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Fortin O, Husein N, Oskoui M, Shevell MI, Kirton A, Dunbar M. Risk Factors and Outcomes for Cerebral Palsy With Hypoxic-Ischemic Brain Injury Patterns Without Documented Neonatal Encephalopathy. Neurology 2024; 102:e208111. [PMID: 38422458 DOI: 10.1212/wnl.0000000000208111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/16/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Perinatal hypoxic-ischemic brain injury is a leading cause of term-born cerebral palsy, the most common lifelong physical disability. Diagnosis is commonly made in the neonatal period by the combination of neonatal encephalopathy (NE) and typical neuroimaging findings. However, children without a history of neonatal encephalopathy may present later in childhood with motor disability and neuroimaging findings consistent with perinatal hypoxic-ischemic injury. We sought to determine the prevalence of such presentations using the retrospective viewpoint of a large multiregional cerebral palsy registry. METHODS Patient cases were extracted from the Canadian Cerebral Palsy Registry with gestational age >36 weeks, an MRI pattern consistent with hypoxic-ischemic injury (HII, acute total, partial prolonged, or combined), and an absence of postnatal cause for HII. Documentation of NE was noted. Maternal-fetal risk factors, labor and delivery, neonatal course, and clinical outcome were extracted. Comparisons were performed using χ2 tests and multivariable logistic regression with multiple imputation. Propensity scores were used to assess for bias. RESULTS Of the 170 children with MRI findings typical for HII, 140 (82.4%, 95% confidence interval [CI] 75.7%-87.7%) had documented NE and 29 (17.0%, 95% CI 11.7%-23.6%) did not. The group without NE had more abnormalities of amniotic fluid volume (odds ratio [OR] 15.8, 95% CI 1.2-835), had fetal growth restriction (OR 4.7, 95% CI 1.0-19.9), had less resuscitation (OR 0.03, 95% CI 0.007-0.08), had higher 5-minute Apgar scores (OR 2.2, 95% CI 1.6-3.0), were less likely to have neonatal seizures (OR 0.004, 95% CI 0.00009-0.03), and did not receive therapeutic hypothermia. MRI was performed at a median 1.1 months (interquartile range [IQR] 0.67-12.8 months) for those with NE and 12.2 months (IQR 6.6-25.9) for those without (p = 0.011). Patterns of injury on MRI were seen in similar proportions. Hemiplegia was more common in those without documented NE (OR 5.1, 95% CI 1.5-16.1); rates of preserved ambulatory function were similar. DISCUSSION Approximately one-sixth of term-born children with an eventual diagnosis of cerebral palsy and MRI findings consistent with perinatal hypoxic-ischemic brain injury do not have documented neonatal encephalopathy, which was associated with abnormalities of fetal growth and amniotic fluid volume, and a less complex neonatal course. Long-term outcomes seem comparable with their peers with encephalopathy. The absence of documented neonatal encephalopathy does not exclude perinatal hypoxic-ischemic injury, which may have occurred antenatally and must be carefully evaluated with MRI.
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Affiliation(s)
- Olivier Fortin
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Nafisa Husein
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Maryam Oskoui
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Michael I Shevell
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Adam Kirton
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Mary Dunbar
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
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Seesahai J, Luther M, Church PT, Maddalena P, Asztalos E, Rotter T, Banihani R. The assessment of general movements in term and late-preterm infants diagnosed with neonatal encephalopathy, as a predictive tool of cerebral palsy by 2 years of age-a scoping review. Syst Rev 2021; 10:226. [PMID: 34384482 PMCID: PMC8359053 DOI: 10.1186/s13643-021-01765-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 07/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The General Movements Assessment is a non-invasive and cost-effective tool with demonstrated reliability for identifying infants at risk for cerebral palsy. Early detection of cerebral palsy allows for the implementation of early intervention and is associated with better functional outcomes. No review to date has summarized the utility of the General Movements Assessment to predict cerebral palsy in term and late-preterm infants diagnosed with neonatal encephalopathy. METHODS We conducted a scoping review involving infants born greater than or equal to 34 weeks gestational age to identify all available evidence and delineate research gaps. We extracted data on sensitivity, specificity, and positive and negative predictive values and described the strengths and limitations of the results. We searched five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL) and the General Movements Trust website. Two reviewers conducted all screening and data extraction independently. The articles were categorized according to key findings, and a critical appraisal was performed. RESULTS Only three studies, a cohort and two case series, met all of the inclusion criteria. The total number of participants was 118. None of the final eligible studies included late-preterm neonates. All three studies reported on sensitivity, specificity, and positive predictive and negative predictive values. An abnormal General Movement Assessment at 3-5 months has a high specificity (84.6-98%) for cerebral palsy with a similarly high negative predictive value (84.6-98%) when it was normal. Absent fidgety movements, in particular, are highly specific (96%) for moderate to severe cerebral palsy and carry a high negative predictive value (98%) when normal. In the time period between term and 4-5 months post-term, any cramped synchronized movements had results of 100% sensitivity and variable results for specificity, positive predictive value, and negative predictive value. CONCLUSIONS A normal General Movements Assessment at 3 months in a term high-risk infant is likely associated with a low risk for moderate/severe cerebral palsy. The finding of cramped synchronized General Movements is a strong predictor for the diagnosis of cerebral palsy by 2 years of age in the term population with neonatal encephalopathy. The deficit of high-quality research limits the applicability, and so the General Movements Assessment should not be used in isolation when assessing this population. SYSTEMATIC REVIEW REGISTRATION Title registration with Joanna Briggs Institute. URL: http://joannabriggswebdev.org/research/registered_titles.aspx .
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Affiliation(s)
- Judy Seesahai
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Maureen Luther
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Paige Terrien Church
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Toronto, Toronto, Canada
| | - Patricia Maddalena
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Asztalos
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Toronto, Toronto, Canada
| | | | - Rudaina Banihani
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Toronto, Toronto, Canada.
- Newborn & Developmental Paediatrics, Sunnybrook Health Science Centre, 2075, Bayview Ave., Toronto, ON, M4N 3M5, Canada.
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Abstract
The definition of FIRS requires systemic inflammation and elevated levels of IL-6 in fetal plasma. That definition does not specify how systemic inflammation is to be recognized, and perinatal measurement of IL-6 is not a standard procedure. FIRS has not been examined in a population-based study that included post-neonatal outcome so its incidence and natural history are not known. The overlap, and similarities and differences, of FIRS as compared with other causes of neonatal encephalopathy, and how these relate to findings in the placenta, have not been jointly examined in a generalizable sample. FIRS has chiefly been discussed in the obstetric literature because of the need for decisions about management of delivery and antibiotic use. If the term "FIRS" is to be employed in other contexts, consensus should be sought as to which clinical, placental, and laboratory findings are most appropriate for identification of perinatal inflammatory processes, infectious or sterile.
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Affiliation(s)
- Karin B Nelson
- Scientist emerita, NINDS, NIH. Retired, Children's Hospital Medical Center, Depart. Neurology, DC. Address: 5524 Charles St, Bethesda, MD, 20814, USA.
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Frank AO, De Souza LH. Problematic clinical features of children and adults with cerebral palsy who use electric powered indoor/outdoor wheelchairs: A cross-sectional study. Assist Technol 2016; 29:68-75. [DOI: 10.1080/10400435.2016.1201873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andrew O. Frank
- Stanmore Specialist Wheelchair Service, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK (since disbanded)
- Department of Clinical Sciences, College of Health and Life Sciences, Brunel University London, Uxbridge, Middlesex, UK
| | - Lorraine H. De Souza
- Department of Clinical Sciences, College of Health and Life Sciences, Brunel University London, Uxbridge, Middlesex, UK
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Garfinkle J, Wintermark P, Shevell MI, Oskoui M. Cerebral palsy after neonatal encephalopathy: do neonates with suspected asphyxia have worse outcomes? Dev Med Child Neurol 2016; 58:189-94. [PMID: 26555029 DOI: 10.1111/dmcn.12953] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 11/26/2022]
Abstract
AIM We sought to investigate how brain injury and severity, and neurological subtype of cerebral palsy (CP) differed in term-born children with CP after neonatal encephalopathy, between those with suspected birth asphyxia and those without. METHOD Using the Canadian CP Registry, which included 1001 children, those with CP born at ≥ 36 wks after moderate or severe neonatal encephalopathy, were dichotomized according to the presence or absence of suspected birth asphyxia. Gross Motor Function Classification System (GMFCS) scores, neurological subtypes, comorbidities, and magnetic resonance imaging findings were compared. RESULTS Of the 147 term-born children with CP (82 males, 65 females; median age 37 months, interquartile range [IQR] 26-52.5) who after moderate or severe neonatal encephalopathy had the required outcome data, 61 (41%) met criteria for suspected birth asphyxia. They had a higher frequency of non-ambulatory GMFCS status (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.72-6.8), spastic quadriplegia (OR 2.8, 95% CI 1.4-5.6), non-verbal communication skills impairment (OR 4.2, 95% CI 2.0-8.6), isolated deep grey matter injury (OR 4.1, 95% CI 1.8-9.5), a lower frequency of spastic hemiplegia (OR 0.17, 95% CI 0.07-0.42), focal injury (OR 0.20; 95% CI 0.04-0.93), and more comorbidities (p=0.017) than those who did not meet criteria. INTERPRETATION Term-born children who develop CP after neonatal encephalopathy with suspected birth asphyxia have a greater burden of disability than those without suspected birth asphyxia.
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Affiliation(s)
- Jarred Garfinkle
- Department of Pediatrics, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada
| | - Pia Wintermark
- Department of Pediatrics, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada.,Division of Neonatology, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada
| | - Michael I Shevell
- Department of Pediatrics, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada.,Department of Neurology/Neurosurgery, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada.,Division of Pediatric Neurology, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada
| | - Maryam Oskoui
- Department of Pediatrics, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada.,Department of Neurology/Neurosurgery, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada.,Division of Pediatric Neurology, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada
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Jary S, Smit E, Liu X, Cowan FM, Thoresen M. Less severe cerebral palsy outcomes in infants treated with therapeutic hypothermia. Acta Paediatr 2015; 104:1241-7. [PMID: 26237284 DOI: 10.1111/apa.13146] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/15/2015] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
Abstract
AIM To describe the incidence, type and severity of cerebral palsy at 24 months in a regional cohort of infants treated with whole-body therapeutic hypothermia for neonatal encephalopathy. METHODS Data were collected prospectively in a regional centre providing TH. Antenatal and perinatal clinical variables and severity of encephalopathy were collected. Infants were assessed at 18 months using the Bayley Scales of Infant and Toddler Development-III, and the presence and severity of CP was investigated at 24 months. RESULTS A total of 125 of 132 infants fulfilled entry criteria for TH trials and completed 72 h of TH. Sixteen (13%) of the 125 infants died, and eight (6%) were not available for follow-up. Eighteen infants (14%; 18% of those assessed) developed CP. Of these, 12 (67%) were classified using the Gross Motor Function Classification System, at level 1, six (33%) at level 5 and none at levels 2, 3 or 4. CONCLUSION Our regional clinical cohort had lower mortality and comparable rates of CP compared with historical outcomes in TH trials. In contrast to historical cohorts, only one-third of the 18 children with CP were severely affected and 12 were mildly affected, all of whom were independently ambulant by 24 months.
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Affiliation(s)
- Sally Jary
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Level D, St Michaels Hospital; Bristol UK
| | - Elisa Smit
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Level D, St Michaels Hospital; Bristol UK
| | - Xun Liu
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Level D, St Michaels Hospital; Bristol UK
| | - Frances M. Cowan
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Level D, St Michaels Hospital; Bristol UK
- Department of Paediatrics and Neonatal Medicine; Imperial College; Hammersmith Hospital; London UK
| | - Marianne Thoresen
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Level D, St Michaels Hospital; Bristol UK
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
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Hurley DS, Sukal-Moulton T, Gaebler-Spira D, Krosschell KJ, Pavone L, Mutlu A, Dewald JPA, Msall ME. Systematic Review of Cerebral Palsy Registries/Surveillance Groups: Relationships between Registry Characteristics and Knowledge Dissemination. INTERNATIONAL JOURNAL OF PHYSICAL MEDICINE & REHABILITATION 2015; 3:266. [PMID: 27790626 PMCID: PMC5079705 DOI: 10.4172/2329-9096.1000266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The aims of this study were to provide a comprehensive summary of the body of research disseminated by Cerebral Palsy (CP) registries and surveillance programs from January 2009 through May 2014 in order to describe the influence their results have on our overall understanding of CP. Secondly, registries/surveillance programs and the work they produced were evaluated and grouped using standardized definitions and classification systems. METHOD A systematic review search in PubMed, CINAH and Embase for original articles published from 1 January 2009 to 20 May 2014 originating from or supported by population based CP registries and surveillance programs or population based national registries including CP were included. Articles were grouped by 2009 World CP Registry Congress aim, registry/surveillance program classification, geographical region, and the International Classification of Function, Disability and Health (ICF) domain. Registry variables were assessed using the ICF-CY classification. RESULTS Literature searches returned 177 articles meeting inclusion criteria. The majority (69%) of registry/surveillance program productivity was related to contributions as a Resource for CP Research. Prevention (23%) and Surveillance (22%) articles were other areas of achievement, but fewer articles were published in the areas of Planning (17%) and Raising the Profile of CP (2%). There was a range of registry/surveillance program classifications contributing to this productivity, and representation from multiple areas of the globe, although most of the articles originated in Europe, Australia, and Canada. The domains of the ICF that were primarily covered included body structures and function at the early stages of life. Encouragingly, a variety of CP registry/surveillance program initiatives included additional ICF domains of participation and environmental and personal factors. INTERPRETATION CP registries and surveillance programs, including novel non-traditional ones, have significantly contributed to the understanding of how CP affects individuals, families and society. Moving forward, the global CP registry/surveillance program community should continue to strive for uniformity in CP definitions, variables collected and consistency with international initiatives like the ICF so that databases can be consolidated for research use. Adaptation to new technologies can improve access, reduce cost and facilitate information transfer between registrants, researchers and registries/surveillance programs. Finally, increased efforts in documenting variables of individuals with CP into adulthood should be made in order to expand our understanding of CP across the lifespan.
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Affiliation(s)
- Donna S Hurley
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Theresa Sukal-Moulton
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Kristin J Krosschell
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | | | - Akmer Mutlu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Julius PA Dewald
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Michael E Msall
- University of Chicago Comer Children’s Hospital and Kennedy Research Center on Intellectual and Neurodevelopmental Disabilities, Chicago, IL, USA
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Shevell M, Dagenais L, Oskoui M. The epidemiology of cerebral palsy: new perspectives from a Canadian registry. Semin Pediatr Neurol 2013; 20:60-4. [PMID: 23948680 DOI: 10.1016/j.spen.2013.06.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michael Shevell
- Department of Neurology/Neurosurgery, McGill University, Montreal, Quebec, Canada.
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