title: Clinically silent preoperative brain injuries do not worsen with surgery in neonates with congenital heart disease.
abstract: OBJECTIVE
  Preoperative brain injury, particularly stroke and white matter injury, is common in neonates with congenital heart disease. The objective of this study was to determine the risk of hemorrhage or extension of preoperative brain injury with cardiac surgery.
  
  
  METHODS
  This dual-center prospective cohort study recruited 92 term neonates, 62 with transposition of the great arteries and 30 with single ventricle physiology, from 2 tertiary referral centers. Neonates underwent brain magnetic resonance imaging scans before and after cardiac surgery.
  
  
  RESULTS
  Brain injury was identified in 40 (43%) neonates on the preoperative magnetic resonance imaging scan (median 5 days after birth): stroke in 23, white matter injury in 21, and intraventricular hemorrhage in 7. None of the brain lesions presented clinically with overt signs or seizures. Preoperative brain injury was associated with balloon atrial septostomy (P = .003) and lowest arterial oxygen saturation (P = .007); in a multivariable model, only the effect of balloon atrial septostomy remained significant when adjusting for lowest arterial oxygen saturation. On postoperative magnetic resonance imaging in 78 neonates (median 21 days after birth), none of the preoperative lesions showed evidence of extension or hemorrhagic transformation (0/40 [95% confidence interval: 0%-7%]). The presence of preoperative brain injury was not a significant risk factor for acquiring new injury on postoperative magnetic resonance imaging (P = .8).
  
  
  CONCLUSIONS
  Clinically silent brain injuries identified preoperatively in neonates with congenital heart disease, including stroke, have a low risk of progression with surgery and cardiopulmonary bypass and should therefore not delay clinically indicated cardiac surgery. In this multicenter cohort, balloon atrial septostomy remains an important risk factor for preoperative brain injury, particularly stroke.
authors.affiliation: Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: A J
authors.initials: AJ
authors.lastname: Block
authors.forename: P S
authors.initials: PS
authors.lastname: McQuillen
authors.forename: V
authors.initials: V
authors.lastname: Chau
authors.forename: H
authors.initials: H
authors.lastname: Glass
authors.forename: K J
authors.initials: KJ
authors.lastname: Poskitt
authors.forename: A J
authors.initials: AJ
authors.lastname: Barkovich
authors.forename: M
authors.initials: M
authors.lastname: Esch
authors.forename: W
authors.initials: W
authors.lastname: Soulikias
authors.forename: A
authors.initials: A
authors.lastname: Azakie
authors.forename: A
authors.initials: A
authors.lastname: Campbell
authors.forename: S P
authors.initials: SP
authors.lastname: Miller
mesh_terms: D001921:Brain / Q000473:pathology*; D001955:British Columbia; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D002404:Catheterization / Q000009:adverse effects; D018450:Disease Progression; D005260:Female; D006330:Heart Defects, Congenital / Q000097:blood / Q000150:complications / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D020300:Intracranial Hemorrhages / Q000097:blood / Q000150:complications* / Q000473:pathology; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D010100:Oxygen / Q000097:blood; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012495:San Francisco; D020521:Stroke / Q000097:blood / Q000150:complications* / Q000473:pathology; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D010100:Oxygen