks' gestation and had either magnetic resonance imaging (MRI) or cranial ultrasound (CUS) performed at term equivalent age. Significant brain injury was diagnosed based on Kidokoro global brain injury score was ≥4 in MRI or cystic periventricular leukomalacia in CUS.

Results

Among the 698 infants, 48 had significant brain injury and 650 were taken as controls. In multiple logistic regression, intraventricular hemorrhage (IVH) grade 3-4 [adjusted odds ratio, 92.892 (19.495-442.619)], culture-positive sepsis [4.162 (1.729-10.021)], prolonged ventilation [3.688 (1.087-12.510)], and small for gestational age (SGA) [2.645 (1.181-5.924] were associated with greater risk of preterm brain injury.

Conclusion

Severe IVH, culture-positive sepsis, prolonged ventilation and SGA were significant risk factors for preterm brain injury with severe IVH being the most significant contributing factor.

Risk Factors for Periventricular Leukomalacia in Preterm Infants: A Systematic Review, Meta-analysis, and GRADE-Based Assessment of Certainty of Evidence

BACKGROUND

We analyzed the certainty of evidence (CoE) for risk factors of periventricular leukomalacia (PVL) in preterm neonates, a common morbidity of prematurity.

METHODS

Medline, CENTRAL, Embase, and CINAHL were searched. Cohort and case-control studies and randomised randomized controlled trials were included. Data extraction was performed in duplicate. A random random-effects meta-analysis was utilizedused. CoE was evaluated as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

One hundred eighty-six studies evaluating 95 risk factors for PVL were included. Of the 2,509,507 neonates assessed, 16,569 were diagnosed with PVL. Intraventricular hemorrhage [adjusted odds ratio: 3.22 (2.52-4.12)] had moderate CoE for its association with PVL. Other factors such as hypocarbia, chorioamnionitis, PPROM >48 hour, multifetal pregnancy reduction, antenatal indomethacin, lack of antenatal steroids, perinatal asphyxia, ventilation, shock/hypotension, patent ductus arteriosus requiring surgical ligation, late-onset circulatory collapse, sepsis, necrotizing enterocolitis, and neonatal surgery showed significant association with PVL after adjustment for confounders (CoE: very low to low). Amongst the risk factors associated with mother placental fetal (MPF) triad, there was paucity of literature related to genetic predisposition and defective placentation. Sensitivity analysis revealed that the strength of association between invasive ventilation and PVL decreased over time (P < 0.01), suggesting progress in ventilation strategies. Limited studies had evaluated diffuse PVL.

CONCLUSION

Despite decades of research, our findings indicate that the CoE is low to very low for most of the commonly attributed risk factors of PVL. Future studies should evaluate genetic predisposition and defective placentation in the MPF triad contributing to PVL. Studies evaluating exclusively diffuse PVL are warranted.

Antenatal corticosteroid therapy is associated with a lower risk of cystic periventricular leukomalacia

AIM

To evaluate the association of antenatal corticosteroids (ACS) therapy on the risk for cystic periventricular leukomalacia (c-PVL) in very low birth weight (VLBW), very preterm infants, whilst accounting for the occurrence of major neonatal morbidities; sepsis, necrotising enterocolitis, intraventricular haemorrhage and bronchopulmonary dysplasia.

METHODS

Population-based observational cohort study applying data collected by the Israel national VLBW infant database from 1995-2016.

RESULTS

Cystic PVL was diagnosed in 692 (6.8%) of the 10,170 study infants. Among 7522 infants exposed to ACS, the rate of c-PVL was 5.4%, compared to 10.7% among those not exposed (p < 0.0001). ACS was associated with significantly lower odds for c-PVL (Odds Ratio [OR] 0.69, 95% confidence interval [CI] 0.57-0.84). In subgroup analyses, excluding infants with one or more morbidities the rates of c-PVL ranged from 2.7% to 5.4% among infants exposed to ACS compared to 5.6% to 10.7% in those not exposed (all p < 0.0001). ACS was associated with significantly lower OR's for c-PVL in all subgroups, ranging from 0.52 (95% CI 0.40-0.66) to 0.62 (95% CI 0.50-0.77).

CONCLUSION

Infants exposed to ACS had a significantly lower risk of c-PVL. Subgroup analyses excluding infants with major neonatal comorbidities showed a consistent reduction of 40%-50% in the risk for c-PVL following ACS therapy.

Reevaluating 30-day head ultrasound screening for preterm infants in the era of decreasing periventricular leukomalacia

Objective: Neonatal brain injury is a potentially devastating cause of neurodevelopmental impairment. There is no consensus, however, on the appropriate timing and frequency of routine head ultrasound (HUS) screening for such injuries. We evaluated the diagnostic utility of routine HUS screening at 30 days of life ("late HUS") for detecting severe intraventricular hemorrhage (IVH) or cystic periventricular leukomalacia (c-PVL) in preterm infants with a negative HUS before 14 days of life ("early HUS").Methods: Single-center retrospective cohort analysis of infants born at ≤ 32 weeks gestational age (GA) admitted to the University of Nebraska Medical Center NICU from 2011-2018. Demographics, HUS and MRI diagnoses were abstracted from clinical records. Fisher's exact test and t-test assessed associations between categorical and continuous variable, respectively.Results: 205 infants were included-120 very preterm (28-32 weeks GA) and 85 extremely preterm (<28 weeks GA). Negative predictive value of early HUS for predicting any clinically significant anomalies (severe IVH or c-PVL) on late HUS was 100% for extremely and 99.2% for very preterm infants. Term-equivalent MRI detected previously undiagnosed c-PVL in 16.7% of the 24 patients that received MRI; all infants with new c-PVL on MRI had severe IVH on early HUS.Conclusion: Following negative early HUS, late HUS detected significant new abnormalities in one infant. These data suggest that in a unit with low prevalence of c-PVL, 30-day HUS may have limited clinical utility following negative screening. In infants with abnormal early HUS, clinicians should consider obtaining term-equivalent MRI screening to detect c-PVL.

[A multicenter epidemiological investigation of brain injury in hospitalized preterm infants in Anhui, China]

OBJECTIVE

To investigate the risk factors for brain injury in preterm infants by a multicenter epidemiological investigation of brain injury in hospitalized preterm infants in Anhui, China.

METHODS

Preterm infants who were hospitalized in the department of neonatology in 9 hospitals of Anhui Neonatal Collaboration Network between January 2016 and January 2017 were enrolled as subjects. The data of maternal pregnancy and clinical data of preterm infants were collected, and the logistic regression model was used to analyze the risk factors for brain injury in preterm infants.

RESULTS

A total of 3 378 preterm infants were enrolled. Of the 3 378 preterm infants, 798 (23.56%) had periventricular-intraventricular hemorrhage (PVH-IVH), and 88 (2.60%) had periventricular leukomalacia (PVL). Intrauterine distress, anemia, hypoglycemia and necrotizing enterocolitis (NEC) were risk factors for PVH-IVH (OR=1.310, 1.591, 1.835, and 3.310 respectively; P<0.05), while a higher gestational age was a protective factor against PVH-IVH (OR=0.671, P<0.05). PVH-IVH, NEC and mechanical ventilation were risk factors for PVL (OR=4.017, 3.018, and 2.166 respectively; P<0.05), and female sex and use of pulmonary surfactant were protective factors against PVL (OR=0.514 and 0.418 respectively; P<0.05).

CONCLUSIONS

Asphyxia/anoxia, infection/inflammation, mechanical ventilation, anemia and hypoglycemia may increase the risk of brain injury in preterm infants.

A population-based study of cystic white matter injury on ultrasound in very preterm infants born over two decades in Nova Scotia, Canada

OBJECTIVE

To identify the temporal trends, risk factors and outcomes of cystic white matter injury (WMI) detected by ultrasound in a population-based cohort of very preterm infants (VPI) with a minimal risk of selection bias.

STUDY DESIGN

All live-born VPIs between 22 and < 31 weeks gestational age born in Nova Scotia, Canada from 1993 to 2013.

RESULTS

Cystic WMI was identified in 87 (7%) out of 1184 eligible infants. The gestational age and mortality adjusted prevalence of cystic WMI decreased over time (p = 0.04). In multivariable analysis, chorioamnionitis, antenatal steroids, admission hypothermia, ventilator support, inotropes, and non-Coagulase-negative Staphylococcal and fungal infections were independently associated with cystic WMI. Cerebral palsy was the most common disability in the survivors, however, half of the survivors had none or mild disability.

CONCLUSIONS

This cohort study demonstrated a decreasing trend in the incidence of cystic WMI and reported population-based neurological outcomes with cystic WMI, which is important for health-care planning and parental counseling.

Vascular placental pathology and the relationship between hypertensive disorders of pregnancy and neonatal outcomes in very low birth weight infants

OBJECTIVE

To investigate vascular placental pathology's effect on known associations between hypertensive disorders and four adverse neonatal outcomes-bronchopulmonary dysplasia, intraventricular hemorrhage or periventricular leukomalacia, necrotizing enterocolitis, and death.

STUDY DESIGN

Retrospective cohort of very low birth weight neonates born at a single center (n = 911). Statistical analysis included χ², t test, modified Poisson regression with robust error variance to measure risk, and Wald test. Stratified models assessed the effect of maternal hypertension on neonatal outcomes in those exposed to placental pathology.

RESULTS

Neonates exposed to maternal hypertension and placental pathology had an increased risk of bronchopulmonary dysplasia (relative risk (RR) = 5.23, 95% confidence interval (CI): 2.07, 13.22) compared to those exposed to hypertension without placental pathology (RR = 1.63, 95% CI: 1.14, 2.34; Wald test p = 0.02). Similar, but non-significant, trends also emerged for necrotizing enterocolitis and death.

CONCLUSION

Vascular placental pathology may amplify the risk of adverse outcomes in neonates exposed to hypertension and may mark the extent to which hypertension affects neonates.

Leading causes of preterm delivery as risk factors for intraventricular hemorrhage in very preterm infants: results of the EPIPAGE 2 cohort study

BACKGROUND

Intraventricular hemorrhage is a major risk factor for neurodevelopmental disabilities in preterm infants. However, few studies have investigated how pregnancy complications responsible for preterm delivery are related to intraventricular hemorrhage.

OBJECTIVE

We sought to investigate the association between the main causes of preterm delivery and intraventricular hemorrhage in very preterm infants born in France during 2011 between 22-31 weeks of gestation.

STUDY DESIGN

The study included 3495 preterm infants from the national EPIPAGE 2 cohort study who were admitted to neonatal intensive care units and had at least 1 cranial ultrasound assessment. The primary outcome was grade I-IV intraventricular hemorrhage according to the Papile classification. Multinomial logistic regression models were used to study the relationship between risk of intraventricular hemorrhage and the leading causes of preterm delivery: vascular placental diseases, isolated intrauterine growth retardation, placental abruption, preterm labor, and premature rupture of membranes, with or without associated maternal inflammatory syndrome.

RESULTS

The overall frequency of grade IV, III, II, and I intraventricular hemorrhage was 3.8% (95% confidence interval, 3.2-4.5), 3.3% (95% confidence interval, 2.7-3.9), 12.1% (95% confidence interval, 11.0-13.3), and 17.0% (95% confidence interval, 15.7-18.4), respectively. After adjustment for gestational age, antenatal magnesium sulfate therapy, level of care in the maternity unit, antenatal corticosteroids, and chest compressions, infants born after placental abruption had a higher risk of grade IV and III intraventricular hemorrhage compared to those born under placental vascular disease conditions, with adjusted odds ratios of 4.3 (95% confidence interval, 1.1-17.0) and 4.4 (95% confidence interval, 1.1-17.6), respectively. Similarly, preterm labor with concurrent inflammatory syndrome was associated with an increased risk of grade IV intraventricular hemorrhage (adjusted odds ratio, 3.4; 95% confidence interval, 1.1-10.2]). Premature rupture of membranes did not significantly increase the risk.

CONCLUSION

Relationships between the causes of preterm birth and intraventricular hemorrhage were limited to specific and rare cases involving acute hypoxia-ischemia and/or inflammation. While the emergent nature of placental abruption would challenge any attempts to optimize management, the prenatal care offered during preterm labor could be improved.

Isolated Cystic Periventricular Leukomalacia Differs from Cystic Periventricular Leukomalacia with Intraventricular Hemorrhage in Prevalence, Risk Factors and Outcomes in Preterm Infants

BACKGROUND

Cystic periventricular leukomalacia (cPVL) is the most severe white matter injury and is often associated with intraventricular hemorrhage (IVH) in preterm infants.

OBJECTIVE

The aim of this study was to investigate the prevalence, risk factors and neurodevelopmental outcomes of isolated cPVL and cPVL with low-grade and high-grade IVH in premature infants.

METHODS

From 2001 to 2012, 9,964 infants with <31 weeks' gestational age (GA) admitted to Taiwan hospitals were enrolled. cPVL was classified into three groups: isolated cPVL, cPVL with low-grade (I/II) IVH, and cPVL with high-grade (III) IVH.

RESULTS

Of 7,805 infants with complete ultrasound data, 286 (3.7%) had cPVL. Among the cPVL infants, 93 (32.5%) were isolated, 118 (41.3%) had low-grade IVH and 75 (26.2%) had high-grade IVH. The risk of cPVL with IVH was significantly higher among infants with <27 weeks' GA than those with ≥27 weeks' GA, in contrast to that of isolated cPVL. Using infants without cPVL and IVH as the reference group, the most significant predictor of isolated cPVL was neonatal sepsis (odds ratio 2.39; 95% confidence interval 1.52-3.77), while 5-min Apgar score <5 (2.50; 1.48-4.21) and prolonged mechanical ventilation (2.19; 1.42-3.42) were associated with cPVL with low-grade IVH, and GA <27 weeks (2.63; 1.56-4.42), pneumothorax (3.04; 1.40-6.65) and prolonged mechanical ventilation (3.36; 1.88-6.01) contributed to cPVL with high-grade IVH. cPVL infants with low-grade and high-grade IVH had a higher risk of abnormal neurodevelopmental outcomes than infants with isolated cPVL at the age of 24 months.

CONCLUSIONS

Isolated cPVL, cPVL with low-grade IVH and cPVL with high-grade IVH had different risk factors and neurodevelopmental outcomes, suggestive of different causal pathways.

Antithrombin for the prevention of intraventricular hemorrhage in very preterm infants

BACKGROUND

Preterm birth remains the major risk factor for the development of intraventricular hemorrhage, an injury that occurs in 25% of very low birth weight infants. Intraventricular hemorrhage is thought to be venous in origin and intrinsic thromboses in the germinal matrix are likely to play a triggering role. Antithrombin, a glycoprotein synthesized in the liver, is the major plasma inhibitor of thrombin thus modulating blood coagulation. Very low birth weight newborn infants have low levels of antithrombin and the risk of developing intraventricular hemorrhage is increased by the presence of hypercoagulability in the first hours of life. The administration of anticoagulants such as antithrombin may offset the increased risk of developing intraventricular hemorrhage. Anticoagulants may also reduce the risk of developing parenchymal venous infarct, a condition known to complicate intraventricular hemorrhage.

OBJECTIVES

To assess whether the prophylactic administration of antithrombin (started within the first 24 hours after birth) reduces the incidence of germinal matrix-intraventricular hemorrhage in very preterm neonates when compared to placebo, no treatment, or heparin.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2015), MEDLINE (1996 to 22 November 2015), EMBASE (1980 to 22 November 2015), and CINAHL (1982 to 22 November 2015). No language restrictions were applied. We searched the abstracts of the major congresses in the field (Perinatal Society of Australia and New Zealand and Pediatric Academic Societies) from 2000 to 2015.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing the administration of early, i.e. within the first 24 hours of life, antithrombin in very preterm infants (gestational age < 32 weeks, any birth weight).

DATA COLLECTION AND ANALYSIS

For each of the included trials, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, antithrombin formulation (plasma-derived or recombinant), mode of administration, and duration of therapy, etc.) and assessed the risk of bias (e.g. adequacy of randomization, blinding, completeness of follow-up). The primary outcomes considered in this review are intraventricular hemorrhage and severe intraventricular hemorrhage.

MAIN RESULTS

Two randomized controlled trials, for a total of 182 infants, met the inclusion criteria of this review. Both trials compared antithrombin with placebo. We found no significant differences in the rates of intraventricular hemorrhage (typical RR 1.30, CI 95% 0.87 to 1.93, typical RD 0.09, 95% CI -0.05 to 0.23; 2 studies, 175 infants; I² = 18% for RR and I² = 42% for RD) and severe intraventricular hemorrhage (typical RR 1.04, CI 95% 0.55 to 1.94; typical RD 0.01, 95% CI -0.11 to 0.12; 2 studies, 175 infants; I² = 0% for RR and I² = 0% for RD). Among secondary outcomes, we found no significant differences in terms of neonatal mortality (typical RR 2.00, CI 95% 0.62 to 6.45; typical RD 0.04, 95% CI -0.03 to 0.12; 2 studies, 182 infants; I² = 46% for RR and I² = 61% for RD) and in the other specified outcomes, such as bronchopulmonary dysplasia. The quality of the evidence supporting these findings is limited due to the imprecision of the estimates.

AUTHORS' CONCLUSIONS

The administration of antithrombin seems not to reduce the incidence and severity of intraventricular hemorrhage in very preterm infants. Limited evidence is available on other clinically relevant outcomes. Given the imprecision of the estimate, the results of this systematic review are consistent with either a benefit or a detrimental effect of antithrombin and do not provide a definitive answer to the review question.

The Neurological Outcome of Isolated PVL and Severe IVH in Preterm Infants: Is It Fair to Compare?

OBJECTIVE

We compared the neurological outcome of isolated periventricular leukomalacia and severe intraventricular hemorrhage in a cohort of very low birth weight infants born and managed at single tertiary-care center in Saudi Arabia.

METHODS

We undertook a descriptive retrospective chart review of the neurological status of very low birth weight infants who were born and managed over a 5-year period at King Abdulaziz Medical City, Riyadh. The neurological outcome of neonates with isolated periventricular leukomalacia and severe intraventricular hemorrhage (grades III and IV) was studied and compared in relation to developmental delay and cerebral palsy.

RESULTS

A total of 20 patients with isolated periventricular leukomalacia and 26 with severe intraventricular hemorrhage (grades III and IV) were identified for this study. Of 20 patients with isolated periventricular leukomalacia, 9 (45%) had good developmental outcome and 11 (55%) had bad developmental outcome. Of 26 patients of severe intraventricular hemorrhage, 14 (54%) had good developmental outcome and 12 (46%) had bad developmental outcome (P = 0.55). Significant motor neurological deficit affecting function is distributed as follows: 11/20 (55%) in the isolated periventricular leukomalacia group and 7/26 (27%) in the severe intraventricular hemorrhage group (P = 0.05). Cerebral palsy was diplegic in 7/11 (64%) and quadriplegic in 4/11 (36%) in the isolated periventricular leukomalacia group, and hemiplegic 3/7 (43%), diplegic in 1/7 (14%), and quadriplegic in 3/7 (43%) in the severe intraventricular hemorrhage group (P = 0.03). Distribution of the neurological outcome according to periventricular leukomalacia grade was as follows: for periventricular leukomalacia grade I (n = 8), 6/8 (75%) had good neurological outcome and 2/8 (25%) had bad neurological outcome. In periventricular leukomalacia grade II (n = 4), good neurological outcome was seen in three patients (75%) and bad neurological outcome was seen in one patient (25%). All patients (n = 8) with periventricular leukomalacia grade III had bad outcome (P < 0.01).

CONCLUSION

About half of patients with isolated periventricular leukomalacia and severe intraventricular hemorrhage had a poor developmental outcome. However, the severity of cerebral palsy was greater in the isolated periventricular leukomalacia patients and correlates highly with periventricular leukomalacia grade. Symmetrical diplegic cerebral palsy is the most common motor deficit associated with isolated periventricular leukomalacia, whereas asymmetrical hemiplegic cerebral palsy is seen exclusively with severe intraventricular hemorrhage.

The whole spectrum of cystic periventricular leukomalacia of the preterm infant: results from a large consecutive case series

PURPOSE

The purpose of this study is to describe features of cystic periventricular leukomalacia (PVL) in a large consecutive cohort study including long-term neurodevelopmental follow-up.

METHODS

We performed a retrospective single-centre cohort study including all preterm infants ≤35 weeks of gestational age with PVL diagnosed by ultrasound scans (US) from a tertiary care university hospital between 1988 and 2012.

RESULTS

The majority of 160 consecutively diagnosed cases had a gestational age between 28 and 32 weeks (60.6%), and male sex was predominant (60.6%). The most common associated clinical findings included respiratory distress syndrome, preterm premature rupture of the membranes, and chorioamnionitis (57.5, 49.4, and 39.4%, respectively). Infants presented with apnoeas in 66.3 and neonatal seizures in 23.1%. Any kind of respiratory support was present in 75.0%. Associated low-grade intraventricular haemorrhage was evident in 33.1, high-grade haemorrhage in 9.4%. Cysts were located on both hemispheres in 75% and PVL grades 3 and 4 were predominant (75.6%). Neurodevelopmental follow-up of 146 cases at a median age of 72 months revealed normal development in 11.0, mental retardation in 50.0, and cerebral palsy in 83.6%. Visual impairment was diagnosed in 21.9% and hearing impairment in one case. A quarter of cases (27.4%) developed seizure disorders. Outcome data were significantly better in unilateral compared to bilateral PVL.

CONCLUSIONS

Long-term neurodevelopmental outcome of bilateral PVL always was adverse and different from unilateral PVL. The latter might be negatively influenced by associated intra- and periventricular haemorrhages.

Neurodevelopmental outcomes of children with periventricular leukomalacia

OBJECTIVES

To examine the neurodevelopmental outcomes of children with periventricular leukomalacia (PVL).

MATERIALS AND METHODS

Twenty-five children diagnosed with grade 1, 2 or 3 PVL on the basis of magnetic resonance imaging (MRI) findings between January 2002 and December 2011 were enrolled and followed from 15 months to 10 years of age.

RESULTS

Of the 25 children, one was a term and 24 were preterm-births. Nine (36%) had spastic diplegia and 12 (48%) had quadriplegia. Ten of the 25 (40%) were able to walk independently at 36 months utilizing short leg braces, whereas 13 children (52%) were unable to walk independently. MRI findings revealed grade 1 PVL in nine (36%), grade 2 in 12 (48%), and grade 3 in four (16%) of the 25 children. Eleven of the 16 children (69%) with grade 2 or 3 PVL had Papile III or IV intraventricular hemorrhage (IVH), and many of these children had severe neurologic motor abnormalities, severe psychomotor delay, and seizures. Five of the nine children (56%) with grade 1 PVL had normal psychomotor development. There were statistically significant differences in the motor impairment and walking ability between the children with grade 1 and those with grade 2 PVL (p = 0.008 and 0.005, respectively).

CONCLUSION

Most children with grade 2 or 3 PVL had severe neurodevelopmental delays, but attention should also be paid to the 56% of children with grade 1 PVL who presented with normal psychomotor development. Further studies of larger populations, including long-term follow-up, are necessary to evaluate the outcomes of children with PVL.

Pregnancy disorders leading to very preterm birth influence neonatal outcomes: results of the population-based ACTION cohort study

BACKGROUND

We examined the relationships between -pregnancy disorders leading to very preterm birth -(spontaneous preterm labor, prelabor premature rupture of -membranes (PPROM), hypertension/preeclampsia, -intrauterine growth restriction (IUGR), antenatal hemorrhage, and maternal -infection), both in isolation and grouped together as -"disorders of placentation" (hypertensive disorders and IUGR) vs. -"presumed infection/inflammation" (all the others), and several unfavorable neonatal outcomes.

METHODS

We examined a population-based prospective cohort of 2,085 singleton infants of 23-31 wk gestational age (GA) born in six Italian regions (the Accesso alle Cure e Terapie Intensive Ostetriche e Neonatali (ACTION) study).

RESULTS

Neonates born following disorders of placentation had a higher GA and better overall outcomes than those born following infection/inflammation. After adjustment for GA, however, they showed higher risk of mortality (odds ratio, OR: 1.4; 95% confidence interval, CI: 1.0-2.0), bronchopulmonary dysplasia (BPD) (OR: 2.5; CI: 1.8-3.6), and retinopathy of prematurity (ROP) (OR: 2.0; CI: 1.1-3.5), especially in growth-restricted infants, and a lower risk of intraventricular hemorrhage (IVH) (OR: 0.5; CI: 0.3-0.8) and periventricular leukomalacia (PVL) (OR: 0.6; CI: 0.4-1.1) as compared with infants born following -infection/inflammation disorders.

CONCLUSION

Our data confirm the hypothesis that, in very preterm infants, adverse outcomes are both a function of immaturity (low GA) and of complications leading to preterm birth. The profile of risk is different in different pregnancy disorders.

Incidence of brain injuries in premature infants with gestational age ≤ 34 weeks in ten urban hospitals in China

BACKGROUND

There is a large number (1.5 million per year) of premature births in China. It is necessary to obtain the authentic incidences of intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL), the common brain injuries, in Chinese premature infants. The present multicenter study aimed to investigate the incidence of brain injuries in premature infants in ten urban hospitals in China.

METHODS

The research proposal was designed by the Subspecialty Group of Neonatology of Pediatric Society of the Chinese Medical Association. Ten large-scale urban hospitals voluntarily joined the multicenter investigation. All premature infants with a gestational age ≤ 34 weeks in the ten hospitals were subjected to routine cranial ultrasound within three days after birth, and then to repeated ultrasound every 3-7 days till their discharge from the hospital from January 2005 to August 2006. A uniform data collection sheet was designed to record cases of brain injuries.

RESULTS

The incidences of overall IVH and severe IVH were 19.7% (305/1551) and 4.6% (72/1551), respectively with 18.4% (56/305) for grade 1, 58.0% (177/305) for grade 2, 17.7% (54/305) for grade 3 and 5.9% (18/305) for grade 4 in nine hospitals. The incidences of overall PVL and cystic PVL were 5.0% (89/1792) and 0.8% (14/1792) respectively, with 84.3% (75/89) for grade 1, 13.5% (12/89) for grade 2, and 2.2% (2/89) for grade 3 in the ten hospitals. The statistically significant risk factors that might aggravate the severity of IVH were vaginal delivery (OR=1.883, 95% CI: 1.099-3.228, P=0.020) and mechanical ventilation (OR=4.150, 95% CI: 2.384-7.223, P=0.000). The risk factors that might result in the development of cystic PVL was vaginal delivery (OR=21.094, 95% CI: 2.650-167.895, P=0.000).

CONCLUSIONS

The investigative report can basically reflect the incidence of brain injuries in premature infants in major big cities of China. Since more than 60% of the Chinese population live in the rural areas of China, it is expected to undertake a further multicenter investigation covering the rural areas in the future.

Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts

OBJECT

Preterm infants are at risk for perinatal complications, including germinal matrix-intraventricular hemorrhage (IVH) and subsequent posthemorrhagic hydrocephalus (PHH). This review summarizes the current understanding of the epidemiology, pathophysiology, management, and outcomes of IVH and PHH in preterm infants.

METHODS

The MEDLINE database was systematically searched using terms related to IVH, PHH, and relevant neurosurgical procedures to identify publications in the English medical literature. To complement information from the systematic search, pertinent articles were selected from the references of articles identified in the initial search.

RESULTS

This review summarizes the current knowledge regarding the epidemiology and pathophysiology of IVH and PHH, primarily using evidence-based studies. Advances in obstetrics and neonatology over the past few decades have contributed to a marked improvement in the survival of preterm infants, and neurological morbidity is also starting to decrease. The incidence of IVH is declining, and the incidence of PHH will likely follow. Currently, approximately 15% of preterm infants who suffer severe IVH will require permanent CSF diversion. The clinical presentation and surgical management of symptomatic PHH with temporary ventricular reservoirs (ventricular access devices) and ventriculosubgaleal shunts and permanent ventriculoperitoneal shunts are discussed. Preterm infants who develop PHH that requires surgical treatment remain at high risk for other related neurological problems, including cerebral palsy, epilepsy, and cognitive and behavioral delay. This review highlights numerous opportunities for further study to improve the care of these children.

CONCLUSIONS

A better grasp of the pathophysiology of IVH is beginning to impact the incidence of IVH and PHH. Neonatologists conduct rigorous Class I and II studies to advance the outcomes of preterm infants. The need for well-designed multicenter trials is essential because of the declining incidence of IVH and PHH, variations in referral patterns, and neonatal ICU and neurosurgical management. Well-designed multicenter trials will eventually produce evidence to enable neurosurgeons to provide their smallest, most vulnerable patients with the best practices to minimize perioperative complications and permanent shunt dependence, and most importantly, optimize long-term neurodevelopmental outcomes.

Incidence of hydrocephalus and the need to ventriculoperitoneal shunting in premature infants with intraventricular hemorrhage: risk factors and outcome

OBJECTIVE

To investigate the associated risk factors for ventriculoperitoneal (VP) shunting in infantile hydrocephalus following intraventricular hemorrhage (IVH) in premature infants.

METHODS

A historical cohort study was conducted, consisting of 97 premature infants in whom the diagnosis of IVH was previously made by cranial ultrasound and were referred to pediatric neurosurgery clinic and/or neonatal intensive care unit of Children's Hospital Medical Center in Tehran, Iran, from April 2004 to March 2009. Among the patients, those who were followed up for at least 6 months after the diagnosis of IVH were included in the study, and data regarding signs and symptoms of increased intracranial pressure, cranial ultrasound, non-surgical treatment (CSF drainage and/or acetazolamide), and shunt requirement were extracted. Patients who required VP shunting were followed up for at least 6 months thereafter considering shunt infection.

RESULTS

All the patients were followed up for at least 1 year, except for three who died at the ages of 6 (two of them) and 7 months. Thirty five percent (35%) of patients required VP shunting, in all of whom IVH was of grade 3 or 4. The need for VP shunting in these patients was predicted only by the severity of IVH. Non-surgical treatments for IVH had no statistically significant effect on shunt requirement. Moreover, 11 of 31 patients with shunt developed shunt infection, which was significantly associated with repeated cerebrospinal fluid (CSF) drainage.

CONCLUSION

It is suggested that children with IVH, especially of higher grades, should be followed up meticulously (by signs, symptoms, and periodic cranial ultrasounds). Non-surgical treatments are considered for patients requiring VP shunting who are not good candidates for immediate surgical intervention. The only predictor for surgical intervention was the grade of IVH.

Cell proliferation in human ganglionic eminence and suppression after prematurity-associated haemorrhage

In premature infants, germinal matrix haemorrhage in the brain is a common occurrence. However, cell proliferation and fate determination in the normal human germinal matrix is poorly understood. Human ganglionic eminence samples were collected prospectively from autopsies of premature and term infants with no evidence of pathological process (n=78; dying at post-menstrual age 14-88 weeks). The ganglionic eminence was thickest at 20-26 weeks and involuted by 34-36 weeks. Proliferating cells, detected by Ki67 immunoreactivity, were abundant throughout the ganglionic eminence prior to 18 weeks, after which a sharp boundary between the dorsal and ventral ganglionic eminence appeared with reduced cell proliferation in the dorsal region. Ki67 immunoreactivity persisted in the majority of ventral cells until ∼28 weeks, after which time the proportion of proliferating cells dropped quickly. The expression of cell lineage markers (such as Olig2, SOX2, platelet-derived growth factor receptor alpha) showed partitioning at the microscopic level. The hypothesis that germinal matrix haemorrhage suppresses cell proliferation was then addressed. In comparison to controls, germinal matrix haemorrhage (n=47; born at post-menstrual age 18-34 weeks followed by survival of 0 h to 98 days) was associated with significantly decreased cell proliferation if survival was >12 h. The cell cycle arrest transcription factor p53 was transiently increased and the oligodendroglial lineage markers Olig2 and platelet-derived growth factor receptor alpha were decreased. Cell death was negligible. A low level of microglial activation was detected. Haemorrhage-associated suppression of cell proliferation in premature human infants could partially explain the reduced brain size and clinical effects in children who suffer germinal matrix haemorrhage after premature birth.