Combined Use of Electroencephalogram and Magnetic Resonance Imaging in Full-Term Neonates With Acute Encephalopathy

Biagioni, Enrico; Mercuri, Eugenio; Rutherford, Mary; Cowan, Frances; Azzopardi, Denis; Frisone, Maria Flavia; Cioni, Giovanni; Dubowitz, Lilly

doi:10.1542/peds.107.3.461

Cited by 115 publications

(74 citation statements)

References 24 publications

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“…A tracing was defined as constant low voltage when the detected background activity amplitude was constantly Ͻ20 V. 23 Constantly discontinuous tracings, defined when there was constant alternating of relatively highamplitude bursts and low-voltage (Ն45 V) intervals, were further classified as exhibiting extreme discontinuity (maximal interval duration of Ͼ40 seconds), severe discontinuity (maximal interval duration of 20 -40 seconds), or moderate discontinuity (maximal interval duration of Ͻ20 seconds). 24 A dysmature tracing was defined when the observed maturational features were immature for Ն2 weeks, compared with the postmenstrual age of the patient. In addition, the incidences of paroxysmal abnormalities (abnormal EEG transients) and ictal EEG discharges were evaluated and were scored as described by Biagioni et al 24,25 …”

Section: Electroencephalographymentioning

confidence: 99%

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Human Recombinant Erythropoietin in Asphyxia Neonatorum: Pilot Trial

Elmahdy¹,

El-Mashad²,

et al. 2010

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WHAT'S KNOWN ON THIS SUBJECT:Neuronal apoptosis that follows hypoxia-ischemia is triggered by upregulation of NO synthase, with excessive accumulation of NO and release of excitatory amino acids such as glutamate. Animal studies demonstrated the ability of erythropoietin to attenuate these mechanisms. WHAT THIS STUDY ADDS:The administration of erythropoietin to infants with asphyxia with mild/moderate HIE was associated with favorable decreases in endogenous NO production, decreases in seizure activity, and improved neurodevelopmental outcomes to 6 months of age. abstract OBJECTIVE: The goal was to examine biochemical, neurophysiologic, anatomic, and clinical changes associated with erythropoietin administration to neonates with hypoxic-ischemic encephalopathy (HIE). METHODS:We conducted a prospective case-control study with 45 neonates in 3 groups, a normal healthy group (N ϭ 15), a HIEerythropoietin group (N ϭ 15; infants with mild/moderate HIE who received human recombinant erythropoietin, 2500 IU/kg, subcutaneously, daily for 5 days), and a HIE-control group (N ϭ 15; did not receive erythropoietin). Serum concentrations of nitric oxide (NO) were measured at enrollment for the normal healthy neonates and at enrollment and after 2 weeks for the 2 HIE groups. The 2 HIE groups underwent electroencephalography at enrollment and at 2 to 3 weeks. Brain MRI was performed at 3 weeks. Neurologic evaluations and Denver Developmental Screening Test II assessments were performed at 6 months. RESULTS:Compared with normal healthy neonates, the 2 HIE groups had greater blood NO concentrations (P Ͻ .001). At enrollment, the 2 HIE groups did not differ in clinical severity, seizure incidence, NO concentrations, or electroencephalographic findings. At 2 weeks of age, electroencephalographic backgrounds improved significantly (P ϭ .01) and NO concentrations decreased (P Ͻ .001) in the HIEerythropoietin group, compared with the HIE-control group; MRI findings did not differ between groups. At 6 months of age, infants in the HIE-erythropoietin group had fewer neurologic (P ϭ .03) and developmental (P ϭ .03) abnormalities. CONCLUSION:This study demonstrates the feasibility of early administration of human recombinant erythropoietin to term neonates with HIE, to protect against encephalopathy.

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Section: Electroencephalographymentioning

confidence: 99%

“…24 A dysmature tracing was defined when the observed maturational features were immature for Ն2 weeks, compared with the postmenstrual age of the patient. In addition, the incidences of paroxysmal abnormalities (abnormal EEG transients) and ictal EEG discharges were evaluated and were scored as described by Biagioni et al 24,25 …”

Section: Electroencephalographymentioning

confidence: 99%

Human Recombinant Erythropoietin in Asphyxia Neonatorum: Pilot Trial

Elmahdy¹,

El-Mashad²,

et al. 2010

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“…[21][22][23] Nine of the 32 studies in the meta-analysis included only surviving infants with HIE, which made their results potentially less relevant to questions about withdrawal of intensive care. [24][25][26][27][28][29][30][31][32] …”

Section: Populationmentioning

confidence: 99%

“…Some performed scans in the first days of life, 21,33-37 whereas others deferred imaging until after the first week. [24][25][26][27][28]38 However, the timing of imaging may be crucial if it is to be used in treatment-limitation decisions. 39 In infants with moderate or severe encephalopathy in cooling trials, the majority of deaths relating to withdrawal of treatment occurred in the first 3 or 4 days of life.…”

Section: Timingmentioning

confidence: 99%

“…However, using a Bayesian approach, MR biomarkers might be used in combination with clinical and electrophysiological evidence to identify infants with a high level of certainty of very severe impairment. There is some evidence that MRI improves outcome prediction when added to clinical staging and electroencephalography, 25,50,70 but it is not possible from published studies to define this group clearly.…”

Section: Implications For Practicementioning

confidence: 99%

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MRI and Withdrawal of Life Support From Newborn Infants With Hypoxic-Ischemic Encephalopathy

Wilkinson

2010

Pediatrics

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The majority of deaths in infants with hypoxic-ischemic encephalopathy (HIE) follow decisions to withdraw life-sustaining treatment. Clinicians use prognostic tests including MRI to help determine prognosis and decide whether to consider treatment withdrawal. A recently published meta-analysis provided valuable information on the prognostic utility of magnetic resonance (MR) biomarkers in HIE and suggested, in particular, that proton MR spectroscopy is the most accurate predictor of neurodevelopmental outcome. How should this evidence influence treatment-limitation decisions? In this article I outline serious limitations in existing prognostic studies of HIE, including small sample size, selection bias, vague and overly inclusive outcome assessment, and potential self-fulfilling prophecies. Such limitations make it difficult to answer the most important prognostic question. Reanalysis of published data reveals that severe abnormalities on conventional MRI in the first week have a sensitivity of 71% (95% confidence interval: 59%-91%) and specificity of 84% (95% confidence interval: 68%-93%) for very adverse outcome in infants with moderate encephalopathy. On current evidence, MR biomarkers alone are not sufficiently accurate to direct treatment-limitation decisions. Although there may be a role for using MRI or MR spectroscopy in combination with other prognostic markers to identify infants with very adverse outcome, it is not possible from meta-analysis to define this group clearly. There is an urgent need for improved prognostic research into HIE. Pediatrics 2010;126:e451-e458Hypoxic-ischemic encephalopathy (HIE) is a major contributor to global child mortality and morbidity. 1 Although therapeutic hypothermia has recently emerged as a means of neuroprotection for infants with HIE, many infants still have an adverse outcome. Almost 50% of infants enrolled in recent trials and treated with hypothermia either died or were found to have severe disability at the 18-month follow-up. 2,3 In developed countries the majority of deaths of infants with HIE follow decisions to withdraw life-sustaining treatment. 4,5 Two-thirds of the deaths in the recent cooling trials followed treatment withdrawal. 3,6 One important factor that clinicians use in making such decisions is the severity of encephalopathy. In particular, infants with severe (Sarnat stage 3) 7 encephalopathy are generally believed to have a uniformly dire prognosis. 8,9 However, prognostication in infants with moderate encephalopathy is more difficult. 9-11 A variety of clinical, electrophysiological, and radiologic tools have been used to help prognosticate. 9 In particular, MRI has emerged as potentially one of the most useful tools for prognostication in HIE, 8,[12][13][14]

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Relationship of EEG sources of neonatal seizures to acute perinatal brain lesions seen on MRI: A pilot study

et al. 2012

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Even though it is known that neonatal seizures are associated with acute brain lesions, the relationship of electroencephalographic (EEG) seizures to acute perinatal brain lesions visible on magnetic resonance imaging (MRI) has not been objectively studied. EEG source localization is successfully used for this purpose in adults, but it has not been sufficiently explored in neonates. Therefore, we developed an integrated method for ictal EEG dipole source localization based on a realistic head model to investigate the utility of EEG source imaging in neonates with postasphyxial seizures. We describe here our method and compare the dipole seizure localization results with acute perinatal lesions seen on brain MRI in 10 full-term infants with neonatal encephalopathy. Through experimental studies, we also explore the sensitivity of our method to the electrode positioning errors and the variations in neonatal skull geometry and conductivity. The localization results of 45 focal seizures from 10 neonates are compared with the visual analysis of EEG and MRI data, scored by expert physicians. In 9 of 10 neonates, dipole locations showed good relationship with MRI lesions and clinical data. Our experimental results also suggest that the variations in the used values for skull conductivity or thickness have little effect on the dipole localization, whereas inaccurate electrode positioning can reduce the accuracy of source estimates. The performance of our fused method indicates that ictal EEG source imaging is feasible in neonates and with further validation studies, this technique can become a useful diagnostic tool.

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Combined Use of Electroencephalogram and Magnetic Resonance Imaging in Full-Term Neonates With Acute Encephalopathy

Cited by 115 publications

References 24 publications

Human Recombinant Erythropoietin in Asphyxia Neonatorum: Pilot Trial

Human Recombinant Erythropoietin in Asphyxia Neonatorum: Pilot Trial

MRI and Withdrawal of Life Support From Newborn Infants With Hypoxic-Ischemic Encephalopathy

Relationship of EEG sources of neonatal seizures to acute perinatal brain lesions seen on MRI: A pilot study

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