Universal cranial ultrasound screening in preterm infants with gestational age 33-36 weeks. A retrospective analysis of 724 newborns

Assessment of role of cranial ultrasound (CUS) in the evaluation of high-risk preterm and term neonates

Background

Cranial ultrasonography (CUS) has become an important tool to depict normal brain anatomy and to detect the ischemic and hemorrhagic brain injury patterns in high-risk neonates. The present study aimed to assess the utility of CUS to diagnose the spectrum of brain injury patterns in high-risk preterm and term neonates admitted to the neonatal intensive care unit (NICU) and to find the association of CUS findings in various adverse antenatal and perinatal feto-maternal factors.

Results

Out of the 200 neonates, 76 (38%) neonates had abnormal CUS findings and 124 (62%) had a normal CUS. Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) (28/76; 36.8 %) was the commonest abnormality with GMH (grade 1) in 14/76 (18.4%), grade 2 in 7 (9.2%), grade 3 in 5 (6.5%), and grade 4 in 2 (2.63%). The other findings observed were cerebral edema (14/76; 18.4%), thalamic hyperechogenicity (10/76; 13.1%), periventricular leukomalacia (PVL) (4/76; 5.2%), and congenital anomalies (8; 10.5%). Abnormal CUS findings had a statistically significant association with birth weight <2000 g, prematurity, Apgar score <7, and adverse peri-natal fetal and maternal factors (all p-values <0.05). Abnormal CUS findings had a statistically significant association with poor cry, poor activity, abnormal tone, and presence of cyanosis (all p-values <0.05).

Conclusion

In this cohort study of high-risk preterm and term infants GMH-IVH, cerebral edema, thalamic hyperechogenicity, PVL, and congenital malformations were the commonest lesions detected on CUS. Abnormal CUS findings were found to have a statistically significant association with various adverse peri-natal fetal and maternal factors.

Analysis of cranial ultrasound images for newborn

Introduction

Neonatal cranial ultrasound plays an important role in the evaluation of neonatal brain development and related diseases.

Methods

This paper preliminarily explored the analysis and interpretation methods of neonatal brain ultrasound images, and applied the relevant medical image analysis methods to analyze the relevant neonatal brain ultrasound images in more detail.

Results

Compared with other types of imaging methods, ultrasound has its unique advantages and characteristics in such applications as neonatal head imaging.

Discussion

The analysis steps and schemes adopted in this paper have certain reference significance for the analysis of other neonatal brain pictures.

Cranial Ultrasound Abnormalities in Small for Gestational Age or Growth-Restricted Infants Born over 32 Weeks Gestation: A Systematic Review and Meta-Analysis

AIM

To perform a systematic review and meta-analysis of existing literature to evaluate the incidence of cranial ultrasound abnormalities (CUAs) amongst moderate to late preterm (MLPT) and term infants, affected by fetal growth restriction (FGR) or those classified as small for gestational age (SGA).

METHODS

A systematic review methodology was performed, and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement was utilised. Descriptive and observational studies reporting cranial ultrasound outcomes on FGR/SGA MLPT and term infants were included. Primary outcomes reported was incidence of CUAs in MLPT and term infants affected by FGR or SGA, with secondary outcomes including brain structure development and growth, and cerebral artery Dopplers. A random-effects model meta-analysis was performed. Risk of Bias was assessed using the Newcastle-Ottawa scale for case-control and cohort studies, and Joanna Briggs Institute Critical Appraisal Checklist for studies reporting prevalence data. GRADE was used to assess for certainty of evidence.

RESULTS

Out of a total of 2085 studies identified through the search, seventeen were deemed to be relevant and included. Nine studies assessed CUAs in MLPT FGR/SGA infants, seven studies assessed CUAs in late preterm and term FGR/SGA infants, and one study assessed CUAs in both MLPT and term FGR/SGA infants. The incidence of CUAs in MLPT, and late preterm to term FGR/SGA infants ranged from 0.4 to 33% and 0 to 70%, respectively. A meta-analysis of 7 studies involving 168,136 infants showed an increased risk of any CUA in FGR infants compared to appropriate for gestational age (AGA) infants (RR 1.96, [95% CI 1.26-3.04], I² = 68%). The certainty of evidence was very low due to non-randomised studies, methodological limitations, and heterogeneity. Another meta-analysis looking at 4 studies with 167,060 infants showed an increased risk of intraventricular haemorrhage in FGR/SGA infants compared to AGA infants (RR 2.40, [95% CI 2.03-2.84], I² = 0%). This was also of low certainty.

CONCLUSIONS

The incidence of CUAs in MLPT and term growth-restricted infants varied widely between studies. Findings from the meta-analyses suggest the risk of CUAs and IVH may indeed be increased in these FGR/SGA infants when compared with infants not affected by FGR, however the evidence is of low to very low certainty. Further specific cohort studies are needed to fully evaluate the benefits and prognostic value of cranial ultrasonography to ascertain the need for, and timing of a cranial ultrasound screening protocol in this infant population, along with follow-up studies to ascertain the significance of CUAs identified.

Incidence of brain lesions in moderate-late preterm infants assessed by cranial ultrasound and MRI: The BIMP-study

PURPOSE

To evaluate the incidence and characteristics of brain lesions in moderate-late preterm (MLPT) infants, born at 32-36 weeks' gestation using cranial ultrasound (cUS) and magnetic resonance imaging (MRI).

METHODS

Prospective cohort study carried out at Isala Women and Children's Hospital between August 2017 and November 2019. cUS was performed at postnatal day 3-4 (early-cUS), before discharge and repeated at term equivalent age (TEA) in MLPT infants born between 32⁺⁰ and 35⁺⁶ weeks' gestation. At TEA, MRI was also performed. Several brain lesions were assessed e.g. hemorrhages, white matter and deep gray matter injury. Brain maturation was visually evaluated. Lesions were classified as mild or moderate-severe. Incidences and confidence intervals were calculated.

RESULTS

166 MLPT infants were included of whom 127 underwent MRI. One or more mild lesions were present in 119/166 (71.7 %) and moderate-severe lesions in 6/166 (3.6 %) infants on cUS and/or MRI. The most frequent lesions were signs suggestive of white matter injury: inhomogeneous echogenicity in 50/164 infants (30.5 %) at early-cUS, in 12/148 infants (8.1 %) at TEA-cUS and diffuse white matter signal changes (MRI) in 27/127 (23.5 %) infants. Cerebellar hemorrhage (MRI) was observed in 16/127 infants (12.6 %). Delayed maturation (MRI) was seen in 17/117 (13.4 %) infants. Small hemorrhages and punctate white matter lesions were more frequently detected on MRI than on cUS.

CONCLUSIONS

In MLPT infants mild brain lesions were frequently encountered, especially signs suggestive of white matter injury and small hemorrhages. Moderate-severe lesions were less frequently seen.

Routine Neuroimaging of the Preterm Brain

Neuroimaging of the preterm infant is a common assessment performed in the NICU. Timely and focused studies can be used for diagnostic, therapeutic, and prognostic information. However, significant variability exists among neonatal units as to which modalities are used and when imaging studies are obtained. Appropriate timing and selection of neuroimaging studies can help identify neonates with brain injury who may require therapeutic intervention or who may be at risk for neurodevelopmental impairment. This clinical report reviews the different modalities of imaging broadly available to the clinician. Evidence-based indications for each modality, optimal timing of examinations, and prognostic value are discussed.

A systematic review on brain injury and altered brain development in moderate-late preterm infants

OBJECTIVES

To provide a systematic review of brain injury and altered brain development in moderate-late preterm (MLPT) infants as compared to very preterm and term infants.

STUDY DESIGN

A systematic search in five databases was performed in January 2020. Original research papers on incidence of brain injury and papers using quantitative data on brain development in MLPT infants were selected. The Johanna Briggs Institute 'Critical Appraisal Checklist for Studies Reporting Prevalence Data' was used for quality appraisal. Data extraction included: imaging modality, incidences of brain injury, brain volumes, 2D-measurements and diffusivity values.

RESULTS

In total, 24 studies were eligible. Most studies had a moderate quality. Twenty studies reported on the incidence of brain injury in MLPT infants. The incidence of intraventricular hemorrhage (IVH) ranged from 0.0% to 23.5% and of white matter injury (WMI) from 0.5% to 10.8%. One study reported the incidence of arterial infarction (0.3%) and none of cerebellar hemorrhage. Eleven studies compared incidences of brain injury between MLPT infants and very preterm or term infants. Five studies reported signs of altered brain development in MLPT infants.

CONCLUSIONS

The incidences of IVH and WMI in MLPT infants varied widely between studies. Other abnormalities were sparsely reported. Evidence regarding a higher or lower incidence of brain injury in MLPT infants compared to very preterm or term infants is weak due to moderate methodological quality of reported studies. There is limited evidence suggesting a difference in brain development between MLPT and term infants.

Investigation of the Effect of the Skull in Transcranial Photoacoustic Imaging: A Preliminary Ex Vivo Study

Although transcranial photoacoustic imaging (TCPAI) has been used in small animal brain imaging, in animals with thicker skull bones or in humans both light illumination and ultrasound propagation paths are affected. Hence, the PA image is largely degraded and in some cases completely distorted. This study aims to investigate and determine the maximum thickness of the skull through which photoacoustic imaging is feasible in terms of retaining the imaging target structure without incorporating any post processing. We identify the effect of the skull on both the illumination path and acoustic propagation path separately and combined. In the experimental phase, the distorting effect of ex vivo sheep skull bones with thicknesses in the range of 0.7~1.3 mm are explored. We believe that the findings in this study facilitate the clinical translation of TCPAI.

L’imagerie cérébrale systématique du nouveau-né prématuré

L’imagerie cérébrale systématique pour déceler les lésions touchant les nouveau-nés prématurés est utilisée pour prédire le pronostic à long terme et déterminer les complications susceptibles de nécessiter une intervention. Même si l’imagerie par résonance magnétique peut être indiquée dans des situations particulières, l’échographie cérébrale est la technique la plus utilisée et demeure la meilleure modalité d’imagerie systématique en raison de sa portabilité et de sa facilité d’accès. L’échographie cérébrale systématique est recommandée pour tous les nouveau-nés venus au monde à 31+6 semaines d’âge gestationnel ou auparavant. Chez les nouveau-nés prématurés venus au monde entre 32+0 et 36+6 semaines d’âge gestationnel l’échographie cérébrale systématique n’est recommandée qu’en présence de facteurs de risque d’hémorragie intracrânienne ou d’ischémie. Il est conseillé d’obtenir une imagerie cérébrale de quatre à sept jours après la naissance pour déceler la plupart des hémorragies de la matrice germinale et des hémorragies intraventriculaires. Il est recommandé de reprendre l’imagerie entre quatre et six semaines de vie pour déceler les lésions de la substance blanche. Chez les nouveau-nés prématurés venus au monde avant 26 semaines d’âge gestationnel, il est recommandé de reprendre l’échographie cérébrale à l’âge équivalant au terme.

Routine imaging of the preterm neonatal brain

Routine brain imaging to detect injuries affecting preterm infants is used to predict long-term outcomes and identify complications that might necessitate an intervention. Although magnetic resonance imaging may be indicated in some specific cases, head ultrasound is the most widely used technique and, because of portability and ease of access, is the best modality for routine imaging. Routine head ultrasound examination is recommended for all infants born at or before 31+6 weeks gestation. For preterm neonates born between 32+0 to 36+6 weeks gestation, routine head ultrasound is recommended only in presence of risk factors for intracranial hemorrhage or ischemia. Brain imaging in the first 7 to 14 days postbirth is advised to detect most germinal matrix and intraventricular hemorrhages. Repeat imaging at 4 to 6 weeks of age is recommended to detect white matter injury.

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.

Analyses of pathological cranial ultrasound findings in neonates that fall outside recent indication guidelines: results of a population-based birth cohort: survey of neonates in Pommerania (SNiP-study)

Background

Recent guidelines recommend a cranial ultrasound (CU) in neonates born at < 30 weeks gestation, admitted to the neonatal intensive care unit (NICU), or with a CU indication. Here, we addressed the need to extend these recommendations.

Methods

We retrospectively reviewed 5107 CUs acquired in the population-based Survey of Neonates in Pomerania, conducted in 2002 to 2008. Neonates with conspicuous CUs that were ≥ 30 weeks gestation without recent indications for CU were identified and assigned to the following groups: with (I) or without (II) admission to neonatal care. We designated CU conspicuities as mild (MC) or significant (SC), and we investigated related neurodevelopment during follow-up.

Results

Of 5107 neonates, 5064 were born at ≥30 weeks gestation and of those, 4306 received CUs without any indication for this examination. We found conspicuities in 7.7% (n = 47/610) of group I (n = 30 MC, n = 17 SC), and 3.2% (n = 117/3696) of group II (n = 100 MC, n = 17 SC). In group II, SC comprised, e.g., bilateral cysts, partial agenesis of the corpus callosum, and periventricular leukomalacia. Follow-up was available in 75% of infants in group II with MCs and SCs; of these, 12.8% had an abnormal neurological follow-up.

Conclusions

We detected a high number of conspicuities in neonates without a CU indication. However, we could not demonstrate that ultrasound findings were associated with the neurological follow-up or any advantage to an earlier diagnosis. Our data did not support extending current guidelines or a general CU screening policy for all neonates.

Late preterm births: New insights from neonatal neuroimaging and neurobehaviour

With increasing evidence of neurodevelopmental problems faced by late preterm children, there is a need to explore possible underlying brain structural changes. The use of brain magnetic resonance imaging has provided insights of smaller and less mature brains in infants born late preterm, associated with developmental delay at 2 years. Another useful tool in the newborn period is neurobehavioural assessment, which has also been shown to be suboptimal in late preterm infants compared with tern infants. Suboptimal neurobehaviour is also associated with poorer 2-year neurodevelopment in late preterm infants. More research into these tools will provide a better understanding of the underlying processes of developmental deficits of late preterm children. The value of their role in clinical care remains to be determined.

Identification of risk factors in infants participating in a Follow-up program

ABSTRACT Purpose: to identify the main health risk factors of infants participating in a follow-up program. Methods: a longitudinal prospective study conducted with 540 high-risk infants observed in the follow-up clinic of the Hospital Materno Infantil in Goiânia in the State of Goiás, Brazil. All biological data of the infants from birth, prenatal, and postnatal periods were collected through assessment sessions with their mothers and medical chart reviews. Data were analyzed through binary logistic regression to identify the highest-risk variables for the infants’ health. Results: in a predictive analysis, the findings showed that neonatal risk was statistically associated with a lower Apgar score at the fifth minute of life, male infants, and longer hospital stay. Infants with increased neonatal risk were more likely to show alterations identified in cranial ultrasound examinations. Moreover, the longer hospital stay was related to mixed breastfeeding after discharge. Conclusion: the main risk factors for the health of high-risk infants in the follow-up program were: low Apgar score at the fifth minute; male sex; longer hospital stay; alterations detected in transfontanellar ultrasound; and mixed feeding after discharge.