Hypoxic Ischemic Encephalopathy - Oren Zarif - Hypoxic Ischemic Encephalopathy

While the incidence of hypoxic ischemic encephalopathies (HIE) varies considerably, the disorder affects approximately 1.5 per thousand live births. Children who survive this condition often have brain damage, neurodevelopmental delay, cerebral palsy, and even epilepsy. HIE is diagnosed by clinical examination, Sarnat staging, and Thompson scores. Neuroimaging is often performed to assess the risk of adverse neurodevelopmental outcomes, and clinical HIE grades are critical for clinical decision making.

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The causes of HIE are multifactorial. The first is the decrease in cerebral perfusion, caused by the tissue's inability to extract oxygen from blood. This mismatch between cerebral blood flow and oxidative metabolism results in the loss of brain cells. Although the exact mechanisms of hypoxic ischemic brain injury vary from case to case, the final pathway to brain cell death is the same. Depending on the underlying cause of the ischemic insult, the extent of cell death and the location are different.

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Seizures are a common symptom in infants with significant HIE. Seizures are more common in infants with moderate or severe HIE. More severe hypoxia-ischemia causes more seizures. Seizures are associated with a detrimental neurodevelopmental outcome in children. Repetitive seizures are associated with lower seizure thresholds in adults and reduced learning ability in childhood.

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Preterm infants with an acidotic cord may also be a candidate for HIE. These babies may have a delayed resolution of acidosis, and elevated liver enzymes. Affected infants may also have abnormal neurological examination. Although a diagnosis of HIE is unlikely in preterm infants, early detection of complications may help prevent the development of the disease. The most important aspect of preventing this disorder is to avoid the risk factors as much as possible.

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In case of suspicion of hypoxic ischemic encephalopathies, neonates should be evaluated with MRI and CT scans. MRI can help determine the etiology of the disease, as well as the prognosis. Head ultrasound can also be helpful for identifying ventriculomegaly and hemorrhage. Although CT scans are rarely used in infants, they can help diagnose some cases of encephalopathy.

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A perinatal HIE may occur only in extremely rare cases due to a recognized sentinel event. The pathogenesis of perinatal HIE is not understood, and there are many coexisting conditions that obscure individual pathologies. A retrospective cohort study of infants with mild HIE at 9 hospitals found that the occurrence of neonatal HII was associated with an increased risk of brain injury. Two reviewers independently scored neonatal brain MRIs using a validated scoring system. Consensus was reached to resolve disagreements. In addition, the severity of MRI brain injury was assessed in a subset of infants who had their first MRI before 8 days of age.

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Neonatal HIE is a heterogeneous disorder characterized by altered mental status, lowered primitive reflexes, and a decreased muscle tone. Treatment is centered on brain-focused management. A comprehensive perinatal evaluation of the neonate should include therapeutic hypothermia and neurophysiologic monitoring. When a neonate develops HIE, neuromonitoring is essential to determine a prognosis.

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Therapeutic hypothermia is often started as soon as possible after HIE is diagnosed. Early improvements in EEG and MRI are predictive of a favorable outcome. If the child has underlying anomalies, he is also at risk of peripartum asphyxia. Even with poor outcomes, therapeutic hypothermia and aggressive treatment may improve the child's condition. So, the early treatment is vital.

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The severity of HIE is dependent on the area of the brain affected and the degree of encephalopathy. Mild encephalopathy is associated with normal neurocognitive outcomes; severe encephalopathy is associated with early death. Severe HIE causes cognitive impairment and physical disabilities. Children who survive severe encephalopathy may face long-term cognitive problems. The prognosis of HIE is highly variable, but ongoing neuropsychological screening can lead to early intervention.

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HIE is often suspected in term newborns. If a child has symptoms of HIE, they should be immediately transferred to an intensive care nursery and receive treatment. During pregnancy, infants with HIE should be monitored for gestational age, birthweight, and clinical diagnosis of chorioamnionitis. In case of severe HIE, there should also be a pregnancy-related problem that led to low blood pressure in the baby.