Original Article

Findings and Patterns on MRI and MR Spectroscopy in Neonates after Therapeutic Hypothermia for Hypoxic Ischemic Encephalopathy Treatment

Authors: Neil H. Thakur, MD, Andrew J. Spencer, BS, Howard W. Kilbride, MD, Lisa H. Lowe, MD

Abstract

Objectives: The purpose of this study is to describe the findings and patterns of injury on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) after whole-body hypothermia treatment for neonatal hypoxic ischemic encephalopathy.

Methods: A retrospective review of consecutive term neonates treated with whole-body hypothermia was performed. Data recorded included demographics and MRI and MRS findings, and day of life (DOL) studies were performed. Injury patterns were classified on MRI as deep, cortical, mixed, or diffuse. The relative apparent diffusion coefficient (rADC) was plotted against DOL scanned and the presence of lactate was recorded.

Results: MRI was performed in 44 infants, 34 of whom also underwent MRS. MRI was abnormal in 32% of neonates, 29.5% of whom were imaged at DOL 4 to 8. rADC values were lowest in neonates scanned on DOL 4 and 5 and remained low up to DOL 8. The deep brain nuclei were involved in hypoxic ischemic encephalopathy in 93% of neonates with abnormal MRIs and lactate was identified on MRS in 18% of neonates between DOL 4 and 8.

Conclusions: MRI performed after therapeutic cooling was abnormal in 29.5% of neonates scanned on DOL 4 to 8. Deep nuclear injury was identified in 93% of neonates. Lactate was present on MRS in 18% of neonates, and rADC values were most reduced on MRI between DOL 4 and 8.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Gluckman PD, Wyatt JS, Azzopardi D, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet. 2005; 365: 663–670.
 
2. Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005; 353: 1574–1584.
 
3. Azzopardi DV, Strohm B, Edwards AD, et al. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med. 2009; 361: 1349–1358.
 
4. Edwards AD, Brocklehurst P, Gunn AJ, et al. Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data. BMJ. 2010; 340: c363
 
5. Sarkar S, Donn SM, Bapuraj JR, et al. Distribution and severity of hypoxic-ischaemic lesions on brain MRI following therapeutic cooling: selective head versus whole body cooling. Arch Dis Child Fetal Neonatal Ed. 2012; 97: F335–F339.
 
6. Filippi L, Fiorini P, Daniotti M, et al. Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI). BMC Pediatr. 2012; 12: 144.
 
7. Chao CP, Zaleski CG, Patton AC. Neonatal hypoxic-ischemic encephalopathy: multimodality imaging findings. Radiographics. 2006; 26: S159–S172.
 
8. Heinz ER, Provenzale JM. Imaging findings in neonatal hypoxia: a practical review. AJR Am J Roentgenol. 2009; 192: 41–47.
 
9. Zanelli S, Buck M, Fairchild K. Physiologic and pharmacologic considerations for hypothermia therapy in neonates. J Perinatol. 2011; 31: 377–386.
 
10. Mathur AM, Smith JR, Donze A. Hypothermia and hypoxic-ischemic encephalopathy: guideline development using the best evidence. Neonatal Netw. 2008; 27: 271–286.
 
11. Rutherford M, Malamateniou C, McGuinness A, et al. Magnetic resonance imaging in hypoxic-ischaemic encephalopathy. Early Hum Dev. 2010; 86: 351–360.
 
12. Wintermark P, Hansen A, Soul J, et al. Early versus late MRI in asphyxiated newborns treated with hypothermia. Arch Dis Child Fetal Neonatal Ed. 2011; 96: F36–F44.
 
13. Neil J. Is MRI still cool after hypothermia? Lancet Neurol. 2010; 9: 19–20.
 
14. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol. 1976; 33: 696–705.
 
15. McKinstry RC, Miller JH, Snyder AZ, et al. A prospective, longitudinal diffusion tensor imaging study of brain injury in newborns. Neurology. 2002; 59: 824–833.
 
16. Neil JJ, Shiran SI, McKinstry RC, et al. Normal brain in human newborns: apparent diffusion coefficient and diffusion anisotropy measured by using diffusion tensor MR imaging. Radiology. 1998; 209: 57–66.
 
17. Penrice J, Cady EB, Lorek A, et al. Proton magnetic resonance spectroscopy of the brain in normal preterm and term infants, and early changes after perinatal hypoxia-ischemia. Pediatr Res. 1996; 40: 6–14.
 
18. Barkovich AJ, Westmark K, Partridge C, et al. Perinatal asphyxia: MR findings in the first 10 days. AJNR Am J Neuroradiol. 1995; 16: 427–438.
 
19. Huang BY, Castillo M. Hypoxic-ischemic brain injury: imaging findings from birth to adulthood. Radiographics. 2008; 28: 417–439.
 
20. Robertson RL, Ben-Sira L, Barnes PD, et al. MR line-scan diffusion-weighted imaging of term neonates with perinatal brain ischemia. AJNR Am J Neuroradiol. 1999; 20: 1658–1670.
 
21. Groenendaal F, Veenhoven RH, van der Grond J, et al. Cerebral lactate and N-acetyl-aspartate/choline ratios in asphyxiated full-term neonates demonstrated in vivo using proton magnetic resonance spectroscopy. Pediatr Res. 1994; 35: 148–151.
 
22. Forbes KP, Pipe JG, Bird R. Neonatal hypoxic-ischemic encephalopathy: detection with diffusion-weighted MR imaging. AJNR Am J Neuroradiol. 2000; 21: 1490–1496.
 
23. Grant PE, Yu D. Acute injury to the immature brain with hypoxia with or without hypoperfusion. Radiol Clin North Am. 2006; 44: 63–77.
 
24. Wijdicks EF, Campeau NG, Miller GM. MR imaging in comatose survivors of cardiac resuscitation. AJNR Am J Neuroradiol. 2001; 22: 1561–1565.
 
25. Barkovich AJ. MR and CT evaluation of profound neonatal and infantile asphyxia. AJNR Am J Neuroradiol. 1992; 13: 959–972.
 
26. Rutherford MA, Azzopardi D, Whitelaw A, et al. Mild hypothermia and the distribution of cerebral lesions in neonates with hypoxic-ischemic encephalopathy. Pediatrics. 2005; 116: 1001–1006.
 
27. Wintermark P, Labrecque M, Warfield SK, et al. Can induced hypothermia be assured during brain MRI in neonates with hypoxic-ischemic encephalopathy? Pediatr Radiol. 2010; 40: 1950–1954.
 
28. Inder TE, Hunt RW, Morley CJ, et al. Randomized trial of systemic hypothermia selectively protects the cortex on MRI in term hypoxic-ischemic encephalopathy. J Pediatr. 2004; 145: 835–837.
 
29. van Wezel-Meijler G, Leijser LM, de Bruine FT, et al. Magnetic resonance imaging of the brain in newborn infants: practical aspects. Early Hum Dev. 2009; 85: 85–92.
 
30. Massaro AN, Kadom N, Chang T, et al. Quantitative analysis of magnetic resonance images and neurological outcome in encephalopathic neonates treated with whole-body hypothermia. J Perinatol. 2010; 30: 596–603.
 
31. Rutherford M, Ramenghi LA, Edwards AD, et al. Assessment of brain tissue injury after moderate hypothermia in neonates with hypoxic-ischaemic encephalopathy: a nested substudy of a randomised controlled trial. Lancet Neurol. 2010; 9: 39–45.
 
32. Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weighted MR imaging of the brain. Radiology. 2000; 217: 331–345.