Neonatal Encephalopathic Cerebral Injury in South India Assessed by Perinatal Magnetic Resonance Biomarkers and Early Childhood Neurodevelopmental Outcome

Abstract

Although brain injury after neonatal encephalopathy has been characterised well in high-income countries, little is known about such injury in low- and middle-income countries. Such injury accounts for an estimated 1 million neonatal deaths per year. We used magnetic resonance (MR) biomarkers to characterise perinatal brain injury, and examined early childhood outcomes in South India.MethodsWe recruited consecutive term or near term infants with evidence of perinatal asphyxia and a Thompson encephalopathy score ≥6 within 6 h of birth, over 6 months. We performed conventional MR imaging, diffusion tensor MR imaging and thalamic proton MR spectroscopy within 3 weeks of birth. We computed group-wise differences in white matter fractional anisotropy (FA) using tract based spatial statistics. We allocated Sarnat encephalopathy stage aged 3 days, and evaluated neurodevelopmental outcomes aged 3½ years using Bayley III.ResultsOf the 54 neonates recruited, Sarnat staging was mild in 30 (56%); moderate in 15 (28%) and severe in 6 (11%), with no encephalopathy in 3 (6%). Six infants died. Of the 48 survivors, 44 had images available for analysis. In these infants, imaging indicated perinatal rather than established antenatal origins to injury. Abnormalities were frequently observed in white matter (n = 40, 91%) and cortex (n = 31, 70%) while only 12 (27%) had abnormal basal ganglia/thalami. Reduced white matter FA was associated with Sarnat stage, deep grey nuclear injury, and MR spectroscopy N-acetylaspartate/choline, but not early Thompson scores. Outcome data were obtained in 44 infants (81%) with 38 (79%) survivors examined aged 3½ years; of these, 16 (42%) had adverse neurodevelopmental outcomes.ConclusionsNo infants had evidence for established brain lesions, suggesting potentially treatable perinatal origins. White matter injury was more common than deep brain nuclei injury. Our results support the need for rigorous evaluation of the efficacy of rescue hypothermic neuroprotection in low- and middle-income countries.

Prevalence, severity and early outcomes of hypoxic ischemic encephalopathy among newborns at a tertiary hospital, in northern Tanzania

“…This is similar to findings done in South India where the proportion of newborns with mild HIE was 56% [10] and from another study conducted in Rotunda hospital in Ireland where of the 237 newborn assessed, 65.4% had the mild form of HIE [11]. Of note to practitioners’ majority (98%) of newborns with mild HIE in this study improved and were discharged similar to observations at Muhimbili National Hospital in Tanzania, in Pakistan and India respectively where a total of 92.3% of the newborns were discharged to their mothers [5, 10, 12]. This indicates that with the appropriate care newborns with HIE can improve sufficiently to be discharged early.…”

Cooling in a low-resource environment: Lost in translation

“…In a prospective study, Tann et al [29] reported that the prevalence of neonatal bacteremia with a pathogenic organism among encephalopathic infants was 3.5% by blood culture alone, 6.9% by polymerase chain reaction (PCR) alone, and 8.9% by blood culture and PCR in combination. A similar incidence of coexistent bloodstream-positive infection and encephalopathy has been reported from India [30,31]. This is similar to that reported from high-income countries: 8.1% in the ICE trial [32], 6% in NICHD [17], 17% in the TOBY registry [33].…”

The Frequency and Severity of Magnetic Resonance Imaging Abnormalities in Infants with Mild Neonatal Encephalopathy

“…7, 11–13, 19 DuPont et al found that 20% (12/60) of infants with mild NE had an abnormal short-term outcome, including presence of seizures, abnormal neurological examination at discharge, and feeding difficulties beyond the first week of life. Few infants had MRIs in their cohort, nine in total, 66% of which were abnormal.…”