Inhaled nitric oxide (iNO) enhances ventilation in very preterm infants, but the effects on the brain remain uncertain. We evaluated the impact of iNO on brain growth and cerebral injury in a premature baboon model. Baboons were delivered at 125 d of gestation (term 185 d of gestation) and ventilated for 14 d with either positive pressure ventilation (PPV) (n ϭ 7) or PPV ϩ iNO (n ϭ 8).Brains were assessed histologically for parameters of development and injury. Compared with gestational controls (n ϭ 7), brain and body weights were reduced but brain-to-body weight ratios were increased in all prematurely delivered (PD) animals; the surface folding index (SFI), was reduced in PPV but not PPV ϩ iNO animals. Compared with controls, the brain damage index was increased (p Ͻ 0.05) in both cohorts of PD animals. There was no difference between ventilatory regimens, however, in 25% of animals with iNO therapy, there were organized hematomas in the subarachnoid space. Overall, iNO did not alter the extent of brain damage but did result in the presence of hematomas. These results do not confirm any protective or major injurious effect of nitric oxide therapy on the developing brain. N ew ventilatory strategies are one of the most important advances contributing to the increased survival rates for premature infants over the past few decades; however, the effects of these strategies on the developing brain are not completely understood. As the increased survival rates are associated with a high rate of poor neurodevelopmental outcome (1,2), understanding the effects of these therapies on the developing brain is crucial.iNO therapy improves oxygenation and reduces the need for extracorporeal membrane oxygenation in term infants (3). However, the benefits of this therapy in preterm infants with respiratory failure are controversial. Potential short-term benefits have been demonstrated including improved arterial oxygenation, a lowering of pulmonary vascular resistance, and a reduction in the duration of mechanical ventilation (4,5).Contrary to the original dogma that iNO was a specific pulmonary vasodilator without systemic effects, it now appears that iNO may have downstream effects (6).Studies reporting on the impact of iNO on the risk of cerebral injury in the preterm infant are conflicting. With relation to periventricular leukomalacia (PVL), iNO therapy has been reported to decrease the severity (7), but not change the incidence (8). For intraventricular hemorrhage (IVH)/ intracranial hemorrhage (ICH), iNO has been reported to decrease the incidence of severe hemorrhages (5,7) and to cause no change in the overall incidence (7), no change in the severity (8), and no change in the progression of the hemorrhage (9). In the study of van Meurs et al. (8), infants that were Ͻ1000 g had increased rates of severe ICH, but the timing of the occurrence of the hemorrhages, whether before commencement of iNO therapy, was not certain. iNO has also been reported to cause no change in the evolution of brain injury (10).In r...