Neurodevelopmental assessment in HIE II and HIE III

Dr Jaimin M PatelDr K M Mehariya, Dr B B Javdekar, Dr B R

Vyas.M P Shah Medical college, Jamnagar.

Case scenario…… FT (Forcep), 3.5 kg, Meconium, hopotonic, depressed Apgar 4 at 3min, HIE II, convulsing on 2nd day,

loaded with 2 anticonvulsants Improved on 5th day. Taking BF by 7th day.

The important issues related to the Neurodevelopmental assessment in HIE are:

At what age is the assessment most predictive?

Which signs or clusters are most specific for predication and early identification of CP?

Which screening or assessment methods/tools are specific and accurate?

Is routine developmental screening useful?

Study design…… Aim : 1. To Evaluate TDSC againt Amiel-Tison

Method. 2. To compare D3 and D7 neurological examination with 1 yr outcome.

Study place: NICU and High Risk Clinic, Guru Gobind Singh Hospital, Jamnagar.

Sample: The infants from the G. G. Hospital with the diagnosis of HIE 2 or 3 during the period 1st Jan 2001 to 31st Jan 2002 were included in the study.

Exclusion Criteria: Infants whose examination was not possible during follow up for at least 2 different examinations were excluded from the study.

Study design…Examination Shedule…

In NICU for Apgar Score, HIE stage, Neurological examination at Day 3, Day 7.

Growth Chart (NCHS) plotting throughout each examination.

TDSC chart plotting and Amiel-Tison examination at each follow up visit at 3 monthly examinations till 1 yr.

Who didn’t turn up where repeatedly contacted and if 2 or more examination was missed excluded from study.

What was “abnormal” neurological examination at D3 or D7?? child had inability to take breast-feeding Irritability, lethargy, Impaired

consciousness or coma Abnormal tone either hypertonia or

hypotonia Exaggerated or depressed reflexes or

clonus Convulsion within last 24 hrs Signs suggestive of raised ICT

Trivendrum Developmental Screening Chart.

Amiel-Tison Method. Major emphasis on tone,

extrapyramidal and pyramidal waves of development of tone.

Scoring system Score wise classification in to

Minor, Moderate, Major deficit. Cluster of signs more important.

Sign clusters

(1) Cortical thumb, which was present in 7 patients at birth,(2) High- arched palate in 8 patients, and (3) Overlapping cranial sutures present in 7 patients – serve as strong

indicators

HIE II

27

2

11 10 811

8 8 1075 5 5 6

3 4 4 3

13 15

25-abnormal

14-abnormal

12-abnormal

05

1015202530

Tota

lpa

tient

s w

ithH

IE I

I

Day

3ex

amin

atio

n

Day

7ex

amin

atio

n

1st

neur

olog

ical

exam

inat

ion

2nd

neur

olog

ical

exam

inat

ion

3rd

neur

olog

ical

exam

inat

ion

4th

neur

olog

ical

exam

inat

ion

TD

SC

Cha

rt

Follow up

No

of

pat

ien

tsNormal

Minor

Moderate

Major

HIE III

9 9

5 5 5 53 3 3 3

1 1 1 1

9

3

0 0 0 0

6-Abnormal

02468

10

Tota

lpa

tient

s w

ithH

IE I

II

Day

3ex

amin

atio

n

Day

7ex

amin

atio

n

1st

neur

olog

ical

exam

inat

ion

2nd

neur

olog

ical

exam

inat

ion

3rd

neur

olog

ical

exam

inat

ion

4th

neur

olog

ical

exam

inat

ion

TD

SC

Cha

rt

Follow up

No

of

pat

ien

ts

Normal

Minor

Moderate

Major

TDSC Vs Neurological outcome at 1 yr using Amiel-Tison Method.

Moderate and Major

Normal and Minor

Total

Normal at TDSC

12 6 18

Abnormal at TDSC

1 17 18

TDSC Vs Amiel-Tison

Sensitivity

92.31%

Specificity

73.91%

PPV 66.67%

NPV 94.44%

D7 examination Vs Neurological Outcome at 1 yr using Amiel-Tison Method

P = 0.000457 (P < 0.01)

Normal Minor Moderate

Major Minor+ moderate+ major

Total Patients.

Normal examination at day 7

9 3 2 0 5 14

Abnormal examination at day 7

2 9 7 4 20 22

Total 11 12 9 4 25 36

Deficit No deficit

Ab D7

20 2

N D7

5 9

Message to take home……. TDSC is a valuable screening tool

to screen out major and moderate deficit as per Amiel-tison method during first yr of life in High Risk HIE patients.

Day 7 Neurological Assessment has statistically significant association with Neurological outcome at 1 yr.

Thank You