Impact of antenatal corticosteroids-to-delivery interval on very preterm neonatal outcomes: a retrospective study in two tertiary centers in Japan.

BACKGROUND: Antenatal corticosteroids (ACS) are administered to prevent neonatal complications and death in women at risk of imminent preterm birth. Internationally, the optimal interval from ACS to delivery (ACS-to-delivery interval) is within seven days; however, evidence in Asian populations specifically is limited. This study aimed to investigate the association between ACS-to-delivery interval and the incidence of neonatal complications in Japan. METHODS: This retrospective observational study enrolled singleton neonates born preterm at < 32 weeks of gestational age between 2012 and 2020 at two tertiary centers. A total of 625 neonates were divided into the following four groups according to the timing of ACS (measured in days): no ACS (n = 145), partial ACS (n = 85), ACS 1-7 (n = 307), and ACS ≥ 8 (n = 88). The following outcomes were compared between the groups: treated respiratory distress syndrome (RDS), severe intraventricular hemorrhage (IVH), treated patent ductus arteriosus (PDA), necrotizing enterocolitis, sepsis, bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity (ROP), periventricular leukomalacia, and death discharge. RESULTS: The ACS 1-7 group had significantly decreased adjusted odds ratios (ORs) for treated RDS (0.37 [95% confidence interval: 0.23, 0.57]), severe IVH (0.21 [0.07, 0.63]), treated PDA (0.47 [0.29, 0.75]), and treated ROP (0.50 [0.25, 0.99]) compared with the no ACS group. The ACS ≥ 8 group also showed significantly reduced adjusted ORs for RDS (0.37 [0.20, 0.66]) and treated PDA (0.48 [0.25, 0.91]) compared with the no ACS group. However, the adjusted ORs for BPD significantly increased in both the ACS 1-7 (1.86 [1.06, 3.28]) and ACS ≥ 8 groups (2.94 [1.43, 6.05]) compared to the no ACS group. CONCLUSIONS: An ACS-to-delivery interval of 1-7 days achieved the lowest incidence of several complications in preterm neonates born at < 32 weeks of gestational age. Some of the favorable effects of ACS seem to continue even beyond ≥ 8 days from administration. In contrast, ACS might be associated with an increased incidence of BPD, which was most likely to be prominent in neonates delivered ≥ 8 days after receiving ACS. Based on these findings, the duration of the effect of ACS on neonatal complications should be studied further.

Differentiating Myelography Contrast from Intraventricular and Subarachnoid Hemorrhage Using Dual-Energy CT of the Head: A Case Report and a Review of Literature.

Single-energy computed tomography (SECT) head is a common diagnostic tool to evaluate for intracranial hemorrhage in emergency settings due to its widespread accessibility and non-invasive nature. However, SECT has densitometric evaluation limitations. For example, hyperdensities on SECT such as blood product and iodine contrast appear similarly. Dual-energy CT (DECT) is a relatively under-utilized imaging modality that has the capability to differentiate between multiple materials. This imaging technique can be extremely useful in identifying materials that are otherwise indistinguishable from standard SECT. The authors present a case of a patient with findings suspicious of intraventricular and subarachnoid hemorrhage on conventional SECT. The suspected hemorrhage was subsequently ruled out utilizing DECT, as iodinated contrast can be subtracted out, yielding an image that can differentiate iodine contrast from blood or other hyperdense material. The authors discuss the underlying physics, potential advantages, and limitations of the DECT.

Glymphatic System in Preterm Neonates: Developmental Insights Following Birth Asphyxia.

BACKGROUND: Birth asphyxia (BA) and germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) are common clinical events in preterm neonates. However, their effects on the glymphatic system (GS) development in preterm neonates remain arcane. PURPOSE: To evaluate the developmental trajectory of the GS, and to investigate the effects of BA and GMH-IVH on GS function in preterm neonates. STUDY TYPE: Prospective. POPULATION: Two independent datasets, prospectively acquired internal dataset (including 99 preterm neonates, 40 female, mean [standard deviation] gestational age (GA) at birth, 29.95 [2.63] weeks) and the developing Human Connectome Project (dHCP) dataset (including 81 preterm neonates, 29 female, median [interquartile range] GA at birth, 32.71 [4.28] weeks). FIELD STRENGTH/SEQUENCE: 3.0 T MRI and diffusion-weighted spin-echo planar imaging sequence. ASSESSMENT: The diffusion-weighted images were preprocessed in volumetric space using the FMRIB Software Library and diffusion along the perivascular space (DTI-ALPS) index was accessed to evaluate GS function. STATISTICAL TESTS: Two sample t tests, one-way analysis of variance followed by least-significant difference (LSD) post hoc analysis, chi-squared tests, and Pearson's correlation analysis. Significance level: P < 0.05. RESULTS: In prospectively acquired internal dataset, preterm neonates with BA exhibited a significant lower DTI-ALPS index than those without BA (0.98 ± 0.08 vs. 1.08 ± 0.07, T = -5.89); however, GMH-IVH did not exert significant influences on the DTI-ALPS index (P = 0.83 and 0.27). The DTI-ALPS index increased significantly at postmenstrual age ranging from 25 to 34 weeks (r = 0.38) and then plateaued after 34 weeks (P = 0.35), which we also observed in the dHCP dataset. DATA CONCLUSION: BA rather than GMH-IVH serves as the major influencing factor in the development of GS in preterm neonates. Moreover, as GS development follows a nonlinear trajectory, we recommend close monitoring of GS development in preterm neonates with a GA less than 34 weeks. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 2.

Noninvasive Respiratory Support or Intubation during Stabilization after Birth and Neonatal and Neurodevelopmental Outcomes in Infants Born Preterm at 23-25 Weeks of Gestation.

OBJECTIVE: To examine the association between noninvasive respiratory support (NRS) or tracheal intubation (TI) during stabilization in infants born at 23-25 weeks of gestation and severe brain injury (sBI) or death, and significant neurodevelopmental impairment (sNDI). STUDY DESIGN: A retrospective cohort study of infants born at 23°/7-256/7 weeks of gestation in Canada. We compared infants successfully managed with NRS or TI during 30 minutes after birth. The primary outcomes were sBI or death before discharge, and sNDI among survivors with follow-up data at 18-24 months corrected age. The associations between exposures and outcomes were assessed using logistic regression models, and propensity score-matched analyses. RESULTS: The mean (SD) of gestational age and birth weight were 24.6 (0.6), 24.3 (0.7) weeks [P < .01], and 757 (173), 705 (130) grams [P < .01] in the NRS, and tracheal intubation (TI) groups, respectively, and 77% of infants in the NRS group were intubated by 7 days of age. sBI or death occurred in 25% (283/1118), and 36% (722/2012) of infants in the NRS and TI groups, respectively (aOR and 95% CI 0.74 [0.60, 0.91]). Among survivors with follow-up data, sNDI occurred in 17% (96/551), and 23% (218/937) of infants in the NRS and TI groups, respectively (aOR [95% CI] 0.77 [0.60, 0.99]). In the propensity score-matched analyses (NRS vs TI), results were consistent for sBI or death (OR [95% CI] 0.72 [0.60, 0.86]), but not for sNDI (OR [95% CI] 0.78 [0.58, 1.05]). CONCLUSIONS: Infants born at 23-25 weeks who were successfully managed with NRS, compared with TI, in the first 30 minutes after birth had lower odds of sBI or death before discharge, but had no significant differences in neurodevelopmental outcomes among survivors.

Revolutionizing Intracranial Hemorrhage Diagnosis: A Retrospective Analytical Study of Viz.ai ICH for Enhanced Diagnostic Accuracy.

Introduction Artificial intelligence (AI) alerts the radiologist to the presence of intracranial hemorrhage (ICH) as fast as 1-2 minutes from scan completion, leading to faster diagnosis and treatment. We wanted to validate a new AI application called Viz.ai ICH to improve the diagnosis of suspected ICH. Methods We performed a retrospective analysis of 4,203 consecutive non-contrast brain computed tomography (CT) reports in a single institution between September 1, 2021, and January 31, 2022. The reports were made by neuroradiologists who reviewed each case for the presence of ICH. Reports and identified cases with positive findings for ICH were reviewed. Positive cases were categorized based on subtype, timing, and size/volume. Viz.ai ICH output was reviewed for positive cases. This AI model was validated by assessing its performance with Viz.ai ICH as the index test compared to the neuroradiologists' interpretation as the gold standard. Results According to neuroradiologists, 9.2% of non-contrast brain CT reports were positive for ICH. The sensitivity of Viz.ai ICH was 85%, specificity was 98%, positive predictive value was 81%, and negative predictive value was 99%. Subgroup analysis was performed based on intraparenchymal, subarachnoid, subdural, and intraventricular subtypes. Sensitivities were 94%, 79%, 83%, and 44%, respectively. Further stratification revealed sensitivity improves with higher acuity and volume/size across subtypes. Conclusion Our analysis indicates that AI can accurately detect ICH's presence, particularly for large-volume/large-size ICH. The paper introduces a novel AI model for detecting ICH. This advancement contributes to the field by revolutionizing ICH detection and improving patient outcomes.

Pharmacological Strategies and Surgical Management of Posthemorrhagic Hydrocephalus Following Germinal Matrix-Intraventricular Hemorrhage in Preterm Infants.

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a detrimental neurological complication that occurs in preterm infants, especially in babies born before 32 weeks of gestation and in those with a very low birth weight. GM-IVH is defined as a rupture of the immature and fragile capillaries located in the subependymal germinal matrix zone of the preterm infant brain, and it can lead to detrimental neurological sequelae such as posthemorrhagic hydrocephalus (PHH), cerebral palsy, and other cognitive impairments. PHH following GM-IVH is difficult to treat in the clinic, and no levelone strategies have been recommended to pediatric neurosurgeons. Several cellular and molecular mechanisms of PHH following GM-IVH have been studied in animal models, but no effective pharmacological strategies have been used in the clinic. Thus, a comprehensive understanding of molecular mechanisms, potential pharmacological strategies, and surgical management of PHH is urgently needed. The present review presents a synopsis of the pathogenesis, diagnosis, and cellular and molecular mechanisms of PHH following GM-IVH and explores pharmacological strategies and surgical management.

Integrating Clinical and Neuroimaging Markers to Predict the Onset of Posthemorrhagic Ventricular Dilatation in Preterm Neonates.

BACKGROUND: Posthemorrhagic ventricular dilatation (PHVD) is a major complication of intraventricular hemorrhage (IVH); it is associated with high risks of cerebral palsy and cognitive deficits compared with infants without PHVD. This study aims to explore the early perinatal risk factors-associated with the risk of progressive PHVD. METHODS: Neonates ≤29 weeks gestational age (GA) with Grade II-III IVH and periventricular hemorrhagic infarct (PVHI) between 2015 and 2021 were retrospectively reviewed. All cranial ultrasounds done within 14 days postnatal age (PNA) were assessed for grade of IVH, anterior horn width (AHW), ventricular index (VI), and thalamo-occipital index (TOD). The outcome was defined as death of any cause or VI and/or AHW and/or TOD ≥ moderate-risk zone based on an ultrasound done beyond two weeks PNA. RESULTS: A total of 146 infants with a mean GA of 26 ± 1.8 weeks, birth weight 900 ± 234 g were included, 46% were females. The primary outcome occurred in 56 (39%) infants; among them 17 (30%) and 11 (20%) needed ventricular reservoir and shunt insertion, respectively. The risk factors present within 14 days PNA that significantly increased the odds of developing PHVD were hemodynamically significant patent ductus arteriosus (odds ratio [OR] 6.1, 95% confidence interval [CI] 1.9 to 22), culture-proven sepsis (OR 5.4, 95% CI 1.8 to 18), Grade III IVH (OR 4.6, 95% CI 1.1 to 22), PVHI (OR 3.0, 95% CI 0.9 to 10), and VI (OR 2.1, 95% CI 1.6 to 2.9). CONCLUSIONS: Clinical predictors such as significant ductus arteriosus and bacterial septicemia, along with risk levels of AHW and VI measured with early cranial ultrasounds, are potential predictors of subsequent onset of PHVD.

Utility of Diffusion Tensor Imaging in Preterm Infants with Germinal Matrix Hemorrhage and Intraventricular Hemorrhage: A Systematic Review.

OBJECTIVE: Intraventricular hemorrhage (IVH) and germinal matrix hemorrhage (GMH) are the most common brain injuries in preterm infants. Neonates with these injuries are at greater risk of impaired neurodevelopmental outcome. Current guidelines recommend screening infants with cranial ultrasound (CUS); however, this is prone to missing subtle injury patterns, particularly within the posterior fossa. The present report sought to discuss the utility of diffusion tensor imaging (DTI) in preterm infants. METHODS: A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality, DTI use, and neurologic outcome. RESULTS: Twenty studies with 1574 infants who underwent DTI were included. There were 574 preterm infants with GMH-IVH on DTI. Twelve studies documented decreased fractional anisotropy, whereas 6 demonstrated structural segregation and asymmetrical white matter myelination in these infants. Seven studies documented concurrent CUS use with 2 studies comparing DTI findings with CUS findings. In both studies, DTI more accurately detected presence of GMH, especially within the cerebellum. Among GMH-IVH preterm infants, 58.5% demonstrated cognitive, intellectual, and language delays at follow-up (mean, 32.4 months). Additionally, lower fractional anisotropy values on initial DTI were associated with cognitive, language, and motor delays. CONCLUSIONS: Although DTI is more sensitive for picking up subtle injury patterns, CUS remains the standard of care when screening for injuries that would necessitate surgical intervention. DTI offers a refined understanding of the sequelae of GMH-IVH with microstructural changes found on DTI being associated with childhood motor and cognitive outcomes.

Predicting neurodevelopmental outcomes in extremely preterm neonates with low-grade germinal matrix-intraventricular hemorrhage using synthetic MRI.

Objectives: This study aims to assess the predictive capability of synthetic MRI in assessing neurodevelopmental outcomes for extremely preterm neonates with low-grade Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH). The study also investigates the potential enhancement of predictive performance by combining relaxation times from different brain regions. Materials and methods: In this prospective study, 80 extremely preterm neonates with GMH-IVH underwent synthetic MRI around 38 weeks, between January 2020 and June 2022. Neurodevelopmental assessments at 18 months of corrected age categorized the infants into two groups: those without disability (n = 40) and those with disability (n = 40), with cognitive and motor outcome scores recorded. T1, T2 relaxation times, and Proton Density (PD) values were measured in different brain regions. Logistic regression analysis was utilized to correlate MRI values with neurodevelopmental outcome scores. Synthetic MRI metrics linked to disability were identified, and combined models with independent predictors were established. The predictability of synthetic MRI metrics in different brain regions and their combinations were evaluated and compared with internal validation using bootstrap resampling. Results: Elevated T1 and T2 relaxation times in the frontal white matter (FWM) and caudate were significantly associated with disability (p < 0.05). The T1-FWM, T1-Caudate, T2-FWM, and T2-Caudate models exhibited overall predictive performance with AUC values of 0.751, 0.695, 0.856, and 0.872, respectively. Combining these models into T1-FWM + T1-Caudate + T2-FWM + T2-Caudate resulted in an improved AUC of 0.955, surpassing individual models (p < 0.05). Bootstrap resampling confirmed the validity of the models. Conclusion: Synthetic MRI proves effective in early predicting adverse outcomes in extremely preterm infants with GMH-IVH. The combination of T1-FWM + T1-Caudate + T2-FWM + T2-Caudate further enhances predictive accuracy, offering valuable insights for early intervention strategies.

High-level feature-guided attention optimized neural network for neonatal lateral ventricular dilatation prediction.

BACKGROUND: Periventricular-intraventricular hemorrhage can lead to posthemorrhagic ventricular dilatation or even posthemorrhagic hydrocephalus if not detected promptly. Sequential cranial ultrasound scans are typically used for their diagnoses. Nonetheless, manual image audit has numerous disadvantages. PURPOSE: This study aimed to develop a predictive model utilizing modified inception (MI) and high-level feature-guided attention (HFA) modules for predicting neonatal lateral ventricular dilation via ultrasound images. METHODS: The MI modules reduced input data sizes and dimensions, while the HFA modules effectively delved into semantic information through supervision from high-level feature images to low-level feature images. The process facilitated the accurate identification of dilated lateral ventricles. A total of 710 neonates, corresponding to 1420 lateral ventricles, were recruited in this study. Each lateral ventricle was captured in two images, one on the parasagittal plane and the other on the coronal plane. The combination of anterior horn width, ventricular index, thalamo-occipital distance, and ventricular height served as the gold standard. A lateral ventricle would be considered dilatated if any of these four indices exceeded its upper reference value. These lateral ventricles were randomly split into training and testing sets at a 7:3 ratio. We evaluated the validity of our proposed approach and its competitors across the coronal plane, parasagittal plane, and overall performance. We also determined the impact of subjects' baseline characteristics on the overall performance of the proposed approach. Additionally, ablation analyses were conducted to ensure the efficacy of the proposed approach. RESULTS: Our proposed approach achieved the largest Youden index (0.65, 95% CI: 0.58-0.72), DOR (27.11, 95% CI: 15.89-46.26), area under curves (AUC) of receiver operating characteristic curve (ROC) (0.84, 95% CI: 0.80-0.88), and AUC of precision-recall curve (PRC) (0.81, 95% CI: 0.74-0.86) in the overall performance assessment and ablation analyses. Moreover, it boasted the biggest Cramer's V values on the coronal (Cramer's V = 0.488, p < 0.001) and parasagittal (Cramer's V = 0.713, p < 0.001) planes individually. Factors such as left side, male sex, singleton birth, and vaginal delivery were positively correlated with higher performance regarding the proposed algorithm, except for the gestational age. CONCLUSION: This work provides a novel attention optimized algorithm for rapid and accurate ventricular dilatation predictions. It surpasses the traditional algorithms in terms of validity whether concerning the coronal plane, parasagittal plane, or overall performance. The overall performance of algorithms will be influenced by the baseline characteristics of populations.

Improving the future of clinical trials and translation of mesenchymal stromal cell therapies for neonatal disorders.

Despite recent advances in neonatal intensive care medicine, neonatal disorders such as (bronchopulmonary dysplasia [BPD], intraventricular hemorrhage [IVH], and hypoxic ischemic encephalopathy [HIE]) remain major causes of death and morbidity in survivors, with few effective treatments being available. Recent preclinical studies have demonstrated the pleiotropic host injury-responsive paracrine protective effects of cell therapy especially with mesenchymal stromal cells (MSCs) against BPD, IVH, and HIE. These findings suggest that MSCs therapy might emerge as a novel therapeutic modality for these currently devastating neonatal disorders with complex multifactorial etiologies. Although early-phase clinical trials suggest their safety and feasibility, their clinical therapeutic benefits have not yet been proven. Therefore, based on currently available preclinical research and clinical trial data, we focus on critical issues that need to be addressed for future successful clinical trials and eventual clinical translation such as selecting the right patient and optimal cell type, route, dose, and timing of MSCs therapy for neonatal disorders such as BPD, HIE, and IVH.

Decrease in the Internal Cerebral Vein Pulsation With Improvement of Patent Ductus Arteriosus in Premature Infants at the Risk of Intraventricular Hemorrhage: Two Interesting Case Reports.

Recently, augmenting the pulsation of the internal cerebral vein (ICV) has been reported to be a predictor of premature intraventricular hemorrhage (IVH); however, prophylaxis for IVH has not yet been established. Venous pulsation is a marker of central venous pressure elevation and may be improved after heart failure treatment. Herein, we report two cases of low-birth-weight infants (29 weeks and 31 weeks of gestational age), who exhibited improvements in ICV pulsation with relief of hemodynamically significant patent ductus arteriosus (hs-PDA) following indomethacin administration. ICV flow patterns were continuously flat early after birth. Thereafter, both patients demonstrated ICV pulsation augmentation with PDA progression and brain natriuretic peptide (BNP) elevation at 52 h and 39 h after birth (in infants born at 29 and 31 weeks of gestational age, respectively). After relieving PDA with indomethacin administration, both infants exhibited an improvement in ICV pulsation with decreased BNP levels. In both cases, ICV pulsation increased when PDA became hemodynamically significant with BNP elevation, and the pulsation improved by reduction in ductal flow with decreasing BNP when PDA was relieved by indomethacin administration. The association between hs-PDA and elevated ICV pulsation indicates that hs-PDA likely leads to heightened central venous pressure. Additionally, indomethacin treatment was effective in reducing the exacerbated ICV pulsation caused by heart failure due to hs-PDA. These cases suggest that treatment for heart failure might improve the augmented ICV pulsation, which is related to the development of premature IVH. However, further studies are needed to confirm this association.

Regional cerebral oxygen saturation variability and brain injury in preterm infants.

Objective: To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants. Study design: A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury. Results: The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury. Conclusions: In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.

Deep learning models for separate segmentations of intracerebral and intraventricular hemorrhage on head CT and segmentation quality assessment.

BACKGROUND: The volume measurement of intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) provides critical information for precise treatment of patients with spontaneous ICH but remains a big challenge, especially for IVH segmentation. However, the previously proposed ICH and IVH segmentation tools lack external validation and segmentation quality assessment. PURPOSE: This study aimed to develop a robust deep learning model for the segmentation of ICH and IVH with external validation, and to provide quality assessment for IVH segmentation. METHODS: In this study, a Residual Encoding Unet (REUnet) for the segmentation of ICH and IVH was developed using a dataset composed of 977 CT images (all contained ICH, and 338 contained IVH; a five-fold cross-validation procedure was adopted for training and internal validation), and externally tested using an independent dataset consisting of 375 CT images (all contained ICH, and 105 contained IVH). The performance of REUnet was compared with six other advanced deep learning models. Subsequently, three approaches, including Prototype Segmentation (ProtoSeg), Test Time Dropout (TTD), and Test Time Augmentation (TTA), were employed to derive segmentation quality scores in the absence of ground truth to provide a way to assess the segmentation quality in real practice. RESULTS: For ICH segmentation, the median (lower-quantile-upper quantile) of Dice scores obtained from REUnet were 0.932 (0.898-0.953) for internal validation and 0.888 (0.859-0.916) for external test, both of which were better than those of other models while comparable to that of nnUnet3D in external test. For IVH segmentation, the Dice scores obtained from REUnet were 0.826 (0.757-0.868) for internal validation and 0.777 (0.693-0.827) for external tests, which were better than those of all other models. The concordance correlation coefficients between the volumes estimated from the REUnet-generated segmentations and those from the manual segmentations for both ICH and IVH ranged from 0.944 to 0.987. For IVH segmentation quality assessment, the segmentation quality score derived from ProtoSeg was correlated with the Dice Score (Spearman r = 0.752 for the external test) and performed better than those from TTD (Spearman r = 0.718) and TTA (Spearman r = 0.260) in the external test. By setting a threshold to the segmentation quality score, we were able to identify low-quality IVH segmentation results by ProtoSeg. CONCLUSIONS: The proposed REUnet offers a promising tool for accurate and automated segmentation of ICH and IVH, and for effective IVH segmentation quality assessment, and thus exhibits the potential to facilitate therapeutic decision-making for patients with spontaneous ICH in clinical practice.

Intervention at an early threshold for post-hemorrhagic ventricular dilatation in preterm infants: a systematic review and meta-analysis.

BACKGROUND: Very few adequately powered studies exploring early thresholds for intervention in the management of post-hemorrhagic ventricular dilatation (PHVD) in preterm infants have identified consistent neurodevelopmental advantages at 12-30 months. We aimed to conduct a meta-analysis on the efficacy and safety of early versus conservative thresholds for intervention, primarily aimed at normalizing cerebrospinal fluid (CSF) pressure, in the management of PHVD in preterm infants. METHODS: Multiple databases were searched for eligible papers, and prospective randomized trials involving preterm infants were selected. The results are expressed as relative risks (RRs) with 95% confidence intervals (CIs). The main outcome was survival without moderate-to-severe neurodevelopmental impairment at 12-30 months. RESULTS: Ten articles representing seven randomized trials comparing early versus conservative thresholds for interventions were included. Five trials (n = 545 infants) reported no difference in the main outcome between early and conservative groups [RR 0.99 (0.71, 1.37)]. Sensitivity analysis excluding data from a medication trial did not alter the main outcome [RR 1.15 (0.95, 1.39)]. Infants in the early threshold group received significantly more interventions [RR 1.48 (1.05, 2.09)]. Deaths before discharge/during the initial study period [RR 1.04 (0.70, 1.54)] or a composite of death or shunt insertion [RR 1.04 (0.86, 1.27)] were comparable between the two groups. CONCLUSIONS: Early intervention for PHVD, before a clinical or ultrasound threshold is met, leads to additional clinical procedures but does not improve survival without moderate-severe neurodevelopmental impairment at 12-30 months. Caution should be exercised in interpreting these results due to significant variation between the studies. Supplementary file 3 (MP4 131172 kb).

Regional variations in morbidity and mortality among neonates with intraventricular hemorrhage: a national database analysis.

BACKGROUND: Intraventricular hemorrhage (IVH) often affects newborns of low gestational age and low birth weight, requires critical care for neonates, and is linked to long-term neurodevelopmental outcomes. Assessing regional differences in the U.S. in care for neonatal IVH and subsequent outcomes can shed light on ways to mitigate socioeconomic disparities. METHODS: Using the 2016-2019 National Inpatient Sample (NIS), patients with a primary diagnosis of IVH were identified using ICD-10-CM codes. A retrospective cohort study was conducted with patients stratified by hospital region. Demographics, comorbidities, presentation, intraoperative variables, and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of insurance status on extended LOS (defined as > 75th percentile of LOS), exorbitant cost (defined as > 75th percentile of cost), and mortality. RESULTS: Included in this study were 1630 newborns with IVH. A larger portion of patients in the South and Midwest were Black, compared to the Northeast and West (Northeast: 12.2% vs Midwest: 30.2% vs South: 22.8% vs West: 5.8%, p < 0.001), while a greater percentage of patients in the West and South were Hispanic (Northeast: 7.3% vs Midwest: 9.5% vs South: 22.8% vs West: 36.2%, p < 0.001). LOS was similar among all regions. Factors associated with prolonged LOS included hydrocephalus and CSF diversions. Median total cost of admission was highest in the West, while the South was associated with decreased odds of exorbitant cost. LOS was associated with exorbitant cost, and large bed-volume hospital, VLBW, and permanent CSF shunt were associated with mortality. CONCLUSIONS: Demographic variables, but not presenting or intraoperative variables, differed among regions, pointing to possible geographic health disparities. The West had the highest total cost of admission, while the South was associated with reduced odds of exorbitant admission costs.

Extracorporeal Membrane Oxygenation Before 34 Wks' Gestation: A Single-Center Experience.

INTRODUCTION: Traditionally, gestational age <34 wk and weight <2 kg are considered relative contraindications to extracorporeal membrane oxygenation (ECMO). There is a paucity of information that explains the outcomes in this unique population of premature neonates. The purpose of this study is to examine outcomes of patients who undergo ECMO at <34 wk at a single institution. METHODS: A single-center retrospective review was performed for neonates managed with ECMO in the neonatal intensive care unit from January 2012 to April 2022. Characteristics and outcome data were collected. The primary outcome studied was survival at discharge. Secondary outcomes were intraventricular hemorrhage, ischemic brain injury, and thrombosis. Data were analyzed with descriptive statistics. RESULTS: Following exclusion, 107 patients were included with eight having initiating ECMO at <34 wk. Three (38%) patients, who received ECMO at <34 wk, incurred intraventricular hemorrhages compared to 14 (14%) in the ≥34-wk cohort. Two (25%), who underwent ECMO at <34 wk, exhibited signs of brain ischemia on imaging compared to 9 (9%) in those ≥34 wk, and 3 (38%) patients <34 wk experienced thrombosis compared to 31 (31%) in the ≥34-wk cohort. Five (63%) of those in the <34-wk cohort survived to discharge, similar to 61 (61%) in the ≥34 wk cohort. CONCLUSIONS: Our data suggest that EGA <34 wk may not be a contraindication for ECMO, with appropriate counseling of potential risks.

Serial Diffusion Tensor Imaging and Rate of Ventricular Blood Clearance in Patients with Intraventricular Hemorrhage.

BACKGROUND: We developed a noninvasive biomarker to quantify the rate of ventricular blood clearance in patients with intracerebral hemorrhage and extension to the ventricles-intraventricular hemorrhage. METHODS: We performed magnetic resonance imaging in 26 patients at 1, 14, 28, and 42 days of onset and measured their hematoma volume (HV), ventricular blood volume (VBV), and two diffusion metrics: fractional anisotropy (FA), and mean diffusivity (MD). The ipasilesional ventricular cerebral spinal fluid's FA and MD were associated with VBV and stroke severity scores (National Institute of Health Stroke Scale [NIHSS]). A subcohort of 14 patients were treated with external ventricular drain (EVD). A generalized linear mixed model was applied for statistical analysis. RESULTS: At day 1, the average HVs and NIHSS scores were 14.6 ± 16.7 cm3 and 16 ± 8, respectively. A daily rate of 2.1% and 1.3% blood clearance/resolution were recorded in HV and VBV, respectively. Ipsilesional ventricular FA (vFA) and ventricular MD (vMD) were simultaneously decreased (vFA = 1.3% per day, posterior probability [PP] > 99%) and increased (vMD = 1.5% per day, PP > 99%), respectively. Patients with EVD exhibited a faster decline in vFA (1.5% vs. 1.1% per day) and an increase in vMD (1.8% vs. 1.5% per day) as compared with patients without EVD. Temporal change in vMD was associated with VBV; a 1.00-cm3 increase in VBV resulted in a 5.2% decrease in vMD (PP < 99%). VBV was strongly associated with NIHSS score (PP = 97-99%). A larger cerebral spinal fluid drained volume was associated with a greater decrease (PP = 83.4%) in vFA, whereas a smaller volume exhibited a greater increase (PP = 94.8%) in vMD. CONCLUSIONS: In conclusion, vFA and vMD may serve as biomarkers for VBV status.

Introduction of Solid Foods in Preterm Infants and Its Impact on Growth in the First Year of Life-A Prospective Observational Study.

The aim of this study was to investigate whether age at introduction of solid foods in preterm infants influences growth in the first year of life. This was a prospective observational study in very low birth weight infants stratified to an early (<17 weeks corrected age) or a late (≥17 weeks corrected age) feeding group according to the individual timing of weaning. In total, 115 infants were assigned to the early group, and 82 were assigned to the late group. Mean birth weight and gestational age were comparable between groups (early: 926 g, 26 + 6 weeks; late: 881 g, 26 + 5 weeks). Mean age at weaning was 13.2 weeks corrected age in the early group and 20.4 weeks corrected age in the late group. At 12 months corrected age, anthropometric parameters showed no significant differences between groups (early vs. late, mean length 75.0 vs. 74.1 cm, weight 9.2 vs. 8.9 kg, head circumference 45.5 vs. 45.0 cm). A machine learning model showed no effect of age at weaning on length and length z-scores at 12 months corrected age. Infants with comorbidities had significantly lower anthropometric z-scores compared to infants without comorbidities. Therefore, regardless of growth considerations, we recommend weaning preterm infants according to their neurological abilities.

Associations between diffusion kurtosis imaging metrics and neurodevelopmental outcomes in neonates with low-grade germinal matrix and intraventricular hemorrhage.

Diffusion Kurtosis Imaging (DKI)-derived metrics are recognized as indicators of maturation in neonates with low-grade germinal matrix and intraventricular hemorrhage (GMH-IVH). However, it is not yet known if these factors are associated with neurodevelopmental outcomes. The objective of this study was to acquire DKI-derived metrics in neonates with low-grade GMH-IVH, and to demonstrate their association with later neurodevelopmental outcomes. In this prospective study, neonates with low-grade GMH-IVH and control neonates were recruited, and DKI were performed between January 2020 and March 2021. These neonates underwent the Bayley Scales of Infant Development test at 18 months of age. Mean kurtosis (MK), radial kurtosis (RK) and gray matter values were measured. Spearman correlation analyses were conducted for the measured values and neurodevelopmental outcome scores. Forty controls (18 males, average gestational age (GA) 30 weeks ± 1.3, corrected GA at MRI scan 38 weeks ± 1) and thirty neonates with low-grade GMH-IVH (13 males, average GA 30 weeks ± 1.5, corrected GA at MRI scan 38 weeks ± 1). Neonates with low-grade GMH-IVH exhibited lower MK and RK values in the PLIC and the thalamus (P < 0.05). The MK value in the thalamus was associated with Mental Development Index (MDI) (r = 0.810, 95% CI 0.695-0.13; P < 0.001) and Psychomotor Development Index (PDI) (r = 0.852, 95% CI 0.722-0.912; P < 0.001) scores. RK value in the caudate nucleus significantly and positively correlated with MDI (r = 0.496, 95% CI 0.657-0.933; P < 0.001) and PDI (r = 0.545, 95% CI 0.712-0.942; P < 0.001) scores. The area under the curve (AUC) were used to assess diagnostic performance of MK and RK in thalamus (AUC = 0.866, 0.787) and caudate nucleus (AUC = 0.833, 0.671) for predicting neurodevelopmental outcomes. As quantitative neuroimaging markers, MK in thalamus and RK in caudate nucleus may help predict neurodevelopmental outcomes in neonates with low-grade GMH-IVH.