Transfontanellar Contrast-enhanced US for Intraoperative Imaging of Cerebral Perfusion during Neonatal Arterial Switch Operation.

Abstract

Background Brain injury and subsequent neurodevelopmental disorders are major determinants for later-life outcomes in neonates with transposition of the great arteries (TGA). Purpose To quantitatively assess cerebral perfusion in neonates with TGA undergoing arterial switch operation (ASO) using transfontanellar contrast-enhanced US (T-CEUS). Materials and Methods In a prospective single-center cross-sectional diagnostic study, neonates with TGA scheduled for ASO were recruited from February 2018 to February 2020. Measurements were performed at five time points before, during, and after surgery (T₁-T₅), and 11 perfusion parameters were derived per cerebral hemisphere. Neonate clinical characteristics, heart rate, mean arterial pressure, central venous pressure, near-infrared spectroscopy, blood gas analyses, ventilation time, time spent in the pediatric intensive care unit, and time in hospital were correlated with imaging parameters. Analysis of variance or a mixed-effects model were used for groupwise comparisons. Results A total of 12 neonates (mean gestational age, 39 6/7 weeks ± 1/7 [SD]) were included and underwent ASO a mean of 6.9 days ± 3.4 after birth. When compared with baseline values, T-CEUS revealed a longer mean time-to-peak (right hemisphere, 4.3 seconds ± 2.1 vs 17 seconds ± 6.4 [<i>P</i> < .001]; left hemisphere, 4.0 seconds ± 2.3 vs 21 seconds ± 8.7 [<i>P</i> < .001]) and rise time (right hemisphere, 3.5 seconds ± 1.7 vs 11 seconds ± 5.1 [<i>P</i> = .002]; left hemisphere, 3.4 seconds ± 2.0 vs 22 seconds ± 7.8 [<i>P</i> = .004]) in both cerebral hemispheres during low-flow cardiopulmonary bypass and hypothermia (T₄) for all neonates. Neonate age at surgery negatively correlated with T-CEUS parameters during ASO, as calculated with the area under the flow curve (AUC) during wash-in (<i>R</i> = -0.60, <i>P</i> = .020), washout (<i>R</i> = -0.82, <i>P</i> = .002), and both wash-in and washout (<i>R</i> = -0.79, <i>P</i> = .004). Mean AUC values were lower in neonates older than 7 days compared with younger neonates during wash-in ([87 arbitrary units {au} ± 77] × 10² vs [270 au ± 164] × 10², <i>P</i> = .049]), washout ([15 au ± 11] × 10³ vs [65 au ± 38] × 10³, <i>P</i> = .020]) and both wash-in and washout ([24 au ± 18] × 10³ vs [92 au ± 53] × 10³, <i>P</i> = .023). Conclusion Low-flow hypothermic conditions resulted in reduced cerebral perfusion, as measured with transfontanellar contrast-enhanced US, which inversely correlated with age at surgery. Clinical trial registration no. NCT03215628 © RSNA, 2022 <i>Online supplemental material is available for this article.</i>