From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada.
Neurology. 2023 Dec 4;101(23):e2401-e2410. doi: 10.1212/WNL.0000000000207766.
Neonatal brain injury is a common and devastating diagnosis conferring lifelong challenges for children and families. The role of mechanical forces applied to the head, often referred to as "birth trauma," are often considered although evidence for this association is lacking. The objective of this study was to investigate the association between common types of neonatal brain injury and scalp swelling using a novel method to quantify scalp swelling as an unbiased proxy for mechanical forces applied to the head.
Case-control study using population-based, prospectively collected tertiary care center databases and healthy controls from the Human Connectome Development Project. Included were infants born 32-42 weeks gestational age and MRI in the first 9 days. Outcomes categories included healthy neonates, hypoxic ischemic encephalopathy (HIE) with or without brain injury, or stroke (ischemic or hemorrhagic). Volume of scalp swelling was objectively quantified by a novel imaging method blinded to brain injury. Variables included mode of delivery and use of instrumentation. Statistical tests included Kruskal-Wallis test, chi square, and multivariable and multinomial logistic regression.
There were 309 infants included (55% male): 72 healthy controls, 77 HIE without brain injury on MRI, 78 HIE with brain injury, and 82 with stroke (60 ischemic, 22 hemorrhagic). Scalp swelling was present in 126 (40.8%, 95% confidence interval [CI] 35.2%-46.5%) with no difference in proportions between outcome groups. Compared to healthy controls, median volume was higher in those with HIE without brain injury (17.5 mL, 95% CI 6.8-28.2), HIE with brain injury (12.1 mL, 95% CI 5.5-18.6), but not ischemic stroke (4.7 mL, 95% CI -1.2-10.6) nor hemorrhagic stroke (8.3 mL, 95% CI -2.2-18.8). Scalp swelling was associated with instrumented delivery (OR 2.1, 95% CI 1.0-4.1), but not associated with increased odds of brain injury in those with HIE (OR 1.5, 95% CI 0.76-3.30). Scalp swelling measures were highly reliable (ICC = 0.97).
"Birth trauma" quantified by scalp swelling volume was more common in infants with difficult deliveries, but not associated with greater odds of brain injury due to hypoxia or stroke. These results may help parents and practitioners to dissociate the appearance of trauma with the risk of brain injury.
新生儿脑损伤是一种常见且严重的疾病，会给患儿及其家庭带来终生的挑战。尽管缺乏证据支持，但人们通常认为，头部所受的机械力（通常被称为“分娩创伤”）在其中发挥了作用。本研究旨在采用一种新方法来量化头皮肿胀，将其作为头部所受机械力的无偏倚替代指标，以此探究新生儿脑损伤的常见类型与头皮肿胀之间的关系。
本研究为病例对照研究，使用基于人群的前瞻性收集的三级护理中心数据库和人类连接组发展计划（Human Connectome Development Project）中的健康对照组。纳入研究的患儿胎龄为 32-42 周，且在出生后第 1 天内进行 MRI 检查。研究的结局类别包括健康新生儿、伴有或不伴有脑损伤的缺氧缺血性脑病（Hypoxic Ischemic Encephalopathy，HIE）以及脑卒中（缺血性或出血性）。采用一种新的成像方法客观地量化头皮肿胀程度，该方法对脑损伤评估结果设盲。纳入的变量包括分娩方式和器械使用情况。统计学检验包括 Kruskal-Wallis 检验、卡方检验以及多变量和多项逻辑回归。
本研究共纳入 309 名患儿（55%为男性）：72 名健康对照组、77 名 MRI 检查未见脑损伤的 HIE 患儿、78 名伴有脑损伤的 HIE 患儿和 82 名脑卒中患儿（60 例缺血性脑卒中，22 例出血性脑卒中）。126 名（40.8%，95%置信区间[Confidence Interval，CI]为 35.2%-46.5%）患儿存在头皮肿胀，各组间的比例无差异。与健康对照组相比，无脑损伤的 HIE 患儿（17.5 mL，95%CI 6.8-28.2）、伴有脑损伤的 HIE 患儿（12.1 mL，95%CI 5.5-18.6）的头皮肿胀中位数更高，但缺血性脑卒中患儿（4.7 mL，95%CI -1.2-10.6）和出血性脑卒中患儿（8.3 mL，95%CI -2.2-18.8）的头皮肿胀中位数则无显著差异。头皮肿胀与器械分娩相关（OR 2.1，95%CI 1.0-4.1），但与 HIE 患儿脑损伤发生率的增加无关（OR 1.5，95%CI 0.76-3.30）。头皮肿胀测量值具有高度可靠性（ICC = 0.97）。
采用头皮肿胀体积量化的“分娩创伤”在分娩困难的患儿中更为常见，但与缺氧或脑卒中引起的脑损伤发生率增加无关。这些结果可能有助于家长和临床医生将创伤的表现与脑损伤的风险区分开来。
