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Cranial Colour Doppler and Electroencephalogram as Early Prognostic Markers in Babies with Hypoxic Ischaemic Encephalopathy: A Prospective Cohort Study |
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Jayendra Arya, Saurabh Patel, Amaresh Shukla, Deepak Dwivedi 1. Senior Resident, Department of Paediatrics, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. 2. Associate Professor, Department of Paediatrics, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. 3. Associate Professor, Department of Radiodiagnosis, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. 4. Professor, Department of Paediatrics, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. |
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Correspondence Address : Deepak Dwivedi, D-2/8, Doctors Colony, Rewa-486001, Madhya Pradesh, India. E-mail: deepakdwi72@gmail.com |
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| ABSTRACT |  | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
: Introduction: Birth asphyxia continues to be a leading cause of neonatal morbidity and mortality globally. Early detection of ischaemic changes through Doppler ultrasound and Electroencephalography (EEG) may play a crucial role in prompt management, timely referral and effective parental counseling. Aim: To evaluate role of Cranial colour doppler and EEG background activity in prediction of short and long-term outcome in term newborn with Hypoxic–Ischaemic Encephalopathy (HIE). Materials and Methods: The present prospective cohort study was carried out in S.S. Medical College and SGM Hospital in central India during January 2020 to June 2022. A total of 71 full term neonates with HIE gone through Cranial Doppler and conventional EEG minimum for 1 hour within 6 hours of birth. Hammersmith Neonatal Neurological Examination (HNNE) was performed at the time of discharge and neurodevelopmental assessment at follow-up visit was done using Hammersmith Infant Neurological Examination (HINE) and Developmental Assessment Scales for Indian Infant (DASII). Association between EEG background activity and HNNE score, HINE score and neurodevelopmental outcome (cerebral palsy, epilepsy and developmental delay) was calculated. Chi-square test and Analysis of Variance (ANOVA) test was done and p-value <0.05 was considered significant. Results: Among babies with abnormal Doppler scan, 26 (92.8%) have bad short-term outcome, similar result were seen with abnormal Doppler and abnormal EEG in which 26 (94%) and 11 (84%) have bad short-term outcome (abnormal HNNE) respectively. After combining all modalities 23 (100%} babies showed bad outcme on short-term basis with p-value <0.05. Mean HNNE and HINE score was significantly lower (p-value=0.001) in newborns with abnormal doppler and severely abnormal EEG as compared to normal Doppler and normal EEG group. A severely abnormal EEG at birth was significantly associated with cerebral palsy (p-value=0.0005), epilepsy (p-value=0.04) and developmental delay (p-value=0.001). Conclusion: Cranial colour doppler with EEG within 6 hours of birth in term HIE babies had high sensitivity and negative predictive value in predicting neurodevelopmental outcome. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Keywords : Cerebral palsy, Developmental delay, Epilepsy, Neurodevelopmental outcome | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJNMR/2025/76902.2448
Date of Submission: Nov 21, 2024 Date of Peer Review: Feb 24, 2025 Date of Acceptance: May 15, 2025 Date of Publishing: Sep 30, 2025 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. NA PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Nov 22, 2024 • Manual Googling: May 10, 2025 • iThenticate Software: May 13, 2025 (4%) ETYMOLOGY: Author Origin EMENDATIONS: 8 |
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| INTRODUCTION |
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The HIE is one of the most common cause of neonatal mortality and morbidity globally; it accounts for 26 out of every 1000 live births in developed and developing country respectively. In US population incidence of perinatal HIE was 1.7 per 1000 (1),(2),(3). In India, estimated incidence of birth asphyxia is 12-16% (4). In newer study the incidence was 5.26% that is, 92 out of 1749 live births in northern India (5). Traditionally, the severity grading of HIE along with advanced neuroimaging techniques like Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) has been utilised to assess the extent of cerebral injury during the neonatal period and to predict long-term neuromotor outcomes. However, the grading of HIE alone is not always reliable for prognostication and advanced imaging modalities are often not readily available in many neonatal care units in resource-limited settings such as India. Moreover, performing such investigations in clinically unstable neonates during the immediate postnatal period is frequently not feasible (6). The EEG has been extensively used for the diagnosis of neonatal seizures and for monitoring of neonates on antiseizure therapy (7). A previous study have shown that EEG provides excellent predictive value for both short-term and long-term outcomes in infants with HIE, with good sensitivity. In addition, cranial colour Doppler has emerged as a valuable tool in evaluating the neurological prognosis of HIE-affected neonates (8). It is a cost-effective, non invasive and easily accessible modality that can be initiated very early, even immediately after birth, making it particularly suitable for low-resource settings (9). The above mentioned modalities have been studied separately in past for prognostication of HIE in babies (10),(11),(12). In a study by Alfaifi J, cranial USG played crucial role in treatment for HIE (10). Similar study done by Annink KV et al., showed validated Cranial Ultrasonography (CUS) scoring system is associated with neurodevelopmental outcome in neonates with HIE (11). A study by Bourel-Ponchel E et al., showed that cranial EEG is also important tool for HIE prognostic value (12). These previous studies focused mainly on EEG and Doppler separately, in present study combined use of cranial colour doppler and EEG with structured neurological examination was used. Early detection of ischaemic changes from Doppler and EEG will provide timely management, referral and parental counseling regarding HIE. The combined use of cranial colour doppler and EEG with structured neurological examination may have a better sensitivity and predictive value for outcome of HIE babies. Hence this study aimed to assess the role of cranial color doppler as early prognostic marker of babies with HIE short-term and long-term outcome and also to investigate the role of EEG background activity and its severity in HIE short-term and long-term outcome. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Results |
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General baseline characteristics of subjects are listed in (Table/Fig 1). A total of 71 neonates were enrolled for study out of which 47 were discharged and 28 babies came for follow-up. Out of them 53 (74.6%) were male and 18 (25.4%) were female, 53 neonates belong to rural population and remaining 18 belongs to urban and 57 (80%) neonates belongs to joint family. The results of the cohort study reveal a strong association between abnormal EEG and Doppler findings with adverse patient outcomes. In the short-term analysis, individuals with severely abnormal EEG results had a 100% incidence of bad outcomes, while moderate abnormalities led to bad outcomes in 85% of cases. Similarly, abnormal Doppler results significantly predicted poor outcomes, with 93% of individuals exhibiting adverse effects. The combined presence of abnormal EEG and Doppler findings further exacerbated the risk, indicating a 100% probability of bad outcomes. These association were statistically significant, as evidenced by p-values less than 0.0001 for both EEG and Doppler results independently predicting short-term outcomes (Table/Fig 2). Long-term outcomes mirrored these trends, where severe EEG abnormalities consistently resulted in 100% bad outcomes. However, the doppler findings showed a less pronounced effect on long-term prognosis compared to the short-term results. The statistical significance of these observations was robust for EEG abnormalities (p-value <0.001) as well as for Doppler results in the long-term outcomes (p-value=<0.001) (Table/Fig 3), (Table/Fig 4). Furthermore, the sensitivity, specificity and predictive values of these markers were significant. For example, the combined assessment of EEG and Doppler in predicting short-term outcomes showed a sensitivity of 78.7% and a specificity of 67%, with a positive predictive value of 82.2%. These diagnostic markers are crucial in determining the prognosis and guiding the clinical management of patients in both short and long-term scenarios (Table/Fig 5). The study reveals significant neurological outcomes among infants with severe EEG abnormalities in the neonatal period, where 100% subsequently developed epilepsy during long-term follow-up and 70% were diagnosed with cerebral palsy upon follow-up. Additionally, all infants who developed epilepsy had hypoxic changes in their Doppler results at birth (Table/Fig 6). The data also shows differing developmental outcomes related to Doppler results at birth: only 16.67% of those with abnormal Doppler findings achieved a Developmental Quotient (DQ) above 70%, while 83.33% scored below 70 (Table/Fig 7). | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discussion |
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The present study highlights crucial relationships between EEG findings, Doppler results and patient outcomes over both short-term and long-term periods. Abnormal EEG results, especially severe cases, are strongly correlated with negative outcomes, a pattern that holds true in the analysis of doppler results where abnormal findings are similarly linked to poorer health outcomes. This relationship is further quantified through statistical significance in the data, underscoring the reliability of these diagnostic tools in predicting patient prognosis. Additionally, the assessment of sensitivity, specificity and predictive values for both EEG and Doppler indicates their effectiveness for predicting short-term outcomes and when combined with HNNE scores they had excellent predictive capability for long-term outcomes also. Hamelin S et al., (25) concluded that worse EEG background categories associated with unfavourable neurologic outcome. Previous studies (26) concluded that patients having normal/mildly abnormal EEG at birth had a excellent PPV for normal long-term outcome similar to results of present study. A structured review by Awal MA et al., also concluded a sensitivity of 87 for severe EEG predicting poor outcome (27) which was also seen in present study. Colour doppler was also used as predictor for outcome of HIE babies in previous studies with good sentivity and specifity by Guan B et al., (28). Though EEG and colour doppler are good enough in predicting outcome of HIE babies, combining both modalities increased the sensitivity and predictive values for short-term in previous studies Enhesari A et al., (29). EEG and colour doppler alone has been studied as a prognostic marker for long-term outcome of HIE babies with good sensitivity like in Murray DM et al., and Wazir S et al., (30),(31) present study proves that in combination with colour doppler and structured neurological exam at birth significantly improves sensitivity for prediction of outomes. Limitation(s) Major limitation was small sample size; lack of continuous EEG monitoring and poor follow-up rate of patients which maybe attribute to Coronavirus Disease-2019 (COVID-19) pandemic during period of study. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Acknowledgement |
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Author would like to acknowledge his family Dr. Prakash Vir Arya, Dr. Sunita Arya, Dr. Kratika and his loving wife Dr. Akansha for their immense support. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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