TYPE Review

PUBLISHED 09 February 2023

DOI 10.3389/fneur.2023.1100623

Review on the application of

OPEN ACCESS imaging examination for brain
injury in premature infants
EDITED BY
Xiaodong Yang,
Xidian University, China

REVIEWED BY
Muhammad Bilal Khan, Qing Zhang1,2* and Xihui Zhou1
Xidian University, China
Daniyal Haider, 1
First Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University Health Science Center, Xi’an
De Montfort University, United Kingdom Jiaotong University, Xi’an, Shaanxi, China, 2 Northwest Women’s and Children’s Hospital, Xi’an Jiaotong
*CORRESPONDENCE
University Health Science Center, Xi’an, Shaanxi, China
Qing Zhang
zhangqingxbfy@163.com

SPECIALTY SECTION Brain injury is the main factor leading to the decline of the quality of life in premature
This article was submitted to infants. The clinical manifestations of such diseases are often diverse and complex,
Applied Neuroimaging,
lacking obvious neurological symptoms and signs, and the disease progresses rapidly.
a section of the journal
Frontiers in Neurology Due to missed diagnosis, it is easy to miss the best treatment opportunity. Brain
RECEIVED 17 November 2022
ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and
ACCEPTED 10 January 2023 other imaging methods can help clinicians diagnose and assess the type and extent of
PUBLISHED 09 February 2023 brain injury in premature infants to some extent, but the three methods have their own
CITATION characteristics. This article briefly reviews the diagnostic value of these three methods
Zhang Q and Zhou X (2023) Review on the
for brain injury in premature infants.
application of imaging examination for brain
injury in premature infants.
Front. Neurol. 14:1100623. KEYWORDS
doi: 10.3389/fneur.2023.1100623
brain injury of premature infants, brain ultrasound, computed tomography (CT), magnetic
COPYRIGHT resonance imaging (MRI), comparison
© 2023 Zhang and Zhou. This is an
open-access article distributed under the terms
of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction 1. Introduction
in other forums is permitted, provided the
original author(s) and the copyright owner(s)
are credited and that the original publication in With the continuous improvement of obstetric and neonatal intensive care unit facilities,
this journal is cited, in accordance with the survival rate of premature infants has increased significantly, but the complications of
accepted academic practice. No use, nerve injury (such as cerebral palsy, audiovisual dysfunction, and intellectual disability) are
distribution or reproduction is permitted which
does not comply with these terms. on the rise (1, 2). The main reason for the high incidence of nervous system damage is
not yet fully developed brain function in premature infants, prone to brain injury. As the
brain tissue of neonates is in the stage of continuous development and remodeling, early
identification of potential sequelae of brain injury and timely intervention is of great significance
to reduce complications of nervous system injury and improve prognosis (3, 4). However,
the clinical manifestations of brain injury in premature infants are diverse, lacking specific
neurological symptoms and signs (5), and can only be further diagnosed by imaging and
other examination methods. Currently, common imaging methods include brain ultrasound,
computed tomography (CT), and magnetic resonance imaging (MRI). This article reviews the
diagnostic value of these three methods for brain injury in premature infants.

2. Definition and epidemiology of brain injury in

premature infants
Brain injury in premature infants refers to pathological brain injury caused by various
factors before, during, or after delivery. It is a common neurological disease in premature
infants. It is not a specific term for a disease but a comprehensive concept of disease (6).
Brain injury in premature infants mainly includes hemorrhagic and ischemic injuries. In clinical
practice, intracranial hemorrhage (including periventricular intraventricular hemorrhage,
subdural hemorrhage, and subarachnoid hemorrhage) and periventricular leukomalacia have
the highest incidence. Severe brain injury may lead to neonatal visual and auditory

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Zhang and Zhou 10.3389/fneur.2023.1100623

impairment, intellectual disability, or cerebral palsy, and may even so it is particularly important to understand the diagnostic value of
threaten the life of the newborn. According to incomplete statistics, these three imaging methods for brain injury in premature infants.
the incidence of brain injury in premature infants in Europe and
the United States is as high as 10–15% (7), whereas in China this
figure is about 8%, ranking second in the world (8). The proportion
of mild brain injury was about 23.48%, and the proportion of severe 4.1. Diagnostic value of brain ultrasound in
brain injury was about 13.57%. According to relevant research, premature infants with brain injury
about 25% of survivors of brain injury in premature infants will
have neurological sequelae, and 10% of children will have cerebral Ultrasound diagnosis is a technique that reflects human tissue
palsy (9). structure and pathological processes through gray-scale imaging
and echoes intensity changes (17). With the rapid development of
ultrasonic instruments, ultrasonic diagnosis is more and more widely
3. Etiology of brain injury in premature used in clinical practice. By the late 1970s, this technique was used
to diagnose neonatal intracranial diseases. Because the fontanel of
infants
the newborn is not closed at birth, the ultrasound is not affected by
the skull during the cranial ultrasound. The development of brain
The main cause of brain injury in premature infants is the
ultrasound technology has opened up a new way for clinicians to
sensitivity of cells and cerebrovascular to inflammatory damage
understand intracranial lesions in vivo (17). The technique has the
caused by ischemia or infection. Because the brain of premature
following advantages in the diagnosis of brain injury in premature
infants is not yet mature, the self-regulation ability of blood vessels
infants: ① Brain ultrasound operation is simple and fast, will not
is poor, and the unique structure and physiological characteristics
cause radiation or trauma to the children, and can be completed at the
of blood vessels around the ventricle (anatomically, the ventricle
bedside, effectively avoiding the impact of multiple children exercise
is in the terminal blood supply area), the brain is prone to
on the diagnosis. ② Brain ultrasound has a high resolution for
ischemia and bleeding. Prenatal and intrapartum factors such
central brain lesions and has specific diagnostic value for intracranial
as intrauterine infection, pregnancy-induced hypertension, and a
hemorrhage, posterior ventricular enlargement, hydrocephalus, and
history of abnormal delivery, as well as neonatal factors such as
other diseases. ③ Brain injury in premature infants is a dynamic
low birth weight, asphyxia, and shock, can cause brain damage in
change. Brain ultrasound can display the type, location, and range
premature infants (10, 11).
of intracranial lesions in real time and provide reliable ultrasound
When the white matter around the brain ventricle is ischemic,
data for clinical diagnosis. ④ It is safe and feasible to detect the
this white matter will interact with inflammatory factors, leading
hemodynamic changes of soybean stem artery in premature infants
to the activation of microglia, leading to oxidative stress, thereby
by color Doppler ultrasound. It can not only reflect the changes in
releasing pro-inflammatory cytokines, leading to glutamate toxicity,
local cerebral blood perfusion but can also be used to evaluate the
which will not only consume energy but also damage the integrity
hemodynamic changes of brain basal ganglia injury (18). ⑤ Brain
of blood vessels (12). Oligodendrocyte precursor is highly sensitive
ultrasound and other clinical diagnosis and treatment activities or
to the aforementioned factors and is vulnerable to injury during
laboratory tests do not conflict and interfere with each other, which
ischemia, which also affects the formation of myelin; however,
can be carried out simultaneously to ensure the accuracy of treatment
intracranial hemorrhage is usually associated with the special
and rescue (19).
structural vulnerability of the germinal matrix itself and cerebral
At present, the types of brain injury in premature infants
blood flow fluctuations (13). The pericytes of neovascularization in
diagnosed by brain ultrasound mainly include periventricular
the germinal stroma of premature infants are few, the substrate is
intraventricular hemorrhage and periventricular leukomalacia. The
immature, the end of the encapsulated astrocytes lacks glial fibrillary
ultrasonographic manifestations of periventricular intraventricular
acidic protein, and the blood vessels grow rapidly. When cerebral
hemorrhage in different periods are as follows (20): ① Acute
blood flow fluctuates, pressure changes can easily lead to intracranial
hemorrhage showed a moderate strong echo, thin edge, and clear
hemorrhage (14–16).
boundary; ② 2–3 days later, if there was no fresh bleeding, the
local echo of the hemorrhage was uniformly enhanced; ③ 7–10 days
later, blood clots into the absorption period. There was no echo
4. Comparison of different imaging
in the center of the clot, and the bleeding lesions were completely
methods in the diagnosis of brain injury absorbed or formed cysts. If 7–10 days later, the ultrasound still
in premature infants shows a strong echo without fading, or the brain hemisphere echo is
unevenly enhanced, there are scattered rough strong echo particles,
Early diagnosis and timely intervention are important ways to and neuronal necrosis may occur (21). Brain ultrasound diagnosis of
improve the prognosis of brain injury and reduce the mortality rate of periventricular white matter injury is usually divided into four stages
premature infants. However, the clinical symptoms of brain injury in (22): ① Echo enhancement stage: coronal anterior horn of the lateral
premature infants are not obvious or lack characteristic identification ventricle, sagittal posterior triangle area, and lateral ventricle with
points. To further clarify the type of lesion, it is necessary to carry rough, uneven, and boundary strong echo area; ② Relative normal
out an imaging examination. At present, the imaging methods for the period: mild localized echo enhancement returned to normal within
diagnosis of brain injury in premature infants mainly include brain a few days, and there was no abnormality in brain ultrasound images;
ultrasound, computed tomography (CT), and magnetic resonance ③ Cystic formation stage: if 1 week after the unilateral ventricle
imaging (MRI). Each examination method has its own characteristics, hyperechoic, it may be an incomplete recovery of the lesion. After

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Zhang and Zhou 10.3389/fneur.2023.1100623

2–3 weeks, the original echo enhancement area may appear in size, in premature infants are very unequal. Therefore, in the clinical
shape, a low echo, or echoless cystic softening lesions; ④ after that, study, computed tomography (CT) is not a routine examination
the smaller cystic softening foci become smaller or disappear after method for diagnosing brain damage in premature infants. CT
being filled with glial cells, and the larger softening foci gradually examination will not be performed for the time being, but the
form larger cysts. patient’s condition should be closely observed. If abnormal conditions
However, due to the limited depth of the probe can be detected, occur, a CT examination should be performed in time to improve the
there is a blind area in the examination of brain surface by positive detection rate of craniocerebral injury and reduce medical
craniocerebral ultrasound, and the edge of the brain hemorrhage costs (28).
(such as subdural hemorrhage and subarachnoid hemorrhage) is not
very sensitive to a missed diagnosis.

4.3. Diagnostic value of magnetic resonance

imaging (MRI) for brain injury in premature
4.2. Diagnostic value of computed infants
tomography (CT) for brain injury in
premature infants Magnetic resonance imaging (MRI) is a relatively new medical
imaging technology, which has been formally applied to clinical
Computed tomography (CT) uses an X-ray beam to scan a layer practice since 1982. Its appearance provides higher spatial resolution
of a certain thickness in a part of the human body. The X-ray passing and contrast resolution for evaluating abnormal pathological changes
through the layer is received by a detector and converted into visible in the brain. At present, the commonly used magnetic resonance
light. The visible light is converted into electrical signals through imaging (MRI) mainly includes conventional MRI, diffusion-
photoelectric conversion and then converted into a digital input weighted imaging (DWI), diffusion tensor imaging (DTI), magnetic
computer system through an analog/digital converter to obtain the resonance spectroscopy (MRS), and magnetic sensitivity weighted
final image (23). Professional doctors can obtain the corresponding imaging (SWI). Conventional MRI is an imaging technique that
focus information by interpreting the final image. This method has reconstructs images using signals generated by nuclear resonance in
the advantages of a short scanning time, a clear imaging structure, a strong magnetic field, including T1-weighted imaging (T1WI) and
and high resolution. It can not only display the pathological changes T2-weighted imaging (T2WI). This technique can clearly diagnose
of brain tissue quickly, intuitively, and clearly but also provide brain parenchymal punctate hemorrhage and parasagittal injury,
clear information about the location, range, and degree of lesions. that is brain injury in premature infants (29). Because it is a
At present, it has been widely used in the diagnosis of cerebral multi-axis examination, it can more accurately reflect the location,
hemorrhage, brain trauma, and other diseases (24). range, nature of intracranial lesions, and the relationship between
Computed tomography (CT) is one of the important auxiliary lesions and surrounding tissues (30). However, due to the incomplete
tools in the early diagnosis and follow-up evaluation of brain injury development of the brain in premature infants, T1 and T2 are
in premature infants. It can not only be used to distinguish neonatal prolonged in conventional MRI examinations. The white matter
hypoxic-ischemic encephalopathy and intracranial hemorrhage manifestations are the same as those of periventricular leukomalacia
(especially highly sensitive to subarachnoid hemorrhage), accurately in the acute phase (within 1 week), both of which are low-
locate the bleeding site but can also be used to diagnose signal T1-weighted imaging and high-signal T2-weighted imaging.
periventricular leukomalacia end stage. However, according to the Therefore, it is difficult to evaluate whether the white matter is
investigation of Yu (25), the frontal lobe tissue of the newborn is damaged or not. The resolution of conventional MRI for fresh
not well developed in the early stage. The white matter in computed intracranial hemorrhage is poor (31). Therefore, the diagnostic value
tomography (CT) is low density, and the classification of CT is easy of conventional MRI for brain injury in early premature infants
to make mistakes. Therefore, when relying on computed tomography is not high (32), which is mainly used for follow-up evaluation
(CT) to diagnose neonatal hypoxic-ischemic encephalopathy and of late premature infants. Diffusion-weighted imaging (DWI) is an
determine prognosis, we should be cautious and need at least 1 imaging technique that reflects the irregular movement of water
month of follow-up review. The degree of low density (i.e., CT- molecules in tissues using quantitative diffusion statistics (ADC).
value) and low-density morphology must be combined to objectively DWI is highly sensitive and specific to hypoxic-ischemic brain cells.
assess the degree of brain injury through computed tomography (CT) In the early stage of hypoxic-ischemic brain damage, DWI can
images. Zhang et al. (26) also confirmed this by dynamic observation sensitively reflect the changes of diffusion characteristics of water
of computed tomography (CT) in neonates with hypoxic-ischemic molecules in brain tissue along nerve fiber bundles and across brain
encephalopathy. They believe that in the early and middle stages cell membranes (33). Therefore, in recent years, it has been widely
of the disease, it is difficult to determine the degree of pathological recognized internationally that DWI screening is recommended for
changes and prognosis of neonatal hypoxic-ischemic encephalopathy early brain injury in premature infants (hours to a week) (34, 35).
by computer tomography (CT) alone. It is more valuable to evaluate At the same time, the decrease in ADC value can be used as an
prognosis and guide intervention by evaluating brain damage with indicator to evaluate the severity of early periventricular leukomalacia
CT signs at 1 month. In addition, computed tomography (CT) (36). However, in the subacute or late stage of white matter injury,
requires children to be fully exposed to ionizing radiation, and cavities or glial scar hyperplasia will occur, and the sensitivity of
the examination time is long, so children need to be transported. DWI will be seriously reduced. Diffusion tensor imaging (DTI)
Brenner and other scholars (27) believe that the benefits and is a new magnetic resonance imaging technique based on DWI.
risk exposure of using this examination to diagnose brain injury Compared with DWI, DTI has added a new collection direction,

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Zhang and Zhou 10.3389/fneur.2023.1100623

which can successfully display the conduction path of nerve fibers or time-consuming, requires high ambient temperature, and generates
the circuity, direction, intersection, interruption, and destruction of large noise. Therefore, computed tomography (CT) and magnetic
nerve fiber bundles (37), and shows higher sensitivity to abnormal resonance imaging (MRI) are often used to supplement the diagnosis
development of premature infants after white matter injury, of brain ultrasound. The complementary application of the three
especially myelination disorders (38). According to Mu et al. (39), the imaging examinations is of great significance for the early diagnosis,
clinical research on DTI is limited, and its clinical application needs treatment, and prognosis of brain injury in premature infants.
to be further explored. Magnetic resonance spectroscopy (MRS)
is a non-invasive method for studying metabolic and biochemical
indicators of living tissue, which can detect changes in chemical Author contributions
composition in the brain. Robertson et al. (40) found that the
lactic acid/creatine (Lac/Cr), N-acetyl aspartate/creatine (NAA/Cr), QZ: manuscript drafting and idea. XZ: guidance. Both authors
myo-inositol/creatine (mI/Cr), choline/creatine (Cho/Cr), and other contributed to the article and approved the submitted version.
indexes in lateral ventricle posterior horn of premature infants
with white matter damage were significantly higher than those
with normal infants. Magnetic susceptibility-weighted imaging (SWI) Funding
is a three-dimensional gradient echo magnetic resonance imaging
technique with a high spatial resolution developed in recent years. This work was supported by the Key Research and Development
It can detect low-signal small-signal lesions (41). It has high Program of Shaanxi (Program No. 2022SF-035).
sensitivity and accuracy in the diagnosis of intracranial hemorrhage
in premature infants, but its application has not been popularized. Acknowledgments
The authors would like to thank Ms. Zhu for her help and
5. Conclusion guidance in literature collation.

To sum up, brain ultrasound, computed tomography (CT),

and magnetic resonance imaging (MRI) in the diagnosis of Conflict of interest
brain injury in premature infants have their own characteristics,
advantages, and disadvantages. Brain ultrasound has the advantages The authors declare that the research was conducted in the
of simple operation, low price, no radiation, no trauma, and absence of any commercial or financial relationships that could be
bedside examination. Color Doppler ultrasound can also dynamically construed as a potential conflict of interest.
monitor the changes in cerebral blood flow, so it should be the first
choice for routine screening of brain injury in premature infants
(42). Computed tomography (CT) can accurately and intuitively Publisher’s note
show the location and scope of brain edema, brain tissue necrosis,
intracranial hemorrhage, and other injuries, but it is easy to cause All claims expressed in this article are solely those of the
radiation in children during the examination and cannot be operated authors and do not necessarily represent those of their affiliated
at the bedside. Magnetic resonance imaging (MRI) can image in organizations, or those of the publisher, the editors and the reviewers.
multiple directions, has a high resolution for soft tissue, and has Any product that may be evaluated in this article, or claim that may
high diagnostic value for diseases such as punctate hemorrhage be made by its manufacturer, is not guaranteed or endorsed by the
and periventricular leukomalacia. However, it is expensive and publisher.

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