54 - Brain Injury in the Preterm Infant

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The preterm brain is susceptible to a broad spectrum of injury that ranges from diffuse nonnecrotic lesions to hemorrhage, to severe necrotic tissue destruction. This chapter addresses three common and frequently overlapping forms of preterm cerebral injury: intraventricular hemorrhage (IVH), white matter injury (WMI), and gray matter injury. The impact of preterm cerebral injury is considerable. Among children born very preterm, even with modern neonatal intensive care, 5% to 10% have major motor deficits, including cerebral palsy related to significant WMI, and more than half have significant cognitive, behavioral, or sensory deficits. Despite a gradual decline in the incidence of most grades of IVH, the increased survival of very low birth weight infants has resulted in an increase in the absolute number of infants with IVH. Cystic WMI is less common in current cohorts but when present is commonly associated with cerebral palsy, cortical visual impairment, and a spectrum of cognitive and learning disabilities. Preterm infants more commonly display diffuse WMI that results in myelination disturbances related to the death of oligodendrocyte progenitors. Diffuse WMI, often reflected in punctate WMI on diagnostic MRI, is linked to a broad spectrum of persistent neurobehavioral disabilities that include impairments in motor and cognitive skills. Chronic diffuse WMI is also accompanied by reduced cerebral gray matter growth that appears to be related to widespread disturbances in neuronal maturation. The spectrum of neurodevelopmental impairments that follow WMI in the preterm neonate are consistent with the dysmaturation in white matter and cerebral gray matter. These recently recognized forms of cerebral gray and white matter dysmaturation present new challenges for diagnosis and suggest new therapeutic strategies.