Original Article
Patterns of brain injury in term neonatal encephalopathy

https://doi.org/10.1016/j.jpeds.2004.12.026Get rights and content

Objectives

To determine whether the pattern of brain injury in term neonatal encephalopathy is associated with distinct prenatal and perinatal factors and to determine whether the pattern of injury is associated with 30-month neurodevelopmental outcome.

Study design

A total of 173 term newborns with neonatal encephalopathy from 2 centers underwent magnetic resonance imaging (MRI) at a median of 6 days of age (range, 1-24 days). Patterns of injury on MRI were defined on the basis of the predominant site of injury: watershed predominant, basal ganglia/thalamus predominant, and normal.

Results

The watershed pattern of injury was seen in 78 newborns (45%), the basal ganglia/thalamus pattern was seen in 44 newborns (25%), and normal MRI studies were seen in 51 newborns (30%). Antenatal conditions such as maternal substance use, gestational diabetes, premature rupture of membranes, pre-eclampsia, and intra-uterine growth restriction did not differ across patterns. The basal ganglia/thalamus pattern was associated with more severe neonatal signs, including more intensive resuscitation at birth (P = .001), more severe encephalopathy (P = .0001), and more severe seizures (P = .0001). The basal ganglia/thalamus pattern was associated with the most impaired motor and cognitive outcome at 30 months.

Conclusion

The patterns of brain injury in term neonatal encephalopathy are associated with different clinical presentations and neurodevelopmental outcomes. Measured prenatal risk factors did not predict the pattern of brain injury.

Section snippets

Methods

Two cohorts of term newborns were studied at the University of California San Francisco (UCSF) and at Loma Linda University Children's Hospital (LLUCH). The Committees on Human Research at each site approved the protocol.

The UCSF cohort consists of 121 newborns studied with MRI (1994-2000), all of whom had neonatal encephalopathy or a marker of perinatal depression: umbilical artery pH <7.1, umbilical artery base deficit >10, or a 5-minute Apgar score ≤5. These inclusion criteria were chosen to

Patterns of Injury

MRI findings consistent with acute or subacute brain injury were common in this cohort, particularly the watershed predominant pattern. At UCSF, 63 newborns had the watershed pattern (52%), 26 had the basal ganglia/thalamus pattern (22%), and 32 had normal MRI results (26%). At LLUCH, 15 newborns had the watershed pattern (29%), 18 had the basal ganglia/thalamus pattern (35%) and 19 had normal MRI results (37%). The predominant region of injury was often accompanied by lesser damage to the

Discussion

In this cohort representative of the spectrum of severity of term neonatal encephalopathy, the watershed predominant injury pattern was most common, seen in 45% of the cohort, and was often accompanied by less severe basal ganglia/thalamus injury. The basal ganglia/thalamus predominant pattern was less common, seen in 25% of the cohort, and was frequently accompanied by more diffuse cortical injury. These patterns are consistent with the regional vulnerability of the term neonatal brain.1, 11,

References (31)

  • P.D. Gluckman et al.

    Selective head cooling with mild systemic hypothermia to improve neurodevelopmental outcome following neonatal encephalopathy: the CoolCap Study

    Pediatr Res

    (2004)
  • T.E. Inder et al.

    Systemic hypothermia selectively protects the cortex in term hypoxic-ischemic encephalopathy

    Pediatr Res

    (2004)
  • N. Badawi et al.

    Intrapartum risk factors for newborn encephalopathy: the Western Australian case-control study

    BMJ

    (1998)
  • N. Badawi et al.

    Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study

    BMJ

    (1998)
  • R.E. Myers

    Four patterns of perinatal brain damage and their conditions of occurrence in primates

    Adv Neurol

    (1975)
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    Supported by the National Center for Research Resources (5 M01 RR-01271), US Public Health Service, and by the National Institutes of Health (NS35902). Dr Miller is supported by the Canadian Institutes of Health Research. Mr Ramaswamy was supported by the American Pediatric Society - Society for Pediatric Research summer research program (NIH grant HD007446).

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