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Routine Neuroimaging of the Preterm Brain Ivan L CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Routine Neuroimaging of the Preterm Brain Ivan L. Hand, MD, FAAP,a Renée A. Shellhaas, MD, MS, FAAP,b Sarah S. Milla, MD, FAAP,c COMMITTEE ON FETUS AND NEWBORN, SECTION ON NEUROLOGY, SECTION ON RADIOLOGY Neuroimaging of the preterm infant is a common assessment performed in abstract the NICU. Timely and focused studies can be used for diagnostic, therapeutic, and prognostic information. However, significant variability exists among a neonatal units as to which modalities are used and when imaging studies are Department of Pediatrics, New York City Health 1 Hospitals/Kings County, State University of New York Downstate Medical Center, obtained. Appropriate timing and selection of neuroimaging studies can help Brooklyn, New York; bPediatric Neurology Division, Department of identify neonates with brain injury who may require therapeutic intervention Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; and cDepartments of Radiology and Pediatrics, Emory or who may be at risk for neurodevelopmental impairment. This clinical report University School of Medicine and Children’s Healthcare of Atlanta, reviews the different modalities of imaging broadly available to the clinician. Atlanta, Georgia Evidence-based indications for each modality, optimal timing of examinations, Clinical reports from the American Academy of Pediatrics benefit from and prognostic value are discussed. expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. Drs Hand, Shellhaas, and Milla researched, conceived, designed, INTRODUCTION analyzed, and interpreted data for this clinical report and drafted and revised this clinical report; and all authors approved the final Central to the assessment of the preterm infant is identifying the presence manuscript as submitted. and extent of brain injury. Preterm infants are at significant risk of The guidance in this report does not indicate an exclusive course of intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. posthemorrhagic ventricular dilatation, and other neurologic injuries that All clinical reports from the American Academy of Pediatrics may or may not have imaging corollaries. Through neuroimaging, the automatically expire 5 years after publication unless reaffirmed, neonatologist may initiate interventions and plan for supportive care and revised, or retired at or before that time. assess the risk of future neurologic impairment. This document is copyrighted and is property of the American 1 fi Academy of Pediatrics and its Board of Directors. All authors have filed In 1968, Abraham Towbin described the frequent nding of IVH at conflict of interest statements with the American Academy of necropsy in preterm infants, with abnormalities almost universally Pediatrics. Any conflicts have been resolved through a process ’ approved by the Board of Directors. The American Academy of present in those born at less than 28 weeks gestation. Not until 10 years Pediatrics has neither solicited nor accepted any commercial later did Papile at al2 describe the computerized tomography (CT) findings involvement in the development of the content of this publication. of 46 consecutive very low birth weight (VLBW) infants and demonstrate DOI: https://doi.org/10.1542/peds.2020-029082 a much higher incidence of IVH than was clinically suspected. That report Address correspondence to Ivan L. Hand, MD, FAAP. E-mail: ivan.hand@ described 4 separate grades of hemorrhage: “Grade I–subependymal nychhc.org hemorrhage, Grade II–intraventricular hemorrhage without ventricular – dilatation, Grade III intraventricular hemorrhage with ventricular To cite: Hand IL, Milla SS, AAP COMMITTEE ON FETUS AND dilatation, and Grade IV–intraventricular hemorrhage with parenchymal NEWBORN, SECTION ON NEUROLOGY, SECTION ON RADIOLOGY. hemorrhage.” Since the initial report, the Papile classification has been Routine Neuroimaging of the Preterm Brain. Pediatrics. modified to grade I, indicating minimal IVH; grade II, with IVH occupying 2020;146(5):e2020029082 Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 5, November 2020:e2020029082 FROM THE AMERICAN ACADEMY OF PEDIATRICS 10% to 50% of the ventricular area; INITIAL SCREENING EXAMINATIONS IVH and, on the basis of current grade III, representing IVH with The VLBW (ie, birth weight ,1500 g) understanding, believed to be caused . 50% of ventricular area; and last, infant is at high risk for germinal by venous infarction. A PVHI is not, as parenchymal hemorrhage, most likely matrix and IVH as well as ischemic once believed, an extension of the IVH attributable to hemorrhagic venous fi into the parenchyma. 3 white matter injury as identi ed by infarction. cranial ultrasonography. Risk of Severity of IVH in the most immature fi severe IVH is inversely related to These ndings led to one of the infants is consistent with the 4 gestational age, with infants born at earliest outcomes studies, in which developmental changes of the less than 24 weeks’ gestation at authors described the association of subependymal germinal matrix as it highest risk.10 In 2017, the Vermont major developmental and decreases in size from 2.5 mm in the Oxford Network database neuromotor handicaps with the 24-week preterm infant to involution fi demonstrated an overall 24.6% ndings of more severe (grade III and at about 36 weeks’ gestational age.3 incidence of IVH and an 8.1% rate of IV) IVH on CT scan performed For these and other reasons affecting severe IVH, defined as grade III or IV between 3 and 10 days of age. On the vascular integrity, the more moderate basis of these and other studies, the among more than 50 000 VLBW 11 and late preterm infants (those born American Academy of Neurology infants. In a recently published between 32 and 36 6/7 weeks’ (AAN) released practice parameters survey of the California Perinatal gestation) are at less risk for in 2002 suggesting universal cranial Quality Care Collaborative, 63% of significant intracranial injury. In ultrasonographic screening for all infants born at 22 to 23 6/7 weeks’ a retrospective study of moderately infants born at less than 30 weeks’ gestation had IVH, with 36% 12 preterm infants born between 29 and gestation.5 The AAN also demonstrating severe IVH. This 33 weeks’ gestation, 60% of a cohort recommended that initial screening incidence decreased to 14% of infants of 7021 infants underwent cranial ultrasonography be performed at 7 to whose gestational age at birth was 30 imaging, and 15% of these 4184 14 days after birth and repeated at to 31 6/7 weeks having any IVH and infants had ultrasonographic near term corrected age. In 2001, the 1.4% having a severe grade. Less abnormalities.16 The rates of severe Canadian Pediatric Society severe grades of IVH (grades I and II) IVH and cystic PVL were 1.7% and recommended screening all infants may have less prognostic influence on 2.6%, respectively, in this born at less than 32 weeks’ gestation clinical outcomes. In a National population.15 The authors noted that at 2 weeks after birth, with a repeat Institute of Child Health and low Apgar scores, maternal risk screening 6 weeks after birth.6 Since Development study of 1472 infants factors, lack of antenatal steroids, and the publication of those guidelines, born at less than 27 weeks’ 13 vaginal delivery were associated with cranial ultrasonography capabilities gestational age, there was no ultrasonographic abnormalities, have evolved, and modern significant difference in including intracranial hemorrhage, ultrasonography technology, along neurodevelopmental outcomes at 18 PVL, and ventriculomegaly. The with the use of supplementary to 22 months of those infants with presence of risk factors such as acoustic windows, can now provide and without these low-grade abnormal neurologic examination, good structural imaging of the hemorrhages. intrauterine growth restriction, preterm infant brain.7 PVL is a disorder of the abnormal head circumference, low Imaging the entire brain was once periventricular cerebral white matter Apgar scores, and need for ventilation performed by using CT scanning. Use that may be cystic or diffuse in or surfactant increased the chance of of head CT has given way to improved nature. Most cystic PVL occurs in detecting an abnormality by fourfold cranial ultrasonography as well as infants born between 26 and 30 in a group of more mature preterm MRI, which yields better detail and weeks’ gestation, initially appearing infants born at 33 to 36 weeks’ avoids the use of ionizing radiation.8 as periventricular increased gestational age.17 In a similar study, However, routine use of MRI for echogenicity (eg, a blush or flare) infants born at .30 weeks’ gestation screening the preterm infant has been with cystic evolution over the course who were found to have significant identified as being of questionable of a few weeks. Periventricular ultrasonographic abnormalities value in the Choosing Wisely hemorrhagic infarcts (PVHIs) (ie, typically had clinically significant campaign of the American Academy formerly grade 4 IVH) occur mainly in events, such as placental abruption, of Pediatrics.9 The aim of
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