Hypoxic Ischemic Encephalopathy MRI

A 7 y o male with delayed mile stone. Birth history significant father mentions delayed cry. NICU admission after birth for 1month.
CT study of Brain

...... Honestly I may pass it off normal if in hurry.

Somehow i was not very convinced with the normal CT looking at patient and requested relatives to get his MRI done.

And that's his MRI...

MRI Axial FLAIR images show bilateral symmetrical T2 hyperintensity involving thalami and Perirolandic cortex consistent with Perinatal Hypoxic Ischemic Brain Insult. 

Take home notes...
It may not be possible every time but as far as possible, keep habit of seeing patient clinically and give a second look to the study. 
My Boss has taught this to me and he always insist me to do so. 
It really works !!!

Hypoxic Ischemic Encephalopathy

HIE, formerly peri natal or birth asphyxia – a cerebral hypoperfusion injury.

Imaging wise best diagnostic clue is Gliosis involving peri rolandic cortex or para sagittal border zones, bilateral and often symmetric involvement. Basal ganglia damaged if ischemic event is profound and acute. Associated findings may be microcephaly, secondary craniosynostosis, cerebral cortical and mid brain atrophy.

Patient with this finding often are term neonates with significant birth history like fetal distress prior to delivery, low Apgar score, required resuscitation at birth, metabolic acidosis (cord pH less than 7), Neurological abnormalities in first 24 hours. Maternal infection, pre-eclampsia and diabetes.

Seek inborn errors of metabolism if apparent HIE with normal Apgar OR if more than 1 HIE child in a family. Other causes can be Inherited prothrombotic disorders leading to arterial or venous occlusions are Protein CIS deficiencies, factor V Leiden mutation, antiphospholipid antibodies.

Epidemiology up to 2/1,000 (0.2%) live births.

Clinical presentation

Mild : Hyperalert/irritable, mydriasis, EEG normal

Moderate: Lethargy, hypotonia, ~ HR, Seizures.

Severe: Stupor, flaccid, reflexes absent; Seizures.

Periventricular leukomalacia (PVL) patient show Lower extremity spasticity.

Unilateral/focal lesions present with Hemiplegia / Hemiparesis.

Parasagittal cystic encephalomalacia show Spastic tetra paresis whereas Bilateral BG damage show Extrapyramidal cerebral palsy.

Reference : Diagnostic imaging Osborn