Continuation or Withdrawal of Life-sustaining Therapies After Acute Anoxic Events in Childhood and Adolescence : Can Early MRI Predict Particularly Severe Outcomes?

Abstract

Purpose: Withholding or withdrawing life-sustaining therapies is often discussed when children or adolescents suffer severe anoxic events. Previous studies have demonstrated that early MRI can identify patients with major neurological sequelae, but not whether, within a cohort with major neurological sequelae, early MRI can predict particularly severe outcomes. This was the purpose of the present study.

Methods: We retrospectively assessed MRI (analyzing 14 brain regions for signal abnormalities on diffusion, T1, T2 and FLAIR) of 38 patients who had suffered acute anoxic events between 8 months and 17 years of age and had required inpatient neurorehabilitation, looking for differences between patients with "particularly severe outcomes" (the 22/38 patients who were still unable to interact with their environment 22 weeks after the event) and patients with "less severe outcomes" (the 16/38 patients who had regained this ability within 22 weeks).

Results: Prediction of "particularly severe outcome" was optimal using diffusion MRI obtained on days 4-5 after the event (available in 11 patients, 7 with particularly severe outcomes), when all patients with diffusion restrictions in any of the following regions-putamen (4/7), caudate nucleus (4/7), globus pallidus (6/7), or substantia nigra (4/7)-later showed particularly severe outcomes. In contrast, identification of "less severe outcome" was optimal using MRI obtained between days 6-9 after the event, when absence of diffusion restrictions in the cerebral white matter always predicted "less severe outcome".

Conclusion: Early MRI can identify patients with particularly severe outcomes-and thus can contribute to discussions about the continuation or withdrawal of life-sustaining therapies in the acute phase after anoxic events.