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Chen H, Aziz KB, Spahic H, Miller S, Guryildirim M, Sellers A, Brooks S, Kilborn A, Everett AD, Northington FJ, Stafstrom CE, Chavez-Valdez R. Interaction of hydrocortisone and illness severity on head growth in cohort of ELBW infants. Pediatr Res 2023; 94:1958-1965. [PMID: 37340101 DOI: 10.1038/s41390-023-02689-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/06/2023] [Accepted: 05/15/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Extremely low birth weight (ELBW) infants comprise a fragile population at risk for neurodevelopmental disabilities (NDD). Systemic steroids were previously associated with NDD, but more recent studies suggest hydrocortisone (HCT) may improve survival without increasing NDD. However, the effects of HCT on head growth adjusted for illness severity during NICU hospitalization are unknown. Thus, we hypothesize that HCT will protect head growth, accounting for illness severity using a modified neonatal Sequential Organ Failure Assessment (M-nSOFA) score. METHODS We conducted a retrospective study that included infants born at 23-29 weeks gestational age (GA) and < 1000 g. Our study included 73 infants, 41% of whom received HCT. RESULTS We found negative correlations between growth parameters and age, similar between HCT and control patients. HCT-exposed infants had lower GA but similar normalized birth weights; HCT-exposed infants also had higher illness severity and longer lengths of hospital stay. We found an interaction between HCT exposure and illness severity on head growth, such that infants exposed to HCT had better head growth compared to those not exposed to HCT when adjusted for illness severity. CONCLUSION These findings emphasize the importance of considering patient illness severity and suggest that HCT use may offer additional benefits not previously considered. IMPACT This is the first study to assess the relationship between head growth and illness severity in extremely preterm infants with extremely low birth weights during their initial NICU hospitalization. Infants exposed to hydrocortisone (HCT) were overall more ill than those not exposed, yet HCT exposed infants had better preserved head growth relative to illness severity. Better understanding of the effects of HCT exposure on this vulnerable population will help guide more informed decisions on the relative risks and benefits for HCT use.
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Affiliation(s)
- Haiwen Chen
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khyzer B Aziz
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harisa Spahic
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Miller
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melike Guryildirim
- Division of Pediatric Neuroradiology, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Austin Sellers
- Division of Neonatology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Sandra Brooks
- Division of Neonatology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alison Kilborn
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen D Everett
- Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raul Chavez-Valdez
- Division of Neonatology - Neuroscience Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Chavez-Valdez R, Aziz K, Burton VJ, Northington FJ. Worse Outcomes From HIE Treatment Associated With Extreme Glycemic States. Pediatrics 2023; 152:e2023062521. [PMID: 37655403 PMCID: PMC10522924 DOI: 10.1542/peds.2023-062521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Affiliation(s)
- Raul Chavez-Valdez
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
| | - Khyzer Aziz
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
- Division of Biomedical Informatics and Data Science, Department of Medicine
| | - Vera Joanna Burton
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
- Department of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland
| | - Frances J. Northington
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
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Wu D, Turnbill V, Lee HH, Wang X, Ba R, Walczak P, Martin LJ, Fieremans E, Novikov DS, Northington FJ, Zhang J. In vivo Mapping of Cellular Resolution Neuropathology in Brain Ischemia by Diffusion MRI. bioRxiv 2023:2023.08.08.552374. [PMID: 37609182 PMCID: PMC10441332 DOI: 10.1101/2023.08.08.552374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Non-invasive mapping of cellular pathology can provide critical diagnostic and prognostic information. Recent developments in diffusion MRI have produced new tools for examining tissue microstructure at a level well below the imaging resolution. Here, we report the use of diffusion time ( t )-dependent diffusion kurtosis imaging ( t DKI) to simultaneously assess the morphology and transmembrane permeability of cells and their processes in the context of pathological changes in hypoxic-ischemic brain (HI) injury. Through Monte Carlo simulations and cell culture organoid imaging, we demonstrate feasibility in measuring effective size and permeability changes based on the peak and tail of t DKI curves. In a mouse model of HI, in vivo imaging at 11.7T detects a marked shift of the t DKI peak to longer t in brain edema, suggesting swelling and beading associated with the astrocytic processes and neuronal neurites. Furthermore, we observed a faster decrease of the t DKI tail in injured brain regions, reflecting increased membrane permeability that was associated with upregulated water exchange upon astrocyte activation at acute stage as well as necrosis with disrupted membrane integrity at subacute stage. Such information, unavailable with conventional diffusion MRI at a single t, can predict salvageable tissues. For a proof-of-concept, t DKI at 3T on an ischemic stroke patient suggested increased membrane permeability in the stroke region. This work therefore demonstrates the potential of t DKI for in vivo detection of the pathological changes in microstructural morphology and transmembrane permeability after ischemic injury using a clinically translatable protocol.
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Catenaccio E, Smith RJ, Chavez-Valdez R, Burton VJ, Graham E, Parkinson C, Vaidya D, Tekes A, Northington FJ, Everett AD, Stafstrom CE, Ritzl EK. Evaluating Injury Severity in Neonatal Encephalopathy Using Automated Quantitative Electroencephalography Analysis: A Pilot Study. Dev Neurosci 2023; 46:136-144. [PMID: 37467736 DOI: 10.1159/000530299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/03/2023] [Indexed: 07/21/2023] Open
Abstract
Quantitative analysis of electroencephalography (qEEG) is a potential source of biomarkers for neonatal encephalopathy (NE). However, prior studies using qEEG in NE were limited in their generalizability due to individualized techniques for calculating qEEG features or labor-intensive pre-selection of EEG data. We piloted a fully automated method using commercially available software to calculate the suppression ratio (SR), absolute delta power, and relative delta, theta, alpha, and beta power from EEG of neonates undergoing 72 h of therapeutic hypothermia (TH) for NE between April 20, 2018, and November 4, 2019. We investigated the association of qEEG with degree of encephalopathy (modified Sarnat score), severity of neuroimaging abnormalities following TH (National Institutes of Child Health and Development Neonatal Research Network [NICHD-NRN] score), and presence of seizures. Thirty out of 38 patients met inclusion criteria. A more severe modified Sarnat score was associated with higher SR during all phases of TH, lower absolute delta power during all phases except rewarming, and lower relative delta power during the last 24 h of TH. In 21 patients with neuroimaging data, a worse NICHD-NRN score was associated with higher SR, lower absolute delta power, and higher relative beta power during all phases. QEEG features were not significantly associated with the presence of seizures after correction for multiple comparisons. Our results are consistent with those of prior studies using qEEG in NE and support automated qEEG analysis as an accessible, generalizable method for generating biomarkers of NE and response to TH. Additionally, we found evidence of an immature relative frequency composition in neonates with more severe brain injury, suggesting that automated qEEG analysis may have a use in the assessment of brain maturity.
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Affiliation(s)
- Eva Catenaccio
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rachel J Smith
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vera J Burton
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Ernest Graham
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allen D Everett
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eva K Ritzl
- Departments of Neurology and Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Rafnsdottir S, Jang K, Halldorsdottir ST, Tomasdottir A, Vinod M, Möller K, Reynisdottir T, Atladottir LH, Allison KE, He J, Zhang L, Northington FJ, Chavez-Valdez R, Anderson KJ, Bjornsson HT. SMYD5 is a novel epigenetic gatekeeper of the mild hypothermia response. bioRxiv 2023:2023.05.11.540170. [PMID: 37333301 PMCID: PMC10274674 DOI: 10.1101/2023.05.11.540170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Organisms have homeostatic mechanisms to respond to cold temperature to ensure survival including the activation of the mammalian neuroprotective mild hypothermia response (MHR) at 32°C. We show activation of the MHR at euthermia by an FDA-approved medication Entacapone, proof-of-principle that the MHR can be medically manipulated. Utilizing a forward CRISPR-Cas9 mutagenesis screen, we identify the histone lysine methyltransferase SMYD5 as an epigenetic gatekeeper of the MHR. SMYD5 represses the key MHR gene SP1 at euthermia but not at 32°C. This repression is mirrored by temperature-dependent levels of H3K36me3 at the SP1-locus and globally indicating that the mammalian MHR is regulated at the level of histone modifications. We identified 45 additional SMYD5-temperature dependent genes suggesting a broader MHR-related role for SMYD5. Our study provides an example of how the epigenetic machinery integrates environmental cues into the genetic circuitry of mammalian cells and suggests novel therapeutic avenues for neuroprotection after catastrophic events.
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Affiliation(s)
- Salvor Rafnsdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Kijin Jang
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sara Tholl Halldorsdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Arnhildur Tomasdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Meghna Vinod
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Katrin Möller
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Tinna Reynisdottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Laufey Halla Atladottir
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Jin He
- Department of Biochemistry and Molecular Biology, College of Natural Science, Michigan State University, MI, USA
| | - Li Zhang
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, MD, USA
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kimberley Jade Anderson
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Hans Tomas Bjornsson
- Louma G. Laboratory of Epigenetic Research, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, MD, USA
- Department of Pediatrics, Johns Hopkins University, MD, USA
- Department of Genetics and Molecular Medicine, Landspitali University Hospital, Reykjavik, Iceland
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Onda K, Chavez-Valdez R, Graham EM, Everett AD, Northington FJ, Oishi K. Quantification of Diffusion Magnetic Resonance Imaging for Prognostic Prediction of Neonatal Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2023; 46:55-68. [PMID: 37231858 PMCID: PMC10712961 DOI: 10.1159/000530938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/20/2023] [Indexed: 05/27/2023] Open
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is the leading cause of acquired neonatal brain injury with the risk of developing serious neurological sequelae and death. An accurate and robust prediction of short- and long-term outcomes may provide clinicians and families with fundamental evidence for their decision-making, the design of treatment strategies, and the discussion of developmental intervention plans after discharge. Diffusion tensor imaging (DTI) is one of the most powerful neuroimaging tools with which to predict the prognosis of neonatal HIE by providing microscopic features that cannot be assessed by conventional magnetic resonance imaging (MRI). DTI provides various scalar measures that represent the properties of the tissue, such as fractional anisotropy (FA) and mean diffusivity (MD). Since the characteristics of the diffusion of water molecules represented by these measures are affected by the microscopic cellular and extracellular environment, such as the orientation of structural components and cell density, they are often used to study the normal developmental trajectory of the brain and as indicators of various tissue damage, including HIE-related pathologies, such as cytotoxic edema, vascular edema, inflammation, cell death, and Wallerian degeneration. Previous studies have demonstrated widespread alteration in DTI measurements in severe cases of HIE and more localized changes in neonates with mild-to-moderate HIE. In an attempt to establish cutoff values to predict the occurrence of neurological sequelae, MD and FA measurements in the corpus callosum, thalamus, basal ganglia, corticospinal tract, and frontal white matter have proven to have an excellent ability to predict severe neurological outcomes. In addition, a recent study has suggested that a data-driven, unbiased approach using machine learning techniques on features obtained from whole-brain image quantification may accurately predict the prognosis of HIE, including for mild-to-moderate cases. Further efforts are needed to overcome current challenges, such as MRI infrastructure, diffusion modeling methods, and data harmonization for clinical application. In addition, external validation of predictive models is essential for clinical application of DTI to prognostication.
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Affiliation(s)
- Kengo Onda
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raul Chavez-Valdez
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M. Graham
- Department of Gynecology & Obstetrics, Division of Maternal-Fetal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen D. Everett
- Department of Pediatrics, Division of Pediatric Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J. Northington
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenichi Oishi
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abramsky R, Acun C, Alt J, Aly H, Arad N, Baak LM, Bakalar D, Balasingham T, Bammler T, Benders MJNL, Benitez D, Boni E, Boylan G, Campbell E, Castri P, Chandrashekar P, Chavez-Valdez R, Chen M, Chiodin E, Comstock B, Damien J, Damien J, de Vries LS, de Vries L, Dickman J, Doucette L, Duckworth E, Duckworth E, Echeverria-Palacio C, El Jalbout R, El-Dib M, Elshibiny H, Flock D, Gallagher A, Gasperoni E, Glass H, Harteman JC, Harvey-Jones K, Hazan I, Heagerty P, Inder T, Jantzie L, Juul S, Karnati S, Kute N, Lacaille H, Lange F, Lemmers PMA, Liu W, Llaguno N, Magalhães M, Mambule I, Marandyuk B, Marks K, Martin LJ, Massaro A, Mathieson S, Mathieson S, McCaul MC, Meehan C, Meledin I, Menna E, Menzato F, Mintoft A, Mitra S, Nakimuli A, Nanyunya C, Norris G, Northington FJ, Numis A, O'Reilly JJ, Ortiz S, Padiyar S, Paquette N, Parmeggiani L, Patrizi S, Pavlidis E, Pellegrin S, Penn AA, Petitpas L, Pinchefsky E, Ponta A, Puthuraya JPS, Rais R, Robertson NJ, Rodrigues D, Salandin M, Salzbank J, Sánchez L, Schalij N, Serrano-Tabares C, Shany E, Staffler A, Steggerda S, Tachtsidis I, Tann C, Tataranno ML, Trabatti C, Tremblay J, Tromp S, Tucker K, Turnbill V, Vacher CM, van Bel F, van der Aa NE, Van Meurs K, Van Steenis A, van Wyk L, Vannasing P, Variane G, Verma V, Voldal E, Wagenaar N, Wu Y, Wustoff C. Proceedings of the 14th International Newborn Brain Conference: Neonatal Neurocritical Care, seizures, and continuous aEEG and /or EEG monitoring. J Neonatal Perinatal Med 2023; 16:S33-S62. [PMID: 37599542 DOI: 10.3233/npm-239003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
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8
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Abdurajan S, Ågren J, Alt J, Axelin A, Bäcke P, Balashova E, Thernström Blomqvist Y, Burckhard Z, Burnsed J, Cornaz Buros S, Chavez-Valdez R, Chen M, Dickie J, Dietz R, Dingman A, Doucette L, El-Dib M, Shibiny H, Flock D, Ganal S, Gorse K, Guo J, Harrison S, Herrmann J, Ionov O, Jackson T, Janesko-Feldman K, Jantzie L, June A, Kathiresh S, Kirtbaya A, Klein A, Kochanek P, Kuter N, Marlicz M, Martin LJ, Matysik W, Munster C, Northington FJ, Quilinan N, Rais R, Schöberlein A, Sharafutdinova D, Suvorov MSI, Suvorova J, Szakmar E, Tiemeier E, Tran P, Trigo NF, Turnbill V, Ushakova L, Vagni V. Proceedings of the 14th International Newborn Brain Conference: Neuroprotection strategies in the neonate. J Neonatal Perinatal Med 2023; 16:S21-S31. [PMID: 37599541 DOI: 10.3233/npm-239002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
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9
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Weinstein RM, Parkinson C, Everett AD, Graham EM, Vaidya D, Northington FJ. A predictive clinical model for moderate to severe intraventricular hemorrhage in very low birth weight infants. J Perinatol 2022; 42:1374-1379. [PMID: 35780234 DOI: 10.1038/s41372-022-01435-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 11/09/2022]
Abstract
IMPORTANCE Intraventricular hemorrhage (IVH) occurs in 15-45% of all very low birth weight (VLBW) preterm infants. Despite improvements in the perinatal care, the incidence of IVH remains high. As more preterm infants survive, there will be a larger burden of neurodevelopmental abnormalities borne by former preterm infants. OBJECTIVE The objective of this study was to develop a predictive clinical model of IVH risk within the first few hours of life in an effort to augment perinatal counseling and guide the timing of future targeted therapies aimed at preventing or slowing the progression of disease. DESIGN This is a prospective observational cohort study of VLBW infants born in the NICU at John's Hopkins Children's Center from 2011 to 2019. The presence and severity of IVH was defined on standard head ultrasound screening (HUS) using the modified Papile classification. Clinical variables were identified as significant using absolute risk regression from a general linear model. The model predictors included clinically meaningful variables that were not collinear. SETTING This study took place at the Johns Hopkins Children's Center Level IV NICU. PARTICIPANTS The study sample included VLBW infants treated in the neonatal intensive care unit (NICU) at John's Hopkins Children's Center from 2011 to 2019. A total of 683 infants included in the study had no or grade I IVH, and 115 infants had grades II through IV IVH. Exclusion criteria included admission to the JHH NICU after 24 h of age, BW > 1500 g, and failure to consent. MAIN OUTCOME The main outcome of this study was the presence of grades II-IV IVH on standard head ultrasound screening using the modified Papile classification [1]. RESULTS A total of 798 VLBW infants were studied in this cohort and 14.4% had moderate to severe IVH. Fifty four percent of the cohort was black, 33% white, and half of the cohort was male. A higher gestational age, 5-min Apgar score, hematocrit, and platelet count were significantly associated with decreased incidence of IVH in a multi-predictor model (ROC 0.826). CONCLUSION AND RELEVANCE In the face of continued lack of treatments for IVH, prevention is still a primary goal to avoid long-term developmental sequela. This model can be used for perinatal counseling and may provide important information during the narrow therapeutic window for targeted prevention therapies.
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MESH Headings
- Cerebral Hemorrhage/diagnostic imaging
- Cerebral Hemorrhage/epidemiology
- Cerebral Hemorrhage/etiology
- Child
- Child, Preschool
- Cohort Studies
- Female
- Gestational Age
- Humans
- Infant
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/etiology
- Infant, Very Low Birth Weight
- Male
- Pregnancy
- Retrospective Studies
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Affiliation(s)
- Rachel M Weinstein
- Division of Neonatal-Perinatal Medicine, Northwestern University, Chicago, IL, USA
- Division of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Charlamaine Parkinson
- Division of Neonatal-Perinatal Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Allen D Everett
- Blalock-Taussig-Thomas Congenital Heart Center, Johns Hopkins University, Baltimore, MD, USA
| | - Ernest M Graham
- Department of Obstetrics and Gynecology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Dhananjay Vaidya
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatal-Perinatal Medicine, Johns Hopkins University, Baltimore, MD, USA.
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10
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Onda K, Catenaccio E, Chotiyanonta J, Chavez-Valdez R, Meoded A, Soares BP, Tekes A, Spahic H, Miller SC, Parker SJ, Parkinson C, Vaidya DM, Graham EM, Stafstrom CE, Everett AD, Northington FJ, Oishi K. Development of a composite diffusion tensor imaging score correlating with short-term neurological status in neonatal hypoxic-ischemic encephalopathy. Front Neurosci 2022; 16:931360. [PMID: 35983227 PMCID: PMC9379310 DOI: 10.3389/fnins.2022.931360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is the most common cause of neonatal acquired brain injury. Although conventional MRI may predict neurodevelopmental outcomes, accurate prognostication remains difficult. As diffusion tensor imaging (DTI) may provide an additional diagnostic and prognostic value over conventional MRI, we aimed to develop a composite DTI (cDTI) score to relate to short-term neurological function. Sixty prospective neonates treated with therapeutic hypothermia (TH) for HIE were evaluated with DTI, with a voxel size of 1 × 1 × 2 mm. Fractional anisotropy (FA) and mean diffusivity (MD) from 100 neuroanatomical regions (FA/MD *100 = 200 DTI parameters in total) were quantified using an atlas-based image parcellation technique. A least absolute shrinkage and selection operator (LASSO) regression was applied to the DTI parameters to generate the cDTI score. Time to full oral nutrition [short-term oral feeding (STO) score] was used as a measure of short-term neurological function and was correlated with extracted DTI features. Seventeen DTI parameters were selected with LASSO and built into the final unbiased regression model. The selected factors included FA or MD values of the limbic structures, the corticospinal tract, and the frontotemporal cortices. While the cDTI score strongly correlated with the STO score (rho = 0.83, p = 2.8 × 10-16), it only weakly correlated with the Sarnat score (rho = 0.27, p = 0.035) and moderately with the NICHD-NRN neuroimaging score (rho = 0.43, p = 6.6 × 10-04). In contrast to the cDTI score, the NICHD-NRN score only moderately correlated with the STO score (rho = 0.37, p = 0.0037). Using a mixed-model analysis, interleukin-10 at admission to the NICU (p = 1.5 × 10-13) and tau protein at the end of TH/rewarming (p = 0.036) and after rewarming (p = 0.0015) were significantly associated with higher cDTI scores, suggesting that high cDTI scores were related to the intensity of the early inflammatory response and the severity of neuronal impairment after TH. In conclusion, a data-driven unbiased approach was applied to identify anatomical structures associated with some aspects of neurological function of HIE neonates after cooling and to build a cDTI score, which was correlated with the severity of short-term neurological functions.
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Affiliation(s)
- Kengo Onda
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eva Catenaccio
- Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jill Chotiyanonta
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Raul Chavez-Valdez
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Bruno P. Soares
- Division of Neuroradiology, Department of Radiology, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Aylin Tekes
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Harisa Spahic
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sarah C. Miller
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Charlamaine Parkinson
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Dhananjay M. Vaidya
- Department of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ernest M. Graham
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carl E. Stafstrom
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Neurology, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Allen D. Everett
- Division of Pediatric Cardiology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Frances J. Northington
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenichi Oishi
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
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11
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Collaco JM, McGrath-Morrow SA, Griffiths M, Chavez-Valdez R, Parkinson C, Zhu J, Northington FJ, Graham EM, Everett AD. Perinatal Inflammatory Biomarkers and Respiratory Disease in Preterm Infants. J Pediatr 2022; 246:34-39.e3. [PMID: 35460699 PMCID: PMC9264338 DOI: 10.1016/j.jpeds.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/01/2022] [Accepted: 04/15/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To measure plasma levels of vascular endothelial growth factor (VEGF) and several cytokines (Interleukin [IL]-6 IL-8, IL-10) during the first week of life to examine the relationship between protein expression and likelihood of developing respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). STUDY DESIGN Levels of IL-6, IL-8, IL-10, and VEGF were measured from plasma obtained from preterm patients during the first week of life. Newborns were recruited from a single center between April 2009 and April 2019. Criteria for the study included being inborn, birth weight of less than 1500 grams, and a gestational age of less than 32 weeks at birth. RESULTS The development of RDS in preterm newborns was associated with lower levels of VEGF during the first week of life. Higher plasma levels of IL-6 and IL-8 plasma were associated with an increased likelihood and increased severity of BPD at 36 weeks postmenstrual age. In contrast, plasma levels of VEGF, IL-6, IL-8, and IL-10 obtained during the first week of life were not associated with respiratory symptoms and acute care use in young children with BPD in the outpatient setting. CONCLUSIONS During the first week of life, lower plasma levels of VEGF was associated with the diagnosis of RDS in preterm infants. Preterm infants with higher levels of IL-6 and IL-8 during the first week of life were also more likely to be diagnosed with BPD. These biomarkers may help to predict respiratory morbidities in preterm newborns during their initial hospitalization.
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Affiliation(s)
- Joseph M Collaco
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD.
| | | | - Megan Griffiths
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Raul Chavez-Valdez
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Jie Zhu
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Ernest M Graham
- Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Allen D Everett
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
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12
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Northington FJ, Kratimenos P, Turnbill V, Flock DL, Asafu-Adjaye D, Chavez-Valdez R, Martin LJ. Basal forebrain magnocellular cholinergic systems are damaged in mice following neonatal hypoxia-ischemia. J Comp Neurol 2022; 530:1148-1163. [PMID: 34687459 PMCID: PMC9014889 DOI: 10.1002/cne.25263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 10/02/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022]
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) causes lifelong neurologic disability. Despite the use of therapeutic hypothermia, memory deficits and executive functions remain severely affected. Cholinergic neurotransmission from the basal forebrain to neocortex and hippocampus is central to higher cortical functions. We examined the basal forebrain by light microscopy and reported loss of choline acetyltransferase-positive (ChAT)+ neurons, at postnatal day (P) 40, in the ipsilateral medial septal nucleus (MSN) after neonatal hypoxia-ischemia (HI) in mice. There was no loss of ChAT+ neurons in the ipsilateral nucleus basalis of Meynert (nbM) and striatum. Ipsilateral striatal and nbM ChAT+ neurons were abnormal with altered immunoreactivity for ChAT, shrunken and crenated somas, and dysmorphic appearing dendrites. Using confocal images with 3D reconstruction, nbM ChAT+ dendrites in HI mice were shorter than sham (p = .0001). Loss of ChAT+ neurons in the MSN directly correlated with loss of ipsilateral hippocampal area. In the nbM and striatum, percentage of abnormal ChAT+ neurons correlated with loss of ipsilateral cerebral cortical and striatal area, respectively. Acetylcholinesterase (AChE) activity increased in adjacent ipsilateral cerebral cortex and hippocampus and the increase was linearly related to loss of cortical and hippocampal area. Numbers and size of cathepsin D+ lysosomes increased in large neurons in the ipsilateral nbM. After neonatal HI, abnormalities were found throughout the major cholinergic systems in relationship to amount of forebrain area loss. There was also an upregulation of cathepsin D+ particles within the nbM. Cholinergic neuropathology may underlie the permanent dysfunction in learning, memory, and executive function after neonatal brain injury.
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Affiliation(s)
- Frances J. Northington
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,Corresponding Author: CMSC 6-104, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287,
| | - Panagiotis Kratimenos
- Department of Pediatrics and Neuroscience, Children’s National Hospital & The George Washington University School of Medicine, Washington, D.C
| | - Victoria Turnbill
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Debra L. Flock
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniella Asafu-Adjaye
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Raul Chavez-Valdez
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Lee J. Martin
- Department of Neuroscience, Pathology, and Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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13
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Northington FJ, Kratimenos P, Turnbill V, Flock DL, Asafu‐Adjaye D, Chavez‐Valdez R, Martin LJ. Cover Image, Volume 530, Issue 8. J Comp Neurol 2022. [DOI: 10.1002/cne.25327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Gauda EB, Chavez-Valdez R, Northington FJ, Lee CKK, Rudek MA, Guglieri-Lopez B, Ivaturi V. Correction to: Clonidine for sedation in infants during therapeutic hypothermia with neonatal encephalopathy: pilot study. J Perinatol 2022; 42:422. [PMID: 34811537 DOI: 10.1038/s41372-021-01245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Estelle B Gauda
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Carlton K K Lee
- Division of Clinical Pharmacology, Department of Pharmacy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michelle A Rudek
- Department of Oncology, Cancer Chemical and Structural Biology Program; Department of Medicine, Division of Clinical Pharmacology; Sidney Kimmel Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Beatriz Guglieri-Lopez
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
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15
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Chen MW, Lee JK, Vezina G, Tekes A, Perin J, Li R, O’Kane A, McGowan M, Chang T, Parkinson C, Krein C, Al-Shargabi T, Northington FJ, Brady KM, Massaro AN, Govindan RB. The Utility of Cerebral Autoregulation Indices in Detecting Severe Brain Injury Varies by Cooling Treatment Phase in Neonates with Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2022; 44:363-372. [PMID: 35100588 PMCID: PMC9828944 DOI: 10.1159/000522314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/27/2022] [Indexed: 01/12/2023] Open
Abstract
Identifying the hemodynamic range that best supports cerebral perfusion using near infrared spectroscopy (NIRS) autoregulation monitoring is a potential physiologic marker for neonatal hypoxic-ischemic encephalopathy (HIE) during therapeutic hypothermia. However, an optimal autoregulation monitoring algorithm has not been identified for neonatal clinical medicine. We tested whether the hemoglobin volume phase (HVP), hemoglobin volume (HVx), and pressure passivity index (PPI) identify changes in autoregulation that are associated with brain injury on MRI or death. The HVP measures the phase difference between a NIRS metric of cerebral blood volume, the total hemoglobin (THb), and mean arterial blood pressure (MAP) at the frequency of maximum coherence. The HVx is the correlation coefficient between MAP and THb. The PPI is the percentage of coherent MAP-DHb (difference between oxygenated and deoxygenated hemoglobin, a marker of cerebral blood flow) epochs in a chosen time period. Neonates cooled for HIE were prospectively enrolled in an observational study in two neonatal intensive care units. In analyses adjusted for study site and encephalopathy level, all indices detected relationships between poor autoregulation in the first 6 h after rewarming with a higher injury score on MRI. Only HVx and PPI during hypothermia and the PPI during rewarming identified autoregulatory dysfunction associated with a poor outcome independent of study site and encephalopathy level. Our findings suggest that the accuracy of mathematical autoregulation algorithms in detecting the risk of brain injury or death may depend on temperature and postnatal age. Extending autoregulation monitoring beyond the standard 72 h of therapeutic hypothermia may serve as a method to provide personalized care by assessing the need for and efficacy of future therapies after the hypothermia treatment phase.
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Affiliation(s)
- May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gilbert Vezina
- Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruoying Li
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Alexandra O’Kane
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Meaghan McGowan
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Taeun Chang
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC, USA
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC, USA
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ken M. Brady
- Department of Anesthesiology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Neonatology, Children’s National Hospital, Washington, DC, USA
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC, USA
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16
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Chavez-Valdez R, Miller S, Spahic H, Vaidya D, Parkinson C, Dietrick B, Brooks S, Gerner GJ, Tekes A, Graham EM, Northington FJ, Everett AD. Therapeutic Hypothermia Modulates the Relationships Between Indicators of Severity of Neonatal Hypoxic Ischemic Encephalopathy and Serum Biomarkers. Front Neurol 2021; 12:748150. [PMID: 34795631 PMCID: PMC8593186 DOI: 10.3389/fneur.2021.748150] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To determine the changes due to therapeutic hypothermia (TH) exposure in the strength of association between traditional clinical and biochemical indicators of severity of neonatal hypoxic-ischemic encephalopathy (HIE) and serum biomarkers. We hypothesized that culmination of TH changes the strength of the relationships between traditional indicators of severity of HIE and serum biomarkers. Methods: This was a single-center observational cohort study of 178 neonates with HIE treated with TH and followed with serum biomarkers: (i) brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) (neurotrophins); (ii) tau and glial fibrillary acidic protein (GFAP) (neural cell injury); and (iii) interleukin 6 (IL-6), IL-8, and IL-10 (cytokines), during their first week of life. Adjusted mixed-effect models tested associations with HIE indicators in relation to TH exposure. Results: At admission, lower Apgar scores and base excess (BE) and higher lactate and nucleated red blood cell (NRBC) count correlated with higher Sarnat scores. These indicators of worse HIE severity, including higher Sarnat score, correlated with lower VEGF and higher tau, GFAP, and IL-10 levels at different time points. Within the first 24 h of life, patients with a Sarnat score >2 had lower VEGF levels, whereas only those with score of 3 also had higher GFAP and IL-10 levels. Tau levels increased during TH in patients with Sarnat score of 3, whereas tau and GFAP increased after TH in those with scores of 2. After adjustments, lower VEGF levels during TH and higher tau, GFAP, and IL-10 levels during and after TH were associated with worse Sarnat scores. Tau and GFAP relationship with Sarnat score became stronger after TH. Conclusion: Therapeutic hypothermia exerts an independent modulatory effect in the relationships between traditional indicators of severity of HIE and serum biomarkers after adjustments. Thus, the timing of biomarker testing in relation to TH exposure must be carefully considered if biomarkers are proposed for patient stratification in novel clinical trials.
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Affiliation(s)
- Raul Chavez-Valdez
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sarah Miller
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Harisa Spahic
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Dhananjay Vaidya
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Charlamaine Parkinson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Barbara Dietrick
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sandra Brooks
- Department of Pediatrics, Division of Neonatology, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States
| | - Gwendolyn J Gerner
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, United States.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Aylin Tekes
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ernest M Graham
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Frances J Northington
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Allen D Everett
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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17
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Chavez-Valdez R, Lechner C, Emerson P, Northington FJ, Martin LJ. Accumulation of PSA-NCAM marks nascent neurodegeneration in the dorsal hippocampus after neonatal hypoxic-ischemic brain injury in mice. J Cereb Blood Flow Metab 2021; 41:1039-1057. [PMID: 32703109 PMCID: PMC8054724 DOI: 10.1177/0271678x20942707] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neonatal hypoxia-ischemia (nHI) disrupts hippocampal GABAergic development leading to memory deficits in mice. Polysialic-acid neural-cell adhesion molecule (PSA-NCAM) developmentally declines to trigger GABAergic maturation. We hypothesized that nHI changes PSA-NCAM abundance and cellular distribution, impairing GABAergic development, and marking nascent neurodegeneration. Cell degeneration, atrophy, and PSA-NCAM immunoreactivity (IR) were measured in CA1 of nHI-injured C57BL6 mice related to: (i) cellular subtype markers; (ii) GAD65/67 and synatophysin (SYP), pre-synaptic markers; (iii) phospho-Ser396Tau, cytoskeletal marker; and (iv) GAP43, axonalregeneration marker. PSA-NCAM IR was minimal in CA1 of shams at P11. After nHI, PSA-NCAM IR was increased in injured pyramidal cells (PCs), minimal in parvalbumin (PV)+INs, and absent in glia. PSA-NCAM IR correlated with injury severity and became prominent in perikaryal cytoplasm at P18. GAD65/67 and SYP IRs only weakly related to PSA-NCAM after nHI. Injured phospho-Ser396Tau+ PCs and PV+INs variably co-expressed PSA-NCAM at P40. While PCs with cytoplasmic marginalized PSA-NCAM had increased perisomatic GAP43, those with perikaryal cytoplasmic PSA-NCAM had minimal GAP43. PSA-NCAM increased in serum of nHI-injured mice. Increased PSA-NCAM is likely a generic acute response to nHI brain injury. PSA-NCAM aberrant cellular localization may aggravate neuronal degeneration. The significance of PSA-NCAM as a biomarker of recovery from nHI and nascent neurodegeneration needs further study.
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Affiliation(s)
- Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles Lechner
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Emerson
- Department of Neuroscience, Johns Hopkins University, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee J Martin
- Department of Neuroscience, Johns Hopkins University, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Liu X, Tekes A, Perin J, Chen MW, Soares BP, Massaro AN, Govindan RB, Parkinson C, Chavez-Valdez R, Northington FJ, Brady KM, Lee JK. Wavelet Autoregulation Monitoring Identifies Blood Pressures Associated With Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy. Front Neurol 2021; 12:662839. [PMID: 33995258 PMCID: PMC8113412 DOI: 10.3389/fneur.2021.662839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/15/2022] Open
Abstract
Dysfunctional cerebrovascular autoregulation may contribute to neurologic injury in neonatal hypoxic-ischemic encephalopathy (HIE). Identifying the optimal mean arterial blood pressure (MAPopt) that best supports autoregulation could help identify hemodynamic goals that support neurologic recovery. In neonates who received therapeutic hypothermia for HIE, we hypothesized that the wavelet hemoglobin volume index (wHVx) would identify MAPopt and that blood pressures closer to MAPopt would be associated with less brain injury on MRI. We also tested a correlation-derived hemoglobin volume index (HVx) and single- and multi-window data processing methodology. Autoregulation was monitored in consecutive 3-h periods using near infrared spectroscopy in an observational study. The neonates had a mean MAP of 54 mmHg (standard deviation: 9) during hypothermia. Greater blood pressure above the MAPopt from single-window wHVx was associated with less injury in the paracentral gyri (p = 0.044; n = 63), basal ganglia (p = 0.015), thalamus (p = 0.013), and brainstem (p = 0.041) after adjustments for sex, vasopressor use, seizures, arterial carbon dioxide level, and a perinatal insult score. Blood pressure exceeding MAPopt from the multi-window, correlation HVx was associated with less injury in the brainstem (p = 0.021) but not in other brain regions. We conclude that applying wavelet methodology to short autoregulation monitoring periods may improve the identification of MAPopt values that are associated with brain injury. Having blood pressure above MAPopt with an upper MAP of ~50–60 mmHg may reduce the risk of brain injury during therapeutic hypothermia. Though a cause-and-effect relationship cannot be inferred, the data support the need for randomized studies of autoregulation and brain injury in neonates with HIE.
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Affiliation(s)
- Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University, Baltimore, MD, United States
| | - May W Chen
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | - Bruno P Soares
- Department of Radiology, University of Vermont, Burlington, VT, United States
| | - An N Massaro
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States.,Division of Neonatology, Children's National Health System, Washington, DC, United States
| | - Rathinaswamy B Govindan
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
| | | | - Raul Chavez-Valdez
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | | | - Ken M Brady
- Department of Anesthesiology, Lurie Children's Hospital, Chicago, IL, United States
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
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19
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Lechner CR, McNally MA, St Pierre M, Felling RJ, Northington FJ, Stafstrom CE, Chavez-Valdez R. Sex specific correlation between GABAergic disruption in the dorsal hippocampus and flurothyl seizure susceptibility after neonatal hypoxic-ischemic brain injury. Neurobiol Dis 2020; 148:105222. [PMID: 33309937 PMCID: PMC7864119 DOI: 10.1016/j.nbd.2020.105222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 01/12/2023] Open
Abstract
Since neonatal hypoxia-ischemia (HI) disrupts the hippocampal (Hp) GABAergic network in the mouse and Hp injury in this model correlates with flurothyl seizure susceptibility only in male mice, we hypothesized that GABAergic disruption correlates with flurothyl seizure susceptibility in a sex-specific manner. C57BL6 mice were exposed to HI (Vannucci model) versus sham procedures at P10, randomized to normothermia (NT) or therapeutic hypothermia (TH), and subsequently underwent flurothyl seizure testing at P18. Only in male mice, Hp atrophy correlated with seizure susceptibility. The number of Hp parvalbumin positive interneurons (PV+INs) decreased after HI in both sexes, but TH attenuated this deficit only in females. In males only, seizure susceptibility directly correlated with the number of PV+INs, but not somatostatin or calretinin expressing INs. Hp GABAB receptor subunit levels were decreased after HI, but unrelated to later seizure susceptibility. In contrast, Hp GABAA receptor α1 subunit (GABAARα1) levels were increased after HI. Adjusting the number of PV+ INs for their GABAARα1 expression strengthened the correlation with seizure susceptibility in male mice. Thus, we identified a novel Hp sex-specific GABA-mediated mechanism of compensation after HI that correlates with flurothyl seizure susceptibility warranting further study to better understand potential clinical translation.
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Affiliation(s)
- Charles R Lechner
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA
| | - Melanie A McNally
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA
| | - Mark St Pierre
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA
| | - Carl E Stafstrom
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, 600 North Wolf Street, Baltimore, MD 21287, USA.
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20
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Carrasco M, Stafstrom CE, Tekes A, Parkinson C, Northington FJ. The Johns Hopkins Neurosciences Intensive Care Nursery Tenth Anniversary (2009-2019): A Historical Reflection and Vision for the Future. Child Neurol Open 2020; 7:2329048X20907761. [PMID: 32215280 PMCID: PMC7081468 DOI: 10.1177/2329048x20907761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 12/11/2022] Open
Abstract
Since 2009, the Neurosciences Intensive Care Nursery at Johns Hopkins Children’s Center has provided a multidisciplinary approach toward the care of newborns with neurological disorders. The program’s cornerstone is an interdisciplinary approach that involves the primary neonatology team plus experts from more than 10 specialties who convene at a weekly team conference at which newborns with neurological problems are discussed in detail. This interdisciplinary approach fosters in-depth discussion of clinical issues to optimize the management of neonates with neurological problems as well as the opportunity to generate research ideas and provide education about neonatal neuroscience at all levels (faculty, nurses, and trainees). The purpose of this article is to provide a 10-year reflection of our Neurosciences Intensive Care Nursery with a view toward expanding efforts in the 3 areas of our mission: clinical care, research, and education. We hope that our experience will enhance the spread of neonatal neuroscience education, care, and research as widely as possible.
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Affiliation(s)
- Melisa Carrasco
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Charla Parkinson
- Division of Neonatology, Department of Pediatrics, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
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21
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Jantzie LL, Maxwell JR, Newville JC, Yellowhair TR, Kitase Y, Madurai N, Ramachandra S, Bakhireva LN, Northington FJ, Gerner G, Tekes A, Milio LA, Brigman JL, Robinson S, Allan A. Prenatal opioid exposure: The next neonatal neuroinflammatory disease. Brain Behav Immun 2020; 84:45-58. [PMID: 31765790 PMCID: PMC7010550 DOI: 10.1016/j.bbi.2019.11.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/29/2019] [Accepted: 11/17/2019] [Indexed: 01/19/2023] Open
Abstract
The rates of opioid use disorder during pregnancy have more than quadrupled in the last decade, resulting in numerous infants suffering exposure to opioids during the perinatal period, a critical period of central nervous system (CNS) development. Despite increasing use, the characterization and definition of the molecular and cellular mechanisms of the long-term neurodevelopmental impacts of opioid exposure commencing in utero remains incomplete. Thus, in consideration of the looming public health crisis stemming from the multitude of infants with prenatal opioid exposure entering school age, we undertook an investigation of the effects of perinatal methadone exposure in a novel preclinical model. Specifically, we examined the effects of opioids on the developing brain to elucidate mechanisms of putative neural cell injury, to identify diagnostic biomarkers and to guide clinical studies of outcome and follow-up. We hypothesized that methadone would induce a pronounced inflammatory profile in both dams and their pups, and be associated with immune system dysfunction, sustained CNS injury, and altered cognition and executive function into adulthood. This investigation was conducted using a combination of cellular, molecular, biochemical, and clinically translatable biomarker, imaging and cognitive assessment platforms. Data reveal that perinatal methadone exposure increases inflammatory cytokines in the neonatal peripheral circulation, and reprograms and primes the immune system through sustained peripheral immune hyperreactivity. In the brain, perinatal methadone exposure not only increases chemokines and cytokines throughout a crucial developmental period, but also alters microglia morphology consistent with activation, and upregulates TLR4 and MyD88 mRNA. This increase in neuroinflammation coincides with reduced myelin basic protein and altered neurofilament expression, as well as reduced structural coherence and significantly decreased fractional anisotropy on diffusion tensor imaging. In addition to this microstructural brain injury, adult rats exposed to methadone in the perinatal period have significant impairment in associative learning and executive control as assessed using touchscreen technology. Collectively, these data reveal a distinct systemic and neuroinflammatory signature associated with prenatal methadone exposure, suggestive of an altered CNS microenvironment, dysregulated developmental homeostasis, complex concurrent neural injury, and imaging and cognitive findings consistent with clinical literature. Further investigation is required to define appropriate therapies targeted at the neural injury and improve the long-term outcomes for this exceedingly vulnerable patient population.
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Affiliation(s)
- Lauren L. Jantzie
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurology, Kennedy Krieger Institute, Baltimore, MD.,Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM.,Correspondence: Lauren L. Jantzie, PhD, Johns Hopkins University, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, 600 N. Wolfe Street, CMSC Building Room 6-104A, Baltimore, MD 21287,
| | - Jessie R. Maxwell
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jessie C. Newville
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Tracylyn R. Yellowhair
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yuma Kitase
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nethra Madurai
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sindhu Ramachandra
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ludmila N. Bakhireva
- Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM
| | | | - Gwendolyn Gerner
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lorraine A. Milio
- Department of Obstetrics & Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan L. Brigman
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrea Allan
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
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22
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Maxwell JR, Zimmerman AJ, Pavlik N, Newville JC, Carlin K, Robinson S, Brigman JL, Northington FJ, Jantzie LL. Neonatal Hypoxic-Ischemic Encephalopathy Yields Permanent Deficits in Learning Acquisition: A Preclinical Touchscreen Assessment. Front Pediatr 2020; 8:289. [PMID: 32582593 PMCID: PMC7291343 DOI: 10.3389/fped.2020.00289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022] Open
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) remains a common problem world-wide for infants born at term. The impact of HIE on long-term outcomes, especially into adulthood, is not well-described. To facilitate identification of biobehavioral biomarkers utilizing a translational platform, we sought to investigate the impact of HIE on executive function and cognitive outcomes into adulthood utilizing a murine model of HIE. HIE mice (unilateral common carotid artery occlusion to induce ischemia, followed by hypoxia with a FiO2 of 0.08 for 45 min) and control mice were tested on discrimination and reversal touchscreen tasks (using their noses) shown to be sensitive to loss of basal ganglia or cortical function, respectively. We hypothesized that the HIE injury would result in deficits in reversal learning, revealing complex cognitive and executive functioning impairments. Following HIE, mice had a mild discrimination impairment as measured by incorrect responses but were able to learn the paradigm to similar levels as controls. During reversal, HIE mice required significantly more total trials, errors and correction trials across the paradigm. Analysis of specific stages showed that reversal impairments in HIE were driven by significant increases in all measured parameters during the late learning, striatal-mediated portion of the task. Together, these results support the concept that HIE occurring during the neonatal period results in abnormal neurodevelopment that persists into adulthood, which can impact efficient associated learning. Further, these data show that utilization of an established model of HIE coupled with touchscreen learning provides valuable information for screening therapeutic interventions that could mitigate these deficits to improve the long-term outcomes of this vulnerable population.
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Affiliation(s)
- Jessie R Maxwell
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
| | - Amber J Zimmerman
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
| | - Nathaniel Pavlik
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States
| | - Jessie C Newville
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
| | - Katherine Carlin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan L Brigman
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
| | - Frances J Northington
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neurology, Kennedy Krieger Institute, Baltimore, MD, United States
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23
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Salas J, Reddy N, Carson KA, Northington FJ, Huisman TA. Ultrasound Predicts White Matter Integrity after Hypothermia Therapy in Neonatal Hypoxic-Ischemic Injury. J Neuroimaging 2019; 29:743-749. [PMID: 31206969 PMCID: PMC6814495 DOI: 10.1111/jon.12644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/01/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Hypoxic-ischemic injury (HII) is a major cause of neonatal death and neurodevelopmental disability. Head ultrasounds (HUS) in neonates with HII often show enhanced gray/white matter differentiation. We assessed the significance of this finding in predicting white matter structural integrity measured by diffusion tensor imaging (DTI) in neonates with HII. METHODS We performed a quantitative region of interest-based analysis of white and gray matter echogenicity within the cingulate gyrus on pre- and posthypothermia HUS. We also completed a quantitative analysis of fractional anisotropy (FA) and mean (MD), axial (AD), and radial (RD) diffusivity within the bilateral anterior and posterior centrum semiovale (CSO) on posthypothermia brain magnetic resonance imaging. For HUS studies, we calculated a white-to-gray matter echogenicity ratio (WGR) and subsequently correlated it to DTI measurements. RESULTS Forty-two term neonates with HII who underwent hypothermia therapy were included. Significant correlation was found between prehypothermia WGR and MD, AD, and RD values in the left anterior CSO (r = .38-.40, P = .02). Prehypothermia WGR also correlated with the following: MD and RD in the right anterior CSO (r = .35-.36, P = .04), MD and AD in the right posterior CSO (r = .32-.45, P = .008-.03), and AD in the left posterior CSO (r = .47, P = .005). No significant correlation was found either between prehypothermia WGR and FA values in the bilateral anterior and posterior CSO or between posthypothermia WGR and all DTI scalars in the bilateral anterior and posterior CSO. CONCLUSIONS Prehypothermia HUS WGR may predict posthypothermia white matter structural integrity and is potentially an early and easily obtainable biomarker of severity in neonatal HII.
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Affiliation(s)
- Jacqueline Salas
- Division of Neonatology, Department of Pediatrics, New-York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA,Neurosciences Intensive Care Nursery Group and Division of Neonatology, Johns Hopkins University School of Medicine
| | - Nihaal Reddy
- Neurosciences Intensive Care Nursery Group and Division of Neonatology, Johns Hopkins University School of Medicine,Division of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathryn A. Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Frances J. Northington
- Neurosciences Intensive Care Nursery Group and Division of Neonatology, Johns Hopkins University School of Medicine,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine
| | - Thierry A.G.M. Huisman
- Neurosciences Intensive Care Nursery Group and Division of Neonatology, Johns Hopkins University School of Medicine,Division of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Gerner GJ, Newman EI, Burton VJ, Roman B, Cristofalo EA, Leppert M, Johnston MV, Northington FJ, Huisman TA, Poretti A. Correlation Between White Matter Injury Identified by Neonatal Diffusion Tensor Imaging and Neurodevelopmental Outcomes Following Term Neonatal Asphyxia and Therapeutic Hypothermia: An Exploratory Pilot Study. J Child Neurol 2019; 34:556-566. [PMID: 31070085 PMCID: PMC7318916 DOI: 10.1177/0883073819841717] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Hypoxic-ischemic encephalopathy is associated with damage to deep gray matter; however, white matter involvement has become recognized. This study explored differences between patients and clinical controls on diffusion tensor imaging, and relationships between diffusion tensor imaging and neurodevelopmental outcomes. METHOD Diffusion tensor imaging was obtained for 31 neonates after hypoxic-ischemic encephalopathy treated with therapeutic hypothermia and 10 clinical controls. A subgroup of patients with hypoxic-ischemic encephalopathy (n = 14) had neurodevelopmental outcomes correlated with diffusion tensor imaging scalars. RESULTS Group differences in diffusion tensor imaging scalars were observed in the putamen, anterior and posterior centrum semiovale, and the splenium of the corpus callosum. Differences in these regions of interest were correlated with neurodevelopmental outcomes between ages 20 and 32 months. CONCLUSION Therapeutic hypothermia may not be a complete intervention for hypoxic-ischemic encephalopathy, as neonatal white matter changes may continue to be evident, but further research is warranted. Patterns of white matter change on neonatal diffusion tensor imaging correlated with neurodevelopmental outcomes in this exploratory pilot study.
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Affiliation(s)
- Gwendolyn J. Gerner
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD USA
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Eric I. Newman
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science
| | - V. Joanna Burton
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD USA
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Brenton Roman
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD USA
| | - Elizabeth A. Cristofalo
- Frederick Memorial Hospital, Department of Neonatology, Frederick, MD, USA
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Mary Leppert
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD USA
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Michael V. Johnston
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD USA
- Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD USA
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Frances J. Northington
- Department of Perinatal-Neonatal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD USA
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Thierry A.G.M. Huisman
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Andrea Poretti
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD USA
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science
- Neurosciences Intensive Care Nursery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
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25
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Chavez-Valdez R, Emerson P, Goffigan-Holmes J, Kirkwood A, Martin LJ, Northington FJ. Delayed injury of hippocampal interneurons after neonatal hypoxia-ischemia and therapeutic hypothermia in a murine model. Hippocampus 2019; 28:617-630. [PMID: 29781223 DOI: 10.1002/hipo.22965] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 05/03/2018] [Accepted: 05/13/2018] [Indexed: 01/29/2023]
Abstract
Delayed hippocampal injury and memory impairments follow neonatal hypoxia-ischemia (HI) despite the use of therapeutic hypothermia (TH). Death of hippocampal pyramidal cells occurs acutely after HI, but characterization of delayed cell death and injury of interneurons (INs) is unknown. We hypothesize that injury of INs after HI is: (i) asynchronous to that of pyramidal cells, (ii) independent of injury severity, and (iii) unresponsive to TH. HI was induced in C57BL6 mice at p10 with unilateral right carotid ligation and 45 min of hypoxia (FiO2 = 0.08). Mice were randomized to normothermia (36 °C, NT) or TH (31 °C) for 4 hr after HI and anesthesia-exposed shams were use as controls. Brains were studied at 24 hr (p11) or 8 days (p18) after HI. Vglut1, GAD65/67, PSD95, parvalbumin (PV) and calbindin-1 (Calb1) were measured. Cell death was assessed using cresyl violet staining and TUNEL assay. Hippocampal atrophy and astroglyosis at p18 were used to assess injury severity and to correlate with number of PV + INs. VGlut1 level decreased by 30% at 24 hr after HI, while GAD65/67 level decreased by ∼50% in forebrain 8 days after HI, a decrease localized in CA1 and CA3. PSD95 levels decreased in forebrain by 65% at 24 hr after HI and remained low 8 days after HI. PV + INs increased in numbers (per mm2 ) and branching between p11 and p18 in sham mice but not in NT and TH mice, resulting in 21-52% fewer PV + INs in injured mice at p18. Calb1 protein and mRNA were also reduced in HI injured mice at p18. At p18, somatodendritic attrition of INs was evident in all injured mice without evidence of cell death. Neither hippocampal atrophy nor astroglyosis correlated with the number of PV + INs at p18. Thus, HI exposure has long lasting effects in the hippocampus impairing the development of the GABAergic system with only partial protection by TH independent of the degree of hippocampal injury. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Raul Chavez-Valdez
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Paul Emerson
- Department of Neuroscience, The Zanvyl Krieger Mind/Brain Institute, Johns Hopkins University, Baltimore, Maryland
| | - Janasha Goffigan-Holmes
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alfredo Kirkwood
- Department of Neuroscience, The Zanvyl Krieger Mind/Brain Institute, Johns Hopkins University, Baltimore, Maryland
| | - Lee J Martin
- Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Frances J Northington
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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26
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Wu D, Martin LJ, Northington FJ, Zhang J. Oscillating-gradient diffusion magnetic resonance imaging detects acute subcellular structural changes in the mouse forebrain after neonatal hypoxia-ischemia. J Cereb Blood Flow Metab 2019; 39:1336-1348. [PMID: 29436246 PMCID: PMC6668516 DOI: 10.1177/0271678x18759859] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The recently developed oscillating-gradient diffusion MRI (OG-dMRI) technique extends our ability to examine brain structures at different spatial scales. In this study, we investigated the sensitivity of OG-dMRI in detecting cellular and subcellular structural changes in a mouse model of neonatal hypoxia ischemia (HI). Neonatal mice received unilateral HI injury or sham injury at postnatal day 10, followed by in vivo T2-weighted and diffusion MRI of the brains at 3-6 h and 24 h after HI. Apparent diffusion coefficient (ADC) maps were acquired using conventional pulsed-gradient dMRI (PG-dMRI) and OG-dMRI with oscillating frequencies from 50 to 200 Hz. Pathology at cellular and subcellular levels was evaluated using neuronal, glial, and mitochondrial markers. We found significantly higher rates of ADC increase with oscillating frequencies (ΔfADC) in the ipsilateral edema region, compared to the contralateral side, starting as early as 3 h after HI. Even in injured regions that showed no apparent change in PG-ADC or pseudo-normalized PG-ADC measurements, ΔfADC remained significantly elevated. Histopathology showed swelling of sub-cellular structures in these regions with no apparent whole-cell level change. These results suggest that OG-dMRI is sensitive to subcellular structural changes in the brain after HI and is less susceptible to pseudo-normalization than PG-dMRI.
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Affiliation(s)
- Dan Wu
- 1 Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou, China.,2 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee J Martin
- 3 Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,4 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- 5 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jiangyang Zhang
- 6 Department of Radiology, New York University School of Medicine, New York, NY, USA
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27
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Liu P, Parkinson C, Jiang D, Ouyang M, De Vis JB, Northington FJ, Tekes A, Huang H, Huisman TA, Golden WC. Characterization of MRI techniques to assess neonatal brain oxygenation and blood flow. NMR Biomed 2019; 32:e4103. [PMID: 31038246 PMCID: PMC6581605 DOI: 10.1002/nbm.4103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/22/2019] [Accepted: 03/12/2019] [Indexed: 06/09/2023]
Abstract
There is increasing interest in applying physiological MRI in neonates, based on the premise that physiological parameters may provide an early biomarker of neonatal brain health and injury. Two commonly used techniques are oxygen extraction fraction (OEF) measurement using T2 -relaxation-under-spin-tagging (TRUST) MRI and cerebral blood flow measurement using phase-contrast (PC) quantitative flow MRI, which collectively provide an assessment of the brain's oxygen consumption. However, prior research has only demonstrated proof of principle of these methods in neonates, without characterization or benchmarking of the techniques. This is because available time is limited in neonatal subjects, especially when scans are performed as add-ons to clinical scans (typically less than 5 min). The work presented aims to examine the TRUST and PC MRI sequences systematically in normal neonates, through research-dedicated scan sessions. A series of characterization and optimization studies were conducted in a total of 26 radiographically normal neonates on 3 T systems. Our results show that TRUST MRI at the superior sagittal sinus (SSS) provides an OEF measurement equivalent to that at the internal jugular vein (r = 0.80, n = 10), yet with shorter scan time. Lower resolution provided better precision in the TRUST measurement (p = 0.001, n = 9). Therefore, the preferred OEF measurement is to apply TRUST MRI at the SSS using a spatial resolution of 2.5 mm. For PC MRI, our results showed that non-gated PC MRI yielded blood flow measurements comparable to those from the more time-consuming gated approach in neonates (r = 0.89, n = 7). It was also found that blood flow could be overestimated by 18% when imaging resolution is larger than 0.3 mm (n = 7). Therefore, non-gated PC MRI with a spatial resolution of 0.3 mm is recommended for neonatal applications. In conclusion, this study verifies consistency of neonatal brain oxygenation and flow measurements across acquisition schemes and points to optimal strategies in parameter selection when using these sequences.
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Affiliation(s)
- Peiying Liu
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dengrong Jiang
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Minhui Ouyang
- Radiology Research, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jill B. De Vis
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aylin Tekes
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hao Huang
- Radiology Research, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Thierry A.G.M. Huisman
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - W. Christopher Golden
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Yellowhair TR, Noor S, Mares B, Jose C, Newville JC, Maxwell JR, Northington FJ, Milligan ED, Robinson S, Jantzie LL. Chorioamnionitis in Rats Precipitates Extended Postnatal Inflammatory Lymphocyte Hyperreactivity. Dev Neurosci 2019; 40:1-11. [PMID: 30921800 PMCID: PMC6765467 DOI: 10.1159/000497273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/25/2019] [Indexed: 12/16/2022] Open
Abstract
Preterm birth is an important cause of perinatal brain injury (PBI). Neurological injury in extremely preterm infants often begins in utero with chorioamnionitis (CHORIO) or inflammation/infection of the placenta and concomitant placental insufficiency. Studies in humans have shown dysregulated inflammatory signaling throughout the placental-fetal brain axis and altered peripheral immune responses in children born preterm with cerebral palsy (CP). We hypothesized that peripheral immune responses would be altered in our well-established rat model of CP. Specifically, we proposed that isolated peripheral blood mononuclear cells (PBMCs) would be hyperresponsive to a second hit of inflammation throughout an extended postnatal time course. Pregnant Sprague-Dawley dams underwent a laparotomy on embryonic day 18 (E18) with occlusion of the uterine arteries (for 60 min) followed by intra-amniotic injection of lipopolysaccharide (LPS, 4 μg/sac) to induce injury in utero. Shams underwent laparotomy only, with equivalent duration of anesthesia. Laparotomies were then closed, and the rat pups were born at E22. PBMCs were isolated from pups on postnatal day 7 (P7) and P21, and subsequently stimulated in vitro with LPS for 3 or 24 h. A secreted inflammatory profile analysis of conditioned media was performed using multiplex electrochemiluminescent immunoassays, and the composition of inflammatory cells was assayed with flow cytometry (FC). Results indicate that CHORIO PBMCs challenged with LPS are hyperreactive and secrete significantly more tumor necrosis factor α (TNFα) and C-X-C chemokine ligand 1 at P7. FC confirmed increased intracellular TNFα in CHORIO pups at P7 following LPS stimulation, in addition to increased numbers of CD11b/c immunopositive myeloid cells. Notably, TNFα secretion was sustained until P21, with increased interleukin 6, concomitant with increased expression of integrin β1, suggesting both sustained peripheral immune hyperreactivity and a heightened activation state. Taken together, these data indicate that in utero injury primes the immune system and augments enhanced inflammatory signaling. The insidious effects of primed peripheral immune cells may compound PBI secondary to CHORIO and/or placental insufficiency, and thereby render the brain susceptible to future chronic neurological disease. Further understanding of inflammatory mechanisms in PBI may yield clinically important biomarkers and facilitate individualized repair strategies and treatments.
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Affiliation(s)
- Tracylyn R Yellowhair
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Shahani Noor
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Brittney Mares
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Clement Jose
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Jessie C Newville
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Jessie R Maxwell
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Frances J Northington
- Division of Newborn Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erin D Milligan
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lauren L Jantzie
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA,
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA,
- Division of Newborn Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
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29
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Chavez-Valdez R, Mottahedin A, Stridh L, Yellowhair TR, Jantzie LL, Northington FJ, Mallard C. Evidence for Sexual Dimorphism in the Response to TLR3 Activation in the Developing Neonatal Mouse Brain: A Pilot Study. Front Physiol 2019; 10:306. [PMID: 30971945 PMCID: PMC6443881 DOI: 10.3389/fphys.2019.00306] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/07/2019] [Indexed: 01/23/2023] Open
Abstract
Toll-like receptor (TLR)3 activation during the neonatal period produces responses linked to the origins of neuropsychiatric disorders. Although there is sexual dimorphism in neuropsychiatric disorders, it is unknown if brain responses to TLR3 activation are sex-specific. We hypothesized that poly I:C in a post-natal day (P)8 model induces a sexually dimorphic inflammatory responses. C57BL6 mice received intraperitoneal injection of poly I:C (10 mg/kg) or vehicle [normal saline (NS)] at P8. Pups were killed at 6 or 14 h for caspase 3 and 8 activity assays, NFkB ELISA, IRF3, AP1, and GFAP western blotting and cytokines/chemokines gene expression real time qRT-PCR (4–6/group). A second group of pups were killed at 24 h (P9) or 7 days (P15) after poly I:C to assess astrocytic (GFAP) and microglia (Iba1) activation in the hippocampus, thalamus and cortex using immunohistochemistry, and gene and protein expression of cytokines/chemokines using real time RT-PCR and MSD, respectively (4–6/group). Non-parametric analysis was applied. Six hours after poly I:C, caspase-3 and -8 activities in cytosolic fractions were 1.6 and 2.8-fold higher in poly I:C-treated than in NS-treated female mice, respectively, while gene expressions of pro-inflammatory cytokines were upregulated in both sexes. After poly I:C, IRF3 nuclear translocation occurred earlier (6 h) in female mice and later (14 h) in male mice. At 14 h after poly I:C, only male mice also had increased nuclear NFκB levels (88%, p < 0.001) and GFAP expression coinciding with persistent IL-6 and FAS gene upregulation (110 and 77%, respectively; p < 0.001) and IL-10 gene downregulation (-42%, p < 0.05). At 24 h after poly I:C, IL-1β, CXCL-10, TNF-α, and MCP-1 were similarly increased in both sexes but at 7 days after exposure, CXCL-10 and INFγ were increased and IL-10 was decreased only in female mice. Accordingly, microglial activation persisted at 7 days after poly I:C in the hippocampus, thalamus and cortex of female mice. This preliminary study suggests that TLR3 activation may produce in the developing neonatal mouse brain a sexually dimorphic response with early activation of caspase-dependent pathways in female mice, activation of inflammatory cascades in both sexes, which then persists in female mice. Further well-powered studies are essential to confirm these sex-specific findings.
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Affiliation(s)
- Raul Chavez-Valdez
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Amin Mottahedin
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Linnea Stridh
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tracylyn R Yellowhair
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States.,Department of Pediatrics and Department of Neurosciences, The University of New Mexico, Albuquerque, NM, United States
| | - Lauren L Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States.,Department of Pediatrics and Department of Neurosciences, The University of New Mexico, Albuquerque, NM, United States
| | - Frances J Northington
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Carina Mallard
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Henan Key Laboratory of Child Brain Injury, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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30
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Fang J, Chavez-Valdez R, Flock DL, Avaritt O, Saraswati M, Robertson C, Martin LJ, Northington FJ. An Inhibitor of the Mitochondrial Permeability Transition Pore Lacks Therapeutic Efficacy Following Neonatal Hypoxia Ischemia in Mice. Neuroscience 2019; 406:202-211. [PMID: 30849447 DOI: 10.1016/j.neuroscience.2019.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 01/08/2023]
Abstract
Neonatal hypoxic ischemic (HI) brain injury causes lifelong neurologic disability. Therapeutic hypothermia (TH) is the only approved therapy that partially mitigates mortality and morbidity. Therapies specifically targeting HI-induced brain cell death are currently lacking. Intracellular calcium dysregulation, oxidative stress, and mitochondrial dysfunction through the formation of the mitochondrial permeability transition pore (mPTP) are drivers of HI cellular injury. GNX-4728, a small molecule direct inhibitor of the mPTP that increases mitochondrial calcium retention capacity, is highly effective in adult neurodegenerative disease models and could have potential as a therapy in neonatal HI. A dose of GNX-4728, equivalent to that used in animal models, 300 mg/kg, IP was highly toxic in p10 mice. We then tested the hypothesis that acute administration of 30 mg/kg, IP of GNX-4728 immediately after HI in a neonatal mouse model would provide neuroprotection. This non-lethal lower dose of GNX-4728 (30 mg/kg, IP) improved the respiratory control ratio of neonatal female HI brain tissue but not in males. Brain injury, assessed histologically with a novel metric approach at 1 and 30 days after HI, was not mitigated by GNX-4728. Our work demonstrates that a small molecule inhibitor of the mPTP has i) an age related toxicity, ii) a sex-related brain mitoprotective profile after HI but iii) this is not sufficient to attenuate forebrain HI neuropathology.
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Affiliation(s)
- Jing Fang
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Debbie L Flock
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Oliver Avaritt
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Manda Saraswati
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Courtney Robertson
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lee J Martin
- Department of Neuroscience and Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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McNally MA, Chavez-Valdez R, Felling RJ, Flock DL, Northington FJ, Stafstrom CE. Seizure Susceptibility Correlates with Brain Injury in Male Mice Treated with Hypothermia after Neonatal Hypoxia-Ischemia. Dev Neurosci 2019; 40:1-10. [PMID: 30820019 PMCID: PMC9109068 DOI: 10.1159/000496468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/20/2018] [Indexed: 11/19/2022] Open
Abstract
Hypoxic-ischemic encephalopathy is a common neonatal brain injury associated with significant morbidity and mortality despite the administration of therapeutic hypothermia (TH). Neonatal seizures and subsequent chronic epilepsy are frequent in this patient population and current treatments are partially effective. We used a neonatal murine hypoxia-ischemia (HI) model to test whether the severity of hippocampal and cortical injury predicts seizure susceptibility 8 days after HI and whether TH mitigates this susceptibility. HI at postnatal day 10 (P10) caused hippocampal injury not mitigated by TH in male or female pups. TH did not confer protection against flurothyl seizure susceptibility at P18 in this model. Hippocampal (R2 = 0.33, p = 0.001) and cortical (R2 = 0.33, p = 0.003) injury directly correlated with seizure susceptibility in male but not female pups. Thus, there are sex-specific consequences of neonatal HI on flurothyl seizure susceptibility in a murine neonatal HI model. Further studies are necessary to elucidate the underlying mechanisms of sex dimorphism in seizure susceptibility after neonatal HI.
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Affiliation(s)
- Melanie A McNally
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Raul Chavez-Valdez
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debra L Flock
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frances J Northington
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carl E Stafstrom
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Salas J, Reddy N, Orru E, Carson KA, Chavez-Valdez R, Burton VJ, Stafstrom CE, Northington FJ, Huisman TAGM. The Role of Diffusion Tensor Imaging in Detecting Hippocampal Injury Following Neonatal Hypoxic-Ischemic Encephalopathy. J Neuroimaging 2018; 29:252-259. [PMID: 30325083 DOI: 10.1111/jon.12572] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/12/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Neonatal hypoxic-ischemic injury of the brain and resultant encephalopathy (HIE) leads to major developmental impairments by school age. Conventional/anatomical MRI often fails to detect hippocampal injury in mild cases. We hypothesize that diffusion tensor imaging (DTI) has greater sensitivity for identifying subtle hippocampal injury. METHODS We retrospectively analyzed DTI data collected from a cohort of neonates with HIE and controls. Conventional MRI sequences were classified qualitatively according to severity using a modified Barkovich scale. Using multivariate linear regression, we compared hippocampal DTI scalars of HIE patients and controls. Spearman correlation was used to test the association of DTI scalars in the hippocampal and thalamic regions. A multiple regression analysis tested the association of the DTI scalars with short-term outcomes. RESULTS Fifty-five neonates with HIE (42% males) and 13 controls (54% males) were included. Hippocampal DTI scalars were similar between HIE and control groups, even when restricting the HIE group to those with moderate-to-severe injury (8 subjects). DTI scalars of the thalamus were significantly lower in the moderate-to-severely affected patients compared to controls (right fractional anisotropy [FA] .148 vs. .182, P = .01; left FA .147 vs. .181, P = .03). Hippocampal and thalamic DTI scalars were correlated (P < .001). Hippocampal DTI scalars were not associated with short-term outcomes. CONCLUSIONS Quantitative DTI analysis of the hippocampus in neonates following HIE is a feasible technique to examine neuronal injury. Although DTI scalars were useful in identifying thalamic injury in our cohort, hippocampal DTI analysis did not provide additional information regarding hippocampal injury following HIE.
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Affiliation(s)
- Jacqueline Salas
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Nihaal Reddy
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emanuele Orru
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathryn A Carson
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Vera Joanna Burton
- Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Carl E Stafstrom
- Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD.,Division of Pediatric Neurology, Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
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Robinson S, Conteh FS, Oppong AY, Yellowhair TR, Newville JC, Demerdash NE, Shrock CL, Maxwell JR, Jett S, Northington FJ, Jantzie LL. Extended Combined Neonatal Treatment With Erythropoietin Plus Melatonin Prevents Posthemorrhagic Hydrocephalus of Prematurity in Rats. Front Cell Neurosci 2018; 12:322. [PMID: 30319361 PMCID: PMC6167494 DOI: 10.3389/fncel.2018.00322] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/06/2018] [Indexed: 12/15/2022] Open
Abstract
Posthemorrhagic hydrocephalus of prematurity (PHHP) remains a global challenge. Early preterm infants (<32 weeks gestation), particularly those exposed to chorioamnionitis (CAM), are prone to intraventricular hemorrhage (IVH) and PHHP. We established an age-appropriate, preclinical model of PHHP with progressive macrocephaly and ventriculomegaly to test whether non-surgical neonatal treatment could modulate PHHP. We combined prenatal CAM and postnatal day 1 (P1, equivalent to 30 weeks human gestation) IVH in rats, and administered systemic erythropoietin (EPO) plus melatonin (MLT), or vehicle, from P2 to P10. CAM-IVH rats developed progressive macrocephaly through P21. Macrocephaly was accompanied by ventriculomegaly at P5 (histology), and P21 (ex vivo MRI). CAM-IVH rats showed impaired performance of cliff aversion, a neonatal neurodevelopmental test. Neonatal EPO+MLT treatment prevented macrocephaly and cliff aversion impairment, and significantly reduced ventriculomegaly. EPO+MLT treatment prevented matted or missing ependymal motile cilia observed in vehicle-treated CAM-IVH rats. EPO+MLT treatment also normalized ependymal yes-associated protein (YAP) mRNA levels, and reduced ependymal GFAP-immunolabeling. Vehicle-treated CAM-IVH rats exhibited loss of microstructural integrity on diffusion tensor imaging, which was normalized in EPO+MLT-treated CAM-IVH rats. In summary, combined prenatal systemic inflammation plus early postnatal IVH caused progressive macrocephaly, ventriculomegaly and delayed development of cliff aversion reminiscent of PHHP. Neonatal systemic EPO+MLT treatment prevented multiple hallmarks of PHHP, consistent with a clinically viable, non-surgical treatment strategy.
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Affiliation(s)
- Shenandoah Robinson
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Fatu S Conteh
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Akosua Y Oppong
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Tracylyn R Yellowhair
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Jessie C Newville
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Nagat El Demerdash
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Christine L Shrock
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Jessie R Maxwell
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Stephen Jett
- Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Frances J Northington
- Division of Neonatology, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Lauren L Jantzie
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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Wu D, Li Q, Northington FJ, Zhang J. Oscillating gradient diffusion kurtosis imaging of normal and injured mouse brains. NMR Biomed 2018; 31:e3917. [PMID: 29601111 PMCID: PMC5980785 DOI: 10.1002/nbm.3917] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 02/07/2018] [Accepted: 02/13/2018] [Indexed: 05/25/2023]
Abstract
Recent advances in diffusion MRI employ multiple diffusion encoding schemes with varying diffusion direction, weighting, and diffusion time to investigate specific microstructural properties in biological tissues. In this study, we examined time-dependent diffusion kurtosis contrast in adult mouse brains and in neonatal mouse brains after hypoxic-ischemic (HI) injury. In vivo diffusion kurtosis maps were acquired with a short diffusion time using an oscillating gradient spin echo (OGSE) sequence at 100 Hz and with a relatively long diffusion time (20 ms) using a pulsed gradient spin echo (PGSE) sequence. In the adult mouse brain, we found that the cortex and hippocampus showed larger differences between OGSE kurtosis and PGSE kurtosis than major white matter tracts. In neonatal mouse brains with unilateral HI injury, the OGSE kurtosis map overall provided stronger edema contrast than the PGSE kurtosis map, and the differences between OGSE and PGSE kurtosis measurements in the edema region reflected heterogeneity of injury. This is the first in vivo study that has demonstrated multi-direction OGSE kurtosis contrasts in the mouse brain. Comparing PGSE and OGSE kurtosis measures may provide additional information on microstructural changes after ischemic stroke.
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Affiliation(s)
- Dan Wu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21205, USA
- Key Laboratory for Biomedical Engineering of Ministry of Education, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou, China
| | - Qiang Li
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21205, USA
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi’an, Shaanxi 710038, China
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21205, USA
| | - Jiangyang Zhang
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University School of Medicine, New York, NY 10016, USA
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Carrasco M, Perin J, Jennings JM, Parkinson C, Gilmore MM, Chavez-Valdez R, Massaro AN, Koehler RC, Northington FJ, Tekes A, Lee JK. Cerebral Autoregulation and Conventional and Diffusion Tensor Imaging Magnetic Resonance Imaging in Neonatal Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2018; 82:36-43. [PMID: 29622488 PMCID: PMC5960435 DOI: 10.1016/j.pediatrneurol.2018.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Deviation of mean arterial blood pressure (MAP) from the range that optimizes cerebral autoregulatory vasoreactivity (optimal MAP) could increase neurological injury from hypoxic-ischemic encephalopathy (HIE). We tested whether a global magnetic resonance imaging (MRI) brain injury score and regional diffusion tensor imaging (DTI) are associated with optimal MAP in neonates with HIE. METHODS Twenty-five neonates cooled for HIE were monitored with the hemoglobin volume index. In this observational study, we identified optimal MAP and measured brain injury by qualitative and quantitative MRIs with the Neonatal Research Network (NRN) score and DTI mean diffusivity scalars. Optimal MAP and blood pressure were compared with brain injury. RESULTS Neonates with blood pressure measurements within optimal MAP during rewarming had less brain injury by NRN score (P = 0.040). Longer duration of MAP within optimal MAP during hypothermia correlated with higher mean diffusivity in the anterior centrum semiovale (P = 0.008) and pons (P = 0.002). Blood pressure deviation below optimal MAP was associated with lower mean diffusivity in cerebellar white matter (P = 0.033). Higher optimal MAP values related to lower mean diffusivity in the basal ganglia (P = 0.021), the thalamus (P = 0.006), the posterior limb of the internal capsule (P = 0.018), the posterior centrum semiovale (P = 0.035), and the cerebellar white matter (P = 0.008). Optimal MAP values were not associated with the NRN score. CONCLUSIONS The NRN score and the regional mean diffusivity scalars detected injury with mean arterial blood pressure deviations from the optimal MAP. Higher optimal MAP and lower mean diffusivity may be related because of cytotoxic edema and limited vasodilatory reserve at low MAP in injured brain. DTI detected injury with elevated optimal MAP better than the NRN score.
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Affiliation(s)
- Melisa Carrasco
- Department of Neurology, Division of Pediatric Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jamie Perin
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jacky M. Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Maureen M. Gilmore
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - An N. Massaro
- Department of Pediatrics, Children’s National Medical Center, George Washington University School of Medicine, Washington, District of Columbia
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frances J. Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aylin Tekes
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer K. Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Jantzie LL, Oppong AY, Conteh FS, Yellowhair TR, Kim J, Fink G, Wolin AR, Northington FJ, Robinson S. Repetitive Neonatal Erythropoietin and Melatonin Combinatorial Treatment Provides Sustained Repair of Functional Deficits in a Rat Model of Cerebral Palsy. Front Neurol 2018; 9:233. [PMID: 29706928 PMCID: PMC5908903 DOI: 10.3389/fneur.2018.00233] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/26/2018] [Indexed: 12/21/2022] Open
Abstract
Cerebral palsy (CP) is the leading cause of motor impairment for children worldwide and results from perinatal brain injury (PBI). To test novel therapeutics to mitigate deficits from PBI, we developed a rat model of extreme preterm birth (<28 weeks of gestation) that mimics dual intrauterine injury from placental underperfusion and chorioamnionitis. We hypothesized that a sustained postnatal treatment regimen that combines the endogenous neuroreparative agents erythropoietin (EPO) and melatonin (MLT) would mitigate molecular, sensorimotor, and cognitive abnormalities in adults rats following prenatal injury. On embryonic day 18 (E18), a laparotomy was performed in pregnant Sprague–Dawley rats. Uterine artery occlusion was performed for 60 min to induce placental insufficiency via transient systemic hypoxia-ischemia, followed by intra-amniotic injections of lipopolysaccharide, and laparotomy closure. On postnatal day 1 (P1), approximately equivalent to 30 weeks of gestation, injured rats were randomized to an extended EPO + MLT treatment regimen, or vehicle (sterile saline) from P1 to P10. Behavioral assays were performed along an extended developmental time course (n = 6–29). Open field testing shows injured rats exhibit hypermobility and disinhibition and that combined neonatal EPO + MLT treatment repairs disinhibition in injured rats, while EPO alone does not. Furthermore, EPO + MLT normalizes hindlimb deficits, including reduced paw area and paw pressure at peak stance, and elevated percent shared stance after prenatal injury. Injured rats had fewer social interactions than shams, and EPO + MLT normalized social drive. Touchscreen operant chamber testing of visual discrimination and reversal shows that EPO + MLT at least partially normalizes theses complex cognitive tasks. Together, these data indicate EPO + MLT can potentially repair multiple sensorimotor, cognitive, and behavioral realms following PBI, using highly translatable and sophisticated developmental testing platforms.
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Affiliation(s)
- Lauren L Jantzie
- Department of Pediatrics, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Akosua Y Oppong
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Fatu S Conteh
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Tracylyn R Yellowhair
- Department of Pediatrics, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Joshua Kim
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Gabrielle Fink
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Adam R Wolin
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Frances J Northington
- Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
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Salas J, Tekes A, Hwang M, Northington FJ, Huisman TAGM. Head Ultrasound in Neonatal Hypoxic-Ischemic Injury and Its Mimickers for Clinicians: A Review of the Patterns of Injury and the Evolution of Findings Over Time. Neonatology 2018; 114:185-197. [PMID: 29936499 DOI: 10.1159/000487913] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 02/22/2018] [Indexed: 11/19/2022]
Abstract
Hypoxic-ischemic injury (HII) of the neonatal brain and resulting clinical hypoxic-ischemic encephalopathy remains a significant cause of morbidity and mortality in the neonatal population. Ultrasound (US) has emerged as a powerful screening tool for evaluation of a neonate with suspected HII. The pattern of injury on brain imaging has crucial implications in therapies and predicted neurodevelopmental outcomes. US has become increasingly effective at determining the pattern, timing, and extent of injury in HII as well as differentiating these findings from a host of diagnoses that can result in a similarly appearing clinical picture. Repeated US studies over a patient's course can define the evolution of findings from the acute through chronic phase in addition to identifying any complications of therapy. US also has the added benefits of easy portability, no need for patient sedation, and a relatively low cost when compared to other imaging modalities like magnetic resonance imaging (MRI). It is crucial that clinicians understand the full capabilities of advanced US in identifying an underlying diagnosis, directing appropriate therapy, monitoring disease progress, and finally in predicting outcomes, thus improving the care of neonates with encephalopathy. The following article demonstrates the breadth of uses for US in the full-term neonate with encephalopathy, its limitations, the patterns of injury seen, and their evolution over time. We will also briefly review several clinical mimickers of HII for comparison.
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Affiliation(s)
- Jacqueline Salas
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Neurosciences-Intensive Care Nursery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aylin Tekes
- Neurosciences-Intensive Care Nursery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Misun Hwang
- Neurosciences-Intensive Care Nursery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Radiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Neurosciences-Intensive Care Nursery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thierry A G M Huisman
- Neurosciences-Intensive Care Nursery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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38
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Affiliation(s)
- Shenandoah Robinson
- Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren L Jantzie
- Departments of Pediatrics and Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
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39
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Affiliation(s)
- Jennifer K Lee
- Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery, Johns Hopkins University, Baltimore, MD, USA
| | - An N Massaro
- Division of Neonatology, Department of Pediatrics, Children's National Health Systems, The George Washington University School of Medicine, Washington D.C., USA
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins University, Baltimore, MD, USA.,Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
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40
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Lee JK, Perin J, Parkinson C, O’Connor M, Gilmore MM, Reyes M, Armstrong J, Jennings J, Northington FJ, Chavez-Valdez R. Relationships between cerebral autoregulation and markers of kidney and liver injury in neonatal encephalopathy and therapeutic hypothermia. J Perinatol 2017; 37:938-942. [PMID: 28471439 PMCID: PMC5578902 DOI: 10.1038/jp.2017.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We studied whether cerebral blood pressure autoregulation and kidney and liver injuries are associated in neonatal encephalopathy (NE). STUDY DESIGN We monitored autoregulation of 75 newborns who received hypothermia for NE in the neonatal intensive care unit to identify the mean arterial blood pressure with optimized autoregulation (MAPOPT). Autoregulation parameters and creatinine, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were analyzed using adjusted regression models. RESULTS Greater time with blood pressure within MAPOPT during hypothermia was associated with lower creatinine in girls. Blood pressure below MAPOPT related to higher ALT and AST during normothermia in all neonates and boys. The opposite occurred in rewarming when more time with blood pressure above MAPOPT related to higher AST. CONCLUSIONS Blood pressures that optimize cerebral autoregulation may support the kidneys. Blood pressures below MAPOPT and liver injury during normothermia are associated. The relationship between MAPOPT and AST during rewarming requires further study.
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Affiliation(s)
- Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jamie Perin
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Matthew O’Connor
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Maureen M. Gilmore
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Michael Reyes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jillian Armstrong
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jacky Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Frances J. Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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Abstract
We aimed to characterize the parent experience of caring for an infant with neonatal encephalopathy. In this mixed-methods study, we performed semistructured interviews with parents whose infants were enrolled in an existing longitudinal cohort study of therapeutic hypothermia between 2011 and 2014. Thematic saturation was achieved after 20 interviews. Parent experience of caring for a child with neonatal encephalopathy was characterized by 3 principal themes. Theme 1: Many families described cumulative loss and grief throughout the perinatal crisis, critical neonatal course, and subsequent missed developmental milestones. Theme 2: Families experienced entangled infant and broader family interests. Theme 3: Parents evolved into and found meaning in their role as an advocate. These data offer insight into the lived experience of parenting an infant with neonatal encephalopathy. Primary data from parents can serve as a useful framework to guide the development and interpretation of parent-centered outcomes.
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Affiliation(s)
- Monica E Lemmon
- 1 Division of Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,2 Division of Pediatric Neurology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.,3 Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pamela K Donohue
- 4 Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.,5 Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Charlamaine Parkinson
- 3 Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, MD, USA.,4 Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- 3 Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, MD, USA.,4 Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Renee D Boss
- 4 Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.,6 Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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Diaz J, Abiola S, Kim N, Avaritt O, Flock D, Yu J, Northington FJ, Chavez-Valdez R. Therapeutic Hypothermia Provides Variable Protection against Behavioral Deficits after Neonatal Hypoxia-Ischemia: A Potential Role for Brain-Derived Neurotrophic Factor. Dev Neurosci 2017; 39:257-272. [PMID: 28196356 DOI: 10.1159/000454949] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite treatment with therapeutic hypothermia (TH), infants who survive hypoxic ischemic (HI) encephalopathy (HIE) have persistent neurological abnormalities at school age. Protection by TH against HI brain injury is variable in both humans and animal models. Our current preclinical model of hypoxia-ischemia (HI) and TH displays this variability of outcomes in neuropathological and neuroimaging end points with some sexual dimorphism. The detailed behavioral phenotype of this model is unknown. Whether there is sexual dimorphism in certain behavioral domains is also not known. Brain-derived neurotrophic factor (BDNF) supports neuronal cell survival and repair but may also be a marker of injury. Here, we characterize the behavioral deficits after HI and TH stratified by sex, as well as late changes in BDNF and its correlation with memory impairment. METHODS HI was induced in C57BL6 mice on postnatal day 10 (p10) (modified Vannucci model). Mice were randomized to TH (31°C) or normothermia (NT, 36°C) for 4 h after HI. Controls were anesthesia-exposed, age- and sex-matched littermates. Between p16 and p39, growth was followed, and behavioral testing was performed including reflexes (air righting, forelimb grasp and negative geotaxis) and sensorimotor, learning, and memory skills (open field, balance beam, adhesive removal, Y-maze tests, and object location task [OLT]). Correlations between mature BDNF levels in the forebrain and p42 memory outcomes were studied. RESULTS Both male and female HI mice had an approximately 8-12% lower growth rate (g/day) than shams (p ≤ 0.01) by p39. TH ameliorated this growth failure in females but not in males. In female mice, HI injury prolonged the time spent at the periphery (open field) at p36 (p = 0.004), regardless of treatment. TH prevented motor impairments in the balance beam and adhesive removal tests in male and female mice, respectively (p ≤ 0.05). Male and female HI mice visited the new arm of the Y-maze 12.5% (p = 0.05) and 10% (p = 0.03) less often than shams, respectively. Male HI mice also had 35% lower exploratory preference score than sham (p ≤ 0.001) in the OLT. TH did not prevent memory impairments found with Y-maze testing or OLT in either sex (p ≤ 0.01) at p26. At p42, BDNF levels in the forebrain ipsilateral to the HI insult were 1.7- to 2-fold higher than BDNF levels in the sham forebrain, and TH did not prevent this increase. Higher BDNF levels in the forebrain ipsilateral to the insult correlated with worse performance in the Y-maze in both sexes and in OLT in male mice (p = 0.01). CONCLUSIONS TH provides benefit in specific domains of behavior following neonatal HI. In general, these benefits accrued to both males and females, but not in all areas. In some domains, such as memory, no benefit of TH was found. Late differences in individual BDNF levels may explain some of these findings.
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Affiliation(s)
- Johana Diaz
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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43
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Lemmon ME, Wagner MW, Bosemani T, Carson KA, Northington FJ, Huisman TAGM, Poretti A. Diffusion Tensor Imaging Detects Occult Cerebellar Injury in Severe Neonatal Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2017; 39:207-214. [PMID: 28095379 DOI: 10.1159/000454856] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the benefits of whole-body hypothermia therapy, many infants with hypoxic-ischemic encephalopathy (HIE) die or have significant long-term neurodevelopmental impairment. Prospectively identifying neonates at risk of poor outcome is essential but not straightforward. The cerebellum is not classically considered to be a brain region vulnerable to hypoxic-ischemic insults; recent literature suggests, however, that the cerebellum may be involved in neonatal HIE. In this study, we aimed to assess the microstructural integrity of cerebellar and linked supratentorial structures in neonates with HIE compared to neurologically healthy neonatal controls. METHODS In this prospective cohort study, we performed a quantitative diffusion tensor imaging (DTI) analysis of the structural pathways of connectivity, which may be affected in neonatal cerebellar injury by measuring fractional anisotropy (FA) and mean diffusivity (MD) within the superior, middle, and inferior cerebellar peduncles, dentate nuclei, and thalami. All magnetic resonance imaging (MRI) studies were grouped into 4 categories of severity based on a qualitative evaluation of conventional and advanced MRI sequences. Multivariable linear regression analysis of cerebellar scalars of patients and controls was performed, controlling for gestational age, age at the time of MRI, and HIE severity. Spearman rank correlation was performed to correlate DTI scalars of the cerebellum and thalami. RESULTS Fifty-seven (23 females, 40%) neonates with HIE and 12 (6 females, 50%) neonatal controls were included. There were 8 patients (14%) in HIE severity groups 3 and 4 (injury of the basal ganglia/thalamus and/or cortex). Based on a qualitative analysis of conventional and DTI images, no patients had evidence of cerebellar injury. No significant differences between patients and controls were found in the FA and MD scalars. However, FA values of the middle cerebellar peduncles (0.294 vs. 0.380, p < 0.001) and MD values of the superior cerebellar peduncles (0.920 vs. 1.007 × 10-3 mm/s2, p = 0.001) were significantly lower in patients with evidence of moderate or severe injury on MRI (categories 3 and 4) than in controls. In patients, cerebellar DTI scalars correlated positively with DTI scalars within the thalami. CONCLUSION Our results suggest that infants with moderate-to-severe HIE may have occult injury of cerebellar white-matter tracts, which is not detectable by the qualitative analysis of neuroimaging data alone. Cerebellar DTI scalars correlate with thalamic measures, highlighting that cerebellar injury is unlikely to occur in isolation and may reflect the severity of HIE. The impact of concomitant cerebellar injury in HIE on long-term neurodevelopmental outcome warrants further study.
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Affiliation(s)
- Monica E Lemmon
- Division of Pediatric Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Jan S, Northington FJ, Parkinson CM, Stafstrom CE. EEG Monitoring Technique Influences the Management of Hypoxic-Ischemic Seizures in Neonates Undergoing Therapeutic Hypothermia. Dev Neurosci 2017; 39:82-88. [PMID: 28081533 DOI: 10.1159/000454855] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022] Open
Abstract
Electroencephalogram (EEG) monitoring techniques for neonatal hypoxia-ischemia (HI) are evolving over time, and the specific type of EEG utilized could influence seizure diagnosis and management. We examined whether the type of EEG performed affected seizure treatment decisions (e.g., the choice and number of antiseizure drugs [ASDs]) in therapeutic hypothermia-treated neonates with HI from 2007 to 2015 in the Johns Hopkins Hospital Neonatal Intensive Care Unit. During this period, 3 different EEG monitoring protocols were utilized: Period 1 (2007-2009), single, brief conventional EEG (1 h duration) at a variable time during therapeutic hypothermia treatment, i.e., ordered when a seizure was suspected; Period 2 (2009-2013), single, brief conventional EEG followed by amplitude-integrated EEG for the duration of therapeutic hypothermia treatment and another brief conventional EEG after rewarming; and Period 3 (2014-2015), continuous video-EEG (cEEG) for the duration of therapeutic hypothermia treatment (72 h) plus for an additional 12 h during and after rewarming. One hundred and sixty-two newborns were included in this retrospective cohort study. As a function of the type and duration of EEG monitoring, we assessed the risk (likelihood) of receiving no ASD, at least 1 ASD, or ≥2 ASDs. We found that the risk of a neonate being prescribed an ASD was 46% less during Period 3 (cEEG) than during Period 1 (brief conventional EEG only) (95% CI 6-69%, p = 0.03). After adjusting for initial EEG and MRI results, compared with Period 1, there was a 38% lower risk of receiving an ASD during Period 2 (95% CI: 9-58%, p = 0.02) and a 67% lower risk during Period 3 (95% CI: 23-86%, p = 0.01). The risk ratio of receiving ≥2 ASDs was not significantly different across the 3 periods. In conclusion, in addition to the higher sensitivity and specificity of continuous video-EEG monitoring, fewer infants are prescribed an ASD when undergoing continuous forms of EEG monitoring (aEEG or cEEG) than those receiving conventional EEG. We recommend that use of continuous video-EEG be considered whenever possible, both to treat seizures more specifically and to avoid overtreatment.
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Affiliation(s)
- Saber Jan
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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45
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Lei J, Paules C, Nigrini E, Rosenzweig JM, Bahabry R, Farzin A, Yang S, Northington FJ, Oros D, McKenney S, Johnston MV, Graham EM, Burd I. Umbilical Cord Blood NOS1 as a Potential Biomarker of Neonatal Encephalopathy. Front Pediatr 2017; 5:112. [PMID: 28649562 PMCID: PMC5466059 DOI: 10.3389/fped.2017.00112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND There are no definitive markers to aid in diagnosis of neonatal encephalopathy (NE). The purpose of our study was (1) to identify and evaluate the utility of neuronal nitric oxide synthase (NOS1) in umbilical cord blood as a NE biomarker and (2) to identify the source of NOS1 in umbilical cord blood. METHODS This was a nested case-control study of neonates >35 weeks of gestation. ELISA for NOS1 in umbilical cord blood was performed. Sources of NOS1 in umbilical cord were investigated by immunohistochemistry, western blot, ELISA, and quantitative PCR. Furthermore, umbilical cords of full-term neonates were subjected to 1% hypoxia ex vivo. RESULTS NOS1 was present in umbilical cord blood and increased in NE cases compared with controls. NOS1 was expressed in endothelial cells of the umbilical cord vein, but not in artery or blood cells. In ex vivo experiments, hypoxia was associated with increased levels of NOS1 in venous endothelial cells of the umbilical cord as well as in ex vivo culture medium. CONCLUSION This is the first study to investigate an early marker of NE. NOS1 is elevated with hypoxia, and further studies are needed to investigate it as a valuable tool for early diagnosis of neonatal brain injury.
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Affiliation(s)
- Jun Lei
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cristina Paules
- Aragón Health Research Institute, SAMID Network ref RD12/0026/001, Zaragoza, Spain
| | - Elisabeth Nigrini
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason M Rosenzweig
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rudhab Bahabry
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Azadeh Farzin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samuel Yang
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Oros
- Aragón Health Research Institute, SAMID Network ref RD12/0026/001, Zaragoza, Spain
| | - Stephanie McKenney
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael V Johnston
- Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurosciences, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M Graham
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurosciences, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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46
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Lee JK, Poretti A, Perin J, Huisman TAGM, Parkinson C, Chavez-Valdez R, O'Connor M, Reyes M, Armstrong J, Jennings JM, Gilmore MM, Koehler RC, Northington FJ, Tekes A. Optimizing Cerebral Autoregulation May Decrease Neonatal Regional Hypoxic-Ischemic Brain Injury. Dev Neurosci 2016; 39:248-256. [PMID: 27978510 DOI: 10.1159/000452833] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/24/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia provides incomplete neuroprotection for neonatal hypoxic-ischemic encephalopathy (HIE). We examined whether hemodynamic goals that support autoregulation are associated with decreased brain injury and whether these relationships are affected by birth asphyxia or vary by anatomic region. METHODS Neonates cooled for HIE received near-infrared spectroscopy autoregulation monitoring to identify the mean arterial blood pressure with optimized autoregulatory function (MAPOPT). Blood pressure deviation from MAPOPT was correlated with brain injury on MRI after adjusting for the effects of arterial carbon dioxide, vasopressors, seizures, and birth asphyxia severity. RESULTS Blood pressure deviation from MAPOPT related to neurologic injury in several regions independent of birth asphyxia severity. Greater duration and deviation of blood pressure below MAPOPT were associated with greater injury in the paracentral gyri and white matter. Blood pressure within MAPOPT related to lesser injury in the white matter, putamen and globus pallidus, and brain stem. Finally, blood pressures that exceeded MAPOPT were associated with reduced injury in the paracentral gyri. CONCLUSIONS Blood pressure deviation from optimal autoregulatory vasoreactivity was associated with MRI markers of brain injury that, in many regions, were independent of the initial birth asphyxia. Targeting hemodynamic ranges to optimize autoregulation has potential as an adjunctive therapy to hypothermia for HIE.
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Affiliation(s)
- Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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47
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Affiliation(s)
- Andrea Poretti
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neuro Intensive Care Nursery Group, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- Neuro Intensive Care Nursery Group, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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48
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Abstract
BACKGROUND Families must process complex information related to neonatal encephalopathy and therapeutic hypothermia. METHODS In this mixed methods study, semi-structured interviews were performed with parents whose infants were enrolled in an existing longitudinal cohort study of therapeutic hypothermia between 2011 and 2014. RESULTS Thematic saturation was achieved after 20 interviews. Parental experience of communicating with clinicians was characterized by 3 principle themes. Theme 1 highlighted that a fragmented communication process mirrored the chaotic maternal and neonatal course. Parents often received key information about neonatal encephalopathy and therapeutic hypothermia from maternal clinicians. Infant medical information was often given to 1 family member (60%), who felt burdened by the responsibility to relay that information to others. Families universally valued the role of the bedside nurse, who was perceived as the primary source of communication for most (75%) families. Theme 2 encompassed the challenges of discussing the complex therapy of therapeutic hypothermia: families appreciated clinicians who used lay language and provided written material, and they often felt overwhelmed by technical information that made it hard to understand the "big picture" of their infant's medical course. Theme 3 involved the uncertain prognosis after neonatal encephalopathy. Parents appreciated specific expectations about their infant's long-term development, and experienced long-term distress about prognostic uncertainty. CONCLUSIONS Communicating complex and large volumes of information in the midst of perinatal crisis presents inherent challenges for both clinicians and families. We identified an actionable set of communication challenges that can be addressed with targeted interventions.
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Affiliation(s)
- Monica E. Lemmon
- Department of Neurology, Division of Pediatric Neurology,,Department of Pediatrics, Division of Pediatric Neurology, Duke University Medical Center, Durham, North Carolina;,Neurosciences Intensive Care Nursery, The Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Pamela K. Donohue
- Department of Pediatrics, Division of Neonatology, and,Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Charlamaine Parkinson
- Department of Pediatrics, Division of Neonatology, and,Neurosciences Intensive Care Nursery, The Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Frances J. Northington
- Department of Pediatrics, Division of Neonatology, and,Neurosciences Intensive Care Nursery, The Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Renee D. Boss
- Department of Pediatrics, Division of Neonatology, and,Berman Institute of Bioethics, Johns Hopkins School of Medicine, Baltimore, Maryland
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49
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Abstract
Recent research in identification of brain injury after trauma shows many possible blood biomarkers that may help identify the fetus and neonate with encephalopathy. Traumatic brain injury shares many common features with perinatal hypoxic-ischemic encephalopathy. Trauma has a hypoxic component, and one of the 1st physiologic consequences of moderate-severe traumatic brain injury is apnea. Trauma and hypoxia-ischemia initiate an excitotoxic cascade and free radical injury followed by the inflammatory cascade, producing injury in neurons, glial cells and white matter. Increased excitatory amino acids, lipid peroxidation products, and alteration in microRNAs and inflammatory markers are common to both traumatic brain injury and perinatal encephalopathy. The blood-brain barrier is disrupted in both leading to egress of substances normally only found in the central nervous system. Brain exosomes may represent ideal biomarker containers, as RNA and protein transported within the vesicles are protected from enzymatic degradation. Evaluation of fetal or neonatal brain derived exosomes that cross the blood-brain barrier and circulate peripherally has been referred to as the "liquid brain biopsy." A multiplex of serum biomarkers could improve upon the current imprecise methods of identifying fetal and neonatal brain injury such as fetal heart rate abnormalities, meconium, cord gases at delivery, and Apgar scores. Quantitative biomarker measurements of perinatal brain injury and recovery could lead to operative delivery only in the presence of significant fetal risk, triage to appropriate therapy after birth and measure the effectiveness of treatment.
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Affiliation(s)
- Ernest M. Graham
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of MedicineBaltimore, MD, USA
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Irina Burd
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of MedicineBaltimore, MD, USA
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of MedicineBaltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of MedicineBaltimore, MD, USA
- Integrated Research Center for Fetal Medicine, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Allen D. Everett
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of MedicineBaltimore, MD, USA
- Division of Cardiology, Department of Pediatrics, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Frances J. Northington
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of MedicineBaltimore, MD, USA
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of MedicineBaltimore, MD, USA
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50
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Tsimis ME, Johnson CT, Raghunathan RS, Northington FJ, Burd I, Graham EM. Risk factors for periventricular white matter injury in very low birthweight neonates. Am J Obstet Gynecol 2016; 214:380.e1-6. [PMID: 26454132 DOI: 10.1016/j.ajog.2015.09.108] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/03/2015] [Accepted: 09/30/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The development of periventricular white matter injury (PWMI) in the preterm neonate is the most common insult portending neurologic impairment and is linked with the later development of cerebral palsy. The pathogenesis of PWMI targets premyelinating oligodendrocytes of the periventricular region secondary to free radicals, cytokine toxicity, and excitatory neurotransmitters. The primitive nature of the vasculature in the developing fetal cortex lends to its predilection to PWMI and cerebral ischemia with less arterial anastomoses at arterial border zones and failure to compensate for global hypotension, termed the "pressure-passive" circulation. OBJECTIVE Our objective is to determine the relative risk (RR) of fetal metabolic acidosis and perinatal infection in the development of PWMI in very low birthweight (VLBW) (<1500 g) neonates. STUDY DESIGN This is a cohort study of all VLBW neonates admitted to our neonatal intensive care unit from April 2009 through December 2014, comparing those who developed PWMI on neonatal head ultrasound at 6 weeks of life to those who did not. Neonates with chromosomal or major congenital abnormalities were excluded. Generalized linear modeling, adjusting for variables significantly different on bivariate analysis, was conducted. RESULTS During this 5-year and 8-month period there were 374 VLBW neonates admitted; 35 (9.4%) had PWMI. VLBW neonates without PWMI were significantly more likely to have intrauterine growth restriction (2.9% PWMI, 21.5% no PWMI; P = .006), while those neonates with PWMI had a significantly lower gestational age (26.3 ± 2.2 vs 28.0 ± 2.5 weeks; P < .001) and birthweight (868 ± 237 vs 993 ± 276 g; P = .009). There was no significant difference in umbilical arterial pH (7.25 ± 0.15 vs 7.27 ± 0.09; P = .34), base deficit (4.6 ± 6.0 vs 3.4 ± 3.3 mmol/L; P = .11), or pH <7.0 or base deficit >12 mmol/L at birth (10.7% vs 3.2%; P = .09). On bivariate analysis neonates with PWMI had a significant increase in positive cerebrospinal fluid (CSF) cultures (22.9% vs 1.5%; P < .001). The initial lumbar puncture was performed at a similar day of life, and neonates with PWMI had significantly elevated CSF white blood cell counts (5%, 50%, and 95%; 16, 175, and 709/mm(3); 1, 3, and 27/mm(3); P = .008). Generalized linear modeling, adjusted for gestational age and the presence of intrauterine growth restriction, showed that fetal metabolic acidosis had RR 2.59 (95% confidence interval, 1.14-5.92; P = .02) and neonatal CSF infection had RR 4.94 (95% confidence interval, 2.4-10.3; P < .001) for association with PWMI. CONCLUSION The RR of neonatal CSF infection being associated with PWMI was 2-fold greater than metabolic acidosis at the time of birth. Decreasing the incidence of CSF infections would have a greater impact on preventing PWMI, a precursor of cerebral palsy.
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Affiliation(s)
- Michael E Tsimis
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Clark T Johnson
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Radhika S Raghunathan
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances J Northington
- Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Irina Burd
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ernest M Graham
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD
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