Sudden Unexpected Postnatal Collapse and Therapeutic Hypothermia: What's Going On?

Abstract

Sudden unexpected postnatal collapse (SUPC) is a rare event, potentially associated with catastrophic consequences. Since the beginning of the 2000s, therapeutic hypothermia (TH) has been proposed as a treatment for asphyxiated neonates after SUPC. However, only a few studies have reported the outcome of SUPC after TH. The current study presents the long-term neurodevelopmental outcome of four cases of SUPC treated with TH in a single Italian center. Furthermore, we reviewed the previous literature concerning 49 cases of SUPC treated with TH. Among 53 total cases (of whom four occurred in our center), 15 (28.3%) died before discharge from the NICU. A neurodevelopmental follow-up was available only for 21 (55.3%) out of the 38 surviving cases, and seven infants developed neurodevelopmental sequelae. TH should be considered in neonates with asphyxia after SUPC. However, SUPC is a rare event, and there is a lack of comparative clinical data to establish the risk/benefit of TH after SUPC with different degrees of asphyxia. Analysis of large cohorts of newborns with SUPC, whether treated with TH or untreated, are needed in order to better identify infants who should undergo TH.

Keywords: brain cooling; cerebral palsy; neurodevelopmental outcome; sudden unexpected postnatal collapse; therapeutic hypothermia.

Figure 1

p-EEG in case 1 (a) at recruitment: severe p-EEG depression with superimposed muscular activity; (b) at 24 h during TH: burst suppression pattern with long inter-burst periods.

Figure 2

p-EEG in case 2 (a) at recruitment: severe p-EEG depression with superimposed muscular activity; (b) at 24 h during TH: mild to normal pEEG.

Figure 3

Brain MRI scans of case 2. (a) At 5 days of life, DWI showed a normal apparent diffusion coefficient of the brain. (b,c) At 40 days of life, T1- and T2-weighted axial spin echo sequence shows normal signal intensity of the brain.

Figure 4

Brain MRI scans of case 4. (a–c) At 5 days of life, T1-weighted axial spin echo sequence (b) showed small foci of increased signal intensity in the fronto-parietal-occipital white matter (arrows), with a reduced apparent diffusion coefficient on DWI (arrows, a). Gradient echo sequence (c) shows a prominent aspect of the profound medullary veins. (d) At 64 days of life, T2-weighted and SWI sequences show reduced extension and appearance of the focal white matter lesions, with a slight increase in the ventricular system.

Figure 4

Brain MRI scans of case 4. (a–c) At 5 days of life, T1-weighted axial spin echo sequence (b) showed small foci of increased signal intensity in the fronto-parietal-occipital white matter (arrows), with a reduced apparent diffusion coefficient on DWI (arrows, a). Gradient echo sequence (c) shows a prominent aspect of the profound medullary veins. (d) At 64 days of life, T2-weighted and SWI sequences show reduced extension and appearance of the focal white matter lesions, with a slight increase in the ventricular system.

Figure 5

Brain MRI scans of case 1. (a) At 5 days of life, DWI showed a symmetric reduction in the apparent diffusion coefficient of thalami and putamen. (b) At 21 days of life, T1-weighted axial spin echo sequence showed severe bilateral abnormally increased signal intensities in the ventro-lateral thalamic nuclei (red arrows) and posterior aspect of the putamen (white arrow), with loss of normal signal intensity in the posterior limb of the internal capsule (arrowheads). (c) FLAIR sequence at 30 months showed atrophic and gliotic evolution of thalami and lenticular nuclei, and quantitative reduction in the posterior periventricular white matter.