OBJECTIVEPeriventricular leukomalacia (PVL), the principal form of brain injury in the premature infant, is characterized by overt focal necrotic lesions in periventricular white matter and diffuse cerebral white matter injury. The early detection of the disease is not consistently possible with cranial ultrasonography or conventional magnetic resonance imaging (MRI). Recently, diffusion-weighted imaging (DWI) has been shown to be highly sensitive in detecting acute ischemic cerebral injury. This study aimed to evaluate possible role of DWI in early diagnosis of PVL.

METHODSImages and clinical data from 12 preterm infants with PVL diagnosed in our NICU from August, 2005 to April, 2007 were reviewed. MRI using conventional and diffusion-weighted imaging, as well as the assays of blood routine test, serum bilirubin, C-reactive protein (CRP), blood culture, blood gas analysis, blood sugar and serum ions were performed in these preterm infants. All examinations were performed on a 3.0-T MRI system (Philips Intera Acheva Magnetom Vision) with echo-planar imaging capability with the use of a standard protocol. The imaging protocol for all the patients contained diffuse weighted images (EPI-SE, TR = 2144 ms, TE = 56 ms), T1-weighted images (TR = 389 ms; TE = 15 ms; slice thickness = 4 mm) as well as T2-weighted images (TR = 3035 ms; TE = 100 ms; slice thickness = 4 mm). The first MR examinations were performed in all these twelve preterm infants (mean age 4.5 days, range 2 - 7 days). Conventional MRI and DWI sequences obtained in the acute phase were compared. All the neonates underwent another two MRI examinations up to 2 and 4 weeks after delivery; five subjects also underwent MRI follow-up for up to 4 - 8 months (in 3 for 4 months, in 1 for 7 months, and in another for 8 months). Qualitative evaluations were performed to assess the presence of DWI changes compatible with PVL.

RESULTSThe gestational ages of these twelve patients were from 31 to 35 weeks. None of them had intrauterine distress or birth asphyxia. None of the patients had localized neurological signs in the early course except for abnormal muscular tone of some extent, but seizure and apnea were their major symptoms. No other positive signs of nervous system was found in these preterm infants with PVL. First DWI detection (on the average of 4.5 days) in all these infants showed bilateral, symmetric, diffuse high signal intensity (including genu and plenum of corpus callosum), while conventional MRI showed normal images on both T1- and T2-weighted imaging; two weeks later, DWI showed irregularly high, low mixed signals while conventional MRI showed punctate high signal intensity on T1-weighted imaging and slightly lower signal on T2-weighted imaging. Four weeks later, DWI showed cystic low signal intensity where conventional MRI showed low signal intensity on T1-weighted imaging and high signal intensity on T2-weighted imaging (cystic PVL). Four months later, DWI showed that the cystic cava became diminished and disappeared, while conventional MRI showed reduced cerebral white matter and dilation of ventricle.

CONCLUSIONBilateral, symmetric, diffuse high signal intensity on DWI seems to be the earliest evidence of PVL; diffusion-weighted imaging performed in the acute phase of the disease may have a higher correlation with later evidence of PVL than does conventional MR imaging. DWI is likely to be a considerable technique in the early assessment of white matter injury and later PVL in preterm infants.