Cardiac Dysfunction in Neonatal HIE Is Associated with Increased Mortality and Brain Injury by MRI

2021 ◽  
Author(s):  
Gabriel Altit ◽  
Sonia L. Bonifacio ◽  
Carolina V. Guimaraes ◽  
Shazia Bhombal ◽  
Ganesh Sivakumar ◽  
...  
Keyword(s):  
Brain Injury ◽  
Therapeutic Hypothermia ◽  
Cardiac Dysfunction ◽  
Systolic Function ◽  
Brain Magnetic Resonance Imaging ◽  
Lv Function ◽  
Severe Brain Injury ◽  
Key Points ◽  
Magnetic Resonance Imaging Mri ◽  
Ischemic Encephalopathy

Objective Describe the association between cardiac dysfunction and death or moderate-to-severe abnormalities on brain magnetic resonance imaging (MRI) in neonates undergoing therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE). Study Design Retrospective study in neonates with moderate or severe HIE undergoing therapeutic hypothermia between 2008 and 2017. Primary outcome was death or moderate-to-severe brain injury using the Barkovich score. Conventional and speckle-tracking echocardiography measures were extracted from available echocardiograms to quantify right (RV) and left (LV) ventricular functions. Results A total of 166 newborns underwent therapeutic hypothermia of which 53 (36.5%) had echocardiography performed. Ten (19%) died prior to hospital discharge, and 11 (26%) had moderate-to-severe brain injury. There was no difference in chronologic age at echocardiography between the normal and adverse outcome groups (22 [±19] vs. 28 [±21] hours, p = 0.35). Cardiac findings in newborns with abnormal outcome included lower systolic and diastolic blood pressure (BP) at echocardiography (p = 0.004) and decreased tricuspid annular plane systolic excursion (a marker of RV systolic function; p = 0.01), while the ratio of systolic pulmonary artery (PA) pressure to systolic BP indicated isosystemic pressures (>2/3 systemic) in both groups. A multilogistic regression analysis, adjusting for weight and seizure status, indicated an association between abnormal outcome and LV function by longitudinal strain, as well as by ejection fraction. Conclusion Newborns who died or had moderate–to-severe brain injury had a higher incidence of cardiac dysfunction but similar PA pressures when compared with those who survived with mild or no MRI abnormalities. Key Points

Hypotension and Brain Injury in Asphyxiated Newborns Treated with Hypothermia

2017 ◽  
Vol 35 (01) ◽  
pp. 031-038 ◽  
Author(s):  
Asim Al Balushi ◽  
Stephanie Barbosa Vargas ◽  
Julie Maluorni ◽  
Priscille-Nice Sanon ◽  
Emmanouil Rampakakis ◽  
...  
Keyword(s):  
Brain Injury ◽  
Brain Magnetic Resonance Imaging ◽  
Severe Brain Injury ◽  
Resonance Imaging ◽  
Increased Risk ◽  
Blood Pressures ◽  
Magnetic Resonance Imaging Mri ◽  
Lactate Levels ◽  
The Impact ◽  
The Brain

Objective This study aimed to assess the incidence of hypotension in asphyxiated newborns treated with hypothermia, the variability in treatments for hypotension, and the impact of hypotension on the pattern of brain injury. Study Design We conducted a retrospective cohort study of asphyxiated newborns treated with hypothermia. Mean blood pressures, lactate levels, and inotropic support medications were recorded during the hospitalization. Presence and severity of brain injury were scored using the brain magnetic resonance imaging (MRI) obtained after the hypothermia treatment was completed. Results One hundred and ninety term asphyxiated newborns were treated with hypothermia. Eighty-one percent developed hypotension. Fifty-five percent of the newborns in the hypotensive group developed brain injury compared with 35% of the newborns in the normotensive group (p = 0.04). Twenty-nine percent of the newborns in the hypotensive group developed severe brain injury, compared with only 15% in the normotensive group. Nineteen percent of the newborns presenting with volume- and/or catecholamine-resistant hypotension had near-total injury, compared with 6% in the normotensive group and 8% in the group responding to volume and/or catecholamines. Conclusion Hypotension was common in asphyxiated newborns treated with hypothermia and was associated with an increased risk of (severe) brain injury in these newborns.

Utilization of Therapeutic Hypothermia and Neurological Injury in Neonates with Mild Hypoxic-Ischemic Encephalopathy: A Report from Children's Hospital Neonatal Consortium

2020 ◽  
Author(s):  
Rakesh Rao ◽  
Ulrike Mietzsch ◽  
Robert DiGeronimo ◽  
Shannon E. Hamrick ◽  
Maria L. V. Dizon ◽  
...  
Keyword(s):  
Brain Injury ◽  
White Matter ◽  
Therapeutic Hypothermia ◽  
Fetal Distress ◽  
Hypoxic Ischemic Encephalopathy ◽  
Neurological Injury ◽  
Mri Scans ◽  
History Of ◽  
Magnetic Resonance Imaging Mri ◽  
Ischemic Encephalopathy

Objective This study was aimed to describe utilization of therapeutic hypothermia (TH) in neonates presenting with mild hypoxic-ischemic encephalopathy (HIE) and associated neurological injury on magnetic resonance imaging (MRI) scans in these infants. Study Design Neonates ≥ 36 weeks' gestation with mild HIE and available MRI scans were identified. Mild HIE status was assigned to hyper alert infants with an exaggerated response to arousal and mild HIE as the highest grade of encephalopathy recorded. MRI scans were dichotomized as “injury” versus “no injury.” Results A total of 94.5% (257/272) neonates with mild HIE, referred for evaluation, received TH. MRI injury occurred in 38.2% (104/272) neonates and affected predominantly the white matter (49.0%, n = 51). Injury to the deep nuclear gray matter was identified in (10.1%) 20 infants, and to the cortex in 13.4% (n = 14 infants). In regression analyses (odds ratio [OR]; 95% confidence interval [CI]), history of fetal distress (OR = 0.52; 95% CI: 0.28–0.99) and delivery by caesarian section (OR = 0.54; 95% CI: 0.31–0.92) were associated with lower odds, whereas medical comorbidities during and after cooling were associated with higher odds of brain injury (OR = 2.31; 95% CI: 1.37–3.89). Conclusion Majority of neonates with mild HIE referred for evaluation are being treated with TH. Odds of neurological injury are over two-fold higher in those with comorbidities during and after cooling. Brain injury predominantly involved the white matter. Key Points

scholarly journals Impact of outreach education program on outcomes of neonates with hypoxic ischemic encephalopathy

2020 ◽  
Author(s):  
Khorshid Mohammad ◽  
Dinesh Dharel ◽  
Ayman Abou Mehrem ◽  
Michael J Esser ◽  
Renee Paul ◽  
...  
Keyword(s):  
Brain Injury ◽  
Tertiary Care ◽  
Brain Magnetic Resonance Imaging ◽  
Hypoxic Ischemic Encephalopathy ◽  
Target Range ◽  
Composite Outcome ◽  
Severe Brain Injury ◽  
Outreach Education ◽  
The Impact ◽  
Ischemic Encephalopathy

Abstract Aim To evaluate the impact of outreach education targeting neuroprotection on outcomes of outborn infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Methods A retrospective cohort study of infants admitted with moderate-to-severe HIE was conducted following the implementation of outreach education in January 2016. Key interventions were early identification and referral of infants with encephalopathy utilizing telemedicine and a centralized communication system, hands-on simulation, and interactive case discussion and dissemination of clinical management guidelines and educational resources. The association between the intervention and a composite outcome of death and/or severe brain injury on brain magnetic resonance imaging (MRI) was tested controlling for the confounding factors. Results Of 165 neonates, 37 (22.4%) died and/or had a severe brain injury. This outcome decreased from 35% (27/77) to 11% (10/88) following the implementation of outreach education (P<0.001). Eligible infants not undergoing therapeutic hypothermia within 6 hours from birth decreased from 19.5% (15/77) to 4.5% (4/88). The use of inotropes decreased from 49.3% (38/77) to 19.6% (13/88). Any core temperature below 33°C was recorded for 20/53 (38%) before and 16/78 (21%) after, while those within the target range of 33°C to 34°C at admission to a tertiary care facility increased from (15/53) 28% to (51/88) 58%. Outreach education was independently associated with decreased composite outcome of death and/or severe brain injury on MRI (adjusted odds ratio 0.2; 95% confidence interval 0.07 to 0.52). Conclusion Outreach education targeting neuroprotection for infants with moderate-to-severe HIE was associated with a reduction in death and/or severe brain injury.

scholarly journals DOES THE TIMING OF INITIATION OF THERAPEUTIC HYPOTHERMIA INFLUENCE MRI FINDINGS AND OUTCOMES IN ENCEPHALOPATHIC BABIES?

2018 ◽  
Vol 23 (suppl_1) ◽  
pp. e23-e23
Author(s):  
Mireille Guillot ◽  
Marissa Philippe ◽  
Elka Miller ◽  
Jorge Davila ◽  
Nick Borrowman ◽  
...  
Keyword(s):  
Brain Injury ◽  
Therapeutic Hypothermia ◽  
Neonatal Intensive Care ◽  
Standard Treatment ◽  
Severe Brain Injury ◽  
Mri Findings ◽  
Neurodevelopmental Outcomes ◽  
Timing Of Initiation ◽  
Ischemic Encephalopathy ◽  
Median Birth Weight

Abstract BACKGROUND Therapeutic hypothermia (TH), initiated < 6h of life, is the standard treatment for infants with moderate to severe hypoxic ischemic encephalopathy (HIE). While preclinical studies show that TH is more effective when started early, little clinical data exists. OBJECTIVES The objectives of our study are to examine the effect of early vs. late TH on the severity and pattern of brain injury on MRI and on the neurodevelopmental outcomes. DESIGN/METHODS This retrospective cohort included infants with HIE treated with TH at a level three neonatal intensive care unit between 2009 and 2016. Babies were grouped into: early cooling (TH started ≤ 180 minutes of life) or late cooling (TH started > 180 minutes of life). Two radiologists evaluated the severity and pattern of brain injury on MRI using both NICHD and Barkovich scoring system. Neurodevelopmental outcomes were evaluated at 4, 10, 18 and 48 months. RESULTS Ninety-four patients (median gestational age 39 weeks; median birth weight 3.3 kg) were included in the study, 55 in the early cooling and 39 in the late cooling group. The early cooling group included more patients with severe HIE (32.7% vs 10.3%, p=0.01). No difference was observed between the 2 groups in regard to the pattern and severity of brain injury. In the late cooling group, there was a trend toward more severe watershed (WS) injury (WS score ≥3) (30.6% vs 17%, p=0.19) and more moderate to severe brain injury (33.3% vs 23.4%, p=0.33). There was no difference in the neurodevelopmental outcomes between the 2 groups. CONCLUSION TH initiated early (before 180 minutes of life) was neither associated with a difference in brain injury on MRI nor better neurodevelopmental outcomes. Despite having more infants with severe HIE in the early cooling group, there was a trend toward less significant brain injury in this group.

Intrapartum Basal Ganglia–Thalamic Pattern Injury and Radiologically Termed “Acute Profound Hypoxic–Ischemic Brain Injury” Are Not Synonymous

2020 ◽  
Author(s):  
Johan Smith ◽  
Regan Solomons ◽  
Lindi Vollmer ◽  
Eduard J. Langenegger ◽  
Jan W. Lotz ◽  
...  
Keyword(s):  
Brain Injury ◽  
Basal Ganglia ◽  
Caesarean Section ◽  
Median Time ◽  
Mode Of Delivery ◽  
Time Interval ◽  
Key Points ◽  
Admission Status ◽  
Sentinel Event ◽  
Magnetic Resonance Imaging Mri

Objective Human cases of acute profound hypoxic-ischemic (HI) injury (HII), in which the insult duration timed with precision had been identified, remains rare, and there is often uncertainty of the prior state of fetal health. Study Design A retrospective analysis of 10 medicolegal cases of neonatal encephalopathy-cerebral palsy survivors who sustained intrapartum HI basal ganglia-thalamic (BGT) pattern injury in the absence of an obstetric sentinel event. Results Cardiotocography (CTG) admission status was reassuring in six and suspicious in four of the cases. The median time from assessment by admission CTG or auscultation to birth was 687.5 minutes (interquartile range [IQR]: 373.5–817.5 minutes), while the median time interval between first pathological CTG and delivery of the infant was 179 minutes (IQR: 137–199.25 minutes). The mode of delivery in the majority of infants (60%) was by unassisted vaginal birth; four were delivered by delayed caesarean section. The median (IQR) interval between the decision to perform a caesarean section and delivery was 169 minutes (range: 124–192.5 minutes). Conclusion The study shows that if a nonreassuring fetal status develops during labor and is prolonged, a BGT pattern HI injury may result, in the absence of a perinatal sentinel event. Intrapartum BGT pattern injury and radiologically termed “acute profound HI brain injury” are not necessarily synonymous. A visualized magnetic resonance imaging (MRI) pattern should preferably solely reflect the patterns description and severity, rather than a causative mechanism of injury. Key Points

Therapeutic Hypothermia in Brazil: A MultiProfessional National Survey

2018 ◽  
Vol 36 (11) ◽  
pp. 1150-1156 ◽  
Author(s):  
G. F. Variane ◽  
L. M. Cunha ◽  
P. Pinto ◽  
P. Brandao ◽  
R. S. Mascaretti ◽  
...  
Keyword(s):  
Therapeutic Hypothermia ◽  
National Survey ◽  
Health Care Professionals ◽  
Brain Magnetic Resonance Imaging ◽  
Significant Heterogeneity ◽  
Online Questionnaire ◽  
Cross Sectional ◽  
Long Term Follow Up ◽  
Magnetic Resonance Imaging Mri

Objective To determine the rate of therapeutic hypothermia (TH) use, current practices, and long-term follow-up. Study Design Prospective cross-sectional national survey with 19 questions related to the assessment of hypoxic–ischemic encephalopathy (HIE) and TH practices. An online questionnaire was made available to health care professionals working in neonatal care in Brazil. Results A total of 1,092 professionals replied, of which 681 (62%) reported using TH in their units. Of these, 624 (92%) provided TH practices details: 136 (20%) did not use any neurologic score or amplitude-integrated electroencephalogram (aEEG) to assess encephalopathy and 81(13%) did not answer this question. Any specific training for encephalopathy assessment was provided to only 81/407 (19%) professionals. Infants with mild HIE are cooled according to 184 (29%) of the respondents. Significant variations in practice were noticed concerning time of initiation and cooling methods, site of temperature measurements and monitoring, and access to aEEG, electroencephalogram (EEG), and neurology consultation. Only 19% could perform a brain magnetic resonance imaging (MRI), and 31% reported having a well-established follow-up program for these infants. Conclusion TH has been implemented in Brazil but with significant heterogeneity for most aspects of hypothermia practices, which may affect safety or efficacy of the therapy. A step forward toward quality improvement is important.

scholarly journals Wavelet Autoregulation Monitoring Identifies Blood Pressures Associated With Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiuyun Liu ◽  
Aylin Tekes ◽  
Jamie Perin ◽  
May W. Chen ◽  
Bruno P. Soares ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Brain Injury ◽  
Therapeutic Hypothermia ◽  
Near Infrared ◽  
Brain Regions ◽  
Hypoxic Ischemic Encephalopathy ◽  
Volume Index ◽  
Arterial Blood ◽  
Blood Pressures ◽  
Ischemic Encephalopathy

Dysfunctional cerebrovascular autoregulation may contribute to neurologic injury in neonatal hypoxic-ischemic encephalopathy (HIE). Identifying the optimal mean arterial blood pressure (MAPopt) that best supports autoregulation could help identify hemodynamic goals that support neurologic recovery. In neonates who received therapeutic hypothermia for HIE, we hypothesized that the wavelet hemoglobin volume index (wHVx) would identify MAPopt and that blood pressures closer to MAPopt would be associated with less brain injury on MRI. We also tested a correlation-derived hemoglobin volume index (HVx) and single- and multi-window data processing methodology. Autoregulation was monitored in consecutive 3-h periods using near infrared spectroscopy in an observational study. The neonates had a mean MAP of 54 mmHg (standard deviation: 9) during hypothermia. Greater blood pressure above the MAPopt from single-window wHVx was associated with less injury in the paracentral gyri (p = 0.044; n = 63), basal ganglia (p = 0.015), thalamus (p = 0.013), and brainstem (p = 0.041) after adjustments for sex, vasopressor use, seizures, arterial carbon dioxide level, and a perinatal insult score. Blood pressure exceeding MAPopt from the multi-window, correlation HVx was associated with less injury in the brainstem (p = 0.021) but not in other brain regions. We conclude that applying wavelet methodology to short autoregulation monitoring periods may improve the identification of MAPopt values that are associated with brain injury. Having blood pressure above MAPopt with an upper MAP of ~50–60 mmHg may reduce the risk of brain injury during therapeutic hypothermia. Though a cause-and-effect relationship cannot be inferred, the data support the need for randomized studies of autoregulation and brain injury in neonates with HIE.

Pontine and cerebellar injury in neonatal hypoxic-ischemic encephalopathy: MRI features and clinical outcomes

2020 ◽  
Vol 61 (10) ◽  
pp. 1398-1405
Author(s):  
Katsumi Hayakawa ◽  
Koichi Tanda ◽  
Sachiko Koshino ◽  
Akira Nishimura ◽  
Zenro Kizaki ◽  
...  
Keyword(s):  
Brain Injury ◽  
Clinical Outcomes ◽  
Dentate Nucleus ◽  
Injury Pattern ◽  
Severe Brain Injury ◽  
Mri Features ◽  
Dorsal Portion ◽  
Cerebellar Injury ◽  
Cerebellar Involvement ◽  
Ischemic Encephalopathy

Background Perinatal hypoxic-ischemic encephalopathy (HIE) is a major cause of death and disability in infants. Magnetic resonance imaging (MRI) is valuable for predicting the outcome in high-risk neonates. The relationship of pontine and cerebellar injury to outcome has not been explored sufficiently. Purpose To characterize MRI features of pontine and cerebellar injury and to assess the clinical outcomes of these neonates. Material and Methods The retrospective study included 59 term neonates (25 girls) examined by MRI using 1.5-T scanner in the first two weeks of life between 2008 and 2017. Involvement of the pons and cerebellum was judged as a high signal intensity on diffusion-weighted image (DWI) and a restricted diffusion on an apparent diffusion coefficient (ADC) map. Results Pontine involvement was observed in the dorsal portion of pons in eight neonates and cerebellar involvement was observed in dentate nucleus (n = 8), cerebellar vermis (n = 3), and hemisphere (n = 1) in 11 neonates. Combined pontine and cerebellar involvement was observed in eight neonates and only cerebellar involvement in three. The pontine and cerebellar injuries were always associated with very severe brain injury including a basal ganglia/thalamus injury pattern and a total brain injury pattern. In terms of clinical outcome, all but four lost to follow-up, had severe cerebral palsy. Conclusion Pontine and cerebellar involvement occurred in the dorsal portion of pons and mostly dentate nucleus and was always associated with a more severe brain injury pattern as well as being predictive of major disability.

Conventional MRI scan and DTI imaging show more severe brain injury in neonates with hypoxic-ischemic encephalopathy and seizures

2018 ◽  
Vol 122 ◽  
pp. 8-14 ◽  
Author(s):  
Beth M. Kline-Fath ◽  
Paul S. Horn ◽  
Weihong Yuan ◽  
Stephanie Merhar ◽  
Charu Venkatesan ◽  
...  
Keyword(s):  
Brain Injury ◽  
Hypoxic Ischemic Encephalopathy ◽  
Severe Brain Injury ◽  
Mri Scan ◽  
Conventional Mri ◽  
Ischemic Encephalopathy

scholarly journals Outcomes of Infants with Mild Hypoxic Ischemic Encephalopathy Who Did Not Receive Therapeutic Hypothermia

2019 ◽  
Vol 4 (3) ◽  
pp. 1-9 ◽  
Author(s):  
Jonathan Reiss ◽  
Mridu Sinha ◽  
Jeffrey Gold ◽  
Julie Bykowski ◽  
Shelley M. Lawrence
Keyword(s):  
Therapeutic Hypothermia ◽  
Severe Disease ◽  
Significant Risk ◽  
Brain Magnetic Resonance Imaging ◽  
Adverse Outcomes ◽  
Hypoxic Ischemic Encephalopathy ◽  
Neurodevelopmental Outcomes ◽  
Specific Patient ◽  
Increased Risk ◽  
Ischemic Encephalopathy

Introduction: Accurately diagnosing and treating infants with mild forms of hypoxic ischemic encephalopathy (HIE) is important, as the majority of neonates with signs and symptoms of HIE after birth do not meet clinical criteria for moderate or severe disease. Emerging evidence, however, suggests that infants with mild HIE (mHIE) have an increased risk for neurodevelopmental impairment (NDI). Methods: This retrospective descriptive study examined all inborn infants ≥35 week’s gestational age at a single, level III neonatal intensive care unit (NICU) in California between January 1, 2012, and December 31, 2015. International Classification of Diseases codes were used as a proxy to identify neonates with mHIE but who did not receive therapeutic hypothermia (TH). Short- and long-term neurodevelopmental outcomes were documented, including abnormal (1) brain magnetic resonance imaging within 10 days of birth suggestive of HIE, (2) electroencephalogram with electrographic seizures, (3) neurologic discharge examination, or (4) NDI following NICU discharge. Results: Over the 4-year study period, 25 infants met inclusion criteria. Eight of 25 (32%) infants demonstrated neurologic impairment, defined by an abnormality in at least one of the four categories. The remaining 17 infants were without documented evidence for adverse outcomes. Conclusion: Our results indicate that children with mHIE are at significant risk for neurologic injury and may benefit from more aggressive interventions. Further prospective studies should be completed to determine the efficacy of TH in this specific patient population.

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