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Three Part Question

In [preterm or lowbirth weight infants] is [neonatal cranial ultrasound scan good] at [predicting longterm neurodevelopmental outcome]?

Clinical Scenario

A 25-week preterm infant is born by a normal vaginal delivery. His apgars at birth are 3 at 1 minute and 7 at 5 minutes of age. He is intubated and given a dose of surfactant and is transferred to a neonatal intensive care unit. You have done a cranial ultrasound scan which suggested a marked intraventricular haemorrhage with parenchymal involvement. Parents want to know how far this scan result will influence their child's neurodevelopment at a later stage???

Search Strategy

Primary source-Medline 1966-2004, using the Dialog Datastar
Secondary source-Google
Primary source-"(( ( ultrasound OR ultrasonography ) .TI. ) AND LG=EN AND HUMAN=YES) AND (( preterm OR low ADJ birth ADJ weight ) .TI.) AND (( ( neurodevelopmental OR outcome ) .TI. ) AND LG=EN AND HUMAN=YES)":
Secondar source –Google, Key words 'neonatal cerebral ultrasound' and 'neurological diability'

Search Outcome

20 papers were found with Medline of which 8 articles were relevent to address the 3 part question. One more article was found with Google which was also suitable for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fawer-C-L, Calame-A, Furrer-M-T. 1985 switzerland	82 preterm infants less than 34 week's gestation born between april 82 to march 83	prospective cohort study	normal ultrasound	14% chance of abnormal neurodevelopmental outcome	Small number It is not clearly stated as to who were doing the ultrasound scans and who performed the neurological assessment and wheher they were blinded or not. Follow-up was not sufficiently long enough to pick up all the cases of neurological disability
			Isolated haemorrhages	20% chane of abnormal neurodevelopmental outcome
			periventricular haemorrhage+periventricular leucomalacia+ventricular dilatation+cerebral atrophy	53 % chance of abnormal neurodevelopmental outcome
Stewart A L etal 1983 UCH,London	Preterm infants born less than 33 week were studied prospectively with ultrasound and neurodevelopmnetal assessment was carried out at 18 months of age	prospective cohort study	normal ultrasound scan	8 % chance of abnormality
			uncomplicated periventriculr haemorrhage(PVH)	8 % chance of abnormality
			ventricular enlargement +/- PVH	38% chance of abnormality
			hydrocephalus + PVH	75% chance of abnormality
			cerebral atrophy	100% chance of abnormality
Chaudhari S, Kinare A S etal.. 1995 India	Preterm infants with gestational age less than 37 week born between jan 1991 to july 1992 had Ultrasound scans and neurodevelopmenatal outcome assessed at 1year and 2 years of age	prospective cohort	correlation between USG findings at term and neurodevelopmental outcome	sensitivity ----14.28%	Small numbers. It is unclear as to who is actually performing the ultrasound scan. Sensitivity and positive predictive value is low in the study due to small number of infants with positive findings.
				specificity ----89.2%
				positive predictive value---12.5%
				negative predictive value---90.6%
Khalid Aziz, David B. Vickar etal.. 1995 canada	669 one year surviving preterm infants with birthweight 500 through 1249 g born between Jan 1,1987 and Dec 31,1990	Prospective cohort study	Disability with abnormal scan	36.7%	Unclear as to who were assessing disability and whether they were blinded or not. Follow up was not sufficiently long enough to account for all the cases neurodevelopmental outcome.
			Disability with normal scan	8.9%
			Those with combination of trnsient intraparenchymal periventricular echodensity,Cerebral Ventriculomegaly,and Periventricular leucomalacia	46% disabled
Ong LC, Boo NY etal 1997 Malaysia	All Newborns with birth weight less than 1500 gms delivered between Dec 1989 and 31 Dec 1992 had cranial U/S done done during neonatal period and neurodevelopmental assessment at 12 months of age	prospective cohort study	Early scan ( Scan done on 5th day of life)	Grade 3 IVH/Periventricular echodensity)---84.6%(mostly major disability)	Unclear who did the assessment and whether they were blinded or not. Follow up was not sufficiently long enough to account for all the cases neurodevelopmental outcome. The small number of the patients in the study did not permit whether venbtrivular size or parenchymal lesion was better in predicting the outcome
				Grade1 and 2 IVH ---25%(mostly minor disabilty)
			Late scan(at the time of discharge)	Uncomplicated (Normal+Resolving IVH+Transient Ventriculomegaly)---21.9%(mostly minor disability)
				complicated scan(ventriculomegaly+Hydrocephalus+cerebral atrophy)---60.7%(mostly major disability)
Stewart A, Kirkbride V etal... 1996 U.C.H ,London ,U.K	cohort of preterm infants (<33 weeks) who survived between 1979 and 1991 Neurodevelopmental assessment was done at 1 ,8 and 14 years	prospective cohort study	unfavourable neonatal scan(ventricular dilatation+hydrocephalus+intraparenchymal haemorrhagic cysts+generalized atrophy)	sensitivity(64%) and specificity(87%) of disabling impairement
				14 year study was still at an early stage as there were insufficient numbers to calculate predictive indices for neonatal ultrasound scan
Jennifer A Pinto-Martin et al.. 1999 USA	All infants weighing between 501gm to 2000gm who were cared in one of the neonatal intensive care units of new Jersey between sep 1984 to jun 1987 Motor and cognitive assessment were carried at 2 ,6 and 9 years	prospective cohort study	Infants with parenchymal lesion or ventricular enlargement	poorer motor response with all ages and there was no difference with respect to the cognitive ability	Unclear whether the person doing the motor and cognitive assessment were blinded or not.
			Infants with no abnormality or isolated GMH or IVH	good motor and cognitive respose at all ages
Roth S C, Baudin J et al 1993 UCH,London ,U.K	Preterm infants born less than 33 week who survive dfollowing treatment in the years 1979,1981,1982 neurodevelopmental assessment at 8 years of age	prospective cohort study	favourable ultrasound scan(normal+uncomplicated PVH)	Impairment--Total(26%) and Major(5%)
			ventricular dilatation+hydrocephalus+cerebral atrophy	Impairment--Total(72%) and Major(41%)
			cerebral atrophy	20 fold increase in the probability of major impairment
Costello A M, Hamilton P A, et al... 1988 UCH,London,U.K	Survivng preterm infants born at less than 33 weeks gestation who were admitted in the years 1979 to 1981 neurological assessment at 4 years of age	prospective cohort study	Normal ultrasound scan/uncomplicated PVH	Impairment--total(22%) and major(7%)
			ventricular dilatation	Impairment---total(50%) and Major(33%)
			hydrocephalus/cerebral atrophy	Impairment---Total(69%) and Major(56%)

Comment(s)

There are number of factors which will determine the neurodevelopmental outcome of preterm or low birth weight infants. One of them being the neonatal cranial ultrasound scan. Brain of a preterm or low birth weight infant is highly susceptible to an insult from ischemic, haemorrhagic and infective factors. Abnormal outcome is associated with both haemorrhagic and ischemic lesion but the severity of the disability depends to a larger extent on the type of the cranial ultrasound appearance in the neonate. Several studies have been published in the literature looking at the neonatal cranial ultrasound appearances and the neurodevelopmental outcome at a later stage. Most of these studies differed with respect to the timing and method of assessing neurodevelopmental outcome. It was also noted from the literature that different systems have been used to classify and grade the ultrasound appearances. This has been proven beyond doubt that neonatal cranial ultrasound scan does play a major role in predicting the neurodevelopmental outcome. The infants who had a normal and an uncomplicated IVH on cranial ultrasound had a good prognosis. How ever these infants did have a lesser chance of neurodevelopmental disability later on but it was most often associated with a minor disability. It has also been shown that the infants who had ventricular dilatation, hydrocephalus, cerebral atrophy, periventricular leucomalacia at the time of discharge carried a poor prognosis and the neurodevelomental outcome was adversely affected by these perinatal ischemic white matter injury. Neonatal cranial ultrasound scan does provide a relatively sensitive and highly specific means of predicting the neurodevelopmental disability at a later stage in preterm and lowbirthweight infants.

Clinical Bottom Line

Although there are number of factors which will determine the neurodevelopmental outcome in a preterm or low birthweight infant, but the neonatal cranial ultrasound scan does play a major role in predicting the neurodevelopmental outcome.

References

1. Fawer-C-L, Calame-A, Furrer-M-T. Neurodevelopmental outcome at 12 months of age related to cerebral ultrasound appearances of high risk preterm infants. Early human development 1985 Jul, VOL: 11 (2), P: 123-32
2. Stewart A L, Thorburn R , Hope , Goldsmith M, Lipscomb A P, Reynolds E O. Ultrasound appearance of the brain in very preterm infants and neurodevelopmental outcome at 18 months of age. Archives of disease in childhood 1983 Aug, VOL: 58 (8), P: 598-604 ISSN: 1468-2044.
3. Chaudhari S, Kinare A S, Kumar R, Pandit A N, Deshpande M. Ultrasonography of the brain in preterm infants and its correlation with neurodevelopmental outcome Indian pediatrics 1995 Jul, VOL: 32 (7), P: 735-42, ISSN: 0019-6061
4. Khalid Aziz, David B. Vickar, Reginald S. Sauve, Philip C. Etches, Kerrie S. Pain and Charlene M T Robertson Province-Based study of neurological disability of children weighing 500 through 1249 grams at birth in relation to neonatal cerebral ultrasound findings. Pediatrics 1995 June, Vol :95(6),page 837-844
5. Ong LC, Boo NY, Chandran V, Zulfiqar A, Zamratol SM, Allison L, Teoh SL, Nyein MK, Lye MS. Neurodevelopmental outcome of Malaysian very low birth weight infants: predictive value of cranial ultrasound appearances. Singapore Med J. 1997 Mar;38(3):108-11
6. Stewart A, Kirkbride V Very preterm infants at fourteen years: relationship with neonatal ultrasound brain scans and neurodevelopmental status at one year. Acta paediatrica. Supplement 1996 Oct, VOL: 416, P: 44-7, ISSN: 0803-5326
7. Jennifer A Pinto-Martin, Agnes H Whitaker, Judit F feldman, NIGEL pANETH Relation of cranial ultrasound abnormalities in low birth weight infants to motor or cognitive performance at ages 2, 6 and 9 years Developmental medicine and Child Neurology 1999,41:826-833
8. Roth S C, Baudin J, McCormick D C, Edwards A D, Townsend J, Stewart A L, Reynolds E O Relation between ultrasound appearance of the brain of very preterm infants and neurodevelopmental impairment at eight years. Developmental medicine and child neurology 1993 Sep, VOL: 35 (9), P: 755-68, ISSN: 0012-1622.
9. Costello A M, Hamilton P A, Baudin J, Townsend J, Bradford B C, Stewart A L, Reynolds E O. Prediction of neurodevelopmental impairment at four years from brain ultrasound appearance of very preterm infants. Developmental medicine and child neurology 1988 Dec, VOL: 30 (6), P: 711-22, ISSN: 0012-1622.