Perlman J, Clinics Perinatol 2006; 33: Underlying causal pathways. Antenatal Intrapartum Postpartum. Acute near total asphyxia

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1 Perlman J, Clinics Perinatol 2006; 33: Underlying causal pathways Antenatal Intrapartum Postpartum Acute injury Subacute injury Associated problem Reduced fetal movements Placental insufficiency Sentinel event Placental abruption Uterus rupture Tight nuchal cord Postnatal collapse Postnatal infection ECMO+complic WS injury BGT injury BGT-WS-stroke Or a combination of two or three Acute near-total asphyxia Acute near total asphyxia Injury to central grey matter with low cord ph is the imaging signature of acute severe hypoxia ischaemia T1 DWI T2 Shoulder dystocia; Apgar 0/1/1; cap.ph 6.4 Homozygous for MTHFR (C677T) Acute Injury GA 42 1/7; emcs, 2 knots in umb.cord; IR sequence / ADC Day 4; normal PLIC? 1

2 Second of full-term twins; EmCS with prolapsed cord; Apgar 2/4/6 Motor outcome according to 3 lesion patterns; mild: Lent.+VLT only; intermediate: Lent, VLT, Perirolandic Severe: same +hippocampus Not able to sit < 2y Mild, walks<5y or sits <2y Neonatal T 2 SE (day 10) and FLAIR at 2 yrs Krägeloh-Mann and de Vries, DMCN 2002 Dyskinetic cerebral palsy: a population based study of children born between 1991 and 1998 Himmelman et al Dev Med Child Neurol 2007 Predicting motor outcome and death in term hypoxicischemic encephalopathy. Martinez-Biarge M et al; Neurology 2011 An abnormal PLIC predicted the inability to walk independently by 2 years with a sensitivity of 0.92, a specificity of 0.77 Martinez- Biarge M, Neurology 2011 * Rutherford et al; Pediatrics

3 Cerebral Magnetic Resonance Biomarkers in Neonatal Encephalopathy: A Meta-analysis. Thayyil S et al; Pediatrics 2010; e382 1 H-MRS Conventional early MRI: Pooled sensitivity 0.86; specificity H MR Spectroscopy Cerebral Magnetic Resonance Biomarkers in Neonatal Encephalopathy: A Meta-analysis. Thayyil S et al; Pediatrics 2010; e382 Cho Cr NAA Lac Lac/NAA ratio day 1-30 Pooled sensitivity 0.95; Specificity 0.82 Asphyxia : Value of DW-MR Imaging and 1 H MR Spectroscopy Asphyxia : Value of Diffusionweighted MR Imaging and 1 H MR Spectroscopy Scatterplots of ADCs in the basal ganglia versus postnatal age in neonates examined 7 days or less after birth = favorable outcome, = adverse outcome 3

4 Asphyxia : Value of Diffusionweighted MR Imaging and 1 H MR Spectroscopy Asphyxia : Value of Diffusionweighted MR Imaging and 1 H MR Spectroscopy Conclusions Function and neuroimaging in cerebral palsy: a populationbased study. Himmelmann K, Uvebrant P, DMCN 2011 Morphologic MR imaging scores combined with either proton 1 H-MRS or BGT-ADC obtained during the 1st week of life showed a significantly better association ( P =.006 for lac/naa; P.0001 for ADC) with neurodevelopmental outcome in term infants with HIE following perinatal asphyxia than morphologic MRI alone. General Movements in Full-Term Infants with Perinatal Asphyxia are Related to Basal Ganglia and Thalamic Lesions. Ferrari et al; J Pediatr 2011 Subacute Partial Asphyxia adapted from Leech

5 Prolonged partial asphyxia Injury to boundary zones-watershed injury is the imaging signature of partial prolonged hypoxia ischaemia injury is best seen with early DWI and can be uni/bilateral T2S E GA 40 5/7; tachycardia CTG, CS DWI 3m T2 DWI DWI MRI day 5 and 3 months and 6 yrs + or Clin. at 6 m T2 3m, IR at 3m and at 15 months Normal outcome in spite of extensive DWI changes and even cystic evolution in one Harteman J et al, Submitted Results: n=18 Clinical characteristics Characteristic (n/%) WS only n = 7 WS + BGT n = 11 Male 4 (57) 5 (46) Gestational age (median) 40,7 40,6 Birth weight (median) Umb art ph (median)** Apgar at 1 min (median)** 8 4 Apgar at 5 min (median)** 9 7 EmCS 2 (29) 6 (55) CTG decelerations 7 (100) 11 (100) MOF 6 (86) 10 (91) Hypoglycaemia < 2.0 mmol/l** 1 (14) 7 (70) Mechanical ventilation** 3 (43) 10 (91) 5

6 Results: MRI findings Results: neurodevelopmental outcome n=18 Bilateral involvement 18 Symmetrical involvement 8 Posterior = anterior 12 Posterior > anterior 3 Anterior > posterior 3 Associated BGT 11 Cystic evolution 3 WS only n=7 WS and BGT involvement n=11 Died 0 6 DQ > 85 at months 6 0 Postneonatal Epilepsy 1 3 Cerebral palsy 0 2 Behavioral problems/autism 2 0 Cerebral Visual impairment 2 1 White Matter and Cortical Injury in HIE: Antecedent Factors and 2-Year Outcome. Martinez-Biarge M, J Pediatr 2012 Neonatal Watershed Brain Injury on MRI Correlates with Verbal IQ; Steinman KJ et al; Pediatrics 2009 Fig 1 Axial illustration of the brain showing the subtypes of intracranial haemorrhage Precipitous delivery Salman, R. A.-S. et al. BMJ 2009;339:b2586 Copyright 2009 BMJ Publishing Group Ltd. 6

7 Intracranial hemorrhage in full-term newborns: a hospital-based cohort study. Brouwer AJ et al; Neuroradiology 2010 N=53 ( ); Clinical or subclinical seizures were seen in 48/53 (90.6%) infants Twenty-one infants (39.6%) showed an associated midline shift. Three had surgical intervention Thirteen infants died (24.5%) Three developed CP (8.6%) and 1 developed ataxia The mean DQ was 97 (SD=12). Head Ultrasound and MR Imaging in the Evaluation of Neonatal Encephalopathy: Competitive or Complementary Imaging Studies? Epelman et al; Magn Reson Imaging Clin N Am 20 (2012) Conclusions cus can paly a role in the full-term infant, but MRI is superior, especially when performed early and including DWI Pattern recognition is helpful and helps to understand the causal pathways Prognosis better than expected in the absence of associated involvement of the basal ganglia 7