Reviewer #2 (Public Review):
In this work, the authors aim "to assess whether the relationship between neural activity and hemodynamic responses is present" "before the time of normal birth". In other words, they aim at showing that neurovascular coupling is present before term-equivalent gestational age. They use simultaneous EEG and fMRI in preterm infants presented with tactile stimuli.
Neuroimaging methods and stimulation methods are sound and rely on previously published works from the same group using neonatal MRI during somatosensory stimulation. The novelty resides in the use of simultaneous EEG to measure neuronal activity simultaneously with BOLD.
Methodological weaknesses are related to:
- Participant selection and characterization: there is a large variability in gestational age at birth, from very preterm (29 weeks) to late preterm (35 weeks) infants, which produces a large variability in chronological age at measurement (2 to 26 days). Considering how physiology and brain structure change dramatically with these factors, such variability seems an important bias. As stated in the introduction "In the time leading up to full-term human birth, rapid maturational changes are taking place across nearly all of the components which both relate to and occur within the neurovascular coupling cascade". There may be an effective neurovascular coupling in a neonate born at 35 weeks and tested at 2 days, and a very atypical or ineffective neurovascular coupling in an infant born at 29 weeks and tested after a month of intensive care, invasive respiratory support, and medication. This bias is also present in EEG analysis since "microstate basis vectors were derived from periods within the grand average signal that were topographically consistent across trials/subjects": any variability due to prematurity/NICU time is lost with this process.
- Not accounting for sleep states. During sleep, preterm infants alternate between slow and agitated sleep states, the pattern of state cycles changing with gestational age. Although the authors used EEG, they do not report looking for sleep states. Sleep state changes during stimulation would likely affect strongly EEG microstates sequence, duration, and power, as well as BOLD amplitude and distribution (ipsi vs. contralateral). This would be easy to verify and would allow a deeper understanding of the data, such as the variability of EEG and BOLD responses in each participant and among participants.
The main issue with the manuscript is the discrepancy between the stated aims ("to assess whether the relationship between neural activity and hemodynamic responses is present") and the literature available on the topic, on one hand, and between the stated aims and the actual work that was performed and discussed in the manuscript, on the other hand.
Aims vs. literature: The presence of a neurovascular coupling before term-equivalent gestational age has already been shown years ago, including by this group. For example, in: Arichi, T., et al. (2010). Somatosensory cortical activation identified by functional MRI in preterm and term infants. NeuroImage, 49(3), 2063-2071, where the following sentence begins the Conclusion "This is the first description of well-localised somatosensory cortical activation in the premature brain using a fully automated and programmable passive motor stimulus. Predominately positive BOLD signal change during stimulation was seen".
Or in:
Arichi, T., et al. (2012). Development of BOLD signal hemodynamic responses in the human brain. NeuroImage, 63, 663-673.
And by other groups using fMRI:
Heep, A., Scheef, L., Jankowski, J., Born, M., Zimmermann, N., Sival, D., et al. (2009). Functional magnetic resonance imaging of the sensorimotor system in preterm infants. Pediatrics, 123(1), 294-300.
Other examples of neurovascular coupling before term can be found with auditory-evoked BOLD responses in fetuses:
Jardri, R., et al. (2008). Fetal cortical activation to sound at 33 weeks of gestation: a functional MRI study. NeuroImage, 42(1), 10-18.<br />
but also, with various types of stimuli using fNIRS, for example:<br />
Mahmoudzadeh, M., et al. (2013). Syllabic discrimination in premature human infants prior to complete formation of cortical layers. Proceedings of the National Academy of Sciences, 110(12), 4846-4851.<br />
And:<br />
Roche-Labarbe, N., et al. (2014). Somatosensory evoked changes in cerebral oxygen consumption measured non-invasively in premature neonates. NeuroImage, 85, 1-8.<br />
Including simultaneous EEG and fNIRS :<br />
Roche-Labarbe, N. et al., 2007. Coupled oxygenation oscillation measured by NIRS and intermittent cerebral activation on EEG in premature infants. NeuroImage, 36(3), pp.718-727.
Be it in the Introduction or the Discussion, the authors only consider MRI literature whereas neurovascular coupling has been described and used for cognitive studies in premature neonates using fNIRS. There is no reason to restrict oneself to one technology when discussing fundamental physiological or cognitive processes.
Aims vs. actual work: The work that was actually performed is to measure EEG microstates' duration and power following tactile stimulation and to compare BOLD amplitude with these measures. The question being answered is whether the relationship that exists between microstates duration and BOLD amplitude in adults can also be observed in preterm infants. This in itself is an interesting purpose and should be stated as such in the Abstract and Introduction.
The Introduction is short and lacking in essential information. A review of microstates, what they are and what they mean, and how they are described in premature infants (particularly sensory-evoked microstates), is necessary. Previous studies of neurovascular coupling in preterm infants using evoked potentials, or no EEG at all when measuring the hemodynamic (fMRI or fNIRS) response associated with sensory stimuli. The introduction should argue why microstates would be more meaningful than SEP for EEG-fMRI studies, and what relationship with hemodynamics is expected based on previous studies with older participants. A comprehensive review of neurovascular coupling in preterm neonates, including non-MRI studies, is also necessary. The sentence "Here we test the hypothesis that despite the apparent immaturity of the underlying physiology, neurovascular coupling is functional before the normal time of birth." should be replaced by something along the lines of "Here we test whether the relationship between EEG microstates and neurovascular response is similar in premature infants with adults". Then the experimental contribution will make sense and the Discussion can focus on what it entails for understanding neurovascular coupling that amplitude is related to the duration, not power, of EEG microstates.
A Discussion (distinct from the Results) of the scientific and clinical relevance is currently lacking and it is difficult to assess the significance of the experimental contribution. An interesting discussion of microstates in the preterm brain is presented, but because the topic of microstates' relevance in neonates was not mentioned in the Introduction, it is confusing to read results such as "the observed composite progression of microstates indicates that the preterm brain is already capable of multi-level local sensory elaboration in the primary sensorimotor cortices." that does not correspond to any previously formulated hypothesis.
In the results, the authors should report if microstate duration varies among repeated identical stimuli in each child. The authors may look at this variability in terms of gestational age at birth (for example, in the participants who were born the earliest and have stayed the longest in the NICU, are microstates durations after a stimulus more variable than in the late-preterm participants?). The method for microstate analysis does not give clear information to the reader unfamiliar with Ragu other than the fact that one duration value was calculated for each participant. However, it would be informative to see some sort of dispersion range for both Mean BOLD and microstate duration values. It would be interesting to regress this information with gestational age at birth (or chronological age at scan) and sleep state.
After these changes have been made, I expect that the authors may find a more relevant title for their manuscript. "Neurophysiological basis of hemodynamic responses" does not give a precise idea of the experimental findings. Similarly, the abstract should be adjusted by removing sentences like "These results suggest that effective neurovascular coupling is present in the human brain even before the normal time of birth", a long-known fact, and detailing instead "a complex relationship between EEG and fMRI signals underpinned by patterns of activity across distinct neural ensembles."
Details of the stimulation sequence are unclear:
- Why were stimuli varying in duration from 7.5 to 10.5 seconds? The results report "the median BOLD hemodynamic response peaked at 14 seconds after stimulus onset": was it calculated regardless of stimulus duration? It is unlikely that the peak was reached after the same delay for 7 and 10 s stim. Was this accounted for in the MRI analysis?<br />
- There was a maximum of 24 epochs per participant, but how many epochs were kept for each participant after artifact rejection? How were distributed the 76 epochs remaining for analysis, among the participants?