8.10 Cranial ultrasound findings suggest that the injury pathway may begin many hours before delivery in encephalopathic infants in Uganda

Abstract

In sub-Saharan Africa, the timing and nature of brain injury and their relation to mortality in neonatal encephalopathy (NE) is unknown. Aim To evaluate cranial ultrasound (cUS) scans from term Ugandan infants with NE and unaffected controls for evidence of established/evolving brain injury. Methods Infants were recruited to a case-control study at Mulago Hospital, Kampala. Cases had NE (score1 >5). Controls were randomly selected unaffected term infants. All had cUS scans <36 h; surviving cases had day 4/5 scans. Minimally 11 views were reported blind to NE status. Scan injury definitions were evolving: extensive white matter (WM) and/or bilateral basal ganglia-thalamic (BGT) echogenicity and established: parenchymal cysts, atrophy, organising haemorrhage. Results Early scans showed significant abnormality in 20.4% (35/172) cases vs 1.0%(1/99) controls (p < 0.0001, mean age 11.2 h/8.1 h, respectively). Case scans at <18 h (120) still showed a high prevalence of abnormalities (16.7%). Case infants had 9.3% WM injury alone, 6.4% BGT injury alone and 4.7% BGT/WM injury. No established injury was seen. Fatality was significantly higher in cases with early cUS abnormalities vs those without (57.1%(20/35) vs 25.9%(35/135); OR 3.81(95% CI 1.76–8.25)). Serial scans were done in 88 mostly surviving NE infants; 74 had normal early scans with 35(47.3%) becoming abnormal by day 4/5. Conclusions The high proportion of infants with early cUS abnormality plus absence of established antepartum injury implies the injury pathway often begins several hours before delivery in this population, with implications for therapeutic interventions considered effective early in the injury pathway. Early cUS abnormality in NE was a significant predictor for death. References Thompson, et al. Acta Paediatr 1997 van Wezel-Meijler, et al. Neuropediatrics 2007

Magnetic Resonance Biomarkers in Neonatal Encephalopathy (MARBLE): a prospective multicountry study

“…The babies will have a cranial ultrasound scan on admission, at 24 h and 3–4 days for detection of malformations, bleeds, loss of normal tissue differentiation and evolving tissue injury. 26 Amplitude-integrated EEG (aEEG) will be performed over the first 48 h, as part of standard clinical care. The aEEG background activity will be classified according to voltage criteria and by background pattern.…”

Cooling in a low-resource environment: Lost in translation

“…Emerging evidence from LMIC suggests similar perinatal origins of brain injury. Tann et al [35] reported that 80% of the early cranial ultrasound (USG) scans were normal in encephalopathic babies admitted to a Sub-Saharan African neonatal unit, and none of them had evidence of established brain injury. Although the utility of USG in term encephalopathic infants is limited [36], these findings are similar to the cerebral MRI reported by Lally et al from a South Indian cohort (n = 54), in which none of the encephalopathic babies had evidence of established brain injury.…”