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Abnormal Cerebral Structure Is Present at Term in Premature Infants

Terrie E. Inder, MD^*,,, Simon K. Warfield, PhD^||, Hong Wang, Petra S. Hüppi, MD^,¶ and Joseph J. Volpe, MD

^* Murdoch Children’s Research Institute, Royal Women’s and Royal Children’s Hospitals, University of Melbourne, Melbourne, Australia
Howard Florey Institute, University of Melbourne, Melbourne, Australia
^|| Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
^¶ Department of Pediatrics, University of Geneva, Geneva, Switzerland
Department of Neurology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts

Background. Long-term studies of the outcome of very prematurely born infants have clearly documented that the majority of such infants have significant motor, cognitive, and behavioral deficits. However, there is a limited understanding of the nature of the cerebral abnormality underlying these adverse neurologic outcomes.

Aim. The overall aim of this study was to define quantitatively the alterations in cerebral tissue volumes at term equivalent in a large longitudinal cohort study of very low birth weight premature infants in comparison to term-born infants by using advanced volumetric 3-dimensional magnetic resonance imaging (MRI) techniques. We also aimed to define any relationship of such perinatal lesions as white matter (WM) injury or other potentially adverse factors to the quantitative structural alterations. Additionally, we wished to identify the relationship of the structural alterations to short-term neurodevelopmental outcome.

Methods. From November 1998 to December 2000, 119 consecutive premature infants admitted to the neonatal intensive care units at Christchurch Women’s Hospital (Christchurch, New Zealand) and the Royal Women’s Hospital (Melbourne, Australia) were recruited (88% of eligible) after informed parental consent to undergo an MRI scan at term equivalent. Twenty-one term-born infants across both sites were recruited also. Postacquisition advanced 3-dimensional tissue segmentation with 3-dimensional reconstruction was undertaken to estimate volumes of cerebral tissues: gray matter (GM; cortical and deep nuclear structures), WM (myelinated and unmyelinated), and cerebrospinal fluid (CSF).

Results. In comparison to the term-born infants, the premature infants at term demonstrated prominent reductions in cerebral cortical GM volume (premature infants [mean ± SD]: 178 ± 41 mL; term infants: 227 ± 26 mL) and in deep nuclear GM volume (premature infants: 10.8 ± 4.1 mL; term infants: 13.8 ± 5.2 mL) and an increase in CSF volume (premature infants: 45.6 ± 22.1 mL; term infants: 28.9 ± 16 mL). The major predictors of altered cerebral volumes were gestational age at birth and the presence of cerebral WM injury. Infants with significantly reduced cortical GM and deep nuclear GM volumes and increased CSF volume volumes exhibited moderate to severe neurodevelopmental disability at 1 year of age.

Conclusions. This MRI study of prematurely born infants further defines the nature of quantitative cerebral structural abnormalities present as early as term equivalent. The abnormalities particularly involve cerebral neuronal regions including both cortex and deep nuclear structures. The pattern of cerebral alterations is related most significantly to the degree of immaturity at birth and to concomitant WM injury. The alterations are followed by abnormal short-term neurodevelopmental outcome.

Key Words: magnetic resonance imaging • prematurity • neurodevelopmental outcome

Abbreviations: VLBW, very low birth weight • WM, white matter • GM, gray matter • SPGR, spoiled gradient recalled • MR, magnetic resonance • DE, spin-echo sequence • CSF, cerebrospinal fluid • ICV, intracranial volume • IVH, intraventricular hemorrhage • IUGR, intrauterine growth restriction

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