The magnetic resonance revolution in brain imaging: impact on neonatal intensive care

Robertson, Nicola J.; Wyatt, John

doi:10.1136/adc.2003.027334

Cited by 28 publications

(20 citation statements)

References 42 publications

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“…14 Magnetic resonance imaging of the brain is regarded by many as the most useful test for determining the extent and severity of brain injury. 15 It too has greater predictive power if it is performed after the first week of life. 16 Consequently there is some reason to delay prognostic testing.…”

Section: The Window Of Opportunitymentioning

confidence: 99%

The Window of Opportunity: Decision Theory and the Timing of Prognostic Tests for Newborn Infants

Wilkinson

2009

Bioethics

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In many forms of severe acute brain injury there is an early phase when prognosis is uncertain, followed later by physiological recovery and the possibility of more certain predictions of future impairment. There may be a window of opportunity for withdrawal of life support early, but if decisions are delayed there is the risk that the patient will survive with severe impairment. In this paper I focus on the example of neonatal encephalopathy and the question of the timing of prognostic tests and decisions to continue or to withdraw life-sustaining treatment. Should testing be performed early or later; and how should parents decide what to do given the conflicting values at stake? I apply decision theory to the problem, using sensitivity analysis to assess how different features of the tests or different values would affect a decision to perform early or late prognostic testing. I draw some general conclusions from this model for decisions about the timing of testing in neonatal encephalopathy. Finally I consider possible solutions to the problem posed by the window of opportunity. Decision theory highlights the costs of uncertainty. This may prompt further research into improving prognostic tests. But it may also prompt us to reconsider our current attitudes towards the palliative care of newborn infants predicted to be severely impaired.

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Section: The Window Of Opportunitymentioning

confidence: 99%

The Window of Opportunity: Decision Theory and the Timing of Prognostic Tests for Newborn Infants

Wilkinson

2009

Bioethics

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“…At present, given the need to identify infants soon after birth and the practical difficulties in obtaining very early imaging, MRI has little or no role here, although other biomarkers such as amplitude-integrated electroencephalography may be useful. 12,76 Second, prognostication may be used to identify infants with potentially abnormal neurodevelopment to inform parents and potentially provide targeted developmental interventions in early childhood. 77 Test results may also be used as a surrogate outcome measure in trials of interventions in the newborn period.…”

Section: Discussionmentioning

confidence: 99%

“…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] …”

Section: Introductionmentioning

confidence: 99%

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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“…3,4 These include focal and generalised white matter abnormalities, impaired cortical folding, and reduced grey and white matter volumes. Reduced growth and development of the posterior corpus callosum and its connections seems to be a particularly common finding.…”

Section: Evidence Of Brain Abnormalities In Preterm Infantsmentioning

confidence: 99%

Mechanisms of brain injury in the newborn

Wyatt

2007

Eye

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The magnetic resonance revolution in brain imaging: impact on neonatal intensive care

Cited by 28 publications

References 42 publications

The Window of Opportunity: Decision Theory and the Timing of Prognostic Tests for Newborn Infants

The Window of Opportunity: Decision Theory and the Timing of Prognostic Tests for Newborn Infants

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

Mechanisms of brain injury in the newborn

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