Amplitude-integrated Electroencephalogram In Neonates With Brain Injury

Background and Purpose:Neonatal hypoxic-ischemic encephalopathy (HIE), one of the main factors leading to cerebral palsy, mental retardation and epilepsy,is the brain damage due to hypoxia in perinatal period. The incidence of HIE is probably six thousandth in livebirths, whereas about15%-20%of these infants die in the neonatal period and about25%-30%of survival may have long-term neurodevelopmental sequelae. All of these can make tremendous impact on the family and society. Thus HIE has always been the focus and the hot spot of research in the neonatology. At present, the facts that diagnosis of both clinic and imaging relatively lagging in the early diagnosis of HIE delay the best time window for effective treatment and affect the early treatment of HIE. It is still the problem resolved on How to improve diagnosis of HIE early.Fetal distress is the syndrome that the fetus endanger acute or chronic hypoxia in the uterus. Studies have shown that fetal distress may be complicated by neonatal asphyxia, hypoxic-ischemic encephalopathy, multi-organ damage, and even death. Infants with fetal distress history and abnormal Apgar scores will be taken care in the neonatal intensive care unit, but those, with history of fetal distress and normal Apgar score after birth, may have less attention from the staff. But research implied that there was no significantly difference in the morbidity of HIE, clinical manifestations, imaging results, and prognosis between one group with fetal distress and normal Apgar score and another one with mild asphyxia. Lack of researches about exclusive fetal distress lead to the weak basis of diagnosis of brain injury and were unable to manage and get therapy early effectively. So the brain injury man occur during infants with fetal distress and normal Apgar score at birth. Therefore, Closely monitor, early evaluation and effective interventions should be taken to reduce long-term concurrent disease and improve the life quality of newborn.At present, foreign has this as a monitoring instrument of the routine neonatal brain injury, but the aEEG is not much in Chinese. Domestic and foreign scholars on aEEG in neonatal HIE early diagnosis and intervention of gradually attention but aEEG little research on brain damage neonatal herpes intrauterine distress. Therefore, further defined the aEEG in early diagnosis of neonatal HIE sensitivity and value, and relationship with blood gas, Apgar score, MRI, degree evaluation of simple fetal distress in patients with brain injury, to explore the clinical value and significance of brain injury on brain function monitoring in fetal distress in simple, in order to improve the early diagnosis of neonatal brain injury, guide to provide the basis for targeted therapy.The clinical study was divided into two parts:1, a retrospective analysis from2012January to2012October in full-term neonates hospitalized in the HIE of newborn Department of Pediatrics in our hospital cases, to understand the correlation between different neonatal HIE disease index and aEEG classification of severity, and Apgar scores, blood, brain magnetic resonance (MRI) correlation between HIE indexing and classification the severity of aEEG, of aEEG in early diagnosis of neonatal HIE sensitivity and value, as well as the relationship with the severity of the disease, to improve the early diagnostic rate of neonatal HIE, guide targeted therapy provides the basis.2, in2012.6months to2013.4in our hospital after birth, no simple without asphyxia intrauterine clinical manifestations or occult choking distress patients as the research object, through the monitoring of brain function check on the children, to observe the monitoring results of functional brain background activity, sleep-wake cycle, epileptiform activity in this model, the neural specificity protein changes and imaging results, tracking the prognosis of nerve behavior observe intrauterine distress patients, the assessment of the degree of simple fetal distress in patients with brain injury, explored the clinical value of brain injury on brain function monitoring in fetal distress in the value and significance.Method1. The relationship of Neonatal amplitude-integrated EEG and HIE diagnosis related indicators2.1.1The object of study:74cases of full-term hospitalized in neonatology, Nanfang Hospital from January2012to October2012.1.2Inclusion and exclusionThe diagnosis and indexing of HIE:Refer to the HIE diagnostic criteria of2006Chinese Medical Society Branch Group of Neonatology and clinical grading standards to screen strictly.Exclude criteria:children whose gestational age<37weeks; weight<2500g: other diseases affect or newborn caused by abnormal brain function or brain damage, and other congenital brain disease of the newborn.1.3Monitoring methods of aEEG and classification criteria1.3.1Instrument:Brain function monitor (Nicoict, NicolctOneMonitor, the United States)1.3.2Monitoring methods and time:6-12hours after birth, each patient for at least6hours. System of the International Federation of EEG Society standard electrode installation method,10-20,8-lead method.1.3.3The classification criteria of aEEG:according to background activity,aEEG is divided into:(1) normal amplitude:amplitude upper boundary>10μV, the lower boundary>5μV;(2) the amplitude of mildly abnormal:the amplitude of the upper boundary>10IV lower boundary<5lV;(3) the amplitude of severe abnormalities:amplitude upper boundary<10μV, the lower boundary<5μV. Three kinds of aEFG can simultaneously epileptiform activity.1.3.4Category of aEEG results:according to the aEEG background activities and the presence of epileptiform activity, aEEG was divided into three categories.(1) normal AEEG:amplitude normal and not associated with epileptiform activity.(2) mildly abnormal aEEG:amplitude mildly abnormal or normal amplitude associated with epileptiform activity.(3) severe abnormal aEEG:amplitude mild abnormalities associated with epileptiform activity, the amplitude of the severe abnormalities with or without epileptiform activity.1.4Clinical Observation Project1.4.1Apgar score:1min,5min,10min after birth, neonatology physicians complete score.1.4.2:blood gas analysis:using blood gas analyzer to measure the trace capillary blood gas values which collected2hours after admission at the foot micro-capillary blood.1.4.3cranial MRI:3-7days after postpartum,in a calm sleep MRI examination, usingSHAO Xiao-Mei’s neonatal HIE MRI indexing standard.1.5Research contents1.aEEG abnormal indexing HIE clinical correlation analysis2. aEEG HIE determine the sensitivity and specificity of the degree of severity3.The aEEG abnormal indexing relationship of Apgar score4.The aEEG abnormal indexing and blood gas analysis of the relationship between5.AEEG exception indexing and cranial magnetic resonance imaging (MRI) indexing1.6Statistical analysis:SPSS13.0for data processing, Measurement data using(χ±s) description, t-test, P<0.05was statistically significant, count data expressed as a percentage, count data application using cardsquare test, P<0.05was considered statistically significant,way ordinal level data analysis using the CMH chi square test and spearman rank correlation analysis, P<0.05was statistically associative, the correlation coefficient r=0.6-0.8was Significantly associated, aEEG evaluate the the degree of severity of HIE,using sensitivity, specificity as predictive diagnostic value.2、Neonatal amplitude-integrated EEG preliminary exploration of the value of in pure fetal distress in children with brain injury 2.1object of study:72cases of our neonatal full-term intrauterine distress newborn from June2012to April2013as the experimental group, the same period in hospital20healthy full-term patients as a control group.2.2Samples of inclusion and exclusion criteriaInclusion criteria:There is a history of fetal distress;1minute Apgar score≥8points; gestational age>37weeks; body weight≥2500g, no suffocation clinical manifestations.Exclusion criteria:1minute Apgar score<8points; gestational age<37weeks; weight<2500g. abnormal brain function or brain damage caused by electrolyte imbalance, low blood sugar, intrauterine infection, genetic metabolic diseases, intracranial hemorrhage, and other congenitaldisease of newborns were exclusied.2.3Monitoring methods and outcome measures of aEEG2.3.1Instrument:Brain function monitor (Nicoict, NicolctOneMonitor, the United States)2.3.2Monitoring methods and time:6-12hours after birth, each patient for at least6hours. System of the International Federation of EEG Society standard electrode installation method,10-20,8-lead method.2.3.3Outcome measures of aEEG:from the background activity, sleep-wake cycle, epileptiform activity to judge aEEG results graphics.①aEEG background activity graph:To observe whether the waveform continuous monitoring of background wave amplitude (minimum and maximum voltage value);(2) the sleep-wake cycle:the SWC characteristics for smooth sine curve divided into of normal SWC and normal SWC.(3) epileptiform activity:divided into single episode (single occurrence of epileptic discharge), recurrent (within30min more than once); status epilepticus (continuous occurrence of epileptic discharge for more than30min) into three categories.2.3.4Monitoring results of aEEG:1, normal AEEG:coexist of continuous normal voltage and normal sleep-wake cycle.2, abnormal aEEG:exist of discontinuous normal voltage,burst-suppression, continuous low voltage platform, no normal sleep-wake cycle, and epileptiform activity in any one or more. 2.4Nerve-specific proteins:Venous blood were took in24-72hours after birth into the2ml vacuum tubes, centrifuged, separated serum and plasma, measured by radioimmunoassay to determine the level of NSE and S-100.2.5Imaging results:in3-7days after birth, transcranial Doppler B-ultrasound and cranial MRI in children.2.6Neurobehavioral assessment:Bailey Scales of Infant Development (BSID)and Peabody ratings(PDMS).2.7Research contents:1、 Simple intrauterine distress newborn the aEEG abnormal rate2、observation simply intrauterine aEEG abnormalities graph type and characteristics of distress of newborn.3、Abnormal aEEG graphics with children imaging results4.、Abnormal aEEG graphics with children with neurobehavioral prognosis5、Abnormal aEEG graphics and children with neural-specific protein relationship2.8Statistical analysis:SPSS13.0for data processing, the voltage calculated using a semi-logarithmic formula, the others as1.5.Result1、The relationship of Neonatal amplitude-integrated EEG and HIE diagnosis related indicators1.1Correlation analysis between the abnormalities indexing of aEEG and clinical correlation analysis of HIEBy chi-square test, chi-square=23.476, P<0.001, means the aEEG the degree of abnormality with HIE clinical grading were associated:Spearman rank correlation coefficient to0.829, P<0.001, indicates a significant correlation between the aEEG classification results with HIE clinicaldividing.1.2aEEG judgs HIE disease severitythe aEEG determines the degree of severity of HIE sensitivity is71.7%, specificity is97.1%, positive predictive value is96.5%,and negative predictive value is75%. 1.3aEEG abnormalities indexing and Apgar scoreApgar score at different times between the aEEG normal group and aEEG mildly abnormal group, severe group,P<0.05, with a significant differences and statistically significant.1.4The relationship between aEEG abnormalities indexing and blood gas analysisthe aEEG normal blood gas pH value with the aEEG mild abnormal group, aEEG severe abnormal group were significantly different (P<0.001); the aEEG normal blood gas BE value of aEEG mildly abnormal group aEEG severe abnormal group showed no statistical learning differences (P>0.05).1.5The correlation between aEEG abnormal indexing and head MRI indexingBy chi-square test, P<0.05the abnormality degree of aEEG and MRI were associated. Spearman rank correlation coefficient is0.702, P<0.001predict a significant correlation between the aEEG Category and HIE clinical grading.2、Neonatal amplitude-integrated EEG preliminary exploration of the value of in pure fetal distress in children with brain injury2.1background activity of aEEGThe experimental group:1case whose background activity is not continuous normal voltage, the rest are continuous normal voltage; control group:20cases were continuous normal voltage without continuous normal voltage, burst-suppression, continuous low voltage platform abnormal background activity; experimental group and the control group broadband and narrowband voltage upper and lower bounds of the aEEG background activity showed no significant difference (P>0.05).2.2aEEG sleep-wake cyclesleep-wake cycle rates in experimental group and control group of normal were90.2and100%, non-normal sleep-wake cycle rate was9.72%, and there is a significant difference (P<0.05).2.3aEEG epileptiform activityOne patient with epileptiform activity in the experimental group of72cases,with the performance of status epilepticus. Epileptiform activity does not appear in the the aEEG graph of the20cases in the control group.2.4abnormal incidence of simple distress neonatal aEEG and aEEG unusual graphical analysisSimple distress neonatal group aEEG abnormal incidence is9.72%(7/72).The pure fetal distress group of7patients with abnormal aEEG cases,1case of discontinuous normal voltage with the normal sleep-wake cycle associated with epileptiform activity,6cases of normal sleep-wake cycle.2.57cases of children with abnormal aEEG graphic imaging resultsSimple intrauterine distress group had seven cases whose aEEG is abnormal,6cases of normal sleep-wake cycle with4cases of B-head test were not normal and abnormal routine cranial MRI examinations showed left transverse sinus and sinus sink of subarachnoid hemorrhage;1case with discontinuous normal voltage and abnormal sleep-wake cycle associated with epileptiform activity, and its B-head and brain MRI, showed no abnormal.2.67cases of children with abnormal aEEG graphics neurobehavioral outcomesSeven cases of the aEEG cases of abnormal fetal distress,3cases shows nerve backward prognosis, one cases neurological development is normal,3were lost.2.7nerve-specific protein comparison between two groupsTwo groups of nerve-specific protein line pairwise comparison results show that: the control and experimental groups on the NSE and S-100were significantly different (P<0.05), but aEEG normal group (28cases) of the pure fetal distress group and aEEG abnormal group (n=4) There was no significant difference (P>0.05) on the NSE and S-100Compare.Conclusion1、The study confirmed the aEEG to early predict diagnosis of neonatal HIE, high sensitivity and specificity.2、The study found that the degree of abnormality of brain function monitoring with HIE disease indexing is highly correlated, suggesting that brain function monitoring has the assessed value in the anticipation of the severity of HIE. 3、The results suggest thatchildren with5minute Apgar score abnormal after birth or2hours blood gas after birth obvious abnormalities has higher abnormal positive rate in brain function monitoring, this children should be classified as brain function monitoring and suspicious of brain damage in high-risk groups.4、Brain MRI is a sensitive indicator of the diagnosis of HIE, but aEEG is significantly better than the head MRI in timeliness and convenience.5、The results of this study proved that the simple intrauterine distress in patients with brain function monitoring abnormal rate is10%, and abnormalities of brain function monitoring is not normal sleep-wake cycle, some of them in prognosis is backward than children of the same age,it prompted that the sleep-wake cycle anticipation in brain dysfunction may also have clinical value,it can not be ignored, it is worth of further exploration.