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PURPOSE: We developed a scoring system for the assessment of perinatal asphyxia as depicted on MR images. METHODS: Four scoring systems were derived to evaluate MR images obtained in asphyxiated neonates: the basal ganglia (BG) score, the watershed (W) score, the combined basal ganglia/watershed (BG/W) score, and the sum of the BG and W scores, the summation (S) score. In addition, three MR sequences, T1-weighted, first-echo T2-weighted, and second-echo T2-weighted, were assessed for each patient for each scoring system. Neuromotor examinations were performed at ages 3 and 12 months, and cognitive development was tested at age 12 months. Statistical analysis was then performed to test the relationship between the MR scores and the outcome scores. RESULTS: The BG/W score, obtained with the first-echo T2-weighted sequence, was the most useful overall score for predicting neuromotor outcome at 3 and 12 months and cognitive outcome at 12 months. T1-weighted and first-echo T2-weighted sequences showed a stronger association with outcome in patients imaged during the first postnatal week, whereas second-echo T2-weighted sequences showed a stronger association with outcome in patients imaged during the second postnatal week. CONCLUSION: It appears that, with the use of the BG/W score, MR imaging discriminates accurately between patients with good and poor neuromotor and cognitive outcome at 3 and 12 months. In terms of our scoring systems, the first-echo T2-weighted sequence appears to discriminate best between patients with good and poor 3- and 12-month outcomes. Proper use of the imaging sequences and scoring systems described in this article can increase the knowledge base upon which treatment decisions are made in asphyxiated neonates.