Early Identification of Cerebral Palsy Using Neonatal MRI and General Movements Assessment in a Cohort of High-Risk Term Neonates

Cerebral oxygenation during immediate fetal-to-neonatal transition and fidgety movements between six to 20 weeks of corrected age: An ancillary study to the COSGOD III trial

Fidgety movements provide early information about a potential development of cerebral palsy in preterm neonates. The aim was to assess differences in the combined outcome of mortality and fidgety movements defined as normal or pathological in very preterm neonates according to the group allocation in the randomised-controlled multicentre COSGOD III trial. Preterm neonates of two centres participating in the COSGOD III trial, whose fidgety movements were assessed as normal or pathological at six to 20 weeks of corrected age, were analysed. In the COSGOD III trial cerebral oxygen saturation (crSO2) was measured by near-infrared spectroscopy (NIRS) during postnatal transition and guided resuscitation in preterm neonates randomised to the NIRS-group, whereby medical support was according routine, as it was also in the control group. Fidgety movements were classified in normal or abnormal/absent at six to 20 weeks of corrected age. Mortality and fidgety movements of preterm neonates allocated to the NIRS-group were compared to the control-group. Normal outcome was defined as survival with normal fidgety movements. One-hundred-seventy-one preterm neonates were included (NIRS-group n = 82; control-group n = 89) with a median gestational age of 29.4 (27.4-30.4) and 28.7 (26.7-31.0) weeks in the NIRS-group and the control-group, respectively. There were no differences in the combined outcome between the two groups: 90.2% of the neonates in the NIRS-group and 89.9% in the control-group survived with normal outcome (relative risk [95% CI]; 0.96 [0.31-2.62]).Conclusions: In the present cohort of preterm neonates, monitoring of crSO2 and dedicated interventions in addition to routine care during transition period after birth did not show an impact on mortality and fidgety movements defined as normal or pathological at six to 20 weeks corrected age. What is Known • Fidgety movements display early spontaneous motoric pattern and may provide early information about a potential development of cerebral palsy in preterm neonates.  What is New  • This retrospective observational study of the randomised-controlled multicentre COSGOD III trial is the first study investigating the potential influence of cerebral oxygenation guided resuscitation during postnatal transition period on combined outcome of mortality and fidgety movements up to 20 weeks of corrected age in very preterm neonates. • This study adds to the growing interest of assessing cerebral oxygenation, that monitoring of cerebral oxygen saturation and dedicated interventions during postnatal transition period according to the COSGOD III trial has no significant influence on mortality and fidgety movements defined as normal or pathological in very preterm neonates.

Infant sleep spindle measures from EEG improve prediction of cerebral palsy

OBJECTIVE

Early identification of infants at risk of cerebral palsy (CP) enables interventions to optimize outcomes. Central sleep spindles reflect thalamocortical sensorimotor circuit function. We hypothesized that abnormal infant central spindle activity would predict later contralateral CP.

METHODS

We trained and validated an automated detector to measure spindle rate, duration, and percentage from central electroencephalogram (EEG) channels in high-risk infants (n = 35) and age-matched controls (n = 42). Neonatal magnetic resonance imaging (MRI) findings, infant motor exam, and CP outcomes were obtained from chart review. Using univariable and multivariable logistic regression models, we examined whether spindle activity, MRI abnormalities, and/or motor exam predicted future contralateral CP.

RESULTS

The detector had excellent performance (F1 = 0.50). Spindle rate (p = 0.005, p = 0.0004), duration (p < 0.001, p < 0.001), and percentage (p < 0.001, p < 0.001) were decreased in hemispheres corresponding to future CP compared to those without. In this cohort, PLIC abnormality (p = 0.004) and any MRI abnormality (p = 0.004) also predicted subsequent CP. After controlling for MRI findings, spindle features remained significant predictors and improved model fit (p < 0.001, all tests). Using both spindle duration and MRI findings had highest accuracy to classify hemispheres corresponding to future CP (F1 = 0.98, AUC 0.999).

CONCLUSION

Decreased central spindle activity improves the prediction of future CP in high-risk infants beyond early MRI or clinical exam alone.

SIGNIFICANCE

Decreased central spindle activity provides an early biomarker for CP.

Clinical outcome prediction with an automated EEG trend, Brain State of the Newborn, after perinatal asphyxia

OBJECTIVE

To evaluate the utility of a fully automated deep learning -based quantitative measure of EEG background, Brain State of the Newborn (BSN), for early prediction of clinical outcome at four years of age.

METHODS

The EEG monitoring data from eighty consecutive newborns was analyzed using the automatically computed BSN trend. BSN levels during the first days of life (a of total 5427 hours) were compared to four clinical outcome categories: favorable, cerebral palsy (CP), CP with epilepsy, and death. The time dependent changes in BSN-based prediction for different outcomes were assessed by positive/negative predictive value (PPV/NPV) and by estimating the area under the receiver operating characteristic curve (AUC).

RESULTS

The BSN values were closely aligned with four visually determined EEG categories (p < 0·001), as well as with respect to clinical milestones of EEG recovery in perinatal Hypoxic Ischemic Encephalopathy (HIE; p < 0·003). Favorable outcome was related to a rapid recovery of the BSN trend, while worse outcomes related to a slow BSN recovery. Outcome predictions with BSN were accurate from 6 to 48 hours of age: For the favorable outcome, the AUC ranged from 95 to 99% (peak at 12 hours), and for the poor outcome the AUC ranged from 96 to 99% (peak at 12 hours). The optimal BSN levels for each PPV/NPV estimate changed substantially during the first 48 hours, ranging from 20 to 80.

CONCLUSIONS

We show that the BSN provides an automated, objective, and continuous measure of brain activity in newborns.

SIGNIFICANCE

The BSN trend discloses the dynamic nature that exists in both cerebral recovery and outcome prediction, supports individualized patient care, rapid stratification and early prognosis.

Intelligence Sparse Sensor Network for Automatic Early Evaluation of General Movements in Infants

General movements (GMs) have been widely used for the early clinical evaluation of infant brain development, allowing immediate evaluation of potential development disorders and timely rehabilitation. The infants' general movements can be captured digitally, but the lack of quantitative assessment and well-trained clinical pediatricians presents an obstacle for many years to achieve wider deployment, especially in low-resource settings. There is a high potential to explore wearable sensors for movement analysis due to outstanding privacy, low cost, and easy-to-use features. This work presents a sparse sensor network with soft wireless IMU devices (SWDs) for automatic early evaluation of general movements in infants. The sparse network consisting of only five sensor nodes (SWDs) with robust mechanical properties and excellent biocompatibility continuously and stably captures full-body motion data. The proof-of-the-concept clinical testing with 23 infants showcases outstanding performance in recognizing neonatal activities, confirming the reliability of the system. Taken together with a tiny machine learning algorithm, the system can automatically identify risky infants based on the GMs, with an accuracy of up to 100% (99.9%). The wearable sparse sensor network with an artificial intelligence-based algorithm facilitates intelligent evaluation of infant brain development and early diagnosis of development disorders.

Predictive Value of Fidgety Movement Assessment and Magnetic Resonance Imaging for Cerebral Palsy in Infants

BACKGROUND

The early prediction of cerebral palsy (CP) could enable the follow-up of high-risk infants during the neuroplasticity period. This study aimed to explore the predictive value of fidgety movement assessment (FMA) and brain magnetic resonance imaging (MRI) for the development of CP in clinic rehabilitation setting.

METHODS

This retrospective observational study included infants who underwent FMA and brain MRI at age nine to 20 weeks at Children's Hospital, Zhejiang University School of Medicine, between March 2018 and September 2019. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy of FMA and MRI for predicting the development of CP were assessed.

RESULTS

A total of 258 infants (169 males, gestational age 37.4 ± 3.0 weeks, birth weight 2987.9 ± 757.1 g) were included. Fifteen children had CP after age two years. The diagnostic value of FMA and brain MRI combination showed 86.7% sensitivity (95% confidence interval [CI]: 58.4% to 97.7%), 98.4% specificity (95% CI: 95.6% to 99.5%), and 97.7% accuracy (95% CI: 95.0% to 99.1%); the combination diagnostic value also showed a significantly higher AUC for predicting CP after age two years than FMA alone (AUC: 0.981 vs 0.893, P = 0.013).

CONCLUSIONS

The diagnostic value of FMA and brain MRI combination during infancy showed a high predictive value for CP development in clinical rehabilitation setting.

Identifying Effective Treatments for Dystonia in Patients With Cerebral Palsy: A Precision Therapeutics Approach

Recent focus on improving the recognition of dystonia in cerebral palsy (DCP) has highlighted the need for more effective treatments. Evidence supports improved functional outcomes with early interventions for patients with cerebral palsy, but it is not known which interventions are most effective for DCP. Current pharmacologic recommendations for DCP are based largely on anecdotal evidence, with medications demonstrating minimal to moderate improvements in dystonia and variable efficacy between patients. Patients, families, and clinicians have identified the need for new and improved treatments in DCP, naming this as the top research theme in a recent Neurology® publication. Precision therapeutics focuses on providing early effective interventions that are individualized to every patient and can guide research priorities to improve treatments for DCP. This commentary outlines current obstacles to improving treatment of DCP and addresses how precision therapeutics can address each of these obstacles through 4 key components: (1) identification of predictive biomarkers to select patients likely to develop DCP in the future and for whom early intervention may be appropriate to delay or prevent full manifestation of dystonia, (2) stratification of patients with DCP into subgroups according to shared features (clinical, functional, biochemical, etc) to provide a targeted intervention based on those shared features, (3) administration of an individualized dose of an effective intervention to ensure adequate concentrations of the therapeutic entity at the site of action, and (4) monitoring of objective biomarkers of response to intervention. With implementation of each of these components of precision therapeutics, new and more effective treatments for every person with DCP can be realized.

Detecting Asymmetry of Upper Limb Activity with Accelerometry in Infants at Risk for Unilateral Spastic Cerebral Palsy

AIMS

To examine whether accelerometry can quantitate asymmetry of upper limb activity in infants aged 3-12 months at risk for developing unilateral spastic cerebral palsy (USCP).

METHOD

A prospective study was performed in 50 infants with unilateral perinatal brain injury at high risk of developing USCP. Triaxial accelerometers were worn on the ipsilateral and contralesional upper limb during the Hand Assessment for Infants (HAI). Infants were grouped in three age intervals (3-5 months, 5-7.5 months and 7.5 until 12 months). Each age interval group was divided in a group with and without asymmetrical hand function based on HAI cutoff values suggestive of USCP.

RESULTS

In a total of 82 assessments, the asymmetry index for mean upper limb activity was higher in infants with asymmetrical hand function compared to infants with symmetrical hand function in all three age groups (ranging from 41 to 51% versus - 2-6%, p < 0.01), while the total activity of both upper limbs did not differ.

CONCLUSIONS

Upper limb accelerometry can identify asymmetrical hand function in the upper limbs in infants with unilateral perinatal brain injury from 3 months onwards and is complementary to the Hand Assessment for Infants.

Hypoxic-Ischemic Encephalopathy: Changing Outcomes Across the Spectrum

Neonatal hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and neurodevelopmental impairment in neonates. Therapeutic hypothermia (TH) is the only established effective therapy and randomized trials affirm that TH reduces death and disability in moderate-to-severe HIE. Traditionally, infants with mild HIE were excluded from these trials due to the perceived low risk for impairment. Recently, multiple studies suggest that infants with untreated mild HIE may be at significant risk of abnormal neurodevelopmental outcomes. This review will focus on the changing landscape of TH, the spectrum of HIE presentations and their neurodevelopmental outcomes.

Development of a Bedside Tool to Predict the Diagnosis of Cerebral Palsy in Term-Born Neonates

Importance

Cerebral palsy (CP) is the most common abnormality of motor development and causes lifelong impairment. Early diagnosis and therapy can improve outcomes, but early identification of infants at risk remains challenging.

Objective

To develop a CP prognostic tool that can be applied to all term neonates to identify those at increased risk of developing CP.

Design, Setting, and Participants

This case-control study used data from the Canadian Cerebral Palsy Registry (data collected from January 2003 to December 2019) for children with CP and the Alberta Pregnancy Outcomes and Nutrition study (mothers enrolled from May 2009 to September 2012; data extracted in 2020) for controls. There were 2771 children with CP and 2131 controls evaluated; 941 and 144, respectively, were removed for gestational age less than 37 weeks at birth, 565 with CP removed for incomplete data, and 2 controls removed for a diagnosis of CP. Data were analyzed from April to August 2022.

Exposures

Potential risk factors were selected a priori based on the literature, including maternal, intrapartum, and infant characteristics.

Main Outcomes and Measures

Diagnosis of CP, defined as a disorder of motor function due to a nonprogressive brain abnormality before age 1 year and classified by Gross Motor Function Classification System levels I to V.

Results

Of 3250 included individuals, 1752 (53.9%) were male, and the median (IQR) gestational age at birth was 39 (38-40) weeks. Encephalopathy was present in 335 of 1184 infants with CP (28%) and 0 controls. The final prediction model included 12 variables and correctly classified 75% of infants, with a sensitivity of 56% (95% CI, 52-60) and specificity of 82% (95% CI, 81-84). The C statistic was 0.74 (95% CI, 71-76). Risk factors were found to be additive. A proposed threshold for screening is probability greater than 0.3, with a sensitivity of 65% (95% CI, 61-68) and specificity of 71% (95% CI, 69-73). The prognostic tool identified 2.4-fold more children with CP than would have presented with encephalopathy (odds ratio, 13.8; 95% CI, 8.87-22.65; P < .001).

Conclusions and Relevance

In this case-control study, a prognostic model using 12 clinical variables improved the prediction of CP compared with clinical presentation with encephalopathy. This tool can be applied to all term newborns to help select infants for closer surveillance or further diagnostic tests, which could improve outcomes through early intervention.

Therapeutic hypothermia is associated with changes in prognostic value of general movements

BACKGROUND AND AIMS

General movements (GMs) have been recognized as the most accurate clinical tools for predicting cerebral palsy (CP). This study aimed to compare the type and prognostic value of abnormal GMs in infants with hypoxic ischemic encephalopathy treated or not with therapeutic hypothermia (TH).

MATERIALS AND METHODS

This was a single-center retrospective study. We compared GMs of 55 cooled term infants versus 30 non-cooled term infants with hypoxic ischemic encephalopathy (HIE) and their motor outcome at 24 months of age. We also included data regarding early brain MRI scans.

RESULTS

Rates of cerebral palsy was 5.4% and 46.7% in cooled and non-cooled infants respectively (p < 0.001). None of cooled infants showed cramped-synchronized GMs, whereas among non-cooled infants the cramped-synchronized pattern was present in 17.2% and 20% of infants at 1 and 3 months of age respectively. Hypokinesis was never seen in cooled infants and it was present in 23.3% of non-cooled ones. Absent fidgety correlated with CP in 14% and 73% of cooled and non-cooled infants respectively. At brain MRI cooled infants had fewer and less severe cerebral lesions compared to non-cooled infants (p = 0.003).

CONCLUSIONS

Abnormal GMs are reduced in infants treated with TH. Hypokinesis and cramped-synchronized GMs are not observed in cooled infants and the associations between absent fidgety movements and CP it is largely abolished. TH is associated with changes in prognostic value of GMs.

Effects of Early Motor Interventions on Gross Motor and Locomotor Development for Infants at-Risk of Motor Delay: A Systematic Review

Aim

To systematically examine the effect of early motor interventions on motor and locomotor development in infants <1 year of age with motor developmental disability or at risk of motor delay.

Methods

Pertinent literature from January 2000 to September 2021 was identified by searching the PubMed, Embase, Cochrane, Pedro and Web of Science databases. Selection criteria included interventions starting before 12 months corrected age. Methodological quality was assessed with AACPDM criteria, Mallen score and Cochrane risk of bias methodology. Evaluation procedure was performed using PRISMA protocol (PICO approach) and AMSTAR-2. This review was preregistered in PROSPERO (CRD42021286445).

Results

Ten articles met the inclusion criteria; seven had moderate to strong methodological quality. The interventions included treadmill training (n = 3), crawling training (n = 1), "tummy time" (n = 1), physical therapy with neonatal developmental program (n = 1) or Bobath approach (n = 1), treadmill training combined with active leg movements (n = 2) or Bobath physiotherapy (n = 1). The three key characteristics of effective interventions that emerged from the review were: (1) the infants' disability or risk of delay was well-defined; (2) the protocol was standardized and easy to replicate; (3) infants were required to make active movements.

Conclusion

There is an urgent need for additional high-quality studies on the effects of early motor interventions on the gross motor and locomotor development of infants with a range of disabilities or risks for delay. Suggestions for future research are outlined.

Effects of gestational age at birth on perinatal structural brain development in healthy term-born babies

Infants born in early term (37-38 weeks gestation) experience slower neurodevelopment than those born at full term (40-41 weeks gestation). While this could be due to higher perinatal morbidity, gestational age at birth may also have a direct effect on the brain. Here we characterise brain volume and white matter correlates of gestational age at birth in healthy term-born neonates and their relationship to later neurodevelopmental outcome using T2 and diffusion weighted MRI acquired in the neonatal period from a cohort (n = 454) of healthy babies born at term age (>37 weeks gestation) and scanned between 1 and 41 days after birth. Images were analysed using tensor-based morphometry and tract-based spatial statistics. Neurodevelopment was assessed at age 18 months using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Infants born earlier had higher relative ventricular volume and lower relative brain volume in the deep grey matter, cerebellum and brainstem. Earlier birth was also associated with lower fractional anisotropy, higher mean, axial, and radial diffusivity in major white matter tracts. Gestational age at birth was positively associated with all Bayley-III subscales at age 18 months. Regression models predicting outcome from gestational age at birth were significantly improved after adding neuroimaging features associated with gestational age at birth. This work adds to the body of evidence of the impact of early term birth and highlights the importance of considering the effect of gestational age at birth in future neuroimaging studies including term-born babies.

The use of neuroimaging, Prechtl's general movement assessment and the Hammersmith infant neurological examination in determining the prognosis in 2-year-old infants with hypoxic ischemic encephalopathy who were treated with hypothermia

BACKGROUND

The use of neuroimaging, the General Movement Assessment (GMA), and the Hammersmith Infant Neurological Examination (HINE) to identify the risk of neurodevelopmental delay in early infancy is recommended.

AIM

The aim of this study was to examine the predictive power of neuroimaging, GMA and HINE for neurodevelopmental delay and cerebral palsy (CP) in infants with hypoxic ischemic encephalopathy (HIE) who were treated with hypothermia.

STUDY DESIGN

Retrospective cohort.

SUBJECTS AND OUTCOME MEASURES

This retrospective study included 47 (18 female and 29 male) infants who were treated with hypothermia due to HIE. Neonates with a diagnosis of HIE were followed and assessed using neuroimaging, GMA, HINE and the Bayley Scales of Infant and Toddler Development-II (Bayley II) between 3 m and 2 years of age.

RESULTS

Out of the 47 infants with HIE, no fidgety movements were observed in 5 infants. The sensitivity and specificity in determining the psychomotor developmental index (PDI) score were 97% and 100%, respectively, for MRI; 92.9% and 100% for GMA; and 91.9% and 80% for the HINE. The sensitivity and specificity in determining the mental developmental index (MDI) score were 95% and 85.7%, respectively, for MRI; 90.5% and 80% for GMA; and 91.9% and 50% for HINE. The sensitivity and specificity in determining CP diagnosis at the age of 2 years were 83.3% and 95%, respectively, for MRI; 83.3% and 100% for GMA; and 83.3% and 87.8% for HINE.

CONCLUSION

The interpretation of MRI, GMA, and HINE that are performed within the early period of life may be the gold standard for the early detection of neurodevelopmental risks in 2-year-old infants with HIE. Clinical implementation of these methods in the early period in the follow-up of these infants offers useful information for the early identification of neurodevelopmental risk and for planning early intervention.

An Emerging Role for Epigenetics in Cerebral Palsy

Cerebral palsy is a set of common, severe, motor disabilities categorized by a static, nondegenerative encephalopathy arising in the developing brain and associated with deficits in movement, posture, and activity. Spastic CP, which is the most common type, involves high muscle tone and is associated with altered muscle function including poor muscle growth and contracture, increased extracellular matrix deposition, microanatomic disruption, musculoskeletal deformities, weakness, and difficult movement control. These muscle-related manifestations of CP are major causes of progressive debilitation and frequently require intensive surgical and therapeutic intervention to control. Current clinical approaches involve sophisticated consideration of biomechanics, radiologic assessments, and movement analyses, but outcomes remain difficult to predict. There is a need for more precise and personalized approaches involving omics technologies, data science, and advanced analytics. An improved understanding of muscle involvement in spastic CP is needed. Unfortunately, the fundamental mechanisms and molecular pathways contributing to altered muscle function in spastic CP are only partially understood. In this review, we outline evidence supporting the emerging hypothesis that epigenetic phenomena play significant roles in musculoskeletal manifestations of CP.

Neurological and developmental outcomes following neonatal encephalopathy treated with therapeutic hypothermia

In randomized trials, therapeutic hypothermia (TH) is associated with reduced prevalence of the composite outcome mortality or neurodevelopmental morbidity in infants with neonatal encephalopathy (NE). Following systematic review, the reduction in prevalence of both mortality and infant neuromorbidity is clear. Among three trials reporting school age outcomes, the effects of NE and TH suggest that such benefit persists into middle childhood, but none of the major trials were powered to detect differences in these outcomes. Cognitive, educational and behavioural outcomes are all adversely affected by NE in children without moderate or severe neuromorbidity. High-quality longitudinal studies of neurocognitive and educational outcomes following NE in the era of TH, including studies incorporating multimodal neuroimaging assessments, are required to characterise deficits more precisely so that robust interventional targets may be developed, and resource planning can occur. Understanding the impact of NE on families and important educational, social, and behavioural outcomes in childhood is critical to attempts to optimise outcomes through interventions.

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

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 .