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Paprocka J, Kijonka M, Rzepka B, Sokół M. Melatonin in Hypoxic-Ischemic Brain Injury in Term and Preterm Babies. Int J Endocrinol 2019; 2019:9626715. [PMID: 30915118 PMCID: PMC6402213 DOI: 10.1155/2019/9626715] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/23/2019] [Accepted: 01/30/2019] [Indexed: 12/05/2022] Open
Abstract
Melatonin may serve as a potential therapeutic free radical scavenger and broad-spectrum antioxidant. It shows neuroprotective properties against hypoxic-ischemic brain injury in animal models. The authors review the studies focusing on the neuroprotective potential of melatonin and its possibility of treatment after perinatal asphyxia. Melatonin efficacy, low toxicity, and ability to readily cross through the blood-brain barrier make it a promising molecule. A very interesting thing is the difference between the half-life of melatonin in preterm neonates (15 hours) and adults (45-60 minutes). Probably, the use of synergic strategies-hypothermia coupled with melatonin treatment-may be promising in improving antioxidant action. The authors discuss and try to summarize the evidence surrounding the use of melatonin in hypoxic-ischemic events in term and preterm babies.
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Affiliation(s)
- Justyna Paprocka
- Department of Pediatric Neurology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Marek Kijonka
- Department of Medical Physics, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Poland
| | - Beata Rzepka
- Students' Scientific Society, Department Pediatric Neurology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Maria Sokół
- Department of Medical Physics, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Poland
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Jiang H, Li X, Jin C, Wang M, Liu C, Chan KC, Yang J. Early Diagnosis of Spastic Cerebral Palsy in Infants with Periventricular White Matter Injury Using Diffusion Tensor Imaging. AJNR Am J Neuroradiol 2019; 40:162-168. [PMID: 30545838 PMCID: PMC7048607 DOI: 10.3174/ajnr.a5914] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 10/30/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Periventricular white matter injury is the common cause of spastic cerebral palsy. However, the early diagnosis of spastic cerebral palsy still remains a challenge. Our aim was to investigate whether infants with periventricular white matter injury with bilateral spastic cerebral palsy have unique lesions different from those in infants without cerebral palsy and to evaluate the efficiency of DTI in the early diagnosis of spastic cerebral palsy. MATERIALS AND METHODS Infants with periventricular white matter injury and controls underwent MR imaging at 6-18 months of age. Fractional anisotropy was calculated from DTI. Cerebral palsy was diagnosed by 24-30 months of age. Subjects were divided into 3 groups: infants with periventricular white matter injury with bilateral spastic cerebral palsy, infants with periventricular white matter injury without cerebral palsy, and controls. Tract-Based Spatial Statistics and Automated Fiber Quantification were used to investigate intergroup differences. Receiver operating characteristic curves were used to assess the diagnostic accuracy of spastic cerebral palsy. Correlations between motor function scores and fractional anisotropy were evaluated along white matter tracts. RESULTS There were 20, 19, and 33 subjects in periventricular white matter injury with spastic cerebral palsy, periventricular white matter injury without cerebral palsy, and control groups, respectively. Decreased fractional anisotropy in the corticospinal tract was only observed in infants with periventricular white matter injury with spastic cerebral palsy, whereas decreased fractional anisotropy in the posterior thalamic radiation and genu and splenium of the corpus callosum was seen in both periventricular white matter injury subgroups. Fractional anisotropy in the corticospinal tract at the internal capsule level was effective in differentiating infants with periventricular white matter injury with spastic cerebral palsy from those without cerebral palsy by a threshold of 0.53, and it had strong correlations with motor function scores. CONCLUSIONS Corticospinal tract lesions play a crucial role in motor impairment related to spastic cerebral palsy in infants with periventricular white matter injury. Fractional anisotropy in the corticospinal tract at the internal capsule level could aid in the early diagnosis of spastic cerebral palsy with high diagnostic accuracy.
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Affiliation(s)
- H Jiang
- From the Department of Radiology (H.J., X.L., C.J., M.W., C.L., J.Y.), First Affiliated Hospital
- Department of Biomedical Engineering (H.J., J.Y.), Key Laboratory of Biomedical Information Engineering of the Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - X Li
- From the Department of Radiology (H.J., X.L., C.J., M.W., C.L., J.Y.), First Affiliated Hospital
| | - C Jin
- From the Department of Radiology (H.J., X.L., C.J., M.W., C.L., J.Y.), First Affiliated Hospital
| | - M Wang
- From the Department of Radiology (H.J., X.L., C.J., M.W., C.L., J.Y.), First Affiliated Hospital
| | - C Liu
- From the Department of Radiology (H.J., X.L., C.J., M.W., C.L., J.Y.), First Affiliated Hospital
| | - K C Chan
- Department of Ophthalmology and Radiology (K.C.C.), School of Medicine, New York University, New York, New York
| | - J Yang
- From the Department of Radiology (H.J., X.L., C.J., M.W., C.L., J.Y.), First Affiliated Hospital
- Department of Biomedical Engineering (H.J., J.Y.), Key Laboratory of Biomedical Information Engineering of the Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
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De Wispelaere LA, Ouwehand S, Olsthoorn M, Govaert P, Smit LS, de Jonge RC, Lequin MH, Reiss IK, Dudink J. Electroencephalography and brain magnetic resonance imaging in asphyxia comparing cooled and non-cooled infants. Eur J Paediatr Neurol 2019; 23:181-190. [PMID: 30279083 DOI: 10.1016/j.ejpn.2018.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/29/2018] [Accepted: 09/04/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim was to establish any differences in the predictive value of EEG and MRI for outcome in infants treated and not-treated with therapeutic hypothermia (HT) for perinatal asphyxia. We hypothesize that they are equally predictive and that combining both has the highest predictive value. STUDY DESIGN We retrospectively compared data of infants with hypoxic-ischemic encephalopathy (HIE) who received HT (n = 45) between September 2009 and December 2013 with those of infants with HIE born between January 2004 and August 2009, before HT was available (NT, n = 37). All received conventional and/or amplitude-integrated EEG during the first days and early MRI (day 4-5). Associations of EEG, MRI and severe neurodevelopmental outcome (death or Bayley's -2SD below mean), were tested with a multivariable logistic regression analysis, corrected for HT. RESULTS Forty-eight hours' EEG background pattern had a PPV of 92% and a NPV of 81% in HT, versus 100% and 58% in NT. MRI had a PPV of 71% and a NPV of 93% in HT, versus 82% and 75% in NT. The adjusted OR for adverse outcome was 0.013 (95% CI 0.002-0.154, p < 0.001) for EEG background normalization within 48 h and 32.19 (95% CI 4.84-214.25, p < 0.001) for abnormal MRI. CONCLUSION The predictive value of EEG and MRI is equal in cooled and non-cooled infants with HIE. Our data show a higher predictive value (death and severe outcome) for EEG compared to MRI. In HIE, persistent abnormal EEG background pattern until 48 h, combined with abnormal early MRI is strongly predictive for poor neurodevelopment.
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Affiliation(s)
- Leen Att De Wispelaere
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands; Department of Neonatology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium.
| | - Sabine Ouwehand
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
| | - Marielle Olsthoorn
- Department of Radiology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
| | - Paul Govaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
| | - Liesbeth S Smit
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
| | - Rogier Cj de Jonge
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands; Department of Neonatology, VU University Medical Center, De Boelelaan 1105, 1081 HV, Amsterdam, the Netherlands.
| | - Maarten H Lequin
- Department of Radiology, Wilhelmina Children's Hospital, University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
| | - Irwin K Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
| | - Jeroen Dudink
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands; Department of Pediatrics, Division of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
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Bracken-Roche D, Shevell M, Racine E. Understanding and addressing barriers to communication in the context of neonatal neurologic injury: Exploring the ouR-HOPE approach. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:511-528. [PMID: 31324327 DOI: 10.1016/b978-0-444-64029-1.00024-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Predicting neurologic outcomes for neonates with acute brain injury is essential for guiding the development of treatment goals and appropriate care plans in collaboration with parents and families. Prognostication helps parents imagine their child's possible future and helps them make ongoing treatment decisions in an informed way. However, great uncertainty surrounds neurologic prognostication for neonates, as well as biases and implicit attitudes that can impact clinicians' prognoses, all of which pose significant challenges to evidence-based prognostication in this context. In order to facilitate greater attention to these challenges and guide their navigation, this chapter explores the practice principles captured in the ouR-HOPE approach. This approach proposes the principles of Reflection, Humility, Open-mindedness, Partnership, and Engagement and related self-assessment questions to encourage clinicians to reflect on their practices and to engage with others in responding to challenges. We explore the meaning of each principle through five clinical cases involving neonatal neurologic injury, decision making, and parent-clinician communication. The ouR-HOPE approach should bring more cohesion to the sometimes disparate concerns reported in the literature and encourage clinicians and teams to consider its principles along with other guidelines and practices they find to be particularly helpful in guiding communication with parents and families.
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Affiliation(s)
- Dearbhail Bracken-Roche
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Pediatrics and Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
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105
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Understanding the metabolite-function relationship after cardiac arrest. Resuscitation 2018; 134:133-135. [PMID: 30562598 DOI: 10.1016/j.resuscitation.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/03/2018] [Indexed: 11/20/2022]
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Lally PJ, Montaldo P, Oliveira V, Soe A, Swamy R, Bassett P, Mendoza J, Atreja G, Kariholu U, Pattnayak S, Sashikumar P, Harizaj H, Mitchell M, Ganesh V, Harigopal S, Dixon J, English P, Clarke P, Muthukumar P, Satodia P, Wayte S, Abernethy LJ, Yajamanyam K, Bainbridge A, Price D, Huertas A, Sharp DJ, Kalra V, Chawla S, Shankaran S, Thayyil S. Magnetic resonance spectroscopy assessment of brain injury after moderate hypothermia in neonatal encephalopathy: a prospective multicentre cohort study. Lancet Neurol 2018; 18:35-45. [PMID: 30447969 PMCID: PMC6291458 DOI: 10.1016/s1474-4422(18)30325-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/21/2018] [Accepted: 08/26/2018] [Indexed: 12/31/2022]
Abstract
Background In neonatal encephalopathy, the clinical manifestations of injury can only be reliably assessed several years after an intervention, complicating early prognostication and rendering trials of promising neuroprotectants slow and expensive. We aimed to determine the accuracy of thalamic proton magnetic resonance (MR) spectroscopy (MRS) biomarkers as early predictors of the neurodevelopmental abnormalities observed years after neonatal encephalopathy. Methods We did a prospective multicentre cohort study across eight neonatal intensive care units in the UK and USA, recruiting term and near-term neonates who received therapeutic hypothermia for neonatal encephalopathy. We excluded infants with life-threatening congenital malformations, syndromic disorders, neurometabolic diseases, or any alternative diagnoses for encephalopathy that were apparent within 6 h of birth. We obtained T1-weighted, T2-weighted, and diffusion-weighted MRI and thalamic proton MRS 4–14 days after birth. Clinical neurodevelopmental tests were done 18–24 months later. The primary outcome was the association between MR biomarkers and an adverse neurodevelopmental outcome, defined as death or moderate or severe disability, measured using a multivariable prognostic model. We used receiver operating characteristic (ROC) curves to examine the prognostic accuracy of the individual biomarkers. This trial is registered with ClinicalTrials.gov, number NCT01309711. Findings Between Jan 29, 2013, and June 25, 2016, we recruited 223 infants who all underwent MRI and MRS at a median age of 7 days (IQR 5–10), with 190 (85%) followed up for neurological examination at a median age of 23 months (20–25). Of those followed up, 31 (16%) had moderate or severe disability, including one death. Multiple logistic regression analysis could not be done because thalamic N-acetylaspartate (NAA) concentration alone accurately predicted an adverse neurodevelopmental outcome (area under the curve [AUC] of 0·99 [95% CI 0·94–1·00]; sensitivity 100% [74–100]; specificity 97% [90–100]; n=82); the models would not converge when any additional variable was examined. The AUC (95% CI) of clinical examination at 6 h (n=190) and at discharge (n=167) were 0·72 (0·65–0·78) and 0·60 (0·53–0·68), respectively, and the AUC of abnormal amplitude integrated EEG at 6 h (n=169) was 0·73 (0·65–0·79). On conventional MRI (n=190), cortical injury had an AUC of 0·67 (0·60–0·73), basal ganglia or thalamic injury had an AUC of 0·81 (0·75–0·87), and abnormal signal in the posterior limb of internal capsule (PLIC) had an AUC of 0·82 (0·76–0·87). Fractional anisotropy of PLIC (n=65) had an AUC of 0·82 (0·76–0·87). MRS metabolite peak-area ratios (n=160) of NAA–creatine (<1·29) had an AUC of 0·79 (0·72–0·85), of NAA–choline had an AUC of 0·74 (0·66–0·80), and of lactate–NAA (>0·22) had an AUC of 0·94 (0·89–0·97). Interpretation Thalamic proton MRS measures acquired soon after birth in neonatal encephalopathy had the highest accuracy to predict neurdevelopment 2 years later. These methods could be applied to increase the power of neuroprotection trials while reducing their duration. Funding National Institute for Health Research UK.
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Affiliation(s)
- Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Aung Soe
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Gaurav Atreja
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Ujwal Kariholu
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Helen Harizaj
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | - Martin Mitchell
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | | | | | | | | | - Paul Clarke
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Priya Muthukumar
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Prakash Satodia
- Neonatal Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Sarah Wayte
- Neonatal Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Kiran Yajamanyam
- Neonatal Unit, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Alan Bainbridge
- Neonatal Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Price
- Neonatal Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Angela Huertas
- Neonatal Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - David J Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, London, UK
| | - Vaneet Kalra
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Sanjay Chawla
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.
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Abbasi H, Drury PP, Lear CA, Gunn AJ, Davidson JO, Bennet L, Unsworth CP. EEG sharp waves are a biomarker of striatal neuronal survival after hypoxia-ischemia in preterm fetal sheep. Sci Rep 2018; 8:16312. [PMID: 30397231 PMCID: PMC6218488 DOI: 10.1038/s41598-018-34654-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 10/16/2018] [Indexed: 01/12/2023] Open
Abstract
The timing of hypoxia-ischemia (HI) in preterm infants is often uncertain and there are few biomarkers to determine whether infants are in a treatable stage of injury. We evaluated whether epileptiform sharp waves recorded from the parietal cortex could provide early prediction of neuronal loss after HI. Preterm fetal sheep (0.7 gestation) underwent acute HI induced by complete umbilical cord occlusion for 25 minutes (n = 6) or sham occlusion (control, n = 6). Neuronal survival was assessed 7 days after HI by immunohistochemistry. Sharp waves were quantified manually and using a wavelet-type-2-fuzzy-logic-system during the first 4 hours of recovery. HI resulted in significant subcortical neuronal loss. Sharp waves counted by the automated classifier in the first 30 minutes after HI were associated with greater neuronal survival in the caudate nucleus (r = 0.80), whereas sharp waves between 2–4 hours after HI were associated with reduced neuronal survival (r = −0.83). Manual and automated counts were closely correlated. This study suggests that automated quantification of sharp waves may be useful for early assessment of HI injury in preterm infants. However, the pattern of evolution of sharp waves after HI was markedly affected by the severity of neuronal loss, and therefore early, continuous monitoring is essential.
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Affiliation(s)
- Hamid Abbasi
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
| | - Paul P Drury
- Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Christopher A Lear
- Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Charles P Unsworth
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand.
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Salas J, Reddy N, Orru E, Carson KA, Chavez-Valdez R, Burton VJ, Stafstrom CE, Northington FJ, Huisman TAGM. The Role of Diffusion Tensor Imaging in Detecting Hippocampal Injury Following Neonatal Hypoxic-Ischemic Encephalopathy. J Neuroimaging 2018; 29:252-259. [PMID: 30325083 DOI: 10.1111/jon.12572] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/12/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Neonatal hypoxic-ischemic injury of the brain and resultant encephalopathy (HIE) leads to major developmental impairments by school age. Conventional/anatomical MRI often fails to detect hippocampal injury in mild cases. We hypothesize that diffusion tensor imaging (DTI) has greater sensitivity for identifying subtle hippocampal injury. METHODS We retrospectively analyzed DTI data collected from a cohort of neonates with HIE and controls. Conventional MRI sequences were classified qualitatively according to severity using a modified Barkovich scale. Using multivariate linear regression, we compared hippocampal DTI scalars of HIE patients and controls. Spearman correlation was used to test the association of DTI scalars in the hippocampal and thalamic regions. A multiple regression analysis tested the association of the DTI scalars with short-term outcomes. RESULTS Fifty-five neonates with HIE (42% males) and 13 controls (54% males) were included. Hippocampal DTI scalars were similar between HIE and control groups, even when restricting the HIE group to those with moderate-to-severe injury (8 subjects). DTI scalars of the thalamus were significantly lower in the moderate-to-severely affected patients compared to controls (right fractional anisotropy [FA] .148 vs. .182, P = .01; left FA .147 vs. .181, P = .03). Hippocampal and thalamic DTI scalars were correlated (P < .001). Hippocampal DTI scalars were not associated with short-term outcomes. CONCLUSIONS Quantitative DTI analysis of the hippocampus in neonates following HIE is a feasible technique to examine neuronal injury. Although DTI scalars were useful in identifying thalamic injury in our cohort, hippocampal DTI analysis did not provide additional information regarding hippocampal injury following HIE.
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Affiliation(s)
- Jacqueline Salas
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Nihaal Reddy
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emanuele Orru
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathryn A Carson
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Vera Joanna Burton
- Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Carl E Stafstrom
- Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD.,Division of Pediatric Neurology, Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
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Value of assessment of multivoxel proton chemical shift imaging to predict long term outcome in patients after out-of-hospital cardiac arrest: A preliminary prospective observational study. Resuscitation 2018; 134:136-144. [PMID: 30248375 DOI: 10.1016/j.resuscitation.2018.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 09/07/2018] [Accepted: 09/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Existing methods to predict recovery after out-of-hospital cardiac arrest (OHCA) lack of accuracy. The aim of this study was to determine whether quantitative proton chemical shift imaging (1H-CSI) during the subacute stage of OHCA can predict neurological outcome of such patients. METHODS This monocentric prospective observational study was conducted in a Intensive Care Unit of a teaching hospital. Forty consecutive patients with OHCA were enrolled between January 1st 2011-December 31st 2013. Multivoxel 1H-CSI values were compared to structural magnetic resonance imaging (MRI) sequences (fluid-attenuated inversion recovery and diffusion-weighted imaging). Ratios of N-acetyl-aspartate (NAA) to creatine (Cr) and choline compounds were analyzed using region of interest in bilateral lenticular cores and thalami. The outcome evaluated was the Cerebral Performance Category (CPC) at 6 months, dichotomized as favorable (CPC 1-2) and unfavorable outcome (CPC 3-5). The performance was compared by area under the receiver operating characteristic (ROCAUC) curves analysis. RESULTS Twenty nine OHCA had an interpretable MRI. Eight patients (28%) had favorable outcome at 6 months. The worst NAA/Cr in lenticular cores was the best 1H-CSI marker, with 80% sensitivity (95% confidence interval (CI), 57-94) and a 100% specificity (95% CI, 63-100) with a positive predictive value of 100%. Prognostic accuracy, as quantified by the ROCAUC, was higher with the worst NAA/Cr in lenticular cores (ROCAUC 0.88; 95% CI, 0.70-0.97) than with the structural MRI sequences. CONCLUSION In this preliminary study we found that multivoxel 1H-CSI in lenticular cores was highly predictive of unfavorable outcome at 6 months.
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Barta H, Jermendy A, Kolossvary M, Kozak LR, Lakatos A, Meder U, Szabo M, Rudas G. Prognostic value of early, conventional proton magnetic resonance spectroscopy in cooled asphyxiated infants. BMC Pediatr 2018; 18:302. [PMID: 30219051 PMCID: PMC6139158 DOI: 10.1186/s12887-018-1269-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/28/2018] [Indexed: 11/20/2022] Open
Abstract
Background Neonatal hypoxic-ischemic encephalopathy (HIE) commonly leads to neurodevelopmental impairment, raising the need for prognostic tools which may guide future therapies in time. Prognostic value of proton MR spectroscopy (H-MRS) between 1 and 46 days of age has been extensively studied; however, the reproducibility and generalizability of these methods are controversial in a general clinical setting. Therefore, we investigated the prognostic performance of conventional H-MRS during first 96 postnatal hours in hypothermia-treated asphyxiated neonates. Methods Fifty-one consecutive hypothermia-treated HIE neonates were examined by H-MRS at three echo-times (TE = 35, 144, 288 ms) between 6 and 96 h of age, depending on clinical stability. Patients were divided into favorable (n = 35) and unfavorable (n = 16) outcome groups based on psychomotor and mental developmental index (PDI and MDI, Bayley Scales of Infant Development II) scores (≥ 70 versus < 70 or death, respectively), assessed at 18–26 months of age. Associations between 36 routinely measured metabolite ratios and outcome were studied. Age-dependency of metabolite ratios in whole patient population was assessed. Prognostic performance of metabolite ratios was evaluated by Receiver Operating Characteristics (ROC) analysis. Results Three metabolite ratios showed significant difference between outcome groups after correction for multiple testing (p < 0.0014): myo-inositol (mIns)/N-acetyl-aspartate (NAA) height, mIns/creatine (Cr) height, both at TE = 35 ms, and NAA/Cr height at TE = 144 ms. Assessment of age-dependency showed that all 3 metabolite ratios (mIns/NAA, NAA/Cr and mIns/Cr) stayed constant during first 96 postnatal hours, rendering them optimal for prediction. ROC analysis revealed that mIns/NAA gives better prediction for outcome than NAA/Cr and mIns/Cr with cut-off values 0.6798 0.6274 and 0.7798, respectively, (AUC 0.9084, 0.8396 and 0.8462, respectively, p < 0.00001); mIns/NAA had the highest specificity (95.24%) and sensitivity (84.62%) for predicting outcome of neonates with HIE any time during the first 96 postnatal hours. Conclusions Our findings suggest that during first 96 h of age even conventional H-MRS could be a useful prognostic tool in predicting the outcome of asphyxiated neonates; mIns/NAA was found to be the best and age-independent predictor. Electronic supplementary material The online version of this article (10.1186/s12887-018-1269-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hajnalka Barta
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary.
| | - Agnes Jermendy
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Marton Kolossvary
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Lajos R Kozak
- MR Research Center, Semmelweis University, Budapest, Hungary
| | - Andrea Lakatos
- MR Research Center, Semmelweis University, Budapest, Hungary
| | - Unoke Meder
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Miklos Szabo
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Gabor Rudas
- MR Research Center, Semmelweis University, Budapest, Hungary
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Abstract
Predicting neurodevelopmental outcomes in high-risk neonates remains challenging despite advances in neonatal care. Early and accurate characterization of infants at risk for neurodevelopmental delays is necessary to best identify those who may benefit from existing early interventions and novel therapies that become available. Although neuroimaging is a promising biomarker in the prediction of neurodevelopmental outcomes in high-risk infants, it requires additional resources and expertise. Despite many advances in neonatal neuroimaging, there remain limitations in relating early neuroimaging findings with long-term outcomes; further studies are necessary to determine the optimal protocols to best identify high-risk patients and improve neurodevelopmental outcome prediction.
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112
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Zou R, Xiong T, Zhang L, Li S, Zhao F, Tong Y, Qu Y, Mu D. Proton Magnetic Resonance Spectroscopy Biomarkers in Neonates With Hypoxic-Ischemic Encephalopathy: A Systematic Review and Meta-Analysis. Front Neurol 2018; 9:732. [PMID: 30233483 PMCID: PMC6127251 DOI: 10.3389/fneur.2018.00732] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 08/10/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Hypoxic-ischemic encephalopathy (HIE) is a major contributor to child mortality and morbidity. Reliable prognostication for HIE is of key importance. Proton magnetic resonance spectroscopy (1H-MRS) is a quantitative, non-invasive method that has been demonstrated to be a suitable complementary tool for prediction. The aim of this study was to investigate the prognostic capability of 1H-MRS in the era of therapeutic hypothermia (TH). Methods: Databases, namely MEDLINE, Embase, Web of Science, and the Cochrane library (Cochrane Center Register of Controlled Trials), were searched for studies published before July 17, 2017. Study selection and data extraction were performed by two independent reviewers. The mean difference (MD) or standardized MD (SMD) and 95% confidence interval (CI) were calculated using random-effects models. Subgroup analyses were conducted based on the use of TH. Results: Among the 1,150 relevant studies, seven were included for meta-analysis, but only two small studies were conducted under TH. For 1H-MRS measurement, three peak area ratios revealed predictive values for adverse outcomes in TH subgroup and the combined results (with and without TH): N-acetylaspartate (NAA)/creatine in basal ganglia/thalamus (BG/T) in TH (MD −0.31, 95%CI −0.55 to −0.07) and combined results (MD −0.37, 95% CI −0.49 to −0.25); NAA/choline in BG/T in TH (MD −0.89, 95%CI −1.43 to −0.35) and combined results (MD −0.25, 95%CI −0.42 to −0.07); and myo-inositol/choline in cerebral cortex in TH (MD −1.94, 95%CI −3.69 to −0.19) and combined results (MD −1.64, 95%CI −2.64 to −0.64). Moreover, NAA relative concentration is associated with adverse outcomes: in TH (MD −0.04, 95%CI −0.06 to −0.02) and combined results (MD −0.06, 95%CI −0.11 to −0.01) in white matter; in TH (MD −0.04, 95%CI −0.07 to −0.01) and combined results (MD −0.05, 95%CI −0.07 to −0.02) in gray matter. Conclusions: NAA may be a potential marker in outcome prediction for all HIE subjects. It seems that MDs for the ratios including NAA are larger than for its relative concentration, and therefore are more likely to be measurable in a clinical context. Larger prospective multicenter studies with a standardized protocol for both measurement protocols and analysis methods are required in future studies.
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Affiliation(s)
- Rong Zou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Shiping Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Fengyan Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Yu Tong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Yi Qu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
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113
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Abstract
PURPOSE OF REVIEW Neonatal encephalopathy is the most common condition in neonates encountered by child neurologists. The etiology is most often global hypoxia-ischemia due to failure of cerebral perfusion to the fetus caused by uterine, placental, or umbilical cord compromise prior to or during delivery. Other etiologies of neonatal encephalopathy include ischemic stroke and intracranial hemorrhage, infection, developmental anomalies, and inborn errors of metabolism. RECENT FINDINGS Therapeutic hypothermia is standard of care for the treatment of neonatal encephalopathy presumed to be caused by hypoxia-ischemia. The number needed to treat is approximately 6 to 7 to prevent one child from either death or disability at age 18 to 22 months. EEG monitoring and MRI are important tools in determining the etiology of encephalopathy and prognosis of the infant. SUMMARY Neonatal encephalopathy is a heterogeneous disorder that is characterized by alterations in mental status, hypotonia, seizures, and abnormalities in feeding and respiration. The most common cause of neonatal encephalopathy is hypoxic-ischemic encephalopathy, for which treatment with 72 hours of therapeutic hypothermia is associated with reduced death or disability.
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114
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Rüegger CM, Davis PG, Cheong JL. Xenon as an adjuvant to therapeutic hypothermia in near-term and term newborns with hypoxic-ischaemic encephalopathy. Cochrane Database Syst Rev 2018; 8:CD012753. [PMID: 30123976 PMCID: PMC6513612 DOI: 10.1002/14651858.cd012753.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hypoxic-ischaemic encephalopathy (HIE) is a serious birth complication affecting term and late preterm newborns. Although therapeutic hypothermia (cooling) has been shown to be an effective therapy for neonatal HIE, many cooled infants have poor long-term neurodevelopmental outcomes. In animal models of neonatal encephalopathy, inhaled xenon combined with cooling has been shown to offer better neuroprotection than cooling alone. OBJECTIVES To determine the effects of xenon as an adjuvant to therapeutic hypothermia on mortality and neurodevelopmental morbidity, and to ascertain clinically important side effects of xenon plus therapeutic hypothermia in newborn infants with HIE. To assess early predictors of adverse outcomes and potential side effects of xenon. SEARCH METHODS We used the standard strategy of the Cochrane Neonatal Review Group to search the Cochrane Library (2017, Issue 8), MEDLINE (from 1966), Embase (from 1966), and PubMed (from 1966) for randomised controlled and quasi-randomised trials. We also searched conference proceedings and the reference lists of cited articles. We conducted our most recent search in August 2017. SELECTION CRITERIA We included all trials allocating term or late preterm encephalopathic newborns to cooling plus xenon or cooling alone, irrespective of timing (starting age and duration) and concentrations used for xenon administration. DATA COLLECTION AND ANALYSIS Two review authors independently assessed results of searches against predetermined criteria for inclusion, assessed risk of bias, and extracted data. We performed meta-analyses using risk ratios (RRs), risk differences (RDs), and number needed to treat for an additional beneficial outcome (NNTB) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) for continuous data. MAIN RESULTS A single randomised controlled trial enrolling 92 participants was eligible for this review. Researchers have not reported long-term neurodevelopmental outcomes, including the primary outcome of this review - death or long-term major neurodevelopmental disability in infancy (18 months to three years of age). Cooling plus xenon was not associated with reduced mortality at latest follow-up, based upon low quality evidence. Investigators noted no substantial differences between groups for other secondary outcomes of this review, such as biomarkers of brain damage assessed with magnetic resonance imaging and occurrence of seizures during primary hospitalisation. Available data do not show an increased adverse event rate in the cooling plus xenon group compared with the cooling alone group. AUTHORS' CONCLUSIONS Current evidence from one small randomised controlled pilot trial is inadequate to show whether cooling plus xenon is safe or effective in near-term and term newborns with HIE. Further trials reporting long-term neurodevelopmental outcomes are needed.
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Affiliation(s)
- Christoph M Rüegger
- University Hospital and University of ZürichNewborn Research, Department of NeonatologyFrauenklinikstrasse 10ZürichZürichSwitzerland8091
- The Royal Women’s HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
| | - Peter G Davis
- The Royal Women’s HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Children's Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
| | - Jeanie L Cheong
- The Royal Women’s HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Children's Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
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115
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Huun MU, Garberg H, Løberg EM, Escobar J, Martinez-Orgado J, Saugstad OD, Solberg R. DHA and therapeutic hypothermia in a short-term follow-up piglet model of hypoxia-ischemia: Effects on H+MRS biomarkers. PLoS One 2018; 13:e0201895. [PMID: 30086156 PMCID: PMC6080779 DOI: 10.1371/journal.pone.0201895] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Therapeutic hypothermia has become the standard of care for newborns with hypoxic-ischemic encephalopathy in high and middle income countries. Docosahexaenoic acid (DHA) has neuroprotective properties of reducing excitotoxicity, neuroinflammation and apoptosis in rodent models. We aim to study whether post hypoxic administration of i.v. DHA will reduce H+MRS biomarkers and gene expression of inflammation and apoptosis both with and without hypothermia in a large animal model. Methods Fifty-five piglets were randomized to severe global hypoxia (N = 48) or not (Sham, N = 7). Hypoxic piglets were further randomized by factorial design: Vehicle (VEH), DHA, VEH + Hypothermia (HT), or DHA + HT. 5 mg/kg DHA was given intravenously 210 min after end of hypoxia. Two-way ANOVA analyses were performed with DHA and hypothermia as main effects. Results Cortical lactate/N-acetylaspartate (Lac/NAA) was significantly reduced in DHA + HT compared to HT. DHA had significant main effects on increasing N-acetylaspartate and glutathione in hippocampus. Therapeutic hypothermia significantly reduced the Lac/NAA ratio and protein expression of IL-1β and TNFα in hippocampus and reduced Troponin T in serum. Neuropathology showed significant differences between sham and hypoxia, but no differences between intervention groups. Conclusion DHA and therapeutic hypothermia significantly improve specific H+MRS biomarkers in this short-term follow up model of hypoxia-ischemia. Longer recovery periods are needed to evaluate whether DHA can offer translational neuroprotection.
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Affiliation(s)
- Marianne Ullestad Huun
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- * E-mail:
| | - Håvard Garberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Else Marit Løberg
- Department of Pathology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Javier Escobar
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Neonatal Research Unit, Health Research Institute Hospital La Fe, Valencia, Spain
| | | | - Ola Didrik Saugstad
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Rønnaug Solberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Pediatrics, Vestfold Hospital Trust, Tønsberg, Norway
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116
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Sorokan ST, Jefferies AL, Miller SP. L’imagerie du cerveau du nouveau-né à terme. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxy002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Todd Sorokan
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Ann L Jefferies
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Steven P Miller
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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117
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Abstract
Brain imaging is important for the diagnosis and management of sick term neonates. Although ultrasound and computed tomography may provide some information, magnetic resonance imaging is now the brain imaging modality of choice because it is the most sensitive technique for detecting and quantifying brain abnormalities and does not expose infants to radiation. This statement describes the principles, roles and limitations of these three imaging modalities and makes recommendations for appropriate use in term neonates. The primary focus is the brain of term infants with neonatal encephalopathy, many of whom are diagnosed with hypoxic-ischemic encephalopathy.
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Affiliation(s)
- S Todd Sorokan
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Ann L Jefferies
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Steven P Miller
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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118
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Sanches EF, Van de Looij Y, Toulotte A, da Silva AR, Romero J, Sizonenko SV. Brain Metabolism Alterations Induced by Pregnancy Swimming Decreases Neurological Impairments Following Neonatal Hypoxia-Ischemia in Very Immature Rats. Front Neurol 2018; 9:480. [PMID: 29988536 PMCID: PMC6026645 DOI: 10.3389/fneur.2018.00480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 06/01/2018] [Indexed: 01/07/2023] Open
Abstract
Introduction: Prematurity, through brain injury and altered development is a major cause of neurological impairments and can result in motor, cognitive and behavioral deficits later in life. Presently, there are no well-established effective therapies for preterm brain injury and the search for new strategies is needed. Intra-uterine environment plays a decisive role in brain maturation and interventions using the gestational window have been shown to influence long-term health in the offspring. In this study, we investigated whether pregnancy swimming can prevent the neurochemical metabolic alterations and damage that result from postnatal hypoxic-ischemic brain injury (HI) in very immature rats. Methods: Female pregnant Wistar rats were divided into swimming (SW) or sedentary (SE) groups. Following a period of adaptation before mating, swimming was performed during the entire gestation. At postnatal day (PND3), rat pups from SW and SE dams had right common carotid artery occluded, followed by systemic hypoxia. At PND4 (24 h after HI), the early neurochemical profile was measured by 1H-magnetic resonance spectroscopy. Astrogliosis, apoptosis and neurotrophins protein expression were assessed in the cortex and hippocampus. From PND45, behavioral testing was performed. Diffusion tensor imaging and neurite orientation dispersion and density imaging were used to evaluate brain microstructure and the levels of proteins were quantified. Results: Pregnancy swimming was able to prevent early metabolic changes induced by HI preserving the energetic balance, decreasing apoptotic cell death and astrogliosis as well as maintaining the levels of neurotrophins. At adult age, swimming preserved brain microstructure and improved the performance in the behavioral tests. Conclusion: Our study points out that swimming during gestation in rats could prevent prematurity related brain damage in progeny with high translational potential and possibly interesting cost-benefits. HIGHLIGHTS- Prematurity is a major cause of neurodevelopmental impairments; - Swimming during pregnancy reduces brain damage after HI injury; - Pregnancy is an important but underestimated preventive window.
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Affiliation(s)
- Eduardo F Sanches
- Division of Child Development and Growth, Department of Pediatrics, University of Geneva, Geneva, Switzerland
| | - Yohan Van de Looij
- Division of Child Development and Growth, Department of Pediatrics, University of Geneva, Geneva, Switzerland.,Laboratory for Functional and Metabolic Imaging, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Audrey Toulotte
- Division of Child Development and Growth, Department of Pediatrics, University of Geneva, Geneva, Switzerland
| | - Analina R da Silva
- Laboratory for Functional and Metabolic Imaging, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Jacqueline Romero
- Laboratory for Functional and Metabolic Imaging, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Stephane V Sizonenko
- Division of Child Development and Growth, Department of Pediatrics, University of Geneva, Geneva, Switzerland
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119
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Shibasaki J, Aida N, Morisaki N, Tomiyasu M, Nishi Y, Toyoshima K. Changes in Brain Metabolite Concentrations after Neonatal Hypoxic-ischemic Encephalopathy. Radiology 2018; 288:840-848. [PMID: 29893645 DOI: 10.1148/radiol.2018172083] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To investigate the time-course changes and predictive utility of brain metabolite concentrations in neonatal hypoxic-ischemic encephalopathy (HIE). Materials and Methods Sixty-eight neonates (age, 35-41 gestational weeks) with HIE were admitted to a neonatal intensive care unit between September 2009 and March 2016 and examined by using proton MR spectroscopy at 18-96 hours (n = 25) and 7-14 days (n = 64) after birth (35-43 postmenstrual weeks) to estimate metabolite concentrations in the deep gray matter. Adverse outcome was defined as death or neurodevelopmental impairment at 18-22 months of age. Areas under the receiver operating characteristic curves were calculated to evaluate the prognostic values of metabolites. Results At 18-96 hours, N-acetylaspartate and creatine concentrations were lower, whereas lactate, and glutamate and glutamine (Glx) concentrations were higher in neonates with adverse outcomes than in those with favorable outcomes. Metabolite concentrations at 18-96 hours decreased during days 7-14 in neonates with adverse outcomes but did not change in those with favorable outcomes. For N-acetylaspartate, creatine, lactate, and Glx concentrations measured at 18-96 hours to predict adverse outcomes, areas under the receiver operating characteristic curve were 0.98, 0.89, 0.96, and 0.88, respectively, whereas at 7-14 days, the areas under the receiver operating characteristic curve were 0.97, 0.97, 0.59, and 0.36, respectively. Conclusion Time-dependent reductions in N-acetylaspartate and creatine concentrations at both 18-96 hours and 7-14 days accurately predicted adverse outcomes. However, higher lactate and glutamate and glutamine concentrations were often transient.
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Affiliation(s)
- Jun Shibasaki
- From the Departments of Neonatology (J.S., K.T.) and Radiology (N.A., M.T., Y.N.), Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan (N.A., M.T.); Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan (N.M.); and Research Center for Child Mental Development, Chiba University, Chiba, Japan (M.T.)
| | - Noriko Aida
- From the Departments of Neonatology (J.S., K.T.) and Radiology (N.A., M.T., Y.N.), Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan (N.A., M.T.); Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan (N.M.); and Research Center for Child Mental Development, Chiba University, Chiba, Japan (M.T.)
| | - Naho Morisaki
- From the Departments of Neonatology (J.S., K.T.) and Radiology (N.A., M.T., Y.N.), Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan (N.A., M.T.); Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan (N.M.); and Research Center for Child Mental Development, Chiba University, Chiba, Japan (M.T.)
| | - Moyoko Tomiyasu
- From the Departments of Neonatology (J.S., K.T.) and Radiology (N.A., M.T., Y.N.), Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan (N.A., M.T.); Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan (N.M.); and Research Center for Child Mental Development, Chiba University, Chiba, Japan (M.T.)
| | - Yuri Nishi
- From the Departments of Neonatology (J.S., K.T.) and Radiology (N.A., M.T., Y.N.), Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan (N.A., M.T.); Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan (N.M.); and Research Center for Child Mental Development, Chiba University, Chiba, Japan (M.T.)
| | - Katsuaki Toyoshima
- From the Departments of Neonatology (J.S., K.T.) and Radiology (N.A., M.T., Y.N.), Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan (N.A., M.T.); Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan (N.M.); and Research Center for Child Mental Development, Chiba University, Chiba, Japan (M.T.)
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120
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Zou R, Tang J, Bao S, Wu T, Huang JL, Qu Y, Mu DZ. [Current status of the application of 1H-magnetic resonance spectroscopy in neonates with hypoxic-ischemic encephalopathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:449-455. [PMID: 29972117 PMCID: PMC7389943 DOI: 10.7499/j.issn.1008-8830.2018.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate the current status of the application of 1H-magnetic resonance spectroscopy (1H-MRS) in neonates with hypoxic-ischemic encephalopathy (HIE), and to describe the trend of research in the field. METHODS PubMed, EMBASE, and Web of Science were searched for English articles published up to January 10, 2018, with the combination of key words and MeSH terms. The articles were screened according to inclusion and exclusion criteria. Excel 2016, Bicomb 2.0, and VOSviewer1.6.6 were used to analyze the key words, to perform a cluster analysis of hot words, and to plot the knowledge map. RESULTS A total of 66 articles were included, and 27 high-frequency key words were extracted. The results showed that 1H-MRS was mainly used in four directions of the clinical practice and scientific research on HIE. In clinical practice, 1H-MRS attracted wide attention as a clinical examination for HIE and a tool for prognostic evaluation; in scientific research, 1H-MRS was used in animal experiments and studies associated with mild hypothermia therapy. CONCLUSIONS As an auxiliary means of magnetic resonance imaging, 1H-MRS plays an important role in investigating the pathogenesis of neonatal HIE, improving existing therapies, and evaluating the prognosis of neonates with HIE.
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Affiliation(s)
- Rong Zou
- Department of Pediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China.
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121
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Diffusion pseudonormalization and clinical outcome in term neonates with hypoxic-ischemic encephalopathy. Pediatr Radiol 2018; 48:865-874. [PMID: 29417166 DOI: 10.1007/s00247-018-4094-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/22/2017] [Accepted: 01/22/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pseudonormalization of diffusion-weighted magnetic resonance imaging (MRI) can lead to underestimation of brain injury in newborns with hypoxic-ischemic encephalopathy (HIE), posing a significant problem. We have noticed that some neonates show pseudonormalization negativity on diffusion-weighted imaging. OBJECTIVE To compare pseudonormalization negativity with clinical outcomes. MATERIALS AND METHODS Seventeen term neonates with moderate or severe HIE underwent therapeutic hypothermia. They were examined by MRI twice at mean ages of 3 days and 10 days. We evaluated the presence of restricted diffusion, and also the presence or absence of pseudonormalization, by diffusion-weighted imaging at the time of the second MRI, and correlated the results with clinical outcome. RESULTS DWI demonstrated no abnormality in seven neonates. Among the 10 neonates with abnormal diffusion-weighted imaging findings, 2 were positive for pseudonormalization and 8 were negative. Among neonates with normal diffusion-weighted imaging findings and with positivity for pseudonormalization, none had major disability. Among the eight neonates with pseudonormalization negativity, all but one, who was lost to follow-up, had major disability. CONCLUSION Abnormal diffusion-weighted imaging with pseudonormalization negativity might be predictive of severe brain injury and major disability. The second-week MRI is important for the judgment of pseudonormalization.
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Rajaram A, Bale G, Kewin M, Morrison LB, Tachtsidis I, St. Lawrence K, Diop M. Simultaneous monitoring of cerebral perfusion and cytochrome c oxidase by combining broadband near-infrared spectroscopy and diffuse correlation spectroscopy. BIOMEDICAL OPTICS EXPRESS 2018; 9:2588-2603. [PMID: 30258675 PMCID: PMC6154190 DOI: 10.1364/boe.9.002588] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/04/2018] [Accepted: 05/07/2018] [Indexed: 05/23/2023]
Abstract
Preterm infants born with very low birth weights are at a high risk of brain injury, in part because the premature brain is believed to be prone to periods of low cerebral blood flow (CBF). Tissue damage is likely to occur if reduction in CBF is sufficient to impair cerebral energy metabolism for extended periods. Therefore, a neuromonitoring method that can detect reductions in CBF, large enough to affect metabolism, could alert the neonatal intensive care team before injury occurs. In this report, we present the development of an optical system that combines diffuse correlation spectroscopy (DCS) for monitoring CBF and broadband near-infrared spectroscopy (B-NIRS) for monitoring the oxidation state of cytochrome c oxidase (oxCCO) - a key biomarker of oxidative metabolism. The hybrid instrument includes a multiplexing system to enable concomitant DCS and B-NIRS measurements while avoiding crosstalk between the two subsystems. The ability of the instrument to monitor dynamic changes in CBF and oxCCO was demonstrated in a piglet model of neonatal hypoxia-ischemia (HI). Experiments conducted in eight animals, including two controls, showed that oxCCO exhibited a delayed response to ischemia while CBF and tissue oxygenation (StO2) responses were instantaneous. These findings suggest that simultaneous neuromonitoring of perfusion and metabolism could provide critical information regarding clinically significant hemodynamic events prior to the onset of brain injury.
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Affiliation(s)
- Ajay Rajaram
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Gemma Bale
- Medical Physics & Biomedical Engineering, University College London, Gower St., Bloomsbury, London, WC1E 6BT, United Kingdom
| | - Matthew Kewin
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Laura B. Morrison
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - Ilias Tachtsidis
- Medical Physics & Biomedical Engineering, University College London, Gower St., Bloomsbury, London, WC1E 6BT, United Kingdom
| | - Keith St. Lawrence
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Mamadou Diop
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
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Hyodo R, Sato Y, Ito M, Sugiyama Y, Ogawa C, Kawai H, Nakane T, Saito A, Hirakawa A, Kidokoro H, Natsume J, Hayakawa M. Magnetic resonance spectroscopy in preterm infants: association with neurodevelopmental outcomes. Arch Dis Child Fetal Neonatal Ed 2018; 103:F238-F244. [PMID: 28724545 DOI: 10.1136/archdischild-2016-311403] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 05/30/2017] [Accepted: 06/07/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare magnetic resonance spectroscopy (MRS) metabolite ratios in preterm infants at term-equivalent age with those in term infants and to evaluate the association between MRS metabolites and neurodevelopmental outcomes at 18 months corrected age in preterm infants. DESIGN We studied infants born at a gestational age <37 weeks and weighing <1500 g during 2009-2013 using MRS at term-equivalent age. Infants with major brain abnormalities were excluded. The ratios of N-acetylaspartate (NAA) to creatine (Cre), NAA to choline-containing compounds (Cho) and Cho to Cre in the frontal white matter and thalamus were measured using multivoxel point-resolved proton spectroscopy sequence. Neurodevelopmental outcomes were assessed at 18 months corrected age. RESULTS Thirty-three preterm infants and 16 term infants were enrolled in this study. Preterm infants with normal development at 18 months showed significantly lower NAA/Cho ratios in the frontal white matter than term infants. There were no differences in the Cre/Cho ratios between preterm and term infants. At 18 months corrected age, 9 preterm infants with a mild developmental delay showed significantly lower NAA/Cho ratios in the thalamus than 24 preterm infants with normal development. CONCLUSIONS Preterm infants at term-equivalent age showed reduced MRS metabolites (NAA/Cho) compared with term infants. Decreased NAA/Cho ratios in the thalamus were associated with neurodevelopmental delay at 18 months corrected age in preterm infants.
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Affiliation(s)
- Reina Hyodo
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Yoshiaki Sato
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Miharu Ito
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Yuichiro Sugiyama
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Chikako Ogawa
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hisashi Kawai
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiki Nakane
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akiko Saito
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Akihiro Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Kidokoro
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Brain and Mind Research Center, Nagoya University, Nagoya, Japan
| | - Jun Natsume
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Brain and Mind Research Center, Nagoya University, Nagoya, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
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Broadband NIRS Cerebral Cytochrome-C-Oxidase Response to Anoxia Before and After Hypoxic-Ischaemic Injury in Piglets. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1072:151-156. [PMID: 30178338 PMCID: PMC6142853 DOI: 10.1007/978-3-319-91287-5_24] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Perinatal hypoxic ischaemic (HI) encephalopathy is associated with severe neurodevelopment problems and mortality. This study uses broadband continuous-wave near-infrared spectroscopy (NIRS) to assess the early changes in cerebral oxygenation and metabolism after HI injury in an animal model using controlled anoxia events. Anoxia was induced before and 1 h after various levels of HI injury to assess the metabolic response via the changes in the oxidation state of cytochrome-c-oxidase (oxCCO), a marker of oxidative metabolism. The oxCCO responses to anoxia were classified into five categories: increase, no change, decrease, biphasic and triphasic responses. The most common response (54%) was a biphasic decrease in oxCCO. A change in the classification of the metabolic response to anoxia after HI injury indicated a severe injury, as determined by proton magnetic resonance spectroscopy, with 86% sensitivity. This shows that broadband NIRS can identify disturbances to cerebral metabolism in the first hours after severe HI injury.
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Peeples ES, Ezeokeke CK, Juul SE, Mourad PD. Evaluating a Targeted Bedside Measure of Cerebral Perfusion in a Nonhuman Primate Model of Neonatal Hypoxic-Ischemic Encephalopathy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:913-920. [PMID: 28960438 PMCID: PMC5867225 DOI: 10.1002/jum.14426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/01/2017] [Accepted: 07/12/2017] [Indexed: 05/03/2023]
Abstract
OBJECTIVES To compare ultrasound-derived resistive indices (RIs) obtained at the level of the thalamus via fast Doppler ultrasound with traditional anterior cerebral artery measures in a model of neonatal hypoxic-ischemic encephalopathy and to correlate each with clinical outcomes. METHODS Nine nonhuman primate neonates underwent no umbilical cord occlusion (n = 3), umbilical cord occlusion without hypothermia (n = 3), or umbilical cord occlusion with hypothermia (n = 3). The RI was measured in the anterior cerebral artery and thalamus on days 0, 1, and 4 of life. Magnetic resonance imaging with spectroscopy was performed on day 4. RESULTS Mean thalamus and anterior cerebral artery RI values in the first 36 hours of life were statistically different in neonates who died (+0.13; P = .019) or developed cerebral palsy (-0.08; P = .003). Thalamic RI values showed stronger associations with serum and spectroscopic lactate values than those in the anterior cerebral artery. The umbilical cord occlusion-with-hypothermia group showed a significant increase in the RI in the thalamus but not the anterior cerebral artery. CONCLUSIONS Resistive index measurements in the thalamus may eventually supplement other bedside measures for predicting outcomes in the HIE population, but further studies need to differentiate the effect of hypothermia from illness severity on thalamic perfusion.
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Affiliation(s)
- Eric S. Peeples
- Department of Pediatrics, University of Washington, Seattle, WA, U.S.A
- Correspondence: Eric Peeples, M.D., Division of Neonatology, Children’s Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114-4113, P: (402) 955-6140, F: (402) 955-3398,
| | | | - Sandra E. Juul
- Department of Pediatrics, University of Washington, Seattle, WA, U.S.A
| | - Pierre D. Mourad
- Department of Neurological Surgery, University of Washington, Seattle, WA, U.S.A
- Division of Engineering and Mathematics, University of Washington, Seattle, WA, U.S.A
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Gardner A, Menon D. Moving to human trials for argon neuroprotection in neurological injury: a narrative review. Br J Anaesth 2018; 120:453-468. [DOI: 10.1016/j.bja.2017.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022] Open
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Mao J. [Patterns of brain injury in neonatal hypoxic-ischemic encephalopathy on magnetic resonance imaging: recommendations on classification]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017. [PMID: 29237520 PMCID: PMC7389802 DOI: 10.7499/j.issn.1008-8830.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Although there are unified criteria for the clinical diagnosis and grading of neonatal hypoxic-ischemic encephalopathy (HIE), clinical features and neuropathological patterns vary considerably among the neonates with HIE due to birth asphyxia in the same classification. The patterns and progression of brain injury in HIE, which is closely associated with long-term neurodevelopment outcomes, can be well shown on magnetic resonance imaging (MRI), but different sequences may lead to different MRI findings at the same time. It is suggested that diffusion-weighted imaging sequence be selected at 2-4 days after birth, and the conventional MRI sequence at 4-8 days. The major patterns of brain injury in HIE on MRI are as follows: injury of the thalamus and basal ganglia and posterior limbs of the internal capsules; watershed injury involving the cortical and subcortical white matter; focal or multifocal minimal white matter injury; extensive whole brain injury. Severe acute birth asphyxia often leads to deep grey matter injury (thalamus and basal ganglia), and the brain stem may also be involved; the pyramidal tract is the most susceptible white matter fiber tract; repetitive or intermittent hypoxic-ischemic insults, with inflammation or hypoglycemia, usually cause injuries in the watershed area and deep white matter. It is worth noting that sometimes the pattern of brain injury among those described above cannot be determined exactly, but rather a predominant one is identified; not all cases of HIE have characteristic MRI findings.
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Affiliation(s)
- Jian Mao
- Neonatologist Society, Chinese Medical Doctor Association
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128
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Chiang MC, Jong YJ, Lin CH. Therapeutic hypothermia for neonates with hypoxic ischemic encephalopathy. Pediatr Neonatol 2017; 58:475-483. [PMID: 28416250 DOI: 10.1016/j.pedneo.2016.11.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 11/14/2016] [Accepted: 11/21/2016] [Indexed: 02/06/2023] Open
Abstract
Therapeutic hypothermia (TH) is a recommended regimen for newborn infants who are at or near term with evolving moderate-to-severe hypoxic ischemic encephalopathy (HIE). The Task Force of the Taiwan Child Neurology Society and the Taiwan Society of Neonatology held a joint meeting in 2015 to establish recommendations for using TH on newborn patients with HIE. Based on current evidence and experts' experiences, this review article summarizes the key points and recommendations regarding TH for newborns with HIE, including: (1) selection criteria for TH; (2) choices of method and equipment for TH; (3) TH prior to and during transport; (4) methods for temperature maintenance, monitoring, and rewarming; (5) systemic care of patients during TH, including the care of respiratory and cardiovascular systems, management of fluids, electrolytes, and nutrition, as well as sedation and drug metabolism; (6) monitoring and management of seizures; (7) neuroimaging, prognostic factors, and outcomes; and (8) adjuvant therapy for TH.
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Affiliation(s)
- Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yuh-Jyh Jong
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Science and Technology, Institute of Molecular Medicine and Bioengineering, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Chyi-Her Lin
- Department of Pediatrics, College of Medicine, National Cheng Kung University, Tainan, Taiwan; National Cheng Kung University Hospital, Tainan, Taiwan.
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Sánchez Fernández I, Morales-Quezada JL, Law S, Kim P. Prognostic Value of Brain Magnetic Resonance Imaging in Neonatal Hypoxic-Ischemic Encephalopathy: A Meta-analysis. J Child Neurol 2017; 32:1065-1073. [PMID: 28925315 DOI: 10.1177/0883073817726681] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To quantify the prognostic value of neonatal brain magnetic resonance imaging (MRI) in neonatal hypoxic-ischemic encephalopathy. METHODS Meta-analysis of studies with ≥35-week neonates with hypoxic-ischemic encephalopathy who underwent brain MRI within age 4 weeks and had neurodevelopmental follow-up for at least 12 months. RESULTS An abnormal neonatal brain MRI was more frequent among patients with unfavorable neurodevelopmental outcome: odds ratio = 18.2 (95% confidence interval: 9.4-34.9), P <.0001. The prognostic value of neonatal brain MRI in moderate hypoxic-ischemic encephalopathy had an odds ratio of 17.7 (95% confidence interval: 5.3-59.3) and in severe hypoxic-ischemic encephalopathy, the odds ratio was 125.0 (95% confidence interval: 2.0-7917.1). Therapeutic hypothermia did not change the prognostic value of neonatal brain MRI (odds ratio for hypothermia, 14.0 [95% confidence interval: 3.1-63.6], vs no hypothermia, 18.1 [95% confidence interval: 10.0-33.1], P = .7525). CONCLUSION Neonatal brain MRI provides prognostic information on outcome beyond early infancy in hypoxic-ischemic encephalopathy and therapeutic hypothermia does not change its prognostic value.
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Affiliation(s)
- Iván Sánchez Fernández
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,2 Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - J Leon Morales-Quezada
- 3 Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Law
- 4 Department of Psychiatry, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Paggie Kim
- 5 Division of Neuroradiology and Pediatric Radiology, Department of Radiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Nakamura T, Asanuma H, Kusuda S, Imai K, Hosono S, Kato R, Suzuki S, Yokoi K, Kokubo M, Yamada S, Kamohara T. Multicenter study for brain/body hypothermia for hypoxic-ischemic encephalopathy: Changes in HMGB-1. Pediatr Int 2017; 59:1074-1079. [PMID: 28741799 DOI: 10.1111/ped.13377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 06/22/2017] [Accepted: 07/20/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND We measured changes in the blood level of high-mobility group box-1 (HMGB-1) at 24 h intervals in neonates treated with brain/body hypothermia (body hypothermia therapy: BHT) for hypoxic-ischemic encephalopathy (HIE), to evaluate the usefulness of HMGB-1 level for determining outcomes. METHODS We studied 15 neonates with HIE who underwent BHT (BHT (+) group) and six neonates with HIE who did not (BHT (-) group). We recorded HMGB-1 changes at 24 h intervals, creatinine phosphokinase, and the resistance index of the anterior cerebral artery. Magnetic resonance imaging (MRI) was used to determine short-term outcome. RESULT Baseline HMGB-1 was significantly higher in the BHT (+) group than in the BHT (-) group. Thereafter, HMGB-1 in the BHT (+) group significantly decreased at 24 h intervals, reaching the reference range by 2 days of age. In the BHT (+) group, when patients were classified into clinically significant neurological disorder due to HIE (+) and (-) according to MRI, the neurological disorder (+) group had higher mean HMGB-1. CONCLUSIONS In HIE, HMGB-1 differs according to the presence of BHT, suggesting that HMGB-1 measurement soon after birth might be useful for determining BHT necessity and short-term outcome.
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Affiliation(s)
| | - Hideomi Asanuma
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Itabshi, Japan
| | - Satoshi Kusuda
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Ken Imai
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Shigeharu Hosono
- Division of Neonatology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Ryota Kato
- Division of Neonatology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Satoshi Suzuki
- Department of Pediatrics, Nagoya City West Medical Center, Nagoya, Japan
| | - Kyoko Yokoi
- Department of Pediatrics, Nagoya City West Medical Center, Nagoya, Japan
| | - Minoru Kokubo
- Department of Pediatrics, Aichi Prefectural Welfare Federation of Agricultural Cooperatives Kainan Hospital, Nagoya, Aichi, Japan
| | - Shingo Yamada
- Division of Development, Shino-Test Corporation Sagamihara, Kanagawa, Japan
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Trivedi SB, Vesoulis ZA, Rao R, Liao SM, Shimony JS, McKinstry RC, Mathur AM. A validated clinical MRI injury scoring system in neonatal hypoxic-ischemic encephalopathy. Pediatr Radiol 2017; 47. [PMID: 28623417 PMCID: PMC6219383 DOI: 10.1007/s00247-017-3893-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Deep nuclear gray matter injury in neonatal hypoxic-ischemic encephalopathy (HIE) is associated with worse neurodevelopmental outcomes. We previously published a qualitative MRI injury scoring system utilizing serial T1-weighted, T2-weighted and diffusion-weighted imaging (DWI), weighted for deep nuclear gray matter injury. OBJECTIVES To establish the validity of the MRI scoring system with neurodevelopmental outcome at 18-24 months. MATERIALS AND METHODS MRI scans from neonates with moderate to severe HIE treated with therapeutic hypothermia were evaluated. Signal abnormality was scored on T1-weighted, T2-weighted and DWI sequences and assessed using an established system in five regions: (a) subcortical: caudate nucleus, globus pallidus and putamen, thalamus and the posterior limb of the internal capsule; (b) white matter; (c) cortex, (d) cerebellum and (e) brainstem. MRI injury was graded as none, mild, moderate or severe. Inter-rater reliability was tested on a subset of scans by two independent and blinded neuroradiologists. Surviving infants underwent the Bayley Scales of Infant and Toddler Development-III (Bayley-III) at 18-24 months. Data were analyzed using univariate and multivariate linear and logistic regression. RESULTS Fifty-seven eligible neonates underwent at least one MRI scan in the first 2 weeks of life. Mean postnatal age at scan 1 was 4±2 days in 50/57 (88%) neonates and 48/54 (89%) surviving infants underwent scan 2 at 10±2 days. In 54/57 (95%) survivors, higher MRI injury grades were significantly associated with worse outcomes in the cognitive, motor and language domains of the Bayley-III. CONCLUSION A qualitative MRI injury scoring system weighted for deep nuclear gray matter injury is a significant predictor of neurodevelopmental outcome at 18-24 months in neonates with HIE.
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Affiliation(s)
- Shamik B. Trivedi
- Division of Newborn Medicine,Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, One Children’s Place, Campus Box 8116,St. Louis, MO 63110, USA
| | - Zachary A. Vesoulis
- Division of Newborn Medicine,Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, One Children’s Place, Campus Box 8116,St. Louis, MO 63110, USA
| | - Rakesh Rao
- Division of Newborn Medicine,Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, One Children’s Place, Campus Box 8116,St. Louis, MO 63110, USA
| | - Steve M. Liao
- Division of Newborn Medicine,Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, One Children’s Place, Campus Box 8116,St. Louis, MO 63110, USA
| | - Joshua S. Shimony
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert C. McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M. Mathur
- Division of Newborn Medicine,Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, One Children’s Place, Campus Box 8116,St. Louis, MO 63110, USA
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Berger HR, Nyman AKG, Morken TS, Vettukattil R, Brubakk AM, Widerøe M. Early metabolite changes after melatonin treatment in neonatal rats with hypoxic-ischemic brain injury studied by in-vivo1H MR spectroscopy. PLoS One 2017; 12:e0185202. [PMID: 28934366 PMCID: PMC5608359 DOI: 10.1371/journal.pone.0185202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/07/2017] [Indexed: 12/31/2022] Open
Abstract
Melatonin is a promising neuroprotective agent after perinatal hypoxic-ischemic (HI) brain injury. We used in-vivo1H magnetic resonance spectroscopy to investigate effects of melatonin treatment on brain metabolism after HI. Postnatal day 7 Sprague-Dawley rats with unilateral HI brain injury were treated with either melatonin 10 mg/kg dissolved in phosphate-buffered saline (PBS) with 5% dimethyl sulfoxide (DMSO) or vehicle (5% DMSO and/or PBS) directly and at 6 hours after HI. 1H MR spectra from the thalamus in the ipsilateral and contralateral hemisphere were acquired 1 day after HI. Our results showed that injured animals had a distinct metabolic profile in the ipsilateral thalamus compared to sham with low concentrations of total creatine, choline, N-acetyl aspartate (NAA), and high concentrations of lipids. A majority of the melatonin-treated animals had a metabolic profile characterized by higher total creatine, choline, NAA and lower lipid levels than other HI animals. When comparing absolute concentrations, melatonin treatment resulted in higher glutamine levels and lower lipid concentrations compared to DMSO treatment as well as higher macromolecule levels compared to PBS treatment day 1 after HI. DMSO treated animals had lower concentrations of glucose, creatine, phosphocholine and macromolecules compared to sham animals. In conclusion, the neuroprotective effects of melatonin were reflected in a more favorable metabolic profile including reduced lipid levels that likely represents reduced cell injury. Neuroprotective effects may also be related to the influence of melatonin on glutamate/glutamine metabolism. The modulatory effects of the solvent DMSO on cerebral energy metabolism might have masked additional beneficial effects of melatonin.
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Affiliation(s)
- Hester Rijkje Berger
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, St. Olavs University Hospital HF, Trondheim, Norway
- * E-mail:
| | - Axel K. G. Nyman
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tora Sund Morken
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Ophthalmology, St. Olavs University Hospital HF, Trondheim, Norway
| | - Riyas Vettukattil
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ann-Mari Brubakk
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Widerøe
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Thayyil S, Oliveira V, Lally PJ, Swamy R, Bassett P, Chandrasekaran M, Mondkar J, Mangalabharathi S, Benkappa N, Seeralar A, Shahidullah M, Montaldo P, Herberg J, Manerkar S, Kumaraswami K, Kamalaratnam C, Prakash V, Chandramohan R, Bandya P, Mannan MA, Rodrigo R, Nair M, Ramji S, Shankaran S. Hypothermia for encephalopathy in low and middle-income countries (HELIX): study protocol for a randomised controlled trial. Trials 2017; 18:432. [PMID: 28923118 PMCID: PMC5604260 DOI: 10.1186/s13063-017-2165-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/29/2017] [Indexed: 11/10/2022] Open
Abstract
Background Therapeutic hypothermia reduces death and disability after moderate or severe neonatal encephalopathy in high-income countries and is used as standard therapy in these settings. However, the safety and efficacy of cooling therapy in low- and middle-income countries (LMICs), where 99% of the disease burden occurs, remains unclear. We will examine whether whole body cooling reduces death or neurodisability at 18–22 months after neonatal encephalopathy, in LMICs. Methods We will randomly allocate 408 term or near-term babies (aged ≤ 6 h) with moderate or severe neonatal encephalopathy admitted to public sector neonatal units in LMIC countries (India, Bangladesh or Sri Lanka), to either usual care alone or whole-body cooling with usual care. Babies allocated to the cooling arm will have core body temperature maintained at 33.5 °C using a servo-controlled cooling device for 72 h, followed by re-warming at 0.5 °C per hour. All babies will have detailed infection screening at the time of recruitment and 3 Telsa cerebral magnetic resonance imaging and spectroscopy at 1–2 weeks after birth. Our primary endpoint is death or moderate or severe disability at the age of 18 months. Discussion Upon completion, HELIX will be the largest cooling trial in neonatal encephalopathy and will provide a definitive answer regarding the safety and efficacy of cooling therapy for neonatal encephalopathy in LMICs. The trial will also provide important data about the influence of co-existent perinatal infection on the efficacy of hypothermic neuroprotection. Trial registration ClinicalTrials.gov, NCT02387385. Registered on 27 February 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2165-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.
| | - Vania Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Paul Bassett
- Stats Consultancy, Amersham, Buckinghamshire, UK
| | | | | | | | | | - Arasar Seeralar
- Institute of Obstetrics & Gynecology, Madras Medical College, Chennai, India
| | - Mohammod Shahidullah
- Neonatal Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Jethro Herberg
- Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Swati Manerkar
- Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | | | | | - Vinayagam Prakash
- Institute of Obstetrics & Gynecology, Madras Medical College, Chennai, India
| | - Rema Chandramohan
- Institute of Child Health, Egmore, Madras Medical College, Chennai, India
| | - Prathik Bandya
- Indira Gandhi Institute of Child health, Bangalore, India
| | | | | | - Mohandas Nair
- Institute of Maternal and Child Health, Government Medical College Calicut, Calicut, India
| | | | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
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Rüegger CM, Davis PG, Cheong JL. Xenon as an adjuvant to therapeutic hypothermia in near term and term newborns with hypoxic ischaemic encephalopathy. Hippokratia 2017. [DOI: 10.1002/14651858.cd012753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christoph M Rüegger
- The Royal Women’s Hospital; Newborn Research Centre and Neonatal Services; Locked Bag 300 Grattan St & Flemington Road Melbourne Victoria Australia Parkville 3052
- University Hospital and University of Zürich; Newborn Research, Department of Neonatology; Frauenklinikstrasse 10 Zürich Zürich Switzerland 8091
| | - Peter G Davis
- The Royal Women’s Hospital; Newborn Research Centre and Neonatal Services; Locked Bag 300 Grattan St & Flemington Road Melbourne Victoria Australia Parkville 3052
- Murdoch Childrens Research Institute; Melbourne Australia
- University of Melbourne; Department of Obstetrics and Gynecology; Melbourne Australia
| | - Jeanie L Cheong
- The Royal Women’s Hospital; Newborn Research Centre and Neonatal Services; Locked Bag 300 Grattan St & Flemington Road Melbourne Victoria Australia Parkville 3052
- Murdoch Childrens Research Institute; Melbourne Australia
- University of Melbourne; Department of Obstetrics and Gynecology; Melbourne Australia
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135
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Martinello K, Hart AR, Yap S, Mitra S, Robertson NJ. Management and investigation of neonatal encephalopathy: 2017 update. Arch Dis Child Fetal Neonatal Ed 2017; 102:F346-F358. [PMID: 28389438 PMCID: PMC5537522 DOI: 10.1136/archdischild-2015-309639] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/15/2017] [Indexed: 12/26/2022]
Abstract
This review discusses an approach to determining the cause of neonatal encephalopathy, as well as current evidence on resuscitation and subsequent management of hypoxic-ischaemic encephalopathy (HIE). Encephalopathy in neonates can be due to varied aetiologies in addition to hypoxic-ischaemia. A combination of careful history, examination and the judicious use of investigations can help determine the cause. Over the last 7 years, infants with moderate to severe HIE have benefited from the introduction of routine therapeutic hypothermia; the number needed to treat for an additional beneficial outcome is 7 (95% CI 5 to 10). More recent research has focused on optimal resuscitation practices for babies with cardiorespiratory depression, such as delayed cord clamping after establishment of ventilation and resuscitation in air. Around a quarter of infants with asystole at 10 min after birth who are subsequently cooled have normal outcomes, suggesting that individualised decision making on stopping resuscitation is needed, based on access to intensive treatment unit and early cooling. The full benefit of cooling appears to have been exploited in our current treatment protocols of 72 hours at 33.5°C; deeper and longer cooling showed adverse outcome. The challenge over the next 5-10 years will be to assess which adjunct therapies are safe and optimise hypothermic brain protection in phase I and phase II trials. Optimal care may require tailoring treatments according to gender, genetic risk, injury severity and inflammatory status.
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Affiliation(s)
- Kathryn Martinello
- Department of Neonatology, Institute for Women's Health, University College London, UK
| | - Anthony R Hart
- Department of Neonatal and Paediatric Neurology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Sufin Yap
- Department of Inherited Metabolic Diseases, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Subhabrata Mitra
- Department of Neonatology, Institute for Women's Health, University College London, UK
| | - Nicola J Robertson
- Department of Neonatology, Institute for Women's Health, University College London, UK
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136
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Merhar SL, Tkach JA, Woods JC, South AP, Wiland EL, Rattan MS, Dumoulin CL, Kline-Fath BM. Neonatal imaging using an on-site small footprint MR scanner. Pediatr Radiol 2017; 47:1001-1011. [PMID: 28470389 DOI: 10.1007/s00247-017-3855-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/09/2017] [Accepted: 03/30/2017] [Indexed: 01/06/2023]
Abstract
With its soft-tissue definition, multiplanar capabilities and advanced imaging techniques, magnetic resonance imaging (MRI) for neonatal care can provide better understanding of pathology, allowing for improved care and counseling to families. However, MR imaging in neonates is often difficult due to patient instability and the complex support necessary for survival. In our institution, we have installed a small footprint magnet in the neonatal intensive care unit (NICU) to minimize patient risks and provide the ability to perform MR imaging safely in this population. With this system, we have been able to provide more information with regard to central nervous system disorders, abdominal pathology, and pulmonary and airway abnormalities, and have performed postmortem imaging as an alternative or supplement to pathological autopsy. In our experience, an MR scanner situated within the NICU has allowed for safer and more expedited imaging of this vulnerable population.
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Affiliation(s)
- Stephanie L Merhar
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Perinatal Institute, Cincinnati, OH, USA
| | - Jean A Tkach
- Imaging Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Jason C Woods
- Imaging Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew P South
- Division of Neonatology, Children's Hospital Medical Center of Akron, Akron, OH, USA
| | - Emily L Wiland
- Division of Neonatology, Children's Hospital Medical Center of Akron, Akron, OH, USA
| | - Mantosh S Rattan
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Charles L Dumoulin
- Imaging Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.
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Cahill AG, Macones GA, Smyser CD, López JD, Inder TE, Mathur AM. Umbilical Artery Lactate Correlates with Brain Lactate in Term Infants. Am J Perinatol 2017; 34:535-540. [PMID: 27788532 PMCID: PMC5530875 DOI: 10.1055/s-0036-1593844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective The objective of this study was to determine the correlation between umbilical artery lactate with brain lactate in nonanomalous term infants. Study Design We performed a nested case-control study within an on-going prospective cohort of more than 8,000 consecutive singleton term (≥ 37 weeks) nonanomalous infants. Neonates underwent cerebral magnetic resonance imaging (MRI) within the first 72 hours of life. Cases (umbilical artery pH ≤ 7.10) were gender and race matched 1:3 to controls (umbilical artery pH > 7.20). Single voxel magnetic resonance spectroscopy (MRS), lactate, and N-acetyl aspartate (NAA) for normalization were calculated using Siemens software (Plano, TX). Linear regression estimated the association between incremental change in umbilical artery lactate and brain lactate, both directly and as a ratio with NAA. Results Of 175 infants who underwent MRI with spectral sequencing, 52 infants had detectable brain lactate. The 52 infants with brain lactate peaks had umbilical artery lactate values of 1.6 to 11.4 mmol/L. For every 1.0 mmol/L increase in umbilical artery lactate, there was an increase in brain lactate of 0.02, which remained significant even when corrected for NAA. Conclusion MRS measured brain lactate is significantly correlated with umbilical artery lactate in nonanomalous term infants, which may help explain the observed association between umbilical artery lactate and neurologic morbidity.
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Affiliation(s)
- Alison G. Cahill
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - George A. Macones
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher D. Smyser
- Division of Neurology, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Julia D. López
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amit M. Mathur
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
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Domi T, Vossough A, Stence NV, Felling RJ, Leung J, Krishnan P, Watson CG, Grant PE, Kassner A. The Potential for Advanced Magnetic Resonance Neuroimaging Techniques in Pediatric Stroke Research. Pediatr Neurol 2017; 69:24-36. [PMID: 28237248 DOI: 10.1016/j.pediatrneurol.2016.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND This article was written to provide clinicians and researchers with an overview of a number of advanced neuroimaging techniques in an effort to promote increased utility and the design of future studies using advanced neuroimaging in childhood stroke. The current capabilities of advanced magnetic resonance imaging techniques provide the opportunity to build on our knowledge of the consequences of stroke on the developing brain. These capabilities include providing information about the physiology, metabolism, structure, and function of the brain that are not routinely evaluated in the clinical setting. METHODS During the Proceedings of the Stroke Imaging Laboratory for Children Workshop in Toronto in June 2015, a subgroup of clinicians and imaging researchers discussed how the application of advanced neuroimaging techniques could further our understanding of the mechanisms of stroke injury and repair in the pediatric population. This subgroup was established based on their interest and commitment to design collaborative, advanced neuroimaging studies in the pediatric stroke population. RESULTS In working toward this goal, we first sought to describe here the magnetic resonance imaging techniques that are currently available for use, and how they have been applied in other stroke populations (e.g., adult and perinatal stroke). CONCLUSIONS With the continued improvement in advanced neuroimaging techniques, including shorter acquisition times, there is an opportunity to apply these techniques to their full potential in the research setting and learn more about the effects of stroke in the developing brain.
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Affiliation(s)
- Trish Domi
- Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas V Stence
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ryan J Felling
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jackie Leung
- Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pradeep Krishnan
- Department of Neuroradiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher G Watson
- Department of Computational Neuroscience, Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, Massachusetts; Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - P Ellen Grant
- Division of Newborn Medicine, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrea Kassner
- Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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139
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Rocha-Ferreira E, Kelen D, Faulkner S, Broad KD, Chandrasekaran M, Kerenyi Á, Kato T, Bainbridge A, Golay X, Sullivan M, Kramer BW, Robertson NJ. Systemic pro-inflammatory cytokine status following therapeutic hypothermia in a piglet hypoxia-ischemia model. J Neuroinflammation 2017; 14:44. [PMID: 28253907 PMCID: PMC5335722 DOI: 10.1186/s12974-017-0821-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 02/24/2017] [Indexed: 11/17/2022] Open
Abstract
Background Inflammatory cytokines are implicated in the pathogenesis of perinatal hypoxia-ischemia (HI). The influence of hypothermia (HT) on cytokines after HI is unclear. Our aim was to assess in a piglet asphyxia model, under normothermic (NT) and HT conditions: (i) the evolution of serum cytokines over 48 h and (ii) cerebrospinal fluid (CSF) cytokine levels at 48 h; (iii) serum pro/anti-inflammatory cytokine profile over 48 h and (iv) relation between brain injury measured by magnetic resonance spectroscopy (MRS) and brain TUNEL positive cells with serum cytokines, serum pro/anti-inflammatory cytokines and CSF cytokines. Methods Newborn piglets were randomized to NT (n = 5) or HT (n = 6) lasting 2–26 h after HI. Serum samples were obtained 4–6 h before, during and at 6–12 h intervals after HI; CSF was obtained at 48 h. Concentrations of interleukin (IL)-1β, −4, −6, −8, −10 and TNF-α were measured and pro/anti-inflammatory status compared between groups. White matter and thalamic voxel lactate/N-acetyl aspartate (Lac/NAA) (a measure of both oxidative metabolism and neuronal loss) were acquired at baseline, after HI and at 24 and 36 h. Results Lac/NAA was reduced at 36 h with HT compared to NT (p = 0.013 basal ganglia and p = 0.033 white matter). HT showed lower serum TNF-α from baseline to 12 h (p < 0.05). Time-matched (acquired within 5 h of each other) serum cytokine and MRS showed correlations between Lac/NAA and serum IL-1β and IL-10 (all p < 0.01). The pro/anti-inflammatory ratios IL-1β/IL-10, IL-6/IL-10, IL-4/IL-10 and IL-8/IL-10 were similar in NT and HT groups until 36 h (24 h for IL-6/IL-10); after this, 36 h pro/anti-inflammatory cytokine ratios in the serum were higher in HT compared to NT (p < 0.05), indicating a pro-inflammatory cytokine surge after rewarming in the HT group. In the CSF at 48 h, IL-8 was lower in the HT group (p < 0.05). At 48 h, CSF TNF-α correlated with Lac/NAA (p = 0.02) and CSF IL-8 correlated with white matter TUNEL positive cell death (p = 0.04). Conclusions Following cerebral HI, there was a systemic pro-inflammatory surge after rewarming in the HT group, which is counterintuitive to the putative neuroprotective effects of HT. While serum cytokines were variable, elevations in CSF inflammatory cytokines at 48 h were associated with MRS Lac/NAA and white matter cell death. Electronic supplementary material The online version of this article (doi:10.1186/s12974-017-0821-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eridan Rocha-Ferreira
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Dorottya Kelen
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Stuart Faulkner
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Kevin D Broad
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | | | - Áron Kerenyi
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Takenori Kato
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Alan Bainbridge
- Department of Medical Physics and Bioengineering, and Institute of Neurology, University College London, London, UK
| | - Xavier Golay
- Institute of Neurology, University College London, London, UK
| | - Mark Sullivan
- Institute of Reproductive and Developmental Biology, Hammersmith Campus, Imperial College London, London, UK
| | - Boris W Kramer
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,Institute of Oncology and Developmental Biology, Institute of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicola J Robertson
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.
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140
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Abstract
Parents often ask neonatologists and neurologists to determine neurologic prognosis in the preterm and term infant after neonatal brain injury. Prognostication in these populations remains rather full of uncertainties. Knowledge of available diagnostic tests and their limitations allows the clinician to synthesize the most likely outcomes after neurologic injury. In this review, we describe the diagnostic tools available to the clinician, active areas of research, and challenges in neurologic prognostication of the neonate.
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Affiliation(s)
- Niranjana Natarajan
- Department of Neurology, University of Washington, Seattle Children׳s Hospital, Seattle, WA
| | - Andrea C Pardo
- Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Box #51, Chicago, IL 60611.
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141
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Alderliesten T, de Vries LS, Staats L, van Haastert IC, Weeke L, Benders MJNL, Koopman-Esseboom C, Groenendaal F. MRI and spectroscopy in (near) term neonates with perinatal asphyxia and therapeutic hypothermia. Arch Dis Child Fetal Neonatal Ed 2017; 102:F147-F152. [PMID: 27553589 DOI: 10.1136/archdischild-2016-310514] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 07/20/2016] [Accepted: 07/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies have demonstrated the association of abnormalities on diffusion-weighted MRI (DW-MRI) and proton magnetic resonance spectroscopy (1H-MRS) in infants with perinatal asphyxia. The use of therapeutic hypothermia might change this association. AIM To study the association between DW-MRI and 1H-MRS and outcome after perinatal asphyxia and therapeutic hypothermia in infants with a gestational age of ≥36 weeks. PATIENTS AND METHODS Infants with perinatal asphyxia and therapeutic hypothermia (n=88) were included when an MR examination was performed within 7 days after birth. Apparent diffusion coefficient (ADC) values of the basal ganglia and thalamus were calculated, as were lactate/N-acetylaspartate (LAC/NAA) and N-acetylaspartate/choline (NAA/Cho) ratios. Death or an abnormal neurodevelopment at ≥24 months was considered an adverse outcome. Receiver operating characteristic analysis was performed to determine cut-off levels. RESULTS Of the 88 infants, 22 died and 7 had an adverse neurodevelopmental outcome. In infants with an adverse outcome, ADC values of the basal ganglia and thalamus were significantly lower, and Lac/NAA ratios were significantly higher than in infants with a normal outcome. Areas under the curve of ADC of the basal ganglia, thalami and Lac/NAA ratio were 0.89, 0.88 and 0.87, respectively. NAA/Cho ratios were in this cohort not associated with outcome. CONCLUSIONS During and after therapeutic hypothermia, low ADC values and high Lac/NAA ratios of the basal ganglia and thalamus are associated with an adverse outcome in infants with perinatal asphyxia.
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Affiliation(s)
- Thomas Alderliesten
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Liza Staats
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingrid C van Haastert
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lauren Weeke
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Corine Koopman-Esseboom
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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142
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Racine E, Bell E, Farlow B, Miller S, Payot A, Rasmussen LA, Shevell MI, Thomson D, Wintermark P. The 'ouR-HOPE' approach for ethics and communication about neonatal neurological injury. Dev Med Child Neurol 2017; 59:125-135. [PMID: 27915463 DOI: 10.1111/dmcn.13343] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2016] [Indexed: 11/26/2022]
Abstract
Predicting neurological outcomes of neonates with acute brain injury is an essential component of shared decision-making, in order to guide the development of treatment goals and appropriate care plans. It can aid parents in imagining the child's future, and guide timely and ongoing treatment decisions, including shifting treatment goals and focusing on comfort care. However, numerous challenges have been reported with respect to evidence-based practices for prognostication such as biases about prognosis among clinicians. Additionally, the evaluation or appreciation of living with disability can differ, including the well-known disability paradox where patients self-report a good quality of life in spite of severe disability. Herein, we put forward a set of five practice principles captured in the "ouR-HOPE" approach (Reflection, Humility, Open-mindedness, Partnership, and Engagement) and related questions to encourage clinicians to self-assess their practice and engage with others in responding to these challenges. We hope that this proposal paves the way to greater discussion and attention to ethical aspects of communicating prognosis in the context of neonatal brain injury.
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Affiliation(s)
- Eric Racine
- Institut de recherches cliniques de Montréal, Montréal, Canada.,Université de Montréal, Montréal, Canada.,McGill University, Montréal, Canada
| | - Emily Bell
- Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Barbara Farlow
- The DeVeber Institute for Bioethics and Social Research, Toronto, Canada.,Patients for Patient Safety Canada, Edmonton, Canada
| | - Steven Miller
- Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Antoine Payot
- Université de Montréal, Montréal, Canada.,CHU Sainte-Justine, Montréal, Canada
| | | | - Michael I Shevell
- McGill University, Montréal, Canada.,Montreal Children's Hospital, Montréal, Canada
| | - Donna Thomson
- NeuroDevNet/Kids Brain Health Network, Vancouver, Canada
| | - Pia Wintermark
- McGill University, Montréal, Canada.,Montreal Children's Hospital, Montréal, Canada
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143
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Antenatal exposure to antidepressants is associated with altered brain development in very preterm-born neonates. Neuroscience 2017; 342:252-262. [DOI: 10.1016/j.neuroscience.2016.11.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 11/21/2022]
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144
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Lemmon ME, Wagner MW, Bosemani T, Carson KA, Northington FJ, Huisman TAGM, Poretti A. Diffusion Tensor Imaging Detects Occult Cerebellar Injury in Severe Neonatal Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2017; 39:207-214. [PMID: 28095379 DOI: 10.1159/000454856] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the benefits of whole-body hypothermia therapy, many infants with hypoxic-ischemic encephalopathy (HIE) die or have significant long-term neurodevelopmental impairment. Prospectively identifying neonates at risk of poor outcome is essential but not straightforward. The cerebellum is not classically considered to be a brain region vulnerable to hypoxic-ischemic insults; recent literature suggests, however, that the cerebellum may be involved in neonatal HIE. In this study, we aimed to assess the microstructural integrity of cerebellar and linked supratentorial structures in neonates with HIE compared to neurologically healthy neonatal controls. METHODS In this prospective cohort study, we performed a quantitative diffusion tensor imaging (DTI) analysis of the structural pathways of connectivity, which may be affected in neonatal cerebellar injury by measuring fractional anisotropy (FA) and mean diffusivity (MD) within the superior, middle, and inferior cerebellar peduncles, dentate nuclei, and thalami. All magnetic resonance imaging (MRI) studies were grouped into 4 categories of severity based on a qualitative evaluation of conventional and advanced MRI sequences. Multivariable linear regression analysis of cerebellar scalars of patients and controls was performed, controlling for gestational age, age at the time of MRI, and HIE severity. Spearman rank correlation was performed to correlate DTI scalars of the cerebellum and thalami. RESULTS Fifty-seven (23 females, 40%) neonates with HIE and 12 (6 females, 50%) neonatal controls were included. There were 8 patients (14%) in HIE severity groups 3 and 4 (injury of the basal ganglia/thalamus and/or cortex). Based on a qualitative analysis of conventional and DTI images, no patients had evidence of cerebellar injury. No significant differences between patients and controls were found in the FA and MD scalars. However, FA values of the middle cerebellar peduncles (0.294 vs. 0.380, p < 0.001) and MD values of the superior cerebellar peduncles (0.920 vs. 1.007 × 10-3 mm/s2, p = 0.001) were significantly lower in patients with evidence of moderate or severe injury on MRI (categories 3 and 4) than in controls. In patients, cerebellar DTI scalars correlated positively with DTI scalars within the thalami. CONCLUSION Our results suggest that infants with moderate-to-severe HIE may have occult injury of cerebellar white-matter tracts, which is not detectable by the qualitative analysis of neuroimaging data alone. Cerebellar DTI scalars correlate with thalamic measures, highlighting that cerebellar injury is unlikely to occur in isolation and may reflect the severity of HIE. The impact of concomitant cerebellar injury in HIE on long-term neurodevelopmental outcome warrants further study.
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Affiliation(s)
- Monica E Lemmon
- Division of Pediatric Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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145
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Fifty years of brain imaging in neonatal encephalopathy following perinatal asphyxia. Pediatr Res 2017; 81:150-155. [PMID: 27673422 DOI: 10.1038/pr.2016.195] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/22/2016] [Indexed: 12/21/2022]
Abstract
In the past brain imaging of term infants with hypoxic-ischemic encephalopathy (HIE) was performed with cranial ultrasound (cUS) and computed tomography (CT). Both techniques have several disadvantages sensitivity and specificity is limited compared with magnetic resonance imaging (MRI) and CT makes use of radiation. At present MRI including diffusion weighted MRI during the first week of life, has become the method of choice for imaging infants with HIE. In addition to imaging, blood vessels and blood flow can be visualized using MR angiography, MR venography, and arterial spin labeling. Since the use of these techniques additional lesions in infants with HIE, such as arterial ischemic stroke, sinovenous thrombosis, and subdural hemorrhages can be diagnosed, and the incidence appears to be higher than shown previously. Phosphorus magnetic resonance spectroscopy (MRS) has led to the concept of secondary energy failure in infants with HIE, but has not been widely used. Proton MRS of the basal ganglia and thalamus is one of the best predictors of neurodevelopmental outcome. cUS should still be used for screening infants admitted to a NICU with neonatal encephalopathy. In the future magnetic resonance techniques will be increasingly used as early biomarkers of neurodevelopmental outcome in trials of neuroprotective strategies.
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146
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Garberg HT, Solberg R, Barlinn J, Martinez-Orgado J, Løberg EM, Saugstad OD. High-Dose Cannabidiol Induced Hypotension after Global Hypoxia-Ischemia in Piglets. Neonatology 2017; 112:143-149. [PMID: 28564654 DOI: 10.1159/000471786] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 03/17/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cannabidiol (CBD) is considered a promising neuroprotectant after perinatal hypoxia-ischemia (HI). We have previously studied the effects of CBD 1 mg/kg in the early phase after global HI in piglets. In contrast to prior studies, we found no evidence of neuroprotection and hypothesized that higher doses might be required to demonstrate efficacy in this animal model. OBJECTIVE To assess the safety and potential neuroprotective effects of high-dose CBD. METHODS Anesthetized newborn piglets underwent global HI by ventilation with 8% O2 until the point of severe metabolic acidosis (base excess -20 mmol/L) and/or hypotension (mean arterial blood pressure ≤20 mm Hg). Piglets were randomized to intravenous treatment with vehicle (n = 9) or CBD (n = 13). The starting dose, CBD 50 mg/kg, was reduced if adverse effects occurred. The piglets were euthanized 9.5 h after HI and tissue was collected for analysis. RESULTS CBD 50 mg/kg (n = 4) induced significant hypotension in 2 out of 4 piglets, and 1 out of 4 piglets suffered a fatal cardiac arrest. CBD 25 mg/kg (n = 4) induced significant hypotension in 1 out of 4 piglets, while 10 mg/kg (n = 5) was well tolerated. A significant negative correlation between the plasma concentration of CBD and hypotension during drug infusion was observed (p < 0.005). Neuroprotective effects were evaluated in piglets that did not display significant hypotension (n = 9) and CBD did not alter the degree of neuronal damage as measured by a neuropathology score, levels of the astrocytic marker S100B in CSF, magnetic resonance spectroscopy markers (Lac/NAA and Glu/NAA ratios), or plasma troponin T. CONCLUSIONS High-dose CBD can induce severe hypotension and did not offer neuroprotection in the early phase after global HI in piglets.
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Affiliation(s)
- Håvard T Garberg
- Division of Pediatric and Adolescent Medicine, Department of Pediatric Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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147
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Heursen EM, Zuazo Ojeda A, Benavente Fernández I, Jimenez Gómez G, Campuzano Fernández-Colima R, Paz-Expósito J, Lubián López SP. Prognostic Value of the Apparent Diffusion Coefficient in Newborns with Hypoxic-Ischaemic Encephalopathy Treated with Therapeutic Hypothermia. Neonatology 2017; 112:67-72. [PMID: 28351039 DOI: 10.1159/000456707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Apparent diffusion coefficient (ADC) quantification has been proven to be of prognostic value in term newborns with hypoxic-ischaemic encephalopathy (HIE) who were treated under normothermia. OBJECTIVES To evaluate the prognostic value of ADC in standardized brain regions in neonates with HIE who were treated with therapeutic hypothermia (TH). METHODS This prospective cohort study included 54 term newborns who were admitted with HIE and treated with TH. All magnetic resonance imaging examinations were performed between days 4 and 6 of life, and ADC values were measured in 13 standardized regions of the brain. At 2 years of age we explored whether ADC values were related to composite outcomes (death or survival with abnormal neurodevelopment). RESULTS The severity of HIE is inversely related to ADC values in different brain regions. We found that lower ADC values in the posterior limb of the internal capsule (PLIC), the thalami, the semioval centre, and frontal and parietal white matter were related to adverse outcomes. ADC values in the PLIC and thalami are good predictors of adverse outcomes (AUC 0.86 and 0.76). CONCLUSIONS Low ADC values in the PLIC, thalamus, semioval centre, and frontal and parietal white matter in full-term infants with HIE treated with TH were associated with a poor outcome.
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Affiliation(s)
- Eva-Marie Heursen
- Radiology Department, "Puerta del Mar" University Hospital, Cadiz, Spain
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148
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Lei J, Paules C, Nigrini E, Rosenzweig JM, Bahabry R, Farzin A, Yang S, Northington FJ, Oros D, McKenney S, Johnston MV, Graham EM, Burd I. Umbilical Cord Blood NOS1 as a Potential Biomarker of Neonatal Encephalopathy. Front Pediatr 2017; 5:112. [PMID: 28649562 PMCID: PMC5466059 DOI: 10.3389/fped.2017.00112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND There are no definitive markers to aid in diagnosis of neonatal encephalopathy (NE). The purpose of our study was (1) to identify and evaluate the utility of neuronal nitric oxide synthase (NOS1) in umbilical cord blood as a NE biomarker and (2) to identify the source of NOS1 in umbilical cord blood. METHODS This was a nested case-control study of neonates >35 weeks of gestation. ELISA for NOS1 in umbilical cord blood was performed. Sources of NOS1 in umbilical cord were investigated by immunohistochemistry, western blot, ELISA, and quantitative PCR. Furthermore, umbilical cords of full-term neonates were subjected to 1% hypoxia ex vivo. RESULTS NOS1 was present in umbilical cord blood and increased in NE cases compared with controls. NOS1 was expressed in endothelial cells of the umbilical cord vein, but not in artery or blood cells. In ex vivo experiments, hypoxia was associated with increased levels of NOS1 in venous endothelial cells of the umbilical cord as well as in ex vivo culture medium. CONCLUSION This is the first study to investigate an early marker of NE. NOS1 is elevated with hypoxia, and further studies are needed to investigate it as a valuable tool for early diagnosis of neonatal brain injury.
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Affiliation(s)
- Jun Lei
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cristina Paules
- Aragón Health Research Institute, SAMID Network ref RD12/0026/001, Zaragoza, Spain
| | - Elisabeth Nigrini
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason M Rosenzweig
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rudhab Bahabry
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Azadeh Farzin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samuel Yang
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frances J Northington
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Oros
- Aragón Health Research Institute, SAMID Network ref RD12/0026/001, Zaragoza, Spain
| | - Stephanie McKenney
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael V Johnston
- Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurosciences, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M Graham
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neurosciences Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurosciences, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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149
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Goeral K, Urlesberger B, Giordano V, Kasprian G, Wagner M, Schmidt L, Berger A, Klebermass-Schrehof K, Olischar M. Prediction of Outcome in Neonates with Hypoxic-Ischemic Encephalopathy II: Role of Amplitude-Integrated Electroencephalography and Cerebral Oxygen Saturation Measured by Near-Infrared Spectroscopy. Neonatology 2017; 112:193-202. [PMID: 28704822 DOI: 10.1159/000468976] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Few data have been published on the combined use of amplitude-integrated electroencephalography (aEEG) and near-infrared spectroscopy (NIRS) for outcome prediction in neonates cooled for hypoxic-ischemic encephalopathy (HIE). OBJECTIVE Our aim was to evaluate the predictive values and the most powerful predictive combinations of single aEEG and NIRS parameters and the respective cut-off values with regard to short-term outcomes in HIE II. METHODS aEEG and NIRS were prospectively studied at the Medical University of Vienna in the first 102 h of life with regard to magnetic resonance imaging (MRI). Thirty-two neonates diagnosed with HIE II treated with hypothermia were investigated. The measurement period was divided into 6-h epochs. According to MRI, 2 outcome groups were defined and predictive values of aEEG parameters, regional cerebral oxygen saturation (rScO2), and the additional value of both methods combined were studied. Receiver operating curves (ROC) were obtained and area under the curve (AUC) values were calculated. ROC were then used to detect the optimal cut-off points, sensitivity, specificity, positive predictive values, and negative predictive values. RESULTS At all time epochs, combined parameter scores were more predictive than single parameter scores. The highest AUC were observed between 18 and 60 h of cooling for the aEEG summation score (0.72-0.84) and for (background pattern + seizures) × rScO2 (0.79-0.85). At 42-60 h sensitivity was similar between those 2 scores (87.5-90.0%), but the addition of NIRS to aEEG led to an increase in specificity (from 52.4-59.1% to 72.7-90.5%). CONCLUSIONS In HIE II, aEEG and NIRS are important predictors of short-term outcome. The combination of both methods improves prognostication. The highest predictive abilities were observed between 18 and 60 h of cooling.
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Affiliation(s)
- Katharina Goeral
- Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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150
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The Impact of Venoarterial and Venovenous Extracorporeal Membrane Oxygenation on Cerebral Metabolism in the Newborn Brain. PLoS One 2016; 11:e0168578. [PMID: 28033354 PMCID: PMC5199081 DOI: 10.1371/journal.pone.0168578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 12/02/2016] [Indexed: 12/13/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective therapy for supporting infants with reversible cardiopulmonary failure. Still, survivors are at risk for long-term neurodevelopmental impairments, the cause of which is not fully understood. Objective To elucidate the effects of ECMO on the newborn brain. We hypothesized that the cerebral metabolic profile of neonates who received ECMO would differ from neonates who did not receive ECMO. To address this, we used magnetic resonance spectroscopy (1H-MRS) to investigate the effects of venoarterial and venovenous ECMO on cerebral metabolism. Methods 41 neonates treated with ECMO were contrasted to 38 age-matched neonates. Results All 1H-MRS data were acquired from standardized grey matter and white matter regions of interest using a short-echo (TE = 35 milliseconds), point-resolved spectroscopy sequence (PRESS) and quantitated using LCModel. Metabolite concentrations (mmol/kg) were compared across groups using multivariate analysis of covariance. Elevated creatine (p = 0.002) and choline (p = 0.005) concentrations were observed in the grey matter among neonates treated with ECMO relative to the reference group. Likewise, choline concentrations were elevated in the white matter (p = 0.003) while glutamate was reduced (p = 0.03). Contrasts between ECMO groups revealed lower osmolite concentrations (e.g. myoinositol) among the venovenous ECMO group. Conclusion Neonates who underwent ECMO were found to have an abnormal cerebral metabolic profile, with the pattern of abnormalities suggestive of an underlying inflammatory process. Additionally, neonates who underwent venovenous ECMO had low cerebral osmolite concentrations as seen in vasogenic edema.
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