Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents

Ariel Cascio; Amaryllis Ferrand; Eric Racine; Marie St-Hilaire; Priscille-Nice Sanon; Andreea Gorgos; Pia Wintermark

doi:10.1016/j.ensci.2022.100424

Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents

eNeurologicalSci. 2022 Sep 11:29:100424. doi: 10.1016/j.ensci.2022.100424. eCollection 2022 Dec.

Authors

Ariel Cascio¹, Amaryllis Ferrand^{2

3

4}, Eric Racine^{2

5

6}, Marie St-Hilaire⁷, Priscille-Nice Sanon⁷, Andreea Gorgos⁸, Pia Wintermark^{7

8}

Affiliations

¹ College of Medicine, Central Michigan University, Mount Pleasant, USA.
² Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada.
³ Division of Newborn Medicine, Department of Pediatrics, Jewish General Hospital, McGill University, Montreal, Canada.
⁴ Faculty of Medicine, Department of Biomedical Sciences, University of Montreal, Montreal, Canada.
⁵ Departments of Medicine and Social and Preventive Medicine, University of Montreal, Montreal, Canada.
⁶ Departments of Neurology and Neurosurgery, Medicine, and Biomedical Ethics Unit, McGill University. Montreal, Canada.
⁷ Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada.
⁸ Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada.

Abstract

Context: Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH).

Purpose: To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents.

Procedures: Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively.

Results: Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were "usually" (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only "sometimes" accurate and only used them "sometimes" (33%) to discuss prognosis; a majority of them (66%) would "always" repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents.

Conclusions: Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.

Keywords: Birth asphyxia; Brain; Clinician; HIE, hypoxic-ischemic encephalopathy; Hypothermia; MRI, magnetic resonance imaging; Magnetic resonance imaging; NICU, neonatal intensive care unit; Neonatal encephalopathy; Neonate; Parents; TH, therapeutic hypothermia.