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Reduced Fractional Anisotropy on Diffusion Tensor Magnetic Resonance

Imaging After Hypoxic-Ischemic Encephalopathy


Phil Ward, Serena Counsell, Joanna Allsop, Frances Cowan, Yuji Shen, David
Edwards and Mary Rutherford
Pediatrics 2006;117;e619; originally published online March 1, 2006;
DOI: 10.1542/peds.2005-0545

The online version of this article, along with updated information and services, is
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ARTICLE

Reduced Fractional Anisotropy on Diffusion Tensor


Magnetic Resonance Imaging After Hypoxic-Ischemic
Encephalopathy
Phil Ward, BSca,b, Serena Counsell, PhDb, Joanna Allsop, DCR(R)b, Frances Cowan, PhDa, Yuji Shen, PhDb, David Edwards, Med Scia,b,
Mary Rutherford, MD, FRCRb

aDepartment of Paediatrics, MRC Clinical Sciences Centre, Imperial College Faculty of Medicine, Hammersmith Hospital, London, England; bImaging Sciences

Department, MRC Clinical Sciences Centre, Imperial College Faculty of Medicine, Hammersmith Hospital, London, England

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. Apparent diffusion coefficients (ADC) that are measured by diffusion-
weighted imaging are reduced in severe white matter (WM) and in some severe
www.pediatrics.org/cgi/doi/10.1542/
basal ganglia and thalamic (BGT) injury in infants who present with hypoxic- peds.2005-0545
ischemic encephalopathy (HIE). However, ADC values may pseudonormalize or doi:10.1542/peds.2005-0545
even be high during this time in some less severe but clinically significant injuries.
Key Words
We hypothesized that fractional anisotropy (FA), a measure of the directional brain imaging, diffusion tensor imaging,
diffusivity of water made using diffusion tensor imaging, may be abnormal in these hypoxic-ischemic encephalopathy,
magnetic resonance imaging, neonates
less severe injuries; therefore, the objective of this study was to use diffusion tensor
Abbreviations
imaging to measure ADC and FA in infants with moderate and severe hypoxic- HIE— hypoxic-ischemic encephalopathy
ischemic brain injury. GA— gestational age
DWI— diffusion-weighted imaging
METHODS. Twenty infants with HIE and 7 normal control infants were studied. All ADC—apparent diffusion coefficient
WM—white matter
infants were born at ⬎36 weeks’ gestational age, and MRI scans were obtained BGT— basal ganglia and thalami
within 3 weeks of delivery. Data were examined for normality, and comparisons ROI—region of interest
DTI— diffusion tensor imaging
were made using analysis of variance or Kruskal-Wallis as appropriate.
FA—fractional anisotropy
RA—relative anisotropy
RESULTS. During the first week, FA values were decreased with both severe and
PLIC—posterior limb of the internal
moderate WM and BGT injury as assessed by conventional imaging, whereas ADC capsule
values were reduced only in severe WM injury and some severe BGT injury. CSO— centrum semiovale
LN—lentiform nuclei
Abnormal ADC values pseudonormalized during the second week, whereas FA MT—medial thalamus
values continued to decrease. VLN—ventrolateral nuclei of the thalamus
Accepted for publication Sep 23, 2005
CONCLUSION. FA is reduced in moderate brain injury after HIE. A low FA may reflect Address correspondence to Mary Rutherford,
a breakdown in WM organization. Moderate BGT injury may result in atrophy but MD, FRCR, Imaging Sciences Department,
Robert Steiner MR Unit, Hammersmith
not overt infarction; it is possible that delayed apoptosis is more marked than Hospital, Du Cane Rd, London W12 0HS.
immediate necrosis, and this may account for normal early ADC values. The E-mail: m.rutherford@imperial,ac.uk

accompanying low FA within some severe and all moderate gray matter lesions, PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2006 by the
which is associated with significant later impairment, may help to confirm clini- American Academy of Pediatrics
cally significant abnormality in infants with normal ADC values.

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H YPOXIC-ISCHEMIC ENCEPHALOPATHY (HIE) is an im-
portant cause of mortality, morbidity, and adverse
neurodevelopmental outcome in infants who are born at
fusion. Only a few relatively small studies have investi-
gated whether DWI may offer more immediate detection
of tissue injury in infants with HIE, with somewhat
term, with an overall incidence between 1 and 2 per conflicting conclusions.13–18 Of note, several of these
1000 live births. Asphyxia accounts for up to 25% of studies did not measure apparent diffusion coefficient
total perinatal morbidity and mortality, as well as up to (ADC) values, reporting the sensitivity of DWI on the
15% of all cases of cerebral palsy.1 basis of visual analysis of the images only, which in some
The pattern of injury after a hypoxic-ischemic event cases may be inconclusive. More recently, we demon-
depends on the gestational age (GA) of the infant and strated in a larger cohort of infants significantly reduced
also the duration and the severity of asphyxia to which ADC values between control subjects and infants with
they are subjected. Despite a range of suggestive clinical severe white matter (WM) lesions and some severe basal
parameters, the diagnosis of HIE and the prediction of its ganglia and thalami (BGT) lesions in several regions of
eventual outcome remain notoriously challenging. Ac- interest (ROI).12 However, values in infants with mod-
curate initial diagnosis is also necessary to assess the erate but nonetheless clinically significant lesions were
effect of an intervention. Early imaging studies have either normal or slightly raised. In addition, pseudonor-
shown that even with relatively strict entry criteria, the malization, whereby abnormal ADC values approximate
pattern of injury in infants with HIE may be very vari- that of normal control subjects toward the end of the
able. It remains unclear whether this reflects differences first week after birth, was also apparent. Although this
in the timing of injury, the nature of the insult, or phenomenon limits the usefulness of DWI later in the
individual susceptibilities. These questions can be an- perinatal period, abnormalities on conventional imaging
swered only by additional studies that improve both are usually apparent by this time.
entry criteria and the description of the brain injury. Diffusion tensor imaging (DTI) allows the measure-
The sensitivity of MRI has been exploited in the study ment of the directional diffusivity of water and may be
of normal brain development,2,3 characterizing changes more sensitive than DWI in detecting brain injury in
in myelination and cortical folding. Given the varying neonates with HIE. At present, no studies have mea-
and sometimes subtle patterns of injury in HIE, MRI is sured fractional anisotropy (FA) values in a cohort of
an attractive diagnostic and prognostic modality. Studies infants with HIE. The objectives of this study were to
with conventional MRI have characterized HIE-associ- ascertain whether DTI can improve the detection of
ated lesions,4,5 and these have been shown to correlate brain injury in infants with HIE and, more specific, (1) to
with the type of hypoxic-ischemic insult, apparent clin- relate DTI findings to the pattern and severity of brain
ical features,6 neurologic examination,7 and electroen- lesions, (2) to determine whether DTI measures of an-
cephalographic measurements.8 Importantly, MRI has isotropy improve the detection of severe and moderate
been shown to be a good predictor of neurodevelopmen- BGT or moderate WM injury, and (3) to relate DTI
tal outcome.9,10 However, abnormalities on conventional findings to the timing of the scan from delivery.
MRI may not be obvious within the first few days after
delivery, particularly to those who are not experienced
in assessing perinatal pathology. Therefore, there is a METHODS
need for objective methods to improve the detection of Study approval was granted by the Research Ethics
ischemic tissue, to confirm suspected tissue injury as Committee of the Hammersmith Hospitals Trust, and
seen on conventional images, and to quantify these find- parental consent for the acquisition of imaging was
ings. For additional understanding of the evolution of gained in all cases. Infants were examined with DTI as
imaging abnormalities after a variety of insults, a more part of an initial assessment after presentation with signs
accurate assessment for timing an injury would be ex- of HIE. Strict inclusion criteria required presentation
tremely useful not only for clinical management but also with abnormal tone patterns, feeding difficulties, altered
for medicolegal issues. alertness, and at least 3 of the following: (1) late decel-
Diffusion-weighted imaging (DWI) has been shown erations on fetal monitoring or meconium staining, (2)
to identify ischemic tissue within hours of the onset of delayed onset of respiration, (3) arterial cord blood pH
adult stroke11; it is able to detect ischemic lesions in ⬍7.1, (4) Apgar scores ⬍7 at 5 minutes or (5) multior-
perinatal stroke, but these studies have been performed gan failure. Infants were excluded when they had evi-
after symptomatic onset, which is usually within days, dence of metabolic disease, congenital infection, major
not hours, of delivery. In perinatal stroke, DWI abnor- malformations, alcohol or drug embryopathies, hydrops,
malities are most notable in the first 4 days after birth or chromosomal abnormalities or when they were in
but later pseudonormalize as conventional MRI scans excess of 3 weeks’ postnatal age at the timing of imaging.
first begin to exhibit pathology.12 However, perinatal The control cohort comprised 7 term-born infants, all
stroke is not typical of the type of brain injury seen with with normal brain imaging and neurologic examination.
HIE, in which the insult is global and followed by reper- None had required resuscitation at birth or had abnor-

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mal Apgar scores, and none had seizures or other neu- FA maps were calculated using


rologic symptoms.
On the basis of our own and other previous DWI 3 冑共␭1 ⫺ D៮ 兲2 ⫹ 共␭2 ⫺ D៮ 兲2 ⫹ 共␭3 ⫺ D៮ 兲2
FA ⫽ (3)
studies that show ADC values to evolve after birth in 2 冑␭12 ⫹ ␭22 ⫹ ␭32
both encephalopathic and control infants, both cohorts RA maps were calculated using
were stratified on the basis of their postnatal age at scan:
the early group included infants who were imaged dur- 冑共␭1 ⫺ D៮ 兲2 ⫹ 共␭2 ⫺ D៮ 兲2 ⫹ 共␭3 ⫺ D៮ 兲2
RA ⫽ 1 冑 3
ing the first week after birth (ⱕ7 days), and the late D៮
group comprised those who were imaged in the second
(4)
and third weeks (8 –21 days).
where ␭1, ␭2, and ␭3 are the principal eigenvectors of the
diffusion tensor
Imaging
␭1 ⫹ ␭2 ⫹ ␭3
All infants were imaged at the Robert Steiner MRI D៮ ⫽ (5)
Unit, Hammersmith Hospital. Patients were usually se- 3
dated using oral chloral hydrate (30 –50 mg/kg),
whereas control subjects were imaged during natural Analysis of Imaging
sleep. Infants wore ear protection that consisted of Conventional T1- and T2-weighted imaging was as-
sessed subjectively for abnormal anatomy and/or signal
molded earplugs and specialist ear protection (Natus
intensity by 1 researcher (M.R.), who was experienced
MiniMuffs; Natus Medical Inc, San Carlos, CA) and were
in interpreting neonatal brain MRI scans. For infants
monitored using pulse oximetry and electrocardiogra-
who were imaged very soon after birth and who sur-
phy throughout the scan. An experienced neonatologist,
vived, repeat imaging was obtained to confirm the pat-
who was trained in MRI procedures, was in attendance
tern of lesions. Each infant was assigned a BGT grade of
throughout the imaging process. normal, mild, moderate, or severe. Mild lesions were
MRI was obtained using a 1.5 Tesla Philips Eclipse small and focal with normal myelination in the posterior
scanner with a dedicated pediatric head coil. Conven- limb of the internal capsule (PLIC), moderate lesions
tional transverse T1-weighted spin echo (500/15 ms) were multifocal with equivocal or abnormal PLIC, and
and T2-weighted fast spin echo (4200/210 ms) with severe lesions showed complete BGT abnormality with
192 ⫻ 256 matrix and 5-mm slice thickness, as well as abnormal PLIC. Similarly, WM was graded as normal,
3D RF spoiled gradient echo images were obtained moderate (areas of increased T1 or T2), or severe (overt
before DTI. Subsequently single-shot echo-planar imag- infarction). These grades were allocated on the basis of
ing DTI was acquired in 12 (6 noncollinear) directions the specific appearance of each of the studied WM re-
using a b value of 710 s/mm2, repetition time 6000 ms, gions (Fig 1).
echo time 100 ms, field of view 240 mm, matrix 100 ⫻ DTI first was assessed visually for signs of rotation or
100, and slice thickness 5 mm. other artifact. The reference (non– diffusion-weighted)
In-house software then was used to remove image image then was used to identify the slices that best
distortion as a result of eddy currents and to construct demonstrated each of the following chosen ROI: central
ADC and FA maps on a per-pixel basis19: WM in the centrum semiovale (CSO), anterior and pos-
ADC maps were calculated using terior WM at the level of the BGT, lateral lentiform
nuclei (LN), medial thalamus (MT) and ventrolateral
1 S nuclei of thalamus (VLN), PLIC, anterior and posterior
ADC ⫽ ⫺ ln (1) brainstem, and cerebellar vermis and cerebellar hemi-
b S0
spheres (Fig 2).
where S is signal in the diffusion-weighted image, S0 is In-house software was used to calculate mean and SD
signal in the reference image, and b is diffusion sensitiv- of ADC, FA, and RA in each ROI. For reducing observer
ity parameter, given by equation 2 error, each ROI was defined 3 times, with the average of
each parameter being used in analysis. Furthermore, the
b ⫽ ␥ 2 G2 ␦ 2 共⌬ ⫺ ␦ /3兲 (2) mean of measurements from the corresponding ROI in
each cerebral hemisphere was used when conventional
where ␥ is gyromagnetic ratio for protons, G is amplitude imaging suggested symmetric abnormality.
of the pulsed gradient, ␦ is duration of the pulsed gradi-
ent, and ⌬ is time between leading edges of the 2 pulsed Statistics
gradients. The rotationally invariant measures of anisot- Intraobserver error was expressed by calculating coeffi-
ropy, FA and relative anisotropy (RA), were used to cients of variability after repeating measurements for 6
characterize the diffusion tensor: infants who were chosen at random. All data were sub-

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FIGURE 1
Conventional imaging examples of abnormality classification. A, Transverse T2-weighted image showing diffuse abnormal signal intensity throughout WM, at 5 days of age. B,
Transverse T1-weighted image at the level of the CSO showing bilateral low-signal intensity cystic areas consistent with infarction, at 15 days of age (arrows). C, Transverse T1-weighted
image showing bilateral foci of abnormal increased signal intensity within the lentiform and thalami nuclei (arrows), at 5 days of age. D, Transverse T1-weighted image showing diffuse
abnormal increased signal intensity throughout the BGT, at 5 days of age; follow-up scan at 3 weeks showed pronounced basal ganglia atrophy.

jected to the Shapiro-Wilk test for nonnormality and 37– 42), birth weight of 3500 g (range: 2330 – 4250), and
then as appropriate unpaired t and analysis of variance median age at scan of 5 days (1–12). Fifteen infants were
methods (for parametric data) or Mann-Whitney U and scanned in the first week from delivery, and 5 were
Kruskal-Wallis tests (for nonparametric data). scanned in the second and third weeks. No significant
difference was observed in any of these parameters be-
RESULTS tween the 2 groups (P ⫽ .53).
DTI data sets was available for 7 control infants and 20
patients; the median GA at birth and birth weight of the Visual Analysis of Conventional Imaging
7 term-born control infants was 39.1 weeks (range: 36 – The imaging of all control infants was within normal
41.4) and 3342 g (range: 2650 – 4780), respectively. The limits for their age. Of the 20 encephalopathic infants, 17
median age at scan was 6 days (range: 1–18), with 4 had moderate or severe BGT abnormality. Only 2 infants
infants scanned in the first week. The cohort of 20 had moderate BGT abnormalities; therefore, all BGT le-
patients had a median GA at birth of 40 weeks (range: sions were grouped together. WM abnormalities were

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FIGURE 2
ROI locations in the present study. A, White matter in the centrum semiovale. B, White matter, basal ganglia, and thalami. C, Posterior limb of the internal capsule. D, Brain stem. E,
Cerebellum.

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more variable: whereas 4 infants had normal WM, 14 subjects are shown in Table 1. The larger range of values
had severe abnormalities in the WM of the CSO, 7 had in the patients represents varying pathologic severity
severe anterior WM abnormalities, and 8 had severe between infants, as well as their age at the time of scan,
posterior WM abnormalities. Two infants had BGT ab- consistent with our previous work.
normality in the absence of any WM changes, and 1
encephalopathic infant had normal BGT and WM imag- White Matter
ing. In infants who were imaged during the first week, both
Four infants, 1 control infant and 3 patients, were anterior and posterior WM (Fig 3) ADC values of pa-
imaged within 48 hours. In 2 of these, repeat imaging tients with severe WM abnormality on visual inspection
confirmed the initial imaging appearances at 2 and 6 were significantly lower than those in control infants
weeks, respectively. The remaining 2 were followed up (median: 1.16 mm2/s [0.71–1.81] vs 1.63 [1.47–1.73], P
but did not have repeat imaging. The control infant had ⫽ .05; 1.14 [0.63–1.45] vs 1.52 [1.39 –1.74], P ⫽ .0107,
normal development, and the patient with BGT lesions respectively). However, infants with moderate abnor-
had developed a motor impairment. The visual analysis mality on visual inspection exhibited values similar to
of DWI and ADC trace images is not included in this those in control infants (anterior WM: 1.69 [1.44 –1.81];
study. posterior WM: 1.41 [1.32–1.62[). In the WM at the level
of the CSO, patients with severe abnormalities on visual
ADC and Anisotropy Measurements inspection had reduced ADC values when compared
A single researcher (P.W.) produced measurements to with control infants, but this did not reach significance
minimize observer error; the average coefficient of vari- (median: 1.09 [0.67–1.70] vs 1.27 [1.19 –1.33[); infants
ability over all ROIs was 1.5% for ADC, 3.89%, for FA who were imaged in the second and third weeks showed
and 4.26% for RA values. For assessment of any influ- higher CSO WM ADC values (median: 1.34 [0.79 –1.49]),
ence of GA at delivery on measurements, changes in but the difference from those who were imaged in week
ADC and anisotropy in all of the WM regions were 1 was not statistically significant. There were too few
examined in the control infants. These areas are known infants with anterior and posterior WM abnormalities
to be actively myelinating during the neonatal period imaged after week 1 for meaningful comparison. Of
and infancy (and thus rapidly changing in terms of dif- interest, 5 patients with lesions had some areas of WM
fusion characteristics). that appeared normal on conventional images, and in
these areas, ADC values were comparable with those in
ADC Values control infants (anterior WM median: 1.71 [1.37–1.73];
In the control infants, although both WM and BGT ADC posterior WM: 1.53 [1.15–1.61]; CSO WM: 1.36 [1.35–
values tended to decrease with increasing age at scan, 1.58]).
this observation did not reach significance over the rel-
atively small range of GA in this study. Similarly, there Basal Ganglia and Thalami
was no difference between the early (imaged ⬍7 days’ In the first week of postnatal life, median patient ADC
postnatal age) and late (imaged 8 –21 days) control values in both the MT and VLN (Fig 4), despite a much
groups. When multiple regression was used to examine greater range, were similar to those in control infants
simultaneously the effect of both GA at delivery and (1.05 mm2/s [0.72–1.28] vs 1.04 [0.94 –1.14] and 0.93
postnatal age at scan, again no significant differences [0.53–1.13] vs 0.86 [0.78 –1.07], respectively). In the
were found. The ADC values for all patients and control LN, ADC values were decreased in patients with BGT

TABLE 1 Median and Ranges of ADC and FA Values


ROI ADC FA
All Controls, All Patients, All Controls All Patients
⫻10⫺3 mm2/s ⫻10⫺3 mm2/s
Anterior WM 1.62 (1.47–1.73) 1.65 (0.71–1.81) 0.158 (0.103–0.202) 0.120 (0.089–0.174)
CSO WM 1.31 (1.18–1.34) 1.20 (0.67–1.70) 0.259 (0.177–0.314) 0.156 (0.082–0.279)
Posterior WM 1.49 (1.39–1.74) 1.39 (0.63–1.79) 0.205 (0.140–0.254) 0.140 (0.096–0.223)
Cerebellar hemispheres 1.10 (0.97–1.18) 1.11 (0.81–1.37) 0.205 (0.109–0.312) 0.178 (0.078–0.391)
Cerebellar vermis 0.90 (0.80–1.14) 0.92 (0.83–1.08) 0.193 (0.141–0.440) 0.200 (0.114–0.312)
Anterior BS 1.13 (0.96–1.23) 1.12 (0.77–1.41) 0.230 (0.156–0.407) 0.194 (0.082–0.434)
Posterior BS 0.96 (0.83–1.10) 0.96 (0.62–1.13) 0.251 (0.170–0.437) 0.268 (0.143–0.346)
LN 1.11 (1.03–1.27) 1.06 (0.63–1.44) 0.171 (0.151–0.227) 0.131 (0.063–0.295)
MT 1.00 (0.94–1.14) 1.10 (0.72–1.48) 0.167 (0.147–0.209) 0.137 (0.082–0.317)
VLN 0.86 (0.78–1.07) 0.94 (0.53–1.20) 0.305 (0.201–0.387) 0.184 (0.115–0.311)
PLIC 1.01 (0.96–1.14) 0.97 (0.54–1.32) 0.439 (0.266–0.466) 0.322 (0.164–0.467)

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FIGURE 5
FIGURE 3 ADC values in VLN. F, control infants; 䊐, infants with moderate/severe BGT abnormality.
ADC values in posterior WM. F, control infants; 䊐, infants with severe WM abnormality;
‚, infants with moderate WM abnormality.
week 1 and week 2 was not statistically significant (P ⫽
.1423).
lesions compared with control infants (0.98 mm2/s
[0.63–1.22] vs 1.10 [1.03–1.27]), but this did not reach Anisotropy Values
significance (P ⫽ .16). In agreement with our previous A positive correlation (P ⬍ .00001) was found between
work, increased patient ADC values were observed in FA and RA values, and so given previous literature20 and
each BGT region during the second and third weeks, a marginally lower coefficient of variability, FA values
equalling or exceeding those found in the control infants were used as the sole measure of anisotropy to simplify
(median values: LN, 1.11; MT, 1.17; VLN, 1.09). ADC data analysis. In the control infants, the only significant
values of the 2 patients with moderate BGT lesions were finding was that FA values within the WM in the CSO
normal in each ROI (MT median: 0.98 mm2/s [0.91– increased with age at scan (P ⫽ .03), but when the effect
1.06]; VLN: 0.84 [0.74 – 0.94]; LN: 1.06 [1.02–1.10]). of GA and age at scan was examined using multiple
regression, this was no longer found to be significant.
Internal Capsule
PLIC ADC values were significantly reduced in patients White Matter
with BGT lesions during the first week (median: 0.93 In the first postnatal week, FA values were significantly
mm2/s [0.54 –1.13] vs 1.06 [0.98 –1.16] in the control decreased not only in infants with severe WM abnor-
group; P ⫽ .0496; Fig 5). The ADC values in the patients mality but also in those with moderate abnormality. In
who were imaged during the second and third weeks the anterior WM, median anisotropy was 0.110 (0.089 –
were higher at 1.04 but not significantly different from 0.164; P ⫽ .0271) and 0.114 (0.098 – 0.140; P ⫽ .0315)
the control group of 0.99. Again, the difference between for patients with moderate and severe WM pathology,
compared with 0.157 (0.137– 0.193) for control infants.
Aberration in posterior WM anisotropy was even more
pronounced (Fig 6), with values of 0.144 (0.096 – 0.175;
P ⫽ .0007), 0.138 (0.124 – 0.198; P ⫽ .0016), and 0.225
(0.184 – 0.254) in the moderate pathology, severe pa-
thology, and control groups, respectively. In the CSO
WM, infants with severe abnormality had significantly
decreased FA in the first week (0.167 [0.091– 0.279] vs
control infants 0.289 [0.210 – 0.314]; P ⫽ .0032). Of
particular interest, given the phenomenon of pseudo-
normalization described with ADC values, is that com-
pared with similarly aged control infants, CSO WM an-
isotropy was also significantly decreased in patients who
had severe abnormality and were imaged during the
second and third weeks (0.113 [0.08 – 0.127] vs 0.221
[0.177– 0.259]; P ⫽ .006). Indeed, there was significant
FIGURE 4
FA values in posterior WM. F, control infants; 䊐, infants with severe WM abnormality; ‚, difference between the values of patients who were
infants with moderate WM abnormality. imaged during the first week and those who were im-

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FIGURE 6 FIGURE 8
FA values in posterior VLN. F, control infants; 䊐, infants with moderate/severe BGT FA values in PLIC. F, control infants; 䊐, infants with moderate/severe BGT abnormality.
abnormality.

imaged during the second and third weeks, the pattern


aged during the second and third weeks (P ⫽ .015), but, of change in FA varied: LN values increased significantly
more important, anisotropy became more deranged to above that of the normal control infants (median:
rather than pseudonormalized. In patients with lesions 0.190 [0.063– 0.295]; P ⫽ .0449), and MT values also
but some areas of normal-appearing WM, values in usu- increased (0.169 [0.090 – 0.317]; P ⫽ .5446). VLN FA,
ally normal WM were as follows: median FA was 0.132 however, remained low (0.198 [0.115– 0.275]) and was
(0.126 – 0.153) in the anterior WM, 0.137 (0.136 –0.160) significantly different from that in similarly aged control
in posterior WM, and 0.151 (0.119 – 0.175) in CSO WM. infants (P ⫽ .012).
In the last 2 ROI, FA was significantly reduced compared
with that in control infants (P ⬍ .03). Internal Capsule
In the PLIC, FA values evolved similarly to those in the
Basal Ganglia VLN. FA in patients who were imaged during the first
FA was significantly decreased in the first week through- week was decreased (median: 0.331 [0.171– 0.467] vs
out the BGT. Median values in the LN were 0.129 0.439 [0.267– 0.467] in controls); however this did not
(0.080 – 0.189) compared with 0.171 (0.151– 0.227) in achieve statistical significance (P ⫽ .0502; Fig 8). Anisot-
the control group (P ⫽ .0357). A similar decrease was ropy decreased further in patients who were imaged in
found in the MT (0.137 [0.082– 0.255] vs 0.170 [0.147– the later age group (median: 0.264 [0.164 – 0.325]), sig-
0.209]; P ⫽ .0321) and VLN (0.175 [0.230 – 0.311] vs nificantly lower than that in the control infants (P ⫽
0.334 [0.300 – 0.387]; P ⫽ .0006; Fig 7). Importantly, FA .0045).
was also decreased in the 2 patients with moderate BGT
abnormality on conventional imaging (median: LN, Other ROIs
0.137; MT, 0.136; VLN, 0.207). For patients who were There was a statistically significantly reduced FA in the
cerebellar hemispheres of patients who had BGT injury
and were imaged in the first week compared with con-
trol infants (median: 0.153 vs 0.205; P ⫽ .0486). This
difference was also present in the second and third
weeks. ADC values in the BGT injury group were higher
during week 1 and then decreased, when compared with
control infants, but this difference did not reach signifi-
cance. No significant differences were noted in the
brainstem between patients and control infants.

Predictive Value of FA
Using data from all of the infants, regardless of postnatal
age at scan or the severity of any WM or BGT injury as
assessed visually, the predictive power of FA for tissue
injury as identified on conventional imaging analysis
FIGURE 7 exceeded that of ADC in all ROIs. Of all WM regions, FA
ADC values in PLIC. F, control infants; 䊐, infants with moderate/severe BGT abnormality. was most predictive in the posterior WM, where a value

e626 WARD, et al
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of ⬍0.16 was 81% sensitive and 85% specific for some WM indicates that axonal diameter and membrane
degree of abnormality. In the BGT, a value ⬍0.260 in the properties and the activity of oligodendrocytes modulate
VLN was 82% sensitive and 86% specific for moderate diffusion characteristics.21,22 These principles underlie
or severe BGT injury. Importantly, the sensitivity and observations that anisotropy increases with increasing
the specificity of these values improved when the data brain development21,23 and that the change is greater in
were limited to infants who were imaged during the first WM than in central gray matter.24
week (sensitivity: ⬎85%; specificity: 100%), indicating Anisotropy was significantly decreased in patients
that the high level of predictive power can be attributed with not only severe but also moderate WM pathology
to the sensitivity of FA, rather than simply the lack of and not only in infants who were imaged in the first
pseudonormalization after insult. FA of ⬍0.380 in the postnatal week but also in infants who were imaged in
PLIC was ⬎80% sensitive and specific for BGT injury but the second and third weeks. Abnormally low FA values
reduced to 75% when based on first week data alone. have also been documented in chronic infarction in
adult stroke studies.25 The persistently abnormal FA dif-
DISCUSSION ferentiates the characteristics of the parameter from
In our previous study,12 we hypothesized that DTI ADC in 2 respects: first, that it seems to be more sensi-
may improve detection of abnormal tissue and fiber tive, given the detection of moderate injury, and, sec-
disruption. We now report ADC and FA values in 7 ond, that the parameter remains abnormal when ADC
term-born control infants and 20 term-born encephalo- values have pseudonormalized.
pathic patients who fulfilled strict criteria for HIE. The FA was also lower throughout the BGT and also the
principle objective was to establish a more objective PLIC. One would expect this in the PLIC given its known
and sensitive detector of tissue damage, particularly in role as a predictor of neurodevelopmental outcome in
infants with BGT abnormalities and moderate WM HIE9 As with WM regions, FA was most abnormal and
abnormalities, all of which are associated with neurode- remained abnormal after the first week in the VLN.
velopmental impairment. After classification on the Anisotropy in the LN and MT, although low in the first
basis of postnatal age at scan and severity of WM and week, was normal in the infants who were scanned
BGT injury as detected on conventional imaging by an later. The PLIC and VLN have the highest FA values in
experienced interpreter of neonatal images, several the control infants; therefore, it is possible that distur-
trends in the measured diffusion parameters could be bance of structure is easier to detect. It is of interest that
elucidated. the FA values within the VLN are relatively high com-
A large range of ADC values was evident in the pa- pared with the LN and even with the MT. Differences
tient group, suggesting that infants had lesions that var- between thalamus and lentiform nucleus anisotropy
ied not only in their location and severity but also in have been shown in other pediatric and adult studies,26,27
their degree of evolution at the time of imaging. ADC but these have not specifically measured different re-
values were decreased in the first postnatal week in the gions of the thalamus. Relatively high FA values in the
WM regions of patients with severe WM abnormality VLN may be explained by the presence of fibers within
and in the LN and PLIC of those with severe BGT pa- these nuclei, which are already myelinated in the term
thology, before normalizing as exhibited by infants who neonate.3 The degree of anisotropy within the nuclei will
were imaged during the second and third weeks. This reflect the relative orientation of these fibers, and this
pseudonormalization obviously limits the absolute sen- has been shown on diffusion tractography in the adult
sitivity of the parameter, but by the time it has occurred, brain.28 The sensitivity of diffusion values in the VLN is
lesions are usually more obvious on conventional imag- consistent with its role within the pyramidal system and
ing. In addition, infants with moderate pathology dem- the sensitivity of this actively myelinating system to
onstrated normal or marginally increased ADC values injury. The evolution of our FA changes may be ex-
compared with control infants. These findings are in plained by irreversible ischemia and subsequent infarc-
agreement with our previous, larger DWI study as well tion within the VLN, whereas changes in the MT and
as other investigations with focal infarction in neonates the LN may comprise in part extracellular edema that
and adult patients. settles after week 1. Conventional images in infants with
Given the concurrence of the present ADC data with BGT lesions often show swollen medial thalami with
previous work, the observed patterns in anisotropy are long T1 and long T2, which could be attributable at
also relevant. In the control infants, FA was highest in least in part to extracellular edema. It is also feasible
the WM of the PLIC (median: 0.439), which is in keep- that we were unable to sample the most vulnerable
ing with the fact that this area consists of tightly packed region of the LN, the posterior putamen, because we
and parallel fibers that are actively myelinating at term; were attempting to avoid partial volume effects on ad-
this organization and the multiple lipid layers of myelin jacent WM in the PLIC. In addition, differences between
tend to restrict the direction across axonal tracts. Exper- the composition and thus diffusion properties of WM
imental demonstration of anisotropy in nonmyelinated and gray matter may explain these different diffusion

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properties; reductions in ADC and anisotropy are known the different patterns of injury resulting in focal infarc-
to be less in central gray matter structures (in some tion and the more global insult associated with HIE.
studies nonexistent) and also possibly pseudonormalize Measuring the separate eigenvectors of the diffusion
earlier.25 tensor and thereby assessing their individual effect on
Of interest, FA values in the cerebellar hemispheres of the overall FA may help to explain the relationship
patients with moderate/severe BGT injury were re- among injury type, age, and FA.
duced. Given the relatively short period of study, how- After the acute phase of adult stroke, FA is decreased
ever, this is unlikely to be attributable to delayed injury, compared with control tissue,33 probably reflecting cell
although it remains unclear whether this is attributable death and loss of structural integrity, resulting, again
to an acute cerebellar injury or a secondary effect from particularly in WM, in an environment that is more
diaschisis. ADC values in the cerebellar hemispheres permissive to multidirectional (isotropic) diffusion
were not reduced acutely, although this does not ex- rather than the vastly unidirectional, anisotropic diffu-
clude a moderate acute injury. Correlation between sion seen in intact WM tracts. Contemporaneously, ADC
perinatal BGT injury and subsequent impaired cerebellar values tend to pseudonormalize and subsequently in-
development has been documented.29 The use of DTI in crease compared with control values.25
a cohort of infants who are imaged during a longer Our current study clearly demonstrates that these
temporal period is indicated, given that reduced FA has concepts occur in a cohort of HIE patients, and that
been shown in areas of Wallerian degeneration after trends in ADC and anisotropy follow different patterns
adult stoke.30 after insult gives 2 important advantages. First, one may
In this study, we used the severity of injury as visually differentiate infants whose conventional imaging will
assessed on conventional imaging to index the sensitiv- eventually show moderate or severe WM lesions, those
ity of the diffusion parameters; therefore, it is clear that who are more likely to sustain a severe injury will have
FA and particularly ADC become more aberrant with both decreased ADC and anisotropy in the first week,
increasing visual abnormality and injury. However, it is whereas those with moderate injury will have a grossly
interesting to observe the variation of ADC and FA in the normal ADC but decreased anisotropy. Second, the tim-
5 infants with areas of apparently normal WM. Where ing of the causative insult may be approximated by
ADC was similar to that in control infants, FA was re- comparing ADC, which may be abnormal or have
duced, significantly in the posterior and CSO WM. Al- pseudonormalized, and FA, which remains or even be-
though we appreciate the small number of patients in comes increasingly abnormal in the first weeks after
this subcohort, this trend suggests that a quantitative birth. We do appreciate, however, the need to charac-
measure of anisotropy may detect abnormality when it is terize the evolution of both parameters more closely,
not obvious on conventional imaging. Therefore mea- and that natural variation may limit the ability to make
suring FA would provide a useful adjunct to the visual accurate assumptions that would be required, for exam-
analysis of conventional MRI, particularly to those who ple, in the medicolegal arena.
are not experienced in assessing perinatal pathology. The sample size of the study prohibited several com-
Other literature using DTI in a similar cohort of in- parisons. Although our findings with WM injury are
fants with HIE is sparse. Given known parallels between extremely encouraging, we realize most importantly a
the evolution of ADC values after infarcts in adults and lack of infants who have particularly moderate BGT
neonates, it is reasonable to relate our findings similarly. lesions and may still experience adverse neurodevelop-
In acute adult stroke, anisotropy changes in distinct tem- mental outcome. This undoubtedly reduced the sensitiv-
poral phases after the onset of ischemia. ity of thalamic ADC values; with a larger cohort, as was
During the first 24 hours, compression of the extra- available in our previous study, a more thorough BGT
cellular space after cellular swelling during necrotic cell lesion classification could have been used. Of critical
death may lead to slightly increased anisotropy, partic- importance is the availability of control data to establish
ularly in WM tracts.25 In a study of adult infarction, normal ranges, but the recruitment of true control in-
however, there were no hyperacute changes in anisot- fants within the postnatal first month is notoriously
ropy within 6 hours of stroke onset.31 Buijs et al32 inves- difficult. It was interesting to note the greater variation
tigated focal neonatal brain ischemia and documented in control FA values compared with ADC values, but this
increased FA immediately after the insult. However, it is may be a manifestation of a more sensitive parameter
unusual for perinatal stroke to present within 12 hours combined with normal variation.
of delivery, and it is possible that focal perinatal injury The ability of FA to predict both WM and BGT abnor-
that was already obvious within 24 hours may have mality either in the first postnatal week or in fact at any
occurred before labor. In our study, despite that 3 pa- time within the first 3 weeks of postnatal life with
tients were imaged on the first day after birth, there ⬎80% sensitivity and specificity is impressive. Despite
were no elevated FA values; this may represent normal the small control cohort, this is testament to the
variation in anisotropy, but more likely, it demonstrates possible applications of DTI in the investigation of HIE.

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e630 WARD, et al
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Reduced Fractional Anisotropy on Diffusion Tensor Magnetic Resonance
Imaging After Hypoxic-Ischemic Encephalopathy
Phil Ward, Serena Counsell, Joanna Allsop, Frances Cowan, Yuji Shen, David
Edwards and Mary Rutherford
Pediatrics 2006;117;e619; originally published online March 1, 2006;
DOI: 10.1542/peds.2005-0545
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