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Prediction of Adverse Outcome with Cerebral Lactate Level and Apparent Diffusion Coefficient in Infants with Perinatal Asphyxia¹

¹ From the Departments of Radiology (M.K.Z., L.G.A., T.Y.P., A.A.T.), Neurology (A.d.P.), and Biostatistics (D.Z.), Children’s Hospital, Harvard Medical School, Boston, Mass. From the 2000 RSNA scientific assembly. Received November 7, 2001; revision requested January 21, 2002; final revision received May 1; accepted May 29. Address correspondence to A.A.T., Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 51 Blossom St, Rm 261, Boston, MA 02114 (e-mail: atzika@partners.org).

View larger version (57K): [in a new window]   Figure 1. Patient 2. Transverse T2-weighted MR image, ADC map, and proton MR spectrum obtained in a 1-day-old full-term male infant. This infant had severe neonatal HIE, persistent seizures, perinatal depression (Apgar scores 2 and 1 at 1 and 5 minutes, respectively), and metabolic acidosis that was due to placental abruption. The infant died at 1 day old. T2-weighted fast spin-echo MR image (3,000/140) shows subtle thalamic hyperintensity (arrow). MR spectrum from an ROI () within the deep gray matter shows a prominent lactate (Lac) peak, with a lactate-choline (Cho) ratio of 1.51. ADC map (calculated by using a line-scan diffusion sequence with 2,850/106 and b = 1,000 sec/mm2) at the level of the basal ganglia shows a reduced ADC value of 0.5 µm2/msec. In this infant, both clinical data and MR imaging findings combined with proton MR spectroscopic variables correlated well with the fatal outcome. tCr = total creatine.

View larger version (77K): [in a new window]   Figure 2. Patient 26. Transverse T2-weighted fast spin-echo (3,000/140) and diffusion-weighted MR images and proton MR spectra at 1 and 2 days old in a full-term male infant. This infant had perinatal depression (Apgar scores 8 and 9 at 1 and 5 minutes, respectively) that was due to placental abruption and developed persistent neonatal seizures. T2-weighted MR images show minimal hyperintensity (arrow) in the thalami bilaterally. At multivoxel proton MR spectroscopy (MRS) at 1 day old, lactate (Lac) accumulation in the basal ganglia was revealed; ROI () includes the basal ganglia. At 2 days old, single-voxel MR spectrum from within deep gray matter showed high levels of lactate (lactate-choline [Cho] ratio = 1.56), and the patient died on that day. Favorable clinical variables could not be used to predict the fatal outcome in this infant, but MR imaging findings combined with proton MR spectroscopic variables were used to do so. tCr = total creatine.

View larger version (52K): [in a new window]   Figure 3. Patient 10. Transverse T2-weighted fast spin-echo (3,000/140) and diffusion-weighted MR images and proton MR spectrum in a 3-day-old full-term male infant. This infant had severe HIE, perinatal depression (Apgar scores 3 and 7 at 1 and 5 minutes, respectively) after placental abruption, persistent seizures, and metabolic acidosis. T2-weighted images show subtle hyperintensity (arrow) in the thalami. This infant had an abnormal neurodevelopmental outcome at 13 months. At proton MR spectroscopy (ROI is indicated []), an increased lactate (Lac) level in the thalamus was revealed. ADC map (calculated by using a line-scan diffusion sequence with 2,850/106 and b = 1,000 sec/mm2) showed restricted diffusion in the thalamus (ADC = 0.45 µm2/msec). Cho = choline, tCr = total creatine.

View larger version (19K): [in a new window]   Figure 4. Box plots show relationship between (A) lactate-choline ratio (Lac/Cho) obtained by using proton MR spectroscopy and (B) ADC obtained by using diffusion-weighted MR imaging in the first 10 days of life and neurologic outcome. Outcome was normal in five infants, abnormal in 14, and fatal in six. In a box plot, the box is divided at the median (50th percentile). The box length is the interquartile range, and the top and bottom of the box represent the upper and lower quartiles. The error bars extend to the largest and smallest observed data points within 1.5 interquartile ranges from the top and bottom of the box, respectively. A shows the significant difference (P < .001) in the lactate-choline ratio of the three groups (ie, fatal, abnormal, and normal). The n represents the number of measurements. The lactate-choline ratio was higher in the fatal group, compared with that in both normal and abnormal groups (P < .001). The lactate-choline ratio was higher in the abnormal group, compared with that in the normal group (P = .004). B shows similar ADCs in the three groups (P = .82).

View larger version (19K): [in a new window]   Figure 5. Graph shows the significant inverse relationship between lactate-choline ratio (Lac/Cho) and the probability of an adverse outcome (likelihood ratio test = 13.5, 1 df, P < .001). Note that at a lactate-choline ratio of 1.00, the probability of an adverse outcome exceeds 95%.