Hypoxic-ischemic encephalopathy (HEI)

Hypoxic is the lack of oxygen to the brain

Ischemic is a decrease in the blood supply to a bodily
organ
Encephalopathy is brain and nervous system damage

HEI is a condition in which there is brain or nervous

system damage due to the lack of oxygen going to the
brain.
Frequency
- HIE will affect 1-8/1000 births in the US and most
technologically advanced countries.
- Internationally birth asphyxia is the cause of 23% of neonatal
deaths.
- one of top 20 leading causes of burden of disease in all age
groups
- 5th largest cause of death of children under 5 years of age (8%)
- estimated to account for 920,000 neonatal deaths per year and
associated with another 1.1 million intrapartum stillbirths
- more than a million children who survive will develop cerebral
palsy, mental retardation, learning disabilities along with other
disabilities
Causes
- injury or complication during birth
- respiratory failure
- blocked or ruptured blood vessel
- drug overdose
- drowning
- lack of oxygen due to smoke inhalation
- extremely low blood pressure
- strangulation
- cardiac arrest
- carbon monoxide poisoning
- high altitudes
- choking
- compression or injury to the trachea that reduces or stops breathing
- complications from general anesthesia
Risk Factors
Any injury or condition that causes the brain to have a
reduction in blood flow or oxygen.
Symptoms
- difficulty concentrating or paying attention
- poor judgment
- poor coordination
- euphoria
- extreme lethargy
- severe oxygen deprivation
- seizures
-coma
- no brain stem reflexes (breathing, responding to light)
Physical symptoms in Infants
Mild hypoxic-ischemic encephalopathy
- Muscle tone may be slightly increased and deep
tendon reflexes may be brisk during the first few days.
- Transient behavioral abnormalities, such as poor
feeding, irritability, or excessive crying or sleepiness,
may be observed.
- The neurologic examination findings normalize by 3-
4 days of life.
 
Cont
Moderately severe hypoxic-ischemic encephalopathy
- The infant is lethargic, with significant hypotonia and diminished deep
tendon reflexes.
- The grasping, Moro, and sucking reflexes may be sluggish or absent.
- The infant may experience occasional periods of apnea.
- Seizures may occur within the first 24 hours of life.
- Full recovery within 1-2 weeks is possible and is associated with a better
long-term outcome.
- An initial period of well-being or mild hypoxic-ischemic
encephalopathy may be followed by sudden deterioration, suggesting
ongoing brain cell dysfunction, injury, and death; during this period,
seizure intensity might increase.
 
Cont
Severe hypoxic-ischemic encephalopathy
- Stupor or coma is typical. The infant may not respond to any physical stimulus.
- Breathing may be irregular, and the infant often requires ventilatory support.
- Generalized hypotonia and depressed deep tendon reflexes are common.
- Neonatal reflexes (eg, sucking, swallowing, grasping, Moro) are absent.
- Disturbances of ocular motion, such as a skewed deviation of the eyes, nystagmus, bobbing,
and loss of "doll's eye" (ie, conjugate) movements may be revealed by cranial nerve
examination.
- Pupils may be dilated, fixed, or poorly reactive to light.
- Seizures occur early and often and may be initially resistant to conventional treatments.
- Irregularities of heart rate and blood pressure (BP) are common during the period of
reperfusion injury, as is death from cardiorespiratory failure.
 
Infants who survive severe hypoxic-ischemic encephalopathy
- The level of alertness improves by days 4-5 of life.
- Hypotonia and feeding difficulties persist, requiring tube feeding for weeks to months.
Diagnosis
- CT Scan
- MRI Scan
- EKG
- Echocardiogram
- Blood Tests
- EEG
- Ultrasound
Diagnosis in Infants
For infants the guidelines from AAP in 1996 all of the
following must be present for the designation of perinatal
asphyxia severe enough to result in acute neurological injury
 - profound metabolic or mixed academia (pH < 7) in an
umbilical artery blood sample
 - persistence of an Apgar score of 0-3 for longer than 5
minutes
 - neonatal neurologic sequelae ( seizures, coma,
hyptonia)
 - multiple organ involvement (kidneys, lungs, liver,
heart, intestines)
Treatment
There is no cure
- Life-sustaining treatment
- mechanical ventilation
- treatments for circulatory system
- seizure control
- cooling
- hyperbaric oxygen treatment
The cooling process
Cooling Cap
Two Recent Trials of infants with moderate
to severe HEI
23-27% of infants died prior to discharge
Mortality rate at 18-22 months was 37-38%.
These are the neurodevelopmental outcomes at 18 months

Mental development index (MDI)

Score of 85 or higher - 40%
Score of 70-84 - 21%
Score less than 70 - 39%
Psychomotor development index (PDI)
Score of 85 or higher - 55%
Score of 70-84 - 10%
Score less than 70 - 35-41%
Disabling cerebral palsy - 30%
Epilepsy - 16%
Blindness - 14-17%
Severe hearing impairment - 6%
Prevention
There is no prevention
Quick and General Overview
General Overview
References
 http://www.med.nyu.edu/patientcare/library/article.html?ChunkIID=230598
  
 http://emedicine.medscape.com/article/973501-overview
  
 http://www.medterms.com/script/main/art.asp?articlekey=3875