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Steven G. Pavlakis, MD; Peter B. Kingsley, PhD; Rita Harper, MD; Sharon Buckwald, MD; Regina Spinazzola, MD; Yitzchak Frank, MD; Isak Prohovnik, PhD

Arch Neurol. 1999;56:1476-1481.

Background  Brain metabolite levels are measured by proton magnetic resonance spectroscopy (¹H MRS) and include N-acetylaspartate (NAA), creatine (Cr), choline (Cho), and lactate and the ratios NAA to Cho and Cr (NAA-ChoCr), NAA-Cr, NAA-Cho, and Cho-Cr. Brain metabolite levels may correlate with the degree of neonatal asphyxia.

Objective  To determine which brain metabolite ratios have the strongest correlation with the Apgar scores in infants with possible asphyxia; whether the correlation is stronger with basal ganglia (BG) or anterior border-zone metabolites; and whether a combined approach using routine MR imaging (MRI), diffusion-weighted MRI, and MRS can be used to evaluate the severity of neonatal asphyxia.

Methods  Twenty infants with 1-minute Apgar scores of 6 or less were studied at 2 to 28 days of age. The MRS variables were compared with routine and diffusion-weighted brain MRI. Clinical variables and MRS findings were subjected to factor analysis and stepwise multiple regressions to determine interrelationships.

Results  The BG region NAA-Cho and NAA-ChoCr ratios correlated with the 1-minute (P<.001) and 5-minute (P = .01 for NAA-Cho; P = .006 for NAA-ChoCr). There was no correlation between metabolite levels and the 10-minute Apgar scores. The stongest predictions exist between the 1-minute Apgar scores and the NAA-Cho and NAA-ChoCr ratios. In the anterior border zone, the only correlation was between the 1-minute Apgar score and the NAA-Cho ratio, but there was a strong age effect in these data. Lactate was found in the BG of 3 infants, all of whom had 5-minute Apgar scores of 6 or less. Three patients had focal lesions on MRI; 2 of these had elevated lactate levels in the abnormal region; and the third, who had an intrauterine stroke, had no lactate in the region.

Conclusions  Correlations between NAA-Cho and NAA-ChoCr ratios and the 1- and 5-minute Apgar scores are stronger in the BG region than in the frontal border zone. The presence or absence of lactate may indicate the severity of the brain insult, and the combination of MRS, MRI, and diffusion-weighted MRI may assist in localizing and predicting a long-term brain injury.

From the Departments of Pediatrics (Drs Pavlakis, Harper, Buckwald, Spinazzola, and Frank), Radiology (Dr Kingsley), and Neurology (Drs Pavlakis and Frank), North Shore University Hospital, Manhasset, NY; and the Departments of Pediatrics (Drs Pavlakis, Harper, Buckwald, Spinazzola, and Frank), Radiology (Dr Kingsley), and Neurology (Drs Pavlakis and Frank), New York University Medical College (Dr Prohovnik) and the Departments of Radiology and Psychiatry, Mt Sinai Medical Center (Dr Prohovnik), New York, NY.

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