Semin Neonatol 2001; 6: 121133

doi:10.1053/siny.2001.0043, available online at http://www.idealibrary.com on

Cerebral white matter damage in the preterm infant:

pathophysiology and risk factors

Elie Salibaa and Stephane Marretb

a
INSERM U 316, Department of
Neonatology, Centre Hospitalier
Universitaire, Tours, France
b
Department of Neonatal Medicine,
Centre Hospitalier Universitaire, Rouen,
France
Key words: neonate, periventricular
leukomalacia, cerebral palsy, risk
factors, cytokines, pathogenesis,
experimental, neuroprotective
Based on clinical, epidemiologic, and experimental studies, the aetiology of white
matter damage, specifically periventricular leukomalacia (PVL), is multifactorial and
involves pre- and perinatal factors possibly including genetic factors, hypoxic-ischaemic
insults, infection, excess cytokines, free radical production, increased excitatory amino
acid release, and trophic factor deficiencies. The article summarizes research findings
about the aetiology of white matter damage and cerebral palsy in preterm infants. The
information is organized according to specific antecedents, for which we present
epidemiological and neurobiological data. The most important prenatal factor appears
to be intrauterine infection. We discuss the evidence supporting the hypothesis that the
foetal inflammatory response contributes to neonatal brain injury and later
developmental disability. We recently established an animal model of excitotoxic
lesions in the developing mouse brain. Brain damage was induced by intra-cortical
injections of ibotenate, a glutamatergic agonist. When administered on post-natal day 5
ibotenate induced the formation of white matter cysts. Our animal model could be
used to further explore the mechanisms involved in the formation of PVL. Potentially
preventive strategies will be discussed.  2001 Harcourt Publishers Ltd

Introduction resonance images of gliosis as a sequelae of peri-

natal PVL [2]. The pathogenesis of WMD is
Cerebral white matter damage (WMD), specifically
complex and probably multifactorial. This review
cystic periventricular leukomalacia (PVL), contrib-
summarizes research findings about the aetiology
utes significantly to neonatal mortality and long-
of WMD in preterm infants. The information is
term neurodevelopmental deficits in the premature
organized according to specific antecedents in very
infant. Periventricular echolucency and ventricular
low-birth weight infants with PVL or cerebral palsy
enlargement, which are thought to indicate damage
and also according to experimental models of
to the periventricular white matter, are associated
WMD, for which we present epidemiological and
with a more than 15-fold increase in risk of cerebral
neurobiological data. A clearer understanding of
palsy (CP). Between 60% and 100% of premature
the pathogenesis of WMD is essential in order to
infants who have ultrasonographic findings con-
provide targeted preventive strategies.
sidered to be characteristics of PVL later have CP
[1]. The rates tend to be higher for images showing
echolucency in cerebral white matter than for those Epidemiology of white matter
showing hyperechoic areas, and are the highest for damage: prenatal factors
large, posterior and bilateral lesions. In terms of
long-term outcome, approximately 90% of children
born preterm who develop CP have magnetic (1) Twin gestation
Correspondence to Elie Saliba, INSERM U 316, Department of Neonatol-
ogy, Hopital Clocheville, 49, Bd Beranger F-37000, France. E-mail: Population-based studies indicate that twins are at
saliba@med.univ-tours.fr greater risk of WMD or CP compared to singletons
10842756/01/020121+13 $35.00/0 2001 Harcourt Publishers Ltd
122
[3]. Much of this increase in risk appears to be
related to the lower mean gestational age of twins
at delivery and to the high incidence of multiple
pregnancy in the populations studied. Although
multiple gestation per se is not a risk factor for
WMD, the death of a co-twin is strongly associ-
ated with PVL. A high incidence (2038%) of
antenatal cerebral ischaemic insults, with lesions
including white matter cysts, lateral ventricular
dilatation and cerebral atrophy, have been reported
in twin-twin transfusion syndrome survivors [4].
(2) Pre-eclampsia
Pre-eclampsia is associated with a decreased risk of
CP. This association can be due to gestational age,
because preterm infants of pre-eclamptic mothers
are, on average, of higher gestational age [5]. The
apparent protective effect of pre-eclampsia cannot
be attributed to magnesium sulphate. A similar
decreased risk of CP has been found among infants
of mothers whose pre-eclampsia was not treated
with magnesium sulfate [6,7].
(3) Foetal growth restriction
Many studies of SGA infants have reported a
modest decrease in or no effects of low weight for
gestational age on risk of CP [810]. One expla-
nation for these findings may be that SGA pre-
term infants are often born to mothers with
pre-eclampsia, which is associated with a decreased
risk of CP [11].
(4) Hypothyroxinaemia and the risk of
WMD
Thyroid hormones are essential for normal brain
development. Experimental studies have shown in
cell cultures that thyroid hormones promote differ-
entiation of oligodendrocytes [12]. Second, thyroid
hormone directly stimulates myelin gene expres-
sion [13]. Clinical studies have shown that, VLBW
infants tend to have low thyroxine levels compared
to term infants. Second, hypothyroxinaemia is
associated with an increased risk of CP [14]. Third,
in infants born before 26 weeks of gestation and in
the presence of some neonatal events such as
severe respiratory disease, hypocarbia and low
E. Saliba and S. Marret
arterial blood pressure, hypothyroxinaemia may be
associated with an increased risk of WMD [15].
(5) Intrauterine infection, inflammation
and white matter damage
Epidemiological studies of WMD in preterm new-
borns have revealed a strong association with
perinatal infection. The hypothesis is that during
pregnancy infection leads to maternal and foetal
inflammatory responses that in turn contribute to
the following: (a) preterm delivery; (b) WMD; and
(c) neurodevelopmental disorders, mainly CP.
a) Preterm delivery. Intrauterine infection (IUI) is
now recognized as one important initiator of
preterm labour and premature rupture of mem-
branes (ROM) [16,17]. Cytokines (Il-1
, IL-6,
TNF) of foetal origin seem to constitute the
link between IUI and preterm delivery [18,19].
In pregnancies complicated by preterm, prema-
ture ROM, foetal plasma IL-6 levels were sig-
nificantly higher in those with infected amniotic
fluid than in those whose amniotic fluid was
sterile. Il-6 levels were also significantly raised in
pregnancies that led to spontaneous delivery
within 48 h than in those that ended later [20].
Increased levels of pro-inflammatory cytokines
(IL-1
, IL-2, IL-6, IL-8, TNF-) and granulocyte-
macrophage colony-stimulating factor (GM-
CSF) have all been identified in the amniotic
fluid of patients with chorioamnionitis [21].
Certain combinations of these cytokines stimu-
late prostaglandin synthesis and release by the
amnion and decidua, contribute to neutrophil
chemotaxis and activation and, ultimately, to
the synthesis and release of metalloproteases.
This cascade participates in the signalling pro-
cess responsible for the initiation of labour in
the setting of infection (contractions, membrane
weakening and rupture and cervical ripening)
[22].
b) White matter damage. The finding that prenatal
cultures of the upper vagina and cervix from
women whose infants subsequently had PVL
are more likely to grow bacteria supports the
hypothesis that foetal exposure to longstanding
infection or inflammation increases the risk of
WMD [23]. Bacterial vaginosis may constitute a
chronic inflammatory stimulus that initiates a
foetal inflammatory response that, in turn,
increases the risk of WMD and CP in preterm
Cerebral white matter damage in the preterm infant
infants. Elevated cytokine levels in the amniotic
fluid, umbilical cord and neonatal blood are
associated with WMD and CP [24,25]. Infants
with elevated IL-6 levels in cordocentesis speci-
mens are twice as likely as infants with lower
levels to have WMD [26]. On the other hand,
levels of pro-inflammatory cytokines appear to
be elevated in the brains of infants who die with
histological evidence of WMD [27]. In addition
to exposure to the maternal inflammatory
response (i.e. membrane inflammation) foetal
vasculitis (chorionic and umbilical cord vessel
inflammation) substantially increases the risks
of PVL. In a prospective multi-centre study,
Leviton et al. showed that foetal vasculitis was
associated with an 11-fold increased risk of
PVL [28].
c) Cerebral palsy. Pooling data from 4 different
studies, OShea and Damman, found significant
univariate association between IUI and cerebral
palsy in very low-birthweight infants (OR: 2.2;
95% CI: 1.63.1) [29]. This association has been
found in a large number of studies. In a recent
meta-analysis, a significant association was
found between clinical chorioamnionitis and
both cerebral palsy and cystic PVL (OR: 1.9;
95% CI: 1.42.5 and OR, 3.0; 95% CI: 2.24.0
respectively) [30]. However, two reports failed
to find such association. In one report, infants
with WMD had lower amniotic fluid cytokine
levels than controls. Although these differences
did not achieve statistical significance, the study
was limited by a very small sample size (n=33)
[31]. Another negative result was recently
reported by Nelson et al. (abstract form) who
found no association between cytokine concen-
tration and risk of CP in infants born at less than
32 weeks GA to non-pre-eclamptic mothers
[32]. To better understand the relationships
between chorioamnionitis, inflammation and
cerebral palsy, it is important to develop con-
sensus definitions of clinical and histological
chorioamnionitis and of cerebral palsy. It is
also crucial to adjust for potential confounders
such as low gestational age, hypocarbia and
pre-eclampsia.
Proinflammatory cytokines might be harmful for
the developing brain by damaging the myelinating
oligodendrocytes and disturbing the develop-
mental transition from the oligodendrocyte pre-
cursor to the mature oligodendrocyte [3336].
In vitro studies have shown that cytokines stimulate
123
astrocyte mitosis and growth [37]. These two
mechanisms might explain the paucity of the white
matter and the focal necrosis observed in WMD of
the preterm newborn infant [38]. The mechanisms
of inflammatory mediated brain injury during
intrauterine infection are shown in Figure 1.
Heightened levels of inflammatory cytokines are
not specific to infection. Nelson et al. found marked
differences in term and near-term infants, in the
concentrations of several inflammatory mediators
in children with CP compared to controls. Children
born of women with clinical signs of IUI tended to
have especially high concentrations of inflam-
matory cytokines, as did infants whose mothers
had clinical evidence of autoimmune disorders.
These findings suggest that inflammation not
caused by infection might also be associated with
the risk of CP. Inflammatory cytokines also
exceeded control levels in children with CP, in
whom there were indicators of coagulation dis-
orders [39]. That a cytokine can be on the causal
pathway to neurological disorder is suggested by
the observation that the administration of INF-
to young children appeared to produce spastic
diplegia [40]. Spastic diplegia is associated with a
significantly high neonatal blood concentration of
interferons [41].
Although at first glance the evidence appears to
support a role for infection-mediated cytokine
release in the pathogenesis of WMD, there are
number of difficulties with this formulation. In the
studies relating to such a role, cerebral ischaemia
can not be ruled out. Cytokines may simply
represent the expected response to ischaemic
injury [42,43]. All together, it is tempting to
combine infection and hypoxia-ischaemia into the
same pathogenesis model, in which both insults
contribute to white matter damage (Fig. 2).
(6) Antenatal steroids
Antenatal steroids have been associated with a
decreased risk of PVL and ventricular dilatation,
especially among VLBW infants and those who had
hypothyroxinaemia or vasculitis of the umbilical
cord or chorionic plate [44]. In one recent study,
antenatal steroid treatment was associated with
over 50% reduction in the incidence of PVL [45].
Pooling the data from seven case-control studies,
OShea and Damman found a significant univariate
association between antenatal steroids and
decreased risk of CP (O.R: 0.7; 95% CI: 0.51) [29].
The protective effects of antenatal steroids on the
124 E. Saliba and S. Marret

IL-1

Figure 1. Mechanisms of inflammatory induced brain injury. Potential interactions between cells of immune system (T cells,
B cells, and macrophages) and central nervous system (astrocytes, microglia, and oligodendrocytes). Endothelium derived
TNF- induces expression of adhesion molecules to allow granulocytes crossing the blood brain barrier. Proinflammatory
cytokines might be harmful for the developing brain by damaging the myelinating oligodendrocytes and stimulating
astrocyte mitosis and growth. These two mechanisms might explain the paucity of the white matter and the focal necrosis
observed in PVL. EC, endothelial cells; ICAM-1, intercellular adhesion molecules; IL, interleukin; TNF, tumour necrosis
factor.

brain might be explained by various mechanisms.
Corticosteroids enhance the development of oligo-
dendrocytes and may accelerate maturation of the
endothelial cells of the cerebral vasculature [46].
Steroids also stimulate increased activity of anti-
oxidant enzymes, which can further reduce neuro-
logical cell damage. Finally, antenatal steroids also
inhibit the proinflammatory cytokine cascade [47].
However a retrospective study of Baud et al.
showed a difference between both commonly used
fluorinated corticosteroids, i.e. dexamethasone and
betamethasone. The PVL rate was increased in the
group of preterm neonates whose mothers received
antenatal dexamethasone, whereas it was decreased
in the group of infants whose mothers had received
betamethasone therapy, suggesting a protective
effect only for the latter corticosteroid. These
differences are possibly explained by the presence
of sulfites in the preparation of dexamethasone
[48]. Sulfites are neurotoxic in neural cell cultures
in vitro.
(7) Antenatal magnesium sulfate therapy
Magnesium sulphate (MgSO4) is currently used in
some countries as a tocolytic agent and in the
treatment of pre-eclampsia. In two retrospective
studies, maternal treatment with MgSO4 was
associated with a 7- to 10-fold reduction in risk
of CP [49,50]. More recent studies are less
encouraging with regard to prevention of CP
with MgSO4 [51]. MgSO4 crosses the placental
barrier and is concentrated in the foetal brain.
Significantly, low levels of Mg concentrations
have been observed in preterm newborns that are
at risk of PVL or intraventricular haemorrhage
[52]. The possibility that MgsO4 is causally
related to a reduced risk of CP is consistent
with the finding that this drug is protective in
experimental models of brain injury [53]. Three
clinical trials are ongoing to test the value of
antenatal MgSO4 injection in the prevention of
PVL.
Cerebral white matter damage in the preterm infant
-
2
Figure 2. Foetal infection and perinatal hypoxia-ischaemia appear to share some characteristics in the pathogenesis of brain
injury, including elevated levels of cytokines.
Epidemiology of white matter
damage: neonatal factors
(1) Impaired cerebral blood flow and
WMD
Perinatal events associated with postnatal PVL
often include a history of respiratory distress
syndrome, asphyxia, sepsis, symptomatic patent
ductus arteriosus and recurrent apnoea and brady-
cardia. Many of these associations share a reduc-
tion in systemic blood pressure. However, studies
of the relationship of cerebral perfusion and PVL or
CP have been inconclusive. The methodological
difficulty has been the inability to measure rapid
changes in the cerebral circulation. In a small
number of studies, hypotension has been associated
with a modest increase in WMD and CP [5456].
Others have failed to demonstrate a consistent
association with hypotension and PVL [57,58].
(2) Hypocarbia
Hyperventilation can induce a decrease in cerebral
blood flow. This may account for the relationships
demonstrated between hypocarbia and PVL or CP.
125
Pooling data from 6 different studies, we found a
significant association between hypocarbia and
PVL in very low birthweight infants (OR: 3.3; 95%
CI: 2.76.5.) [5964]. Although it is plausible that
hypocarbia contributes to WMD by inducing
marked cerebral vasoconstriction, it might also be a
marker of illness severity.
Animal models of periventricular
leukomalacia
A few animal models of PVL have been set up to
replicate some aspects of brain lesions observed in
premature neonates.
In vivo animal models of PVL
Two types of insult were mainly used in
animal models to produce white matter lesions:
hypoxia-ischaemia and inflammatory events.
(1) Hypoxic-ischaemic models
Use of unilateral carotid artery occlusion combined
with hypoxia in immature 7-day-old rats (P7) is a
126
well-known model of hypoxia-ischaemia [65]. It has
expanded our knowledge about the critical steps
and biochemical changes occurring during or after
such insult. In particular, it has been demonstrated
that excitatory amino acids are markedly elevated
and play a key role in the genesis of brain damage
by inducing secondary neuronal death. However,
in this experimental model the main lesions were
severe neuronal damage found in the cerebral
cortex ipsilateral to the side of the carotid artery
occlusion. The P7 rat pup has served to mimic the
response to HI injury at or near term gestation in
humans. Sheldon et al. have proposed that HI injury
suffered on postnatal day 1 (P1) in the newborn rat
might cause significant brain injury, simulating that
seen in a midgestation human brain [66]. In this
model astrocyte and microglia reactivity was seen
as early as 24 h after injury and by P10 there was
marked loss of white matter. Animal models of
PVL have also been developed in other species at
specific stages of brain development, correspond-
ing to a period of high vulnerability of the white
matter and to the peak production of astrocyte and
oligodendrocyte precursors by the germinative
zone. Isolated hypoxaemia or hypoxia-ischaemia
was used in these models. Cerebral hypoperfusion
due to bilateral carotid artery occlusion was able
to produce hypoxic-ischaemic and white matter
injuries in neonatal dogs and 5-day-old rats [67,68].
Cerebral ischaemia-reperfusion secondary to
repeated umbilical cord occlusion also induced PVL
in foetal sheep at 118 days gestation [69]. White
mater injuries were also observed after haemor-
rhagic hypotension in neonatal dogs and in foetal
sheep at 113 days gestation [70,71]. Isolated
hypoxaemia, sufficient to reduce arterial O2 content
by approximately 50% by restriction of uterine
blood flow, was accompanied by acidosis and was
also able to provoke PVL without reducing mean
foetal arterial blood pressure [72].
(2) Inflammation-related WMD
The first model, which addressed the link between
bacterial infection and PVL, was reported by Gilles
et al. [73]. Perinatal telencephalic leukoencephalo-
pathy was induced in newborn full term kittens,
injected intraperitoneally with E. Coli endotoxin
between 2 and 20 days of life. Using a similar
method, Young et al. obtained cerebral damage
with important inflammatory infiltrates in neonatal
dogs at 1 to 10 days of age [74]. However, this
E. Saliba and S. Marret
stage of brain development corresponds approxi-
mately to 3438 weeks of gestation in humans,
raising a question about the relevance of this model
to human PVL. Foetal rabbit models described by
Yoon et al. seem to be more applicable than
neonatal dogs and kitten to human PVL. White
matter damage was observed in 12 (6%) foetuses
born to 10 pregnant rabbits inoculated through the
cervix with E. Coli [75]. More recently Debillon
et al. inoculated E. Coli into the uterine horns of
pregnant rabbits and observed extensive apoptosis
in the white matter of 13 (100%) foetuses. Three of
the 13 brains displayed periventricular white matter
cysts [76]. In another animal model, Cai et al.
demonstrated that the endotoxin lipopolysac-
charide (LPS) injected into pregnant rats at 18 and
19 days of gestation induced brain injuries in
8-day-old rat pups [77]. Maternal LPS admin-
istration seems to change the immunoreactivity of
microglia, decreasing myelin basic protein (a
marker of myelin) and increasing glial fibrillary
acidic protein-positive astrocytes in the brains of
off-spring. Moreover, this is the first report to
assess direct induction of cytokine genes such as
interleukin-1
and tumour necrosis factor-a in the
foetal brain after maternal administration of LPS.
Some forms of white matter diseases in humans
could also probably be linked to virus infection.
Maternal infection with pestiviruses leads to
necrosis and cyst formation in the developing
periventricular white matter of foetal sheep [78].
(3) Excitotoxic models of WMD
Many mechanisms have been involved in neural
cell damage observed in brain lesions of neonates.
Neural cell death could be due to excess of
cytokines, free radical overproduction, extracellular
matrix damage and excess excitatory amino acid or
growth factor deficiency. The excitotoxic cascade
could represent a common final pathway for a
number of these mechanisms [79]. After an initial
insult, an excessive amount of glutamate is released
and results in massive influx of ions, in particular
calcium and zinc, through the N-methyl-D-
aspartate glutamate receptor (NMDA) of the post-
synaptic neuronal membrane. An abnormal amount
of intracellular calcium triggers metabolic pathways
(synthesis of nitric oxide, lipid peroxidation, syn-
thesis of free radical, platelet-activated factor, pro-
tease activation and DNA fragmentation) that leads
to neuronal cell death. It has recently been shown
Cerebral white matter damage in the preterm infant
Figure 3. White matter cystic lesion induced by intra-cortical injection of a glutamatergic agonist, ibotenate, in post-natal
day 5 mice pups.
that oligodendroglia, the glial cell type responsible
for the generation of myelin, are particularly sensi-
tive to the toxic effects of glutamate due to
impairment of glutamate transport and free radical
damage [36]. We recently established an animal
model of excitotoxic lesions in the developing
mouse brain [80]. Brain damage was induced by
intra-cortical injections of ibotenate, a glutamater-
gic agonist, at different stages of brain develop-
ment and neuronal maturation. This study was the
first to report developmental changes in the
responses of white and grey matter in neonatal
mouse brain to excitotoxicity. When administered
at birth soon after completion of neuronal migra-
tion to the supragranular layers, ibotenate induced
neuronal death in cortical layers VVI; the lesion
mimics microgyria, a cortical lesion observed
between 14 and 28 weeks of human gestation.
When administered on post-natal day 5 (P5) after
all neurons have completed migration in the neo-
cortex, ibotenate produced severe neuronal loss in
neocortical layers II, III, IV, V and VI. Furthermore,
ibotenate induced the formation of white matter
cysts between P2 and P10, with a 100% peak of
intensity and frequency at P5 (Fig. 3). Although
ibotenate is able to activate both N-methyl-D-
aspartate (NMDA) and metabotropic glutamate
receptors, all ibotenate-induced brain lesions were
inhibited by treatment with a specific NMDA
antagonist (D,L-2-amino-7-phosphoheptanoic acid)
but not by an antagonist of phosphoinositide-
linked metabotropic receptors [L(+)-2-amino-3-
127
phosphonopropionic acid]. We also demonstrated
in this model that activation of microglia was the
first detectable cellular event associated with astro-
cyte death [81]. The presence of NMDA receptors
on white matter cells was transient with a peak at
P5 and a dramatic decrease at P15. Ibotenate-
induced white matter lesions were also aggravated
by excess of cytokines or iron supplementation and
decreased by suppression of tissue plasminogen
activator [82,83]. This in vivo animal model of
NMDA-mediated white matter cystic lesions,
reproduced some aspects of human PVL for several
reasons including the following: (1) ibotenate-
induced white matter lesions are periventricular
and cystic, and develop into glial scar; (2) the
developing murine white matter exhibits a discrete
ontogenic window of sensitivity to ibotenate-
induced damage, as observed in humans; (3) the
developmental stage of white matter at P5 in the
mouse corresponds approximately to 2430 weeks
of gestation in humans in terms of precursors of
white matter astrocytes, while mid-gestation in the
human corresponds to birth in the mouse in terms
of completion of neuronal migration; (4) the asyn-
chronism of the ontogenic window observed
between the ibotenate-induced cortical plate dam-
age (P0 to adult) and cystic white matter lesions
(P2 to P10) strongly suggest that white matter
lesions are not secondary to cortical plate lesions.
Moreover, the fact that melatonin and vaso-
active intestinal peptide (VIP) decrease P5-white
matter damage but not the cortical plate lesion
128 E. Saliba and S. Marret

Table 1. Pathogenesis of white matter damage

 Intrauterine infection foetal inflammation cytokine release

 Hypoxic-ischemic insults glutamate toxicity
 Cerebral ischemia impaired cerebrovascular autoregulation hypocarbia
 Intrinsic vulnerability of white matter trophic factor deficiencies hypothyroxinemia
 Vulnerability of early differentiating oligodendrocyte to free radicals glutamate cytokines
strengthens the hypothesis that grey and white
matter cerebral lesions are independently produced
[84,85].
(4) Growth or hormonal factor
deficiency and experimental WMD
In the previously described model of PVL caused
by pestivirus infection, a decrease in thyroid hor-
mone activity was observed in lambs [86]. Thyroid
hormones are crucial for normal brain develop-
ment, and this animal study corroborated an epi-
demiological study in humans, which reported an
11-fold increased risk of cerebral palsy among
preterm infants with severe hypothyroxinaemia
(see above). In the excitotoxic model of PVL,
blockade of endogenous growth factor such as VIP
increased the severity of ibotenate-induced WMD
[87]. Premature delivery provokes a dramatic loss
of maternal supply of substances that are not
produced in sufficient amounts by the foetus.
Growth factors and hormones such as VIP and
thyroxine probably belong to this category.
In vitro experimental models of
PVL
Immunohistochemical studies realized in human
brains suggest that there is a myelination defect
after periventricular white matter injury. In vitro
models of pre-oligodendroglial and mature oligo-
dendroglial cells have shown that early differ-
entiating oligodendrocytes but not mature
oligodendrocytes are highly sensitive to free
radicals. Free radical-mediated cell death could be
triggered by exposure to glutamate via cystine
efflux and glutathione depletion [88]. Also, oligo-
dendrocytes express AMPA glutamate receptors,
suggesting a second mechanism for oligodendro-
glial cell death induced by glutamate [89,90].
In vitro astrocyte cell cultures, medium conditioned
by microglia treatment with ibotenate significantly
enhanced astrocyte death [81]. These and other
findings suggest that microglial activation, which is
the earliest detectable cellular event following
ibotenate injection, can lead to astrocyte death.
In conclusion, all the above-described exper-
imental models contribute to the understanding of
some aspects of WMD formation (Table 1). Com-
bined with human pathology studies, they suggest
that the cystic lesions observed on cranial ultra-
sonography are only the visible parts of more
diffuse encephalopathy involving white and grey
matter.
Neuroprotection in experimental
models of white matter disease
In vitro and in vivo studies have suggested that
several pharmacological targets could be addressed
for prevention of white matter disease. Most of
them have been tested in animal models of
hypoxia-ischaemia at a stage of brain development
that could be compared to that of term newborns
[91].
In the inflammation models of WMD, maternal
antibiotic administration did not eradicate intra-
uterine infection or prevent brain white matter
lesion. The crucial factor determining the prophy-
lactic effects of antibiotics may be whether intra-
uterine infection has reached the foetus and caused
white matter damage at the time of antibiotic
administration.
In the excitotoxic mouse model of WMD,
several drugs have been tested that could poten-
tially prevent white matter brain lesions in human
preterm newborns. These agents could operate
differently on grey and white matter, suggesting
different anti-insult mechanisms. For example,
melatonin and VIP were able to prevent white
matter brain lesions but not grey matter lesions.
We have also been able to show that magnesium
sulphate (MgSO4) protects both grey and white
matter when ibotenate was injected at P5; but this
drug failed to be protective at P0 or at P10,
Cerebral white matter damage in the preterm infant 129

Table 2. Neuroprotective agents tested in excitotoxic white matter injury induced by a

glutamatergic agonist (ibotenate) in mouse at post-natal day 5

Neuroprotective
Molecule Mechanism
effect

Magnesium sulfate Voltage-dependant blockade of NMDA receptor +++

Zinc gluconate Inhibition of NMDA receptor 0
Kynurenique acid Inhibition of glycine site of NMDA receptor ++
NG-nitro-L-arginine Inhibition of NOa synthase ++
21-aminosteroids Inhibition of free radicals 0
VIPb Neuropeptide +++
Melatonin Inhibition of free radicals +++
WEB 2170 Antagonist of PAFc ++
Betamethasone Anti-inflammatory ++

a
Nitric oxide; bvasoactive intestinal peptide; cplatelet activating factor.

Table 3. Treatment strategies to prevent white matter born infants, it is likely that most PVL and cerebral
damage in human preterm newborns palsies originate prenatally or at least in the first
few days of life. Therefore, the ideal strategy for
1. Antenatal strategies:
 Maternal antibiotic therapy
the prevention of cerebral lesions should take place
 Antenatal steroid therapy
before birth. However, there is evidence from
newborn rats and preterm monkeys that the brain
2. Post-natal strategies: may reorganize to achieve complete functional
 Careful ventilatory management avoid hypocarbia, compensation if cortical damage occurs early dur-
and hypoxaemia
ing development [93]. Additional post-natal treat-
 Appropriate treatment of low blood pressure
 Careful use of oxygen and iron
ment could optimize functional compensation at a
 Prevention of stress: effective treatment of pain
time of rapid brain growth and development.
 Nutritional intervention polyunsaturated fatty acids
glutamine?
 Thyroxine supplementation in VLBW infants?
suggesting that there is an ontogenic window
for brain protection by MgSO4 [53,92]. Other
neuroprotectors are listed in Table 2.
Treatment strategies in human
preterm newborns (Table 3)
Adverse effects, bioavailability and ability to cross
the bloodbrain barrier are of paramount impor-
tance in developing new neuroprotective agents.
Several drugs used with great benefit in animals
have potentially detrimental effects in humans.
Therefore, only a few anti-insult strategies can be
contemplated in human preterm newborns or their
mothers before premature delivery.
In view of the better understanding of the
pathogenesis of cerebral lesions in prematurely
1. Antenatal strategies
Maternal antibiotic therapy
There is clinical data suggesting that specific treat-
ment of genital tract infections, such as bacterial
vaginosis, reduces the risk of preterm birth [94]. A
recent meta-analysis evaluating the effectiveness
and long-term safety of the effects of antibiotic
administration to women with preterm pre-labour
rupture of membranes only showed a trend
towards a reduction in the incidence of major
cerebral abnormalities diagnosed by cranial ultra-
sonography [95]. However, the meta-analysis did
indicate improvement in neonatal morbidity.
Antenatal steroid therapy
It is now well established that antenatal treatment
with corticosteroids in the case of threaten-
ing preterm birth, reduces respiratory distress
130
syndrome, intraventricular/periventricular haemor-
rhage, periventricular leukomalacia and perinatal
morbidity [96]. There is, however, no evidence to
support multiple courses of corticosteroids and
there are even some reports indicating adverse
effects. Repeated doses of corticosteroids have
been shown to reduce head circumference and to
be associated with an increased risk of neurobehav-
ioural abnormalities [97,98]. (See article by David F
Adams, Laura R Ment and Betty Vohr in this issue.)
2. Post-natal strategies
Early post-natal dexamethasone therapy
Several large randomized controlled trials of post-
natal dexamethasone, administered early for the
prevention and the treatment of chronic lung
disease in preterm newborns, yielded an increased
incidence of cerebral palsy and developmental
delay [99].
Prevention of post-natal risks of PVL
The precise impact of several post-natal risk factors
of PVL is still a matter of debate. Specific potential
strategies include: (1) careful ventilatory manage-
ment of infants with respiratory distress in order to
avoid hypocarbia, hyperoxia and hypoxaemia; (2)
appropriate treatment of infants with low blood
pressure for a given gestational age with volume
replacement therapy or inotropic support as clini-
cally indicated; (3) careful use of free iron that could
limit the free radical injury demonstrated in exper-
imental models; (4) pragmatic and careful use of
certain drugs (e.g. benzodiazepine and morphine)
[100].
Prevention of stress
Perinatal brain plasticity increases the vulnerability
to early adverse experiences, leading to permanent
damage to neuronal and synaptic organization.
Appropriate treatment of neonatal pain and
prevention of maternal separation are of clinical
importance in the prevention of insults [101,102].
Nutritional intervention
Sub-optimal nutrition during vulnerable stages in
early brain development may have long-term
E. Saliba and S. Marret
effects on cognitive function. Verbal intelligence
quotient below 85 and cerebral palsy were more
prevalent at 78 years of age in a group of preterm
infants fed with standard term formula than in a
group of preterm infants fed with preterm formula
[103]. It is now assumed that polyunsaturated fatty
acids are required for cell membranes stability and
that glutamine might be an essential aminoacid.
Cognitive development was better at 10 months
of age in babies fed milk supplemented with
long-chain polyunsaturated fatty acids [104].
However polyunsaturated fatty acid supplemen-
tation remains controversial. The value of enteral
glutamine is currently being evaluated in
prospective studies.
Thyroxine supplementation
Preterm infants with hypothyroxinaemia are at
increased risk of cerebral white matter damage and
cerebral palsy. Thyroxine supplementation of pre-
term babies less than 30 weeks of gestational age
significantly increases cognitive development at
2 years of age in children born before 27 weeks
gestational age [105]. The value of thyroid
supplementation needs to be evaluated.
Conclusions
Injury to cerebral white matter remains a significant
problem affecting approximately 415% of VLBW
infants, and at present there is no effective means of
prevention. The outcome following such injury is
invariably unfavourable with motor as well as
cognitive impairment. A clearer understanding of
the pathogenesis is critical in order to provide
targeted intervention to those infants at highest
risk.
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