Imaging findings in neonates with hypoxic-ischaemic encephalopathy and terapeutic hypothermia.

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1 Imaging findings in neonates with hypoxic-ischaemic encephalopathy and terapeutic hypothermia. Poster No.: C-1577 Congress: ECR 2014 Type: Scientific Exhibit Authors: S. Manso Garcia, M. J. Velasco Marcos, T. Escudero Caro, C. Sales Fernandez, V. Alvarez-Guisasola Blanco, M. Mendo Gonzalez, S. Caserio Carbonero, M. V. Garcia urbon, A. A. Monte Tome; Valladolid/ES Keywords: Ischemia / Infarction, Technical aspects, Ultrasound, MR-Diffusion/ Perfusion, MR, Pediatric, Neuroradiology brain DOI: /ecr2014/C-1577 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Aims and objectives Review the radiological findings in newborns infants wiith hypoxic-ischaemic encephalopathy treated with hypothermia in our hospital between Images for this section: Fig. 1: TOTAL BODY HYPOTERMIA SYSTEM CRITICOOL Page 2 of 15

3 Methods and materials Neonatal encephalopathy is a heterogeneous syndrome characterized by symptoms of central nervous system dysfunction in newborns born at term or late preterm (#36 weeks gestation). An infant with neonatal encephalopathy may exhibit abnormal level of consciousness, seizures, tone and reflex abnormalities, apnea, and feeding difficulties Hypoxic Ischemic Encephalopathy (HIE) caused by perinatal asphyxia is one of the primary causes of morbidity and mortality among term infants.therapeutic hypothermia in newborns with hypoxic-ischaemic encephalopathy reduces the risk of death and neurological impaiment at 18 months and is a safe procedure when applied in specific neonatal units and following strict protocols and cooling overheating. Neuroimaging is important in the evaluation of neonatal encephalopathy, and may provide information regarding the type and timing of brain injury. Cranial sonography has a high sensitivity and specificity (91 and 81 percent, respectively) for locating hemorrhages and defining ventricular size. It may also detect severe parasagittal white matter damage and obvious cystic lesions, but it does not adequately image the outer limits of the cerebral cortex, nor is cranial sonography a sensitive tool for identifying milder white matter abnormalities that can be appreciated on head MRI(Fig 2 y 3) MRI is increasingly being used to examine brain pathology among HIE infants. Brain edema, a consequence of perinatal asphyxia, can be visualized using diffusion weighted imaging (DWI). Already at 24 hours following the insult, decreased apparent diffusion coefficient (ADC) values can be measured using DWI. The number of lesions seen on DWI images, has been shown to correlate with later neurodevelopmental outcome(fig 7 y 8). We review all newborns infants with therapeutic hypothermia in hospital rio hortega between june 2010 and may 2013 with a established protocol of whole body hyppthermia. A retrospective analysis of 21 newborns treated with therapeutic hypothermia using ultrasound and MRI 1,5 T between first and fifteen days of life was performed. Images for this section: Page 3 of 15

4 Fig. 2: We performed first ultrasound in the first 24 hours and evaluate to IR with Doppler. Fig. 3: Findings include increased echogenicity in white matter and resultant increased gray matter-white matter differentiation Page 4 of 15

5 Fig. 4: MRI is esential in encephalopathy ischaemic-hipoxic study. MRI performed between 7-14 days after the insult.in this moment MRI shows the thalami and basal ganglia lesions. Page 5 of 15

6 Fig. 5: Evaluation of neonatal brain images for signs of hypoxic injury required attention to a specific set of signs.this four signs facilitate the diagnosis of hipoxia in the neonate. Page 6 of 15

7 Fig. 6: Axial T1 sequences. large arrow: high intensity of signal in basal ganglia. short arrow: Loss of the normal signal in the posterior limb of the internal capsule. Page 7 of 15

8 Fig. 7: Diffusion sequences Page 8 of 15

9 Fig. 8: Aim and Objetives Page 9 of 15

10 Fig. 9: Matherial and methods Page 10 of 15

11 Results Of births, we studied 21 newborns who were treated with therapeutic hypothermia. This represent a prevalence of 0.1%. HIE was moderated in 12(57%) and severe in 9(43%).Five patients died (23,8%). Eco-Doppler after the first twelve hours detected pathology in seven infants (33,3%) with a IR < 0,6. MRI was performed after seven days in 19 newborns (90,4%) and was normal in 8 (42,1%).In 11(57,8%),we detected the characteristic radiological findings in a terms neonats hipoxy such a high signal in basal ganglia,high signal in thalamy, loss of the normal signal ontensity within the posterior limb of the internal capsule in T1 sequences and restriction in difussion sequences. Images for this section: Fig. 10: Results Page 11 of 15

12 Fig. 11: Results Page 12 of 15

13 Fig. 12: Results Fig. 13: Results Page 13 of 15

14 Conclusion Hypothermia is the only effective neuroprotective therapy currently available for treatment of neonatal encephalopathy. It is easy to administer and appears to be safe. There is a consensus among experts that therapeutic hypothermia should be more widely available, based upon the benefit and safety of hypothermia, and the lack of other effective treatments. Therapeutic hypothermia improves survival and neurodevelopment in newborns with moderate to severe HIE. Cranial ultrasound will always provide a method for screening and monitoring the evolution of lesions but is not as good as MRI at determining the exact site, and extent of lesions. The combination of cranial ultrasound and MRI is ideal for assessing the newborn brain. Implementation of therapeutic hypothermia should follow published protocols employed in one of the major published trials. MRI provides information that allows fairly accurate approach to the prediction of long term neurodevelopmental form. Images for this section: Fig. 14: Conclusions Page 14 of 15

15 Personal information References Rutherford, M., et al., Assessment of brain tissue injury after moderate hypothermia in neonates with hypoxic-ischaemic encephalopathy: a nested substudy of a randomised controlled trial. Lancet Neurol, (1): p Heinz ER, Provenzale JM.Imaging findings in neonatal hypoxia:a practical review.ajr.2009;192: Page 15 of 15