Novel Quantitative Contrast-Enhanced Ultrasound Detection of Hypoxic Ischemic Injury in Neonates and Infants: Pilot Study 1.
Hwang Misun,Sridharan Anush,Darge Kassa,Riggs Becky,Sehgal Chandra,Flibotte John,Huisman Thierry A G M
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVES:To investigate whether quantitative contrast-enhanced ultrasound (CEUS) can accurately identify neonates and infants with hypoxic ischemic brain injury. METHODS:In this prospective cohort study, 8 neonates and infants with a suspicion of hypoxic ischemic injury were evaluated with CEUS. RESULTS:An interesting trend was observed in the central gray nuclei-to-cortex perfusion ratios. The ratios at the peak enhancement, wash-in area under the curve, perfusion index, and maximum wash-in slopes were lower in all of the affected cases compared to the normal group but not statistically significant given the small sample size (P = .0571). Additionally, when the central gray nuclei-to-cortex perfusion ratio was plotted for all time points along the time-intensity curve, it was observed that the affected cases showed a trend that was qualitatively different from that of the normal cases. In the affected cases, the ratio time-intensity curves either stayed below 1.0 for the entire enhancement period or reached 1.0 close to peak wash-in before falling just below 1.0 for the remaining period of enhancement. However, in the unaffected patients, there was a steep wash-in that crossed the 1.0 threshold and remained above 1.0 for most of the enhancement period. CONCLUSIONS:Bedside CEUS is an easily obtainable brain-imaging modality that has the potential to effectively identify infants and neonates with evolving brain injury. A larger prospective study evaluating the correlation between CEUS findings and the reference standard of diffusion- and perfusion-weighted magnetic resonance imaging is needed to establish it as a diagnostic tool.
Ultrafast Doppler reveals the mapping of cerebral vascular resistivity in neonates.
Demené Charlie,Pernot Mathieu,Biran Valérie,Alison Marianne,Fink Mathias,Baud Olivier,Tanter Mickaël
Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism
In vivo mapping of the full vasculature dynamics based on Ultrafast Doppler is showed noninvasively in the challenging case of the neonatal brain. Contrary to conventional pulsed-wave (PW) Doppler Ultrasound limited for >40 years to the estimation of vascular indices at a single location, the ultrafast frame rate (5,000 Hz) obtained using plane-wave transmissions leads to simultaneous estimation of full Doppler spectra in all pixels of wide field-of-view images within a single cardiac cycle and high sensitivity Doppler imaging. Consequently, 2D quantitative maps of the cerebro-vascular resistivity index (RI) are processed and found in agreement with local measurements obtained on large arteries of healthy neonates using conventional PW Doppler. Changes in 2D resistivity maps are monitored during recovery after therapeutic whole-body cooling of full-term neonates treated for hypoxic ischemic encephalopathy. Arterial and venous vessels are unambiguously differentiated on the basis of their distinct hemodynamics. The high spatial (250 × 250 μm(2)) and temporal resolution (<1 ms) of Ultrafast Doppler imaging combined with deep tissue penetration enable precise quantitative mapping of deep brain vascular dynamics and RI, which is far beyond the capabilities of any other imaging modality.
Routine assessment of cerebroplacental ratio at 35-37 weeks' gestation in the prediction of adverse perinatal outcome.
Akolekar Ranjit,Ciobanu Anca,Zingler Emilie,Syngelaki Argyro,Nicolaides Kypros H
American journal of obstetrics and gynecology
BACKGROUND:Third-trimester studies in selected high-risk pregnancies have reported that low cerebroplacental ratio, due to high pulsatility index in the umbilical artery, and or decreased pulsatility index in the fetal middle cerebral artery, is associated with increased risk of adverse perinatal outcomes. OBJECTIVE:To investigate the predictive performance of screening for adverse perinatal outcome by the cerebroplacental ratio measured routinely at 35-37 weeks' gestation. STUDY DESIGN:This was a prospective observational study in 47,211 women with singleton pregnancies undergoing routine ultrasound examination at 35 to 37 weeks' gestation, including measurement of umbilical artery-pulsatility index and middle cerebral artery-pulsatility index. The measured umbilical artery-pulsatility index and middle cerebral artery-pulsatility index and their ratio were converted to multiples of the median after adjustment for gestational age. Multivariable logistic regression analysis was used to determine whether umbilical artery-pulsatility index, middle cerebral artery-pulsatility index, and cerebroplacental ratio improved the prediction of adverse perinatal outcome that was provided by maternal characteristics, medical history, and obstetric factors. The following outcome measures were considered: (1) adverse perinatal outcome consisting of stillbirth, neonatal death, or hypoxic-ischemic encephalopathy grades 2 and 3; (2) presence of surrogate markers of perinatal hypoxia consisting of umbilical arterial or venous cord blood pH ≤7 and ≤7.1, respectively, 5-minute Apgar score <7, or admission to the neonatal intensive care unit for >24 hours; (3) cesarean delivery for presumed fetal compromise in labor; and (4) neonatal birthweight less than the third percentile for gestational age. RESULTS:First, the incidence of adverse perinatal outcome, presence of surrogate markers of perinatal hypoxia, and cesarean delivery for presumed fetal compromise in labor was greater in pregnancies with small for gestational age neonates with birthweight <10th percentile compared with appropriate for gestational age neonates; however, 80%-85% of these adverse events occurred in the appropriate for gestational age group. Second, low cerebroplacental ratio <10th percentile was associated with increased risk of adverse perinatal outcome, presence of surrogate markers of perinatal hypoxia, cesarean delivery for presumed fetal compromise in labor, and birth of neonates with birthweight less than third percentile. However, multivariable regression analysis demonstrated that the prediction of these adverse outcomes by maternal demographic characteristics and medical history was only marginally improved by the addition of cerebroplacental ratio. Third, the performance of low cerebroplacental ratio in the prediction of each adverse outcome was poor, with detection rates of 13%-26% and a false-positive rate of about 10%. Fourth, the detection rates of adverse outcomes were greater in small for gestational age than in appropriate for gestational age babies and in pregnancies delivering within 2 weeks rather than at any stage after assessment; however, such increase in detection rates was accompanied by an increase in the false-positive rate. Fifth, in appropriate for gestational age neonates, the predictive accuracy of cerebroplacental ratio was low, with positive and negative likelihood ratios ranging from 1.21 to 1.82, and 0.92 to 0.98, respectively; although the accuracy was better in small for gestational age neonates, this was also low with positive likelihood ratios of 1.31-2.26 and negative likelihood ratios of 0.69-0.92. Similar values were obtained in fetuses classified as small for gestational age and appropriate for gestational age according to the estimated fetal weight. CONCLUSIONS:In pregnancies undergoing routine antenatal assessment at 35-37 weeks' gestation, measurement of cerebroplacental ratio provides poor prediction of adverse perinatal outcome in both small for gestational age and appropriate for gestational age fetuses.
Ultrasound Predicts White Matter Integrity after Hypothermia Therapy in Neonatal Hypoxic-Ischemic Injury.
Salas Jacqueline,Reddy Nihaal,Carson Kathryn A,Northington Frances J,Huisman Thierry A G M
Journal of neuroimaging : official journal of the American Society of Neuroimaging
BACKGROUND:Hypoxic-ischemic injury (HII) is a major cause of neonatal death and neurodevelopmental disability. Head ultrasounds (HUS) in neonates with HII often show enhanced gray/white matter differentiation. We assessed the significance of this finding in predicting white matter structural integrity measured by diffusion tensor imaging (DTI) in neonates with HII. METHODS:We performed a quantitative region of interest-based analysis of white and gray matter echogenicity within the cingulate gyrus on pre- and posthypothermia HUS. We also completed a quantitative analysis of fractional anisotropy (FA) and mean (MD), axial (AD), and radial (RD) diffusivity within the bilateral anterior and posterior centrum semiovale (CSO) on posthypothermia brain magnetic resonance imaging. For HUS studies, we calculated a white-to-gray matter echogenicity ratio (WGR) and subsequently correlated it to DTI measurements. RESULTS:Forty-two term neonates with HII who underwent hypothermia therapy were included. Significant correlation was found between prehypothermia WGR and MD, AD, and RD values in the left anterior CSO (r = .38-.40, P = .02). Prehypothermia WGR also correlated with the following: MD and RD in the right anterior CSO (r = .35-.36, P = .04), MD and AD in the right posterior CSO (r = .32-.45, P = .008-.03), and AD in the left posterior CSO (r = .47, P = .005). No significant correlation was found either between prehypothermia WGR and FA values in the bilateral anterior and posterior CSO or between posthypothermia WGR and all DTI scalars in the bilateral anterior and posterior CSO. CONCLUSIONS:Prehypothermia HUS WGR may predict posthypothermia white matter structural integrity and is potentially an early and easily obtainable biomarker of severity in neonatal HII.
The value of ultrasonography and Doppler sonography in prognosticating long-term outcomes among full-term newborns with perinatal asphyxia.
Kudrevičienė Aušrelė,Basevičius Algidas,Lukoševičius Saulius,Laurynaitienė Jūratė,Marmienė Vitalija,Nedzelskienė Irena,Buinauskienė Jūratė,Stonienė Dalia,Tamelienė Rasa
Medicina (Kaunas, Lithuania)
BACKGROUND AND OBJECTIVE:The aim of the study was to determine the correlation of hypoxic-ischemic (HI) brain injury in full-term neonates detected via ultrasonography (USG) and blood flow parameters evaluated via Doppler sonography (DS) with long-term outcomes of mental and neuromotor development at the age of 1-year. MATERIALS AND METHODS:In total, 125 full-term neonates (78 subjects of case group and 47 subjects of control group) were studied. During the first five days of life, the subjects daily underwent cerebral USG and DS. At the age of 1-year the neuromotor condition and mental development was evaluated. RESULTS:The HI injury groups detected during USG significantly correlated with the mental development groups (r=0.3; P=0.01) and the neurological evaluation groups (r=0.3; P<0.001). In the presence of brain swelling (edema) and thalamus and/or basal ganglia (E/T/BG) injury, USG demonstrated high accuracy values when prognosticating spastic quadriparesis and severe mental development impairment in 1-year-old subjects: sensitivity - 100%, specificity - 93-100%, positive predictive value (PPV) - 60-100%, and NPV - 100%. In subjects with spastic quadriparesis, mean end-diastolic velocity (Vd) values were significantly higher (P≤0.05), and mean resistive index (RI) values were significantly lower (P<0.05) than those in subjects with normal neuromotor development. In subjects with severe mental retardation, mean Vd values in ACA were statistically significantly higher, and mean RI values in ACA and ACM were statistically significantly lower than those in subjects with normal mental development. CONCLUSIONS:Hypoxic-ischemic brain changes detected during ultrasonography and cerebral blood flow parameters associated with long-term outcomes of mental and neuromotor development at the age of 1-year.
Biventricular function on early echocardiograms in neonatal hypoxic-ischaemic encephalopathy.
Aggarwal Sanjeev,Natarajan Girija
Acta paediatrica (Oslo, Norway : 1992)
AIM:To compare early (<24 hours) echocardiograms (ECHOs) in infants with perinatal hypoxic-ischaemic encephalopathy (HIE) undergoing (i) therapeutic hypothermia (TH), (ii) normothermia and (iii) normal controls. METHODS:This was a single-centre retrospective review of clinical early ECHOs of term infants with moderate or severe HIE and controls (with a normal ECHO <72 hours of age). Right (RVO) and left ventricular output (LVO), RV and LV myocardial performance index (MPI), systolic to diastolic duration ratio (S/D) and eccentricity indices (EI) in systole and diastole were compared using ANOVA. RESULTS:Among infants with HIE (n = 56, 38 in the TH and 18 in normothermia groups), 14 (25%) infants died and 42 survived. Significantly elevated biventricular MPI, lower RVO and LVO and pulmonary hypertension (abnormal EI, higher RV S/D and bidirectional or right-to-left ductal shunt) were found in groups with HIE, compared to controls (n = 35). LV MPI was lower in HIE-TH, compared to the HIE-normothermia group. Infants with HIE who died (n = 14) had a significantly lower EId [0.77 (0.09) vs. 0.83 (0.08), p = 0.021] compared to survivors (n = 42). CONCLUSION:Infants with perinatal HIE have ventricular dysfunction; those who died had significantly lower EId than survivors; this association needs to be further validated.
Early MRI in neonatal hypoxic-ischaemic encephalopathy treated with hypothermia: Prognostic role at 2-year follow-up.
Charon Valérie,Proisy Maïa,Bretaudeau Gilles,Bruneau Bertrand,Pladys Patrick,Beuchée Alain,Burnouf-Rose Gladys,Ferré Jean-Christophe,Rozel Céline
European journal of radiology
UNLABELLED:The prognostic role of early MRI (≤ 6 days of life) is still uncertain in hypoxic-ischaemic encephalopathy (HIE) treated with hypothermia. OBJECTIVE:To compare the prognostic value of early (≤ 6 days) and late MRIs (≥ 7 days) in predicting adverse outcome at 2 years old in asphyxiated term neonates treated with hypothermia. METHODS:This retrospective study included all asphyxiated neonates eligible for hypothermia treatment between November 2009 and July 2012. Two MRI scans were performed at a median age of day 4 (early MRI) and day 11 (late MRI). Two radiologists analysed independently each MRI. Imaging was classified as normal/subnormal or abnormal, using a visual analysis. Apparent diffusion coefficient (ADC) values were measured within predefined areas and posterior limb of internal capsule (PLIC) signal intensity was analysed. Neurodevelopmental outcome was assessed at 18-41 months (median age 24 months) as favourable or adverse. RESULTS:Of the 38 neonates followed up, 8 had an adverse outcome, all related to abnormal MRIs. Twenty-nine neonates had both MRIs sequentially. Both early and late MRIs yielded 100% sensitivity for adverse outcome by using the visual analysis. Early MRI had a higher specificity than late MRI (96.3% versus 89.3%). ADC measurements did not provide further information than visual analysis. PLIC signal abnormalities were a good predictor of adverse outcome on both MRIs. CONCLUSION:Early MRI (≤ 6 days) was a good predictor of neurodevelopmental outcome at 2 years old. It could reliably guide intensive care decisions after the end of hypothermia treatment.
A study on voiding pattern of newborns with hypoxic ischemic encephalopathy.
Wen Jian G,Yang Li,Xing Lu,Wang Ya L,Jin Chao N,Zhang Qian
OBJECTIVE:To investigate the difference of voiding pattern between newborns with and those without hypoxic ischemic encephalopathy (HIE). METHODS:Forty hospitalized newborns aged 4-21 days were included in this study. Twenty-one were preterm newborns with HIE, and the remaining 19 preterm newborns were without HIE. The voided volume, postvoid residual (PVR) volume, consciousness at voiding, voiding time, voiding frequency, and quantity of intake milk and liquid within 4 hours from 8 am-12 pm were recorded. The liquid intake was the same in both groups according to standard protocol. The diaper weight difference before and after voiding was defined as voided volume. The PVR volume was determined by ultrasound. The state of consciousness at voiding was monitored by electroencephalography. RESULTS:Voided volume and rate of consciousness at voiding was significant lower in newborns with HIE compared with the control group ([10.8 ± 6.5 mL, 16.3 ± 17.1%] vs [14.1 ± 7.1 mL, 57.1 ± 21.0%], P <.05, respectively), whereas PVR volume and voiding frequency were significant higher ([1.6 ± 1.0 mL, 4.0 ± 1.1 times] vs [1.2 ± 0.9 mL, 3.2 ± 0.9 times] per 4 hours, P <.05, respectively). CONCLUSION:The differences in voiding pattern supported the concept that the higher centers of the central nervous system were involved in the control of voiding. HIE had a significant effect on voiding pattern of preterm newborn.
Low cerebral blood flow velocity and head circumference in infants with severe hypoxic ischemic encephalopathy and poor outcome.
Ilves Pilvi,Lintrop Mare,Talvik Inga,Muug Külli,Maipuu Lea,Metsvaht Tuuli
Acta paediatrica (Oslo, Norway : 1992)
AIMS:To evaluate long-term changes in cerebral blood flow velocity (CBFV) and head circumference in asphyxiated infants. METHODS:CBFV was measured in 83 asphyxiated and 115 healthy term infants in anterior and middle cerebral, basilar and internal carotid artery (ICA) up to the age of 60-149 days. The psychomotor development and head circumference was followed for 18 months. RESULTS. Mean CBFV was increased (p < 0.05) during the first days after asphyxia in infants with severe hypoxic-ischemic encephalopathy (HIE) (n = 25) compared to control group or infants with mild to moderate HIE (n = 58) with maximum values found at the age of 36-71.9 h: in ICA (mean [95% CI]) 31.2 (25.5-36.6) cm/s in severe HIE infants compared to 13.0 (12.2-13.9) cm/s in controls. Decreased (p < 0.0001) mean CBFV developed in severe HIE infants by the age of 21-59 days: in ICA 14.1 (11.5-16.8) cm/s compared to 22.9 (21.4-24.4) cm/s in controls. Infants with severe HIE had similar mean height but lower head circumferences compared to controls (p < 0.05) at the age of 21-59 days. CONCLUSION:The high mean CBFV found in infants with severe HIE during the first days after asphyxia is temporary and low CBFV and head circumference develops by the age of 21-59 days.
Changes in pulmonary arterial pressure in term-infants with hypoxic-ischemic encephalopathy.
Liu Jing,Feng Zhi-Chun
Pediatrics international : official journal of the Japan Pediatric Society
BACKGROUND:Hypoxic-ischemic encephalopathy (HIE) is an important complication that results from birth asphyxia or some other adverse conditions and has a high risk of neonatal morbidity and mortality. It is unclear, however, whether the elevated pulmonary arterial pressure (PAP) can aggravate the condition and prognosis of HIE. The purpose of the present study was to investigate the relationship between the changes of PAP and HIE in term infants after birth asphyxia. METHODS:The left/right ventricle pre-ejection phase (LPEP/RPEP), left/right ventricle ejection time (LVET/RVET) and the ratios of LPEP/LVET and RPET/RVET were evaluated in 40 term infants with HIE and 40 healthy controls on days 1, 3, 7, and 12-14 after birth using echocardiogram. PAP such as pulmonary arterial diastolic pressure (PADP, mmHg), pulmonary arterial resistance (PAR, mmHg), and pulmonary arterial resistance/systemic resistance ratio (PAR/RS) was calculated using these indexes. Patient mortality was also evaluated. RESULTS:PADP, PAR, and PAR/RS were significantly higher in HIE patients than in healthy controls during the first week after birth, particularly in severe-degree HIE patients. And until the end of the first week of life, these indexes may return to the levels of healthy controls. Persistent fetal circulation (PFC) was found in nine patients (7/16 severe, 2/12 moderate HIE patients), and non-PFC was found in mild HIE patients. Two patients with PFC died. No patients without PFC died. The course of HIE was longer in patients with pulmonary hypertension than in those without. CONCLUSION:Increased PAP is an important pathophysiological process that may influence the course and prognoses of HIE in infants after birth asphyxia, particular in severe HIE patients who often have PFC. Thus it is important to assess changes in PAP using echocardiography.
Changes in cerebral and visceral blood flow velocities in asphyxiated term neonates with hypoxic-ischemic encephalopathy.
Ilves Pilvi,Lintrop Mare,Talvik Inga,Muug Külli,Maipuu Lea
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVE:The purpose of this study was to evaluate changes in the Doppler blood flow velocity (BFV) in the cerebral and visceral arteries in asphyxiated term neonates. METHODS:The BFV was measured in 47 asphyxiated and 37 healthy term neonates in the anterior cerebral artery, middle cerebral artery, basilar artery, internal carotid artery, celiac artery (CA), superior mesenteric artery (SMA), and renal artery (RA) up to the age of 60 to 149 days. RESULTS:At the age of 12 to 120 hours after asphyxia, the mean BFV had increased, and the resistive index (RI) had decreased (P < .05) in all cerebral arteries in neonates with severe hypoxic-ischemic encephalopathy (HIE) compared with the control group. In neonates with severe HIE, the mean BFV in the RA had significantly decreased at the age of 3 to 240 hours, and the RI had increased at the age of 24 to 240 hours, normalizing by the age of 21 to 59 days compared with the control group (P < .05). In the SMA, a decreased mean BFV was found in neonates with severe HIE compared with those with mild to moderate HIE only at the age of 24 to 36 hours. In neonates with mild to moderate HIE, the mean BFV had increased in the SMA and CA compared with the control group at the age of 2 to 11.9 hours. CONCLUSIONS:A severe alteration of the cerebral and visceral BFV takes place during the first days after asphyxia in neonates with different severities of HIE.
Basal ganglia perfusion using dynamic color Doppler sonography in infants with hypoxic ischemic encephalopathy receiving therapeutic hypothermia: a pilot study.
Faingold Ricardo,Cassia Guilherme,Morneault Linda,Saint-Martin Christine,Sant'Anna Guilherme
Quantitative imaging in medicine and surgery
BACKGROUND:The objective of this study was to evaluate the cerebral perfusion of the basal ganglia in infants with hypoxic-ischemic encephalopathy (HIE) receiving hypothermia using dynamic color Doppler sonography (CDS) and investigate for any correlation between these measurements and survival. METHODS:Head ultrasound (HUS) was performed with a 9S4 MHz sector transducer in HIE infants submitted to hypothermia as part of their routine care. Measurements of cerebral perfusion intensity (CPI) with an 11LW4 MHz linear array transducer were performed to obtain static images and DICOM color Doppler videos of the blood flow in the basal ganglia area. Clinical and radiological data were evaluated retrospectively. The video images were analyzed by two radiologists using dedicated software, which allows automatic quantification of color Doppler data from a region of interest (ROI) by dynamically assessing color pixels and flow velocity during the heart cycle. CPI is expressed in cm/sec and is calculated by multiplying the mean velocity of all pixels divided by the area of the ROI. Three videos of 3 seconds each were obtained of the ROI, in the coronal plane, and used to calculate the CPI. Data are presented as mean ± SEM or median (quartiles). RESULTS:A total of 28 infants were included in this study: 16 male, 12 female. HUS was performed within the first 48 hours of therapeutic hypothermia treatment. CPI values were significantly higher in the seven non-survivors when compared to survivors (0.226±0.221 . 0.111±0.082 cm/sec; P=0.02). CONCLUSIONS:Increased perfusion intensity of the basal ganglia area within the first 48 of therapeutic hypothermia treatment was associated with poor outcome in neonates with HIE.
White-gray matter echogenicity ratio and resistive index: sonographic bedside markers of cerebral hypoxic-ischemic injury/edema?
Pinto P S,Tekes A,Singhi S,Northington F J,Parkinson C,Huisman T A G M
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE:Head ultrasonography (HUS) is a reliable and easy to perform bedside imaging technique that can give valuable information about degree of brain injury/edema after perinatal asphyxia in term neonates. The goals of our study were to determine whether semiquantitative markers such as standardized white matter/gray matter (WM/GM) echogenicity ratio and resistive index (RI) value measured by HUS differs between asphyxiated term neonates and healthy controls. STUDY DESIGN:Thirty-one carefully selected term neonates who suffered from perinatal hypoxic-ischemic encephalopathy (HIE) were included in the study. The ratio of the WM/GM echogenicity of the cingulate gyrus was calculated. In addition, the RI value was measured in the anterior cerebral artery. US scalars were compared with 11 healthy neonates. RESULT:WM/GM ratio is significantly increased and RI value significantly decreased in asphyxiated term neonates compared with healthy subjects. CONCLUSION:WM/GM ratio and RI value allows discriminating between asphyxiated neonates and healthy subjects. These US scalars may serve as valuable, easy to acquire semiquantitative bedside markers of brain HIE, when magnetic resonance imaging is unavailable or cannot be performed in the acute setting.
Reduction in cerebral blood flow volume in infants complicated with hypoxic ischemic encephalopathy resulting in cerebral palsy.
Fukuda Sumio,Mizuno Keisuke,Kawai Satomi,Kakita Hiroki,Goto Tatenobu,Hussein Mohamed Hamed,Daoud Ghada A,Ito Tetsuya,Kato Ineko,Suzuki Satoshi,Togari Hajime
Brain & development
Hypoxic ischemic brain can result in cerebral palsy, mental retardation, and learning disabilities in surviving children. The purpose of this study was to elucidate the cerebral blood flow volume in infants complicated with brain damage after the birth. Nine term infants with hypoxic ischemic encephalopathy and 41 normal term infants were studied. Four infants with HIE suffered from CP or mental retardation, and the other five infants exhibited normal neurodevelopment. The mean blood flow velocity and diameter of the internal carotid artery and the vertebral artery were measured for 28 days. The intravascular flow volume was determined by calculating the flow velocity and the cross-sectional area. The ejection fraction and cardiac output were obtained, and the mean blood pressures were recorded. The summed flow volumes in both the ICA and VA, and the total CBFV increased after the birth in both the normal infants and the infants diagnosed with HIE with no disability complications. The total blood flow volume was significantly lower in infants with HIE and CP than in normal infants on days 0, 2, 5, 7, 10, 21, and 28, and significantly lower in infants with HIE and CP than in normal infants with HIE on days 2, 4, and 7. The ejection fraction was significantly lower in infants with HIE than in normal infants only on day 0. Our results suggest that the total cerebral blood supply is decreased in infants with HIE in those complicated with brain damage.
Neuroimaging and Other Neurodiagnostic Tests in Neonatal Encephalopathy.
Merhar Stephanie L,Chau Vann
Clinics in perinatology
Hypoxic-ischemic encephalopathy is associated with a high risk of morbidity and mortality in the neonatal period. Long-term neurodevelopmental disability is also frequent in survivors. Conventional MRI defines typical patterns of injury that reflect specific pathophysiologic mechanisms. Advanced magnetic resonance techniques now provide unique perspectives on neonatal brain metabolism, microstructure, and connectivity. The application of these imaging techniques has revealed that brain injury commonly occurs at or near the time of birth and evolves over the first weeks of life. Amplitude-integrated electroencephalogram and near-infrared spectroscopy are increasingly used as bedside tools in neonatal intensive care units to monitor brain function.
Therapeutic hypothermia initiated within 6 hours of birth is associated with reduced brain injury on MR biomarkers in mild hypoxic-ischaemic encephalopathy: a non-randomised cohort study.
Montaldo Paolo,Lally Peter J,Oliveira Vânia,Swamy Ravi,Mendoza Josephine,Atreja Gaurav,Kariholu Ujwal,Shivamurthappa Vijayakumar,Liow Natasha,Teiserskas Justinas,Pryce Russell,Soe Aung,Shankaran Seetha,Thayyil Sudhin
Archives of disease in childhood. Fetal and neonatal edition
OBJECTIVE:To examine the effect of therapeutic hypothermia on MR biomarkers and neurodevelopmental outcomes in babies with mild hypoxic-ischaemic encephalopathy (HIE). DESIGN:Non-randomised cohort study. SETTING:Eight tertiary neonatal units in the UK and the USA. PATIENTS:47 babies with mild HIE on NICHD neurological examination performed within 6 hours after birth. INTERVENTIONS:Whole-body cooling for 72 hours (n=32) or usual care (n=15; of these 5 were cooled for <12 hours). MAIN OUTCOME MEASURES:MRI and MR spectroscopy (MRS) within 2 weeks after birth, and a neurodevelopmental outcome assessment at 2 years. RESULTS:The baseline characteristics in both groups were similar except for lower 10 min Apgar scores (p=0.02) in the cooled babies. Despite this, the mean (SD) thalamic NAA/Cr (1.4 (0.1) vs 1.6 (0.2); p<0.001) and NAA/Cho (0.67 (0.08) vs 0.89 (0.11); p<0.001) ratios from MRS were significantly higher in the cooled group. Cooled babies had lower white matter injury scores than non-cooled babies (p=0.02). Four (27%) non-cooled babies with mild HIE developed seizures after 6 hours of age, while none of the cooled babies developed seizures (p=0.008). Neurodevelopmental outcomes at 2 years were available in 40 (85%) of the babies. Adverse outcomes were seen in 2 (14.3%) non-cooled babies, and none of the cooled babies (p=0.09). CONCLUSIONS:Therapeutic hypothermia may have a neuroprotective effect in babies with mild HIE, as demonstrated by improved MRS biomarkers and reduced white matter injury on MRI. This may warrant further evaluation in adequately powered randomised controlled trials.
The correlation between myocardial function and cerebral hemodynamics in term infants with hypoxic-ischemic encephalopathy.
Liu Jing,Li Jian,Gu Mei
Journal of tropical pediatrics
This study investigated the effect of myocardial dysfunction on the cerebral hemodynamics in term infants with hypoxic-ischemic encephalopathy (HIE). We evaluated myocardial systolic and diastolic functional parameters and cerebral hemodynamic parameters in 40 term newborn infants with HIE and 30 healthy controls during the first 14 days of life using two-dimensional/pulsed Doppler ultrasound. The results showed that there were significant cerebral hemodynamic disturbances and cardiac dysfunction in neonates with HIE, and the more cardiac dysfunction the patients have, the more severe encephalopathy they would suffer. Therefore, it is important to preserve cardiac function and treat myocardial dysfunction in infants with HIE.
Ultrasonography of the internal carotid artery during therapeutic hypothermia.
Fukuda Sumio,Tanimura Tomoshige,Iwaki Toshihiko,Higuchi Machiko,Suyama Megumi,Goto Tomoki,Koide Wakato,Maki Kanemasa,Ushijima Katsumi,Ban Kyoko
Pediatrics international : official journal of the Japan Pediatric Society
The purpose of this study was to determine the accuracy of mean blood flow velocity (mean V) in the internal carotid artery (ICA) for prediction of outcome in infants with hypoxic-ischemic encephalopathy (HIE) exposed to therapeutic hypothermia (TH). Five newborns with HIE who met the criteria for TH were enrolled. Ultrasonography of the right and left ICA was performed before, during, and after TH. Mean V of the sampling point in each ICA was measured. Mean V was suppressed during TH and increased after rewarming in four infants with normal neurological development. In one infant with neurological disability, however, mean V increased during TH and decreased after therapy. In conclusion, cervical ultrasonography for ICA in infants during TH may be useful for the prediction of neurodevelopmental outcome.
[Usefulness of Doppler ultrasound imaging in monitoring of hypoxic-ischemic encephalopathy in preterm infants].
Wilczyńska Małgorzata,Pustuła-Mańko Elzbieta,Stefańczyk Ludomir,Maroszyńska Iwona,Biegański Tadeusz
Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego
Cerebral blood flow disregulation could be one of the main causes of hypoxic-ischaemic encephalopathy (HIE). It is difficult to differentiate between sonographic appearance of immature periventricular white matter of premature neonate and changes of HIE type. Therefore the diagnostic and prognostic value of doppler ultrasound resistance index (RI) examination in anterior cerebral arteries of premature infants with early sonographic signs of periventricular white matter hyperechogenicity was the aim of the study. The study group consisted of 23 premature infants: birth weight 1550 +/- 570 g, gestational age 24-32 weeks, Apgar score 2-7 points, of which 19 were ventilated. Doppler ultrasound imaging was performed twice: during the first 24 hours of life and 3 weeks later. As not all infants survived to the time of control examination, the final study group consisted of 17 subjects. Doppler examination of premature infants having finally sonographic signs of HIE (n = 12) revealed that RI value in this group of infants was increased during initial as well as the next examination. In the group of premature infants having finally normal sonographic scan (n = 5), doppler examinations showed that RI value stayed in normal limits or was slightly decreased all the time. We conclude that doppler imaging of premature infants could be important diagnostic and prognostic tool in differentiating between the ultrasonographic view of immature periventricular white matter and real HIE. Doppler imaging is useful in identification of patients having increased risk of HIE and supplements routine transfontanellar ultrasound in estimation of HIE progression.
The dynamic changes of plasma neuropeptide y and neurotensin and their role in regulating cerebral hemodynamics in neonatal hypoxic-ischemic encephalopathy.
Liu Jing,Zhao Juan,Di Ying-Fen,Guo Xiu-Xia,Zhai Gui-Rong,Huang Xing-Hua
American journal of perinatology
Hypoxic-ischemic encephalopathy (HIE) is a common cause of neonatal encephalopathy and is one of the most important causes of neonatal death and disabilities, especially those infants with moderate to severe encephalopathy. However, the pathogenesis of HIE still remains unclear. The purpose of this study was to explore the dynamic changes in plasma neuropeptide Y (NPY) and neurotensin (NT) as well as their role in regulating cerebral hemodynamics in HIE patients. The plasma levels of NPY and NT in the umbilical artery and peripheral blood on the first, third, and seventh days after birth in 40 term infants with HIE and 40 healthy controls were measured using radioimmunoassay. On the first day of life, the blood samples were collected immediately when ultrasound examinations were finished. The ultrasound transducer was placed on the temporal fontanelle to detect the hemodynamic parameters of the middle cerebral artery, including peak systolic flow velocity, end-diastolic flow velocity, time-average mean velocity, pulsatility index, and resistance index (RI) in both groups were measured by pulse Doppler ultrasound in the first day after birth. The relationship between RI and NPY or NT was analyzed by linear regression analysis. NPY levels in umbilical blood ([mean +/- standard deviation] 615.5 +/- 130.7 ng/L) and first-day peripheral blood (355.9 +/- 57.4 ng/L) in neonates with HIE were significantly higher than those in normal newborns' blood (199.1 +/- 63.2 and 214.4 +/- 58.0 ng/L, respectively; P < 0.01). NPY levels in HIE neonates then declined to control levels on the third day after birth ( P > 0.05). However, the levels of plasma NT in umbilical blood and peripheral blood were much higher in the HIE group than those in normal newborns during the first week ( P < 0.01). The results of Doppler ultrasound examinations showed that cerebral blood flow velocity significantly decreased, whereas RI increased markedly in HIE patients compared with healthy controls ( P < 0.01). Linear regression analysis revealed that the RI was positively correlated with NPY levels ( R = 0.614; P < 0.01) and negatively correlated with NT levels ( R = -0.579; P < 0.01). The results of this study showed that there was a significant increase in plasma NPY and NT levels in HIE patients and this was strongly related to the severity of HIE, and the hemodynamic parameter RI was significantly correlated with NPY and NT. Therefore, we believe that the dynamic changes in plasma NPY or NT levels participate in the mechanisms of HIE by regulating cerebral hemodynamic changes after neonatal asphyxia occurs.
Urinary S100A1B and S100BB to predict hypoxic ischemic encephalopathy at term.
Bashir Moataza,Frigiola Alessandro,Iskander Iman,Said Hala Mufeed,Aboulgar Hanna,Frulio Rosanna,Bruschettini Pierluigi,Michetti Fabrizio,Florio Pasquale,Pinzauti Serena,Abella Raul,Mussap Michele,Gazzolo Diego
Frontiers in bioscience (Elite edition)
Urinary S100A1B and S100BB were measured to detect cases at risk of hypoxic-ischemic encephalopathy (HIE) in asphyxiated newborns. We recruited 42 asphyxiated infants and 63 healthy term neonates. S100A1B and S100BB were measured at first urination (time 0) and at 4 (time 1), 8 (time 2), 12 (time 3), 16 (time 4), 20 (time 5), 24 (time 6), 72 (time 7) hours after birth. 20 infants had no/mild HIE with good prognosis (Group A) and 22 had moderate/severe HIE with a greater risk of neurological handicap (Group B). Urine S100A1B and S100BB levels were significantly (P less than 0.0.01, for all) higher at all monitoring time-points in Group B than Group A and controls, but not between Group A and controls. Both S100A1B and S100BB have great sensitivity and specificity for HIE since their first measurement. In conclusion, S100A1B and S100BB are increased in urine collected from asphyxiated newborns who will develop HIE since first urination, and their measurement may be useful to early predict HIE when monitoring procedures are still of no avail.
Hypoxic-ischemic encephalopathy in the term infant.
Fatemi Ali,Wilson Mary Ann,Johnston Michael V
Clinics in perinatology
Hypoxia-ischemia in the perinatal period is an important cause of cerebral palsy and associated disabilities in children. There has been significant research progress in hypoxic-ischemic encephalopathy over the last 2 decades, and many new molecular mechanisms have been identified. Despite all these advances, therapeutic interventions are still limited. In this article the authors discuss several molecular pathways involved in hypoxia-ischemia, and potential therapeutic targets.
Biomarkers of impaired placentation at 35-37 weeks' gestation in the prediction of adverse perinatal outcome.
Ciobanou A,Jabak S,De Castro H,Frei L,Akolekar R,Nicolaides K H
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology
OBJECTIVE:To investigate the potential value of uterine artery pulsatility index (UtA-PI) and serum levels of the angiogenic placental growth factor (PlGF) and the antiangiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1) in the prediction of adverse perinatal outcome in small-for-gestational-age (SGA) and non-SGA neonates at 35-37 weeks' gestation. METHODS:This was a prospective observational study of 19 209 singleton pregnancies attending for a routine hospital visit at 35 + 0 to 36 + 6 weeks' gestation. This visit included recording of maternal demographic characteristics and medical history, sonographic estimation of fetal weight, color Doppler ultrasound for measurement of mean UtA-PI, and measurement of serum concentrations of PlGF and sFlt-1. Multivariable logistic regression analysis was carried out to determine which of the factors from maternal or pregnancy characteristics and measurements of UtA-PI, PlGF and sFlt-1 provided a significant contribution in the prediction of each of four adverse outcome measures: first, stillbirth; second, Cesarean delivery for suspected fetal compromise in labor; third, neonatal death or hypoxic ischemic encephalopathy Grade 2 or 3; and, fourth, admission to the neonatal unit (NNU) for ≥ 48 h. Predicted probabilities from logistic regression analysis were used to construct receiver-operating characteristics curves to assess the performance of screening for these adverse outcomes. RESULTS:First, 83% of stillbirths, 82% of Cesarean sections for presumed fetal compromise in labor, 91% of cases of neonatal death or hypoxic ischemic encephalopathy and 86% of NNU admissions for ≥ 48 h occurred in pregnancies with a non-SGA neonate. Second, UtA-PI > 95 percentile, sFlt-1 > 95 percentile and PlGF < 5 percentile were associated with increased risk of Cesarean delivery for suspected fetal compromise in labor and NNU admission for ≥ 48 h; the number of stillbirths and cases of neonatal death or hypoxic ischemic encephalopathy was too small to demonstrate significance in the observed differences from cases without these adverse outcomes. Third, multivariable logistic regression analysis demonstrated that, in the prediction of Cesarean delivery for suspected fetal compromise in labor, there was no significant contribution from biomarkers; the prediction of NNU admission for ≥ 48 h by maternal demographic characteristics and medical history was only marginally improved by the addition of sFlt-1 or PlGF. Fourth, for each biomarker, the detection rate of adverse outcome was higher in SGA than in non-SGA neonates, but this increase was accompanied by an increase in false-positive rate. Fifth, the relative risk of UtA-PI > 95 , sFlt-1 > 95 and PlGF < 5 percentiles for most adverse outcomes was < 2.5 in both SGA and non-SGA neonates. CONCLUSIONS:In pregnancies undergoing routine antenatal assessment at 35-37 weeks' gestation, measurements of UtA-PI, sFlt-1 or PlGF provide poor prediction of adverse perinatal outcome in both SGA and non-SGA fetuses. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
[Relation between the resistance index obtained by the transfontanellar Doppler ultrasonography and the neurological development until the first year of life in term infants with mild or moderate hypoxic-ischaemic encephalopathy].
arcia Maria Helena Martins,Monteiro Alexandra Maria Vieira,Freire Sergio Miranda
Arquivos de neuro-psiquiatria
OBJECTIVE:To evaluate the relation between the resistance index (RI) obtained by transfontanellar Doppler ultrasonography, and the neurodevelopment until one year of life, at term newborns with mild or moderate hypoxic-ischaemic encephalopathy due to intrapartum asphyxia. METHOD:20 term newborns, with mild or moderate hypoxic-ischemic encephalopathy, high values of resistance index in the first exam, and without cerebral morfologic abnormalities or other diseases. They were submitted to serial bimonthly transfontanellar Doppler ultrasonography, from the seventh day of life on, and monthly clinical neurodevelopment assessment until one year of life. RESULTS:There was a progressive normalization of RI values until the last examination. In five cases there were clinical neurologic normalization in the neonatal period after the first Doppler exam. Fifteen infants presented neurologic abnormalities, with normalization after the second trimester of life. CONCLUSION:There was a relation between the normal RI values with the normalization of the clinical assessment.
[Comparison of left and right ventricular pulsed and tissue Doppler myocardial performance index values using Z-score in newborns with hypoxic-ischemic encephalopathy].
Alp Hayrullah,Karaaslan Sevim,Baysal Tamer,Oran Bülent,Ors Rahmi
Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology
OBJECTIVE:The aim of the study is determination of myocardial performance index (MPI/Tei index) using pulsed (PD) and tissue Doppler (TD) techniques to show cardiac response in newborns with hypoxic-ischemic encephalopathy (HIE) and healthy newborns and eventually evaluation of the differences between these two techniques. METHODS:The study is a prospective observational study. Twenty term newborns diagnosed as perinatal asphyxia during postnatal 24 hours due to the defined criteria and fifty healthy term neonates as control group were included the study. Hypoxic group was divided into two groups with Sarnat stages, Sarnat Stage 1 and 2-3. MPIs (Tei indexes) were calculated with PD and TD echocardiographic techniques in all groups after the 24 hours of birth and one year later. The statistical differences between same techniques were calculated with Kruskal-Wallis test and Z score was used to compare the superiority of two techniques. RESULTS:The MPI values calculated by PD (0.41±0.04, 0.51±0.02) and TD (0.59±0.04, 0.51±0.02) during the first day of life in Sarnat Stage 2-3 in both ventricles were significantly higher than the control group (p<0.01, p<0.02, p<0.03). While the Z score, calculated for MPI measured by PD and TD methods, were found similar in both ventricles in Sarnat Stage 1 and control groups, it was significantly different in other groups of Sarnat stages. CONCLUSION:The degree of cardiac response in neonates with HIE is associated with the severity of hypoxia. MPI values are not different from the controls in newborns received mild hypoxia while they are higher in the patients who were received moderate or severe hypoxia. Any advantage could not be found between two techniques according to the measurement values, but higher variability in the value of MPI, measured by TD method, calculated from moderate and severe hypoxia group was detected.
Neuroimaging for Neurodevelopmental Prognostication in High-Risk Neonates.
Sewell Elizabeth K,Andescavage Nickie N
Clinics in perinatology
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.
The myocardial function during and after whole-body therapeutic hypothermia for hypoxic-ischemic encephalopathy, a cohort study.
Nestaas Eirik,Skranes Janne Helen,Støylen Asbjørn,Brunvand Leif,Fugelseth Drude
Early human development
BACKGROUND:Therapeutic hypothermia has become standard treatment for moderate and severe neonatal hypoxic-ischemic encephalopathy (HIE) to reduce cerebral morbidity and mortality. The effect on the heart is incompletely explored. AIM:To assess the myocardial function during and after whole-body therapeutic hypothermia for HIE. STUDY DESIGN:Observational cohort study. SUBJECTS:Forty-four infants with HIE cooled for 72hours were compared with 48 healthy term infants and 20 normothermic infants with HIE. OUTCOME MEASURES:Tissue Doppler deformation indices of myocardial function (peak systolic strain, peak systolic strain-rate, early diastole strain-rate and strain-rate in atrial systole) during (days 1 and 3) and after (day 4) therapeutic hypothermia. RESULTS:On days one and three all indices in both HIE groups were lower than the corresponding indices in the healthy infants. The two HIE groups had similar indices, except peak systolic strain-rate on days 1 and 3 and strain-rate in atrial systole on day 1. All strain-rate indices improved from day 3 to 4 (after rewarming) in the cooled group and achieved similar values to those in healthy infants on day 3. All indices were higher in the cooling-group after rewarming than in the normothermic infants with HIE on day 3, except early diastolic strain-rate. CONCLUSIONS:Infants with HIE had similarly impaired myocardial function during days 1-3 whether normothermic or hypothermic. The myocardial function improved significantly at day 4 (after rewarming), approaching the day 3 levels in the healthy neonates.
The pattern and early diagnostic value of Doppler ultrasound for neonatal hypoxic-ischemic encephalopathy.
Liu Jing,Cao Hai-Ying,Huang Xing-Hua,Wang Qi
Journal of tropical pediatrics
This article investigates the value of early diagnosis and prognostic evaluation of Doppler ultrasound for neonatal hypoxic-ischemic encephalopathy (HIE). Study population included 40 term neonates with HIE and 30 healthy controls. Color Doppler ultrasound was performed at the bedside within 24 h after birth. The transducer was placed on the temporal fontanelle to detect the hemodynamic parameters of bilateral middle cerebral arteries. The results showed that infants with HIE had significant cerebral hemodynamic disturbance. The cerebral blood flow velocity decreased or increased markedly as resistive index (RI) decreased or increased markedly, which usually suggested the diagnosis of HIE, RI < 0.50 or RI > 0.90 usually occurred in severe patients, while RI > 1.0 would be associated with later brain death. So we believe that using Pulsed Doppler ultrasound to monitor the changes of cerebral hemodynamics can be used for the early diagnosis of HIE and help us to distinguish the grades of HIE.
Left ventricular rotational mechanics in infants with hypoxic ischemic encephalopathy and preterm infants at 36 weeks postmenstrual age: A comparison with healthy term controls.
Breatnach Colm R,Forman Eva,Foran Adrienne,Monteith Cathy,McSweeney Lisa,Malone Fergal,McCallion Naomi,Franklin Orla,El-Khuffash Afif
Echocardiography (Mount Kisco, N.Y.)
BACKGROUND AND AIMS:There is a paucity of data on left ventricle (LV) rotational physiology in neonates. We aimed to assess rotational mechanics in infants with hypoxic ischemic encephalopathy (HIE) and premature infants (<32 weeks) at 36 weeks postmenstrual age (PMA) (preterm group) and compare them with healthy term controls (term controls). We also compared the parameters in preterm infants with and without chronic lung disease (CLD). METHODS:Echocardiography was performed within 48 hours of birth or at 36 weeks PMA. LV basal and apical rotation, twist (and torsion=twist/LV length), twist rate (LVTR), and untwist rate (LVUTR) were measured. One-way ANOVA was used to compare values. RESULTS:There was no difference in gestation (40.0 [39.1-40.3] vs 39.9 [39.0-40.9], P>.05) or birthweight (3.7 [3.4-4.1] vs 3.5 [3.2-3.9], P>.05) between the HIE group (n=16) and term controls (n=30). The preterm group (n=35) had a gestation and weight of 36.0 [34.6-36.3] weeks and 2.3 [2.0-2.4] kg. The HIE group had lower twist, torsion, LVTR, and LVUTR than the other two groups. The preterm group had a more negative (clockwise) basal rotation while the term group had a more positive (counterclockwise) apical rotation. Preterm infants with CLD had higher apical rotation, twist, and torsion when compared to infants without CLD. CONCLUSION:Infants with HIE have reduced rotational mechanics. Preterm infants at 36 weeks PMA have comparable measurements of twist to term infants. This is achieved by predominant basal rather than apical rotation. Infants with CLD have increased apical rotation.
[Predictive value of color Doppler neuro-sonography for the development of neurological sequels in newborn infants with hypoxic ischemic encephalopathy].
Vasiljević Brankica,Maglajlić-Djukić Svjetlana,Stanković Sanja,Lutovacs Dragana,Gojnić Miroslava
BACKGROUND/AIM:The use of color Doppler neurosonography (cD-US) allows simultaneous examination of parenchymal and vascular cerebral structures. Evaluation of cerebral blood flow velocities (CBFV) and vascular resistance are important in assessment of cerebral circulation in neonates with hypoxic ischemic encephalopathy (HIE). The aim of this study was to evaluate the predictive value of cD-US for abnormal neurodevelopmental outcome in the neonates with HIE. METHODS:A total of 90 neonates (> 32 weeks gestational age) with HIE were enrolled prospectively. All the neonates with HIE were categorized into three grades according to the Sarnat and Sarnat clinical staging system: mild HIE, moderate HIE, and severe HIE. cD-US was performed simultaneously during the first 24 h of life. Neurodevelopment outcome was assessed at 12 months of age in all the neonates. RESULTS:The values of CBFV and the values of index resistance (RI) correlated with the severity of HIE (p < 0.0001) and subsequent neurodevelopmental outcome (p < 0.001). We detected a significant difference in values of CBFV and in values of RI between preterm and full-term neonates (p < 0.01). The cut-off value of RI for poor neurodevelopmental outcomes was 0.81. CONCLUSIONS:cD-US could be very useful and safe diagnostic tool for assessing severity of HIE and subsequent adverse neurodevelopmental outcome.
Cerebral regional oxygen saturation trends in infants with hypoxic-ischemic encephalopathy.
Jain Siddharth V,Pagano Lindsay,Gillam-Krakauer Maria,Slaughter James C,Pruthi Sumit,Engelhardt Barbara
Early human development
BACKGROUND:Neurological outcomes in neonatal hypoxic-ischemic encephalopathy (HIE) continue to be sub-optimal despite therapeutic hypothermia (TH). Cerebral near-infrared spectroscopy provides real-time regional oxygen saturation (CrSO) that may be a marker of adverse MRI findings and neurodevelopmental outcomes. AIM:The aim of this study was to examine the value of CrSO monitoring in infants with HIE undergoing TH. STUDY DESIGN AND SUBJECTS:In this prospective study, CrSO was continuously recorded in 21 infants with HIE admitted for TH. OUTCOME MEASURES:Brain MRI signal abnormalities at 2weeks were scored in individual brain region and classified as none/mild, moderate and severe. 13 infants completed Bayley Scales of Infant Development (BSID) testing at 18-24months. RESULTS:Between 24 and 36h of life, there was a significant increase in odds of having moderate-severe brain MRI abnormalities with higher absolute CrSO values. Per 10% increase in absolute CrSO, the odds ratio for moderate-severe brain MRI abnormalities was greatest at 30h (OR 3.78; confidence intervals (CI): 1.23-11.6, p=0.011). CrSO increased more rapidly in infants with greater injury seen on MRI (0.20/h for MRI scores 0/1, by 0.48/h for MRI score 2, and by 0.68/h for MRI score 3, p=0.05). At 30h, absolute CrSO correlated significantly with abnormal MRI findings in basal ganglia (92% vs. 78%, p=0.001), white matter (88% vs. 76%, p=0.01), posterior limb of internal capsule (92% vs. 78%, p=0.001), and brain stem (94% vs. 80%, p=0.03) but not with cortical injury (86% vs. 80%, p=0.17). Higher CrSO beyond 24h correlated with greater odds of worse BSID scores. CONCLUSIONS:Increasing CrSO is associated with moderate-severe brain injury as assessed by MRI. Higher absolute CrSO2 values during TH correlates with subcortical injury on MRI and poor neurodevelopmental outcomes in infants with HIE undergoing TH. CrSO can inform providers seeking early identification of patients at risk of worse injury who may benefit from further intervention.
[Neonatal hypoxic-ischemic encephalopathy].
Hypoxic-ischemic encephalopathy is a clearly recognizable clinical syndrome of in term newborns due to fetal asphyxia at birth. The incidence is 1.5 (95% CI 1.3 to 1.7) but it ranges from 1-8 and 25 out of every 1000 born in developed and developing countries, respectively. The most frequent causes are detachment of the placenta, prolapse of the umbilical cord and uterine rupture. The diagnostic criteria include partial or total incapacity for the newborn to cry and breath at birth even when stimulated, requiring assisted ventilation in the delivery room, Apgar < 5 in 5 and 10 minutes, acidemia (pH ≤ 7 and / or bases deficit ≥ 12 mmol/l), alterations of the conscience and the reflexes of Moro, grasping and suction, muscular stretching and muscle tone. The clinical forms are mild, moderate and severe. In the mild forms, the recovery is total in three days without, or with minimal, neurodevelopmental alterations. The moderate and severe forms cause permanent neurological deficits and neurodevelopmental alterations (48%) or death (27%). The regular or amplitude integrated EEG and the magnetic and spectroscopic magnetic resonance imaging performed between 24 and 96 hours and 7 and 21 days after birth, respectively, have a high diagnostic and prognostic value. Induced hypothermia (33.5° C for 72 hours) is recommended before 6 hours old. The result is a decrease in mortality (from 35% to 27%) and morbidity (from 48% to 27%).
Gastrointestinal hemodynamic changes during therapeutic hypothermia and after rewarming in neonatal hypoxic-Ischemic encephalopathy.
Sakhuja Pankaj,More Kiran,Ting Joseph Y,Sheth Jesal,Lapointe Annie,Jain Amish,McNamara Patrick J,Moore Aideen M
Pediatrics and neonatology
BACKGROUND:Hypoxic-ischemic encephalopathy (HIE) is associated with disturbances in visceral blood flow velocities. Therapeutic Hypothermia (TH) is a standard of care; however, its impact on gastrointestinal blood flow in infants with HIE is unknown. The objective of this study was to assess gastrointestinal (GI) blood flow and left ventricle output (LVO) in infants with hypoxic-ischemic encephalopathy during whole body TH and after rewarming. METHODS:Serial echocardiography and Doppler evaluation of intestinal blood flow (celiac (CA) and superior mesenteric (SMA) arteries) were prospectively performed in a cohort of 20 newborn infants with HIE at 4 time points during hypothermia and after rewarming. Demographic, clinical and biochemical data were collected and analyzed for their relevance. RESULTS:Median gestational age and birth weight was 40 weeks (37-41) and 3410 g (2190-4950) respectively. Celiac and mesenteric artery flow remained low during hypothermia and rose significantly after rewarming [peak systolic velocity in CA (0.63 m/s to 0.77 m/s, p = 0.004) and SMA (0.43 m/s to 0.55 m/s, p = 0.001)]. This increase was temporally associated with increased left ventricular output (106 ml/kg/min to 149 ml/kg/min, p < 0.0001). Median age to reach 25% of the feeds was 5 days (1-7 days). All patients survived. CONCLUSIONS:CA and SMA blood flow velocity and LVO did not vary during hypothermia but rose after rewarming. This may suggest protective effect of therapeutic hypothermia on gastrointestinal system. The association of these physiological changes with neonatal outcome needs further assessment.
Preferential cephalic redistribution of left ventricular cardiac output during therapeutic hypothermia for perinatal hypoxic-ischemic encephalopathy.
Hochwald Ori,Jabr Mohammad,Osiovich Horacio,Miller Steven P,McNamara Patrick J,Lavoie Pascal M
The Journal of pediatrics
OBJECTIVE:To determine the relationship between left ventricular cardiac output (LVCO), superior vena cava (SVC) flow, and brain injury during whole-body therapeutic hypothermia. STUDY DESIGN:Sixteen newborns with moderate or severe hypoxic-ischemic encephalopathy were studied using echocardiography during and immediately after therapeutic hypothermia. Measures were also compared with 12 healthy newborns of similar postnatal age. Newborns undergoing therapeutic hypothermia also had cerebral magnetic resonance imaging as part of routine clinical care on postnatal day 3-4. RESULTS:LVCO was markedly reduced (mean ± SD 126 ± 38 mL/kg/min) during therapeutic hypothermia, whereas SVC flow was maintained within expected normal values (88 ± 27 mL/kg/min) such that SVC flow represented 70% of the LVCO. The reduction in LVCO during therapeutic hypothermia was mainly accounted by a reduction in heart rate (99 ± 13 vs 123 ± 17 beats/min; P < .001) compared with immediately postwarming in the context of myocardial dysfunction. Neonates with brain injury on magnetic resonance imaging had higher SVC flow prerewarming, compared with newborns without brain injury (P = .013). CONCLUSION:Newborns with perinatal hypoxic-ischemic encephalopathy showed a preferential systemic-to-cerebral redistribution of cardiac blood flow during whole-body therapeutic hypothermia, which may reflect a lack of cerebral vascular adaptation in newborns with more severe brain injury.
Head Ultrasound in Neonatal Hypoxic-Ischemic Injury and Its Mimickers for Clinicians: A Review of the Patterns of Injury and the Evolution of Findings Over Time.
Salas Jacqueline,Tekes Aylin,Hwang Misun,Northington Frances J,Huisman Thierry A G M
Hypoxic-ischemic injury (HII) of the neonatal brain and resulting clinical hypoxic-ischemic encephalopathy remains a significant cause of morbidity and mortality in the neonatal population. Ultrasound (US) has emerged as a powerful screening tool for evaluation of a neonate with suspected HII. The pattern of injury on brain imaging has crucial implications in therapies and predicted neurodevelopmental outcomes. US has become increasingly effective at determining the pattern, timing, and extent of injury in HII as well as differentiating these findings from a host of diagnoses that can result in a similarly appearing clinical picture. Repeated US studies over a patient's course can define the evolution of findings from the acute through chronic phase in addition to identifying any complications of therapy. US also has the added benefits of easy portability, no need for patient sedation, and a relatively low cost when compared to other imaging modalities like magnetic resonance imaging (MRI). It is crucial that clinicians understand the full capabilities of advanced US in identifying an underlying diagnosis, directing appropriate therapy, monitoring disease progress, and finally in predicting outcomes, thus improving the care of neonates with encephalopathy. The following article demonstrates the breadth of uses for US in the full-term neonate with encephalopathy, its limitations, the patterns of injury seen, and their evolution over time. We will also briefly review several clinical mimickers of HII for comparison.
Impaired cerebral autoregulation and brain injury in newborns with hypoxic-ischemic encephalopathy treated with hypothermia.
Massaro An N,Govindan R B,Vezina Gilbert,Chang Taeun,Andescavage Nickie N,Wang Yunfei,Al-Shargabi Tareq,Metzler Marina,Harris Kari,du Plessis Adre J
Journal of neurophysiology
Impaired cerebral autoregulation may contribute to secondary injury in newborns with hypoxic-ischemic encephalopathy (HIE). Continuous, noninvasive assessment of cerebral pressure autoregulation can be achieved with bedside near-infrared spectroscopy (NIRS) and systemic mean arterial blood pressure (MAP) monitoring. This study aimed to evaluate whether impaired cerebral autoregulation measured by NIRS-MAP monitoring during therapeutic hypothermia and rewarming relates to outcome in 36 newborns with HIE. Spectral coherence analysis between NIRS and MAP was used to quantify changes in the duration [pressure passivity index (PPI)] and magnitude (gain) of cerebral autoregulatory impairment. Higher PPI in both cerebral hemispheres and gain in the right hemisphere were associated with neonatal adverse outcomes [death or detectable brain injury by magnetic resonance imaging (MRI), P < 0.001]. NIRS-MAP monitoring of cerebral autoregulation can provide an ongoing physiological biomarker that may help direct care in perinatal brain injury.
Plasma Biomarkers of Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy.
Massaro An N,Wu Yvonne W,Bammler Theo K,Comstock Bryan,Mathur Amit,McKinstry Robert C,Chang Taeun,Mayock Dennis E,Mulkey Sarah B,Van Meurs Krisa,Juul Sandra
The Journal of pediatrics
OBJECTIVES:To evaluate plasma brain specific proteins and cytokines as biomarkers of brain injury in newborns with hypoxic-ischemic encephalopathy (HIE) and, secondarily, to assess the effect of erythropoietin (Epo) treatment on the relationship between biomarkers and outcomes. STUDY DESIGN:A study of candidate brain injury biomarkers was conducted in the context of a phase II multicenter randomized trial evaluating Epo for neuroprotection in HIE. Plasma was collected at baseline (<24 hours) and on day 5. Brain injury was assessed by magnetic resonance imaging (MRI) and neurodevelopmental assessments at 1 year. The relationships between Epo, brain-specific proteins (S100B, ubiquitin carboxy-terminal hydrolase-L1 [UCH-L1], total Tau, neuron specific enolase), cytokines (interleukin [IL]-1β, IL-6, IL-8, IL-10, IL-12P70, IL-13, interferon-gamma [IFN-γ], tumor necrosis factor alpha [TNF-α], brain-derived neurotrophic factor [BDNF], monocyte chemoattractant protein-1), and brain injury were assessed. RESULTS:In 50 newborns with encephalopathy, elevated baseline S100B, Tau, UCH-L1, IL-1β, IL-6, IL-8, IL-10, IL-13, TNF-α, and IFN-γ levels were associated with increasing brain injury severity by MRI. Higher baseline Tau and lower day 5 BDNF were associated with worse 1 year outcomes. No statistically significant evidence of Epo treatment modification on biomarkers was detected in this small cohort. CONCLUSIONS:Elevated plasma brain-specific proteins and cytokine levels in the first 24 hours of life are associated with worse brain injury by MRI in newborns with HIE. Only Tau and BDNF levels were found to be related to neurodevelopmental outcomes. The effect of Epo treatment on the relationships between biomarkers and brain injury in HIE requires further study. TRIAL REGISTRATION:ClinicalTrials.gov: 01913340.
A Qualitative Study of Physician Perspectives on Prognostication in Neonatal Hypoxic Ischemic Encephalopathy.
Rasmussen Lisa Anne,Bell Emily,Racine Eric
Journal of child neurology
Hypoxic ischemic encephalopathy is the most frequent cause of neonatal encephalopathy and yields a great degree of morbidity and mortality. From an ethical and clinical standpoint, neurological prognosis is fundamental in the care of neonates with hypoxic ischemic encephalopathy. This qualitative study explores physician perspectives about neurological prognosis in neonatal hypoxic ischemic encephalopathy. This study aimed, through semistructured interviews with neonatologists and pediatric neurologists, to understand the practice of prognostication. Qualitative thematic content analysis was used for data analysis. The authors report 2 main findings: (1) neurological prognosis remains fundamental to quality-of-life predictions and considerations of best interest, and (2) magnetic resonance imaging is presented to parents with a greater degree of certainty than actually exists. Further research is needed to explore both the parental perspective and, prospectively, the impact of different clinical approaches and styles to prognostication for neonatal hypoxic ischemic encephalopathy.
Hemodynamic Changes During Rewarming Phase of Whole-Body Hypothermia Therapy in Neonates with Hypoxic-Ischemic Encephalopathy.
Wu Tai-Wei,Tamrazi Benita,Soleymani Sadaf,Seri Istvan,Noori Shahab
The Journal of pediatrics
OBJECTIVE:To delineate the systemic and cerebral hemodynamic response to incremental increases in core temperature during the rewarming phase of therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN:Continuous hemodynamic data, including heart rate (HR), mean arterial blood pressure (MBP), cardiac output by electrical velocimetry (CO), arterial oxygen saturation, and renal (RrSO) and cerebral (CrSO) regional tissue oxygen saturation, were collected from 4 hours before the start of rewarming to 1 hour after the completion of rewarming. Serial echocardiography and transcranial Doppler were performed at 3 hours and 1 hour before the start of rewarming (T-3 and T-1; "baseline") and at 2, 4, and 7 hours after the start of rewarming (T+2, T+4, and T+7; "rewarming") to determine Cardiac output by echocardiography (CO), stroke volume, fractional shortening, and middle cerebral artery (MCA) flow velocity indices. Repeated-measures analysis of variance was used for statistical analysis. RESULTS:Twenty infants with HIE were enrolled (mean gestational age, 38.8 ± 2 weeks; mean birth weight, 3346 ± 695 g). During rewarming, HR, CO, and CO increased from baseline to T+7, and MBP decreased. Despite an increase in fractional shortening, stroke volume remained unchanged. RrSO increased, and renal fractional oxygen extraction (FOE) decreased. MCA peak systolic flow velocity increased. There were no changes in CrSO or cerebral FOE. CONCLUSIONS:In neonates with HIE, CO significantly increases throughout rewarming. This is due to an increase in HR rather than stroke volume and is associated with an increase in renal blood flow. The lack of change in cerebral tissue oxygen saturation and extraction, in conjunction with an increase in MCA peak systolic velocity, suggests that cerebral flow metabolism coupling remained intact during rewarming.
Evaluating a Targeted Bedside Measure of Cerebral Perfusion in a Nonhuman Primate Model of Neonatal Hypoxic-Ischemic Encephalopathy.
Peeples Eric S,Ezeokeke Chikodinaka K,Juul Sandra E,Mourad Pierre D
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
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.
Impacts of therapeutic hypothermia on cardiovascular hemodynamics in newborns with hypoxic-ischemic encephalopathy: a case control study using echocardiography.
Yoon Ji Hong,Lee Eun-Jung,Yum Sook Kyung,Moon Cheong-Jun,Youn Young-Ah,Kwun Yoo Jin,Lee Jae Young,Sung In Kyung
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians
PURPOSE:The effects of therapeutic hypothermia (TH) on hemodynamics in newborns with hypoxic-ischemic encephalopathy (HIE) were evaluated. MATERIALS AND METHODS:Thirty-two neonates (gestational age, 39.4 ± 1.3 weeks) who had TH for HIE and echocardiographic hemodynamic assessments during TH and post-TH period were studied. Gestational-age-matched 34 healthy neonates were enrolled for comparison. RESULTS:During TH, patients had significantly decreased left ventricular cardiac output (LVCO), descending aorta blood flow (DABF), and DABF/LVCO ratio, and increased resistive index of DA compared to controls. Upper body blood flow (UBBF) remained unchanged but UBBF/LVCO ratio significantly increased during TH. Urine output decreased significantly during TH and increased after rewarming, and showed significant positive correlation with DABF/LVCO ratio. Sixteen patients (50%) showed hypoxic-ischemic (HI) lesions on brain magnetic resonance imaging (MRI) and had significantly increased UBBF/LVCO ratio during TH compared to patients without HI lesions. Patients with UBBF/LVCO ratio >55% had significantly higher risk of having HI lesions on brain MRI (odds ratio 13.0; 95% CI, 2.4-70.2). CONCLUSIONS:Decrease in cardiac output and descending aorta blood flow, and preferential cerebral redistribution of cardiac output along with an increase in systemic peripheral vascular resistance may affect systemic organ perfusion and cerebral metabolism.
[Evaluation of neonatal hypoxic-ischemic encephalopathy by ultrasound measurement of the hemodynamics in the central branches of the middle cerebral artery].
Wang Na,Zhang Yule,Guan Buyun
Nan fang yi ke da xue xue bao = Journal of Southern Medical University
OBJECTIVE:To evaluate the hemodynamic changes in the central branches of the middle cerebral artery in different stages of neonatal hypoxic-ischemic encephalopathy (HIE) and provide new evidence for clinical diagnosis of HIE. METHODS:From March, 2013 to July, 2013, a total of 136 newborn infants were diagnosed to have HIE in our center. We performed two-dimensional ultrasonography and color Doppler ultrasound for assessments of systolic velocity (Vs) and resistant index (RI) of the central branches of the middle cerebral artery. The data were compared with the results of a control group consisting of 251 normal full-term infants. RESULTS:Infants with mild HIE showed hyperechoic changes in the white matter around the ventricle, while in moderate and severe HIE, such hyperechoic changes were diffuse in both hemispheres with unclear echoes of the brain structures. Pulse Doppler assessments of hemodynamics of the central branches of the middle cerebral artery demonstrated a significant decrease in Vs and an increase in RI regardless of HIE severity (P<0.05). In addition, Vs and RI values in mild HIE infants differed significantly (P<0.05) from those in infants with moderate and severe HIE, who had comparable Vs and RI values (P>0.05). CONCLUSION:Transcranial ultrasonography may provide dynamic information on cerebral blood flow in neonates and hemodynamic parameters of the central branches of the middle cerebral artery are valuable for clinical diagnosis and early intervention of HIE.
Prognostic Value of Resistive Index in Neonates with Hypoxic Ischemic Encephalopathy.
Kumar A Senthil,Chandrasekaran Aparna,Asokan Rajamannar,Gopinathan Kathirvelu
OBJECTIVE:To evaluate the role of Resistive index measured by cranial doppler ultrasonography in predicting the risk of death/ abnormal neurodevelopmental outcomes in term neonates with hypoxic ischemic encephalopathy. METHODS:We enrolled 50 term asphyxiated neonates with hypoxic ischemic encephalopathy and measured resistive index within 72 hours from the anterior cerebral artery. Participants underwent tone and developmental assessment at 6-12 months. RESULTS:Among the 50 neonates, 25 (50%) had abnormal resistive index (<0.56 or >0.80). Presence of abnormal resistive index increased the risk of death/ abnormal neurological outcomes at 6-12 months [RR (95% CI): 7.5 (2.0,8.6), P<0.01]. CONCLUSION:An abnormal resistive index is associated with death/ neurodevelopmental impairment in neonatal hypoxic ischemic encephalopathy.
Impaired Right Ventricular Performance Is Associated with Adverse Outcome after Hypoxic Ischemic Encephalopathy.
Giesinger Regan E,El Shahed Amr I,Castaldo Michael P,Breatnach Colm R,Chau Vann,Whyte Hilary E,El-Khuffash Afif F,Mertens Luc,McNamara Patrick J
American journal of respiratory and critical care medicine
Asphyxiated neonates with hypoxic ischemic encephalopathy (HIE) are at risk of myocardial dysfunction; however, echocardiography studies are limited and little is known about the relationship between hemodynamics and brain injury. To analyze the association between severity of myocardial dysfunction and adverse outcome as defined by the composite of death and/or abnormal magnetic resonance imaging. Neonates with HIE undergoing therapeutic hypothermia were enrolled. Participants underwent echocardiography at 24 hours, 72 hours (before rewarming), and 96 hours (after rewarming). Cerebral hemodynamics were monitored by near-infrared spectroscopy and middle cerebral artery Doppler. Fifty-three patients with a mean gestation and birthweight of 38.8 ± 2.0 weeks and 3.33 ± 0.6 kg, respectively, were recruited. Thirteen patients (25%) had mild encephalopathy, 27 (50%) had moderate encephalopathy, and 13 (25%) had severe encephalopathy. Eighteen patients (34%) had an adverse outcome. Severity of cardiovascular illness ( < 0.001) and severity of neurologic insult ( = 0.02) were higher in neonates with adverse outcome. Right ventricle (RV) systolic performance at 24 hours was substantially lower than published normative data in all groups. At 24 hours, lower tricuspid annular plane systolic excursion ( = 0.004) and RV fractional area change ( < 0.001), but not pulmonary hypertension, were independently associated with adverse outcome on logistic regression. High brain regional oxygen saturation ( = 0.007) and low middle cerebral artery resistive index ( = 0.04) were associated with RV dysfunction on analysis. RV dysfunction is associated with the risk of adverse outcome in asphyxiated patients with HIE undergoing hypothermia. Echocardiography may be a valuable diagnostic and prognostic tool in this vulnerable population.
Intestinal ultrasonography in infants with moderate or severe hypoxic-ischemic encephalopathy receiving hypothermia.
Faingold Ricardo,Cassia Guilherme,Prempunpong Chatchay,Morneault Linda,Sant'Anna Guilherme M
BACKGROUND:Infants with hypoxic-ischemic encephalopathy (HIE) may develop multiorgan dysfunction, but assessment of intestinal involvement is imprecise and based on nonspecific clinical signs that may occur several days later. Ultrasound imaging has been described as a helpful tool in assessing intestinal involvement in many gastrointestinal disorders. OBJECTIVE:Describe abdominal ultrasonography findings in infants receiving therapeutic hypothermia and investigate its association with the severity of the hypoxic-ischemic insult and death. MATERIALS AND METHODS:Studies were performed within the first 36 h of life to assess intestinal appearance (normal bowel, bowel wall echogenicity and thickness, and sloughed mucosa), free fluid, peristalsis and intramural perfusion. These findings were compared between infants with moderate and severe encephalopathy. Ultrasound findings were also categorized in three major groups and compared with markers of severity of the hypoxic-ischemic insult and with mortality. RESULTS:Nineteen infants with moderate and 9 with severe HIE at admission were studied (17.7 ± 9.5 h of life). Major ultrasonography findings were increased bowel wall echogenicity (78%), free fluid (75%), decreased or absent peristalsis (50%) and sloughing of the intestinal mucosa (21%). Abnormal intestinal findings such as increased bowel wall echogenicity in all quadrants and presence of sloughed mucosa were associated with more severe hypoxic-ischemic insult. All 12 patients with normal bowel appearance or increased bowel wall echogenicity restricted to only one quadrant survived, whereas 7/15 (47%) patients with increased bowel wall echogenicity in all four quadrants died during hospitalization. The presence of sloughed mucosa was associated with increased mortality (P < 0.001). CONCLUSION:In infants receiving therapeutic hypothermia, a high prevalence of intestinal involvement was noted by using ultrasonographic assessment. An association between intestinal findings and severity of hypoxic-ischemic insult was observed. The presence of sloughed mucosa is a potential ultrasonographic sign of severity.
Fecal retention in childhood: Evaluation on ultrasonography.
Hatori Reiko,Tomomasa Takeshi,Ishige Takashi,Tatsuki Maiko,Arakawa Hirokazu
Pediatrics international : official journal of the Japan Pediatric Society
BACKGROUND:To assess the usefulness of rectal diameter measurement on ultrasonography as a diagnostic tool for fecal retention in children. METHODS:One hundred children (median age, 5.0 years), consisting of 80 with functional constipation and 20 without constipation, participated in the study. All patients underwent physical examination that included digital rectal examination. Forty-five children underwent ultrasonography in three differential planes: transection above the symphysis; under the ischial spine; and at the bladder neck. The measurement of the rectal diameter at the transection above the symphysis could most easily detect fecal retention and had the closest correlations with retention among the three planes. RESULTS:Rectal diameter was wider at all measuring points (35.2 vs 20.9 mm above the symphysis, P < 0.0001; 35.7 vs 24.0 mm under the ischial spine, P < 0.0001; and 19.4 vs 8.7 mm at the bladder neck, P < 0.0001) in children with fecal retention than in those with no fecal retention. With regard to presence of constipation, children with fecal retention had a wider rectal diameter above the symphysis than those with no fecal retention (children with functional constipation, 35.3 vs 20.0 mm, P < 0.0001; children without constipation: 32.6 vs 14.6 mm, P = 0.0026). The cut-off for the rectal diameter measured above the symphysis to identify fecal retention was 27 mm, with high sensitivity and specificity (95.5% and 94.1%, respectively). CONCLUSION:Ultrasound rectal diameter measurement can be used to detect fecal retention in children.
A successful treatment strategy in infants and adolescents with anorectal malformation and incontinence with combined hydrocolonic ultrasound and bowel management.
Grasshoff-Derr Sabine,Backhaus Kathrin,Hubert Désirée,Meyer Thomas
Pediatric surgery international
PURPOSE:Patients with anorectal malformation (ARM) frequently suffer postoperatively from fecal incontinence (25%) and constipation (75%). Depending on the type of malformation, some cases will not have a chance to control bowel movements. For these patients with fecal incontinence, we started to combine bowel management with hydrocolonic ultrasound to keep them clean. MATERIAL:From January 2003 until December 2010, overall 63 patients (aged 4-22 years) with ARM and fecal incontinence were treated by specific bowel management. Hydrocolonic ultrasound was used as a diagnostic parameter to determine stool texture and activity of the colon as well as to determine the appropriate volume which is needed to clean the colon. Each patient received an individually adjusted enema. Patients were classified into two groups: Group I: patients with incontinence and tendency to constipation and Group II: patients with incontinence and tendency to diarrhea. Subsequent controls were focused on problems such as bowel dilatation, bowel motility, constipation or too little enema due to the patient's growing. RESULTS:Up to now, 63 patients were investigated in our study (Group I n = 37 patients and Group II n = 26 patients). In addition, the patients were classified according to the type of malformation. With specific bowel management combined with hydrocolonic ultrasound, 97% of patients in Group I (36/37) stayed clean (demonstration of complete bowel control). All 57.7% of patients in Group II (15/26) stayed clean after daily bowel management, and 34.6% with smearing less than three times per week (n = 9/26). In addition, a specific diet and constipating medication were often necessary to get patients in Group II clean. CONCLUSIONS:Treating young patients with fecal incontinence is always a challenge. Hydrocolonic ultrasound diagnostically conclusive and less invasive. The combination with bowel management results in better bowel control and serves as a valuable tool in affected infants and adolescents. Thus, hydrocolonic ultrasound may be an essential instrument in postoperative diagnostic procedure and therapy of patients with fecal incontinence.
Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation.
Joensson Iben Moeller,Siggaard Charlotte,Rittig Soren,Hagstroem Soren,Djurhuus Jens Christian
The Journal of urology
PURPOSE:We tested whether transverse rectal diameter measured by ultrasound could identify rectal impaction, investigated whether transverse diameter is enlarged in constipated children compared to healthy children and evaluated transverse diameter during treatment of constipation. MATERIALS AND METHODS:A total of 51 children 4 to 12 years old were included in the study. Of the children 27 (mean age 7.0 +/- 1.8 years) had been diagnosed with chronic constipation by Rome III criteria and 24 (9.1 +/- 2.7 years) were healthy controls. All patients underwent a thorough medical history and physical examination, including digital rectal examination and measurement of rectal diameter by transabdominal ultrasound. Constipated children underwent repeat investigations after 4 weeks of laxative treatment. RESULTS:Average rectal diameter of children with negative digital rectal examination was 21 +/- 4.2 mm (mean +/- SD), leading to the approximation that a value greater than 29.4 mm (mean +/- 2 SD) indicates rectal impaction. All children with rectal impaction identified by digital examination had a rectal diameter larger than 29.4 mm. Moreover, constipated children had a significantly larger rectal diameter (42.1 +/- 15.4 mm) than healthy children (21.4 +/- 6.0 mm, p <0.001). After 4 weeks of laxative treatment constipated children had a significant reduction in rectal diameter (mean 26.9 +/- 5.6 mm, p <0.001). CONCLUSIONS:Transverse rectal diameter seems to be a valuable tool to identify rectal impaction and may replace digital rectal examination. Constipated children have a significantly larger rectal diameter compared to healthy children, and when constipation is treated the diameter is reduced significantly.
Transabdominal ultrasound measurement of rectal diameter is dependent on time to defecation in constipated children.
Modin Line,Dalby Kasper,Walsted Anne-Mette,Jakobsen Marianne
Journal of paediatrics and child health
AIM:To study whether diurnal variations and time in relation to defecation has to be taken into account when measurements of rectal diameter are used to determine faecal impaction in constipated children. METHODS:Repeated ultrasound measures of rectal diameter were performed in 28 children (14 constipated/14 healthy, aged between 4 and 12 years) every third hour during 24 h. After defecation, three additional scans were performed at 1-h intervals. RESULTS:No diurnal variation in rectal diameter was found in the healthy group. In the constipated group, mean rectal diameter was significantly larger at 2 pm (P = 0.038) and 5 pm (P = 0.006). There were significant differences between rectal diameter in the healthy group and the constipated group at 2 pm (P = 0.016) and 5 pm (P = 0.027). When we omitted the rectal diameter of five constipated children who had their first bowel movement after 5 pm, there were no difference between groups (2 pm (P = 0.103)/5 pm (P = 0.644) ). Only in the constipated group, rectal diameter exceeded 3 cm without the patients feeling the urge to defecate. CONCLUSION:We found no independent daily variation in either group without relation to defecation. There was a relation between defecation and changes in rectal diameter in both healthy children and constipated children during maintenance treatment.Asking for defecation signals before scanning should be considered a routine question, and a positive answer should cause postponement of the scan.