Intraventricular Hemorrhage Research Articles

Technical nuance

Background. Colloid cyst treatment with purely endoscopic surgery is considered to be safe and effective. Complete capsule removal for gross total resection is usually recommended to prevent recurrence but may not always be safely feasible. Our objective was to go for complete endoscopic surgery using mainly aspiration, manipulation and coagulation with complete capsule resection and discuss the rationale for the procedure. Methods and materials. A case report with a third ventricle colloid cyst was surgically treated with a complete endoscopic excision using the proper technique. Results. Our patient underwent Transforaminal endoscopic surgery and the cyst was excised completely and the capsule was removed intentionally. Cyst remnants were absent on postoperative MRI. Mild Intraventricular haemorrhage was an intraoperative complication. Surgery was statistically associated with cyst volume and ventricular size reduction. There were no serious complications postoperatively. Follow-up did not show any recurrence or remnant growth that needed further treatment. Conclusion. Gross total resection may be the main objective for selected cases and seems to be safer while preserving good results, especially in a limited resource environment. Surgical planning allows the surgeon to choose among the different resection routes and techniques available. Decisions are predominantly based on preoperative imaging and intraoperative findings. Full-endoscopic approach for third ventricle colloid cyst removal is a feasible technique. Cyst aspiration followed by grasping and rotational manoeuvre for the cyst wall provides total removal with the resolution of the obstruction if present and relief of symptoms.

PRECIOUS study (PREterm Caesarean/vaginal birth and IVH/OUtcomeS): does mode of birth reduce the risk of death or brain injury in very preterm babies? A cohort and emulated target trial protocol

IntroductionVery preterm babies are at risk of poor neurodevelopmental outcomes and death. Intraventricular haemorrhage (IVH) after birth is the most prevalent cause of this. Birth by caesarean section may protect...

Combined treatment of wounded with traumatic aneurysm of posterior communicating artery complicated by intraventricular hemorrhage

Cerebral blood vessel trauma (CBVT) is a serious condition of craniocerebral injury. According to literature data, different varieties of CBVT in penetrating gunshot craniocerebral injuries are found in 30–45 % of cases. Traumatic pseudoaneurysms are the most common finding in late evaluation and can lead to life-threatening episodes of intracranial hemorrhage.In addition, CBVT includestraumatic occlusion, dissection of vessels, rupture of cerebral arteries, formation of arteriovenous fistulas (carotid-cavernous anastomoses), venous stasis, etc. Injured persons with traumatic dissection and injury of vertebrobasilar pool have the highest risks of lethal outcome. There are no largerandomised trials and national recommendations for the treatment of CBVT, individual observations and small series of clinical cases have been published. In this connection, there is a need for a detailed analysis of all clinical cases, the development of tactics for early diagnosis and an algorithm for the treatment of wounded with CBVT.The article presents a review of the literature data that characterizes the current understanding of CBVT, and a clinical case of traumatic occlusion of the middle cerebral artery and pseudoaneurysm of the posterior communicating artery in a wounded man with a gunshot penetrating cranioorbital wound, who was treated at the neurosurgical center of the N.N. Burdenko Main Military Clinical Hospital.In the early period after the injury, the patient underwent endovasal occlusion of a traumatic aneurysm of the posterior connective artery by microspirals followed by local thrombolysis of intraventricular hematomas through a ventricular catheter. The catamnesis was 150 days, the score on the modified Rankin scale was 3, the Glasgow outcome scale extended was 5.

Blood-brain barrier breach after acute cerebral hypoxia in infants

Background. Neuronal lesion, including hypoxic-ischemic damage to the central nervous system (CNS) in perinatal period, leads to the release of neuron-specific enolase (NSE) into peripheral bloodstream. Consequently, NSE can be considered as a biological marker of nervous system injury. Based on NSE level analysis, timely rehabilitation for newborns can be provided, thereby reducing the likelihood of complications associated with CNS injury.Objective: retrospective assessment of NSE level in peripheral blood over a 24-week period in infants of different gestational age with perinatal hypoxic-ischemic CNS damage.Material and methods. The study included 49 newborns who had suffered perinatal hypoxic-ischemic CNS lesion. Gestation period differed from 32 to 41 weeks. The control group consisted of 28 healthy full-term infants. NSE levels were measured using enzyme immunoassay. Patients of the main group were additionally divided into subgroups depending on Apgar scores at the 1st minute after birth, gestational age, as well as predominant CNS lesion – hemorrhagic with intraventricular hemorrhages or ischemic with periventricular leukomalacia.Results. Throughout the observation period, NSE concentrations were inversely correlated with Apgar scores: lower Apgar indicators were associated with higher NSE levels. In addition, the subgroup of 32–33-week gestational age had significantly higher NSE concentrations compared with 34–36-week, 37–41-week subgroups, and control group. NSE levels in infants with periventricular leukomalacia were consistently lower than those in newbornes with intraventricular hemorrhage starting from the 1st week. Notably, a delayed increase in serum NSE concentrations was observed at the 4th week.Conclusion. The obtained data indicate that blood-brain barrier permeability for NSE is preserved during perinatal hypoxicischemic CNS injury. Serum NSE concentration measurement can serve as a valuable tool in clinical practice for assessing the effectiveness of therapy at the stages of treatment and rehabilitation.

Incidence and Risk Factors of Intraventricular Hemorrhage in Early Preterm Infants: A Cross-Sectional Study.

Early preterm infants are susceptible to a serious disorder called intraventricular hemorrhage (IVH), which may cause severe neurological damage. To determine the incidence of IVHin preterm infants at Lady Reading Hospital, Peshawar, Pakistan, and to identify associated risk factors and potential preventive measures. This cross-sectional research examined the prevalence of IVH among early preterm infants and was carried out at Lady Reading Hospital in Peshawar from 1January 2021 to 31 December 2023. After excluding individuals with congenital defects, insufficient medical records, or non-consent, the research comprised 210 newborns born before 28 weeks of gestation and diagnosed with IVH during the first 72 hours of life. Medical record reviews and in-person observations were used to gather data, with an emphasis on clinical, risk, and demographic characteristics. Using the StatisticalPackage for the Social Sciences (IBM SPSS Statistics for Windows, IBMCorp., Version 25.0, Armonk,NY) with a significance threshold of p < 0.05, descriptive techniques were used in the statistical studies to summarize the features and inferential approaches, such as univariate and multivariate logistic regression, to identify IVH risk variables. Among the 210 early preterm newborns studied, the frequency of IVH according to severity was as follows: 79 infants (37.62%) had Grade I, 65 infants (30.95%) had Grade II, 39 infants (18.57%) had Grade III, and 27 infants (12.86%) had Grade IV. Three key demographic findings were that 63 births (30.00%) occurred before 26 weeks of gestation, 87 infants (41.43%) had birth weights of less than 1000 grams, and 111 infants (52.86%) were male. Significant predictors of IVH identified through multivariate logistic regression included birth weight less than 1000 grams (odds ratio (OR) = 3.10, 95% confidence interval (CI): 1.78-5.42, p < 0.01), gestational age less than 26 weeks (OR = 2.68, 95% CI: 1.50-4.76, p < 0.01), Apgar score ≤5 (OR = 4.01, 95% CI: 2.23-7.21, p < 0.01), resuscitation at birth (OR = 2.23, 95% CI: 1.12-4.45, p = 0.02), mechanical ventilation (OR = 3.55, 95% CI: 1.85-6.82, p < 0.01), and sepsis (OR = 2.98, 95% CI: 1.50-5.92, p = 0.02). The high incidence of IVH and its association with critical risk factors underscore the need for improved neonatal care practices and targeted interventions in early preterm infants.

Intraventricular haemorrhage in premature infants: the role of immature neuronal salt and water transport.

Intraventricular haemorrhage is a common complication of premature birth. Survivors are often left with cerebral palsy, intellectual disability and/or hydrocephalus. Animal models suggest that brain tissue shrinkage, with subsequent vascular stretch and tear, is an important step in the pathophysiology, but the cause of this shrinkage is unknown. Clinical risk factors for intraventricular haemorrhage are biomarkers of hypoxic-ischaemic stress, which causes mature neurons to swell. However, immature neuronal volume might shift in the opposite direction in these conditions. This is because immature neurons express the chloride, salt and water transporter NKCC1, which subserves regulatory volume increases in non-neural cells, whereas mature neurons express KCC2, which subserves regulatory volume decreases. When hypoxic-ischaemic conditions reduce active ion transport and increase the cytoplasmic membrane permeability, the effects of these transporters are diminished. Consequentially, mature neurons swell (cytotoxic oedema), whereas immature neurons might shrink. After hypoxic-ischaemic stress, in vivo and in vitro multi-photon imaging of perinatal transgenic mice demonstrated shrinkage of viable immature neurons, bulk tissue shrinkage and blood vessel displacement. Neuronal shrinkage was correlated with age-dependent membrane salt and water transporter expression using immunohistochemistry. Shrinkage of immature neurons was prevented by prior genetic or pharmacological inhibition of NKCC1 transport. These findings open new avenues of investigation for the detection of acute brain injury by neuroimaging, in addition to prevention of neuronal shrinkage and the ensuing intraventricular haemorrhage, in premature infants.

Evaluation of Shunt-Related Ventriculitis in Infants

Aims: Shunt-related infections are resistant to antibiotics. This study examined patients aged under two years after ventriculitis. It is the first study on ventriculitis developed in a completely closed system (without skin defect infection, or puncture history), evaluating infants only. Method: The study included 13 subjects (four females) with ventriculitis who had undergone surgery for hydrocephalus during the neonatal period and were monitored for shunt infection, evaluating certain parameters. Results: Ventriculitis developed on an average of 2.8 months after surgery. The most common causes of hydrocephalus were spina bifida and intraventricular hemorrhage. Bacteria grown in culture included Staphylococcus epidermidis, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Serratia marcescens. Seven (53.8%) patients were treated without complications. Among other patients, three (23.1%) developed multilocular cystic hydrocephalus and three (23.1%) exhibited decreased cerebrospinal fluid production and did not require shunting. Conclusions: Patients receiving intraventricular therapy showed no complications, warranting further studies on early intraventricular therapy. In the presence of gram-negative bacterial growth, cerebrospinal fluid production may decrease and affected patients do not require shunts.

Impact of targeted neonatal echocardiography consultations for critically sick preterm neonates

RationalePreterm neonates needing rescue treatments with inotropes and/or inhaled nitric oxide (iNO) (acute critical illnesses, ACIs) in neonatal intensive care units (NICUs) are at high risk of mortality. While targeted...

Umbilical cord management in newborn resuscitation: a systematic review and meta-analysis.

Evidence supporting the benefits of delayed cord clamping is increasing; however, there is no clear recommendation on cord management during newborn resuscitation. This study aimed to investigate the effects of resuscitation initiated with an intact umbilical cord, hypothesizing it is a safe stabilization procedure that improves neonatal outcomes. Systematic search was conducted in MEDLINE, Embase, CENTRAL, and Web of Science from inception to March 1, 2024. Eligible articles compared neonatal outcomes in newborns receiving initial stabilization steps before and after cord clamping. Twelve studies met our inclusion criteria, with six RCTs included in the quantitative analysis. No statistically significant differences were found in delivery room parameters, in-hospital mortality, or neonatal outcomes between the examined groups. However, intact cord resuscitation group showed higher SpO2 at 5 min after birth compared to cord clamping prior to resuscitation group (MD 6.67%, 95% CI [-1.16%, 14.50%]). There were no significant differences in early complications of prematurity (NEC ≥ stage 2: RR 2.05, 95% CI [0.34, 12.30], IVH: RR 1.25,95% CI [0.77, 2.00]). Intact cord management during resuscitation appears to be a safe intervention; its effect on early complications of prematurity remains unclear. Further high-quality RCTs with larger patient numbers are urgently needed. Initiating resuscitation with an intact umbilical cord appears to be a safe intervention for newborns. No statistically significant differences were found in delivery room parameters, in-hospital mortality, and neonatal outcomes between the examined groups. The utilization of specialized resuscitation trolleys appears to be promising to reduce the risk of intraventricular hemorrhage in preterm infants. Further high-quality RCTs with larger sample sizes are urgently needed to refine recommendations.

Clinicoepidemiological Profile of Retinopathy of Prematurity.

Purpose In previously performed studies, retinopathy of prematurity (ROP) has been shown to occur postpartum. As a result, mechanical ventilation and oxygen dependence were eventually connected to the development of ROP in these preterm children, and ROP prevalence is on the rise globally. Despite various improvements in childcare, ROP still tends to arise due to various risk factors associated with the disease. So, clinically the research was performed to determine the clinical and epidemiological profile of ROP. Materials and methods A total of 268 participants were to be enrolled in the study. It was an observational, cross-sectional study carried out at Department of Ophthalmology and Neonatal Intensive Care Unit in Veer Surendra Sai Institute of Medical Sciences and Research Centre, Burla, Sambalpur, Odisha, India. Ethical approval was provided on 30 November 2019. Results Overall 123 (46%) infants out of 268 infants developed retinopathy of prematurity. Majorly, the infants had stage 1 and stage 2 ROP. Most of the infants were male. Birth weight in ROP patients was 1000 g or less in 54% of infants, 1000-1500 g in 46% of infants and >1500 g in 33% of infants. Gestational age was found to be a predictor of retinopathy of prematurity. The adverse events that were found to be associated with retinopathy of prematurity were sepsis (53%), respiratory distress syndrome (RDS) (54.6%), intraventricular haemorrhage (IVH) (60%), anaemia (61.5%). Conclusion It has been observed that babies with higher birth weights and older gestations are also susceptible to developing ROP. Therefore, the greater birth weight newborns up to 1750 g and older gestational age babies >34 weeks should also be included in the screening criteria, especially if they have risk factors such as oxygen supplementation, sepsis, RDS, and anaemia.

O103 ANTENATAL AND NEONATAL EXPOSURES AND CHILDHOOD HYPERTENSION: FINDINGS FROM THE BOSTON BIRTH COHORT

Background: Early-life factors impact the development of hypertension (HTN). Impact of antenatal exposures, prematurity and subsequent early life exposures (including those in the neonatal intensive care unit (NICU)) on the development of HTN warrants further investigation. Objective: 1. Expand our prior findings on the association of maternal cardiometabolic conditions with childhood HTN in the Boston Birth Cohort (BBC). 2.Investigate the combined association between prematurity and NICU exposures with childhood HTN. Methods: We analyzed factors associated with childhood HTN up to 18 years. HTN was defined according to national guidelines. Composite categories were created based on gestational age and NICU comorbidities. Chi-square and ANOVA tests were used for categorical and continuous variables, respectively. Regression analyses explored the association with HTN, while repeated measures analysis assessed BP percentiles. Results: We analyzed 2461 infants (695 preterm), with a total of 19,689 repeated BP measurements. Maternal pre-existing diabetes, older maternal age, maternal stress in index pregnancy and chronic maternal stress, were positively associated with childhood HTN, after adjusting for important covariables. HTN incidence (25.9% vs. 16.31%) was higher in children born preterm, with an inverse dose-response trend. Compared to children born term without NICU exposure, those born term with NICU stay (OR 1.65 CI: 1.03-2.65), and those born preterm with NICU stay even without complications (OR 1.84 CI:1.38-2.46) had higher odds of developing HTN. Preterm children with NICU stay had the highest odds of developing HTN (OR 2.36 CI: 1.38-4.04), if they also had one or more major comorbidities (sepsis, chronic lung disease, necrotizing enterocolitis and intraventricular hemorrhage). Repeated measures analysis further revealed a positive association of systolic and diastolic BP percentiles with maternal cardiometabolic conditions, prematurity, and presence of NICU complications. Results remained consistent after adjustment for child BMI. Conclusion: In this US minority cohort, we found various early life factors linked to childhood HTN. Notably, preterm infants with a history of major NICU complications were more likely to develop childhood HTN.

Cord blood utilization as a blood conservation measure in the neonatal intensive care unit

Extremely low birth weight (ELBW) and very low birth weight (VLBW) infants are often exposed to several laboratory blood draws throughout their neonatal intensive care unit (NICU) stay, particularly at admission. Required routine admission labs place patients at risk for iatrogenic blood loss and need for treatment. Studies have demonstrated that blood collected from an umbilical cord segment may be used to obtain admission labs rather than drawing blood directly from the patient. The purpose of the quality improvement (QI) project was to determine if the utilization of umbilical cord blood for routine admission labs compared to the standard practice of infant phlebotamization result in fewer cases of iatrogenic anemia and the need for treatment in ELBW and VLBW infants. The following outcomes were monitored pre/post-implementation: number of blood transfusions, intra-ventricular hemorrhage (IVH) diagnosis, IVH severity, and vasopressor use. Despite a small sample size, statistically significant results were obtained.

Resident Opinions on Image Guidance for External Ventricular Drain Placement: A National Survey

BACKGROUND AND OBJECTIVES: Low-quality data on image-guided external ventricular drain (EVD) accuracy are in large part due to a lack of widespread usage of this system for EVD placement. The potential disconnect between user preferences and existing technologies should be explored to guide future developments. The goal of this study was to survey neurosurgical residents regarding their EVD practices and determine the acceptable amount of setup time for an ideal neuronavigation system. METHODS: A 4-question survey was sent to approximately 1512 residents at 108 Acreditation Council for Graduate Medical Education–approved medical doctor neurosurgical training programs in the United States. The responses were received electronically, tabulated, and analyzed using descriptive statistics. RESULTS: A total of 130 respondents (9%) completed the survey, reflecting the highest number of neurosurgical resident respondents in an electronic qualitative survey of EVD practices thus far. Residents were willing to accept 6.39 min (SD = 3.73 min) on average for the setup of a bedside EVD image guidance system. The majority chose to use image guidance during EVD placement for cases of narrow slit-like ventricles (86.92%) over intraventricular hemorrhage (13.08%) and hydrocephalus (0%). A total of 90% of all resident respondents misplaced at least 1 EVD with 74% of post-graduate year–7 respondents misplacing more than 3 EVDs in their career. A total of 88.46% of respondents deemed more than a single pass as acceptable. CONCLUSION: Future EVD neuronavigation technologies should focus on achieving rapid registration times. These systems may be prioritized for patients with anatomic distortions. Current resident attitudes are accepting multiple EVD passes, likely because of the inherent limitations of the traditional freehand approach. Efforts should be made to encourage the best course for the patient.

Optimal treatment for women with acute hypertension in pregnancy; a randomized trial comparing intravenous labetalol versus nicardipine

ObjectivesBlood pressure control in severe hypertension of pregnancy is crucial for mother and neonate. In absence of evidence, guidelines recommend either intravenous labetalol or nicardipine. We compared the effectiveness and safety of these two drugs in women with severe hypertension in pregnancy. Study designWe performed an open label randomized controlled trial. Women with a singleton pregnancy complicated by severe hypertension (systolic ≥ 160 mmHg and/or diastolic ≥ 110 mmHg) requiring intravenous antihypertensive treatment were randomized to intravenous labetalol or intravenous nicardipine. The primary outcome was a composite adverse neonatal outcome defined as severe Respiratory Distress Syndrome (RDS), Broncho Pulmonary Dysplasia (BPD), Intraventricular Hemorrhage (IVH) IIB or worse, Necrotizing Enterocolitis (NEC), or perinatal death defined as fetal death or neonatal death before discharge from the neonatal intensive care unit (NICU).Based on a power analysis, we estimated that 472 women (236 per group) needed to be included to detect a difference of 15% in the primary outcome with 90% power. The study was halted prematurely at 30 inclusions because of slow recruitment and trial fatigue. ResultsBetween August 2018 and April 2022, we randomized 30 women of which 16 were allocated to intravenous nicardipine and 14 to intravenous labetalol. The composite adverse neonatal outcome was not significantly different between the two groups (25 % versus 43 % OR 0.28 (95 % CI 0.05–1.43), p = 0.12)). Respiratory distress syndrome occurred more often in the labetalol group than in the nicardipine group (42.9 % versus 12.5 %). Neonatal hypoglycemia occurred more often in the nicardipine group than in the labetalol group (31 % versus 7 %). Time until blood pressure control was faster in women treated with nicardipine than in women treated with labetalol (45 (15–150 min vs. 120 (60–127,5) min). ConclusionIn our prematurely halted small RCT, we were unable to provide evidence for the optimal choice of treatment for severe hypertension to improve neonatal outcome and/or to obtain faster blood pressure control. Differences in Respiratory distress syndrome and neonatal hypoglycemia between the groups might be the result of coincidental finding due to the small groups included in the study. A larger randomized trial would be needed to determine the safest and most efficacious (intravenous) therapy for severe hypertension in pregnancy. This study emphasizes the challenges of conducting a RCT for the optimal treatment for these women.

A Study on the Effect of Umbilical Cord Milking Along With Delayed Cord Clamping on Hematological Parameters in Comparison to Delayed Cord Clamping Alone in Moderate-to-Late Preterm Newborns.

Background Anemia, particularly iron deficiency anemia (IDA), is a global public health issue with serious implications for infant cognitive and developmental outcomes. Preterm infants are especially vulnerable to IDA due to reduced placental blood transfer at birth. Delayed cord clamping (DCC) and umbilical cord milking (UCM) are interventions aimed at enhancing this blood transfer, thereby improving neonatal iron status. While DCC allows passive blood transfer by delaying cord clamping, UCM actively expedites the process. However, there remains a lack of consensus on the comparative benefits of these methods, particularly in preterm infants. This study aims to clarify the efficacy of UCM combined with DCC versus DCC alone in improving hematological outcomes in moderate-to-late preterm newborns. Methodology This comparative study was conducted at Maharaja Agrasen Medical College, Agroha, Hisar, Haryana, over a 12-month period. The study included 200 moderate-to-late preterm infants (32-36+6 weeks of gestation), divided into two groups: Group A (DCC alone) and Group B (DCC combined with UCM). The study aimed to compare the effects of these two interventions on hematological outcomes. Data were collected on baseline characteristics, birth weight, hemoglobin (Hb) levels at birth and at six weeks, serum ferritin levels at six weeks, and any complications. Statistical analyses included independent t-tests for continuous variables and chi-squared tests for categorical variables to assess the differences between the two groups. Results There were no significant differences in the baseline characteristics, birth weight, or clamping time between the two groups. Mean Hb levels at birth were 15.46 g/dL in the DCC group and 15.72 g/dL in the DCC+UCM group (p = 0.429). At six weeks, the mean Hb levels were 13.10 g/dL for the DCC and 13.24 g/dL for the DCC+UCM (p = 0.541). Serum ferritin levels at six weeks were 239.26 ng/mL for the DCC and 258.06 ng/mL for DCC+UCM (p = 0.146). Complications were similar between the groups, with no significant differences in the rates of intraventricular hemorrhage (IVH), jaundice, or polycythemia. Conclusion In this study, the combination of UCM with DCC did not show significant differences in hematological outcomes compared to DCC alone in moderate-to-late preterm infants. Both interventions demonstrated similar results for hemoglobin and ferritin levels, and there were no notable differences in adverse outcomes. Further research with larger sample sizes and longer follow-ups is necessary to better understand the potential benefits of UCM in preterm neonates.

Fetal Intraparenchymal Hemorrhage Imaging Patterns, Etiology, and Outcomes: A Single Center Cohort Study.

This study examines associations among fetal brain magnetic resonance imaging (MRI) injury patterns, etiologies, and outcomes in fetal intraparenchymal hemorrhage (IPH). This is a retrospective, single-center cohort study of IPH diagnosed on fetal MRI (1996-2022). IPH and associated abnormalities were categorized by 2 pediatric neuroradiologists; electronic medical records were reviewed by 2 pediatric neurologists to classify etiology and outcomes including cerebral palsy, epilepsy, developmental delay, and death. Forty-four fetuses with IPH were identified (34 singleton and 10 twin gestations) with MRI at median 24 weeks gestation (interquartile range [IQR] = 22-28 weeks). IPH was commonly supratentorial (84%) and focal (50%) or focal with diffuse injury (43%) and was often associated with germinal matrix hemorrhage (GMH; 75%) and/or intraventricular hemorrhage (IVH; 52%). An etiology was identified in 75%, including twin-twin transfusion syndrome (TTTS, n = 10), COL4A1/2 variants (n = 8), or other fetal/maternal conditions (n = 15). COL4A1/2 variants were associated with focal IPH and the presence of hemorrhagic porencephaly, and intrauterine transfusion was associated with infratentorial hemorrhage. Twenty-two fetuses were liveborn, and 18 pregnancies were terminated. Among those with follow-up ≥ 12 months (median = 7 years), 12 of 13 had cerebral palsy, 6 of 13 had developmental delay, and 5 of 13 had epilepsy. An etiology for fetal IPH with or without GMH-IVH is identified in most cases in our cohort and is commonly TTTS, COL4A1/2 variants, or other maternal/fetal comorbidities. Pattern of fetal IPH on MRI is associated with etiology. Cerebral palsy and neurodevelopmental impairment were common in liveborn infants. Genetic studies should be considered in cases of fetal IPH without an otherwise apparent cause. ANN NEUROL 2024.

Obstetric and neonatal outcomes in pregnancies complicated by placental abruption with vs. without supporting sonographic findings- A retrospective cohort study

Placental abruption (PA) is a major obstetric complication associated with worse maternal and neonatal outcomes. Though ultrasound findings may support the diagnosis of PA, the association of such findings to the severity of PA and maternal and neonatal outcomes is not yet clear. We aimed to assess the maternal and neonatal outcomes of PA cases with vs. without related sonographic findings. In this retrospective cohort study, all deliveries complicated by PA between 2009 and 2022 were included. Placental histopathology, obstetric, and neonatal outcomes were compared between cases of PA with vs. without supporting sonographic findings. A composite of severe neonatal morbidity was compared between the groups, including ≥1 of the following: seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, periventricular leukomalacia, respiratory-distress syndrome, sepsis, anemia, blood transfusion or death. Of the 420 cases with PA eligible for the study, 50 patients (12%) were in the PA with sonographic features group and 370 (88%) were in the PA without sonographic features group. The PA with sonographic features group was characterized by significantly higher rates of prematurity (p<0.001), severe composite adverse neonatal outcome (p<0.01), and a composite maternal vascular malperfusion lesions in placental histopathology (p=0.001) In multivariable regression analyses, preterm birth was independently associated with the presence of sonographic features (aOR=8.79, 95% CI 2.41-31.93, p<0.001). PA with supporting sonographic features is associated with higher rates of adverse obstetric and neonatal outcomes and placental lesions. These findings emphasize the importance of sonographic evaluation for every case of PA before deciding upon management.

Fetal Brain MRI Abnormalities in Pyruvate Dehydrogenase Complex Deficiency.

Pyruvate dehydrogenase complex deficiency (PDCD) is a disorder of mitochondrial metabolism that is caused by pathogenic variants in multiple genes, including PDHA1. Typical neonatal brain imaging findings have been described, with a focus on malformative and encephaloclastic features. Fetal brain MRI in PDCD has not been comprehensively described. The aims of this study were (1) to further characterize the fetal brain MRI findings in PDCD using comprehensive fetal imaging and genetic testing and (2) to determine whether markers of diagnosis of PDCD could be identified on prenatal imaging. Fetuses with a diagnosis of PDCD related to a genetic etiology that had undergone fetal MRI were included. Fetuses were identified retrospectively from local databases of 4 fetal diagnostic clinics within tertiary pediatric health care centers. Electronic medical records were reviewed retrospectively: demographics, maternal and pregnancy history, fetal outcomes, and neonatal outcomes (if available) were reviewed and recorded. Fetal and neonatal imaging reports were reviewed; source fetal and neonatal brain MRI scans were reviewed by a single pediatric neuroradiologist (J.W.S.) for consistency. Genetic testing strategies and results including variant type, zygosity, inheritance pattern, and pathogenicity were recorded. Deidentified data were combined and reported descriptively. A total of 10 fetuses with a diagnosis of PDCD were included. 8 fetuses had corpus callosum dysgenesis, 6 had an abnormal gyration pattern, 10 had reduced brain volumes, and 9 had cystic lesions. 1 fetus had intraventricular hemorrhages. 1 fetus had a midbrain malformation with aqueductal stenosis and severe hydrocephalus. 6 fetuses imaged in the second trimester had cystic lesions involving the ganglionic eminences (GEs) while GE cysts were not present in the 4 fetuses imaged in the third trimester. Fetuses with PDCD have similar brain MRI findings to neonates described in the literature, although some of these findings are subtle early in pregnancy. Additional features, such as cystic lesions of the GEs, are noted in the second trimester in fetuses with PDCD. These may represent an early diagnostic marker of PDCD, although more data are needed to validate this association. Early diagnosis of PDCD using fetal MRI may inform genetic counseling, pregnancy decision making, and neonatal care planning.

The Potential of Ambroxol as a Panacea for Neonatal Diseases: A Scoping Review.

Ambroxol, a commonly used mucolytic agent, has been extensively studied for its clinical effectiveness in managing respiratory conditions in pediatric and adult patients. The existing body of research on ambroxol demonstrates its safety and efficacy. However, its potential role in preventing and treating neonatal diseases still needs to be explored. This scoping review aims to shed light on the unexplored potential of ambroxol, particularly its applications in perinatal and neonatal care. We aim to offer valuable insights for healthcare professionals, researchers, and academics, thus presenting a positive perspective. Key scientific databases such as Google Scholar, PubMed, Cochrane Library, and Europe PMC were meticulously searched for relevant literature on ambroxol in perinatal and neonatal medicine. Gray literature was also surveyed, and the search encompassed all study designs and languages up to June 2024. Furthermore, citations and reference lists of relevant articles were scrutinized to identify additional pertinent literature. Ambroxol has demonstrated promising effects in preventing and managing respiratory distress syndrome (RDS). It can enter the placental circulation and rapidly build up in human lung tissue to a much greater extent than in plasma. It promotes fetal lung maturation, surfactant production, and alveolar expansion. Numerous studies have demonstrated the efficacy of antenatal and postnatal ambroxol in the prevention and treatment of RDS. Ambroxol has the potential to be administered intravenously or through nebulization, offering the hopeful possibility of reducing the high failure rate typically associated with non-invasive ventilation in extremely preterm infants, instilling a sense of hope and optimism about the potential of ambroxol. It also shows potential in treating bronchopulmonary dysplasia, meconium aspiration syndrome, and neonatal infections. Ambroxol has been observed to assist in the closure of patent ductus arteriosus in preterm infants by inhibiting vasodilator agents such as nitric oxide and exerting vasoconstrictive properties. However, these biological actions may raise concerns regarding the potential induction of pulmonary hypertension and an increased risk of necrotizing enterocolitis. The present scoping review also examines the clinical evidence and the potential of ambroxol in reducing the incidence of intraventricular hemorrhage in preterm infants. Ambroxol may have potential analgesic properties in managing neonatal pain, and as it can penetrate the blood-brain barrier, it suggests potential neuroprotective properties. These properties may encompass the modulation of microglial activation and the antagonistic impact on glutamate receptors. Ambroxol's attributes could contribute to a decreased susceptibility to neurological complications and have demonstrated anticonvulsant effects in preclinical studies. While low-to-moderate-quality evidence indicates potential applications of ambroxol in neonatal care, further research is needed to determine the drug's optimal dosing, timing, and safety profiles in this patient population. We need to investigate ambroxol's potential synergistic effects with antenatal steroids. Exploration is required to assess ambroxol's potential in reducing the high failure rate associated with non-invasive respiratory support for RDS. Lastly, comprehensive studies on the long-term neurodevelopmental outcomes of neonates exposed to ambroxol are essential.

Early neurodevelopmental outcomes of preterm infants with intraventricular haemorrhage and periventricular leukomalacia.

Intraventricular haemorrhage (IVH) and periventricular leukomalacia (PVL) in preterm infants are associated with an increased risk of long-term neurodevelopmental impairments (NDI) and cerebral palsy (CP). However, little is known about their impact on early neurodevelopmental outcomes despite increasing evidence highlighting the feasibility and importance of early NDI/CP diagnosis. We aimed to determine the early neurodevelopmental outcomes of preterm infants with IVH and PVL. This was a retrospective single-centre cohort study of preterm infants born at <29 weeks gestation or <1000 g birth weight who attended an Early Neurodevelopment Clinic at 3 to 4 months of corrected age. Primary outcomes of early NDI and CP/high-risk CP diagnoses based on Prechtl's General Movements Assessment and the Hammersmith Infant Neurological Examination were compared between infants without IVH and infants with mild IVH (grades I-II), severe IVH (grades III-IV), and severe brain injury (SBI; severe IVH or cystic PVL). Of 313 infants, 52.1% (n = 163), 41.2% (n = 129), 6.7% (n = 21) and 8.6% (n = 27) had no IVH, mild IVH, severe IVH and SBI, respectively. The adjusted odds of early CP/high-risk CP diagnosis were significantly higher in infants with severe IVH (aOR 6.07, 95% CI 1.50-24.50) and SBI (aOR 15.28, 95% CI 3.70-63), but not in those with mild IVH (aOR 1.24, 95% CI 0.49-3.10). However, the adjusted odds of any early NDI were similar across groups. Preterm infants with severe IVH and SBI are at increased risk of early CP/high-risk of CP diagnosis at 3 to 4 months of corrected age.