JOURNAL CLUB · ARTICLE OF THE WEEK
Early cranial ultrasound vs MRI in HIE, stratified by severity
Cizmeci MN, Wilson D, Singhal M, et al. J Pediatr. 2024;266:113866. doi:10.1016/j.jpeds.2023.113866. A single-centre retrospective cohort study.
MRI INJURY IN
SEVERE HIE
cUS injury tracks HIE severity
Abnormal white matter and deep grey matter echogenicity in the first 48h were far commoner in severe than mild HIE (WM 81% vs 39%; DGM 50% vs 0%; P<0.001).
A normal early cUS is reassuring
95% of babies with a normal cUS had a normal or only mildly abnormal MRI. No baby with mild HIE had a severely abnormal cUS.
A severely abnormal cUS is ominous
Of babies with a severely abnormal cUS, none had a normal MRI and 83% had a severely abnormal MRI. No baby with severe HIE had a normal cUS.
MRI still drives prognosis
On multivariable analysis, a severely abnormal MRI was the only independent predictor of an adverse outcome (OR 19.9, 95% CI 4.0-98.1).
The verdict
Early cUS is a useful complementary first look that agrees with MRI at the extremes, but MRI remains the gold standard for confirming the pattern and prognosticating.
WHY THIS MATTERS
- HIE is recognised and cooling is started at or near the special care nursery, often before MRI is available
- MRI is the gold standard but needs a stable baby, transfer, and the right timing (first postnatal week)
- Cranial ultrasound can be done at the cot, early, and repeatedly
- Families often want some sense of severity before the MRI is done
- Knowing what an early cUS can and cannot tell you helps frame those conversations
STRENGTHS
- A relatively large HIE cohort (149), including mild HIE
- Strict, standardised cUS and MRI protocols with consistent timing
- Objective, validated injury scores on both modalities
- Linked imaging to a meaningful 18-month composite outcome
- Spans the full HIE severity spectrum, not just severe cases
LIMITATIONS
- Single-centre and retrospective, which limits generalisability
- Only 24% had a cUS within 24h (elective daytime scanning), so early antenatal injury and DWI pseudo-normalisation may be missed
- cUS was done once and not repeated before MRI, so evolution was not captured; no Doppler
- An 18-month follow-up may miss later cognitive or behavioural problems
- Potential confounders (social factors, parental education) were not collected
Practice implications
For a special care nursery that recognises HIE and starts cooling before retrieval, the message is practical: an early cranial ultrasound is a reasonable first look while you arrange transfer and MRI. A normal early cUS is somewhat reassuring (most such babies have a normal or mildly abnormal MRI), and a severely abnormal cUS in a baby with severe HIE points strongly to significant injury. But the scan does not replace MRI. MRI in the first week remains the gold standard for confirming the pattern and severity of injury and for prognosis - a severely abnormal MRI was the only independent predictor of adverse outcome here. Use early cUS to look for haemorrhage or a mimic and to inform early conversations, keep cooling and the ABCs solid, and let MRI drive definitive prognostication and goals-of-care discussions.
When would an early cranial ultrasound actually change what you do for a baby with HIE?
How would you frame a normal early cUS to parents while the MRI is still pending?
Why does MRI remain the gold standard for prognosis even though cUS agrees at the extremes?
Does your unit have a standard time point for the first cUS and the MRI in HIE?
J Pediatr 2024HIE
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Take-home message: In cooled babies with HIE, an early cranial ultrasound (first 48h) agrees with the post-rewarming MRI at the extremes: a normal cUS usually means a normal or mildly abnormal MRI, and a severely abnormal cUS in severe HIE usually means severe injury. It is a useful first look at the cot, but MRI remains the gold standard - a severely abnormal MRI was the only independent predictor of adverse outcome at 18 months. Use early cUS to inform, not replace, the MRI.
For educational purposes only. Journal club appraisal - figures paraphrased from the published trial; read the full article for complete data. Always align practice to your local guidelines.