Clinical Trials

Neonatology
Neonatology Received: February 3, 2023
Accepted: September 5, 2023
DOI: 10.1159/000534009 Published online: October 20, 2023

Magnetic Resonance Imaging-Based Reference

Values for Two-Dimensional Quantitative Brain
Metrics in a Cohort of Extremely Preterm Infants

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Julia Buchmayer a Gregor Kasprian b Raphaela Jernej a Sophie Stummer a
Victor Schmidbauer b Vito Giordano a Katrin Klebermass-Schrehof a
Angelika Berger a Katharina Goeral a
a
Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent
Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria; bDivision of
Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna,
Austria

Keywords significant correlation between gestational age at birth and

Neonatal brain · Neonatal intensive care · Magnetic resonance
imaging · Neurodevelopment · Brain
Abstract
Introduction: Cerebral magnetic resonance imaging (cMRI)
is an important diagnostic tool in neonatology. In addition to
qualitative analysis, quantitative measurements may help
identify infants with impaired brain growth. This study
aimed to create reference values for brain metrics of various
brain areas in neonates without major brain injuries born
before 28 weeks of gestation. Methods: This retrospective
study analyzes cMRI imaging data of high-risk patients
without severe brain pathologies at term-equivalent age,
collected over 4 years since November 2017. Nineteen brain
larger “tissue” parameters, as well as smaller “fluid” pa-
rameters, including intracerebral and extracerebral spaces.
Discussion: With quantitative brain metrics infants with
impaired brain growth might be detected earlier. Compared
to preexisting reference values, these are the first of a
contemporary collective of extremely preterm neonates
without severe brain injuries. Measurements can be easily
performed by radiologists as well as neonatologists without
specialized equipment or computational expertise.
Conclusion: Two-dimensional cMRI brain measurements at
term-equivalent age represent an easy and reliable ap-
proach for the evaluation of brain size and growth in infants
at high risk for neurodevelopmental impairment.
© 2023 The Author(s).
Published by S. Karger AG, Basel

areas were measured, reference values created, and com-

pared to published values from fetal and postnatal MRI.
Furthermore, correlations between brain metrics and ges-
tational age at birth were evaluated. Results: A total of 174
cMRI examinations were available for analysis. Reference
values including cut-offs for impaired brain growth were
established for different gestational age groups. There was a
Introduction
Extremely preterm infants born before 28 weeks
gestational age (GA) show increasing survival rates over
recent years [1], but nevertheless, they remain at high risk

karger@karger.com © 2023 The Author(s). Correspondence to:

www.karger.com/neo Published by S. Karger AG, Basel Katharina Goeral, katharina.goeral @ meduniwien.ac.at

This article is licensed under the Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC) (http://www.
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commercial purposes requires written permission.
of cognitive, motor, learning, or behavioral disabilities
[2–5]. As a consequence, research interest is moving
toward more accurate prediction of neurodevelopmental
outcomes.
Serial cranial ultrasound is the most used bedside
neuroimaging tool in preterm infants [6]. Two-
dimensional (2D) measurements have been im-
plemented in cranial sonography, and have been
shown to be associated with outcome [7]. Cerebral
magnetic resonance imaging (cMRI) provides a more
accurate description of the neonatal brain and is fre-
quently performed around term-equivalent age (TEA).
cMRI offers an improved prediction of motor and
cognitive outcomes and a possibility for further risk
stratification [8] as abnormal cMRI findings at TEA in
very preterm infants have been shown to strongly
predict adverse neurodevelopmental outcome [9, 10].
Studies have shown that some infants without brain
injuries on conventional cMRI at TEA, such as in-
traventricular hemorrhage (IVH), white matter in-
juries (WMD), or cerebellar injuries (CBI), are affected
by adverse outcome [11]. Impaired brain growth
identified by cMRI could offer a valuable tool for the
identification of preterm infants at high risk of neu-
rodevelopmental impairment.
Quantitative evaluation of cerebral structures in at-risk
infants, especially those born extremely preterm, may
assist in defining the impact of preterm birth on cerebral
development. 2D parameters, including “tissue” and
“fluid” (intracerebral and extracerebral) measurements,
have been implemented by Garel [12], showing a close
correlation with maturity. Tissue parameters mean dis-
tances and areas of structural brain tissue, whereas fluid
measurements refer to liquid spaces. Nguyen The Tich
et al. [13] described that preterm infants born before
30 weeks of gestation had impaired brain metrics at TEA
compared to full-term infants. Kidokoro et al. [14]
connected impaired brain growth with impaired
outcome. Previously published values by Garel [12] and
Nguyen The Tich et al. [13] were either created using fetal
MRI or postnatal cMRI including infants with severe
brain injuries. The advantage of those measurements is
that they can be done rather quickly.
Reference values based on postnatal cMRI from a large
cohort of preterm infants without major pathologies are
warranted. The aim of our study was to create reference
values of 19 brain areas for a contemporary cohort of
extremely preterm infants born before 28 weeks of ges-
tation without severe brain pathologies, which might help
identify patients with impaired brain growth in clinical
practice.
2 Neonatology
DOI: 10.1159/000534009
Methods
Subjects
This retrospective study included preterm infants born at
221/7–276/7 weeks of gestation with a cMRI examination from No-
vember 2017 to October 2021. The preterm infants were admitted to a
level 4 neonatal intensive care unit of the Medical University Hospital
in Vienna, Austria. Perinatal and clinical variables were obtained,
including GA, mode of delivery, multiple birth, sex, birth weight, and
respective percentile, APGAR, pH from both umbilical cord and first
postnatal; important neonatal diagnoses (IVH, graded per Papile et al.
[15]; WMD, including cystic periventricular leukomalacia [16]; CBI,
graded per Kidokoro et al. [17]; blood culture-proven sepsis; patent
ductus arteriosus requiring intervention [both surgical or interven-
tional closure]; necrotizing enterocolitis above Bell’s stage 2 [18];
severe retinopathy of prematurity, defined as stage 3 and above
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according to the international classification [19] requiring inter-
vention; and bronchopulmonary disease, defined as oxygen re-
quirement ≥36 weeks’ [20]). Also, the duration of respiratory support
and supplemental oxygen were obtained.
cMRI Examinations
Since the implementation of routine cMRI at the Medical
University of Vienna in November 2017, every extremely preterm
infant was offered a cMRI at TEA independently of clinical an-
amnesis, medical history, or aforementioned brain pathologies
seen on serial routine cranial ultrasound. cMRI over a 4-year
period was analyzed within this study. All examinations were
conducted without sedation according to our local feed-and-wrap
protocol using a vacuum immobilization mattress. A similar
protocol was previously published by Woodward et al. [8].
cMRI Protocol
Image acquisition was performed at the local department of
radiology, division of neuroradiology and musculoskeletal radi-
ology on a Philips Ingenia (Philips Healthcare, Best, The Neth-
erlands) 1.5 Tesla MR system (Table 1). During and after cMRI,
the images were manually rotated to a standardized alignment by
technical radiology assistants.
Quantitative cMRI Metrics
The 2D measurements were performed in the standard radio-
logical DICOM program IMPAX EE (https://global.agfahealthcare.
com/dicomconformance/). In five standard slices (displayed with
landmarks in Fig. 1) 19 parameters were measured, adapted from
Garel et al. [12] and Nguyen The Tich et al. [13]. Brain measurements
were performed by two independent investigators (J.B. and R.J.), who
were blinded to the clinical history. Reference values as well as cut-off
values for impaired brain growth (defined as two standard deviations
below the mean for “tissue” parameters and two standard deviations
above the mean for “fluid” parameters) were created.
The first coronal slice was taken at the level of the olfactory sulci
with four teeth apparent. The bifrontal diameter (BFD) was
measured as the maximal distance perpendicular to the inter-
hemispheric fissure and the anterior horn height (AHH) at the
level of the gyrus rectus.
The second coronal slice measurements were taken at the level
of the temporal horns of the lateral ventricles with the basilar
truncus apparent and the bilateral cochlea as a landmark. The
cerebral biparietal width (cBPW) corresponded to the greatest
Buchmayer et al.
 Table 1. Standardized neonatal cMRI protocol

Sequence Plane AT TR TE Voxela FOVa Matrixa

T1 SE Axial 03:07 400 15 0.83 × 1.05 × 3.00 120 × 120 × 90 144 × 115 × 30
T1 3D Sagittal 03:46 25 7.6 0.75 × 0.75 × 2.00 120 × 120 × 99 160 × 160 × 99
T2 TSE Axial 01:48 3,000 140 0.94 × 1.06 × 3.00 120 × 120 × 102 128 × 113 × 34
T2 TSE Sagittal 01:48 3,000 140 0.94 × 1.06 × 3.00 120 × 120 × 108 128 × 113 × 36
T2 TSE Coronal 01:48 3,000 140 0.94 × 1.06 × 3.00 110 × 110 × 108 116 × 103 × 36
SWI Axial 03:35 51 12 0.85 × 1.00 × 2.00 170 × 139 × 90 200 × 138 × 90
DWI Axial 01:34 4,066 90 1.14 × 1.15 × 3.00 200 × 200 × 92 176 × 170 × 28

AT, acquisition time (min); DWI, diffusion-weighted imaging; FOV, field-of-view; SE, spin echo; SWI,
susceptibility-weighted imaging; TE, echo time (ms); TR, repetition time (ms); TSE, turbo spin echo. amm.

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Fig. 1. Slices and landmarks of neonatal cMRI brain metrics. a,
right; b, left; 1, BFD, bifrontal diameter; 2a+2b, AHH, anterior
horn height; 3, cBPW, cranial biparietal width; 4, bBPW, bone
biparietal width; 5, IHD, interhemispheric distance; 6a+6b, ECS,
extracerebellar space; 7a+7b, VI, ventricular index; 8a+8b, AHW,
anterior ventricular horn width; 9, 3V, third ventricle; 10a+10b,
CCI, craniocaudal interopercular distance; 11, TCD, transverse
cerebellar diameter; 12a+12b, AtrialV, ventricular atria; 13, FOD,
fronto-occipital diameter; 14, CClength, corpus callosum length;
15, 4V, fourth ventricle; 16, dVermis, vermis diameter; 17,
hVermis, vermis height; 18, sVermis, vermis surface; 19, DGMA,
deep gray matter area.

transverse brain width at the mentioned level, while the bone
biparietal width (bBPW) was defined as the maximum diameter
between the inner limits of the skull. Interhemispheric distance
(IHD) was measured as the horizontal distance between the in-
ternal edges of the superior frontal gyri, directly above the cingular
sulcus, at an equal distance from the corpus callosum and vertex.
The extracerebral space (ECS) was obtained as the distance be-
tween the superior frontal gyri to the inner limit of the skull.
Ventricular measurements, including the ventricular index (VI;
distance between the falx and the lateral wall of the anterior horn),
anterior horn width (diagonal width of the anterior ventricular
horn measured at its widest point), and maximal lateral distance of
the third ventricle were assessed in this slice. Furthermore, the
craniocaudal interopercular distance (CCI) as the maximum di-
ameter of the fossa lateralis was measured [13, 21]. The third
coronal slice was obtained at the maximum diameter of the
cerebellum, where the transverse cerebellar diameter (TCD) and
the ventricular atria at ventricular mid-height were measured.
The sagittal slice was analyzed in midline and the front-
occipital distance (FOD) was measured as the maximal distance
from the anterior to the posterior edge of the brain. Next, the
length of the corpus callosum (CClength) from the genu to the
posterior extremity of the splenium was assessed. The height of
the vermis (hVermis) parallel to the 4th ventricle, the diameter
of the vermis (90 degrees to hVermis), and the surface of the
vermis (sVermis) were also measured in the sagittal slice. In the
axial slice, the deep gray matter area (DGMA) corresponding to
the maximal surface of the basal ganglia was measured.
The brain metrics were compared with growth curves of
normative data published by Garel [12] and Nguyen The Tich
et al. [13] and respective Z-scores were calculated. cMRI done
until 370/7 weeks was compared with Garel [12] and cMRI done
between 37 and 42 weeks was compared with the measure-
ments from Nguyen The Tich et al. [13]. Furthermore, cor-
relations between measurements and GA at birth were eval-
uated. Additionally, impaired brain growth was implemented
and defined as two standard deviations below mean for tissue
parameters and two standard deviations above mean for fluid
parameters.
Statistical Analysis and Ethics
The analysis was performed using SPSS, version 21 for Mac
(IBM Corp., Armonk, NY, USA). Data distribution was tested with
the Kolmogorov-Smirnov test. Depending on the distribution,
Student’s t test or Mann-Whitney U test as well as linear regression
were employed for group comparison. Analysis of categorical data
and calculation of odds ratio were performed using χ2 or Fisher’s
exact test. p values <0.05 were considered statistically significant.
To evaluate intraobserver variability, measurements were re-
peated on two subsequent days by a single observer. The

MRI Reference Values for 2D Quantitative Neonatology 3

Brain Metrics in Preterm Infants DOI: 10.1159/000534009
Table 2. Neonatal and clinical characteristics another hospital [n = 18], lack of parental consent [n = 5],
infant too ill [n = 5], no routine cMRI during first months of
Characteristics cMRI (n = 174) COVID-19 [n = 4], reason unclear retrospectively [n = 5],
GA at birth, weeks 261/7 (251/7–271/7) examination discontinued/halted due to lack of compliance
22 weeks GA 2 (1.5) [motion artifacts, n = 1]). Furthermore, 74 (19.7%) neonates
23 weeks GA 15 (8.6) were excluded because of severe pathologies found on cMRI
24 weeks GA 24 (13.8) (IVH Grade ≥2; any WMD; CBI Grade ≥3) and 11 (2.9%)
25 weeks GA 31 (17.8) because of GA at cMRI (<35 or ≥42 GA).
26 weeks GA 46 (26.4)
27 weeks GA 56 (32.2) In total, 174 cMRI acquisitions were included. Mean
Caesarean delivery 151 (86.8) birth weight was 825 ± 201 grams, median GA at birth
Multiple birth 50 (28.7) 261/7 (251/7–271/7; range 221/7–276/7) weeks. cMRI ex-
Male 98 (56.3) aminations were performed at a median post-menstrual
Birth weight, g 825±201 age of 372/7 (364/7–382/7) weeks. Further neonatal
Birth weight percentile 52 (30–74)

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<10th percentile 13 (7.5) characteristics are shown in Table 2.
APGAR 1 8 (7–8)
APGAR 5 9 (8–9) Brain Metrics – Reference Values
APGAR 10 9 (9–9) Results for the 19 variables are presented in Table 3.
pHumb 7.3±0.1 The analysis is displayed for the entire cohort as well as
pHneon 7.2±0.1
Blood culture-proven sepsis 42 (24.1)
two GA groups (n = 72 [41.4%] born at 221/7–256/7; n =
Early-onset sepsis (culture proven) 5 (2.9) 102 [58.6%] at 260/7–276/7); as well as groups for three
Late-onset sepsis (culture proven) 38 (21.8) timepoints of cMRI (n = 67 [38.5%] from 350/7–366/7 GA;
IVH grade 1 27 (15.5) n = 78 [44.8%] from 370/7–386/7 GA; n = 29 [16.7%] from
CBI grade 1 or 2 23 (13.8) 390/7–416/7 GA).
PDA with intervention 13 (7.5)
NEC with surgery 8 (4.6)
ROP with intervention 12 (6.9) Comparison with Preexisting Literature
BPD (oxygen requirement ≥36 weeks’) 56 (32.2) cMRI measurements from 350/7 to 376/7 GA at cMRI
GA at cMRI 37.3 (36.6–38.3) were compared with Garel [12] and above 380/7 GA with
GA at discharge 38.4 (37.3–40.0) Nguyen The Tich et al. [13]. In our analysis, compared to
Data are n (%), mean ± SD, or median (IQR) as appropriate. BPD,
the respective reference groups Z-scores were −2.4 (−2.9
bronchopulmonary disease; CBI, cerebellar injury; cMRI, cerebral to −1.9) for cBPW; −2.2 (−2.7 to −1.7) for bBPW; −0.6
magnetic resonance imaging; GA, gestational age; IVH, intraven- (−1.8 to −0.0) for TCD; −1.6 (−2.9 to −0.9) for FOD; −0.8
tricular hemorrhage; NEC, necrotizing enterocolitis; PDA, patent (−1.2 to −0.3) for CClength; 2.1 (0.7–3.6) for IHD, and 1.0
ductus arteriosus; pHneon, first neonatal pH after birth; pHumb, (0.2–1.7) for third ventricle.
umbilical artery pH; ROP, retinopathy of prematurity.
Differences and Correlations Concerning
Gestational Age
interobserver reliability was evaluated by repeating measurements Comparing the more immature infants (below 261/7
by a second observer, who was unaware of the first observer’s data. GA) of our cohort to the more mature ones (≥261/7 GA),
Intra- as well as interrater agreement were assessed in 15% of our results show that infants in the group with <261/7 GA
patients. Correlation coefficients were calculated using a 2-way
had a significantly later cMRI timepoint (376/7 vs. 370/7
random model for absolute agreement and interpreted according
to the strength of agreement scale of Brennan and Silman [22]. The GA). Corrected for GA at cMRI, BFD, AHH, FOD,
study protocol was approved by the Institutional Review Board of CClength, hVermis, sVermis, and DGMA were signifi-
the Medical University of Vienna (EK 1667/2022). cantly smaller. In contrast to that, “fluid” parameters, like
VI and CCI were significantly larger in the more im-
mature group. All findings are displayed in Table 4.
Results Increasing GA at birth was significantly associated with a
larger AHH (p = 0.001), FOD (p = 0.042), CClength (p =
Subjects 0.001), hVermis (p = 0.010), sVermis (p = 0.002), and
During the 4-year study period, 375 preterm infants <28 DGMA (p = 0.024), whereas IHD (p = 0.044), ECS (p =
GA were born, of whom 78 (20.8%) died and 38 (10.1%) did 0.001), VI (p = 0.002), CCI (p = 0.025), and ventricular
not undergo cMRI due to various reasons (transfer into atria (0.015) were significantly smaller.

4 Neonatology Buchmayer et al.

DOI: 10.1159/000534009
 Table 3. Reference values with cut-offs for impaired brain growth according to GA

GA cMRI

350/7–366/7 (n = 67) 370/7–386/7 (n = 78) 390/7–416/7 (n = 29)

mean SD impBG mean SD impBG mean SD impBG

BFDa
221/7–256/7 GA 56.4 2.6 51.2 57.1 3.0 51.1 59.8 3.6 52.6
260/7–276/7 GA 58.1 3.4 51.3 58.6 2.9 52.8 59.1 3.2 52.7
Entire cohort 57.6 3.3 51.0 57.8 3.0 51.8 59.4 3.4 52.6
AHHa
221/7–256/7 GA 39.1 3.0 33.1 38.9 3.8 31.3 41.4 4.4 32.6
260/7–276/7 GA 41.1 3.8 33.5 41.8 3.4 35.0 40.7 3.7 33.3
Entire cohort 40.6 3.7 33.2 40.3 3.9 32.5 41.0 4.1 32.8
cBPWa
221/7–256/7 GA 68.6 2.6 63.4 72.8 3.7 65.4 74.3 4.5 65.3

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260/7–276/7 GA 70.3 2.6 65.1 71.5 3.0 65.5 74.8 4.9 65.0
Entire cohort 69.8 3.0 63.8 72.2 3.4 65.4 74.5 4.6 65.9
bBPWa
221/7–256/7 GA 73.5 2.7 68.1 78.5 3.7 71.1 79.5 5.0 69.5
260/7–276/7 GA 74.9 3.2 68.5 76.1 3.2 69.7 79.9 5.8 68.3
Entire cohort 74.5 3.1 68.3 77.3 3.6 70.1 79.7 5.4 68.9
IHDa
221/7–256/7 GA 4.0 1.4 6.8 4.6 1.7 8.0 4.0 1.9 7.8
260/7–276/7 GA 4.0 1.4 6.8 3.7 1.1 5.9 4.0 1.7 7.4
Entire cohort 4.0 1.4 6.8 4.1 1.5 7.1 4.1 1.8 7.7
ECSa
221/7–256/7 GA 6.5 2.0 10.5 7.2 2.3 11.8 6.2 2.2 10.6
260/7–276/7 GA 5.4 1.8 9.0 5.6 1.9 9.4 6.3 2.3 10.9
Entire cohort 5.7 1.9 9.5 6.4 2.3 11.0 6.3 2.2 10.7
VIa
221/7–256/7 GA 11.5 1.5 14.5 13.0 1.3 15.6 12.9 1.3 15.5
260/7–276/7 GA 11.4 1.3 14.0 12.0 1.8 15.6 13.1 1.8 16.7
Entire cohort 11.6 1.4 14.4 12.5 1.6 15.7 13.0 1.6 16.2
AHWa
221/7–256/7 GA 3.2 1.2 5.6 4.0 1.2 6.4 4.0 1.3 6.6
260/7–276/7 GA 3.5 1.1 5.7 3.6 1.3 6.2 3.9 1.6 7.1
Entire cohort 3.4 1.1 5.6 3.8 1.3 6.4 3.9 1.5 6.9
3Va
221/7–256/7 GA 3.1 0.8 4.7 3.8 0.7 5.2 4.0 0.6 5.2
260/7–276/7 GA 3.4 0.7 4.8 3.6 0.8 5.2 3.9 1.3 6.5
Entire cohort 3.3 0.8 4.9 3.7 0.8 5.3 4.0 1.0 6.0
CCIa
221/7–256/7 GA 2.5 1.1 4.7 3.7 2.4 8.5 2.8 1.8 6.4
260/7–276/7 GA 2.7 1.5 5.7 2.6 1.9 6.4 2.5 1.4 5.3
Entire cohort 2.6 1.4 5.4 3.2 2.3 7.8 2.6 1.6 5.8
TCDa
221/7–256/7 GA 46.6 2.9 40.8 48.8 4.7 39.4 48.8 3.1 42.6
260/7–276/7 GA 47.0 2.2 42.6 48.2 2.3 43.6 50.7 3.3 44.1
Entire cohort 46.9 2.4 42.1 48.5 3.7 41.1 49.8 3.3 43.2
AtrialVa
221/7–256/7 GA 6.8 1.2 9.2 7.4 1.8 11.0 7.1 1.5 10.1
260/7–276/7 GA 6.5 1.5 9.5 6.5 1.8 10.1 7.5 1.8 11.1
Entire cohort 6.5 1.4 9.3 6.9 1.9 10.7 7.3 1.7 10.7
FODa
221/7–256/7 GA 94.5 4.2 86.1 95.1 5.1 84.9 96.1 6.3 83.5
260/7–276/7 GA 96.2 4.8 86.6 97.2 5.3 86.6 99.1 7.3 84.5
Entire cohort 95.7 4.6 86.5 96.1 5.3 85.5 97.6 6.9 83.8
CClengtha
221/7–256/7 GA 39.0 3.3 32.4 37.6 3.4 44.4 37.7 2.8 32.1
260/7–276/7 GA 39.6 2.6 34.4 39.4 2.8 33.8 39.9 3.7 32.5
Entire cohort 39.4 2.8 33.8 38.5 3.2 32.1 38.9 3.4 32.1

MRI Reference Values for 2D Quantitative Neonatology 5

Brain Metrics in Preterm Infants DOI: 10.1159/000534009
 Table 3 (continued)

GA cMRI

350/7–366/7 (n = 67) 370/7–386/7 (n = 78) 390/7–416/7 (n = 29)

mean SD impBG mean SD impBG mean SD impBG

4Va
221/7–256/7 GA 5.5 0.8 7.1 5.8 0.9 7.5 5.9 1.4 8.7
260/7–276/7 GA 5.5 0.8 7.1 5.8 0.9 7.5 6.3 1.1 8.5
Entire cohort 5.5 0.8 7.1 5.8 0.9 7.5 6.1 1.3 8.7
dVermisa
221/7–256/7 GA (n = 72) 14.8 2.3 10.2 15.4 1.7 12.0 14.3 2.1 10.1
260/7–276/7 GA (n = 102) 15.6 2.4 10.8 15.2 1.6 12.0 15.8 3.1 9.6
Entire cohort (n = 174) 15.4 2.4 10.6 15.3 1.7 11.9 15.0 2.7 9.6
hVermisa
221/7–256/7 GA 22.0 2.2 17.6 22.3 1.8 18.7 21.9 1.3 19.3

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260/7–276/7 GA 22.4 1.8 18.8 22.7 2.0 18.7 23.2 1.8 19.6
Entire cohort 22.3 1.9 18.5 22.5 1.9 18.7 22.6 1.7 19.2
sVermisb
221/7–256/7 GA 272.6 45.3 182.0 278.1 30.5 217.1 268.6 50.1 186.4
260/7–276/7 GA 292.2 48.4 195.4 298.5 51.5 195.5 312.4 60.6 191.2
Entire cohort 286.6 48.0 190.6 288.1 43.0 202.1 291.3 59.1 173.1
DGMAb
221/7–256/7 GA 896.3 67.9 760.5 902.2 60.3 781.6 921.0 117.0 687.0
260/7–276/7 GA 898.4 75.5 747.4 941.7 85.4 770.9 982.5 98.2 768.1
Entire cohort 897.8 72.8 752.2 921.4 75.8 769.8 952.3 110.2 731.9

Data are in mm and mm2. Entire cohort (n = 174); 221/7–256/7 GA (n = 72); 260/7–276/7 GA (n = 102). Bold = mean value for the
reference metrics. Normal = standard deviation. impBG (impaired brain growth) = value resembling a cut-off two-standard deviations
below or above the mean value for a better identification of patients at risk. cMRI, cerebral magnetic resonance imaging; GA, gestational
age; impBG, impaired brain growth; dVermis, diameter vermis; 4V, fourth ventricle; AtrialV, ventricular atria; AHW, anterior ventricular horn
height; 3V, third ventricle; cBPW, cranial biparietal width. aDistance. bArea.

Intraobserver and Interobserver Reliability
The reproducibility of measurements by a single ob-
server, as well as between observers, was classified as very
good (≥0.81) according to the strength of agreement scale
of Brennan and Silman for all 19 parameters.
Discussion
The purpose of this study was to create reference values
for cerebral structures and cut-off values for impaired
brain growth in a large, contemporary cohort of ex-
tremely preterm infants without major brain abnor-
malities. Two-dimensional cMRI brain metrics have been
used since 1999 in adolescents, where former preterm
infants were compared with term-born neonates and had
smaller brain parameters reflecting poor postnatal growth
[23]. The used variables are easily reproducible with a
high intra- as well as interrater reliability in the literature
as well as in our analysis [13]. Several studies examined
the correlation between brain structures and neuro-
developmental outcome [7, 24, 25]. Kidokoro et al. [14]
showed that impaired brain growth was connected to
adverse neurodevelopment in preterm neonates.
Although extremely preterm neonates show smaller
brain metrics at TEA compared to term-born, it is im-
portant to find the ones at risk for impaired brain growth
and consecutive adverse neurodevelopment. The creation
of reference values for this high-risk collective is im-
portant, as no comparable values currently exist.
Concerning “tissue” parameters, reductions of cBPW,
bBPW, and FOD have been related to impaired brain
growth and are therefore predictors for adverse outcome
[14]. We compared the more immature half to the mature
ones and found significantly smaller “tissue” parameters,
like BFD, AHH, FOD, hVermis, and sVermis [13]. WMD
are one of the major pathologies in extremely preterm
infants [26]. CClength resembles the amount of white
matter and a narrowing can be associated with poorer
developmental outcome and a lower intelligence quotient
[27]. Although we excluded all patients with WMD in this
analysis, we observed significantly lower values in more
premature infants, which could resemble quantitative
white matter defects.

6 Neonatology Buchmayer et al.

DOI: 10.1159/000534009
Table 4. Differences of brain
measurements at TEA and GA at birth GA birth 221/7–260/7 GA 261/7–276/7 GA p value*

BFDa 57.4 (55.3–59.6) 58.8 (56.4–60.1) 0.005

AHHa 39.2 (37.0–41.9) 41.6 (39.2–43.5) 0.001
cBPWa 71.1 (68.9–75.5) 71.7 (69.1–73.7) 0.907
bBPWa 76.6 (74.0–80.2) 76.2 (73.6–78.5) 0.342
IHDa 4.4 (3.2–5.4) 3.8 (2.7–5.0) 0.108
ECSa 6.4 (5.3–8.4) 5.5 (4.5–6.8) 0.001
VIa 12.5 (11.5–13.5) 12.0 (11.1–13.0) 0.459
AHWa 3.6 (2.9–4.5) 3.3 (2.7–4.4) 0.928
3Va 3.7±0.8 3.6±0.9 0.704
CCIa 3.2±1.8 2.7±1.5 0.049
TCDa 48.1 (45.9–49.9) 47.7 (46.4–49.9) 0.288
AtrialVa 6.9 (6.1–8.0) 6.6 (5.7–7.5) 0.231
FODa 94.4 (91.9–97.9) 96.9 (93.0–101.0) 0.002

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CClengtha 38.3 (36.1–40.4) 39.6 (37.7–41.7) 0.003
4Va 5.7 (5.1–6.3) 5.7 (5.0–6.3) 0.154
dVermisa 14.7 (13.7–16.4) 15.3 (14.0–16.8) 0.266
hVermisa 22.2 (20.9–23.7) 22.7 (21.7–23.9) 0.017
sVermisb 272.0 (248.0–298.0) 291.0 (261.5–330.3) 0.002
DGMAb 903.0 (854.5–945.5) 925.5 (871.8–976.8) 0.004

AHH, anterior horn height; AHW, anterior ventricular horn width; AtrialV, ventricular
atria; BFD, bifrontal diameter; bBPW, bone biparietal width; cBPW, cerebral biparietal
width; CCI, craniocaudal interopercular distance; CClength, corpus callosum length;
cMRI, cerebral magnetic resonance imaging; DGMA, deep gray matter area; dVermis,
vermis diameter; ECS, extracerebral space; FOD, fronto-occipital diameter; GA, ges-
tational age; IHD, interhemispheric distance; hVermis, vermis height; TCD, transverse
cerebellar diameter; sVermis, vermis surface; VI, ventricular index; 2D, two-
dimensional; 3V, third ventricle; 4V, fourth ventricle. *p values were corrected for
GA at cMRI. aDistance. bArea.

Another vulnerable and clinically important part of the
neonatal brain is the cerebellum [28]. CBI have been
linked to white matter as well as supratentorial injuries
and are associated with cognitive, learning, and behav-
ioral disabilities in very preterm infants [29–31]. Liter-
ature supports the idea that impaired growth in certain
brain regions happens in presence of supratentorial le-
sions, like IVH, hemorrhagic parenchymal infarction, or
cystic periventricular leukomalacia [13, 30]. Those pa-
thologies were excluded in our analysis as they might have
an influence on brain development and thus distort the
derived reference values [24, 25].
Another analysis was the DGMA, resembling the basal
ganglia, which was significantly smaller in preterm in-
fants compared to term infants. It is well accepted that
this area is highly connected with the premotor, motor,
and somatosensory cortices [32, 33].
Concerning “fluid” parameters like IHD and VI, in-
fants born at a younger GA had significantly higher values
at TEA. Enlarged ECSs have been associated with lower
cognitive and psychomotor abilities [34]. Kidokoro et al.
[14] showed that a larger IHD has been associated with
worse motor outcome at 2 years of corrected age and
enhanced ventricles at TEA have been associated with
other brain injuries and atrophy [35].
Garel [12] measured most of the used brain metrics in
fetal cMRI. They found good comparability between 2D
measurements and quantitative volumetric cMRI data.
Nguyen The Tich et al. [13] examined 189 preterm infants
and compared them to term-born controls. In contrast to
our cohort, the studied infants were more mature (274/7 vs.
261/7 GA) and their cMRI was done later (400/7 vs. 372/7
GA). This partly explains the smaller “tissue” measure-
ments with Z-Scores of −2.4 for cBPW or −1.9 for FOD
and larger “fluid” measurements with +1.0 for IHD
compared to the abovementioned existing values [12, 13].
Hammerl et al. [34] published that >50% of their
cohort of very preterm infants were below cut-off values
for cBPW previously defined by Kidokoro et al. [17],
which limits those values as references for extremely
preterm infants. Considering this, the extensive reference
values presented within this study are to our knowledge
the first ones published in extremely preterm infants
born <28 GA without severe brain injury.

MRI Reference Values for 2D Quantitative Neonatology 7

Brain Metrics in Preterm Infants DOI: 10.1159/000534009
 Strengths and Limitations
The main strength of our study is the creation of
reference values including cut-off values for impaired
brain growth in a contemporary cohort of extremely
preterm infants without major pathologies for various
brain areas. Another advantage is that the measurements
could be done by neonatologists without the dependency
of radiologists as they are easily reproducible.
Coming to the limitations, cMRI was performed shortly
before discharge with a median GA of 372/7 (364/7–382/7)
weeks. Kidokoro et al. [14] or Hammerl et al. [34] were able
to show impairments in the presence of altered measure-
ments, the investigation of standardized follow-up will be
Statement of Ethics
The study protocol was approved by the Institutional Review
Board of the Medical University of Vienna (EK 1667/2022).
Samples used in this study were obtained as part of routine medical
care. Written informed consent from participants’ parents was not
required in accordance with local/national guidelines. For this
study, the images were analyzed retrospectively, which was ap-
proved by our Ethics Committee.
Conflict of Interest Statement
The authors have no conflicts of interest relevant to this article
to disclose.

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obtained in our population. In addition, as previously stated,
we refrained from rotating the images following the stan-
dardization and manual realignment processes conducted
by our skilled technical radiology assistants during and
directly after cMRI. Furthermore, reproducibility was better
for large values (e.g., FOD or BPW) and less accurate for
small ones (e.g., IHD or CCI), but still all measurements had
a very good intra- as well as interrater agreement according
to Brennan and Silman [22].
Conclusion
This study demonstrates that 2D cMRI brain measure-
ments at TEA may represent an easy and reliable approach
for the evaluation of brain size and hence brain growth in
infants at high risk for neurodevelopmental impairment.
They can be easily performed by radiologists as well as
neonatologists and the proposed reference values may assist
in research as well as clinical settings to better understand the
impact of prematurity on brain development.
Funding Sources
No funding was secured for this study.
Author Contributions
Dr. Katharina Goeral and Dr. Julia Buchmayer conceptualized
and designed the study, designed the data collection instruments,
collected data, made formal analysis, visualized the data, drafted
the initial manuscript, and critically reviewed and revised the
manuscript. Prof. Gregor Kasprian, Dr. Sophie Stummer, PhD
Vito Giordano, Dr. Katrin Klebermass-Schrehof, and Dr. Victor
Schmidbauer critically reviewed and revised the manuscript. Dr.
Raphaela Jernej collected data and critically reviewed and revised
the manuscript. Prof. Angelika Berger coordinated and supervised
data collection and critically reviewed and revised the manuscript
for important intellectual content. All authors approved the final
manuscript as submitted and agreed to be accountable for all
aspects of the work.

Acknowledgments Data Availability Statement

We would like to thank our little patients and their parents for Data are not publicly available due to ethical reasons. Further
participating in our survey. inquiries can be directed to the corresponding author.

References

1 Pascal A, Govaert P, Oostra A, Naulaers G,
Ortibus E, Van den Broeck C. Neuro-
developmental outcome in very preterm and
very-low-birthweight infants born over the
past decade: a meta-analytic review. Dev Med
Child Neurol. 2018 Apr;60(4):342–55.
2 Allen MC. Neurodevelopmental outcomes of
preterm infants. Curr Opin Neurol. 2008
Apr;21(2):123–8.
3 Anderson PJ, Doyle LW. Cognitive and ed-
ucational deficits in children born extremely
preterm. Semin Perinatol. 2008 Feb;32(1):
51–8.
4 de Kieviet JF, Piek JP, Aarnoudse-Moens CS,
Oosterlaan J. Motor development in very
preterm and very low-birth-weight children
from birth to adolescence: a meta-analysis.
JAMA. 2009 Nov 25;302(20):2235–42.
5 Twilhaar ES, Wade RM, de Kieviet JF, van
Goudoever JB, van Elburg RM, Oosterlaan J.
Cognitive outcomes of children born ex-
tremely or very preterm since the 1990s and
associated risk factors: a meta-analysis and
meta-regression. JAMA Pediatr. 2018 Apr 1;
172(4):361–7.
6 Ment LR, Bada HS, Barnes P, Grant PE, Hirtz
D, Papile LA, et al. Practice parameter:
neuroimaging of the neonate – [retired]:
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.

8 Neonatology Buchmayer et al.

DOI: 10.1159/000534009
 7 Anderson NG, Laurent I, Cook N, Wood-
ward L, Inder TE. Growth rate of corpus
callosum in very premature infants. AJNR
Am J Neuroradiol. 2005 Nov–Dec;26(10):
2685–90.
8 Woodward LJ, Anderson PJ, Austin NC,
Howard K, Inder TE. Neonatal MRI to
predict neurodevelopmental outcomes in
preterm infants. N Engl J Med. 2006 Aug 17;
355(7):685–94.
9 Marlow N, Wolke D, Bracewell MA, Samara
M; EPICure Study Group. Neurologic and
developmental disability at six years of age
after extremely preterm birth. N Engl J Med.
2005 Jan 6;352(1):9–19.
10 Miller SP, Ferriero DM, Leonard C, Piecuch
R, Glidden DV, Partridge JC, et al. Early brain
injury in premature newborns detected with
magnetic resonance imaging is associated
with adverse early neurodevelopmental out-
come. J Pediatr. 2005 Nov;147(5):609–16.
11 Hammerl M, Zagler M, Griesmaier E, Janjic
T, Gizewski ER, Kiechl-Kohlendorfer U, et al.
Reduced cerebellar size at term-equivalent
age is related to a 17% lower mental devel-
opmental index in very preterm infants
without brain injury. Neonatology. 2020;
117(1):57–64.
12 Garel C. MRI of the fetal brain, normal de-
velopment an cerebral pathologies. Springer-
Verlag Berlin Heidelberg; 2004.
13 Nguyen The Tich S, Anderson PJ, Shimony
JS, Hunt RW, Doyle LW, Inder TE. A novel
quantitative simple brain metric using MR
imaging for preterm infants. AJNR Am
J Neuroradiol. 2009 Jan;30(1):125–31.
14 Kidokoro H, Anderson PJ, Doyle LW,
Woodward LJ, Neil JJ, Inder TE. Brain injury
and altered brain growth in preterm infants:
predictors and prognosis. Pediatrics. 2014
Aug;134(2):e444–53.
15 Papile LA, Burstein J, Burstein R, Koffler H.
Incidence and evolution of subependymal
and intraventricular hemorrhage: a study of
infants with birth weights less than 1,500 gm.
J Pediatr. 1978 Apr;92(4):529–34.
16 de Vries LS, Eken P, Dubowitz LM. The
spectrum of leukomalacia using cranial ul-
trasound. Behav Brain Res. 1992 Jul 31;
49(1):1–6.
MRI Reference Values for 2D Quantitative
Brain Metrics in Preterm Infants
17 Kidokoro H, Neil JJ, Inder TE. New MR
imaging assessment tool to define brain ab-
normalities in very preterm infants at term.
AJNR Am J Neuroradiol. 2013 Nov–Dec;
34(11):2208–14.
18 Bell MJ, Ternberg JL, Feigin RD, Keating JP,
Marshall R, Barton L, et al. Neonatal nec-
rotizing enterocolitis. Therapeutic decisions
based upon clinical staging. Ann Surg. 1978
Jan;187(1):1–7.
19 International Committee for the Classifica-
tion of Retinopathy of Prematurity. The In-
ternational classification of retinopathy of
prematurity revisited. Arch Ophthalmol.
2005 Jul;123(7):991–9.
20 Shennan AT, Dunn MS, Ohlsson A, Lennox
K, Hoskins EM. Abnormal pulmonary out-
comes in premature infants: prediction from
oxygen requirement in the neonatal period.
Pediatrics. 1988 Oct;82(4):527–32.
21 Garel C, Chantrel E, Elmaleh M, Brisse H,
Sebag G. Fetal MRI: normal gestational
landmarks for cerebral biometry, gyration
and myelination. Childs Nerv Syst. 2003 Aug;
19(7–8):422–5.
22 Brennan P, Silman A. Statistical methods for
assessing observer variability in clinical
measures. BMJ. 1992 Jun 6;304(6840):
1491–4.
23 Cooke RW, Abernethy LJ. Cranial magnetic
resonance imaging and school performance
in very low birth weight infants in adoles-
cence. Arch Dis Child Fetal Neonatal Ed.
1999 Sep;81(2):F116–21.
24 Volpe JJ. The encephalopathy of prematurity:
brain injury and impaired brain development
inextricably intertwined. Semin Pediatr
Neurol. 2009 Dec;16(4):167–78.
25 Roelants JA, Koning IV, Raets MM, Wil-
lemsen SP, Lequin MH, Steegers-Theunissen
RP, et al. A new ultrasound marker for
bedside monitoring of preterm brain growth.
AJNR Am J Neuroradiol. 2016 Aug;37(8):
1516–22.
26 Buchmayer J, Kasprian G, Giordano V,
Schmidbauer V, Steinbauer P, Klebermass-
Schrehof K, et al. Routine use of cerebral
magnetic resonance imaging in infants born
extremely preterm. J Pediatr. 2022 Jun 20;
248:74–80.e1.
Neonatology
DOI: 10.1159/000534009
27 Nosarti C, Rushe TM, Woodruff PW, Stewart
AL, Rifkin L, Murray RM. Corpus callosum
size and very preterm birth: relationship to
neuropsychological outcome. Brain. 2004
Sep;127(Pt 9):2080–9.
28 Volpe JJ. Cerebellum of the premature infant:
rapidly developing, vulnerable, clinically
important. J Child Neurol. 2009 Sep;24(9):
1085–104.
29 Shah DK, Anderson PJ, Carlin JB, Pavlovic
M, Howard K, Thompson DK, et al. Re-
duction in cerebellar volumes in preterm
infants: relationship to white matter injury
and neurodevelopment at two years of age.
Pediatr Res. 2006 Jul;60(1):97–102.
30 Srinivasan L, Allsop J, Counsell SJ, Boardman
JP, Edwards AD, Rutherford M. Smaller
cerebellar volumes in very preterm infants at
Downloaded from http://karger.com/neo/article-pdf/doi/10.1159/000534009/4032001/000534009.pdf by guest on 21 October 2023
term-equivalent age are associated with the
presence of supratentorial lesions. AJNR Am
J Neuroradiol. 2006 Mar;27(3):573–9.
31 Limperopoulos C, Bassan H, Gauvreau K,
Robertson RL Jr, Sullivan NR, Benson CB,
et al. Does cerebellar injury in premature
infants contribute to the high prevalence of
long-term cognitive, learning, and behavioral
disability in survivors? Pediatrics. 2007 Sep;
120(3):584–93.
32 Draganski B, Kherif F, Kloppel S, Cook PA,
Alexander DC, Parker GJ, et al. Evidence for
segregated and integrative connectivity pat-
terns in the human Basal Ganglia. J Neurosci.
2008 Jul 9;28(28):7143–52.
33 Loh WY, Anderson PJ, Cheong JLY, Spittle
AJ, Chen J, Lee KJ, et al. Neonatal basal
ganglia and thalamic volumes: very preterm
birth and 7-year neurodevelopmental out-
comes. Pediatr Res. 2017 Dec;82(6):970–8.
34 Hammerl M, Zagler M, Zimmermann M,
Griesmaier E, Janjic T, Gizewski ER, et al.
Supratentorial brain metrics predict neuro-
developmental outcome in very preterm in-
fants without brain injury at age 2 years.
Neonatology. 2020;117(3):287–93.
35 Kersbergen KJ, Makropoulos A, Aljabar P,
Groenendaal F, de Vries LS, Counsell SJ,
et al. Longitudinal regional brain develop-
ment and clinical risk factors in extremely
preterm infants. J Pediatr. 2016 Nov;178:
93–100 e6.
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