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Neuroimaging in the Neonate Debra B. Selip, MD Fetal and Neonatal Medicine Center and Division of Neonatology Rush University Medical Center March 4, 2011.

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Presentation on theme: "Neuroimaging in the Neonate Debra B. Selip, MD Fetal and Neonatal Medicine Center and Division of Neonatology Rush University Medical Center March 4, 2011."— Presentation transcript:

1 Neuroimaging in the Neonate Debra B. Selip, MD Fetal and Neonatal Medicine Center and Division of Neonatology Rush University Medical Center March 4, 2011

2 Neuroimaging in the Neonate Wide array of imaging modalities readily available Expanding and rapidly changing body of literature examining appropriate imaging methods and prognostic applications

3 Neuroimaging Modalities Xray Ultrasound CT scan MRI T1 T2 DWI / DTI / FA / Tractography MR Spectroscopy NM Scans SPECT PET

4 Why Image? 2 Roles: Diagnose brain injury in at risk newborns Improve and provide acute medical management/interventions Detect lesions associated with long- term neurodevelopmental disability Appropriate prognosis/predictions

5 Prognostic Concerns Clinical evaluation insufficient for prognostication Cerebral Palsy? School Performance? Neurocognitive & neurodevelopmental disabilities Behavioral disabilities Role for neuroimaging?

6 2 Types of Neonates Preterm Infants Periventricular Leukomalacia Intraventricular Hemorrhage Post-hemorrhaghic Hydrocephalus Periventricular Hemorrhagic Infarction Intraparenchymal Hemorrhage Cortical and Deep Gray Matter Injury

7 2 Types of Neonates Full term Infant Stroke Intracerebral Hemorrhage Periventricular Leukomalacia Intraventricular Hemorrhage Congenital Anomalies Cortical and Deep Gray Matter Injury

8 Outline Preterm infant: ELGAN / VLBW Epidemiology Neuroimaging modalities Indications for use Findings and clinical correlates Conclusions Term Epidemiology Neuroimaging modalities Indications for use Findings and clinical correlates Conclusions

9 The brain is a wonderful organ; it starts working the moment you get up in the morning and does not stop until you get into the office. Robert Frost Robert Frost


11 Epidemiology: Preterm Infant ELGAN/ VLBW: number preterm infants and survival: For babies less than 32 wks Greater than 2% of all live births Up to greater than 85% survival Emphasis on Outcomes: Improvement in ND outcomes Infants less than 26 wks: Approximately 15% with CP At 11 yrs: 25% severe ND disability 35% moderate ND disability 20% mild ND disability Marlow et al. NEJM 2005 Anderson et al. JAMA 2003 Epicure, 2005

12 Epidemiology: Preterm Infants Emphasis on Outcomes: Infants less than 30 wks 25 – 50% cognitive, behavioral, social difficulties requiring special ed. intervention 5 – 15% cerebral palsy, severe neuro-sensory impairment or both Overall: At 8 years of age 50% children BW less than 1 kg in special education 20% children BW less than 1 kg repeat a grade % children BW less than 1 kg with spastic motor CP Marlow et al. NEJM 2005 Anderson et al. JAMA 2003

13 Typical Injury Patterns: ELGA / VLBW Hemorrhage Hypoxia Ischemia IVH Ventriculomegaly White matter injury PHH Gray matter injury LEADS TO Volpe, Neurology of the Newborn, 2008 Follett et al, JNeurosci, 2001, 2004 Deng et al, PNAS, 2006

14 Evolution of Injury: ELGA / VLBW Local necrosis with congestion or hemorrhage Ventriculomegaly, cysts disappear, deficient myelin and/or gliosis with collapse of cysts, echo-densities Echo-lucent cysts in periventricular white matter

15 Factors to Consider When Imaging Critically Ill Infants Timing Technique Transport Compatibility Availability Sedation

16 Ultrasound: Diagnostic Capabilities Hemorrhagic Hydrocephalus Periventricular hemorrhaghic infarction Non-hemorrhagic Echodensities Echolucencies Ventricular enlargement Edema Hydrocephalus Sensitivity much increased with multiple scans DeVries et al, JPediatric, 2004

17 El-Dib, M. et al. Am J Perinatol

18 Grades of IVH – grade 1 to 4 El-Dib, M. et al. Am J Perinatol


20 Ultrasound: Prognostic Capabilities Major abnormalities Gr 3 IVH, PHI, Cystic PVL Predictive of CP and NM delay at follow up Predictive of impaired cognitive outcome but with less sensitivity and specificity Mild abnormalities Prediction of CP or cognitive deficits is problematic Not predictive of NORMAL outcome El-Dib, M. et al. Am J Perinatol

21 Ultrasound: Prognostic Capabilities Diffuse PVL: low sensitivity Misses greater than 50% diffuse white matter injury Hemorrhage conveys less prognostic info than evidence of white matter damage and PHH Cerebellar Injury

22 Ultrasound: Prognostic Capabilities Recent literature gr1 and gr2 IVH in infants <26 GA with poorer ND/NC outcomes Significant assoc. btwn gr 3 – 4 IVH, Cystic PVL, mod- sev ventriculomegaly, and CP at 2 - 9yrs in babies < 1500g Patra, K et al. JPeds, 2006

23 Ultrasound: Prognostic Capabilities Grade 4 IVH and ventriculomegaly strong assoc with MR and neuropsych disorders at yrs in infants <1500g Odds Ratio: 10 fold increase in adverse outcome with above sonographic findings

24 Ultrasound: Limitations Poor contrast for lesions of brain parenchyma Limited field of view Insensitive for identification of hemorrhage adjacent to bone Fair cerebellar views Operator dependent

25 Ultrasound: Conclusions ELGAN / VLBW Routine screening <30 wks Screen btwn days 80% IVH Screen 36 wks PMA White matter injury Diagnostic utility quite good Prognostic role limited to more severe injury patterns

26 He who joyfully marches to music in rank and file has already earned my contempt. He has been given a large brain by mistake, since for him the spinal cord would suffice. Albert Einstein


28 MRI: ELGAN / VLBW T1 T2 DWI/ DTI/ FA / tractography / fMRI Volumetrics Early MRI Corrected term (40 – 42 wks CGA) Utility in preterm brain Utility in term corrected brain T.M. OShea et al. EarlyHumDev, 2005.

29 MRI: ELGAN /VLBW Superior evaluation of: Brain structures Gray / white matter Brain stem / posterior fossa Identifies: More abnl findings 1 st wk of life More hemorrhagic lesions More extensive cysts Subtle / Diffuse white matter injury Prognostic benefit: CP Learning disabilities Behavioral problems


31 MRI : Prognostic Capabilities Woodward et al. Neonatal MRI to Predict Neurodevelopmental Outcomes in Preterm Infants. NEJM, August infants < 30 wks At 2 yrs 17 % severe cognitive delay 10 % severe psychomotor delay 10% CP 11% neurosensory impairment 21% moderate – severe cerebral white matter injury

32 Woodward et al. NEJM. Aug 2006

33 MRI: Prognostic Capabilities Cont…d Majority of preemies have Loss of volume Cystic abnormality Enlarged ventricles Thinning of the corpus callosum Delayed myelination Can these term findings be associated with definitive outcomes at 2yr, 4yrs, 6yrs, etc

34 Study Results 28% no white matter injury 5% mild white matter injury 17% moderate white matter injury 6% severe white matter injury Correlation of MRI at term with outcome at 2 yrs of age (corrected) More signif the white matter injury, the greater the neuro dev impairment

35 The chief function of the body is to carry the brain around. Thomas A. Edison


37 CT Scan: ELGAN / VLBW Good imaging modality Hemorrhage Cerebral volume / Ventricles / Extra-axial space Bones Limited use due to: Ionizine radiation / risk of future malignancy Cognitive impairment Correlations btwn clinical outcome and image results weak

38 MRI vs Ultrasound vs CT in the ELGAN/VLBW: Conclusion Ultrasound Early MRI Later Forget the CT Scan

39 Imaging the Term Infant Hypoxic Ishcemic Encephalopathy Neonatal Stroke Arterial Ischemic Stroke Cerebral Venous Thrombosis Intracerebral Hemorrhage Periventricular Leukomalacia Intraventricular Hemorrhage Congenital Anomalies

40 Ultrasound: Term Infant Not ubiquitously helpful Poor parenchymal evaluation Poor anatomic views Poor for stroke Good for IVH evaluation Doppler views Vascular Hydrocephalus vs Ventriculomegaly RI = (systolic ACA blood flow – diastolic ACA blood flow) diastolic ACA blood flow

41 CT Scan: Term Infant Significant findings Calcifications Hemorrhage Low attenuation in basal ganglia and thalamus Global picture of injury Extremely fast Emergent situation Limited use due to: Risk of future malignancy Risk of future cognitive impairment

42 MRI: Term Infant No ionizing radiation Multi-planar imaging More sensitive and specific for CNS evaluation than CT or US Grey matter White matter Modality of choice

43 MRI: Hypoxic Ischemic Encephalopathy Water and the brain T1 – 7 days T2 – 7 days DWI: one of the earliest indicators of tissue injury (within hours) – best 2 – 4 days No ionizing radiation Volumetric data Volumetric data of sensorimotor and mid- temporal cortices are assoc with full scale verbal and performance IQ scores

44 MRI: Pattern of Brain Injury 2 main types Basal Ganglia-Thalamus Acute near total asphyxia CP / cognitive injury readily apparent Watershed Predominant Prolonged partial asphyxia Ant – Mid cerebral artery Post –Mid cerebral artery Childhood symptoms / Deficits at 30 mo.

45 MRI: HIE Prognostic Capabilities Neurodevelopmental handicap at 1-2 yrs of age if: Basal ganglia or thalamic abnormality 50 – 94% with CP, mental retardation, seizure disorder Well established

46 I was taught that the human brain was the crowning glory of evolution so far, but I think it's a very poor scheme for survival. Kurt Vonnegut


48 MR Spectroscopy: Term Infant Non-invasive in vivo biochemical analysis Cellular metabolic information Detection of biochemical changes before morphological changes apparent NAA Lactate Creatine Choline Prognosis Early H-MRS studies promising

49 Summary Appropriate modality for particular investigation Pre-term Imaging US MRI MR Spect? Full-term Imaging CT MRI MR Spect?



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