This study aimed to compare the ability of serial cranial ultrasounds (CUS) and early MRI scans in detecting preterm brain injuries. The study found that CUS allowed for more scans due to better feasibility in the NICU, and was better at detecting grade I-II intraventricular hemorrhages and perforator strokes. MRI was superior for identifying smaller cerebellar hemorrhages and provided more quantitative data. Overall, the combination of serial CUS and MRI provided the highest sensitivity for detecting common preterm brain injuries, though MRI could not be performed in the sickest infants.

2. JOURNAL CLUB
Dr Inayat Ullah
PG Résident Pediatrics

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

4. Reference
 Plasier A, Rates MMA, Ecury-Gosson GM,
et al. Arch Dis Child Fetal Neonatal Ed
2015; 100:F293-F300.

5. Institute of Study
 Division of Neonatology, Department of
Pediatrics, Erasmus Medical Center-Sophia,
Rotterdam, The Netherlands.
 Department of Radiology, Erasmus Medical
Center, Rotterdam, The Netherlands
 Department of Pediatrics, Koningin Paola
Children’s Hospital, Antwerp, Belgium
 Division of Pediatric Neurology,department of
neurology, Erasmus Medical Center Rotterdam
The Netherlands.

6. OUTLINE
o Background
o Objective
o Hypothesis
o Method
o Result
o Discussion
o Conclusion
o Already Known About Topic?
o This Study Adds?

7. BACKGROUND
 Neurodevelopmental problems are
common in preterm infants. Early objective
diagnosis is important for prognostication
and decision making in NICU.MRI is suited
for quantitative assesment of injury and can
provide insight into pathogenesis of
preterm brain injury,

8. BACKGROUND Cont…
 MRI is considered the best method to
consider and quantify diffuse non cystic
white matter injury WMI.
 MRI is however, expensive time
consuming, and challenging for critically ill
infants.

9. BACKGROUND Cont
 Cranial Ultrasonography CUS is relatively cheap directly
available, and allowes serial bedside scanning with
limited disturbances of infant.
 CUS is used to detect germinal matrix hemorrhage and
intraventricular hemorrhage (GMH-IVH), and
periventicular leukomalacia PVL.
 Ultrasound is however , observer dependent, and the
challenge of reproducible objective measurements and
problems to detect posterior fossa abnormalities and
cerebral cortical changes.

10. BACKGROUND Cont
 Based on comparative studies between
MRI nd CUS regarding abilities to predict
outcome, MRI is proposed the imaging
method of choice for high risk preterm
infants.
 However these studies donot use acoustic
window, high resolution USG and doppler
Imaging-as recommended by others.

11. OBJECTIVE
To investigate detection ability and
feasibility of serial cranial
ultrasonography and early MRI in
preterm brain injury.

12. Hypothesis
 Dedicated advanced cranial
ultrasonography (CUS) is equally effective
as a single routine MRI scan at 30 weeks’
PMA to diagnose common brain lesions in
preterm infants and has higher clinical
availability.

13. Method
 Study design: Prospectve cohort study

14. Method conti
 Serial cranial USG 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.

15. Method conti
Inclusion criteria:
Infants born below 29 weeks GA were
recruited prospectively.
Exclusion criteria:
Congenital malformation
Uncertainty regarding GA.
Refusal of parental informed consent.

16. Method conti
CUS and MRI were assessed for signs of
preterm brain injury by experienced investigators
independently using detailed classification
system that covers the types of brain injury.
IVH was graded according to Volpe.
WMI was classified to cystic PVL and diffuse
non-cystic WMI.
Cerebellar hemorrhages were calssified into folial
or lobar hemmorhages.

18. Results
 Serial CUS was performed in all infants;
early MRI was often postponed (n=59)
cancelled (n=126).
 Injury was found in 146 infants 47.6%.
Clinical characteristic differed significantly
between groups that were subdivided
according to timing of MRI.

19. Results
 61 discrepant imaging findings were found.
 MRI was superior in identifying cerebellar
hemorrhages, perforator stroke and
cerebellar sinovenous thrombosis CSVT.

20. Result cont

21. Study limitations
 Exclusion of deceased patient, and those
referred to another hospital before MRI.
 Inability to calculate sensitivity of MRI CUS
 Inability to perform MRI in sick infants.

22. Discussion
 The study demonstrates high number of
preterm infants with detectable brain injury
47.6%.
 CUS has higher clinical faesibility than
MRI, which cannot always be performed in
severly ill infants.
 This study demonstrates the complementry
role of both imaging modalities to detect
common preterm brain injuries.

23. Discussions.
 MRI was better to detct GMH and posterior
fassa abnormalities, whereas CUS was
better at grade I-II IVH, perforator stroke.
 Comprehensive application of CUS, usage
of supplemental acoustic windows,colur
doppler.high transducer frequency and
careful interpretation of images by
experienced sonologist result in high
accuracy in identifying certain lesion.

24. Discussions.
 Serial CUS outperformed MRI scanning in
diagnosing focal lesion in 27 infants,
because of high sensetivity of detcting
perforator stroke,and CSVT.
 Higher sensitivty of CUS in detecting grade
II IVH is due to its consective application
and timing of onset of IVH.
 Conventional MRI do not always detect low
grade IVH.

25. CONCLUSION
 Brain injury is frequently encountered in preterm infants 47.6%.
 Advanced CUS is adequate in detecting preterm brain injury and deserves
more appreciation.
 MRI is invaluable because it allowes quantitative assessments of
microstrucral brain properties and superior in detecting post-fossa
abnormalities.
 However clinical use in preterm is limited due to logistics and safety
issues..
 Dual use of sequential CUS and MRI provides high sensitivity to detect
common patterns of preterm brain injury .
 Further research should focus on improvement of their complementary
applications.

26. WHAT'S KNOWN ON THIS SUBJECT
 MRI is considered the optimal imaging
method to identify preterm brain injury,
but clinical circumstances may preclude
its use.
 Cranial ultrasonography (CUS) allows
serial scanning at bedside and technical
developments are improving detection of
injury.

27. WHAT THIS STUDY ADDS
 Combined use of advanced serial CUS
and MRI improves detection of common
patterns of preterm brain injury.
 Compared to MRI, CUS seems more
sensitive for recognising acute
intraventricular hemorrhage , perforator
stroke and sinovenous thrombosis, but less
for small cerebellar hemorrhages.

28. WHAT THIS STUDY ADDS
(cont’d)
 Clinical faesibilty of MRI is limited for
critically ill preterm infants.