We implemented a preoperative screening brain magnetic resonance imaging (MRI) protocol for neonates undergoing cardiac surgery. The intent was to identify unrecognized central nervous system (CNS) injury that might alter the timing or type of surgical intervention.

This retrospective study included 397 neonates who underwent cardiac surgery with cardiopulmonary bypass between 2017 and 2025. Patients were stratified by whether they received a preoperative brain MRI (pre-MRI vs no-MRI).

Of 397 neonates, 339 (85%) received preoperative brain MRI, and 58 (15%) did not. Patients who did not receive preoperative brain MRI were more likely to present with emergent or salvage-level acuity, likely precluding the opportunity for preoperative imaging. When performed, preoperative brain MRI identified abnormal findings in 47% of patients. However, the surgical plan was altered in only 2 stable patients (0.6%) due to low-grade MRI findings (grade II intraventricular hemorrhage in 1 and trace subdural hematoma with large cephalohematoma in another). In both patients, surgery was delayed by 2 weeks and then proceeded uneventfully. Despite differences in acuity between groups, postoperative neurologic outcomes were similar between pre-MRI and no-MRI groups, including postoperative seizure (no-MRI: 5% vs pre-MRI: 4%, P = .71), stroke (2% vs 3%, P > .99), and cerebral hemorrhage (2% vs 1%, P = .53).

Our preoperative brain MRI screening protocol revealed that nearly half of neonates with congenital heart disease harbor abnormal findings on presurgical imaging. However, early identification of clinically silent brain abnormalities rarely altered the surgical plan and did not reduce the rate of postoperative CNS injury.