Abnormal Cranial Ultrasound Findings Research Articles

Prechtl’s General Movements performed at writhing age may help target MRI use in the NICU (P9-9.012)

<h3>Objective:</h3> We aimed to determine if Prechtl’s general movement assessment (GMA) could help target the use of magnetic resonance imaging (MRI) in the neonatal intensive care unit (NICU) to detect infants with neuroimaging abnormalities not detected by cranial ultrasound (CUS) alone. <h3>Background:</h3> Prechtl’s GMA is a bedside evaluation performed to identify infants at high-risk for neurological and motor disorders such as cerebral palsy (CP). Cramped synchronized (CS) GMA at writhing age has been associated with poor neuromotor outcomes. However, no clinical practice guideline exists to recommend routine use of term-equivalent MRI in infants with CS GMAs. <h3>Design/Methods:</h3> We retrospectively reviewed neuroimaging reports from pediatric neuroradiologists of all infants who had CS GMA between 36 and 44 weeks post-menstrual age at two level III and three level IV NICUs. All three sites used standard protocols for preterm neuroimaging with at least one CUS in the first week after birth and another near 30 weeks corrected gestational age. If an MRI was obtained (due to clinical suspicion for intracranial abnormality, abnormal CUS findings, or CS GMA) the reason for performing the MRI was recorded. <h3>Results:</h3> 144 infants had CS GMA, and of these, only 19 did not receive neuroimaging. Initial neuroimaging demonstrated abnormal (mild and severe) findings in 64.5% and clinically significant in 45.6%. When MRI was performed secondarily, agreement between the two types of imaging occurred most of the time. A higher level of insult was present in 20.7% of those receiving a secondary MRI. The frequency of clinically significant abnormal findings on final determination was 48.8%. In 14 cases, secondary MRI was performed in response to GMA CS pattern only; in this case, MRI was abnormal in 11 (76.8%) cases. <h3>Conclusions:</h3> These results suggest that infants with CS GMA at writhing age may represent a population with a high-likelihood of clinically significant abnormal neuroimaging findings. <b>Disclosure:</b> Dr. Chirigos has nothing to disclose. Dr. Burton has nothing to disclose. Dr. Maitre has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Thrive Neuromedical. Dr. Maitre has stock in Thrive Neuromedical. Dr. Ostrander has nothing to disclose.

Cranial ultrasound findings in asphyxiated term neonates and their correlation clinically with hypoxic ischemic encephalopathy staging

Background: The survival of asphyxiated neonates has significantly increased in recent years because of numerous advancements in contemporary neonatal intensive care. The most popular and easily repeatable imaging method for the neonatal brain, the neurosonogram can demonstrate the most common types of cerebral injury in preterms and term infants. This study aims to analyse the value of cranial ultrasonography as an investigative tool for birth asphyxia babies (&gt;34 weeks) will be evaluated to learn the morphology of various cerebral lesions and to compare clinical findings with neurosonogram results. Methods: An observational study was conducted in 75 neonates (&gt;34 weeks) admitted in Government Cuddalore medical college with birth asphyxia. A detailed history and clinical examination was carried out according to the designed proforma. All the babies in the study group were subjected to cranial ultrasound and the morphology of findings studied. CUS findings were correlated clinically. Results: Among babies with HIE stage I, 89.7% had normal Cranial Ultrasound Findings, and 10.3% had abnormal findings. 43.3% babies had abnormal Cranial ultrasound findings in HIE stage II, and 70% had abnormal findings in HIE stage 3. Conclusions: Cerebral oedema was the commonest neurosonogram finding in Asphyxiated babies and HIE 3 had the maximum abnormal findings in our study. Since there is a positive correlation between the severity of hypoxic ischemic encephalopathy and cranial ultrasound findings, USG cranium can be performed as a screening tool in all neonates with birth asphyxia in whom additional investigations could not be performed.

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

BackgroundCranial ultrasonography (CUS) has become an important tool to depict normal brain anatomy and to detect the ischemic and hemorrhagic brain injury patterns in high-risk neonates. The present study aimed to assess the utility of CUS to diagnose the spectrum of brain injury patterns in high-risk preterm and term neonates admitted to the neonatal intensive care unit (NICU) and to find the association of CUS findings in various adverse antenatal and perinatal feto-maternal factors.ResultsOut of the 200 neonates, 76 (38%) neonates had abnormal CUS findings and 124 (62%) had a normal CUS. Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) (28/76; 36.8 %) was the commonest abnormality with GMH (grade 1) in 14/76 (18.4%), grade 2 in 7 (9.2%), grade 3 in 5 (6.5%), and grade 4 in 2 (2.63%). The other findings observed were cerebral edema (14/76; 18.4%), thalamic hyperechogenicity (10/76; 13.1%), periventricular leukomalacia (PVL) (4/76; 5.2%), and congenital anomalies (8; 10.5%). Abnormal CUS findings had a statistically significant association with birth weight <2000 g, prematurity, Apgar score <7, and adverse peri-natal fetal and maternal factors (all p-values <0.05). Abnormal CUS findings had a statistically significant association with poor cry, poor activity, abnormal tone, and presence of cyanosis (all p-values <0.05).ConclusionIn this cohort study of high-risk preterm and term infants GMH-IVH, cerebral edema, thalamic hyperechogenicity, PVL, and congenital malformations were the commonest lesions detected on CUS. Abnormal CUS findings were found to have a statistically significant association with various adverse peri-natal fetal and maternal factors.

Cranial Ultrasound in Preterm Neonates of Gestational Age 28 to 34 Weeks: A Single Centre Experience From Western India

Context: Intraventricular hemorrhage and periventricular leukomalacia, the common brain injuries in premature infants, are major causes for early death in the neonatal period and later motor and cognitive disabilities. This study was undertaken to find out the incidence of normal cranial ultrasound (CUS), normal variants, and abnormal CUS findings. Evidence Acquisition: This prospective, observational study was conducted at Neonatal ICU, Department of Paediatrics, Civil Hospital, Ahmedabad, over a period of 2 years from September 1, 2014, to August 31, 2016. Detailed history, examination, and risk factor assessment was done for all 180 subjects. The neonates were subjected to cranial ultrasound during admission and on follow-up. Results: Upon sonographic evaluation, 125 (69.44%) neonates had normal ultrasound, 34 (18.90%) had normal variants, and 21 (11.66%) had abnormal cranial ultrasound findings. The predominant normal variants observed were cavum septum pellucidum (18; 10%) and choroid plexus cyst (11; 6.1%). The most common abnormality detected was intraventricular hemorrhage (15; 8.3%) and was found to have a clinically significant correlation with surfactant use and with mechanical ventilation ( P value &lt; .05). Follow-up scans could be performed on 70 subjects out of which 2 had normal variants and 3 had abnormal CUS findings. Conclusion: Establishing institutional CUS scanning protocols will go a long way in decreasing morbidity and mortality in preterm neonates.

CRANIAL ULTRASOUND: EFFICIENT SCREENING TOOL FOR EARLY DETECTION OF BRAIN INJURY IN PRETERM INFANTS

Background: Cranial ultrasound becomes an important diagnostic tool to evaluate brain injury in infants. Brain injury is a major complication for preterm birth. The brain injury of preterm infants differs from that of a term infant. Brain injury has correlation with gestational age and mode of delivery. Objective: To analyze the correlation between cranial ultrasound findings with gestational age and mode of delivery and to reveal if cranial ultrasound can be used to detect brain injury in premature infants. Methods: An observational analytic study using cross-sectional design took place in Saiful Anwar Hospital Malang, Indonesia. 38 healthy preterm infants underwent cranial ultrasound examination within the first four day of life. Fisher Exact test was used to analyze the correlation between cranial ultrasound findings with gestational age and mode of delivery. Results: Most of the healthy preterm infants (89.5%) were ≥ 32 weeks gestational age, and 52.6% of samples had caesarean section as their mode of delivery. There were three abnormal findings in cranial ultrasound; increased periventricular echogenic (5.3%), increased parenchym echogenic (5.3%), and indistinguishable of gray-white matter differentiation (5.3%). There was no significant correlation between abnormal cranial ultrasound findings with gestational age and mode of delivery (p= 0.202; p= 0.218). Conclusion: There were abnormal cranial ultrasound findings in some healthy preterm infants despite no significant correlation between ultrasound findings with gestational age and mode of delivery. Cranial ultrasound in preterm infants could become a screening tool for early detection of brain injury.

Cranial ultrasound in high-risk neonates and their neurodevelopmental outcome

Introduction: With the advancement in neonatal care over the last two decades, neonatal mortality is decreased but simultaneously there is an increase in the adverse outcomes including neurodevelopmental abnormalities in the high-risk neonates. Purpose: To evaluate the association between cranial ultrasound findings and the clinical neurodevelopmental outcome among high-risk neonates at 12 months (corrected gestational age in preterm infants) and to assess the various perinatal risk factors associated with neurodevelopmental outcome. Material and Methods: 123 high-risk neonates admitted in NICU were enrolled. Cranial ultrasound was performed and morphology was noted. The neurodevelopmental assessment was done using DDST Test II at 12 months age and these neonates were labeled as normal or abnormal based on the findings. Association between the two non-parametric variables was seen using the Pearson Chi-square test. Results: There was a statistically significant association between clinical neurodevelopmental outcome and gestational age at birth; birth weight; Apgar score 0.05). The sensitivity of CUS was 89.2%, specificity 47.3%, positive predictive value 89.2%, and negative predictive value 47.3%. Conclusions: The neurodevelopmental outcome in high-risk neonates was associated with gestational age at birth; birth weight; Apgar score at 5 minutes; neonatal seizures and abnormal cranial ultrasound findings. The current study recommend the use of cranial ultrasound for the prediction of neurodevelopmental abnormalities especially in neonates with above risk factors.

Establishing reference values for amplitude-integrated electroencephalography in preterms below 35 weeks of gestational age: A prospective observational cohort study.

Characteristic patterns in amplitude-integrated electroencephalography (aEEG) develop with gestational age (GA), and so can be used to evaluate brain maturation in premature infants. Reference aEEG values in normal preterm infants have not been identified and data are scarce. We aimed to validate a currently available aEEG scoring system. We also investigated the development of aEEG activity during the first week after birth, determining reference values in preterm infants with no abnormal cranial ultrasound findings. We prospectively studied aEEG and cranial ultrasounds in infants with a GA of < 35 weeks. We conducted aEEG at 12-14 hours, 46-48 hours, 70-72 hours, and 1 week after birth. The aEEG recordings were evaluated using Burdjalov criteria, scored by two independent neonatologists. Thirty-four infants were enrolled and completed the 1-week evaluation. GA ranged from 24 to 35 weeks and birth weights varied between 570 and 2,100 g. We analyzed 134 aEEG tracings, with a mean difference between raters of -0.05. Total scores, summed from scores for each assessed variable, increased gradually with advancing gestational and postnatal age. However, highest scores were not attained until 35 weeks' gestational age. There was high inter-rater agreement for aEEG scoring, and we could ascertain some approximate reference values for aEEG development in preterm infants at varying GA. To establish standardized aEEG reference criteria, further studies in larger cohorts of premature infants should be performed over longer periods.

Respiratory inhibition after crying and feeding hypoxemia in infants

Objective: To determine the incidence, risk factors and natural history of respiratory inhibition after crying (RIAC) and feeding hypoxemia.Methods: We screened for RIAC and feeding hypoxemia among 393 infants with a gestational age ≥ 36 weeks using pulse oximetry. Twenty-seven infants were treated in the neonatal intensive care unit.Results: RIAC and feeding hypoxemia were observed in 95 (24.2%) and 124 (31.6%) infants, respectively. RIAC correlated with feeding hypoxemia (p < 0.001), grade II increased echogenicity in the ganglionic eminence (p = 0.005), dilation of the lateral ventricle (p = 0.044), threatened premature labor (p = 0.033) and twin gestation (p = 0.089). Feeding hypoxemia correlated with RIAC (p < 0.001), abnormal cranial ultrasound findings (p < 0.001), maternal smoking during pregnancy (p = 0.083), asymmetric intrauterine growth restriction (p = 0.012) and twin gestation (p = 0.067). All infants recovered from RIAC in an average of 4.5 (2.0–7.0) d. Fifteen infants recovered from feeding hypoxemia, but 10 infants needed additional assistance and monitoring by nursing until the day of discharge. The day of discharge was day 8.0 (5.0–12.4).Conclusions: RIAC and feeding hypoxemia are observed among healthy infants, and these infants experience repeated events of prolonged hypoxemia.

Incidence and Impact of CMV Infection in Very Low Birth Weight Infants

Congenital cytomegalovirus (CMV) is the leading cause of nongenetic deafness in children in the United States and can cause neurodevelopmental impairment in term infants. Limited data exist regarding congenital CMV infections in preterm infants. We aimed to determine the incidence and association with outcomes of congenital CMV in very low birth weight (VLBW) preterm infants. VLBW infants born in 1993 to 2008 and admitted to the University of Alabama in Birmingham Regional Neonatal ICU were screened on admission for congenital CMV. CMV status and clinical outcomes were identified by using internal patient databases and hospital-based medical records. The primary outcome was death. Secondary outcomes included evidence of neurologic injury in the form of abnormal cranial ultrasound findings, sensorineural hearing loss, or abnormal motor development. Multivariate analysis was performed. Eighteen of 4594 VLBW infants had congenital CMV (0.39%; 95% confidence interval, 0.25%-0.62%). An additional 16 infants (0.35%; 95% confidence interval, 0.21%-0.57%) were identified who acquired CMV postnatally. Congenital CMV was not associated with death. Compared with controls, congenitally infected VLBW infants were more likely to have hearing loss at initial screening (67% vs. 9%, P < .0001) and confirmed at follow-up (83% vs. 2.1%, P < .0001). Congenital CMV was also associated with abnormal neuroimaging (72% vs. 25%, P < .0001) and adverse developmental motor outcomes (43% vs. 9%, P = .02). Acquired CMV was not associated with any adverse outcomes. Congenital CMV in VLBW infants is associated with high rates of neurologic injury and hearing loss but not death.

Effective method for screening for respiratory inhibition after crying in infants

In order to establish an effective screening method for respiratory inhibition after crying (RIAC), we prospectively studied the correlations between infant RIAC and perinatal factors. We monitored infants (n=141) born from May through July 2009 with polygraphy and evaluated the presence of RIAC and respiratory pause that occurred when feeding was initiated immediately after crying with a decrease in oxygen saturation (SpO(2) ) to <60%. The infants were screened for increased echogenicity, a cyst in the ganglionic eminence (GE), or a subependymal cyst by cranial ultrasound. Furthermore, we evaluated the correlations between RIAC and perinatal factors. Eleven infants displayed RIAC and 31 experienced respiratory pause during feeding with a decrease in SpO(2) to <60%. There were no significant correlations between RIAC and perinatal factors. Forty infants had ultrasound abnormalities (increased echogenicity in the GE, 26; cyst in the GE, nine; and subependymal cyst, seven). Sensitivity, specificity, and efficiency of abnormal cranial ultrasound findings for RIAC were 1.00, 0.777, and 0.794, respectively. The odds ratio, sensitivity, specificity, and efficiency of the combination of abnormal cranial ultrasound findings and respiratory pause during feeding with a decrease in SpO(2) to <60% and RIAC were 35.9 (P<0.001), 0.727, 0.931, and 0.915, respectively. The combination of abnormal cranial ultrasound findings and respiratory pause during feeding with a decrease in SpO(2) appears to be an effective method of screening for RIAC.

Current Definitions of Hypotension Do Not Predict Abnormal Cranial Ultrasound Findings in Preterm Infants

Hypotension is a commonly treated complication of prematurity, although definitions and management guidelines vary widely. Our goal was to examine the relationship between current definitions of hypotension and early abnormal cranial ultrasound findings. We prospectively measured mean arterial pressure in 84 infants who were < or = 30 weeks' gestational age and had umbilical arterial catheters in the first 3 days of life. Sequential 5-minute epochs of continuous mean arterial pressure recordings were assigned a mean value and a coefficient of variation. We applied to our data 3 definitions of hypotension in current clinical use and derived a hypotensive index for each definition. We examined the association between these definitions of hypotension and abnormal cranial ultrasound findings between days 5 and 10. In addition, we evaluated the effect of illness severity (Score for Neonatal Acute Physiology II) on cranial ultrasound findings. Acquired lesions as shown on cranial ultrasound, present in 34 (40%) infants, were not predicted by any of the standard definitions of hypotension or by mean arterial pressure variability. With hypotension defined as mean arterial pressure < 10th percentile (< 33 mmHg) for our overall cohort, mean value for mean arterial pressure and hypotensive index predicted abnormal ultrasound findings but only in infants who were > or = 27 weeks' gestational age and those with lower illness severity scores. Hypotension as diagnosed by currently applied thresholds for preterm infants is not associated with brain injury on early cranial ultrasounds. Blood pressure management directed at these population-based thresholds alone may not prevent brain injury in this vulnerable population.

Pathological Prenatal Doppler Sonography Findings and Their Association with Neonatal Cranial Ultrasound Abnormalities in a High Risk Collective

The aim of this study was to evaluate whether prenatal Doppler ultrasound plays a role in the risk assessment of neonatal abnormal cranial ultrasound findings (NACU). Doppler examinations of blood flow velocities in the umbilical artery ( n = 132), the fetal middle cerebral artery ( n = 96) and the ductus venosus ( n = 46) were conducted in 132 consecutive high-risk cases. The cases were divided into three groups: normal (I), pathological (II) and highly pathological Doppler (III) results, according to the resistance index calculated and were assessed for any association between the Doppler groups and the short-term outcome of the neonate, especially NACU. A significant association was found between Doppler groups and gestational age at delivery, birth weight, length and head circumference, growth restriction, cesarean section rate, Apgar score and pH values. NACU was diagnosed significantly more often in the pathological (12.1%) and highly pathological (38.5%) Doppler groups than in the group with normal Doppler (1.7%; p < 0.001). Multivariate analysis showed that the Doppler groups (odds ratio 1.67, 95% confidence interval [CI] 1.14–2.84, p < 0.001) and gestational age at delivery (odds ratio 1.37, 95% CI 1.08–2.74; p < 0.001) were independent variables that could be used to predict NACU. The present study showed that a pathological prenatal Doppler result is highly predictive for NACU in addition to gestational age and can therefore be used for risk assessment. (E-mail: gabriele.meyberg-solomayer@med.uni-tuebingen.de)

Association of antenatal and postnatal dexamethasone exposure with outcomes in extremely low birth weight neonates.

Recent studies of preterm neonates have indicated that antenatal dexamethasone (ADX) may have adverse effects on cranial ultrasound findings at the time of hospital discharge, including periventricular leukomalacia. Furthermore, both ADX and postnatal dexamethasone (PDX) may have adverse effects on subsequent neurodevelopmental outcome. 1) To assess the effects of ADX exposure on cranial ultrasound findings at the time of hospital discharge and 2) to evaluate the individual effects of ADX and/or PDX exposure on subsequent neurodevelopmental outcome in extremely low birth weight (ELBW) neonates in whom confounding risk factors known to influence outcome were controlled. One hundred seventy-three ELBW (< or =1000 g) neonates were studied using a prospectively collected database and hospital and clinic records. Study patients were assigned to 1 of 4 groups according to dexamethasone exposure: group I, no dexamethasone exposure; group II, ADX exposure to hasten fetal lung maturity; group III, PDX exposure for chronic lung disease; group IV, both ADX and PDX exposure. The 4 groups were compared using multinomial logistic regression or analysis of covariance to control for confounding variables. Primary outcome variables were cranial ultrasound findings at hospital discharge and results of developmental testing at 18 to 22 months' corrected age (Bayley Scales of Infant Development). Cranial ultrasound results as well as Bayley Scales of Infant Development scores were similar in groups I and II and in groups III and IV. The likelihood of abnormal cranial ultrasound studies and lower scores on neurodevelopmental testing was greater in groups III and IV versus groups I and II. In this study, ADX did not seem to increase the risk of periventricular leukomalacia. ADX exposure is not associated with an increase in abnormal cranial ultrasound findings in ELBW neonates. PDX exposure, but not ADX exposure, is associated with worse neurodevelopmental outcome in this population. These results are supportive of the recent statement by the American Academy of Pediatrics (Committee on Fetus and Newborn) and the Canadian Paediatric Society (Fetus and Newborn Committee) and emphasize that PDX should be used with caution in ELBW neonates.

Long-term cognitive benefits of antenatal corticosteroids for prematurely born children with cranial ultrasound abnormalities

Objective: Previous studies have examined possible long-term effects of antenatal corticosteroids, but not by the presence of neonatal brain lesions. This study of long-term neurodevelopmental outcomes of antenatal corticosteroid exposure among preterm, very-low-birth-weight infants investigated whether the effects are differential by the presence of neonatal brain injury. Study design: Prospective cohort study of cognition, behavior, and cerebral palsy in 251 children (ages 6-8 years) born at ≤32 weeks of gestation. This sample included 91 children with abnormal neonatal cranial ultrasound findings and 106 children who had been exposed to antenatal corticosteroids. Results: In children with abnormal cranial ultrasound findings, a complete course of antenatal corticosteroids was associated with an 8.7-point advantage in IQ (95% CI, 1.8, 15.6; P = .016), controlling for confounding factors. Both verbal and nonverbal cognitive scores were increased in a dose-response manner. The advantage was greater for infants born at ≤28 weeks of gestation and in those with ventriculomegaly. In children with normal cranial ultrasound scans, cognitive function was not related to antenatal corticosteroid exposure. No statistically significant associations were observed between antenatal corticosteroid exposure and either childhood behavioral scores or cerebral palsy. Conclusion: Antenatal corticosteroids appear to confer substantial long-term benefits on cognition of very-low-birth-weight infants with cranial ultrasound abnormalities. (Am J Obstet Gynecol 2002;186:818-25.)

Postasphyxial encephalopathy in full-term infants: ultrasound diagnosis.

Abnormal cranial ultrasound findings are described in 18 infants with severe asphyxia. The examinations performed within the first 7 days after the asphyxial episode frequently showed obliteration of the ventricles and extra-axial fluid spaces with mildly increased cerebral echogenicity, presumably representing cerebral edema. Others showed diffusely abnormal parenchymal echogenicity with normal ventricles and sulci. Ultrasound findings seen after the first week of life included increased size of the ventricles and extra-axial fluid, the result of cerebral atrophy. The sensitivity, specificity, and accuracy of both early and late abnormal ultrasonograms were calculated for predicting an abnormal neurological outcome. While the sensitivity of the abnormal early (performed within 7 days of birth) ultrasonogram was relatively low (46%), the sensitivity of an abnormal late (performed after 7 days) ultrasonogram was high (86%). The specificity for both abnormal early and late ultrasound was 100%. These findings suggest that cranial ultrasonography can be used as a screening procedure to provide information about the neurologic outcome to clinicians caring for these infants.