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Published on: October 28, 2022
Patterns of MRI Brain Injury in Children after Out-of-Hospital Cardiac Arrest
Jonathan J Shih1, Amanda Baker2, Rachel Vassar3
1From the Department of Radiology and Biomedical Imaging (J.J.S., E.G., C.L., O.G., S.H., D.X., Y.L.), University of California, San Francisco, San Francisco, California.
Insights
Brain MRI reveals varied injury patterns in pediatric out-of-hospital cardiac arrest (OHCA) survivors. Injury location and evolution depend on age, imaging timing, and arrest severity, impacting hypoxic-ischemic brain injury assessment.
Area of Science:
- Neurology
- Pediatric critical care
- Radiology
Background:
- Pediatric out-of-hospital cardiac arrest (OHCA) poses significant risks of hypoxic-ischemic brain injury.
- Understanding brain injury patterns on MRI after pediatric OHCA is crucial for prognosis and management.
- Current knowledge on the evolution and specific regional patterns of MRI-detected brain injury following pediatric OHCA is limited.
Purpose of the Study:
- To investigate the regional patterns and evolution of brain injury visualized on MRI in pediatric patients following OHCA.
- To explore the association between these MRI-identified brain injury patterns and clinical factors such as patient age and cardiac arrest characteristics.
Main Methods:
- Retrospective analysis of pediatric patients (48 hours to 18 years) who experienced OHCA and underwent brain MRI (DWI and T2-weighted sequences) within 8 days post-arrest.
- Two independent neuroradiologists assessed signal abnormalities in specific brain regions: cortex, white matter (WM), globus pallidus, putamen/caudate, thalamus, posterior limb of the internal capsule (PLIC), hippocampus, brainstem, and cerebellum.
- Clinical data including age, time to return of spontaneous circulation (ROSC), and imaging timing were correlated with MRI findings.
Main Results:
- Out of 68 patients, 46 (68%) showed brain injury on MRI, most commonly in the cortex (50%), putamen/caudate (43%), and WM (40%).
- Younger patients exhibited a higher incidence of WM (median age 1.4 years) and PLIC (median age 0.4 years) injuries compared to older patients.
- Longer time to ROSC correlated with injury in more brain regions (P<0.001), and WM injury was observed more frequently on later MRIs (73% on second MRI vs. 36% on first).
Conclusions:
- Brain injury patterns following pediatric OHCA are significantly influenced by patient age, timing of MRI, and cardiac arrest severity.
- The delayed appearance of WM injury and the increased vulnerability of WM and PLIC in younger children are key findings.
- Recognizing these evolving injury patterns on post-arrest MRI, considering clinical context, is vital for accurate diagnosis of hypoxic-ischemic brain injury, especially with limited clinical history.
Background And Purpose:
Pediatric out-of-hospital cardiac arrest (OHCA) is associated with a high rate of morbidity and mortality from hypoxic-ischemic brain injury. The patterns and evolution of brain injury on MRI after pediatric OHCA have not been well described. The purpose of this study was to evaluate regional brain injury patterns on MRI after pediatric OHCA and its association with clinical factors.
Materials And Methods:
We analyzed a retrospective cohort of pediatric patients aged between 48 hours and 18 years who experienced OHCA between 2016-2023 and underwent brain MRI containing DWI and T2-weighted sequences within 8 days postarrest. Two neuroradiologists independently scored the presence or absence of signal abnormality in the cortex, WM, globus pallidus, putamen/caudate, thalamus, posterior limb of the internal capsule (PLIC), hippocampus, brainstem, and cerebellum.
Results:
Of the 68 patients included, 46 (68%) exhibited brain injury on initial MRI, with the most common locations being the cortex (50%), putamen/caudate (43%), and WM (40%). First MRI was obtained at a median of 3 (interquartile range 1-4) days postarrest. Patients with WM injury were younger (median age 1.4 years) than those without WM injury (3.6 years; P = .01), and those with PLIC injury were younger (median age 0.4 years) than those without PLIC injury (3.5 years; P = .003). Longer time to return of spontaneous resuscitation was associated with injury across a greater number of brain regions (P < .001). Among 11 patients who underwent 2 MRIs within 8 days, WM injury occurred more frequently on later imaging (36% on first MRI versus 73% on second MRI; P < .05).
Conclusions:
Patterns of injury after pediatric OHCA are influenced by patient age, timing of imaging, and cardiac arrest characteristics. The evolving distribution of injury, such as delayed appearance of WM injury, and greater vulnerability of WM and PLIC in younger patients, highlights the importance of considering clinical context when interpreting postarrest brain MRI. Recognizing these patterns may aid in identifying hypoxic-ischemic injury, especially when clinical history is limited.
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