A Uniform Description of Perioperative Brain MRI Findings in Infants with Severe Congenital Heart Disease: Results of a European Collaboration

Abstract

BACKGROUND AND PURPOSE:A uniform description of brain MR imaging findings in infants with severe congenital heart disease to assess risk factors, predict outcome, and compare centers is lacking. Our objective was to uniformly describe the spectrum of perioperative brain MR imaging findings in infants with congenital heart disease. MATERIALS AND METHODS:Prospective observational studies were performed at 3 European centers between 2009 and 2019. Brain MR imaging was performed preoperatively and/or postoperatively in infants with transposition of the great arteries, singleventricle physiology, or left ventricular outflow tract obstruction undergoing cardiac surgery within the first 6 weeks of life. Brain injury was assessed on T1, T2, DWI, SWI, and MRV. A subsample of images was assessed jointly to reach a consensus. RESULTS:A total of 348 MR imaging scans (180 preoperatively, 168 postoperatively, 146 pre-and postoperatively) were obtained in 202 infants. Preoperative, new postoperative, and cumulative postoperative white matter injury was identified in 25%, 30%, and 36%; arterial ischemic stroke, in 6%, 10%, and 14%; hypoxic-ischemic watershed injury in 2%, 1%, and 1%; intraparenchymal cerebral hemorrhage, in 0%, 4%, and 5%; cerebellar hemorrhage, in 6%, 2%, and 6%; intraventricular hemorrhage, in 14%, 6%, and 13%; subdural hemorrhage, in 29%, 17%, and 29%; and cerebral sinovenous thrombosis, in 0%, 10%, and 10%, respectively. CONCLUSIONS:A broad spectrum of perioperative brain MR imaging findings was found in infants with severe congenital heart disease. We propose an MR imaging protocol including T1-, T2-, diffusion-, and susceptibility-weighted imaging, and MRV to identify ischemic, hemorrhagic, and thrombotic lesions observed in this patient group. ABBREVIATIONS: AIS ¼ arterial ischemic stroke; CHD ¼ severe congenital heart disease; CSVT ¼ cerebral sinovenous thrombosis; IVH ¼ intraventricular hemorrhage; KCL ¼ St. Thomas' Hospital London; LVOTO ¼ left ventricular outflow tract obstruction; SVP ¼ single ventricle physiology; TGA ¼ transposition of the great arteries; UCZ ¼ University Children's Hospital Zurich; WKZ ¼ Wilhelmina Children's Hospital Utrecht; WMI ¼ white matter injury T he incidence of patients with severe congenital heart disease (CHD), presenting as severely ill and requiring expert cardiologic care in the neonatal period or early infancy is around 3/1000 live births. 1 Mortality among infants has declined in recent decades, and 90% of children with CHD now survive into adulthood. 2,3

Risk Factors for Perioperative Brain Lesions in Infants With Congenital Heart Disease: A European Collaboration

“…New postoperative AIS was associated with younger age at surgery (7 [6-9] versus 11 [7][8][9][10][11][12][13][14][15] S4).…”

“… 5 – 7 White matter injury (WMI) and arterial ischemic stroke (AIS) are most commonly reported, 8 , 9 , 11 however, cerebral sinus venous thrombosis (CSVT), hypoxic-ischemic watershed injury, and intraparenchymal hemorrhage are also observed. 12 , 13 …”

“…Here, we assessed risk factors for preoperative and new postoperative AIS, CSVT, and WMI, due to their common occurrence and potential impact on neurodevelopment, in infants with CHD requiring cardiac surgery <6 weeks after birth. 13 …”

Neonatal frontal-limbic connectivity is associated with externalizing behaviours in toddlers with Congenital Heart Disease

“…MRI studies have identified both acquired brain lesions ( Beca et al, 2013 , Kelly et al, 2019a , Miller et al, 2007 , Stegeman et al, 2021 ) and impaired brain development in infants with CHD. In particular, brain volumes are reduced ( Bouyssi-Kobar et al, 2012 , Limperopoulos et al, 2010 , Ng et al, 2020 , von Rhein et al, 2015 ) and development of the cortex is impaired compared to healthy controls ( Kelly et al, 2017 , Kelly et al, 2019b ).…”

Proton magnetic resonance spectroscopy assessment of neonatal brain metabolism during cardiopulmonary bypass surgery

“…The potential for neuronal injury remains an ongoing concern for both children and adult patients requiring cardiopulmonary bypass (CPB) heart surgery. 1,2 Postoperative MRI findings have consistently reported multiple abnormalities believed to be associated with ischemic events, [3][4][5] and studies of cognitive function have consistently found neurodevelopment deficits. 6 For decades, cooling via deep hypothermia circulatory arrest (DHCA) has been used to reduce brain metabolism and associated metabolic needs during these surgeries.…”