RESUMO
OBJECTIVE: To evaluate the association of therapeutic hypothermia with magnetic resonance imaging (MRI) findings and 30-month neurodevelopment in term neonatal encephalopathy. STUDY DESIGN: Cross-sectional analysis of 30-month neurodevelopment (IQR 19.0-31.4) in a prospective cohort of mild-to-severe neonatal encephalopathy imaged on day 4 (1993-2017 with institutional implementation of therapeutic hypothermia in 2007). MRI injury was classified as normal, watershed, or basal ganglia/thalamus. Abnormal motor outcome was defined as Bayley-II psychomotor developmental index <70, Bayley-III motor score <85 or functional motor deficit. Abnormal cognitive outcome was defined as Bayley-II mental developmental index <70 or Bayley-III cognitive score <85. Abnormal composite outcome was defined as abnormal motor and/or cognitive outcome, or death. The association of therapeutic hypothermia with MRI and outcomes was evaluated with multivariable logistic regression adjusted for propensity to receive therapeutic hypothermia. RESULTS: Follow-up was available in 317 (78%) surviving children, of whom 155 (49%) received therapeutic hypothermia. Adjusting for propensity, therapeutic hypothermia was independently associated with decreased odds of abnormal motor (OR 0.15, 95% CI 0.06-0.40, P < .001) and cognitive (OR 0.11, 95% CI 0.04-0.33, P < .001) outcomes. This association remained statistically significant after adjustment for injury pattern. The predictive accuracy of MRI pattern for abnormal composite outcome was unchanged between therapeutic hypothermia-treated (area under the receiver operating curve 0.76; 95% CI 0.61-0.91) and untreated (area under the receiver operating curve 0.74; 95% CI 0.67-0.81) infants. The negative predictive value of normal MRI was high in therapeutic hypothermia-treated and untreated infants (motor 96% vs 90%; cognitive 99% vs 95%). CONCLUSIONS: Therapeutic hypothermia is associated with lower rates of brain injury and adverse 30-month outcomes after neonatal encephalopathy. The predictive accuracy of MRI in the first week of life is unchanged by therapeutic hypothermia. Normal MRI remains reassuring for normal 30-month outcome after therapeutic hypothermia.
Assuntos
Hipotermia Induzida/métodos , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Transtornos do Neurodesenvolvimento/prevenção & controle , Adulto , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Hipóxia-Isquemia Encefálica/terapia , Lactente , Recém-Nascido , Doenças do Recém-Nascido/diagnóstico por imagem , Doenças do Recém-Nascido/terapia , Imageamento por Ressonância Magnética , Masculino , Valor Preditivo dos Testes , Gravidez , Estudos ProspectivosRESUMO
OBJECTIVE: To determine the association of antenatal magnesium sulfate with cerebellar hemorrhage in a prospective cohort of premature newborns evaluated by magnetic resonance imaging (MRI). STUDY DESIGN: Cross-sectional analysis of baseline characteristics from a prospective cohort of preterm newborns (<33 weeks gestation) evaluated with 3T-MRI shortly after birth. Exclusion criteria were clinical evidence of a congenital syndrome, congenital infection, or clinical status too unstable for transport to MRI. Antenatal magnesium sulfate exposure was abstracted from the medical records and the indication was classified as obstetric or neuroprotection. Two pediatric neuroradiologists, blinded to the clinical history, scored axial T2-weighted and iron susceptibility MRI sequences for cerebellar hemorrhage. The association of antenatal magnesium sulfate with cerebellar hemorrhage was evaluated using multivariable logistic regression, adjusting for postmenstrual age at MRI and known predictors of cerebellar hemorrhage. RESULTS: Cerebellar hemorrhage was present in 27 of 73 newborns (37%) imaged at a mean ± SD postmenstrual age of 32.4 ± 2 weeks. Antenatal magnesium sulfate exposure was associated with a significantly reduced risk of cerebellar hemorrhage. Adjusting for postmenstrual age at MRI, and predictors of cerebellar hemorrhage, antenatal magnesium sulfate was independently associated in our cohort with decreased cerebellar hemorrhage (OR, 0.18; 95% CI, 0.049-0.65; P = .009). CONCLUSION: Antenatal magnesium sulfate exposure is independently associated with a decreased risk of MRI-detected cerebellar hemorrhage in premature newborns, which could explain some of the reported neuroprotective effects of magnesium sulfate.
Assuntos
Hemorragias Intracranianas/prevenção & controle , Sulfato de Magnésio/uso terapêutico , Fármacos Neuroprotetores/uso terapêutico , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Imageamento por Ressonância Magnética/métodos , Masculino , Gravidez , Estudos ProspectivosRESUMO
OBJECTIVES: To determine the rate of magnetic resonance imaging (MRI)-detected noncystic white matter injury (WMI) in a prospective cohort of premature newborns, and to evaluate its associations with changes in clinical predictors of WMI over the study period. STUDY DESIGN: A prospective cohort of premature newborns (<33 weeks gestational age) was studied with MRI within 4 weeks of birth and near term-equivalent age. A pediatric neuroradiologist scored the severity of WMI on T1-weighted MRI according to published criteria. WMI was classified as none/mild or moderate/severe. Subjects with severe cystic WMI, periventricular hemorrhagic infarction, or motion artifact on MRI were excluded. Changes in clinical characteristics and predictors of WMI over the study period (1998-2011) were evaluated. Predictors of moderate/severe WMI, including birth year, were evaluated using multivariate logistic regression. RESULTS: Among 267 newborns, 45 (17%) had moderate/severe WMI. The rate of moderate/severe WMI decreased over the study period (P = .002, χ(2) test for trends). On multivariate logistic regression, the odds of moderate/severe WMI decreased by 11% for each birth year of the cohort (OR, 0.89; 95% CI, 0.81-0.98; P = .02). Prolonged exposure to indomethacin also was independently associated with reduced odds of moderate/severe WMI. CONCLUSION: The decreasing burden of MRI-detected moderate/severe noncystic WMI in our cohort of premature newborns is independent over time of changes in the known clinical predictors of WMI. Prolonged exposure to indomethacin is associated with reduced WMI.
Assuntos
Dano Encefálico Crônico/fisiopatologia , Recém-Nascido Prematuro , Imageamento por Ressonância Magnética/métodos , Substância Branca/lesões , Anti-Inflamatórios não Esteroides/administração & dosagem , Dano Encefálico Crônico/diagnóstico , Dano Encefálico Crônico/prevenção & controle , California , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Indometacina/administração & dosagem , Recém-Nascido , Modelos Logísticos , Masculino , Estudos Prospectivos , Fatores de Risco , Substância Branca/patologiaRESUMO
OBJECTIVE: To compare the association between perinatal events and the pattern and extent of brain injury on early magnetic resonance imaging in newborn infants with and without therapeutic hypothermia for hypoxic-ischemic encephalopathy. STUDY DESIGN: We performed a cohort study of 35 treated and 25 nontreated neonates who underwent magnetic resonance imaging. The injury patterns were defined a priori as: normal, watershed, or basal ganglia/thalamus-predominant, as well as a dichotomous outcome of moderate-to-severe versus mild-no injury. RESULTS: Neonates with hypothermia had less extensive watershed and basal ganglia/thalamus injuries and a greater proportion had normal imaging. Therapeutic hypothermia was associated with a decreased risk of both basal ganglia/thalamus injury (relative risk, 0.29; 95% CI, 0.10 to 0.81, P = .01) and moderate-severe injury. Neonates with sentinel events showed a decrease in basal ganglia/thalamus-predominant injury and an increase in normal imaging. All neonates with decreased fetal movements had injury, predominantly watershed, regardless of therapeutic hypothermia. CONCLUSIONS: These results validate reports of reduced brain injury after therapeutic hypothermia and suggest that perinatal factors are important indicators of response to treatment.
Assuntos
Hipotermia Induzida , Hipóxia-Isquemia Encefálica/patologia , Hipóxia-Isquemia Encefálica/terapia , Imageamento por Ressonância Magnética , Feminino , Humanos , Recém-Nascido , Modelos Logísticos , Masculino , Resultado do TratamentoRESUMO
OBJECTIVE: To assess whether birth at <26 weeks gestation is an important predictor of brain microstructure maturation as determined by using diffusion tensor imaging. STUDY DESIGN: We performed serial magnetic resonance imaging and diffusion tensor imaging in 176 infants born at <33 weeks gestation. Diffusion parameters were calculated for white and gray matter regions. Linear regression for repeated measures was used to assess the effect of extremely premature birth on brain maturation. RESULTS: In white matter, fractional anisotropy increased by 0.008 per week (95% CI, 0.007-0.009; P < .0001) and mean diffusivity decreased by 0.021 mm(2)/sec per week, (95% CI, -0.24-0.018; P < .0001). Birth at <26 weeks was associated with lower white matter fractional anisotropy (-0.01; 95% CI, -0.018-0.003; P = .008), but this effect was eliminated when co-morbid conditions were added to the model. Moderate-severe brain injury was associated with decreased mean white matter fractional anisotropy (-0.012; 95% CI, -0.02-0.004; P = .002). CONCLUSION: Brain microstructure maturation as measured serially in premature infants is independent of extremely premature birth. Brain injury and co-morbid conditions may be the important determinants of microstructure maturation.