Advertisement

Sarnat Grading Scale for Neonatal Encephalopathy after 45 Years: An Update Proposal

  • Harvey B. Sarnat
    Correspondence
    Communications should be addressed to: Dr. Sarnat; Owerko Centre; University Drive NW; 3rd Floor - CDC# 395, AB T2N 1N4; 2500, Calgary, Canada.
    Affiliations
    Section of Neurology, Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada

    Section of Neuropathology, Department of Pathology, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada

    Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada
    Search for articles by this author
  • Laura Flores-Sarnat
    Affiliations
    Section of Neurology, Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada

    Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada
    Search for articles by this author
  • Carlos Fajardo
    Affiliations
    Section of Neonatology, Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada
    Search for articles by this author
  • Lara M. Leijser
    Affiliations
    Section of Neonatology, Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada
    Search for articles by this author
  • Courtney Wusthoff
    Affiliations
    Department of Pediatrics and Neurology, Stanford University, Stanford, California
    Search for articles by this author
  • Khorshid Mohammad
    Affiliations
    Section of Neonatology, Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children’s Hospital Research Institute (Owerko Centre), Calgary, Alberta, Canada
    Search for articles by this author
      In 1976, one of us (H.B.S.) published a pilot study of 21 term neonates with documented hypoxic-ischemic encephalopathy (HIE) by introducing a grading scale for scoring severity of encephalopathy on the basis of objective clinical criteria.
      • Sarnat H.B.
      • Sarnat M.S.
      Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study.
      The title of the article did not include the terms HIE or birth asphyxia because the scale was thought to be applicable in a broader context to multiple other neonatal encephalopathies of metabolic or infectious origin in term neonates, although all cases presented had HIE. The grading scale was, and continues to be, intended for nonprogressive encephalopathies in which an adverse event, whether lasting minutes at birth or weeks prenatally, is now complete. The scale thus excludes ongoing progressive metabolic encephalopathies and continuing postnatal hypoxia due to pulmonary, cardiac, or hematological disorders. It also was not the intent in 1976 or now to restrict encephalopathy to intrapartum events, but rather that the Sarnat grading scale can be applicable to infants with chronic prenatal ischemia even resulting in intrauterine growth restriction. Specific antepartum risk factors may increase susceptibility to acute intrapartum brain injury. In the 1976 article,
      • Sarnat H.B.
      • Sarnat M.S.
      Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study.
      the first paragraph under the heading, “Comment” was,None of the clinical or electroencephalographic characteristics here described are specific for postanoxic encephalopathy, but rather are manifestations of a state of functional impairment of the brain, especially the cerebral cortex, and also occur in other perinatal encephalopathies.”

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Pediatric Neurology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sarnat H.B.
        • Sarnat M.S.
        Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study.
        Arch Neurol. 1976; 33: 696-705
        • Thompson C.M.
        • Puterman A.S.
        • Linley L.L.
        • Hann F.M.
        • Van der Elst C.W.
        • Molteno C.D.
        The value of a scoring system for hypoxic-ischaemic encephalopathy in predicting neurodevelopmental outcome.
        Acta Paediatr. 1997; 86: 757-761
        • Amiel-Tison C.
        Update of the Amiel-Tison neurological assessment for the term neonate or at 40 weeks corrected age.
        Pediatr Neurol. 2002; 27: 196-212
        • Mia A.H.
        • Akter K.R.
        • Rouf M.A.
        • et al.
        Grading of perinatal asphyxia by clinical parameters and agreement between this grading and Sarnat & Sarnat stages without measures.
        Mymensingh Med J. 2013; 22: 807-813
        • O’Connor C.M.
        • Ryan C.A.
        • Boylan G.B.
        • Murray D.M.
        The ability of early serial developmental assessment to predict outcome at 5 years following neonatal hypoxic-ischaemic encephalopathy.
        Early Hum Dev. 2017; 110: 1-8
        • Ambalavanan N.
        • Carlo W.A.
        • Shankaran S.
        • et al.
        • National Institute of Child Health and Human Development Neonatal Research Network
        Predicting outcomes of neonates diagnosed with hypoxemic-ischemic encephalopathy.
        Pediatrics. 2006; 118: 2084-2093
        • Kota S.
        • Massaro A.N.
        • Chang T.
        • et al.
        Prognostic value of continuous electroencephalogram delta power in neonates with hypoxic-ischemic encephalopathy.
        J Child Neurol. 2020; 35: 517-525
        • Mercuri E.
        • Guzzetta A.
        • Haataja L.
        • et al.
        Neonatal neurological examination in infants with hypoxic ischaemic encephalopathy: correlation with MRI findings.
        Neuropediatrics. 1999; 30: 83-89
        • Shankaran S.
        • Laptook A.R.
        • Ehrenkranz R.A.
        • et al.
        • National Institute of Child Health and Human Development Neonatal Research Network
        Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy.
        N Engl J Med. 2005; 353: 1574-1584
        • Finder M.
        • Boylan G.B.
        • Twomey D.
        • Ahearne C.
        • Murray D.M.
        • Hallberg B.
        Two-year neurodevelopmental outcomes after mild hypoxic-ischemic encephalopathy in the era of therapeutic hypothermia.
        JAMA Pediatr. 2020; 174: 48-55
        • The American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy and Cerebral Palsy and the American Academy of Pediatrics
        Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology.
        American College of Obstetricians and Gynecologists, Washington, DC2003: 1-85
        • The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics
        Neonatal Encephalopathy and Neurologic Outcome.
        2nd ed. American Academy of Pediatrics, Itasca, IL2014
      1. Executive summary: neonatal encephalopathy and neurologic outcome, 2nd edition. Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy.
        Obstet Gynecol. 2014; 123: 896-901
        • Sarnat H.B.
        Clinical neuropathology practice guide 5-2013: markers of neuronal maturation.
        Clin Neuropathol. 2013; 32: 340-369
        • Sarnat H.B.
        Immunocytochemical markers of neuronal maturation in human diagnostic neuropathology.
        Cell Tissue Res. 2015; 359: 279-294
        • Ouwehand S.
        • Smidt L.C.A.
        • Dudink J.
        • et al.
        Predictors of outcomes in hypoxic-ischemic encephalopathy following hypothermia: a meta-analysis.
        Neonatology. 2020; ([Epub ahead of print]): 1-17https://doi.org/10.1159/000505519
        • Shankaran S.
        • Laptook A.R.
        • Pappas A.
        • et al.
        Effects of depth and duration of cooling on death or disability at age 18 months among neonates with hypoxic-ischemic encephalopathy: a randomized clinical trial.
        JAMA. 2017; 318: 57-67
        • Pavageau L.
        • Sanchez P.J.
        • Brown L.S.
        • Chalak L.F.
        Inter-rater reliability of the modified Sarnat examination in preterm infants of 32 to 36 weeks’ gestation.
        Pediatr Res. 2020; 87: 697-702
        • Sarnat H.B.
        Editorial commentary: inter-observer concordance in applying the Sarnat Grading Scale of neonatal encephalopathy to mildly preterm infants.
        Pediatr Res. 2020; 87: 622-623
        • Harteman J.C.
        • Nikkels P.G.
        • Benders M.J.
        • Kwee A.
        • Groenendaal F.
        • de Vries L.S.
        Placental pathology in full-term infants with hypoxic-ischemic neonatal encephalopathy and association with magnetic resonanace imaging pattern of brain injury.
        J Pediatr. 2013; 163: 968-995
        • Sarnat H.B.
        • Flores-Sarnat L.
        • Boltshauser E.
        Area postrema: fetal maturation; tumours; vomiting centre; growth; role in neuromyelitis optica.
        Pediatr Neurol. 2019; 94: 21-31
        • Sarnat H.B.
        Olfactory reflexes in the newborn infant.
        J Pediatr. 1978; 92: 624-626
        • Sarnat H.B.
        • Flores-Sarnat L.
        Olfactory development. Part 1. Functional, from fetal perception to adult wine-tasting.
        J Child Neurol. 2017; 32: 566-578
        • Mennella J.A.
        • Johnson A.
        • Beauchamp G.K.
        Garlic ingestion by pregnant women alters the odor of amniotic fluid.
        Chem Senses. 1995; 20: 207-209
        • Schaal B.
        • Marlier L.
        • Soussignan R.
        Olfactory function in the human fetus: evidence from selective neonatal responsiveness to the odor of amniotic fluid.
        Behav Neurosci. 1998; 112: 1438-1449
        • Merrick C.
        • Godwin C.A.
        • Geisler M.W.
        • Morsella E.
        The olfactory system as the gateway to the neural correlates of consciousness.
        Front Psychol. 2014; 4: 1011
        • Arzi A.
        • Rozenkrantz L.
        • Gorodisky L.
        • et al.
        Olfactory sniffing signals consciousness in unresponsive patients with brain injuries.
        Nature. 2020; 581: 428-433
        • Sarnat H.B.
        • Flores-Sarnat L.
        Survey on olfactory testing by paediatric neurologists. Is the olfactory a ‘true’ cranial nerve?.
        J Child Neurol. 2020; 35: 317-321
        • Lawrence D.G.
        • Kuypers H.G.
        The functional organization of the motor system in the monkey. I. The effects of bilateral pyramidal lesions; II. The effects of lesions of the descending brain-stem pathways.
        Brain. 1968; 91: 15-36
        • Sarnat H.B.
        Functions of the corticospinal and corticobulbar tracts in the human newborn.
        J Pediatr Neurol. 2003; 1: 3-8
        • Peiper A.
        Cerebral Function in Infancy and Childhood.
        Consultants Bureau, New York1963: 250-253 (English translation from original German publication by VEB Georg Thieme, Leipzig, 1961)
        • Sarnat H.B.
        • Auer R.N.
        • Flores-Sarnat L.
        Synaptogenesis in the fetal corpus striatum, globus pallidus and substantia nigra. Correlations with striosomes of Graybiel and dyskinesias in premature infants.
        J Child Neurol. 2013; 28: 60-69
        • He X.
        • Chaitanya G.
        • Asma B.
        • et al.
        Disrupted basal ganglia-thalamocortical loops in focal to bilateral tonic-clonic seizures.
        Brain. 2020; 143: 175-190
        • Sarnat H.B.
        • Flores-Sarnat L.
        • Trevenen C.L.
        Synaptophysin immunoreactivity in the human hippocampus and neocortex from 6 to 41 weeks of gestation.
        J Neuropathol Exp Neurol. 2010; 69: 234-245
        • Sie L.T.
        • van der Knapp M.S.
        • Oosting S.
        • de Vries L.
        • Lafeben H.N.
        • Valk J.
        MR patterns of hypoxic-ischemic brain damage after prenatal, perinatal or postnatal asphyxia.
        Neuropediatrics. 2000; 31: 128-131
        • Lally P.J.
        • Montaldo P.
        • Oliveira V.
        • et al.
        Magnetic resonance spectroscopy assessment of brain injury after moderate hypothermia in neonatal encephalopathy: a prospective multicentre cohort study.
        Lancet Neurol. 2019; 18: 35-45
        • Chalak L.F.
        • Adams-Huet B.
        • Sant’Anna G.
        A total Sarnat score in mild hypoxic-ischemic encephalopathy can detect infants at higher risk of disability.
        J Pediatr. 2019; 214: 217-221