Table 3.

Recommendations for neuroimaging in term neonates with neonatal encephalopathy (NE).

	Neuroimaging of the Neonate (2002 – retired on February 27, 2018)	*Neonatal Encephalopathy and Neurologic Outcome 2nd edition (2014, reaffirmed in 2019)	Imaging the term neonatal brain (2018)	Neuroimaging in the term newborn with neonatal encephalopathy (2021)
Organization	Practice Parameter of the American Academy of Neurology (AAN) and Child Neurology Society (CNS)	American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP)	Position Statement of the Canadian Pediatric Society (CPS)	Newborn Brain Society (NBS) Guidelines and Publications Committee
Objective				- To identify patterns consistent with hypoxic-ischemic brain injury - To inform management decisions - To prognosticate long-term outcome - To rule out other etiologies than hypoxic-ischemic brain injury
Cranial ultrasound (cUS)	- No specific recommendation	- Cranial ultrasonography on admission and in the first 2–3 days of life to exclude major cerebral dysgenesis	- May be useful as first-line imaging if trained technologists and radiologists available - Not recommended as sole imaging modality	- May be useful as a first-line imaging modality, if qualified personnel available for interpretation, to rule-out major intracranial hemorrhage and to assess for lesions of antenatal onset or abnormalities suggestive of NE mimics - Timing: during the first day of life as a screening tool - Should be complemented with MRI
CT scan	- Non-contrast CT should be performed as a first-line if NE in context of significant birth trauma and low hematocrit or abnormal coagulopathy - MRI should be performed if CT findings cannot explain the clinical status	No specific recommendation, but the document acknowledges CT as a rapidly acquired neuroimaging technique that is sensitive to hemorrhage, but not to brain injury in the first 24–48 h	- May be useful in urgent situations when MRI is not available - At 72 ± 12 h	- May be considered only in urgent situations (e.g., concern for significant intracranial hemorrhage or herniation) - Only when MRI or US are not available
MR imaging	- For all other neonates with NE between days 2–8 of life - Include single-voxel MRS and DWI to be added if available - CT should be performed if MRI is not available or if neonate is too unstable for MRI	- Should be acquired in all term neonates with moderate to severe NE - MRI, MRS and DWI between 24 and 96 h provide the most useful guide on the potential timing of cerebral insult - MRI undertaken optimally at 10 days of life (acceptable 7–21 days) will best delineate the full extent of cerebral injury	- Preferred imaging technique - Between days 3–5 of life if no hypothermia - If hypothermia, after rewarming has taken place - Consistent timing to facilitate recognition of injury - A repeat MRI on days 10–14 of life if discordance between imaging and clinical features	- Preferred imaging technique - Sequences: at least T1- and T2-weighted sequences, DWI with ADC maps, and MRS - Timing: (A) early MRI (days 2–5 of life) recommended for diagnosis and prognosis; typically immediately after TH since the most practical in routine clinical practice; may consider during TH to inform the direction (or possible redirection) of care, even though the full extent of brain injury may not yet be visible (B) consider repeating MRI at 10–14 days of life when discrepancy between early imaging and clinical condition of the neonate, or if ambiguity persist
Additional recommendations			- When a qualified radiologist is not on site, images should be sent electronically elsewhere for interpretation	- If trained and experienced neuroradiologist not on site, send electronically images for interpretation to a center with such clinician on site

Abbreviations: AAN, Academy of Neurology; ACOG, American College of Obstetricians and Gynecologists; ADC, apparent diffusion coefficient; CNS, Child Neurology Society; CPS, Canadian Pediatric Society; CT, computed tomography; cUS, cranial ultrasound; DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging; MRS, magnetic resonance spectroscopy; NBS, Newborn Brain Society; NE, neonatal encephalopathy.