Fetal brain death syndrome--a case report and literature review

Resting-State Functional Magnetic Resonance Imaging Network Association With Mortality, Epilepsy, Cognition, and Motor Two-Year Outcomes in Suspected Severe Neonatal Acute Brain Injury

BACKGROUND AND OBJECTIVES

In acute brain injury of neonates, resting-state functional magnetic resonance imaging (MRI) (RS) showed incremental association with consciousness, mortality, cognitive and motor development, and epilepsy, with correction for multiple comparisons, at six months postgestation in neonates with suspected acute brain injury (ABI). However, there are relatively few developmental milestones at six months to benchmark against, thus, we extended this cohort study to evaluate two-year outcomes.

METHODS

In 40 consecutive neonates with ABI and RS, ordinal scores of resting-state networks; MRI, magnetic resonance spectroscopy, and electroencephalography; and up to 42-month outcomes of mortality, general and motor development, Pediatric Cerebral Performance Category Scale (PCPC), and epilepsy informed associations between tests and outcomes.

RESULTS

Mean gestational age was 37.8 weeks, 68% were male, and 60% had hypoxic-ischemic encephalopathy. Three died in-hospital, four at six to 42 months, and five were lost to follow-up. Associations included basal ganglia network with PCPC (P = 0.0003), all-mortality (P = 0.005), and motor (P = 0.0004); language/frontoparietal network with developmental delay (P = 0.009), PCPC (P = 0.006), and all-mortality (P = 0.01); default mode network with developmental delay (P = 0.003), PCPC (P = 0.004), neonatal intensive care unit mortality (P = 0.01), and motor (P = 0.009); RS seizure onset zone with epilepsy (P = 0.01); and anatomic MRI with epilepsy (P = 0.01).

CONCLUSION

For the first time, at any age, resting state functional MRI in ABI is associated with long-term epilepsy and RSNs predicted mortality in neonates. Severity of RSN abnormality was associated with incrementally worsened neurodevelopment including cognition, language, and motor function over two years.

Association of network connectivity via resting state functional MRI with consciousness, mortality, and outcomes in neonatal acute brain injury

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Basal ganglia and seizure onset zone networks were associated with motor outcomes.

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Broad language/cognitive region networks were associated with developmental delay.

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Discharge with mortality was linked to default mode and language/cognitive networks.

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Exams were not linked to networks after multiple testing corrections.

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Lack of detection of all studied networks only occurred in those who did not survive.

Background

An accurate and comprehensive test of integrated brain network function is needed for neonates during the acute brain injury period to inform on morbidity. This retrospective cohort study assessed whether integrated brain network function acquired by resting state functional MRI during the acute period in neonates with brain injury, is associated with acute exam, neonatal mortality, and 6-month outcomes.

Methods

Study subjects included 40 consecutive neonates with resting state functional MRI acquired within 31 days after suspected brain insult from March 2018 to July 2019 at Phoenix Children’s Hospital. Acute-period exam and test results were assigned ordinal scores based on severity as documented by respective treating specialists. Analyses (Fisher exact, Wilcoxon-rank sum test, ordinal/multinomial logistic regression) examined association of resting state networks with demographics, presentation, neurological exam, electroencephalogram, anatomical MRI, magnetic resonance spectroscopy, passive task functional MRI, and outcomes of discharge condition, outpatient development, motor tone, seizure, and mortality.

Results

Subjects had a mean (standard deviation) gestational age of 37.8 (2.6) weeks, a majority were male (63%), with a diagnosis of hypoxic ischemic encephalopathy (68%). Findings at birth included mild distress (48%), moderately abnormal neurological exam (33%), and consciousness characterized as awake but irritable (40%). Significant associations after multiple testing corrections were detected for resting state networks: basal ganglia with outpatient developmental delay (odds ratio [OR], 14.5; 99.4% confidence interval [CI], 2.00–105; P < .001) and motor tone/weakness (OR, 9.98; 99.4% CI, 1.72–57.9; P < .001); language/frontoparietal network with discharge condition (OR, 5.13; 99.4% CI, 1.22–21.5; P = .002) and outpatient developmental delay (OR, 4.77; 99.4% CI, 1.21–18.7; P=.002); default mode network with discharge condition (OR, 3.72; 99.4% CI, 1.01–13.78; P=.006) and neurological exam (P = .002 (FE); OR, 11.8; 99.4% CI, 0.73–191; P = .01 (OLR)); and seizure onset zone with motor tone/weakness (OR, 3.31; 99.4% CI, 1.08–10.1; P=.003). Resting state networks were not detected in three neonates, who died prior to discharge.

Conclusions

This study provides level 3 evidence (OCEBM Levels of Evidence Working Group) demonstrating that in neonatal acute brain injury, the degree of abnormality of resting state networks is associated with acute exam and outcomes. Total lack of brain network detection was only found in patients who did not survive.

Cardiotocographic and Doppler Ultrasonographic Findings in a Fetus with Brain Death Syndrome

OBJECTIVE

The diagnosis of brain death syndrome by cardiotocography (CTG) and Doppler ultrasonography (US) is reported in a fetus at 35 weeks of gestation.

CASE REPORT

A 23-year-old, gravida 2, para 0, woman was referred to our hospital because of the absence of fetal movements. CTG showed fixed fetal heart rate (FHR) pattern. A detailed Doppler US examination of the fetus showed extensive cystic lesions of both cerebral hemispheres, polyhydramnios, total absence of neuromuscular parameters of biophysical profile (BPP) and the cessation of cerebral blood flow. Umbilical cord artery blood gas analysis showed pH 7.3, PaO2 30 mmHg and PaCO2 35 mmHg. A floppy male infant weighing 2,450 g was delivered vaginally at 36 weeks of gestation and the Apgar scores were 1 and 1 at 5 and 10 minutes, respectively. The neonate died 2 days after delivery. Postmortem examination of the brain showed diffuse, anoxic changes with multicystic encephalomalacia in both hemispheres and the brain stem. No other maternal or placental abnormalities were seen.

CONCLUSION

The possibility of intrauterine brain death should be considered in all cases of prolonged fixed FHR pattern, accompanied by absence of neuromuscular parameters of BPP, polyhydramnios and demonstrated cessation of cerebral blood flow by Doppler US. Increased awareness of this event may prevent unnecessary emergency cesarean section.

Fetal movement counts

Monitoring fetal movement serves as an indirect measure of central nervous system integrity and function. The coordination of whole body movement in the fetus, which requires complex neurologic control, is similar to the coordination of movement in the preterm newborn infant. Short-term observations of the fetus are best performed using real-time ultrasound imaging or Doppler ultrasound. Daily fetal kick counting by the compliant gravida is a worthwhile adjunct in determining the need for fetal surveillance tests in the office and in predicting abnormal FHR patterns and perhaps impending stillbirth. Monitoring has its greatest value when placental insufficiency is long-standing; its routine role in low-risk pregnancies requires further clinical investigation. The presence of a vigorous fetus is reassuring. Perceived inactivity requires a reassessment of any underlying antepartum complication and a more precise evaluation by FHR testing or real-time ultrasonography before delivery is considered.