Study of transcranial colour
Doppler in the measurement of cerebral edema in birth asphyxia
Jain H1, Arya S2, Thakur
K3, Joshi S4
1Dr Hemant Jain, Professor, 2Dr Sunil Arya, Assistant Professor, 3Dr
Kuldeep Thakur, P.G Student, 4Dr Swati Joshi, P.G Student.
All affiliated with Department of Pediatrics, M.G.M Medical College,
Indore, MP, India
Address for
Correspondence: Dr Sunil Arya, email-
drsunilarya22@gmail.com
Abstract
Background:
Perinatal asphyxia is an insult to fetus or newborn due to lack of
oxygen /perfusion to various organs. Perinatal asphyxia occurs in 1 to
3 per 1000 live births and is related to gestational age and birth
weight. Worldwide 4-9 million suffer from birth asphyxia. It occur in
9% of infants of <36 wks of gestation and 0.5% in > 36
wks. Hypoxic ischemic brain injury is the most important consequence of
perinatal asphyxia. Aim
of study: To detect the measurement of cerebral blood flow
in full term infants with birth asphyxia, by use of transcranial colour
Doppler to measure RI (Resistive Index). Setting: Department
of Paediatrics at MY hospital in collaboration with department of
radiodiagnosis over a period of 1 yr from November 2013- October 14. Design:
Observational study. Method:
It included 40 consecutive cases of birth asphyxia who suffered from
HIE. Measurement of cerebral blood flow velocity was done by the use of
colour doppler ultrasound. Result:
Resistive index values were lower in measured vessels in asphyxiated
infant as compared by blood flow velocity, resistive index of ACA and
MCA. It is observed in our study that maximum number of patients in
asphyxiated group belongs to grade II HIE 87.5% (35), while in stage
III there were 2.5% (1) and in stage I only 4 (10%) patients.
Conclusion:
Colour Doppler USG would be of practical importance in evaluating the
cerebral blood flow velocity in neonate with HIE. A skillful detection
of decrease in cerebral blood flow of neonate in postnatal first 12 hrs
& treatment being based on such detection would contribute to a
good prognosis.
Key words:
Resistive index, Birth asphyxia, Hypoxic ischemic encephalopathy,
Colour Doppler
Manuscript received:10th
March 2016,Reviewed: 24th
March 2016
Author Corrected;
11th April 2016,Accepted
for Publication: 23rd April 2016
Introduction
Perinatal asphyxia refers to a condition during the first and second
stage of labour in which impaired gas exchange leads to fetal hypoxemia
and hypercarbia which in turn can lead to cerebral edema and various
circulatory disturbances [1]. Asphyxia can be determined on the basis
of indirect clinical markers, depressed Apgar scores, cord blood
acidosis or clinical signs in the neonate due to hypoxic ischemic
encephalopathy. Asphyxia is one of the leading causes of perinatal
death and a recognized cause of neuromotor disability later in life
among survivors [2].
During the post asphyxial period a consistent observation has been a
marked increase in cerebral blood flow which continues for several
hours and may or may not decline towards baseline. This reperfusion
phase is responsible for secondary brain injury. In infants with HIE,
high cerebral blood flow measured at 12 and 24 hours is associated with
a poor neurological outcome [3].
Doppler sonography is a non invasive method and can help in early
assessment of neonatal cerebral hemodynamics and shows consistent
changes in cerebral blood flow velocities in infants with intrapartum
asphyxia.
Methodology
It included 40 consecutive cases of birth asphyxia that suffered from
HIE. Measurement of cerebral blood flow velocity was done by the use of
colour doppler ultrasound. Cranial Ultrasound was done in
neonates with birth asphyxia in first 24 hours of life and repeat scan
on 3rd postnatal day. Cerebral blood flow velocity recordings were made
by colour duplex Doppler scanner 3 to 5 MHz. Recordings of CBF
velocities were made in the supine position 30-60 minutes after
feeding. Observations were made when the infants was in the quiet
state, eyes closed and with no gross body movements. Anterior cerebral
artery was visualized in the sagittal plane through the anterior
fontanel and the signals were recorded from the point midway between
the inferior-most border of the corpus callosum and the vessel origin
from the circle of Willis. Middle cerebral artery was visualized
through the temporal bone in the region above the zygomatic arch in the
fold of the temporal lobe from the straight mid-portion of the artery.
Neonates with Hypoxic ischemic encephalopathy included in this study
were classified according to Sarnat n Sarnat classification [4].
Measurement of Peak systolic velocity, End diastolic velocity and
resistive index from anterior and middle cerebral arteries were
conducted. In the present study we are taking an RI above 0.55 as
normal and an RI value less than 0.55 as abnormal [5].
Exclusion Criteria
• Those infant who underwent ventilation treatment
due to any reason.
• Those who are receiving medication such as
dopamine, adrenaline.
• Those with major congenital anomalies or shock.
• Premature infants <36 weeks
Our study analysed the relationship of cerebral blood circulation
parameters (PSV, EDV & RI) registered in the anterior &
middle cerebral arteries evaluated at 12-24 hr of life and at 3rd post
natal day and its relation to long term neurological outcome.
Results
1. Maximum numbers of asphyxiated infants were in grade-2- 35
patients (87.5%) and remaining in grade-1 (10%) 4 patient and in
grade-3 (2.5%) only 1 patient.
2. Maximum number of cases of HIE were in birth weight between
2.5 – 2.9 kg 23 (57.5%).
Table 1: Distribution of
patients
|
Grade
|
Male
|
%
|
Female
|
%
|
|
HIE -1
|
4
|
10%
|
0
|
0
|
|
HIE-2
|
24
|
60%
|
11
|
27.5%
|
|
HIE-3
|
1
|
2.5%
|
0
|
0
|
|
TOTAL
|
29
|
72.5%
|
11
|
27.5%
|
Male neonates involved more commonly than females. This
table shows mean resistive index of anterior and middle cerebral artery
on 1st day was 0.68±0.021 and 0.53±0.052
respectively, and on day 3rd it was 0.55±0.061 and
0.52±0.08 respectively. There was no difference in mean
value resistive index on day 1 and day 3.
Table 2: Mean RI value in
Anterior Cerebral artery according to grading of birth asphyxia
|
|
Number
of cases
|
1st
day
|
3rd
day
|
|
HIE-1
|
4
|
0.68±0.021
|
0.55±0.061
|
|
HIE-2
|
35
|
0.53±0.052
|
0.52±0.08
|
|
HIE-3
|
1
|
0.22
|
0.28
|
This table show that means RI value in Middle cerebral
artery decrease with severity of birth asphyxia, it is lowest in HIE-3,
and in grade -2.
Table 3: Correlation of
resistive index with grading of birth asphyxia
|
Grade
|
Total
|
Abnormal
|
Normal
|
|
|
|
No.
|
1st day
|
3rd day
|
No.
|
1st day
|
3rd day
|
|
HIE-1
|
4
|
0
|
0
|
0
|
4
|
0.62
|
0.56
|
|
HIE-2
|
35
|
35
|
0.53
|
0.55
|
0
|
0
|
0
|
|
HIE-3
|
1
|
1
|
0.22
|
0.53
|
0
|
0
|
0
|
Resistive index was low in grade II and grade III HIE on day
1 and day 3 and was normal in HIE grade I.
Discussion
When asphyxia is followed by hypoxic ischemic injury to brain, a
syndrome has been described known as 'Hypoxic ischemic encephalopathy'.
Early assessment of the degree of resulting hypoxic–
ischaemic encephalopathy (HIE) can provide prognostic information for
both clinical management and the potential use of cerebroprotective
strategies. However, clinical assessment is often difficult because the
neurological state of the infant may be altered by pharmacological
interventions such as sedation, muscle relaxation, or anticonvulsant
treatment. Moreover, clinical signs of HIE may not develop until at
least 12 hours after birth.
The haemodynamics in term infants with acute encephalopathy are
deranged during the first 24 hours after presumed perinatal asphyxia.
These consist of an increase in cerebral blood flow velocity (CBV) and
a significant reduction in cerebral blood flow velocity resistance
(CBVR). CBVR tended to return to normal values after the first 24 hours
of age. CBV and CBF were frequently increased in the first 24 hours
after birth were associated with a greater severity of acute
encephalopathic signs and adverse outcome [6].
Attempts have been made to diagnose ischemic encephalopathy by use of
CT, MRI and ultrasonography. Various authors in different study have
emphasized that Doppler sonography is a practical, non-invasive and
accurate method of diagnosing a wide spectrum of intra-cranial
conditions due to HIE in neonate. Sonography is now established as a
primary method for recognizing neonatal cerebral ischemia.
Having found normal RI values with Doppler method, the clinician can
confidently reassure parents that their baby has a little risk of
death. Prognostication of long term outcomes is one of the main
objectives in Doppler sonography of the brain of full term neonate who
experienced perinatal asphyxia. In this study maximum number of cases
occurred in male.
Maximum number of patients were weighing between 2.5-2.9kg 23 (57.5%)
in HIE-2. Ellis et al [7] & Badani et al 2000 [8] in their
studies observed that out of 144 infant 93 infant of weight
>2.5kg suffered from grade -2 and 51 of weight between 2-2.5 kg
suffered from mild asphyxia. In our study out of 40 asphyxiated infants
77.5% (31) patients were born by vaginal delivery, and 22.5% (5) by
LSCS.
Our study analyzed the relationship of cerebral blood circulation
parameters (PSV, EDV & RI) registered in the anterior &
middle cerebral arteries evaluated at 12-24 hr of life and its relation
to long term neurological outcome.
Doppler studies done in intracranial vessels in asphyxiated
infants found an increase in diastolic flow and lowering of the RI to
be the usual initial response detectable in initial 4 days of birth
asphyxia[8].
In our study maximum cases were of HIE grade 2 and an abnormal RI on
1st and 3rd day was observed in 87.5% (35 ) cases ( 0.53-0.55 in both
MCA and ACA). sHowever further studies are needed to determine whether
the cerebral blood flow velocity measurement in the intracranial artery
is an accurate tool for assessing the severity of neurologic insult
after birth asphyxia.
Conclusion
In the final course of our study, we have come to the conclusion that
color Doppler USG would be of practical importance in evaluating the
cerebral blood flow velocity in neonate with HIE. A skillful detection
of decrease in cerebral blood flow of neonate in postnatal first 12
hrs& medication & treatment being based on such
detection would contribute to a good prognosis.
Early recognition of the hypoxic ischemic injury is important in
guiding the management during those critical first days.
Limitation
1. Cerebral blood flow velocity was measured in intracranial artery
(ACA ,MCA ) on day-1 and a repeat after 3rd day. However no repeat
measurement was done on follow up.
2. The number of patient in this series, specially severely asphyxiated
infants (HIE-3) is small because grade 3 infants have respiratory
distress and their conditions often deteriorate after 2nd day.
Funding:
Nil, Conflict of
interest: Nil
Permission from IRB:
Yes
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How to cite this article?
Jain H, Arya S, Thakur K, Joshi S, Study of transcranial colour Doppler
in the measurement of cerebral edema in birth asphyxia : Int J Pediatr
Res 2016;3(4):274-277.doi:10.17511/ijpr.2016.4.012.