Researchers at Hammersmith Hospital, London, UK, studied the accuracy of early brain MRI for predicting death, the presence and severity of motor impairment, and ability to walk at 2 years in 175 term infants treated for hypoxic-ischemic encephalopathy (HIE) in the period 1993 to 2007. The severity of basal ganglia-thalamic (BGT) lesions identified within 6 postnatal weeks (median 10 days; range 2-42 days) was strongly associated with the severity of motor impairment staged using the Gross Motor Function Classification System (Palisano RJ et al, 2000). Abnormal signal intensity at the posterior limb of the internal capsule predicted the inability to walk independently by 2 years. Brainstem injury was the only factor with an independent association with death. An early MRI is predictive of outcome of term newborns with HIE and BGT injury. Of 126 surviving infants, 89 (71%) had cerebral palsy, and only 9 with CP were able to walk at 2 years. Severe BGT lesions predict severe motor impairment with a sensitivity of 0.96 and specificity of 0.77. 
COMMENT. Guillet R and Dees R, in their editorial , acknowledge the value of the information provided by this study but list a number of limitations: the study was retrospective; timing of MRI and follow-up assessments were not standardized; only those infants with lesions of the basal ganglia and thalamus were included; neonates who underwent therapeutic hypothermia were excluded; and only 33% of infants were scanned between 2 and 7 days, the optimum time for parents and caregivers to make decisions to limit treatment. In the Hammersmith hospital, the decision to withdraw intensive care was based on the history, clinical state, cranial ultrasound findings, EEG data, as well as lesions seen on the MRI scan. Brainstem injury had a similar predictive value for death in infants who died early, after withdrawal of intensive care, or later.