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Velasquez-Minoli JP, Cardona-Ramirez N, Garcia-Arias HF, Restrepo-Restrepo F, Porras-Hurtado GL. Clinical-functional correlation with brain volumetry in severe perinatal asphyxia: a case report. Ital J Pediatr 2024; 50:66. [PMID: 38594715 PMCID: PMC11003057 DOI: 10.1186/s13052-024-01633-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/22/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) appears in neurological conditions where some brain areas are likely to be injured, such as deep grey matter, basal ganglia area, and white matter subcortical periventricular áreas. Moreover, modeling these brain areas in a newborn is challenging due to significant variability in the intensities associated with HIE conditions. This paper aims to evaluate functional measurements and 3D machine learning models of a given HIE case by correlating the affected brain areas with the pathophysiology and clinical neurodevelopmental. CASE PRESENTATION A comprehensive analysis of a term infant with perinatal asphyxia using longitudinal 3D brain information from Machine Learning Models is presented. The clinical analysis revealed the perinatal asphyxia diagnosis with APGAR <5 at 5 and 10 minutes, umbilical arterial pH of 7.0 BE of -21.2 mmol / L), neonatal seizures, and invasive ventilation mechanics. Therapeutic interventions: physical, occupational, and language neurodevelopmental therapies. Epilepsy treatment: vagus nerve stimulation, levetiracetam, and phenobarbital. Furthermore, the 3D analysis showed how the volume decreases due to age, exhibiting an increasing asymmetry between hemispheres. The results of the basal ganglia area showed that thalamus asymmetry, caudate, and putamen increase over time while globus pallidus decreases. CLINICAL OUTCOMES spastic cerebral palsy, microcephaly, treatment-refractory epilepsy. CONCLUSIONS Slight changes in the basal ganglia and cerebellum require 3D volumetry for detection, as standard MRI examinations cannot fully reveal their complex shape variations. Quantifying these subtle neurodevelopmental changes helps in understanding their clinical implications. Besides, neurophysiological evaluations can boost neuroplasticity in children with neurological sequelae by stimulating new neuronal connections.
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Affiliation(s)
| | | | - Hernan Felipe Garcia-Arias
- Salud Comfamiliar, Caja de Compensación Familiar de Risaralda, Pereira, Colombia
- SISTEMIC Research Group, Universidad de Antioquia, Medellín, Colombia
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Kebaya LMN, Kapoor B, Mayorga PC, Meyerink P, Foglton K, Altamimi T, Nichols ES, de Ribaupierre S, Bhattacharya S, Tristao L, Jurkiewicz MT, Duerden EG. Subcortical brain volumes in neonatal hypoxic-ischemic encephalopathy. Pediatr Res 2023; 94:1797-1803. [PMID: 37353661 DOI: 10.1038/s41390-023-02695-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/07/2023] [Accepted: 05/21/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Despite treatment with therapeutic hypothermia, hypoxic-ischemic encephalopathy (HIE) is associated with adverse developmental outcomes, suggesting the involvement of subcortical structures including the thalamus and basal ganglia, which may be vulnerable to perinatal asphyxia, particularly during the acute period. The aims were: (1) to examine subcortical macrostructure in neonates with HIE compared to age- and sex-matched healthy neonates within the first week of life; (2) to determine whether subcortical brain volumes are associated with HIE severity. METHODS Neonates (n = 56; HIE: n = 28; Healthy newborns from the Developing Human Connectome Project: n = 28) were scanned with MRI within the first week of life. Subcortical volumes were automatically extracted from T1-weighted images. General linear models assessed between-group differences in subcortical volumes, adjusting for sex, gestational age, postmenstrual age, and total cerebral volumes. Within-group analyses evaluated the association between subcortical volumes and HIE severity. RESULTS Neonates with HIE had smaller bilateral thalamic, basal ganglia and right hippocampal and cerebellar volumes compared to controls (all, p < 0.02). Within the HIE group, mild HIE severity was associated with smaller volumes of the left and right basal ganglia (both, p < 0.007) and the left hippocampus and thalamus (both, p < 0.04). CONCLUSIONS Findings suggest that, despite advances in neonatal care, HIE is associated with significant alterations in subcortical brain macrostructure. IMPACT Compared to their healthy counterparts, infants with HIE demonstrate significant alterations in subcortical brain macrostructure on MRI acquired as early as 4 days after birth. Smaller subcortical volumes impacting sensory and motor regions, including the thalamus, basal ganglia, and cerebellum, were seen in infants with HIE. Mild and moderate HIE were associated with smaller subcortical volumes.
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Affiliation(s)
- Lilian M N Kebaya
- Neuroscience program, Western University, London, ON, Canada.
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada.
| | - Bhavya Kapoor
- Applied Psychology, Faculty of Education, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
| | - Paula Camila Mayorga
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
| | - Paige Meyerink
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
| | - Kathryn Foglton
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
| | - Talal Altamimi
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
- Division of Neonatal Intensive Care, Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Emily S Nichols
- Applied Psychology, Faculty of Education, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
| | - Sandrine de Ribaupierre
- Neuroscience program, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Soume Bhattacharya
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
| | - Leandro Tristao
- Department of Medical Imaging, London Health Sciences Centre, London, ON, Canada
| | - Michael T Jurkiewicz
- Neuroscience program, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Medical Imaging, London Health Sciences Centre, London, ON, Canada
| | - Emma G Duerden
- Neuroscience program, Western University, London, ON, Canada
- Applied Psychology, Faculty of Education, Western University, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
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Korf JM, McCullough LD, Caretti V. A narrative review on treatment strategies for neonatal hypoxic ischemic encephalopathy. Transl Pediatr 2023; 12:1552-1571. [PMID: 37692539 PMCID: PMC10485647 DOI: 10.21037/tp-23-253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Objective Hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and disability worldwide. Therapeutic hypothermia (TH) represents a significant achievement in the translation of scientific research to clinical application, but it is currently the only neuroprotective treatment for HIE. This review aims to revisit the use of TH for HIE and its longitudinal impact on patient outcomes to readers new to the field of HIE. We discuss how emerging therapies address the broader pathophysiology of injury progression in the neonatal brain days to years after HIE. Methods We included full articles and book chapters published in English on PubMed with references to "hypoxic ischemic encephalopathy", "birth asphyxia", "therapeutic hypothermia", or "neonatal encephalopathy". We limited our review to outcomes on term infants and to new therapeutics that are in the second phase of clinical trials. Key Content and Findings Despite the use of TH for HIE, mortality remains high. Analysis of longitudinal studies reveals a high incidence of ongoing disability even with the implementation of TH. New therapeutics addressing the secondary phase and the less understood tertiary phase of brain injury are in clinical trials as adjunctive treatments to TH to support additional neurological repair and regeneration. Conclusions TH successfully improves outcomes after HIE, and it continues to be optimized. Larger studies are needed to understand its use in mild cases of HIE and if certain factors, such as sex, affect long term outcomes. TH primarily acts in the initial phases of injury, while new pharmaceutical therapies target additional injury pathways into the tertiary phases of injury. This may allow for more effective approaches to treatment and improvement of long-term functional outcomes after HIE.
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Affiliation(s)
- Janelle M. Korf
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Louise D. McCullough
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Viola Caretti
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
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Beck J, Loron G, Ancel PY, Alison M, Hertz Pannier L, Vo Van P, Debillon T, Bednarek N. An Updated Overview of MRI Injuries in Neonatal Encephalopathy: LyTONEPAL Cohort. CHILDREN 2022; 9:children9040561. [PMID: 35455605 PMCID: PMC9032533 DOI: 10.3390/children9040561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
Background: Brain magnetic resonance imaging (MRI) is a key tool for the prognostication of encephalic newborns in the context of hypoxic−ischemic events. The purpose of this study was to finely characterize brain injuries in this context. Methods: We provided a complete, descriptive analysis of the brain MRIs of infants included in the French national, multicentric cohort LyTONEPAL. Results: Among 794 eligible infants, 520 (65.5%) with MRI before 12 days of life, grade II or III encephalopathy and gestational age ≥36 weeks were included. Half of the population had a brain injury (52.4%); MRIs were acquired before 6 days of life among 247 (47.5%) newborns. The basal ganglia (BGT), white matter (WM) and cortex were the three predominant sites of injuries, affecting 33.8% (n = 171), 33.5% (n = 166) and 25.6% (n = 128) of participants, respectively. The thalamus and the periventricular WM were the predominant sublocations. The BGT, posterior limb internal capsule, brainstem and cortical injuries appeared more frequently in the early MRI group than in the late MRI group. Conclusion: This study described an overview of brain injuries in hypoxic−ischemic neonatal encephalopathy. The basal ganglia with the thalamus and the WM with periventricular sublocation injuries were predominant. Comprehensive identification of brain injuries in the context of HIE may provide insight into the mechanism and time of occurrence.
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Affiliation(s)
- Jonathan Beck
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (G.L.); (N.B.)
- EPOPé (Obstetrical Perinatal and Pediatric Epidemiology Research Team), CRESS (Centre of Research in Epidemiology and StatisticS), INSERM (Institut National de la Santé et de la Recherche Médicale), INRAE (Institut National de la Recherche Agronomique), Université de Paris, 75004 Paris, France;
- Correspondence:
| | - Gauthier Loron
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (G.L.); (N.B.)
- CReSTIC EA (Centre de Recherche en Traitement du Signal Informatique) 3804, Université de Reims Champagne Ardenne, 51097 Reims, France
| | - Pierre-Yves Ancel
- EPOPé (Obstetrical Perinatal and Pediatric Epidemiology Research Team), CRESS (Centre of Research in Epidemiology and StatisticS), INSERM (Institut National de la Santé et de la Recherche Médicale), INRAE (Institut National de la Recherche Agronomique), Université de Paris, 75004 Paris, France;
- Assistance Publique—Hôpitaux de Paris, Clinical Investigation Center P1419, 75004 Paris, France
| | - Marianne Alison
- Service d’Imagerie Pédiatrique, Hôpital Robert Debré, APHP (Assistance Publique—Hôpitaux de Paris), 75019 Paris, France;
- Unit 1141 NeuroDiderot, Inserm, CEA (Commissariat à l’Énergie Atomique et aux Énergies Alternatives), Université Paris Cité, 75019 Paris, France;
| | - Lucie Hertz Pannier
- Unit 1141 NeuroDiderot, Inserm, CEA (Commissariat à l’Énergie Atomique et aux Énergies Alternatives), Université Paris Cité, 75019 Paris, France;
- UNIACT (Unité de Recherche en NeuroImagerie Applicative Clinique et Translationnelle), Neurospin, CEA (Commissariat à l’Énergie Atomique et aux Énergies Alternatives)-Saclay, 91191 Gif sur Yvette, France
| | - Philippe Vo Van
- Department of Neonatology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Pinel, 69500 Bron, France;
| | - Thierry Debillon
- Neonatal Intensive Care Unit CHU (Centre Hospital-Universitaire) Grenoble Alpes, 38000 Grenoble, France;
- Grenoble INP (Institut d’Ingénierie et de Management), TIMC (Techniques de l’Ingénierie Médicale et de la Complexité)-IMAG (Informatique, Mathématiques et Applications, Grenoble), CNRS (Centre National de la Recherche Scientifique), University Grenoble Alpes, 38000 Grenoble, France
| | - Nathalie Bednarek
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (G.L.); (N.B.)
- CReSTIC EA (Centre de Recherche en Traitement du Signal Informatique) 3804, Université de Reims Champagne Ardenne, 51097 Reims, France
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Mathew JL, Kaur N, Dsouza JM. Therapeutic hypothermia in neonatal hypoxic encephalopathy: A systematic review and meta-analysis. J Glob Health 2022; 12:04030. [PMID: 35444799 PMCID: PMC8994481 DOI: 10.7189/jogh.12.04030] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Therapeutic hypothermia (TH) is regarded as the most efficacious therapy for neonatal hypoxic encephalopathy. However, limitations in previous systematic reviews and the publication of new data necessitate updating the evidence. We conducted this up-to-date systematic review to evaluate the effects of TH in neonatal encephalopathy on clinical outcomes. Methods In this systematic review and meta-analysis, we searched Medline, Cochrane Library, Embase, LIVIVO, Web of Science, Scopus, CINAHL, major trial registries, and grey literature (from inception to October 31, 2021), for randomized controlled trials (RCT) comparing TH vs normothermia in neonatal encephalopathy. We included RCTs enrolling neonates (gestation ≥35 weeks) with perinatal asphyxia and encephalopathy, who received either TH (temperature ≤34°C) initiated within 6 hours of birth for ≥48 hours, vs no cooling. We excluded non-RCTs, those with delayed cooling, or cooling to >34°C. Two authors independently appraised risk-of-bias and extracted data on mortality and neurologic disability at four time points: neonatal (from randomization to discharge/death), infancy (18-24 months), childhood (5-10 years), and long-term (>10 years). Other outcomes included seizures, EEG abnormalities, and MRI findings. Summary data from published RCTs were pooled through fixed-effect meta-analysis. Results We identified 36 863 citations and included 39 publications representing 29 RCTs with 2926 participants. Thirteen studies each had low, moderate, and high risk-of-bias. The pooled risk ratios (95% confidence interval, CI) were as follows: neonatal mortality: 0.87 (95% CI = 0.75, 1.00), n = 2434, I2 = 38%; mortality at 18-24 months: 0.88 (95% CI = 0.78, 1.01), n = 2042, I2 = 51%; mortality at 5-10 years: 0.81 (95% CI = 0.62, 1.04), n = 515, I2 = 59%; disability at 18-24 months: 0.62 (95% CI = 0.52, 0.75), n = 1440, I2 = 26%; disability at 5-10 years: 0.68 (95% CI = 0.52, 0.90), n = 442, I2 = 3%; mortality or disability at 18-24 months: 0.78 (95% CI = 0.72, 0.86), n = 1914, I2 = 54%; cerebral palsy at 18-24 months: 0.63 (95% CI = 0.50, 0.78), n = 1136, I2 = 39%; and childhood cerebral palsy: 0.63 (95% CI = 0.46, 0.85), n = 449, I2 = 0%. Some outcomes showed significant differences by study-setting; the risk ratio (95% CI) for mortality at 18-24 months was 0.79 (95% CI = 0.66,0.93), n = 1212, I2 = 7% in high-income countries, 0.67 (95% CI = 0.41, 1.09), n = 276, I2 = 0% in upper-middle-income countries, and 1.18 (95% CI = 0.94, 1.47), n = 554, I2 = 75% in lower-middle-income countries. The corresponding pooled risk ratios for ‘mortality or disability at 18-24 months’ were 0.77 (95% CI = 0.69, 0.86), n = 1089, I2 = 0%; 0.56 (95% CI = 0.41, 0.78), n = 276, I2 = 30%; and 0.92 (95% CI = 0.77, 1.09), n = 549, I2 = 86% respectively. Trials with low risk of bias showed risk ratio of 0.97 (95% CI = 0.80, 1.16, n = 1475, I2 = 62%) for neonatal mortality, whereas trials with higher risk of bias showed 0.71 (95% CI = 0.55, 0.91), n = 959, I2 = 0%. Likewise, risk ratio for mortality at 18-24 months was 0.96 (95% CI = 0.83, 1.13), n = 1336, I2 = 58% among low risk-of-bias trials, but 0.72 (95% CI = 0.56, 0.92), n = 706, I2 = 0%, among higher risk of bias trials. Conclusions Therapeutic hypothermia for neonatal encephalopathy reduces neurologic disability and cerebral palsy, but its effect on neonatal, infantile and childhood mortality is uncertain. The setting where it is implemented affects the outcomes. Low(er) quality trials overestimated the potential benefit of TH.
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Affiliation(s)
- Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - Navneet Kaur
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
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Predictive Values of Location and Volumetric MRI Injury Patterns for Neurodevelopmental Outcomes in Hypoxic-Ischemic Encephalopathy Neonates. Brain Sci 2020; 10:brainsci10120991. [PMID: 33339156 PMCID: PMC7765589 DOI: 10.3390/brainsci10120991] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/21/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a severe neonatal complication with up to 40–60% long-term morbidity. This study evaluates the distribution and burden of MRI changes as a prognostic indicator of neurodevelopmental (ND) outcomes at 18–24 months in HIE infants who were treated with therapeutic hypothermia (TH). Term or late preterm infants who were treated with TH for HIE were analyzed between June 2012 and March 2016. Brain MRI scans were obtained from 107 TH treated infants. For each infant, diffusion weighted brain image (DWI) sequences from a 3T Siemens scanner were obtained for analysis. Of the 107 infants, 36 of the 107 infants (33.6%) had normal brain MR images, and 71 of the 107 infants (66.4%) had abnormal MRI findings. The number of clinical seizures was significantly higher in the abnormal MRI group (p < 0.001) than in the normal MRI group. At 18–24 months, 76 of the 107 infants (70.0%) showed normal ND stages, and 31 of the 107 infants (29.0%) exhibited abnormal ND stages. A lesion size count >500 was significantly associated with abnormal ND. Similarly, the total lesion count was larger in the abnormal ND group (14.16 vs. 5.29). More lesions in the basal ganglia (BG) and thalamus areas and a trend towards more abnormal MRI scans were significantly associated with abnormal ND at 18–24 months. In addition to clinical seizure, a larger total lesion count and lesion size as well as lesion involvement of the basal ganglia and thalamus were significantly associated with abnormal neurodevelopment at 18–24 months.
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Kashou NH, Dar IA, El-Mahdy MA, Pluto C, Smith M, Gulati IK, Lo W, Jadcherla SR. Brain Lesions among Orally Fed and Gastrostomy-Fed Dysphagic Preterm Infants: Can Routine Qualitative or Volumetric Quantitative Magnetic Resonance Imaging Predict Feeding Outcomes? Front Pediatr 2017; 5:73. [PMID: 28443270 PMCID: PMC5385332 DOI: 10.3389/fped.2017.00073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/24/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The usefulness of qualitative or quantitative volumetric magnetic resonance imaging (MRI) in early detection of brain structural changes and prediction of adverse outcomes in neonatal illnesses warrants further investigation. Our aim was to correlate certain brain injuries and the brain volume of feeding-related cortical and subcortical regions with feeding method at discharge among preterm dysphagic infants. MATERIALS AND METHODS Using a retrospective observational study design, we examined MRI data among 43 (22 male; born at 31.5 ± 0.8 week gestation) infants who went home on oral feeding or gastrostomy feeding (G-tube). MRI scans were segmented, and volumes of brainstem, cerebellum, cerebrum, basal ganglia, thalamus, and vermis were quantified, and correlations were made with discharge feeding outcomes. Chi-squared tests were used to evaluate MRI findings vs. feeding outcomes. ANCOVA was performed on the regression model to measure the association of maturity and brain volume between groups. RESULTS Out of 43 infants, 44% were oral-fed and 56% were G-tube fed at hospital discharge (but not at time of the study). There was no relationship between qualitative brain lesions and feeding outcomes. Volumetric analysis revealed that cerebellum was greater (p < 0.05) in G-tube fed infants, whereas cerebrum volume was greater (p < 0.05) in oral-fed infants. Other brain regions did not show volumetric differences between groups. CONCLUSION This study concludes that neither qualitative nor quantitative volumetric MRI findings correlate with feeding outcomes. Understanding the complexity of swallowing and feeding difficulties in infants warrants a comprehensive and in-depth functional neurological assessment.
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Affiliation(s)
- Nasser H Kashou
- Wright State University, Image Analysis Lab, Dayton, OH, USA
| | - Irfaan A Dar
- Wright State University, Image Analysis Lab, Dayton, OH, USA.,Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Mohamed A El-Mahdy
- Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Pluto
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark Smith
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ish K Gulati
- Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Warren Lo
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Neonatal brain MRI segmentation: A review. Comput Biol Med 2015; 64:163-78. [DOI: 10.1016/j.compbiomed.2015.06.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/06/2015] [Accepted: 06/18/2015] [Indexed: 11/20/2022]
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Alix JJP, Zammit C, Riddle A, Meshul CK, Back SA, Valentino M, Fern R. Central axons preparing to myelinate are highly sensitive [corrected] to ischemic injury. Ann Neurol 2013; 72:936-51. [PMID: 23280842 DOI: 10.1002/ana.23690] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 05/22/2012] [Accepted: 06/15/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Developing central white matter is subject to ischemic-type injury during the period that precedes myelination. At this stage in maturation, central axons initiate a program of radial expansion and ion channel redistribution. Here we test the hypothesis that during radial expansion axons display heightened ischemic sensitivity, when clusters of Ca(2+) channels decorate future node of Ranvier sites. METHODS Functionality and morphology of central axons and glia were examined during and after a period of modeled ischemia. Pathological changes in axons undergoing radial expansion were probed using electrophysiological, quantitative ultrastructural, and morphometric analysis in neonatal rodent optic nerve and periventricular white matter axons studied under modeled ischemia in vitro or after hypoxia-ischemia in vivo. RESULTS Acute ischemic injury of central axons undergoing initial radial expansion was mediated by Ca(2+) influx through Ca(2+) channels expressed in axolemma clusters. This form of injury operated only in this axon population, which was more sensitive to injury than neighboring myelinated axons, smaller axons yet to initiate radial expansion, astrocytes, or oligodendroglia. A pharmacological strategy designed to protect both small and large diameter premyelinated axons proved 100% protective against acute ischemia studied under modeled ischemia in vitro or after hypoxia-ischemia in vivo. INTERPRETATION Recent clinical data highlight the importance of axon pathology in developing white matter injury. The elevated susceptibility of early maturing axons to ischemic injury described here may significantly contribute to selective white matter pathology and places these axons alongside preoligodendrocytes as a potential primary target of both injury and therapeutics.
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Affiliation(s)
- James J P Alix
- Department of Cell Physiology and Pharmacology, University of Leicester, Leicester, United Kingdom
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Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013; 2013:CD003311. [PMID: 23440789 PMCID: PMC7003568 DOI: 10.1002/14651858.cd003311.pub3] [Citation(s) in RCA: 753] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Newborn animal studies and pilot studies in humans suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae without adverse effects. OBJECTIVES To determine the effect of therapeutic hypothermia in encephalopathic asphyxiated newborn infants on mortality, long-term neurodevelopmental disability and clinically important side effects. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group as outlined in The Cochrane Library (Issue 2, 2007). Randomised controlled trials evaluating therapeutic hypothermia in term and late preterm newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2007, Issue 2), MEDLINE (1966 to June 2007), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching. We updated this search in May 2012. SELECTION CRITERIA We included randomised controlled trials comparing the use of therapeutic hypothermia with standard care in encephalopathic term or late preterm infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS Four review authors independently selected, assessed the quality of and extracted data from the included studies. Study authors were contacted for further information. Meta-analyses were performed using risk ratios (RR) and risk differences (RD) for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals (CI). MAIN RESULTS We included 11 randomised controlled trials in this updated review, comprising 1505 term and late preterm infants with moderate/severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (typical RR 0.75 (95% CI 0.68 to 0.83); typical RD -0.15, 95% CI -0.20 to -0.10); number needed to treat for an additional beneficial outcome (NNTB) 7 (95% CI 5 to 10) (8 studies, 1344 infants). Cooling also resulted in statistically significant reductions in mortality (typical RR 0.75 (95% CI 0.64 to 0.88), typical RD -0.09 (95% CI -0.13 to -0.04); NNTB 11 (95% CI 8 to 25) (11 studies, 1468 infants) and in neurodevelopmental disability in survivors (typical RR 0.77 (95% CI 0.63 to 0.94), typical RD -0.13 (95% CI -0.19 to -0.07); NNTB 8 (95% CI 5 to 14) (8 studies, 917 infants). Some adverse effects of hypothermia included an increase sinus bradycardia and a significant increase in thrombocytopenia. AUTHORS' CONCLUSIONS There is evidence from the 11 randomised controlled trials included in this systematic review (N = 1505 infants) that therapeutic hypothermia is beneficial in term and late preterm newborns with hypoxic ischaemic encephalopathy. Cooling reduces mortality without increasing major disability in survivors. The benefits of cooling on survival and neurodevelopment outweigh the short-term adverse effects. Hypothermia should be instituted in term and late preterm infants with moderate-to-severe hypoxic ischaemic encephalopathy if identified before six hours of age. Further trials to determine the appropriate techniques of cooling, including refinement of patient selection, duration of cooling and method of providing therapeutic hypothermia, will refine our understanding of this intervention.
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Affiliation(s)
- Susan E Jacobs
- Neonatal Services, Royal Women’s Hospital, Parkville, Melbourne, Australia.
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11
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Gray matter volumetric MRI differences late-preterm and term infants. Brain Dev 2013; 35:10-6. [PMID: 22285528 DOI: 10.1016/j.braindev.2011.12.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 11/02/2011] [Accepted: 12/28/2011] [Indexed: 11/23/2022]
Abstract
Gray matter develops rapidly during the third trimester of pregnancy, which is a critical period for lipid deposition. We measured brain volume in term and late-preterm infants to determine if it is related to disabilities in late-preterm infants. In addition, we measured serum lipid concentrations to investigate the relationship between brain volume and lipid nutrition. Magnetic resonance imaging scans were obtained in 16 late-preterm and 13 term infants. We measured cerebrum, gray matter, and white matter volumes. We performed serum cholesterol, triglyceride (TG), and lipoprotein analyses in cord blood by high-performance liquid chromatography using gel permeation columns to assess lipid nutritional levels. The gray matter volume and percent cerebrum volume of gray matter were significantly smaller in late-preterm infants (p<0.001). Head circumference and cerebrum and white matter volume did not differ between the two groups. Gray matter volume correlated positively with gestational age (r=0.647, p<0.001), head circumference (r=0.688, p<0.001), and high-density lipoprotein (HDL)-TG levels (r=0.496, p=0.006). Late-preterm infants had a normal head circumference and a lower gray matter volume than term infants. Gestational age and head circumference were significantly associated with gray matter volume. Only HDL-TG levels were significantly associated with gray matter volume. HDL-TG might contribute to the transport of fatty acids and gray matter development during the postnatal period. Thus, delayed gray matter development may partly contribute to neurodevelopmental disabilities in late-preterm infants.
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Mulkey SB, Yap VL, Swearingen CJ, Riggins MS, Kaiser JR, Schaefer GB. Quantitative cranial magnetic resonance imaging in neonatal hypoxic-ischemic encephalopathy. Pediatr Neurol 2012; 47:101-8. [PMID: 22759685 PMCID: PMC3683989 DOI: 10.1016/j.pediatrneurol.2012.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/17/2012] [Indexed: 11/28/2022]
Abstract
The volume of acute injury detected by diffusion-weighted imaging and quantitative brain growth on serial cranial magnetic resonance imaging was not previously used to predict neurodevelopmental outcomes in infants with neonatal hypoxic-ischemic encephalopathy treated with head cooling. Our longitudinal study involved 16 head-cooled term infants with hypoxic-ischemic encephalopathy who underwent early and follow-up cranial magnetic resonance imaging and follow-up neurologic evaluations, out of 105 infants who received therapeutic hypothermia. The volume of acute injury was measured on initial cranial magnetic resonance imaging, using diffusion-weighted images. Total brain volumes were measured in both early and follow-up magnetic resonance imaging studies. Acute injury volume in the corpus callosum >0.5 cm(3) was associated with developing epilepsy (odds ratio, 20; 95% confidence interval, 1.01-1059.6; P = 0.013). Follow-up whole brain volume was reduced in those with unfavorable outcomes (i.e., epilepsy, cerebral palsy, and delayed developmental milestones), compared with infants without all three outcomes. Although acute brain injury volume and brain growth measurements may be useful predictors of outcomes in neonatal hypoxic-ischemic encephalopathy, the evolution of brain injury in these infants has yet to be fully understood and should be studied prospectively.
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Affiliation(s)
- Sarah B. Mulkey
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas,Communications should be addressed to: Dr. Mulkey; Section of Pediatric Neurology; Department of Pediatrics; University of Arkansas for Medical Sciences; Arkansas Children's Hospital; 1 Children's Way, Slot 512-15; Little Rock, AR 72202
| | - Vivien L. Yap
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
| | - Christopher J. Swearingen
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
| | - Melissa S. Riggins
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey R. Kaiser
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas,Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - G. Bradley Schaefer
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
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13
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Bednarek N, Mathur A, Inder T, Wilkinson J, Neil J, Shimony J. Impact of therapeutic hypothermia on MRI diffusion changes in neonatal encephalopathy. Neurology 2012; 78:1420-7. [PMID: 22517107 DOI: 10.1212/wnl.0b013e318253d589] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective of this work was to determine the impact of therapeutic hypothermia (TH) on the magnitude and time course of mean diffusivity (MD) changes following hypoxic-ischemic encephalopathy (HIE) in newborns. METHODS Cerebral MRI scans of infants undergoing whole body TH for HIE from 2007 to 2010 were retrospectively reviewed. The data were analyzed identically to a control group of newborns with HIE previously published, prior to the development of TH. Anatomic injury was defined on T1- and T2-weighted ("late") MRI obtained after the fifth day of life. Since MD values vary regionally, the ratios of MD values for injured and normal tissue were calculated for areas of injury. Normal values were obtained from corresponding brain regions of 12 infants undergoing TH who had no injury on MRI studies. RESULTS Twenty-three of 59 infants who underwent TH and MRI displayed cerebral injury on late MRI and were included in the study. MD ratios were decreased in all injured infants within the first 7 days of life. The return of MD to normal (pseudonormalization) occurred after the tenth day as compared to 6-8 days in the control group. Infants with severest injury demonstrated greater reduction in MD, but no difference in time to pseudonormalization. CONCLUSION TH slows the evolution of diffusion abnormalities on MRI following HIE in term infants.
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Affiliation(s)
- N Bednarek
- Neonatology Unit, Alix de Champagne, Reims, France
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14
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Zanelli S, Buck M, Fairchild K. Physiologic and pharmacologic considerations for hypothermia therapy in neonates. J Perinatol 2011; 31:377-86. [PMID: 21183927 PMCID: PMC3552186 DOI: 10.1038/jp.2010.146] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
With mounting evidence that hypothermia is neuroprotective in newborns with hypoxic-ischemic encephalopathy (HIE), an increasing number of centers are offering this therapy. Hypothermia is associated with a wide range of physiologic changes affecting every organ system, and awareness of these effects is essential for optimum patient management. Lowering the core temperature also alters pharmacokinetic and pharmacodynamic properties of medications commonly used in asphyxiated neonates, necessitating close attention to drug efficacy and side effects. Rewarming introduces additional risks and challenges as the hypothermia-associated physiologic and pharmacologic changes are reversed. In this review we provide an organ system-based assessment of physiologic changes associated with hypothermia. We also summarize evidence from randomized controlled trials showing lack of serious adverse effects of moderate hypothermia therapy in term and near-term newborns with moderate-to-severe HIE. Finally, we review the effects of hypothermia on drug metabolism and clearance based on studies in animal models and human adults, and limited data from neonates.
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Affiliation(s)
- S Zanelli
- Department of Pediatrics, University of Virginia, Charlottesville, USA.
| | - M Buck
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA,Department of Pharmacy, University of Virginia, Charlottesville, VA, USA
| | - K Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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15
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Yu X, Zhang Y, Lasky RE, Datta S, Parikh NA, Narayana PA. Comprehensive brain MRI segmentation in high risk preterm newborns. PLoS One 2010; 5:e13874. [PMID: 21079730 PMCID: PMC2975631 DOI: 10.1371/journal.pone.0013874] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 10/14/2010] [Indexed: 11/28/2022] Open
Abstract
Most extremely preterm newborns exhibit cerebral atrophy/growth disturbances and white matter signal abnormalities on MRI at term-equivalent age. MRI brain volumes could serve as biomarkers for evaluating the effects of neonatal intensive care and predicting neurodevelopmental outcomes. This requires detailed, accurate, and reliable brain MRI segmentation methods. We describe our efforts to develop such methods in high risk newborns using a combination of manual and automated segmentation tools. After intensive efforts to accurately define structural boundaries, two trained raters independently performed manual segmentation of nine subcortical structures using axial T2-weighted MRI scans from 20 randomly selected extremely preterm infants. All scans were re-segmented by both raters to assess reliability. High intra-rater reliability was achieved, as assessed by repeatability and intra-class correlation coefficients (ICC range: 0.97 to 0.99) for all manually segmented regions. Inter-rater reliability was slightly lower (ICC range: 0.93 to 0.99). A semi-automated segmentation approach was developed that combined the parametric strengths of the Hidden Markov Random Field Expectation Maximization algorithm with non-parametric Parzen window classifier resulting in accurate white matter, gray matter, and CSF segmentation. Final manual correction of misclassification errors improved accuracy (similarity index range: 0.87 to 0.89) and facilitated objective quantification of white matter signal abnormalities. The semi-automated and manual methods were seamlessly integrated to generate full brain segmentation within two hours. This comprehensive approach can facilitate the evaluation of large cohorts to rigorously evaluate the utility of regional brain volumes as biomarkers of neonatal care and surrogate endpoints for neurodevelopmental outcomes.
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Affiliation(s)
- Xintian Yu
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
| | - Yanjie Zhang
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
| | - Robert E. Lasky
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
- Center for Clinical Research and Evidence Based Medicine, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
| | - Sushmita Datta
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
| | - Nehal A. Parikh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
- * E-mail:
| | - Ponnada A. Narayana
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston Medical School, Houston, Texas, United States of America
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Azzopardi D, Edwards AD. Magnetic resonance biomarkers of neuroprotective effects in infants with hypoxic ischemic encephalopathy. Semin Fetal Neonatal Med 2010; 15:261-9. [PMID: 20359970 DOI: 10.1016/j.siny.2010.03.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Evaluation of infants with hypoxic ischemic encephalopathy by magnetic resonance spectroscopy and imaging is useful to direct clinical care, and may assist the evaluation of candidate neuroprotective therapies. Cerebral metabolites measured by magnetic resonance spectroscopy, and visual analysis of magnetic resonance images during the first 30 days after birth accurately predict later neurological outcome and are valid biomarkers of the key physiological processes underlying brain injury in neonatal hypoxic ischemic encephalopathy. Visual assessment of magnetic resonance images may also be a suitable surrogate outcome in studies of neuroprotective therapies but current magnetic resonance methods are relatively inefficient for use in early phase, first in human infant studies of novel neuroprotective therapies. However, diffusion tensor imaging and analysis of fractional anisotropy with tract-based spatial statistics promises to be a highly efficient biomarker and surrogate outcome for rapid preliminary evaluation of promising therapies for neonatal hypoxic ischemic injury. Standardisation of scanning protocols and data analysis between different scanners is essential.
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Affiliation(s)
- Denis Azzopardi
- Institute of Clinical Sciences, Imperial College London and MRC Clinical Sciences Centre, Hammersmith Hospital, London, UK.
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17
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Massaro AN, Kadom N, Chang T, Glass P, Nelson K, Baumgart S. Quantitative analysis of magnetic resonance images and neurological outcome in encephalopathic neonates treated with whole-body hypothermia. J Perinatol 2010; 30:596-603. [PMID: 20182435 DOI: 10.1038/jp.2010.7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate whether quantitative measures from magnetic resonance imaging (MRI) performed in hypothermia-treated encephalopathic newborns can differentiate patients with unfavorable neurological outcome. STUDY DESIGN Retrospective analysis of clinical data and MRI studies was performed in 47 full-term infants treated with whole-body hypothermia for neonatal encephalopathy. Apparent diffusion coefficients (ADCs) and T1 and T2 intensity ratios were measured in the basal ganglia and thalamus on axial MRI images. Unfavorable outcome was defined as (1) death or severe neurological deficits at discharge and (2) death or cerebral palsy/severe motor deficit at follow-up through age 9 months. Differences between groups with favorable versus unfavorable neurological outcome at each time point were compared. Optimal cutoff values for significant MR variables were determined with receiver operating curve analyses. Sensitivity and specificity of these cutoff values for predicting unfavorable outcome were calculated and results were compared with qualitative MRI interpretation. RESULT Infants presented with a median pH of 6.86, base deficit of 20 and Apgar scores of 1, 3 and 4 at 1, 5 and 10 min, respectively. Severe encephalopathy was present in 38%. Unfavorable outcome was present in 9 patients at discharge and in 13 of 26 patients with available follow-up data through 9 months. ADC values and T1 ratios were not significantly different between groups at either time point. T2 ratios in both the basal ganglia and thalamus were significantly higher in patients with unfavorable outcome, both at discharge and in follow-up. T2 intensity ratio in the basal ganglia and thalamus remained significantly associated with death or severe neurological deficit at discharge, after controlling for covariates in logistic regression analysis. Sensitivity and specificity of T2 intensity ratio for predicting unfavorable outcome at discharge were comparable to qualitative grading of injury in the basal ganglia and thalamus by a neuroradiologist. CONCLUSION Increased T2 signal intensity in the basal ganglia or thalamus in patients with hypothermia-treated neonatal encephalopathy is associated with unfavorable neurological outcome at discharge and later with motor deficit/cerebral palsy. Quantitative methods to assess MRI evidence of brain injury are important for providing objective measures to predict outcome in this high-risk population.
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Affiliation(s)
- A N Massaro
- Department of Neonatology, Children's National Medical Center, Washington, DC, USA.
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Jacobs S, Hunt R, Tarnow-Mordi W, Inder T, Davis P. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2003:CD003311. [PMID: 14583966 DOI: 10.1002/14651858.cd003311] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Newborn animal and human pilot studies suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae, without adverse effects. OBJECTIVES To determine whether therapeutic hypothermia in encephalopathic asphyxiated newborn infants reduces mortality and long-term neurodevelopmental disability, without clinically important side effects. SEARCH STRATEGY The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library (Issue 2, 2003) was used. Randomised controlled trials evaluating therapeutic hypothermia in term newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue Issue 2, 2003), MEDLINE (1966 to July 2003), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching. SELECTION CRITERIA Randomised controlled trials comparing the use of therapeutic hypothermia with normothermia in encephalopathic newborn infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies were included. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS Three reviewers independently selected, assessed the quality of and extracted data from the included studies. Authors were contacted for further information. Meta-analyses were performed using relative risk and risk difference for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals. MAIN RESULTS Two randomised controlled trials were included in this review, comprising 50 term infants with moderate/ severe encephalopathy and evidence of intrapartum asphyxia. There was no significant effect of therapeutic hypothermia on the combined outcome of death or major neurodevelopmental disability in survivors followed. No adverse effects of hypothermia on short term medical outcomes or on some 'early' indicators of neurodevelopmental outcome were detected. REVIEWER'S CONCLUSIONS Although two small randomised controlled trials demonstrated neither evidence of benefit or harm, current evidence is inadequate to assess either safety or efficacy of therapeutic hypothermia in newborn infants with hypoxic ischaemic encephalopathy. Therapeutic hypothermia for encephalopathic asphyxiated newborn infants should be further evaluated in well designed randomised controlled trials.
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Affiliation(s)
- S Jacobs
- Division of Paediatrics, Royal Women's Hospital, 132 Grattan Street, Carlton, Melbourne, Victoria, Australia, 3953
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