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Hypothermie pour la neuroprotection cérébrale de l’encéphalopathie anoxo-ischémique: certitudes et incertitudes

Hypothermia for the cerebral neuroprotection of hypoxic-ischemic encephalopathy: certainties and uncertainties

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Revue de médecine périnatale

Résumé

L’hypothermie (HT) est une des premières stratégies neuroprotectrices ayant démontré son efficacité en recherche expérimentale et clinique. Elle est maintenant recommandée par les guidelines internationaux pour la prise en charge des encéphalopathies anoxo-ischémiques (EAI) du nouveau-né à terme. L’HT agirait à différents niveaux de la cascade excitotoxique afin de limiter la mort neuronale secondaire. Elle doit être mise en oeuvre dans les six heures après la naissance, après avoir démontré l’existence d’une asphyxie pernatale et argumenté une certaine gravité pour l’EAI. L’efficacité sur la réduction du taux combiné de décès ou séquelles graves à 18 mois est prouvée par plusieurs essais randomisés. Par contre, le bénéfice à plus long terme durant la petite enfance reste mal connu, incitant à suivre les enfants traités par HT au-delà de l’âge de deux ans. Une réflexion sur les extensions d’indication (prématurité tardive, enfant admis en réanimation au-delà de six heures de vie) est d’actualité et des essais cliniques sont en cours aux États-Unis sur ces sujets. Le devenir à 18 mois des EAI est certes amélioré par l’HT mais reste préoccupant pour plus de 40 % des enfants traités. D’autres stratégies neuroprotectrices comme l’érythropoïétine, la mélatonine, le xénon, le sulfate de magnésium sont en cours d’évaluation. Les résultats de ces travaux en cours mériteront une attention certaine, car ils pourraient, dans l’avenir, être proposés en complément de l’HT.

Abstract

Cerebral hypothermia is one of the first neuroprotective strategies that can improve outcome of experimental and human perinatal cerebral hypoxia-ischemia. Now, international guidelines for hypoxic-ischemic encephalopathy in term neonates recommend hypothermia. At several places, hypothermia could block the cascade of neurochemical events that mediate brain damage insult in term infants. Extended cooling must be initiated 6 h after injury, after obtaining accurate data about perinatal asphyxia and the severity of hypoxic-ischemic encephalopathy. At 18 months of life, hypothermia reduces the risk of death or disability in infants with moderate or severe hypoxic-ischemic encephalopathy. However, longer-term data have not been available to assess whether the benefits of hypothermia persist after 2 years of age. Extensions of indication are debated for late preterm infants or newborns admitted in intensive care unit after 6 hours of life, and clinical studies are actually performed on these subjects. However, if prognosis at 18 months is improved, more than 40% of treated newborns will have an unfavorable evolution. Other neuroprotective strategies as erythropoietin, melatonin, and xenon or magnesium sulfate are actually evaluated. Results of these last studies would be interesting in the future, because these strategies could be associated with hypothermia.

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Authors and Affiliations

  1. Clinique universitaire de réanimation pédiatrique et néonatologie, hôpital Couple-Enfant, CHU de Grenoble, CS 10217, F-38043, Grenoble cedex 09, France

    T. Debillon, M. Chevallier, A. Ego & F. Cneude

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  1. T. Debillon
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  2. M. Chevallier
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  3. A. Ego
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  4. F. Cneude
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Correspondence to T. Debillon.

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Debillon, T., Chevallier, M., Ego, A. et al. Hypothermie pour la neuroprotection cérébrale de l’encéphalopathie anoxo-ischémique: certitudes et incertitudes. Rev. med. perinat. 5, 81–86 (2013). https://doi.org/10.1007/s12611-013-0237-5

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  • DOI: https://doi.org/10.1007/s12611-013-0237-5

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