Elsevier

Pediatric Neurology

Volume 31, Issue 4, October 2004, Pages 267-274
Pediatric Neurology

Hypoxic-ischemic encephalopathy: Correlation of serial MRI and outcome

https://doi.org/10.1016/j.pediatrneurol.2004.04.011Get rights and content

Twenty-four patients with hypoxic-ischemic encephalopathy were examined with serial magnetic resonance imaging up to 4 years of age. Magnetic resonance imaging studies were performed in the neonatal period, at the fourth month and the fourth year of age, and the findings were compared with the patients' neurodevelopmental outcome at the fourth year of age. Periventricular signal alterations and deep gray matter involvement were usually evident in the initial magnetic resonance imaging studies, and encephalomalacia, periventricular leukomalacia, and atrophy were the common findings on follow-up magnetic resonance imaging studies. In the patients with hypoxic-ischemic encephalopathy, some correlation between magnetic resonance imaging findings and neurodevelopmental outcome was recognized. The patients with deep gray matter involvement on the initial magnetic resonance imaging had a poor prognosis, and the ones with normal magnetic resonance imaging findings had a favorable neurodevelopmental outcome. On the follow-up magnetic resonance imaging findings, encephalomalacia and periventricular leukomalacia were associated with poor neurodevelopmental outcome. In predicting the neurologic outcome at 4 years of age, magnetic resonance imaging findings of the neonatal period had the highest negative predictive value, whereas magnetic resonance imaging findings at 4 months of age and 4 years of age had the highest positive predictive value.

Introduction

Neonatal asphyxia causing hypoxic-ischemic encephalopathy frequently results in the chronic handicapping conditions of cerebral palsy, mental retardation, learning disability, epilepsy, behavioral problems, intellectual deficits, and mortality [1]. The stage of encephalopathy was suggested as the main predictor of outcome in perinatal asphyxia. However, follow-up studies have demonstrated that the outcome cannot be always predicted by the severity of hypoxic-ischemic encephalopathy [2]. One way to establish brain injury in asphyxiated children is to use neuroimaging methods. Magnetic resonance imaging has been demonstrated to be a useful tool for evaluation of brain damage in asphyxiated infants. Because of higher sensitivity and specificity to maturational changes such as evaluation of myelination, magnetic resonance imaging has had an enormous impact on neurologic imaging. Especially serial imaging can identify specific patterns of injury accurately [3], [4]. Several studies have tried to establish the predictive value of magnetic resonance imaging in children with perinatal asphyxia [5], [6], [7], [8], [9], [10]. There are few reports that document serial magnetic resonance imaging findings in infants with hypoxic-ischemic encephalopathy in association with long-term neurologic assessment [11], [12], [13]. Neurologic outcome was determined usually at 12-24 months of age in these studies. However, cerebral palsy may not be accurately diagnosed until 3 to 4 years of age.

This study aimed to evaluate the role of serial magnetic resonance imaging examinations in predicting late neurodevelopmental outcome, and to describe the characteristic magnetic resonance imaging findings observed during the first 4 years of life in patients with hypoxic-ischemic encephalopathy.

Section snippets

Patient data

Twenty-four neonates who suffered perinatal asphyxia and had hypoxic-ischemic encephalopathy were included in a prospective study. Term infants older than 37 weeks of gestation who manifested signs of fetal distress before delivery (including abnormal cardiotocograph recordings such as decreased variability, late decelerations, and a baseline bradycardia) with or without meconium-stained amnistic fluid,who had abnormal Apgar scores (≤6 at 5 minutes), who required resuscitation at birth and who

Results

All infants were 37 weeks of age or older by maternal dates or Dubowitz examination. The mean birth weight was 3184.2 ± 89.0 gm (range 2300-4000 gm), mean gestation was 39.5 ± 0.2 weeks (range 38-42 weeks). There were 17 male infants and 7 females. The perinatal characteristics and demographic features of allinfants are listed in Table 1.

Three patients died between 8-22 months; one died as a result of aspiration secondary to neurologic handicap, and the remaining two died as a direct result of

Discussion

In this study, normal magnetic resonance imaging findings in the neonatal period were associated with normal neurologic outcome, and magnetic resonance imaging findings both at 4 months and 4 years of age had the highest predictive value in predicting the abnormal neurologic outcome at 4 years of age. We think that the magnetic resonance imaging at 4 months of age is more important because it can be an early clue in predicting a poor neurologic outcome. It will be appropriate to monitor the

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