Abstract
AimTo describe the spectrum of parasagittal injury on MRI studies performed on children following severe perinatal term hypoxia–ischaemia, using a novel MRI grading system, and propose a new central pattern correlated with neuropathologic features.MethodsMR scans of 297 patients with perinatal term hypoxia–ischaemia were evaluated for typical patterns of brain injury. A total of 83 patients that demonstrated the central/basal ganglia–thalamus and perirolandic pattern of injury were categorised according to the degree of severity. The perirolandic injury was graded by the degree of interhemispheric widening, paracentral lobule involvement and perirolandic cortex destruction leading to a tiered categorisation. Of these 83 patients, 19 had the most severe subtype of injury. A detailed analysis of the clinical data of a subset of 11 of these 19 patients was conducted.ResultsWe demonstrated the mild subtype in 21/83(25%), the moderate subtype in 22/83(27%) and the severe subtype in 21/83(25%). A fourth pattern was identified in 19/83(23%) patients with a diamond-shaped expansion of the interhemispheric fissure, concomitant thalamic, putaminal, hippocampal and other smaller substrate involvement indicative of the most destructive subtype.ConclusionsWe propose a new MR grading system of injury at the parasagittal perirolandic region related to severe, sustained central perinatal term hypoxia–ischaemia. We also introduce a previously undescribed pattern of injury, the most severe form of this spectrum, seen especially after prolongation of the second stage of labour. This constellation of high metabolic substrate, targeted tissue destruction is consistently demonstrated by MRI, termed the massive paramedian injury pattern.
Highlights
The pattern of hypoxic–ischaemic brain injury (HIBI) in cases of profound ischaemia has been well described [1,2,3,4,5,6]
The purpose of this study is to describe the spectrum of parasagittal brain injuries identified at the perirolandic region in term neonates attributable to severe central type hypoxia–ischaemia
The patients were referred to the imaging centre for the evaluation of brain injuries related to hypoxia–ischaemia and this sample population compares well with prior studies [5, 6] and is considered representative of the spectrum of HIBI in term neonates
Summary
The pattern of hypoxic–ischaemic brain injury (HIBI) in cases of profound ischaemia has been well described [1,2,3,4,5,6]. There is generally a variable degree of involvement of the basal ganglia (especially the dorsal putamen) and the ventral thalamus which combines to create the basal ganglia–thalamus (BGT) pattern [2]. Associated perirolandic injury, which may be of varying degrees of severity, is found in combination with the central nuclei destruction [2, 4,5,6], which we refer to in this review as the Rolandicbasal ganglia–thalamus (RBGT) pattern. The term parasagittal cerebral hypoxic–ischaemic brain injury has been attributed predominantly to watershed territory involvement in partial prolonged type of HIBI [7]. The parasagittal cortex on either side of the inter-hemispheric fissure is traditionally recognised as a watershed zone, located between the major arterial territories supplying the cerebral cortex. Careful examination reveals continuity of the lesions with no intervening normal cerebral substrate, indicating that all the affected structures are contiguously destroyed, most likely due to a common pathophysiological mechanism [8]
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