From the Guidelines
Hypoxic-ischemic encephalopathy (HIE) in adults should be managed with a focus on targeted temperature management, maintaining adequate cerebral perfusion, and supportive care to minimize secondary brain injury, as these interventions have been shown to improve outcomes in terms of morbidity, mortality, and quality of life. The management of HIE involves identifying and treating the underlying cause while providing supportive care. Although the provided evidence [ 1 ] primarily focuses on the management of spontaneous intracerebral hemorrhage, it emphasizes the importance of acute stroke unit care in reducing death and dependency [ 1 ].
Key Management Strategies
- Maintaining adequate cerebral perfusion is crucial, with goals of keeping systolic blood pressure above 90 mmHg and mean arterial pressure above 65 mmHg, avoiding hypotension [ 1 ].
- Oxygen saturation should be maintained between 94-98%, avoiding both hypoxemia and hyperoxemia.
- Blood glucose should be kept between 140-180 mg/dL, as both hyperglycemia and hypoglycemia worsen outcomes.
- Seizures should be treated promptly with antiepileptics.
- Prognosis assessment should be delayed until at least 72 hours after the event and should incorporate multiple factors including clinical examination, neurophysiological testing, and neuroimaging.
Considerations for Care
- The use of rFVIIa is not recommended for adults with acute spontaneous intracerebral hemorrhage not associated with antithrombotic drug use outside randomized controlled trials (RCTs) [ 1 ].
- There is insufficient evidence to support surgical intervention on a routine basis to improve outcome after supratentorial intracerebral hemorrhage [ 1 ].
- Intermittent pneumatic compression is recommended to improve outcome and reduce the risk of deep vein thrombosis (DVT) in immobile patients [ 1 ]. In summary, the management of hypoxic-ischemic encephalopathy in adults requires a multifaceted approach focusing on supportive care, prevention of secondary brain injury, and treatment of underlying causes, with the goal of improving morbidity, mortality, and quality of life.
From the Research
Definition and Pathophysiology of Hypoxic-Ischemic Encephalopathy
- Hypoxic-ischemic encephalopathy (HIE) is a brain lesion caused by inadequate blood supply and oxygen deprivation, often occurring in neonates and adults 2.
- The precise pathophysiological mechanisms underlying HIE are not entirely understood, but contributions of hypoxia-ischemia, reperfusion injury, inflammation, oxidative stress, mitochondrial dysfunction, excitotoxicity, ferroptosis, endoplasmic reticulum stress, and apoptosis have been identified 3.
Current Treatment Options
- Therapeutic hypothermia has emerged as the standard of care treatment to improve morbidity and mortality in infants with HIE 4, 5.
- Hypothermia therapy stands as the sole standard treatment for neonatal HIE, albeit providing only partial neuroprotection 3.
- Drug therapy and stem cell therapy have been explored in the treatment of HIE, exhibiting certain neuroprotective effects 3.
Future Research Directions
- Optimization of respiratory management as an approach to prevent further damage and improve neurodevelopmental outcome in HIE patients 4.
- Employing drug therapy or stem cell therapy as adjunctive treatments to hypothermia therapy holds great significance 3.
- Further research is needed to better understand the long-term impact of experimental treatments and whether combinations of experimental treatments can improve outcomes in infants with HIE 6.
Epidemiology and Outcomes
- HIE occurs in 1 to 8 per 1000 live births in developed countries 5.
- Historically, the clinician has had little to offer neonates with HIE other than systemic supportive care, with 40-60% of affected infants dying by 2 years of age or having severe disabilities 6.
- The emergence of serum-based biomarkers, placental pathology, and magnetic resonance imaging as useful tools to predict long-term outcomes has been highlighted 5.