Objectives: Central gray matter damage, the hallmark of term acute perinatal hypoxia-ischemia, frequently leads to severe cerebral palsy and sometimes death. The precision with which these outcomes can be determined from neonatal imaging has not been fully explored. We evaluated the accuracy of early brain MRI for predicting death, the presence and severity of motor impairment, and ability to walk at 2 years in term infants with hypoxic-ischemic encephalopathy (HIE) and basal ganglia-thalamic (BGT) lesions. From 1993From to 2007 term infants with evidence of perinatal asphyxia, HIE, and BGT injury seen on early MRI scans were studied. BGT, white matter, posterior limb of the internal capsule (PLIC), and cortex and brainstem abnormality were classified by severity. Motor impairment was staged using the Gross Motor Function Classification System. Methods: Results:The severity of BGT lesions was strongly associated with the severity of motor impairment (Spearman rank correlation 0.77; p Ͻ 0.001). The association between white matter, cortical, and brainstem injury and motor impairment was less strong and only BGT injury correlated significantly in a logistic regression model. The predictive accuracy of severe BGT lesions for severe motor impairment was 0.89 (95% confidence interval 0.83-0.96). Abnormal PLIC signal intensity predicted the inability to walk independently by 2 years (sensitivity 0.92, specificity 0.77, positive predictive value 0.88, negative predictive value 0.85). Brainstem injury was the only factor with an independent association with death. Conclusion:We have shown that in term newborns with HIE and BGT injury, early MRI can be used to predict death and specific motor outcomes. Neurology ® 2011;76:2055-2061 GLOSSARY BFMF ϭ Bimanual Fine Motor Function; BGT ϭ basal ganglia and thalami; CI ϭ confidence interval; CP ϭ cerebral palsy; GMFCS ϭ Gross Motor Function Classification System; HIE ϭ hypoxic-ischemic encephalopathy; LRM ϭ logistic regression model; NE ϭ neonatal encephalopathy; NPV ϭ negative predictive value; PLIC ϭ posterior limb of the internal capsule; PPV ϭ positive predictive value; SCPE ϭ Surveillance of Cerebral Palsy in Europe; SI ϭ signal intensity; WM ϭ white matter.Central gray matter damage, the hallmark of acute perinatal hypoxia-ischemia in term infants, 1 is an important cause of death and cerebral palsy (CP). CP is a lifelong condition affecting not only motor function, but the child's global development. Commonly associated impairments include learning, visual, feeding, and communication difficulties and epilepsy that all place a heavy burden on the children and their families. Coping with the birth of a severely asphyxiated baby is extremely distressing for parents. Apart from the initial concern that their infant may die, parents have to deal with uncertainty about their child's future. They usually want to know not only if their child will have a motor problem, but its severity and whether their child will be able to walk 3 ; unfortunately, these questions can b...
WHAT'S KNOWN ON THIS SUBJECT: Etiology and timing of onset of neonatal hypoxic-ischemic encephalopathy continue to be controversial. Previous studies suggest antepartum events are the main contributing factors, but have used a broad definition of encephalopathy and included infants with genetic, congenital, and developmental abnormalities.WHAT THIS STUDY ADDS: Our study suggests that when strict criteria defining hypoxic-ischemic encephalopathy are applied with supporting neuroimaging evidence of an acute hypoxicischemic insult, intrapartum events are the final and necessary pathway leading to this condition. abstract OBJECTIVE: To determine whether antepartum factors alone, intrapartum factors alone, or both in combination, are associated with term neonatal hypoxic-ischemic encephalopathy (HIE). METHODS:A total of 405 infants $35 weeks' gestation with early encephalopathy, born between 1992 and 2007, were compared with 239 neurologically normal infants born between 1996 and 1997. All cases met criteria for perinatal asphyxia, had neuroimaging findings consistent with acute hypoxia-ischemia, and had no evidence for a non-hypoxic-ischemic cause of their encephalopathy.RESULTS: Both antepartum and intrapartum factors were associated with the development of HIE on univariate analysis. Case infants were more often delivered by emergency cesarean delivery (CD; 50% vs 11%, P , .001) and none was delivered by elective CD (vs 10% of controls). On logistic regression analysis only 1 antepartum factor (gestation $41 weeks) and 7 intrapartum factors (prolonged membrane rupture, abnormal cardiotocography, thick meconium, sentinel event, shoulder dystocia, tight nuchal cord, failed vacuum) remained independently associated with HIE (area under the curve 0.88; confidence interval 0.85-0.91; P , .001). Overall, 6.7% of cases and 43.5% of controls had only antepartum factors; 20% of cases and 5.8% of controls had only intrapartum factors; 69.5% of cases and 31% of controls had antepartum and intrapartum factors; and 3.7% of cases and 19.7% of controls had no identifiable risk factors (P , .001). CONCLUSIONS:Our results do not support the hypothesis that HIE is attributable to antepartum factors alone, but they strongly point to the intrapartum period as the necessary factor in the development of this condition. Pediatrics 2013;132:e952-e959
NAIS is multifactorial in origin and shares risk factors in common with HIE. Intrapartum events may play a more significant role in the pathogenesis of NAIS than previously recognized.
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