Preterm thalamic injury: An under-recognized determinant of neurodevelopmental outcome

Introduction: Advances in neonatal intensive care have markedly improved survival among very and extremely preterm infants; however, neurodevelopmental impairment remains common. Despite improved survival, a substantial proportion of preterm survivors experience long-term cognitive, behavioral, and executive difficulties rather than severe motor disability. While white-matter injury has historically dominated conceptual models of prematurity-related brain injury, contemporary neuroimaging studies indicate that deep gray matter structures—particularly the thalamus—are frequently affected and clinically significant contributors to long-term outcome. Aim: The aim of this article is to provide a narrative review of the developmental vulnerability, mechanisms, diagnostic challenges, and neurodevelopmental consequences of thalamic injury in preterm infants, with emphasis on its persistent under-recognition in modern neonatal imaging and follow-up practice. Methods: A narrative review of peer-reviewed human studies was performed using major biomedical databases. Literature published predominantly within the last decade was prioritized, with selective inclusion of earlier foundational studies where conceptually essential. Results: Thalamic abnormalities are common in very preterm infants, particularly in association with white-matter injury, intraventricular hemorrhage, systemic inflammation, and hemodynamic instability. Cranial ultrasound has limited sensitivity for detecting thalamic pathology, whereas MRI at term-equivalent age enables identification of volumetric reduction, signal abnormalities, and disrupted thalamocortical connectivity. Thalamic injury is associated with later impairments in attention, executive functioning, sensory processing, emotional regulation, and motor coordination, many of which emerge beyond infancy. Conclusion: Preterm thalamic injury is common, under-diagnosed, and clinically significant. Intentional thalamic assessment using neonatal MRI, combined with prolonged neurodevelopmental surveillance into school age, may improve risk stratification, counseling, and long-term outcomes in preterm survivors.