Brain Injury, Hypoxic-Ischemic Encephalopathy, Neonatal Seizure
Conditions
Keywords
Hypoxic Ischemic encephalopathy
Brief summary
A multicenter observational pilot study will be conducted to determine the natural history of infants with early diagnosis (≤ 6 hrs of age) of mild neonatal encephalopathy (NE) who are not qualified for therapeutic hypothermia. The intervention includes: neurologic examination by using modified Sarnat score at ≤ 6 hrs of age, 24 hrs and before discharge home, amplitude-integrated electroencephalography (aEEG) at 6 ± 3 hrs of age, brain MRI at before discharge home to 30 days of age and follow-up at 18-22 months of age. Primary outcome is the percentage of mild NE infants with evidence of brain injury defined by the presence of at least 1 abnormality of brain MRI, aEEG or neurologic examination in the neonatal period. Secondary outcome is the percentage of brain MRI, aEEG and neurological exam abnormalities, seizure, length of hospital stay, need of gavage feeds or gastrostomy at discharge home, death and long-term outcome.
Detailed description
Globally, an estimated 1.8 to 7.7 infants per 1000 live term births suffer from perinatal asphyxia, which remains an important cause of neonatal encephalopathy (NE) and neurodevelopmental impairment. Over the last six years, several randomized control trials have demonstrated that prolonged and moderate therapeutic hypothermia (TH) reduces the rate of death or disability at 18 months of age among infants who survived. In these trials, infants were eligible if there was evidence of perinatal hypoxia-ischemia and a moderate or severe degree of encephalopathy on neurological evaluation performed at ≤ 6 hrs of age. However, it has been recognized that the level of NE may change over time. Preliminary and unpublished observations from our group indicated that some infants who were not classified as moderate or severe NE had neurological abnormalities at discharge or evidence of brain injury on MRI performed during the neonatal period. Unfortunately, precise data on the outcomes of this specific population is not clear. Since TH is not offered to this population, the outcomes of infants that do not qualify for TH based on neurological evaluation performed ≤ 6 hrs of life requires a more precise investigation.
Interventions
Neurologic examination includes: (1) neurologic examination using modify Sarnat score at \</= 6 hrs of age, 24 hrs and at discharge home, (2) aEEG at 6 ± 3 hrs of age, (3) Brain MRI before discharge home to 30 days of age.
Sponsors
Brown University
University of Texas Southwestern Medical Center
Wayne State University
Mahidol University
Ohio State University
Imperial College London
McGill University Health Centre/Research Institute of the McGill University Health Centre
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
No minimum to 6 Hours
Healthy volunteers
No
Inclusion criteria
* Infants with birth weight \> or = 1800g and gestational age \> or = 36 weeks AND * Admission to neonatal intensive care unit (NICU) for possible hypothermia at \< or = 6hr of life
Exclusion criteria
* Infants with normal neurological evaluation * Major congenital abnormalities * Refusal of informed consent * Infants who receive passive or active cooling prior to the NICU admission * Infants that develop seizures or moderate/severe NE within the first 24 hr of life and are initiated on therapeutic hypothermia after 6 hr of life.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Percentage of Infants With Evidence of Neurological Dysfunction, Brain Injury and/or Abnormality. | 1 month | Evidence of neurological dysfunction/injury/abnormality will be defined by any of these 3 criteria, as follows: 1. MRI = Brain MRI score of pattern of injury (NICHD-NRN) \> 0, 2. aEEG = abnormal background pattern on aEEG (voltage or background pattern) at 6 ± 3 hrs of age. 3. Any abnormality on the neurological at discharge exam. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percentage of Infants With Seizures | Participants will be followed for the duration of hospital stay, an expected average of 3 days | Development of clinical or electrographic seizures |
| Length of Hospital Stay | Participants will be followed for the duration of hospital stay, an expected average of 3 days | — |
| Percentage of Infants Who Need Gavage Feeds or Gastrostomy at Discharge Home | Participants will be followed for the duration of hospital stay, an expected average of 3 days | — |
| Mortality Rate | Participants will be followed for the duration of hospital stay, an expected average of 3 days | Death during the hospitalization |
Other
| Measure | Time frame | Description |
|---|---|---|
| Long-term Neurodevelopment | 18-22 months of age | Long-term outcomes (18-22 months of age): Severe disability if there is a Bayley III Cognitive score \< 70, severe cerebral palsy (CP), defined by the Gross Motor Function Classification System (GMFCS) grade level 3 to 5, blindness or profound hearing loss. Moderate disability will be defined as the Bayley Cognitive score is 70-84 and either seizures, moderate CP (defined by GMFCS grade level 2) or a hearing deficit requiring amplification to understand commands. Mild disability will be defined by a cognitive score 70-84, or a cognitive score ≥ 85 and either presence of mild or moderate CP (GMFCS grade levels 1 or 2), a seizure disorder or hearing loss with or without amplification. Normal will be defined as Bayley III Cognitive score ≥ 85 without any visual or hearing impairment, or CP. |
Countries
Canada, Thailand, United Kingdom, United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Mild NE Infants with evidence of a perinatal event and NE who do not qualify for therapeutic hypothermia.
Neurologic examination: Neurologic examination includes: (1) neurologic examination using modify Sarnat score at \</= 6 hrs of age, 24 hrs and at discharge home, (2) aEEG at 6 ± 3 hrs of age, (3) Brain MRI before discharge home to 30 days of age. | 54 |
| Total | 54 |
Baseline characteristics
| Characteristic | Mild NE | — |
|---|---|---|
| Age, Categorical <=18 years | 54 Participants | — |
| Age, Categorical >=65 years | 0 Participants | — |
| Age, Categorical Between 18 and 65 years | 0 Participants | — |
| Age, Continuous | 39.4 Gestational age(weeks) STANDARD_DEVIATION 1.4 | — |
| Race and Ethnicity Not Collected | — | — Participants |
| Sex: Female, Male Female | 22 Participants | — |
| Sex: Female, Male Male | 32 Participants | — |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | — / — |
| other Total, other adverse events | 0 / 63 |
| serious Total, serious adverse events | 0 / 63 |
Outcome results
Primary
Percentage of Infants With Evidence of Neurological Dysfunction, Brain Injury and/or Abnormality.
Evidence of neurological dysfunction/injury/abnormality will be defined by any of these 3 criteria, as follows: 1. MRI = Brain MRI score of pattern of injury (NICHD-NRN) \> 0, 2. aEEG = abnormal background pattern on aEEG (voltage or background pattern) at 6 ± 3 hrs of age. 3. Any abnormality on the neurological at discharge exam.
Time frame: 1 month
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Mild NE | Percentage of Infants With Evidence of Neurological Dysfunction, Brain Injury and/or Abnormality. | 28 Participants |
Secondary
Length of Hospital Stay
Time frame: Participants will be followed for the duration of hospital stay, an expected average of 3 days
Secondary
Mortality Rate
Death during the hospitalization
Time frame: Participants will be followed for the duration of hospital stay, an expected average of 3 days
Secondary
Percentage of Infants Who Need Gavage Feeds or Gastrostomy at Discharge Home
Time frame: Participants will be followed for the duration of hospital stay, an expected average of 3 days
Secondary
Percentage of Infants With Seizures
Development of clinical or electrographic seizures
Time frame: Participants will be followed for the duration of hospital stay, an expected average of 3 days
Other Pre-specified
Long-term Neurodevelopment
Long-term outcomes (18-22 months of age): Severe disability if there is a Bayley III Cognitive score \< 70, severe cerebral palsy (CP), defined by the Gross Motor Function Classification System (GMFCS) grade level 3 to 5, blindness or profound hearing loss. Moderate disability will be defined as the Bayley Cognitive score is 70-84 and either seizures, moderate CP (defined by GMFCS grade level 2) or a hearing deficit requiring amplification to understand commands. Mild disability will be defined by a cognitive score 70-84, or a cognitive score ≥ 85 and either presence of mild or moderate CP (GMFCS grade levels 1 or 2), a seizure disorder or hearing loss with or without amplification. Normal will be defined as Bayley III Cognitive score ≥ 85 without any visual or hearing impairment, or CP.
Time frame: 18-22 months of age