Neonatal functional brain maturation in the context of perioperative critical care and pain management: A case report

Remarkable plasticity during the first year of life imparts heighted vulnerability of the developing infant brain. Application of resting-state functional magnetic resonance imaging (rs-fMRI) in infants may contribute to our understanding of neuroplastic changes associated with therapeutic interventions and/or brain insults. In addition to showing clinically relevant incidental brain MRI findings, the objective of our pilot study was to test feasibility of rs-fMRI methods at this early age in the context of pediatric perioperative critical care.

We report the case of a former 33-week premature infant born with long-gap esophageal atresia that underwent complex perioperative critical care (Foker process) requiring prolonged post-operative sedation and whom presented with incidental subdural hematoma. Rs-fMRI data was acquired before (at 1-month corrected age) and after (at 2.25-months corrected age) complex perioperative care. We evaluated resting-state functional connectivity (RSFC) using graph theory to explore the complex structure of brain networks.

A transient increase in head circumference coincided temporally with lifting of sedation and initiation of sedation drugs weaning, and qualified for hydrocephalus (93%) but not macrocephaly (>95%). RSFC analysis identified networks spatially consistent with those previously described in the literature, with notable pre-post-treatment qualitative differences in correlated and anticorrelated spontaneous brain activity.

Current definitions of macrocephaly may require lower threshold criteria for monitoring of critically ill infants. Although we demonstrate that available rs-fMRI could be effectively applied in a critically ill infant in the setting of brain pathology, future group-level studies should investigate RSFC to evaluate maintenance of network homeostasis during development of both healthy and critically ill infants.