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Proietti J, O'Toole JM, Murray DM, Boylan GB. Advances in Electroencephalographic Biomarkers of Neonatal Hypoxic Ischemic Encephalopathy. Clin Perinatol 2024; 51:649-663. [PMID: 39095102 DOI: 10.1016/j.clp.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Electroencephalography (EEG) is a key objective biomarker of newborn brain function, delivering critical, cotside insights to aid the management of encephalopathy. Access to continuous EEG is limited, forcing reliance on subjective clinical assessments. In hypoxia ischaemia, the primary cause of encephalopathy, alterations in EEG patterns correlate with. injury severity and evolution. As HIE evolves, causing secondary neuronal death, EEG can track injury progression, informing neuroprotective strategies, seizure management and prognosis. Despite its value, challenges with interpretation and lack of on site expertise has limited its broader adoption. Technological advances, particularly in digital EEG and machine learning, are enhancing real-time analysis. This will allow EEG to expand its role in HIE diagnosis, management and outcome prediction.
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Affiliation(s)
- Jacopo Proietti
- Department of Engineering for Innovation Medicine, University of Verona, Strada le Grazie, Verona 37134, Italy; INFANT Research Centre, University College Cork, Cork, Ireland
| | - John M O'Toole
- INFANT Research Centre, University College Cork, Cork, Ireland; Cergenx Ltd., Dublin, Ireland
| | - Deirdre M Murray
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics & Child Health, University College Cork, Paediatric Academic Unit, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics & Child Health, University College Cork, Paediatric Academic Unit, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland.
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2
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Zhou KQ, Dhillon SK, Bennet L, Davidson JO, Gunn AJ. How do we reach the goal of personalized medicine for neuroprotection in neonatal hypoxic-ischemic encephalopathy? Semin Perinatol 2024; 48:151930. [PMID: 38910063 DOI: 10.1016/j.semperi.2024.151930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Therapeutic hypothermia is now standard of care for neonates with hypoxic-ischemic encephalopathy (HIE) in high income countries (HIC). Conversely, compelling trial evidence suggests that hypothermia is ineffective, and may be deleterious, in low- and middle-income countries (LMIC), likely reflecting the lower proportion of infants who had sentinel events at birth, suggesting that injury had advanced to a stage when hypothermia is no longer effective. Although hypothermia significantly reduced the risk of death and disability in HICs, many infants survived with disability and in principle may benefit from targeted add-on neuroprotective or neurorestorative therapies. The present review will assess biomarkers that could be used to personalize treatment for babies with HIE - to determine first whether an individual infant is likely to respond to hypothermia, and second, whether additional treatments may be beneficial.
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Affiliation(s)
- Kelly Q Zhou
- Dept of Physiology, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Simerdeep K Dhillon
- Dept of Physiology, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Laura Bennet
- Dept of Physiology, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Joanne O Davidson
- Dept of Physiology, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Alistair J Gunn
- Dept of Physiology, The University of Auckland, Private Bag 92019, Auckland, New Zealand.
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3
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Damien J, Vannasing P, Tremblay J, Petitpas L, Marandyuk B, Balasingam T, El Jalbout R, Paquette N, Donofrio G, Birca A, Gallagher A, Pinchefsky EF. Relationship between EEG spectral power and dysglycemia with neurodevelopmental outcomes after neonatal encephalopathy. Clin Neurophysiol 2024; 163:160-173. [PMID: 38754181 DOI: 10.1016/j.clinph.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/28/2024] [Accepted: 03/23/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE We investigated how electroencephalography (EEG) quantitative measures and dysglycemia relate to neurodevelopmental outcomes following neonatal encephalopathy (NE). METHODS This retrospective study included 90 neonates with encephalopathy who received therapeutic hypothermia. EEG absolute spectral power was calculated during post-rewarming and 2-month follow-up. Measures of dysglycemia (hypoglycemia, hyperglycemia, and glycemic lability) and glucose variability were computed for the first 48 h of life. We evaluated the ability of EEG and glucose measures to predict neurodevelopmental outcomes at ≥ 18 months, using logistic regressions (with area under the receiver operating characteristic [AUROC] curves). RESULTS The post-rewarming global delta power (average all electrodes), hyperglycemia and glycemic lability predicted moderate/severe neurodevelopmental outcome separately (AUROC = 0.8, 95%CI [0.7,0.9], p < .001) and even more so when combined (AUROC = 0.9, 95%CI [0.8,0.9], p < .001). After adjusting for NE severity and magnetic resonance imaging (MRI) brain injury, only global delta power remained significantly associated with moderate/severe neurodevelopmental outcome (odds ratio [OR] = 0.9, 95%CI [0.8,1.0], p = .04), gross motor delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), global developmental delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), and auditory deficits (OR = 0.9, 95%CI [0.8,1.0], p = .03). CONCLUSIONS In NE, global delta power post-rewarming was predictive of outcomes at ≥ 18 months. SIGNIFICANCE EEG markers post-rewarming can aid prediction of neurodevelopmental outcomes following NE.
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Affiliation(s)
- Janie Damien
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Phetsamone Vannasing
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Julie Tremblay
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Laurence Petitpas
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Bohdana Marandyuk
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Thameya Balasingam
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Ramy El Jalbout
- Department of Radiology, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Natacha Paquette
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Gianluca Donofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Ala Birca
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Anne Gallagher
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Elana F Pinchefsky
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
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Hua T, Nguyen TT, Nguyen TT. Progression of Amplitude-Integrated Electroencephalography and Neurological Outcomes in Neonates With Hypoxic-Ischemic Encephalopathy: A Single-Institution Cohort Study in Vietnam. Cureus 2024; 16:e62317. [PMID: 38882227 PMCID: PMC11177235 DOI: 10.7759/cureus.62317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 06/18/2024] Open
Abstract
Background The characteristics of amplitude-integrated electroencephalography (aEEG) are associated with neurological outcomes in neonates with hypoxic-ischemic encephalopathy (HIE). We perform a longitudinal analysis of continuous monitoring of aEEG during therapeutic hypothermia and explore the association between aEEG interpretation and clinical neurological outcomes. Method We conducted a prospective cohort study on HIE neonates undergoing hypothermia with aEEG monitoring. Results A total of 37 HIE infants underwent hypothermia with improved aEEG background activity in 28 (75.7%) neonates, of which 18 (48.6%) neonates had background activity returned to a continuous pattern, and the median recovery time was 26.5 hours. Sleep-wake cycle (SWC) appeared in 14 (37.8%) cases, with a median onset time of 34.5 hours. Seizure activity on aEEG was present in 26 (70.3%) infants. Factors associated with poor outcomes at discharge included low voltage or flat trace background activity, a lack of improvement in background activity after hypothermia, and the absence of SWC. Neonates who took longer than 62 hours to return to continuous background activity (time to normal trace) or did not have SWC before the end of hypothermia were more likely to have unfavorable outcomes at discharge. Conclusions Longitudinal analysis of aEEG during hypothermia should be implemented in neonatal care units. The progression of these features on aEEG may predict neurological outcomes for HIE neonates.
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Affiliation(s)
- Thu Hua
- Department of Pediatrics, Children's Hospital 2, Ho Chi Minh, VNM
| | - Thien T Nguyen
- Department of Pediatrics and Neonatology, Children's Hospital 2, Ho Chi Minh, VNM
| | - Tinh T Nguyen
- Department of Pediatrics, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM
- Department of Neonatology, Children's Hospital 2, Ho Chi Minh, VNM
- Department of Neonatology, Ho Chi Minh University Medical Center, Ho Chi Minh, VNM
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Montazeri S, Nevalainen P, Metsäranta M, Stevenson NJ, Vanhatalo S. Clinical outcome prediction with an automated EEG trend, Brain State of the Newborn, after perinatal asphyxia. Clin Neurophysiol 2024; 162:68-76. [PMID: 38583406 DOI: 10.1016/j.clinph.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 02/13/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To evaluate the utility of a fully automated deep learning -based quantitative measure of EEG background, Brain State of the Newborn (BSN), for early prediction of clinical outcome at four years of age. METHODS The EEG monitoring data from eighty consecutive newborns was analyzed using the automatically computed BSN trend. BSN levels during the first days of life (a of total 5427 hours) were compared to four clinical outcome categories: favorable, cerebral palsy (CP), CP with epilepsy, and death. The time dependent changes in BSN-based prediction for different outcomes were assessed by positive/negative predictive value (PPV/NPV) and by estimating the area under the receiver operating characteristic curve (AUC). RESULTS The BSN values were closely aligned with four visually determined EEG categories (p < 0·001), as well as with respect to clinical milestones of EEG recovery in perinatal Hypoxic Ischemic Encephalopathy (HIE; p < 0·003). Favorable outcome was related to a rapid recovery of the BSN trend, while worse outcomes related to a slow BSN recovery. Outcome predictions with BSN were accurate from 6 to 48 hours of age: For the favorable outcome, the AUC ranged from 95 to 99% (peak at 12 hours), and for the poor outcome the AUC ranged from 96 to 99% (peak at 12 hours). The optimal BSN levels for each PPV/NPV estimate changed substantially during the first 48 hours, ranging from 20 to 80. CONCLUSIONS We show that the BSN provides an automated, objective, and continuous measure of brain activity in newborns. SIGNIFICANCE The BSN trend discloses the dynamic nature that exists in both cerebral recovery and outcome prediction, supports individualized patient care, rapid stratification and early prognosis.
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Affiliation(s)
- Saeed Montazeri
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland.
| | - Päivi Nevalainen
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Clinical Neurophysiology, Epilepsia Helsinki, Full Member of ERN Epicare, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjo Metsäranta
- Department of Pediatrics, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nathan J Stevenson
- Brain Modelling Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sampsa Vanhatalo
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland; Department of Clinical Neurophysiology, Epilepsia Helsinki, Full Member of ERN Epicare, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Sakpichaisakul K, El-Dib M, Munster C, Supapannachart KJ, Yang E, Walsh BH, Volpe JJ, Inder TE. Amplitude-Integrated Electroencephalography Evolution and Magnetic Resonance Imaging Injury in Mild and Moderate to Severe Neonatal Encephalopathy. Am J Perinatol 2024; 41:e2463-e2473. [PMID: 37369240 DOI: 10.1055/a-2118-2953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVE This study aimed to describe the evolution of amplitude-integrated electroencephalography (aEEG) in neonatal encephalopathy (NE) during therapeutic hypothermia (TH) and evaluate the association between aEEG parameters and magnetic resonance imaging (MRI) injury. STUDY DESIGN aEEG data of infants who underwent TH were reviewed for background, sleep wake cycling (SWC), and seizures. Conventional electroencephalography (cEEG) background was assessed from the reports. Discordance of background on aEEG and cEEG was defined if there was a difference in the severity of the background. MRI injury (total score ≥ 5) was assessed by using the Weeke scoring system. RESULTS A total of 46 infants were included; 23 (50%) with mild NE and 23 (50%) with moderate to severe NE. Comparing mild NE with moderate to severe NE, the initial aEEG background differed with more mild being continuous (70 vs. 52%), with fewer being discontinuous (0 vs. 22%) and flat tracing (0 vs. 4%), whereas burst suppression (4 vs. 4%) and low voltage (26 vs. 18%) did not differ. There was a notably common discordance between the background assessment on cEEG with aEEG in 82% with continuous and 40% low voltage aEEG background. MRI abnormalities were identified in four infants with mild NE and seven infants with moderate to severe NE. MRI injury was associated with aEEG seizures in infants with moderate to severe NE. CONCLUSION aEEG seizures are useful to predict MRI injury in moderate to severe NE infants. There is a large discrepancy between aEEG, cEEG, and MRI in neonates treated by TH. KEY POINTS · MRI injury was identified in 29% of moderate NE infants and in 50% of severe NE infants.. · aEEG seizures were associated with MRI injury in the moderate to severe NE infants.. · MRI injury was identified in 16% infants with mild NE.. · Mild NE infants with normal aEEG were unlikely to have MRI injury.. · There was a large discrepancy between aEEG, cEEG, and MRI in infants treated by TH..
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Affiliation(s)
- Kullasate Sakpichaisakul
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Division of Neurology, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chelsea Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Krittin J Supapannachart
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brain H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Joseph J Volpe
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Mietzsch U, Flibotte JJ, Law JB, Puia-Dumitrescu M, Juul SE, Wood TR. Temperature dysregulation during therapeutic hypothermia predicts long-term outcome in neonates with HIE. J Cereb Blood Flow Metab 2023; 43:1180-1193. [PMID: 36883364 PMCID: PMC10291460 DOI: 10.1177/0271678x231162174] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 03/09/2023]
Abstract
Few reliable or easily obtainable biomarkers to predict long-term outcome in infants with hypoxic-ischemic encephalopathy (HIE) have been identified. We previously showed that mattress temperature (MT), as proxy for disturbed temperature regulation during therapeutic hypothermia (TH), predicts injury on early MRI and holds promise as physiologic biomarker. To determine whether MT in neonates treated with TH for moderate-severe HIE is associated with long-term outcome at 18-22 months, we performed a secondary analysis of the Optimizing Cooling trial using MT data from 167 infants treated at a core temperature of 33.5°C. Median MTs from four time-epochs (0-6 h, 6-24 h, 24-48 h, and 48-72 h of TH) were used to predict death or moderate-severe neurodevelopmental impairment (NDI), using epoch-specific derived and validated MT cutoffs. Median MT of infants who died or survived with NDI was consistently 1.5-3.0°C higher throughout TH. Infants requiring a median MT above the derived cut-offs had a significantly increased odds of death or NDI, most notably at 0-6 h (aOR 17.0, 95%CI 4.3-67.4). By contrast, infants who remained below cut-offs across all epochs had 100% NDI-free survival. MTs in neonates with moderate-severe HIE during TH are highly predictive of long-term outcome and can be used as physiologic biomarker.
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Affiliation(s)
- Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - John J Flibotte
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Janessa B Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
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Li R, Lee JK, Govindan RB, Graham EM, Everett AD, Perin J, Vezina G, Tekes A, Chen MW, Northington F, Parkinson C, O’Kane A, McGowan M, Krein C, Al-Shargabi T, Chang T, Massaro AN. Plasma Biomarkers of Evolving Encephalopathy and Brain Injury in Neonates with Hypoxic-Ischemic Encephalopathy. J Pediatr 2023; 252:146-153.e2. [PMID: 35944723 PMCID: PMC9828943 DOI: 10.1016/j.jpeds.2022.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the relationship between a panel of candidate plasma biomarkers and (1) death or severe brain injury on magnetic resonance imaging (MRI) and (2) dysfunctional cerebral pressure autoregulation as a measure of evolving encephalopathy. STUDY DESIGN Neonates with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) at 2 level IV neonatal intensive care units were enrolled into this observational study. Patients were treated with therapeutic hypothermia (TH) and monitored with continuous blood pressure monitoring and near-infrared spectroscopy. Cerebral pressure autoregulation was measured by the hemoglobin volume phase (HVP) index; a higher HVP index indicates poorer autoregulation. Serial blood samples were collected during TH and assayed for Tau, glial fibrillary acidic protein, and neurogranin. MRIs were assessed using National Institutes of Child Health and Human Development scores. The relationships between the candidate biomarkers and (1) death or severe brain injury on MRI (defined as a National Institutes of Child Health and Human Development score of ≥ 2B) and (2) autoregulation were evaluated using bivariate and adjusted logistic regression models. RESULTS Sixty-two patients were included. Elevated Tau levels on days 2-3 of TH were associated with death or severe injury on MRI (aOR: 1.06, 95% CI: 1.03-1.09; aOR: 1.04, 95% CI: 1.01-1.06, respectively). Higher Tau was also associated with poorer autoregulation (higher HVP index) on the same day (P = .022). CONCLUSIONS Elevated plasma levels of Tau are associated with death or severe brain injury by MRI and dysfunctional cerebral autoregulation in neonates with HIE. Larger-scale validation of Tau as a biomarker of brain injury in neonates with HIE is warranted.
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Affiliation(s)
- Ruoying Li
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Ernest M. Graham
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allen D. Everett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra O’Kane
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Meaghan McGowan
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, Washington, DC;,Department of Pediatrics, The George Washington University School of Medicine, Washington, DC
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Neonatology, Children’s National Hospital, Washington, DC
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Rent S, Bidegain M, Lemmon ME. Neonatal neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:185-199. [PMID: 36599508 PMCID: PMC10615113 DOI: 10.1016/b978-0-12-824535-4.00008-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Neonatal neuropalliative care is directed toward patients and families impacted by serious, life limiting, or debilitating neurologic illness in the antenatal and newborn period. This chapter will outline key considerations for clinicians hoping to provide a neuropalliative care approach antenatally, at birth, and in the neonatal intensive care unit. We focus on three core domains: (1) family-centered communication and care, (2) prognostication and decision-making, and (3) pain and symptom management. In each domain, we outline key considerations in the antenatal period, at birth, and in the neonatal intensive care unit. We also address special considerations in care at the end of life and in varied cultural and practice contexts. We conclude with suggestions for future research and key considerations for neonatal clinicians who wish to incorporate a neuropalliative approach to care into their practice.
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Affiliation(s)
- Sharla Rent
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Margarita Bidegain
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Monica E Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.
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10
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Chock VY, Rao A, Van Meurs KP. Optimal neuromonitoring techniques in neonates with hypoxic ischemic encephalopathy. Front Pediatr 2023; 11:1138062. [PMID: 36969281 PMCID: PMC10030520 DOI: 10.3389/fped.2023.1138062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Neonates with hypoxic ischemic encephalopathy (HIE) are at significant risk for adverse outcomes including death and neurodevelopmental impairment. Neuromonitoring provides critical diagnostic and prognostic information for these infants. Modalities providing continuous monitoring include continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), near-infrared spectroscopy (NIRS), and heart rate variability. Serial bedside neuromonitoring techniques include cranial ultrasound and somatic and visual evoked potentials but may be limited by discrete time points of assessment. EEG, aEEG, and NIRS provide distinct and complementary information about cerebral function and oxygen utilization. Integrated use of these neuromonitoring modalities in addition to other potential techniques such as heart rate variability may best predict imaging outcomes and longer-term neurodevelopment. This review examines available bedside neuromonitoring techniques for the neonate with HIE in the context of therapeutic hypothermia.
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Flower A, Vasiliu D, Zhu T, Andris R, Abubakar M, Fairchild K, Zanelli S, Matsumoto J, Mathur AM, Delos J, Vesoulis Z. Low Variability of Blood Pressure Predicts Abnormal Electroencephalogram in Infants with Hypoxic Ischemic Encephalopathy. Am J Perinatol 2022; 39:288-297. [PMID: 32819015 PMCID: PMC7895863 DOI: 10.1055/s-0040-1715822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study aimed to evaluate the role of an objective physiologic biomarker, arterial blood pressure variability, for the early identification of adverse short-term electroencephalogram (EEG) outcomes in infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN In this multicenter observational study, we analyzed blood pressure of infants meeting these criteria: (1) neonatal encephalopathy determined by modified Sarnat exam, (2) continuous mean arterial blood pressure (MABP) data between 18 and 27 hours after birth, and (3) continuous EEG performed for at least 48 hours. Adverse outcome was defined as moderate-severe grade EEG at 48 hours. Standardized signal preprocessing was used; the power spectral density was computed without interpolation. Multivariate binary logistic regression was used to identify which MABP time and frequency domain metrics provided improved predictive power for adverse outcomes compared with standard clinical predictors (5-minute Apgar score and cord pH) using receiver operator characteristic analysis. RESULTS Ninety-one infants met inclusion criteria. The mean gestational age was 38.4 ± 1.8 weeks, the mean birth weight was 3,260 ± 591 g, 52/91 (57%) of infants were males, the mean cord pH was 6.95 ± 0.21, and 10/91 (11%) of infants died. At 48 hours, 58% of infants had normal or mildly abnormal EEG background and 42% had moderate or severe EEG backgrounds. Clinical predictor variables (10-minute Apgar score, Sarnat stage, and cord pH) were modestly predictive of 48 hours EEG outcome with area under curve (AUC) of 0.66 to 0.68. A composite model of clinical and optimal time- and frequency-domain blood pressure variability had a substantially improved AUC of 0.86. CONCLUSION Time- and frequency-domain blood pressure variability biomarkers offer a substantial improvement in prediction of later adverse EEG outcomes over perinatal clinical variables in a two-center cohort of infants with HIE. KEY POINTS · Early outcome prediction in HIE is suboptimal.. · Patterns in blood pressure physiology may be predictive of short-term outcomes.. · Early time- and frequency-domain measures of blood pressure variability predict short-term EEG outcomes in HIE infants better than perinatal factors alone..
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Affiliation(s)
- Abigail Flower
- School of Data Science, University of Virginia, Charlottesville, VA
| | - Daniel Vasiliu
- Department of Mathematics, College of William & Mary, Williamsburg, VA
| | - Tianrui Zhu
- Department of Mathematics, College of William & Mary, Williamsburg, VA
| | - Robert Andris
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Maryam Abubakar
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Karen Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Santina Zanelli
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Julie Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Amit M. Mathur
- Division of Neonatal-Perinatal Medicine, Saint Louis University, St. Louis, MO
| | - John Delos
- Department of Physics, College of William & Mary, Williamsburg, VA
| | - Zachary Vesoulis
- Department of Pediatrics, Washington University St. Louis, St. Louis, MO
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12
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Sharma GK, Natarajan CK, Hementhakumar V, Sundaram S, Sharma SS. Prognostic Value of Amplitude-Integrated Electroencephalography in Term Neonates With Encephalopathy. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2323-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Garcia-Alix A, Arnaez J, Arca G, Agut T, Alarcon A, Martín-Ancel A, Girabent-Farres M, Valverde E, Benavente-Fernández I. Development, Reliability, and Testing of a New Rating Scale for Neonatal Encephalopathy. J Pediatr 2021; 235:83-91.e7. [PMID: 33857465 DOI: 10.1016/j.jpeds.2021.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To develop and test the Neonatal Encephalopathy-Rating Scale (NE-RS), a new rating scale to grade the severity of neonatal encephalopathy (NE) within the first 6 hours after birth. STUDY DESIGN A 3-phase process was conducted: (1) design of a comprehensive scale that would be specific, sensitive, brief, and unsophisticated; (2) evaluation in a cohort of infants with neonatal encephalopathy and healthy controls; and (3) validation with brain magnetic resonance imaging findings and outcome at 2 years of age. RESULTS We evaluated the NE-RS in 54 infants with NE and 28 healthy infants. The NE-RS had excellent internal consistency (Cronbach alpha coefficient: 0.93 [95% CI 0.86-0.94]) and reliability (intraclass correlation coefficient in the NE cohort 0.996 [95% CI 0.993-0.998; P < .001]). Alertness, posture, motor response, and spontaneous activity were the top discriminators for degrees of NE. The cut-off value for mild vs moderate NE was 8 points (area under the curve [AUC] 0.99, 95% CI 0.85-1.00) and for moderate vs severe NE, 30 points (AUC 0.93, 95% CI 0.81-0.99). The NE-RS was significantly correlated with the magnetic resonance imaging score (Spearman Rho 0.77, P < .001) and discriminated infants who had an adverse outcome (AUC 0.91, 95% CI 0.83-0.99, sensitivity 0.82, specificity 0.81, positive predictive value 0.87, negative predictive value 0.74). CONCLUSIONS The NE-RS is reliable and performs well in reflecting the severity of NE within the first 6 hours after birth. This tool could be useful when assessing clinical criteria for therapeutic hypothermia in NE.
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Affiliation(s)
- Alfredo Garcia-Alix
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain; NeNe Foundation, Madrid, Spain.
| | - Juan Arnaez
- NeNe Foundation, Madrid, Spain; Hospital Universitario de Burgos, Burgos, Spain
| | - Gemma Arca
- NeNe Foundation, Madrid, Spain; Hospital Clínic (Maternitat)-IDIBAPS, Barcelona, Spain
| | - Thais Agut
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain; NeNe Foundation, Madrid, Spain
| | - Ana Alarcon
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Ana Martín-Ancel
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Montserrat Girabent-Farres
- Department of Physioterapy, School of Health Sciences, TecnoCampus-Pompeu Fabra University, Mataró, Barcelona, Spain
| | - Eva Valverde
- NeNe Foundation, Madrid, Spain; Hospital Universitario La Paz, Madrid, Spain
| | - Isabel Benavente-Fernández
- NeNe Foundation, Madrid, Spain; Hospital Puerta del Mar, Cadiz, Spain; Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cádiz, Spain
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14
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Koskela T, Kendall GS, Memon S, Sokolska M, Mabuza T, Huertas-Ceballos A, Mitra S, Robertson NJ, Meek J, Whitehead K. Prognostic value of neonatal EEG following therapeutic hypothermia in survivors of hypoxic-ischemic encephalopathy. Clin Neurophysiol 2021; 132:2091-2100. [PMID: 34284244 PMCID: PMC8407358 DOI: 10.1016/j.clinph.2021.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Early prediction of neurological deficits following neonatal hypoxic-ischemic encephalopathy (HIE) may help to target support. Neonatal animal models suggest that recovery following hypoxia-ischemia depends upon cortical bursting. To test whether this holds in human neonates, we correlated the magnitude of cortical bursting during recovery (≥postnatal day 3) with neurodevelopmental outcomes. METHODS We identified 41 surviving infants who received therapeutic hypothermia for HIE (classification at hospital discharge: 19 mild, 18 moderate, 4 severe) and had 9-channel electroencephalography (EEG) recordings as part of their routine care. We correlated burst power with Bayley-III cognitive, motor and language scores at median 24 months. To examine whether EEG offered additional prognostic information, we controlled for structural MRI findings. RESULTS Higher power of central and occipital cortical bursts predicted worse cognitive and language outcomes, and higher power of central cortical bursts predicted worse motor outcome, all independently of structural MRI findings. CONCLUSIONS Clinical EEG after postnatal day 3 may provide additional prognostic information by indexing persistent active mechanisms that either support recovery or exacerbate brain damage, especially in infants with less severe encephalopathy. SIGNIFICANCE These findings could allow for the effect of clinical interventions in the neonatal period to be studied instantaneously in the future.
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Affiliation(s)
- Tuomas Koskela
- Research IT Services, University College London, London WC1E 7HB, UK.
| | - Giles S Kendall
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Academic Neonatology, Institute for Women's Health, University College London, London WC1E 6HU, UK.
| | - Sara Memon
- Department of Neuroscience, Physiology & Pharmacology, University College London, London WC1E 6BT, UK.
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Thalitha Mabuza
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Angela Huertas-Ceballos
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Subhabrata Mitra
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Academic Neonatology, Institute for Women's Health, University College London, London WC1E 6HU, UK.
| | - Nicola J Robertson
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Academic Neonatology, Institute for Women's Health, University College London, London WC1E 6HU, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
| | - Judith Meek
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Kimberley Whitehead
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Department of Neuroscience, Physiology & Pharmacology, University College London, London WC1E 6BT, UK.
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15
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Lee IC, Hong SY, Weng YH, Chen YT. Amplitude Integrated Electroencephalography and Continuous Electroencephalography Monitoring Is Crucial in High-Risk Infants and Their Findings Correlate With Neurodevelopmental Outcomes. Front Pediatr 2021; 9:691764. [PMID: 34414144 PMCID: PMC8369262 DOI: 10.3389/fped.2021.691764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To evaluate seizure diagnosis in sick infants in the neonatal intensive care unit (NICU) based on electroencephalography (EEG) monitoring combined with amplitude integrated electroencephalography (aEEG). Methods: We retrospectively reviewed EEG and aEEG findings and determined their correlations with neurodevelopmental outcomes at the age of >1 year in 65 patients with diagnosed seizures, encephalopathy, or both. Results: Seizure identification rate was 43.1%. The rate in nonstructural groups (hypocalcemic, hypoglycemic, and genetic seizures) was 71.4%, which was higher (p < 0.05) than the rate of 35.3% of structural brain lesion group [hypoxic-ischemic encephalopathy (HIE) and congenital brain structural malformation]. The aEEG background correlating with neurodevelopmental outcomes had 70.0% positive prediction value (PPV), 65.5%% negative prediction value (NPV), 67.7% specificity, and 67.9% sensitivity (p < 0.005). The aEEG background strongly (PPV, 93.8%; p < 0.005) correlated with the outcomes in HIE. For genetic seizures, the detected rate was high. The ictal recordings for the nonstructural seizures revealed downflected on the aEEG background initially, which differed from the structural lesion. Conclusions: EEG monitoring combined with aEEG can detect seizures, facilitating early treatment. EEG changes during seizures could exhibit delta-theta waves with or without clinical seizures in patients with brain lesions. In non-structural etiologies (hypocalcemic and KCNQ2 seizures), aEEG initially exhibited lower background during seizures that could aid in differentiating these EEG changes from those of other etiologies. The aEEG background was correlated with neurodevelopmental outcome and exhibited high PPV but not NPV in neonatal HIE.
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Affiliation(s)
- Inn-Chi Lee
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Syuan-Yu Hong
- Division of Pediatrics Neurology, Department of Pediatrics, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Yi-Ho Weng
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yi-Ting Chen
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
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16
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Walas W, Bandoła D, Ostrowski Z, Rojczyk M, Mączko A, Halaba Z, Nowak AJ. Theoretical basis for the use of non-invasive thermal measurements to assess the brain injury in newborns undergoing therapeutic hypothermia. Sci Rep 2020; 10:22167. [PMID: 33335145 PMCID: PMC7747633 DOI: 10.1038/s41598-020-79009-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/30/2020] [Indexed: 11/09/2022] Open
Abstract
The aim of this paper is to propose a new non-invasive methodology to estimate thermogenesis in newborns with perinatal asphyxia (PA) undergoing therapeutic hypothermia (TH). Metabolic heat production (with respect to either a neonate’s body mass or its body surface) is calculated from the newborn’s heat balance, estimating all remaining terms of this heat balance utilising results of only non-invasive thermal measurements. The measurement devices work with standard equipment used for therapeutic hypothermia and are equipped with the Global System for Mobile Communications (GSM), which allows one to record and monitor the course of the therapy remotely (using an internet browser) without disturbing the medical personnel. This methodology allows one to estimate thermogenesis in newborns with perinatal asphyxia undergoing therapeutic hypothermia. It also offers information about instantaneous values of the rate of cooling together with values of remaining rates of heat transfer. It also shows the trend of any changes, which are recorded during treatment. Having information about all components of the heat balance one is able to facilitate comparison of results obtained for different patients, in whom these components may differ. The proposed method can be a new tool for measuring heat balance with the possibility of offering better predictions regarding short-term neurologic outcomes and tailored management in newborns treated by TH.
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Affiliation(s)
- Wojciech Walas
- Paediatric and Neonatal Intensive Care Unit, University Clinical Hospital, Opole, Poland.,Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dominika Bandoła
- Department of Thermal Technology, Silesian University of Technology, Gliwice, Poland
| | - Ziemowit Ostrowski
- Department of Thermal Technology, Silesian University of Technology, Gliwice, Poland
| | - Marek Rojczyk
- Department of Thermal Technology, Silesian University of Technology, Gliwice, Poland
| | - Anna Mączko
- Paediatric and Neonatal Intensive Care Unit, University Clinical Hospital, Opole, Poland
| | - Zenon Halaba
- Department of Paediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Andrzej J Nowak
- Department of Thermal Technology, Silesian University of Technology, Gliwice, Poland.
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17
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Pacella M, Ghosh S, Middlebrook E, Bennett J, Bliznyuk N, Huene M, Copenhaver N, Sura L, Weiss MD. Combined vEEG and Cerebral Oximetry Results to Determine the Severity of Hypoxic–Ischemic Encephalopathy. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0039-1687883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AbstractThe objectives of the study were to evaluate the prognostic utility of bedside monitoring tools for hypoxic–ischemic encephalopathy (HIE) outcome and develop a prognostic predictive model. This retrospective study reviewed neonatal HIE treated with hypothermia between 2013 and 2016. Continuous video electroencephalography (vEEG) recordings scored for background electrocerebral activity, seizure, and sleep–wake cycles, and rSO2 data were stratified by magnetic resonance imaging (MRI) severity. The vEEG and rSO2 were combined in a predictive model. The analysis included 38 patients. The rSO2 was significantly higher in the severe group. vEEG showed early and persistent maximal suppression in the severe group. The predictive correlation of the rSO2 improves when combined with the vEEG.
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Affiliation(s)
- Marisa Pacella
- Department of Pediatrics, University of Florida, Gainesville, Florida, United States
| | - Suman Ghosh
- Department of Pediatrics, University of Florida, Gainesville, Florida, United States
| | - Erik Middlebrook
- Department of Radiology, University of Florida, Gainesville, Florida, United States
| | - Jeffrey Bennett
- Department of Radiology, University of Florida, Gainesville, Florida, United States
| | - Nikolay Bliznyuk
- Department of Agricultural and Biological Engineering, University of Florida, Gainesville, Florida, United States
| | - Melissa Huene
- Department of Pediatrics, University of Florida, Gainesville, Florida, United States
| | - Nicole Copenhaver
- Department of Pediatrics, University of Florida, Gainesville, Florida, United States
| | - Livia Sura
- Department of Pediatrics, University of Florida, Gainesville, Florida, United States
| | - Michael D. Weiss
- Department of Pediatrics, University of Florida, Gainesville, Florida, United States
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18
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Ouwehand S, Smidt LCA, Dudink J, Benders MJNL, de Vries LS, Groenendaal F, van der Aa NE. Predictors of Outcomes in Hypoxic-Ischemic Encephalopathy following Hypothermia: A Meta-Analysis. Neonatology 2020; 117:411-427. [PMID: 32235122 DOI: 10.1159/000505519] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/18/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prediction of neurodevelopmental outcome in infants with hypoxic-ischemic encephalopathy remains an important challenge. Various studies have shown that the predictive ability of different modalities changed after the introduction of therapeutic hypothermia. This paper reviews the diagnostic test accuracy of the different modalities that are being used to predict neurodevelopmental outcomes following therapeutic hypothermia. METHODS A systematic literature search was performed using Embase and PubMed. Two reviewers independently included eligible studies and extracted data. The quality of the studies was assessed using the Quality in Prognosis Studies Tool. Meta-analyses were performed where possible. RESULTS Forty-seven articles and 3 conference abstracts were included, reporting on 3,072infants of whom 39% died or had an adverse neurodevelopmental outcome. A meta-analysis could be performed using 37 articles on (amplitude-integrated) electroencephalography (EEG), conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), and proton magnetic resonance spectroscopy (1H-MRS). Amplitude-integrated EEG (aEEG) at 24 and 72 h showed similar high diagnostic OR, while aEEG at 6 h and EEG performed less, both due to a low specificity. For MRI, most studies reported scoring systems in which early (<8 days) MRI performed better than late (≥8 days) MRI. Injury to the posterior limb of the internal capsule on MRI or to the thalami on DWI were strong individual predictors, as was an increased lactate/N-acetylaspartate peak on 1H-MRS. CONCLUSIONS In the era of therapeutic hypothermia, the different modalities remain good predictors of neurodevelopmental outcome. However, timing should be taken into account. aEEG may initially be false positive and gets more reliable after 24 h. In contrast, MRI should be used during the first week, as its predictive value decreases afterwards.
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Affiliation(s)
- Sabine Ouwehand
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisanne C A Smidt
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands, .,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,
| | - Niek E van der Aa
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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19
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Govindan RB, Massaro A, Vezina G, Chang T, du Plessis A. Identifying an optimal epoch length for spectral analysis of heart rate of critically-ill infants. Comput Biol Med 2019; 113:103391. [PMID: 31446320 PMCID: PMC7040438 DOI: 10.1016/j.compbiomed.2019.103391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVE To identify the optimal epoch length for power spectral analysis of cardiac beat-to-beat intervals (BBi) in critically ill newborns. MATERIALS AND METHOD BBi of 49 term newborns undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy with well-defined outcomes (good outcome (n = 28): no or mild brain injury and adverse outcome (n = 21): moderate or severe brain injury or death) served as test population. A power spectrum of BBi was calculated with an autoregressive model in three different epoch lengths: 2 min, 5 min, and 10 min. Spectral power was quantified in three different frequency bands: very low-frequency (0.016-0.04 Hz), low-frequency (0.05-0.25 Hz), and high-frequency (0.3-1 Hz). In each frequency band, the absolute power and the normalized power were calculated. Furthermore, standard deviation (SDNN) of BBi was calculated. These metrics were compared between the outcome groups with a receiver operator characteristic (ROC) analysis in 3-h windows. The ROC curve area >0.7 was regarded as a significant separation. RESULTS The absolute spectral powers in all three epoch lengths in all three frequency bands and SDNN distinguished the two outcome groups consistently for most time points. The spectral metrics calculated with a 2-min epoch length performed as well as the five- and 10-min epoch lengths (paired t-test P < 0.05). CONCLUSION Spectral analysis of BBi in 2-min epoch shows a similar discriminatory power as longer epoch lengths. A shorter epoch also has clinical advantages for translation into a continuous real-time bedside monitor of heart rate variability in the intensive care unit.
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Affiliation(s)
- R B Govindan
- Fetal Medicine Institute, Children's National Medical Center, Washington, DC, USA; The George Washington University School of Medicine, USA.
| | - An Massaro
- The George Washington University School of Medicine, USA; Neonatology, Children's National Medical Center, Washington, DC, USA
| | - Gilbert Vezina
- The George Washington University School of Medicine, USA; Diagnostic Imaging and Radiology, Children's National Medical Center, Washington, DC, USA
| | - Taeun Chang
- The George Washington University School of Medicine, USA; Neurology, Children's Medical Center, Washington, DC, USA
| | - Adre du Plessis
- Fetal Medicine Institute, Children's National Medical Center, Washington, DC, USA; The George Washington University School of Medicine, USA
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20
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Bruns N, Sanchez-Albisua I, Weiß C, Tschiedel E, Dohna-Schwake C, Felderhoff-Müser U, Müller H. Amplitude-Integrated EEG for Neurological Assessment and Seizure Detection in a German Pediatric Intensive Care Unit. Front Pediatr 2019; 7:358. [PMID: 31555625 PMCID: PMC6722192 DOI: 10.3389/fped.2019.00358] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/15/2019] [Indexed: 01/04/2023] Open
Abstract
Objective: The aim of our study was to assess the use of aEEG in our pediatric intensive care unit (PICU), indications for neuromonitoring and its findings, utility for seizure detection, and associations with outcome. Design: We retrospectively analyzed non-neonates who were treated in our PICU and received amplitude-integrated EEG (aEEG). Patients: 27 patients aged between 29 days and 10 0/12 years (median 7.3 months) were included, who received a total of 35 aEEGS. Measurements: aEEG tracings were assessed for background (BG) pattern and its evolution, seizures, and side differences using a visual classification (Hellström-Westas). Clinical data were collected from patients' histories and analyzed for correlation with aEEG findings. Main results: While rare in early years, there was an increase in use over time. Most aEEGs were conducted because of (suspected) seizures or for management of antiepileptic treatment. aEEG had low sensitivity but high specificity for recognition of pathological BG pattern with reference to conventional EEG. Worsening of BG pattern or failure to improve was associated with death. Seizure detection rates by aEEG were higher than by clinical observation, especially for identification of non-convulsive epileptic state (ES). Side differences in aEEG were rare, but if present, they were associated with unilateral brain injury. Conclusions: aEEG is useful for the detection of seizures and ES in pediatric intensive care patients. Abnormal BG pattern and poor evolution of BG are negatively associated with survival. aEEG is a potential supplement to conventional EEG, facilitating long-term surveillance of cerebral function when continuous full-channel EEG is not available. Further investigation is needed.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Iciar Sanchez-Albisua
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christel Weiß
- Department of Medical Statistics and Biomathematics, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Eva Tschiedel
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Hanna Müller
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
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