Cerebral near-infrared spectroscopy for early recognition of impending cardiac tamponade in a preterm neonate.

Cardiac tamponade is a rare but life-threatening complication of umbilical venous catheter (UVC) placement in neonates. Mortality rates are high; therefore, early diagnosis is important. We present a case of a preterm infant with a UVC in situ who underwent a laparotomy on the first day of life for pneumoperitoneum secondary to meconium ileus. The operation was uneventful; however, 2 hours after surgery, the patient developed cardiac tamponade, requiring resuscitation and pericardiocentesis. In retrospect, near-infrared spectroscopy (NIRS) showed a gradual decline in cerebral oxygenation (crSO2) in the 30 min prior to the cardiac arrest, while other vital signs were within normal ranges. Our case demonstrates that cerebral NIRS monitoring can serve as an additional clinical marker for early recognition of impending cardiac tamponade.

NEOnatal Central-venous Line Observational study on Thrombosis (NEOCLOT): evaluation of a national guideline on management of neonatal catheter-related venous thrombosis.

BACKGROUND: In critically ill (preterm) neonates, catheter-related venous thromboembolism (CVTE) can be a life-threatening complication. Evidence on optimal management in the literature is lacking. In the Netherlands, a consensus-based national management guideline was developed to create uniform CVTE management. OBJECTIVES: To evaluate the efficacy and safety of the national guideline. METHODS: This prospective, multicenter, observational study included all infants aged ≤6 months with CVTE in the Netherlands between 2014 and 2019. CVTE was divided into thrombosis in veins and that in the right atrium, with their own treatment algorithms. The primary outcomes were recurrent venous thrombotic events (VTEs) and/or death due to CVTE as well as major bleeding. RESULTS: Overall, 115 neonates were included (62% male; 79% preterm). The estimated incidence of CVTE was 4.0 per 1000 neonatal intensive care unit admissions. Recurrent thrombosis occurred in 2 (1.7%) infants and death due to CVTE in 1 (0.9%) infant. Major bleeding developed in 9 (7.8%) infants: 2 of 7 (29%) on recombinant tissue plasminogen activator, which was given for high-risk right-atrium thrombosis, and 7 of 63 (11%) on low-molecular-weight heparin (LMWH). Five of the 7 bleedings because of LMWH were complications of subcutaneous catheter use for LMWH administration. CONCLUSION: The management of neonatal CVTE according to the Dutch CVTE management guideline led to a low incidence of recurrent VTEs and death due to VTEs. Major bleeding occurred in 7.8% of the infants. Specific guideline adjustments may improve efficacy and, especially, safety of CVTE management in neonates.

Effect of Preterm Birth on Echogenicity in Basal Ganglia.

In this study, the influence of prematurity on echogenicity of deep gray matter at 30-wk corrected age was assessed using ultrasound measurements. In an observational cohort study, ultrasound scans of 224 extremely preterm infants were prospectively collected. Gray values were assessed in putamen and globus pallidus. Intra- and inter-observer reliability was analyzed and showed excellent agreement. The globus pallidus to putamen ratio was significantly related to gestational age at birth, adjusted regression coefficient in points per wk: 1.28 (95% confidence interval [CI]: 0.38-2.19) for left and 2.12 (95% CI: 1.23-3.02) for right-side images. At 30-wk corrected age this was still the case, adjusted regression coefficient: 0.45 (95% CI: -0.57 to 1.47) for left and 1.29 (95% CI: 0.10-2.48) for right. The putamen is more hyperechoic with lower gestational age. Measuring ultrasound gray values in deep gray matter seems highly reproducible. Prematurity shows a negative correlation with echogenicity of the putamen, this persists at 30-wk corrected age, suggesting altered maturation.

Resistive indices of cerebral arteries in very preterm infants: values throughout stay in the neonatal intensive care unit and impact of patent ductus arteriosus.

BACKGROUND: Little is known about cerebral artery resistive index values in infants born extremely preterm. OBJECTIVE: To report resistive index values in various cerebral arteries in a prospective cohort of preterm infants born at <29 weeks' gestation, and to compare resistive index in these arteries and assess the relationship between resistive index and hemodynamically significant patent ductus arteriosus. MATERIALS AND METHODS: Using Doppler imaging, we obtained resistive index values of internal carotid arteries, basilar artery, anterior cerebral artery, and pial and striatal arteries in the first 3 days of age and weekly thereafter until discharge or death. We analyzed paired observations using the Wilcoxon signed-rank test, between-group comparisons with the Mann-Whitney test. RESULTS: We performed 771 examinations in 235 infants. Resistive indices differed among arteries: vessels with larger diameters showed significantly higher resistive indices. Resistive index in infants without patent ductus arteriosus was lower than that in infants with hemodynamically significant patent ductus arteriosus (median in anterior cerebral artery: 0.75 and 0.82, respectively; P<0.001), though this was not statistically significant in all arteries. There was no difference in pre- and post-ligation resistive indices in infants who underwent patent ductus arteriosus ligation. CONCLUSION: For accurate follow-up and comparison of cerebral artery resistive index, the same artery should be examined on each occasion.

Serial cranial ultrasonography or early MRI for detecting preterm brain injury?

OBJECTIVE: To investigate detection ability and feasibility of serial cranial ultrasonography (CUS) and early MRI in preterm brain injury. DESIGN: Prospective cohort study. SETTING: Level III neonatal intensive care unit. PATIENTS: 307 infants, born below 29 weeks of gestation. METHODS: Serial CUS and MRI were performed according to standard clinical protocol. In case of instability, MRI was postponed or cancelled. Brain images were assessed by independent experts and compared between modalities. MAIN OUTCOME MEASURES: Presence of preterm brain injury on either CUS or MRI and discrepant imaging findings on CUS and MRI. RESULTS: Serial CUS was performed in all infants; early MRI was often postponed (n=59) or cancelled (n=126). Injury was found in 146 infants (47.6%). Clinical characteristics differed significantly between groups that were subdivided according to timing of MRI. 61 discrepant imaging findings were found. MRI was superior in identifying cerebellar haemorrhage; CUS in detection of acute intraventricular haemorrhage, perforator stroke and cerebral sinovenous thrombosis. CONCLUSIONS: Advanced serial CUS seems highly effective in diagnosing preterm brain injury, but may miss cerebellar abnormalities. Although MRI does identify these lesions, feasibility is limited. Improved safety, better availability and tailored procedures are essential for MRI to increase its value in clinical care.

Brain vein disorders in newborn infants.

The brain veins of infants are in a complex phase of remodelling in the perinatal period. Magnetic resonance venography and susceptibility-weighted imaging, together with high-resolution Doppler ultrasound, have provided new tools to aid study of venous developmental anatomy and disease. This review aims to provide a comprehensive background of vein development and perinatal venous lesions in preterm and term-born infants, and to encourage further research in both the fetus and the newborn infant, with the aim of preventing or mitigating parenchymal injury related to diseases involving veins.

Motor performance after neonatal extracorporeal membrane oxygenation: a longitudinal evaluation.

OBJECTIVE: To assess longitudinally children's motor performance 5 to 12 years after neonatal extracorporeal membrane oxygenation (ECMO) and to evaluate associations between clinical characteristics and motor performance. METHODS: Two hundred fifty-four neonatal ECMO survivors in the Netherlands were tested with the Movement Assessment Battery for Children at 5, 8, and/or 12 years. Percentile scores were transformed to z scores for longitudinal evaluation (norm population mean = 0 and SD = 1). Primary diagnoses: meconium aspiration syndrome (n = 137), congenital diaphragmatic hernia (n = 49), persistent pulmonary hypertension of the newborn (n = 36), other diagnoses (n = 32). RESULTS: Four hundred fifty-six tests were analyzed. At 5, 8, and 12 years motor performance was normal in 73.7, 74.8, and 40.5%, respectively (vs 85% expected based on reference values; P < .001 at all ages). In longitudinal analyses mean (95% confidence interval [CI]) z scores were -0.42 (-0.55 to -0.28), -0.25 (-0.40 to -0.10) and -1.00 (-1.26 to -0.75) at 5, 8, and 12 years, respectively. Mean score at 8 years was significantly higher than at 5 years (difference 0.16, 95% CI 0.02 to 0.30), and mean score at 12 years was significantly lower than at both other ages (differences -0.59 and -0.75; 95% CI -0.33 to -0.84 and -0.49 to -1.00, respectively). Children with congenital diaphragmatic hernia encountered problems at all ages. The presence of chronic lung disease was negatively related with outcome. CONCLUSIONS: Motor problems in neonatal ECMO survivors persist throughout childhood and become more obvious with time.

Brain injury associated with neonatal extracorporeal membrane oxygenation in the Netherlands: a nationwide evaluation spanning two decades.

OBJECTIVE: To determine the prevalence of and to classify ultrasound-proven brain injury during neonatal extracorporeal membrane oxygenation in The Netherlands. DESIGN: Retrospective nationwide study (Rotterdam and Nijmegen), spanning two decades. SETTING: Level III university hospitals. SUBJECTS: All neonates who underwent neonatal extracorporeal membrane oxygenation from 1989 to 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cranial ultrasound images were reviewed independently by two investigators without knowledge of primary diagnosis, outcome, type of extracorporeal membrane oxygenation, or statistics. The scans were reviewed for lesion type and timing, with the use of a refined classification method for focal brain injury. Extracorporeal membrane oxygenation type was venoarterial in 88%. Brain abnormalities were detected in 17.3%: primary hemorrhage was most frequent (8.8%). Stroke was identified in 5% of the total group, with a notable significant preference for the left hemisphere (in 70%). Lobar hematoma (prevalence 2.2 %) was also significantly left predominant. CONCLUSION: The incidence of brain injury found with cranial ultrasound in The Netherlands of the patients treated with extracorporeal membrane oxygenation during the neonatal period was 17.3%. Primary hemorrhage was the largest group of lesions, not clearly side-specific except for lobar bleeding, most probably related to changes in venous flow. Arterial ischemic stroke occurred predominant in the left hemisphere.

Serial cranial US for detection of cerebral sinovenous thrombosis in preterm infants.

PURPOSE: To report the incidence of cerebral sinovenous thrombosis (CSVT) in a prospective cohort of preterm infants with a gestational age of less than 29 weeks. MATERIALS AND METHODS: The local medical ethics review board approved this study, and written parental consent was obtained. Preterm infants with a gestational age of less than 29 weeks who were admitted to the neonatal intensive care unit were prospectively studied with cranial ultrasonography (US). The scanning protocol included visualization with color Doppler imaging of the superior sagittal sinus and transverse sinuses through the anterior (8.5-MHz probe) and mastoid (13-MHz probe) fontanelles. When feasible, magnetic resonance imaging was performed to confirm cranial US-diagnosed CSVT. The differences between preterm infants with and those without CSVT were analyzed by using Mann-Whitney tests for continuous variables and Fisher exact tests for categorical data. RESULTS: Cranial US was used to document CSVT in 11 of 249 preterm infants with a gestational age of less than 29 weeks. Transverse sinuses were most frequently affected (in all 11 patients with CSVT). All infants with CSVT were asymptomatic. Postnatal age at diagnosis ranged from 5 to 34 days. The mean gestational age was significantly lower in infants with CSVT (25.9 weeks vs 26.8 weeks, P = .038). Of the risk factors studied, only duration of mechanical ventilation was associated with CSVT; it was significantly longer in the CSVT group. CONCLUSION: Systematic serial cranial US of infants with a gestational age of less than 29 weeks showed a remarkably high incidence of CSVT of 4.4%. Cranial US including color Doppler imaging with scans obtained through the mastoid fontanelle can depict CSVT at an early stage. Treatment of this possibly important condition needs attention.

Risk factors, clinical presentation, and neuroimaging findings of neonatal perforator stroke.

BACKGROUND AND PURPOSE: To date, studies on neonatal stroke have mainly focused on cortical stroke. We have focused on perforator strokes, noncortical strokes in the arterial vascular perforator area. We sought to identify risk factors and evaluate clinical presentation and neuroimaging findings for neonatal perforator stroke, which seems to be under-recognized. METHODS: All infants admitted to our tertiary intensive care unit in ≈12 years, whose perforator stroke was diagnosed with postnatal brain imaging, were enrolled in this study. Demographic, perinatal, and postnatal data were evaluated. RESULTS: Seventy-nine perforator strokes were detected in 55 patients (28 boys), with a median gestational age of 37 1/7 weeks (range 24 1/7 to 42 1/7 weeks, 25 preterm). Perforator stroke was asymptomatic in most patients (58%). Initial diagnosis was predominantly made with cranial ultrasound (80%) in the first week of life (60%). Risk factors for stroke were present in all cases: maternal, fetal, and perinatal. Likely pathogenic mechanisms were prolonged birth asphyxia (16%), hypoxia or hypotension (15%), embolism (15%), infection (15%), acute blood loss (9%), and birth trauma (9%). CONCLUSIONS: Previously described risk factors for developing neonatal main artery stroke are probably also associated with neonatal perforator stroke. Perforator stroke is often asymptomatic, but cranial ultrasound is a reliable diagnostic tool in diagnosing perforator stroke.

Neurodevelopmental, educational and behavioral outcome at 8 years after neonatal ECMO: a nationwide multicenter study.

PURPOSE: Reporting neurodevelopmental outcome of 8-year-old children treated with neonatal extracorporeal membrane oxygenation (ECMO). METHODS: In a follow-up study in 135 8-year-old children who received neonatal ECMO between 1996 and 2001 we assessed intelligence (Revised Amsterdam Intelligence Test), concentration (Bourdon-Vos test), eye-hand coordination (Developmental Test of Visual-Motor Integration) and behavior (Child Behavior Checklist and Teacher Report Form). RESULTS: Intelligence fell within normal range (mean IQ 99.9, SD 17.7, n = 125) with 91 % of the children following regular education. Significantly more children attended special education (9 %) or received extra support in regular education (39 %) compared with normative data. Slower working speed (χ(2) = 132.36, p < 0.001) and less accuracy (χ(2) = 12.90, p < 0.001) were found on the Bourdon-Vos test (n = 123) compared with normative data. Eye-hand coordination fell within the normal range (mean 97.6, SD 14.3, n = 126); children with congenital diaphragmatic hernia scored lowest but still normally (mean 91.0, SD 16.4, n = 28). Mothers (n = 117) indicated more somatic and attention behavior problems; teachers (n = 115) indicated more somatic, social, thought, aggression and total problems compared with normative data. Mothers indicated more somatic problems than teachers (p = 0.003); teachers reported more attention problems than mothers (p = 0.036; n = 111). CONCLUSIONS: Eight-year-old children treated with neonatal ECMO fall in the normal range of intelligence with problems with concentration and behavior. Long-term follow-up for children treated with neonatal ECMO should focus on early detection of (subtle) learning deficits.

Incidental sonographic diagnosis of neonatal carotid occlusion.

UNLABELLED: Cranial ultrasonography including colour Doppler can detect neonatal carotid flow problems at an early stage, even before symptoms occur. Different pathogeneses can be identified. The condition is more frequent than previously reported. If the circle of Willis is fully developed, this can prevent brain injury even in case of total carotid flow obstruction CONCLUSION: Screening of the carotid artery in critically ill neonates may detect complications of treatment at an early stage.

Safety of routine early MRI in preterm infants.

BACKGROUND: Cerebral MRI performed on preterm infants at term-equivalent 30 weeks' gestational age (GA) is increasingly performed as part of standard clinical care. OBJECTIVE: We evaluated safety of these early MRI procedures. MATERIALS AND METHODS: We retrospectively collected data on patient safety of preterm infants who underwent early MRI scans. Data were collected at fixed times before and after the MRI scan. MRI procedures were carried out according to a comprehensive guideline. RESULTS: A total of 52 infants underwent an MRI scan at 30 weeks' GA. Although no serious adverse events occurred and vital parameters remained stable during the procedure, minor adverse events were encountered in 26 infants (50%). The MRI was terminated in three infants (5.8%) because of respiratory instability. Increased respiratory support within 24 h after the MRI was necessary for 12 infants (23.1%) and was significantly associated with GA, birth weight and the mode of respiratory support. Hypothermia (core temperature < 36°C) occurred in nine infants (17.3%). Temperature dropped significantly after the MRI scan. CONCLUSION: Minor adverse events after MRI procedures at 30 weeks GA were common and should not be underestimated. A dedicated and comprehensive guideline for MRI procedures in preterm infants is essential.