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. 2016 Jun 3;11(6):e0156245.
doi: 10.1371/journal.pone.0156245. eCollection 2016.

MRI Based Preterm White Matter Injury Classification: The Importance of Sequential Imaging in Determining Severity of Injury

Miriam Martinez-Biarge  1 , Floris Groenendaal  2 , Karina J Kersbergen  2 , Manon J N L Benders  2 , Francesca Foti  1 , Frances M Cowan  1 , Linda S de Vries  2
Affiliations

MRI Based Preterm White Matter Injury Classification: The Importance of Sequential Imaging in Determining Severity of Injury

Miriam Martinez-Biarge et al. PLoS One. .

Abstract

Background: The evolution of non-hemorrhagic white matter injury (WMI) based on sequential magnetic resonance imaging (MRI) has not been well studied. Our aim was to describe sequential MRI findings in preterm infants with non-hemorrhagic WMI and to develop an MRI classification system for preterm WMI based on these findings.

Methods: Eighty-two preterm infants (gestation ≤35 weeks) were retrospectively included. WMI was diagnosed and classified based on sequential cranial ultrasound (cUS) and confirmed on MRI.

Results: 138 MRIs were obtained at three time-points: early (<2 weeks; n = 32), mid (2-6 weeks; n = 30) and term equivalent age (TEA; n = 76). 63 infants (77%) had 2 MRIs during the neonatal period. WMI was non-cystic in 35 and cystic in 47 infants. In infants with cystic-WMI early MRI showed extensive restricted diffusion abnormalities, cysts were already present in 3 infants; mid MRI showed focal or extensive cysts, without acute diffusion changes. A significant reduction in the size and/or extent of the cysts was observed in 32% of the infants between early/mid and TEA MRI. In 4/9 infants previously seen focal cysts were no longer identified at TEA. All infants with cystic WMI showed ≥2 additional findings at TEA: significant reduction in WM volume, mild-moderate irregular ventriculomegaly, several areas of increased signal intensity on T1-weighted-images, abnormal myelination of the PLIC, small thalami.

Conclusion: In infants with extensive WM cysts at 2-6 weeks, cysts may be reduced in number or may even no longer be seen at TEA. A single MRI at TEA, without taking sequential cUS data and pre-TEA MRI findings into account, may underestimate the extent of WMI; based on these results we propose a new MRI classification for preterm non-hemorrhagic WMI.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. 26 week gestation infant; cUS and MRI at 32 weeks post-menstrual age.
(a) cUS mid-coronal view, showing a focal lesion in the white matter also seen on early MRI-T2 weighted (b) and at TEA-T1 weighted MRI (c)
Fig 2
Fig 2. 28 week gestation infant; cUS at 5 weeks and TEA-MRI.
cUS, coronal (a) and left parasagittal (b) views showing a single cyst and echogenicity surrounding the cyst. T1-weighted MRI at TEA confirming the cyst and several focal lesions of increased signal intensity bilaterally (c).
Fig 3
Fig 3. 27 week gestation infant.
(a) right parasagittal cUS (day 21) showing extensive cysts. The cysts are no longer seen at TEA but there are some punctate lesions of increased echogenicity in the periventricular white matter; there is also white matter loss with sulci abutting the ventricles as well as increased/enlarged extracerebral space (b).
Fig 4
Fig 4. Same infant as above.
(a) Early coronal T2-weighted MRI (day 27) showing extensive cysts, more prominent on the right. (b) The cysts are no longer seen on the T1-weighted TEA-MRI but extensive high signal intensity changes and white matter loss are seen instead, more marked on the right side; and (c) a single small cyst on the right is still seen shown on the T2-weighted MRI.
Fig 5
Fig 5. Survivor of monochorionic diamniotic twin pregnancy, who had inhomogeneous echogenicity at birth and showed cystic evolution by day fourteen.
Note the discrepancy between the appearance of the cysts on cUS (a) and on the T2-weighted MRI (b), both performed at three weeks. Also note the abnormalities on cUS and MRI in the thalami.
Fig 6
Fig 6. Diagram showing evolution of cystic lesions between early/mid MRI and TEA MRI in the 22 infants with early extensive cysts and at least 2 MRIs in the neonatal period.
Fig 7
Fig 7. 31 week gestation infant; cUS performed 4 weeks after birth.
Coronal (a) and right parasagittal view (b) showing extensive cysts, more so on the right. (c) First T2-weighted MRI performed 4 weeks after birth showing extensive cysts, more prominent on the right. (d) The cysts were no longer seen on the T1-weighted TEA-MRI; extensive high SI changes and white matter loss are seen instead, also more marked on the right side.
Fig 8
Fig 8. Inversion Recovery images, performed in three preterm infants at TEA.
(a) Normal myelination of the PLIC. (b) Sparse myelination, slightly better on the right; and (c) no myelination.
See this image and copyright information in PMC

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