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## Complete Summary

#### GUIDELINE TITLE

Practice parameter: neuroimaging of the neonate: report of the Quality
Standards Subcommittee of the American Academy of Neurology and the
Practice Committee of the Child Neurology Society.

#### BIBLIOGRAPHIC SOURCE(S)

Ment LR, Bada HS, Barnes P, Grant PE, Hirtz D, Papile LA, Pinto-Martin
J, Rivkin M, Slovis TL. Practice parameter: neuroimaging of the neonate:
report of the Quality Standards Subcommittee of the American Academy of
Neurology and the Practice Committee of the Child Neurology Society.
Neurology 2002 Jun 25;58(12):1726-38. \[117 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12084869)

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed
and is still considered to be current as of October 2005. This review
involved new literature searches of electronic databases followed by
expert committee review of new evidence that has emerged since the
original publication date.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Conditions that may require neuroimaging of the neonate, such as:

-   Very low birth weight (preterm)

-   Neonatal encephalopathy

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Risk Assessment\
Screening\
Technology Assessment

#### CLINICAL SPECIALTY

Family Practice\
Neurology\
Pediatrics\
Radiology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations in response to the following questions
regarding brain imaging of preterm (PT) infants:

-   Which preterm infants should undergo routine screening
    ultrasonography (US)?

-   When should these studies be performed?

-   Do abnormalities on neonatal ultrasonography require follow-up
    magnetic resonance imaging (MRI)?

-   What is the ability of ultrasonography to accurately predict
    long-term neurodevelopmental outcome in this patient population?

To provide recommendations in response to the following questions
regarding brain imaging of term infants:

-   Which imaging strategies are able to provide clinically important
    information in term infants with neonatal encephalopathy?

-   Can magnetic resonance imaging provide prognostic information in
    these infants?

#### TARGET POPULATION

-   Very low birth weight (VLBW) preterm neonates

-   Encephalopathic term neonates

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Cranial ultrasonography (US), including gray-scale ultrasonography
    and Doppler ultrasonography

2.  Computed tomography (CT)

3.  Magnetic resonance imaging (MRI), including diffusion weighted
    magnetic resonance imaging (DWI) and proton magnetic resonance
    spectroscopy (MRS)

#### MAJOR OUTCOMES CONSIDERED

**Primary neuroimaging measures**:

-   Intraventricular hemorrhage

-   Preterm white matter injury

-   Ventriculomegaly

**Primary and secondary outcome measures**:

-   Specificity and sensitivity of neuroimaging for adverse
    neurodevelopmental outcomes

-   Cerebral palsy

-   Seizures

-   Developmental delay at age 1 year

-   Mental retardation

-   Developmental quotient

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Evidence reviewed for this parameter was identified through literature
searches using MEDLINE and EMBASE for the years 1990 to 2000 and CURRENT
CONTENTS for 2000. This literature search was updated in June 2001.
Relevant articles were included from English language literature using
the following search terms: neonate, infant, brain, cerebral, MRI, MRS,
diffusion weighted imaging (DWI), diffusion tensor imaging, US,
echoencephalography, Doppler ultrasonography, cranial axial tomography,
near-infrared spectroscopy, SPECT, germinal matrix hemorrhage,
intraventricular hemorrhage (IVA), periventricular leukomalacia (PVL),
stroke, ischemia, ventriculomegaly, and echodensity. Because neonatal
practices and imaging strategies have changed over the past decade, the
guideline developers reviewed only those references from 1990 onward.

#### NUMBER OF SOURCE DOCUMENTS

\>1320 citations

90 met the predefined inclusion criteria

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Definitions for classification of diagnostic evidence**

**Class I**: Evidence provided by a prospective study in a broad
spectrum of persons with the suspected condition, using a \"gold
standard\" for case definition, where test is applied in a blinded
evaluation, and enabling the assessment of appropriate tests of
diagnostic accuracy.

**Class II**: Evidence provided by a prospective study of a narrow
spectrum of persons with the suspected condition, or a well designed
retrospective study of a broad spectrum of persons with an established
condition (by \"gold standard\") compared to a broad spectrum of
controls, where test is applied in a blinded evaluation, and enabling
the assessment of appropriate tests of diagnostic accuracy.

**Class III**: Evidence provided by a retrospective study where either
persons with the established condition or controls are of a narrow
spectrum, and where test is applied in a blinded evaluation.

**Class IV**: Any design where test is not applied in blinded evaluation
OR evidence provided by expert opinion alone or in descriptive case
series (without controls).

**Definitions for classification of prognostic evidence**

**Class I**: Evidence provided by a prospective study of a broad
spectrum of persons who may be at risk for developing the outcome (e.g.,
target disease, work status). The study measures the predictive ability
using an independent gold standard for case definition. The predictor is
measured in an evaluation that is masked to clinical presentation, and
the outcome is measured in an evaluation that is masked to the presence
of the predictor.

**Class II**: Evidence provided by a prospective study of a narrow
spectrum of persons who may be at risk for developing the outcome or by
a retrospective study of a broad spectrum of persons with the outcome
compared to a broad spectrum of controls. The study measures the
predictive ability using an acceptable independent gold standard for
case definition. The risk factor is measured in an evaluation that is
masked to the outcome.

**Class III**: Evidence provided by a retrospective study where either
the persons with the condition or the controls are of a narrow spectrum.
The study measures the predictive ability using an acceptable
independent gold standard for case definition. The risk factor is
measured in an evaluation that is masked to the outcome.

**Class IV**: Any design where the predictor is not applied in a masked
evaluation OR evidence provided by expert opinion or case series without
controls.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Each of the selected articles was reviewed, abstracted, and classified
by at least two reviewers. Abstracted data included patient number, mean
birth weights (BW), mean gestational ages, ages at the time(s) of the
neuroimaging study(ies), primary neuroimaging measure, primary and
secondary outcome measures, and timing of subject selection
(prospective, retrospective, case-control, or case series). Guideline
developers also noted both inclusion and exclusion criteria for patient
selection and a description of the neuroimaging strategy in addition to
the results of the given study.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Definitions for strength of recommendations**

**Level A**: Established as useful/predictive or not useful/ predictive
for the given condition in the specified population (requires at least
one convincing class I study or at least two consistent, convincing
class II studies).

**Level B**: Probably useful/predictive or not useful/predictive for the
given condition in the specified population (requires at least one
convincing class II study or at least three consistent class III
studies).

**Level C**: Possibly useful/predictive or not useful/predictive for the
given condition in the specified population (requires at least two
convincing and consistent class III studies).

**Level U**: Data inadequate or conflicting. Given current knowledge,
test/predictor is unproven.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft guidelines were reviewed for accuracy, quality, and thoroughness
by the American Academy of Neurology (AAN) members, topic experts, and
pertinent physician organizations.

Final guidelines were approved by the American Academy of Neurology
Quality Standards Subcommittee on December 8, 2001, the American Academy
of Neurology Practice Committee on January 28, the American Academy of
Neurology Board of Directors on February 23, the Child Neurology Society
(CNS) Practice Committee on January 20, 2002. They were published in
Neurology 2002;58:1726-1738.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the classification of diagnostic evidence (Class I-IV),
classification of prognostic evidence (Class I-IV), and strength of
recommendations (A, B, C, U) are provided at the end of the \"Major
Recommendations\" field.

**Very Low Birth Weight (VLBW) Preterm (PT) Infants**

*Which pre-term infants should undergo routine screening cranial
ultrasonography (US)?*

[Recommendations (Level B)]{.underline}: Close to 25% of infants with
gestational age (GA) of \<30 weeks have significant cranial US
abnormalities which trigger important changes in acute and long-term
care. Therefore, routine screening cranial US should be performed on all
infants with GA of \<30 weeks.

*When should screening cranial US studies be performed?*

[Recommendation (Level B)]{.underline}: Screening cranial US should be
performed on all infants with GA of \<30 weeks at 7 to 14 days of age
and should be optimally repeated at 36 to 40 weeks´ postmenstrual age.
This recommendation is designed to detect both clinically unsuspected
intraventricular hemorrhage (IVH), which may require additional clinical
and/or radiologic monitoring and changes in management plans, and
evidence for periventricular leukomalacia (PVL) and/or ventriculomegaly,
which are useful for prognosis and best seen when the infants are
examined at term.

*Do abnormalities on neonatal screening cranial US require follow-up
magnetic resonance imaging (MRI) either to obtain information for
patient management or to provide long-term prognostic data?*

[Recommendation (Level C)]{.underline}: Currently, data available from
class II studies do not provide sufficient evidence that routine MRI
should be performed on all very low birth weight (VLBW) infants for whom
results of screening cranial US are abnormal.

*What is the ability of neonatal cranial US to predict long-term
neurodevelopmental outcome in VLBW PT infants?*

[Recommendation (Level A)]{.underline}: For VLBW PT infants, US should
be used to predict long-term neurodevelopmental outcome. The findings of
grades 3 and 4 intraventricular hemorrhage, periventricular cystic
lesions, and moderate to severe ventriculomegaly are all associated with
adverse outcome.

**Term Infants with Neonatal Encephalopathy**

*Which neonatal neuroimaging strategies can detect cerebral
abnormalities that will affect the immediate and long-term management of
the infant with neonatal encephalopathy?*

[Recommendations for Diagnostic Assessment]{.underline}

1.  For infants with a history of neonatal encephalopathy, significant
    birth trauma, and evidence for low hematocrit or coagulopathy:

    a.  Noncontrast computed tomography (CT) should be performed to look
        for hemorrhage (Level B)

    b.  If the CT findings cannot explain the clinical status of the
        neonate, MRI should be performed (Level A).

2.  For other neonates with acute encephalopathy:

    a.  MRI should be performed between days 2 and days 8 of life (Level
        A).

    b.  If single-voxel proton magnetic resonance spectroscopy (MRS) is
        available, MRI should include MRS (Level B).

    c.  At the time of the MRI, diffusion-weighted MRI (DWI) should also
        be performed if this modality is available (Level C).

    d.  CT should be performed only if MRI is not available, or if the
        neonate is too unstable for MRI (Level A).

*Can MRI studies provide prognostic data for term infants with neonatal
encephalopathy?*

[Recommendation]{.underline}. MRI should be performed within the first 2
to 8 days of life to provide predictive data for neurodevelopmental
outcome in encephalopathic term infants (Level A). DWI (Level C) and MRS
(Level B), when available, should also be performed within the first 2
to 8 days of life to provide prognostic data concerning
neurodevelopmental outcome in these patients.

**[Definitions]{.underline}**:

**Definitions for classification of diagnostic evidence**

**Class I**: Evidence provided by a prospective study in a broad
spectrum of persons with the suspected condition, using a \"gold
standard\" for case definition, where test is applied in a blinded
evaluation, and enabling the assessment of appropriate tests of
diagnostic accuracy.

**Class II**: Evidence provided by a prospective study of a narrow
spectrum of persons with the suspected condition, or a well designed
retrospective study of a broad spectrum of persons with an established
condition (by \"gold standard\") compared to a broad spectrum of
controls, where test is applied in a blinded evaluation, and enabling
the assessment of appropriate tests of diagnostic accuracy.

**Class III**: Evidence provided by a retrospective study where either
persons with the established condition or controls are of a narrow
spectrum, and where test is applied in a blinded evaluation.

**Class IV**: Any design where test is not applied in blinded evaluation
OR evidence provided by expert opinion alone or in descriptive case
series (without controls).

**Definitions for classification of prognostic evidence**

**Class I**: Evidence provided by a prospective study of a broad
spectrum of persons who may be at risk for developing the outcome (e.g.,
target disease, work status). The study measures the predictive ability
using an independent gold standard for case definition. The predictor is
measured in an evaluation that is masked to clinical presentation, and
the outcome is measured in an evaluation that is masked to the presence
of the predictor.

**Class II**: Evidence provided by a prospective study of a narrow
spectrum of persons who may be at risk for developing the outcome, or by
a retrospective study of a broad spectrum of persons with the outcome
compared to a broad spectrum of controls. The study measures the
predictive ability using an acceptable independent gold standard for
case definition. The risk factor is measured in an evaluation that is
masked to the outcome.

**Class III**: Evidence provided by a retrospective study where either
the persons with the condition or the controls are of a narrow spectrum.
The study measures the predictive ability using an acceptable
independent gold standard for case definition. The risk factor is
measured in an evaluation that is masked to the outcome.

**Class IV**: Any design where the predictor is not applied in a masked
evaluation OR evidence provided by expert opinion or case series without
controls.

**Definitions for strength of recommendations**

**Level A**: Established as useful/predictive or not useful/predictive
for the given condition in the specified population (requires at least
one convincing class I study or at least two consistent, convincing
class II studies).

**Level B**: Probably useful/predictive or not useful/predictive for the
given condition in the specified population (requires at least one
convincing class II study or at least three consistent class III
studies).

**Level C**: Possibly useful/predictive or not useful/predictive for the
given condition in the specified population (requires at least two
convincing and consistent class III studies).

**Level U**: Data inadequate or conflicting. Given current knowledge,
test/predictor is unproven.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Overall benefits**

-   These guidelines may assist physicians in making appropriate
    clinical decisions regarding the use of neuroimaging in preterm and
    term infants.

-   Neuroimaging plays two important roles: (1) diagnosis of brain
    injury in the newborn at risk so that appropriate medical management
    can be provided, and (2) detection of those lesions associated with
    long-term neurodevelopmental disability.

**Specific benefits**

-   Routine screening cranial ultrasonography (US) on preterm infants
    detects lesions such as intraventricular hemorrhage, which
    influences clinical care, and those such as periventricular
    leukomalacia and low-pressure ventriculomegaly, which provide
    information about long-term neurodevelopmental outcome.

-   The pattern of injury identified with conventional magnetic
    resonance imaging (MRI) may provide diagnostic and prognostic
    information for term infants with evidence of encephalopathy.

-   Diffusion-weighted imaging may allow earlier detection than
    conventional magnetic resonance imaging of cerebral injuries.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This statement is provided as an educational service of the American
Academy of Neurology (AAN) and the Child Neurology Society (CNS). It is
based on an assessment of current scientific and clinical information.
It is not intended to include all possible proper methods of care for a
particular neurologic problem or all legitimate criteria for choosing to
use a specific procedure. Neither is it intended to exclude any
reasonable alternative methodologies. The American Academy of Neurology
and the Child Neurology Society recognize that specific patient care
decisions are the prerogative of the patient and the physician caring
for the patient, based on all of the circumstances involved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Ment LR, Bada HS, Barnes P, Grant PE, Hirtz D, Papile LA, Pinto-Martin
J, Rivkin M, Slovis TL. Practice parameter: neuroimaging of the neonate:
report of the Quality Standards Subcommittee of the American Academy of
Neurology and the Practice Committee of the Child Neurology Society.
Neurology 2002 Jun 25;58(12):1726-38. \[117 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12084869)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 Jun 25 (reviewed 2005 Oct)

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society\
Child Neurology Society - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology (AAN)

#### GUIDELINE COMMITTEE

Quality Standards Subcommittee of the American Academy of Neurology\
Practice Committee of the Child Neurology Society

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*American Academy of Neurology (AAN) Quality Standards Subcommittee
Members*: Gary Franklin, MD, MPH (Co-Chair); Catherine Zahn, MD
(Co-Chair); Milton Alter, MD, PhD; Stephen Ashwal, MD (facilitator);
Richard M. Dubinsky, MD; Jacqueline French, MD; Michael Glantz, MD; Gary
Gronseth, MD; Deborah Hirtz, MD; Robert G. Miller, MD; and William
Weiner, MD

*Child Neurology Society (CNS) Practice Committee Members*: Carmela
Tardo, MD (Chair); Bruce Cohen, MD (Vice-Chair); Elias Chalhub, MD; Roy
Elterman, MD; Murray Engel, MD; Bhuwan P. Garg, MD; Brian Grabert, MD;
Annette Grefe, MD; Michael Goldstein, MD; David Griesemer, MD; Betty
Koo, MD; Edward Kovnar, MD; Leslie Anne Morrison, MD; Colette Parker,
MD; Ben Renfroe, MD; Anthony Riela, MD; Michael Shevell, MD; Shlomo
Shinnar, MD; Gerald Silverboard, MD; Russell Snyder, MD; Dean Timmns,
MD; Greg Yim, MD; Mary Anne Whelan, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed
and is still considered to be current as of October 2005. This review
involved new literature searches of electronic databases followed by
expert committee review of new evidence that has emerged since the
original publication date.

#### GUIDELINE AVAILABILITY

Electronic copies: A list of American Academy of Neurology (AAN)
guidelines, along with a link to a Portable Document Format (PDF) file
for this guideline, is available at the [AAN Web
site](http://aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   AAN guideline development process \[online\]. St. Paul (MN):
    American Academy of Neurology.

Electronic copies: Available from the [American Academy of Neurology Web
site](http://aan.com/go/practice/guidelines/development).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 5, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008