Congenital hemiplegia: morphology of cerebral lesions and pathogenetic aspects from MRI

Gabapentin as Add-on Therapy to Trihexyphenidyl in Children with Dyskinetic Cerebral Palsy: A Randomized, Controlled Trial

OBJECTIVE

To compare the efficacy of gabapentin as add-on therapy to trihexyphenidyl in the treatment of children with dyskinetic cerebral palsy (CP).

METHODS

An open-labelled, randomized, controlled trial was conducted among children aged 3-9 y with dyskinetic CP [Gross Motor Functional Classification System (GMFCS) 4-5]. Participants were assigned into two groups: gabapentin with trihexyphenidyl (n = 30) and trihexyphenidyl alone (n = 30). Dyskinesia Impairment Scale (DIS), Dystonia Severity Assessment Plan (DSAP), and International Classification of Functioning, Disability, and Health-Children and Youth Version (ICF-CY) were measured at baseline, 4 and 12 wk.

RESULTS

There was significant reduction in baseline dystonia in both the groups (DIS: p < 0.001; DSAP: p = 0.007; ICF-CY: p < 0.001) but when data were compared between the groups, there was no significant difference in the severity of dystonia at 4 wk and at 12 wk (DIS: p = 0.09; DSAP: p = 0.49; ICF-CY: p = 0.25). Constipation was the commonest side effect observed in both the groups [3 (11.5%) vs. 4 (14.3%)].

CONCLUSION

Trihexyphenidyl alone is as effective as combination of gabapentin with trihexyphenidyl in decreasing the severity of dystonia at 12 wk. Hence, there is no added benefit of gabapentin as add-on therapy for dystonia among children with dyskinetic CP.

TRIAL REGISTRATION

CTRI/2019/04/018603.

Motor learning in unilateral cerebral palsy and the influence of corticospinal tract reorganization

Cerebral Palsy (CP) is a complex neurological disorder, characterized by congenital motor disability associated with behaviour, perception and cognition disorders. The sensorimotor impairments represent the main hallmark of the disease, significantly impacting the quality of life. So far, few studies have investigated motor learning abilities in CP and their association with the plastic reorganization of the motor system remains largely unknown. The present proof-of-principle study explored explicit motor sequence learning in children with unilateral CP and different patterns of motor system reorganization (bilateral, ipsilateral, contralateral). Children with unilateral CP, and a group of age-matched typically developing (TD) children, underwent a sequential finger tapping task, performed with the affected hand by children with CP and with the non-dominant hand by TD children. The pattern of corticospinal tract projections in hemiparetic patients was assessed by single-pulse Transcranial Magnetic Stimulation (TMS). Results showed the presence of finger dexterity impairments in children with unilateral CP presenting with a bilateral or an ipsilateral control of the affected (trained) hand, as compared to TD children. Conversely, motor sequence learning was impaired in unilateral CP with ipsilateral or contralateral corticospinal reorganization, but not in the case of a bilateral control of the paretic hand. These preliminary findings, although referred to small clinical samples, suggest that unilateral control of the paretic upper-limb, from the ipsilateral or the contralateral motor cortex, may not be sufficient to develop typical motor learning with the affected hand, which seems to require a bilateral representation in the motor cortex. This evidence has potential implications for fine motor skills rehabilitation in CP.

Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.

Reduced integrity of sensorimotor projections traversing the posterior limb of the internal capsule in children with congenital hemiparesis

There is reduced integrity of corticospinal projections that traverse the posterior limb of the internal capsule (PLIC) in children with unilateral cerebral palsy (CP). It remains unclear whether there are changes in integrity of other projections traversing the PLIC. Forty children with congenital hemiparesis and 15 typically developing children underwent structural and diffusion-weighted MRI. All children with congenital hemiparesis showed lesions to the periventricular white matter. Structural images were parcellated into 34 cortical regions per hemisphere and posterior limb of the internal capsule was identified. PLIC connections to each cortical region were extracted using probabilistic tractography. Differences between hemispheres for each cortical projection (asymmetry index (AI)) and tract microstructure (fractional anisotropy (FA), mean diffusivity (MD)) were assessed. The results showed that 17 children (42.5%) with congenital hemiparesis showed bilateral lesions on structural MRI. Projections to the primary motor cortex (precentral gyrus and paracentral lobule) showed greater asymmetry in unilateral CP group compared to typically developing children and indicate reduced projections on the hemisphere contralateral to the impaired limb (i.e., contralateral hemisphere). Reduced FA and increased MD were also observed for connections with the primary motor cortex, primary sensory cortex (postcentral gyrus) and precuneus on the contralateral hemisphere in children with congenital hemiparesis. Similar changes were observed between children with unilateral and bilateral lesions on structural MRI. Notably, microstructural changes were associated with deficits in both sensory and motor function. The findings further unravel the underlying neuroanatomical correlates of sensorimotor deficits in children with congenital hemiparesis.

Schizencephaly as a cause of spastic cerebral palsy

PURPOSE

The objective was to investigate the clinical features of schizencephaly in children with spastic cerebral palsy.

MATERIAL AND METHODS

The present study included 180 children with cerebral palsy, spastic tetraplegia, diplegia, and hemiplegia. All magnetic resonance (MR) scans were obtained using a 1.5 T MR scanner with the use of a standard circularly polarized head coil.

RESULTS

Significant abnormalities relevant to cerebral palsy were evident on MRI in 95%. Periventicular leukomalacia was detected more frequently in children with spastic diplegia than in other patients. Cerebral atrophy was found more often in tetraplegic patients. Porencephalic cysts were detected more often in children with spastic hemiplegia. Congenital brain anomalies were evident in 20 (11.1%) children with spastic cerebral palsy. Twelve patients had schizencephaly with cerebral palsy. Children with spastic diplegia and tetraplegia had bilateral schizencephaly; patients with spastic hemiplegia only had unilateral schizencephaly. Most patients with schizencephaly had epilepsy.

CONCLUSIONS

Schizencephaly occurred more often in patients with spastic hemiplegia. Early detection of brain abnormalities in children with cerebral palsy may help in the prognosis and in the introduction of appropriate therapy.

Relation between neuroradiological findings and upper limb function in hemiplegic cerebral palsy

The relation between neuroradiological findings and upper limb function was examined in 53 children with hemiplegic cerebral palsy (CP). CT and MRI images of the children were classified into four groups (malformations, periventricular lesions, congenital cortical-subcortical lesions and postnatally acquired lesions). Additionally, each single affected neuroanatomical structure was noted. Clinical assessments included measures of activity (Melbourne Assessment of Unilateral Upper Limb Function and House Classification) and body functions (motor and sensory impairments). Comparative statistics and correlation analysis were used. Three children had a malformation, 28 a periventricular lesion, 14 a cortical-subcortical lesion and eight a postnatally acquired lesion. Children with periventricular lesions obtained the best motor functioning. Within this group, children with pure periventricular lesions performed significantly better compared to mixed lesions. The differences between congenital cortical-subcortical lesions and acquired lesions were not significant. Results further showed that middle cerebral artery infarctions and basal ganglia/thalamic lesions were significantly correlated to a worse performance. The type of lesion determined by the timing of the brain insult, and the location of the lesion distinguish children with hemiplegic CP regarding upper limb function. These insights are valuable for prognosis and may contribute to a better delineation of therapeutic interventions.

Early destructive lesions in the developing brain: clinical and electrographic correlates

OBJECTIVE

Early brain insults can cause cavitary lesions including porencephaly (POR) and multicystic encephalopathy (MCE). The objective of this study was to investigate clinical and electrographic correlates associated to these types of destructive brain lesions.

METHOD

Patients with POR and MCE were selected and submitted to clinical and Video-EEG monitoring. The following variables were analyzed: demographic data, type of lesion, presence of gliosis, perinatal complications, epilepsy, brain atrophy, and presence and frequency of epileptiform discharges.

RESULTS

Twenty patients were included, 65% males, 35% females, ages ranging from 1 to 40 years, 14 with MCE and 6 with POR. Eighteen patients had hemiparesis, 19 had epilepsy (current or in the past), seven of them had refractory seizures, and 16 had epileptiform discharges. All patients with MCE had gliosis while only 2 with POR had it.

CONCLUSIONS

No correlation was observed between type of lesion and clinical and electrographical outcome. However, a positive correlation was observed between frequency of discharges and presence of brain atrophy, and between MCE and gliosis.

A systematic review of neuroimaging for cerebral palsy

The American Academy of Neurology now recommends that all cases of cerebral palsy of unknown origin undergo neuroimaging. Controversy surrounds this recommendation because of concerns about the adequacy of the supporting evidence. This article reviews the evidence provided by magnetic resonance imaging (MRI) and computed tomography (CT) imaging studies in cerebral palsy and discusses the potential benefits of imaging, techniques in current use, and future directions, with a focus on improving etiologic understanding. Most (83%) children with cerebral palsy have abnormal neuroradiological findings, with white matter damage the most common abnormality. Combined gray and white matter abnormalities are more common among children with hemiplegia; isolated white matter abnormalities are more common with bilateral spasticity or athetosis, and with ataxia; isolated gray matter damage is the least common finding. About 10% of cerebral palsy is attributable to brain malformations, and 17% of cerebral palsy cases have no abnormality detectable by conventional MR or CT imaging. Although neuroimaging studies have increased our understanding of the abnormalities in brain development in cerebral palsy, they are less informative than they might be because of 4 common problems: (1) inappropriate assignment of etiology to morphologic findings, (2) inconsistent descriptions of radiologic findings, (3) uncertain relationship of pathologic findings to brain insult timing estimates, and (4) study designs that are not based on generalizable samples. Neuroimaging is not necessarily required for diagnosis of cerebral palsy because the disorder is based on clinical findings. The principal contribution of imaging is to the understanding of etiology and pathogenesis, including ruling in or out conditions that may have implications for genetic counseling, such as malformations. In the future, as more sophisticated imaging procedures are applied to cerebral palsy, specific morphologic findings may be linked to etiologic events or exposures, thus leading to potential pathways for prevention.

Clinical and neuroimaging profile of congenital brain malformations in children with spastic cerebral palsy

PURPOSE

Analysis of the incidence of congenital brain malformations in children with spastic cerebral palsy (CP) in a hospital-based study.

MATERIAL AND METHODS

The present study included 74 boys and 56 girls with spastic tetraplegia, diplegia, and hemiplegia CP. Magnetic resonance imaging MRI findings were analyzed in children with CP.

RESULTS

Significant abnormalities relevant to the CP were evident on MRI in 124 (95.3%) subjects. Periventicular leukomalacia (PVL) was detected more frequently in children with spastic diplegia than in patients with tetraplegia or hemiplegia. Cerebral atrophy was found more often in the tetraplegic group compared to the diplegic patients. Porencephalic cysts were detected more often in children with spastic hemiplegia. Congenital brain anomalies were evident in 15 (10.7%) children with spastic CP. Brain malformations included: schizencephaly (5), agenesis corpus callosum (4), polymicrogyria (2), holoprosencephaly (2) and lissencephaly (2). Intractable epilepsy and mental retardation were observed more often in children with brain anomalies. Twelve patients with congenital brain malformations were born at term and three born at preterm.

CONCLUSIONS

Neuroimaging results in children with CP may help determine the etiology and make better prognosis of CP.

[Congenital hemiplegia. A disease with manifold problems]

Congenital hemiplegia, defined as unilateral motor disability, is the hemiplegic type of cerebral palsy. The prevalence of congenital hemiplegia is estimated to be about 0.41-0.79/1000 live births. We examined 223 children (122 boys and 101 girls) suffering from congenital hemiplegia at the age of 3 months to 12 years. Mild hemiplegia was found in 31%, a moderate form in 48%, and a severe form in 21%. The upper limb was affected in more than half of the patients, only the lower extremity in one third, and both upper and lower limbs in 20%. Electroencephalographic abnormalities were found in 75.8% of the patients. The most frequent type of epilepsy was complex partial seizures (33%). Severity of the motor handicap, grade of EEG abnormalities, and the prevalence of epilepsy showed a significant correlation. The magnitude of the lesions in neuroimaging directly correlated with these three clinical variables, particularly in children with cortical and subcortical defects (84.2%). Strabismus was the most common visual impairment (17%), while hearing impairment was found in 8% of the patients. Of them, 38.3% showed no cognitive deficits, while those with severe congenital hemiplegia were found to have a lower intelligence quotient.

The role of magnetic resonance imaging in elucidating the pathogenesis of cerebral palsy: a systematic review

The aim of this study was to show the role of magnetic resonance imaging (MRI) in elucidating the aetiology, or at least pathogenesis, of cerebral palsy (CP). A systematic review of studies using MRI in children with CP was performed according to pathogenetic patterns characterizing different timing periods of occurence of the lesions, and with respect to gestational age (term vs preterm) and CP subtypes. Out of the studies published since 1990 in English, six met all the inclusion criteria; they involved children with spastic and dyskinetic CP. Abnormal MRI was reported in 334 out of 388 (86%) patients and gave clues to pathogenesis in 83%. Fourteen studies met only part of the inclusion criteria and abnormal MRIs were reported even more frequently in these (91%; 930/1022). Periventricular white matter lesions were most frequent (56%) followed by cortical and deep grey matter lesions (18%); brain maldevelopments were rather rare, described in 9%. Brain maldevelopments and grey matter lesions were more often seen in term than in preterm-born children with CP (brain maldevelopments: 16% vs 2.5%; grey matter lesions: 33% vs 3.5%); periventricular white matter lesions occurred significantly more often in preterm than in term-born children (90% vs 20%). CP is mainly characterized by brain lesions which can be identified by MRI in around 75% of preterm infants; brain maldevelopments occur in around 10%.

MRI Findings in Patients with Hemiparetic Cerebral Palsy

Given the more severe and extensive unilateral brain abnormalities in hemiparetic cerebral palsy (HCP) patients than in other spastic cerebral palsy patients we focused exclusively on the localization of brain lesions in children with HCP. The relationship between neuroradiological findings and side of hemiparesis was investigated in a group of 30 children with HCP. Seventeen boys and 13 girls aged four to 18 years (mean age 9.7±4.2 years) were included in this study. Computed tomography and magnetic resonance imaging examinations were correlated with the birth histories, obstetrical records and clinical summaries. Of the 30 patients with HCP, 2 (6.6%) had normal neuroradiological examinations, 20 (66.6%) had unilateral and eight (26.6%) bilateral brain lesions. A brain lesion on the contralateral side of hemiparesis was found in 93.3% of the neuroradiological examinations. The commonest neuroradiological findings in our study were periventricular leukomalacia (PVL, 80%), atrophy (70%) and porencephalic cyst (50%). There was a significant relationship between the symptomatic side and contralateral PVL, atrophy and porencephalic cyst (40%). PVL, atrophy and porencephalic cyst were significantly concomitant on the same side (46.6%). We demonstrated for the first time in the literature that PVL, atrophy and porencephaly are usually observed concomitantly and contralateral to the side of motor impairement in HCP patients.

Neuroimaging abnormalities in infants with congenital hemiparesis

Clinical and neuroimaging characteristics of congenital hemiparesis were examined in a retrospective cohort study nested within 199,176 births within the Kaiser Permanente Medical Care Program, 1997-2002. Infants with a physician diagnosis of paresis or cerebral palsy were electronically identified, and charts were reviewed to confirm congenital hemiparesis. A neuroradiologist reviewed available head MRI and CT scans. Of 96 infants with congenital hemiparesis (population prevalence 4.8 per 10,000), 81% received either a head magnetic resonance imaging (n = 55) or head computed tomography only (n = 23). Perinatal arterial infarction was the most common (30%) neuroimaging finding in term infants. Infants with right-sided hemiparesis (relative risk 4.6, 95% confidence interval 1.4-14.4) or moderate to severe weakness (relative risk 4.4, 95% confidence interval 1.1-17.7) were more likely to have had a perinatal arterial infarction. Periventricular white matter lesions predominated in preterm infants (71%). Brain malformations observed in 14 (18%) patients included polymicrogyria, heterotopia, and schizencephaly. The 14 infants (18%) with a normal head imaging study were more likely to outgrow all signs of hemiparesis by age 3 than were infants with an abnormal brain image (29% vs 0%, P < 0.001). Neuroimaging studies provide useful diagnostic and prognostic information in infants with congenital hemiparesis.

Living a normal life with the nondominant hemisphere: magnetic resonance imaging findings and clinical outcome for a patient with left-hemispheric hydranencephaly

In hemihydranencephaly, the human brain lacks 1 complete hemisphere. An occlusion of the carotid artery, affecting all supplied territories, is thought to be the underlying mechanism. This extremely rare disorder, of which only 7 cases have been reported to date, is thought to occur before the last trimester of gestation (20th to 27th week), after neural migration but before synaptogenesis. We report on a 36-year-old man born at term, with no complications, from nonconsanguineous healthy parents. Cranial computed tomography had been performed because of left-sided headaches. Because of the imaging findings, the patient presented at our institution for additional MRI and clinical testing (including the Motor Activity Log, Wolf motor function test, 2-point discrimination test, Purdue pegboard test, gross motor function test, Physician Rating Scale, and Aachener aphasia test, including patterns for spontaneous speech, repetition, naming, comprehension, written language, and the token test). The patient's disabilities were related to deficits in fine motor control and reduced precision. Therefore, the patient was unable to perform the Purdue pegboard test with his affected hand. According to the Aachener aphasia test, no aphasia could be demonstrated for this strongly left-handed patient. Strong mirror movements were found. Cortical reorganization is possible if damage occurs in very early childhood. Motor function and speech were controlled by the remaining, nonaffected hemisphere, with a remarkable outcome. Because the damage is thought to occur before synaptogenesis, existing or prepared cortical areas and pathways have the potential to execute the lacking functions of the destroyed hemisphere.

Factors identified during the neonatal period associated with risk of cerebral palsy

OBJECTIVE

To identify factors during the neonatal period that are associated with the subsequent development of cerebral palsy (CP).

DESIGN

Case-control study.

SETTING

Ten hospitals in Victoria, Australia.

SAMPLE

Cases were babies with moderate or severe CP identified from the Victorian Cerebral Palsy Register. Controls were matched with cases for year of birth, plurality, sex, birthweight, gestation and hospital of birth.

METHODS

A range of neonatal variables was compared between cases and controls, initially in a univariate analysis and subsequently in a logistic regression. The analysis was matched where possible. Where missing data prevented a matched analysis, an adjusted unmatched analysis was performed.

MAIN OUTCOME MEASURES

Those neonatal factors making an independent contribution to the risk of CP in both term and preterm infants.

RESULTS

Among babies born at term, 73% of cases and 2% of controls were identified by at least one of the following factors: seizures, congenital abnormalities of the brain and elsewhere, 'other lesions', abnormal muscle tone and meconium aspiration. Among babies born preterm, 68% of cases and 26% of controls were identified by the following factors: seizures, intraventricular haemorrhage, periventricular leukomalacia, 'other lesions' and abnormal muscle tone.

CONCLUSIONS

The neonatal factors which best identify neonates who will subsequently develop CP are different for term and preterm babies. Babies born at term are identified more efficiently than those born preterm. Among term babies especially, some of these factors are clearly of a long-standing nature and are not associated with delivery.

Magnetic resonance imaging in 122 children with spastic cerebral palsy

The interrelationship between magnetic resonance imaging findings, types of cerebral palsy, and gestation was studied. We analyzed the magnetic resonance imaging of brain in 122 children with spastic cerebral palsy. Forty-three patients had spastic hemiplegia, 61 had spastic diplegia, and 18 had spastic tetraplegia. Magnetic resonance imaging abnormalities were observed in 75% of patients. Periventricular leukomalacia accounted for 66% of abnormalities observed in patients with spastic diplegia; other types of brain lesions were uncommon. In patients with spastic tetraplegia, two types of magnetic resonance imaging abnormalities predominated: congenital brain anomalies and term-type brain injuries, 42% and 33% respectively. Types of magnetic resonance imaging abnormalities were more heterogeneous in patients with spastic hemiplegia. Preterm brain injuries (periventricular leukomalacia and posthemorrhagic porencephaly) were observed often in patients born at preterm but were also observed in patients born at term. Term-type brain injuries (term-type border-zone infarct, basal ganglia-thalamic lesion, subcortical leukomalacia, and multicystic encephalomalacia) were observed only in patients born at or near term. We conclude that magnetic resonance imaging findings for patients with spastic cerebral palsy were closely related to types of cerebral palsy and gestation at birth. Magnetic resonance imaging in patients with perinatal brain injury may reflect pathologic changes and is useful in understanding and evaluating cerebral palsy.

Antenatal risk factors for cerebral palsy

Two of every 1000 live-born children develop cerebral palsy (CP). The aetiology of CP is often unclear and because CP is a symptom complex rather than a disease, clinically defined at 4-5 years of age, it is not surprising that there are considerable problems associated with epidemiological studies of its aetiology. The only reason for the CP concept is that it emanates from an insult to a growing, developing brain and a dynamic clinical picture from static pathology. Evidence suggests that 70-80% of CP cases are due to prenatal factors and that birth asphyxia plays a relatively minor role (<10%). Some antenatal risk factors are repeatedly observed to be related to CP: low gestational age, male gender, multiple gestation, intrauterine viral infections and maternal thyroid abnormalities. Recently, intrauterine infection/inflammation with a maternal response (consisting of chorioamnionitis) and a fetal inflammatory response (consisting of funicitis or elevated interleukin-6 in fetal plasma) has been found to be related to white matter injury and CP. Some risk factors are associated with CP at all gestational ages whereas others mostly affect term or preterm infants, e.g. intrauterine growth restriction seems to be a risk factor in term infants. There also seems to be an association between autoimmune and coagulation disorders and CP.

The epidemiology and causes of cerebral palsy

Cerebral palsy is the commonest physical disability in childhood, occurring in 2.0 to 2.5 per 1000 live births. Although the total number of children with cerebral palsy has remained stable or increased slightly since 1970, there has been a consistent rise in the proportion of cerebral palsy associated with preterm and very preterm births. Known causes of cerebral palsy--whether prenatal, perinatal or postnatal--must be distinguished from risk factors or associations. Much is known about such risk factors which, alone or in combination, may indirectly result in cerebral palsy. Causes and risk factors implicated in cerebral palsy are discussed in detail, together with directions for future research.

Antenatal causes of cerebral palsy: associations between inherited thrombophilias, viral and bacterial infection, and inherited susceptibility to infection

Cerebral palsy rates of 2 in every 1,000 births have varied little over the last 40 years, despite improvements in obstetric care. In the past, cerebral palsy was thought to be due to poor obstetric care and management; however, epidemiological studies have refuted this, suggesting that there is usually an antenatal timing to the neuropathology of cerebral palsy. There are many known risk factors for cerebral palsy, including multiple gestation, prematurity, and low birth weight. Recently, intrauterine infection, maternal pyrexia, and the presence of thrombophilic disorders (thrombophilia) have been identified as major risk factors for subsequent cerebral palsy. This review examines the links between intrauterine infection, the fetal inflammatory response, and thrombophilia as possible causes of cerebral palsy. The interactions of viral or bacterial infections during pregnancy, normal or abnormal fetal cytokine responses, and hereditary fetal thrombophilias as antenatal causes of the neuropathology of cerebral palsy are now areas of research priority.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to describe the condition cerebral palsy, list the risk factors for the development of cerebral palsy, outline the ultrasound findings associated with cerebral palsy, and point out other conditions associated with cerebral palsy.

Timing and type of congenital brain lesion determine different patterns of language lateralization in hemiplegic children

Cerebral lateralization for language has been assessed by means of the Fused Dichotic Words Test in 26 hemiplegic children (mean age 7 years 2 months) with congenital focal brain damage (ten with left, seven with right and nine with bilateral lesions). The specific aim of the study was to investigate the relation between lesion characteristics (side, size and localization) at high field, multiple plane MRI and the pattern of language lateralization at the dichotic test. Significant side and site effects were found at group level; in children with lesions of the left hemisphere a left ear advantage (LEA) was found, while children with right lesions had the expected right ear advantage (REA). Analysis of individual data, however, revealed that type of lesion, cortical-subcortical or periventricular, occurring at term or preterm age, respectively, may be the primary factor responsible for inter versus intrahemispheric organization of language after congenital brain lesions. Only when the left lesions involved cortical-subcortical regions encroaching the temporal lobe and occurred at term age, was language reorganized in the right hemisphere; when lesions (whether left or right) involved only the periventricular white matter and occurred at preterm age, language was lateralized in the left hemisphere. Our results provide evidence that within 'congenital hemiplegias', strictly defined as hemiplegias whose causal lesion occurs before the end of the neonatal period, different recovery mechanisms are at work, depending on the type of brain lesion (neuropathology) which largely depends on the timing of insult (preterm vs. term period).

Magnetic resonance imaging findings in cerebral palsy

OBJECTIVE

To review all cases of cerebral palsy (CP) that had magnetic resonance imaging (MRI) over a defined period of time.

METHODOLOGY

The MRI brain scans of 42 children (12 premature, 30 full-term) with CP were studied. The scans were performed at the Royal Children's Hospital, Melbourne, between January 1995 and June 1996.

RESULTS

Abnormalities were found in 39 of the 42 scans. Five children had cortical malformations and three children had white matter hypoplasia, indicating insults during the second trimester of pregnancy. Twenty-one children had hypoxic-ischaemic lesions (eight premature, 13 full-term) with patterns of periventricular leucomalacia, subcortical lesions or cortical infarction indicating insults perinatally or in the third trimester. Only 10 children had scans that could not be categorized into these groups.

CONCLUSIONS

In this study sample of children with CP, MRI was useful in revealing underlying brain abnormalities, most of which were due to events in the third trimester or the perinatal period.

Magnetic resonance imaging of periventricular leukomalacia and its clinical correlation in children

The prevalence of periventricular leukomalacia and its association with clinical neurological signs in school-age preterm children are unknown. We matched 42 eight-year-old children who were born before term with birth weights lower than 1,750 gm (mean, 1,410 gm; gestational age, 31 weeks) with 42 children who were born at term and of normal birth weight, to compare clinical neurological status and magnetic resonance imaging findings. Of the children born prematurely, 9.5% had cerebral palsy and 31% had minor neurological dysfunction whereas 9% of the children born at term had minor neurological dysfunction and none had cerebral palsy. Deviations in tongue movements, heel walking. Fogs test results, and finger opposition, as well as behavioral disturbances, differentiated the preterm from the full-teem group. The prevalence of periventricular leukomalacia among all children born prematurely was 32%. It was observed in all children with cerebral palsy, in 25% with minor neurological dysfunction, and in 25% of the clinically healthy preterm children. None of the children born at term had evidence of periventricular leukomalacia. Children with periventricular leukomalacia especially demonstrated poor performance on heel walking and Fogs test. Though commonly found in preterm children, periventricular leukomalacia is not uniformly associated with abnormal neurological findings. A thorough neurological examination is a better predictor of later developmental problems than is magnetic resonance imaging.

Periventricular haemosiderin deposition in patients with congenital hemiplegia

Two patients with congenital hemiplegia without obvious prenatal, perinatal or neonatal difficulties showed linear low signal intensity lesions along the wall of the dilated lateral ventricles without any parenchymal lesions on T2- and proton density weighted MRI. Haemosiderin deposition secondary to intra-uterine subependymal haemorrhage with intraventricular haemorrhage was considered most likely from the signal intensity, distribution and clinical histories. MRI, which is the only means of detecting haemosiderin deposition, could be beneficial for evaluating the pathogenetic cause of congenital hemiplegia.

Bilateral spastic cerebral palsy--MRI pathology and origin. Analysis from a representative series of 56 cases

MRI of the brain was performed on 56 children with bilateral spastic cerebral palsy (CP) at a mean age of 10.7 years. Specific pathology was found in 91 per cent; periventricular leukomalacia was present in 42 per cent of term- and 87 per cent of preterm-born children. Parasagittal subcorticocortical injury, multicystic encephalomalacia and basal ganglia lesions were identified in 16 per cent, in all but one associated with severe peri-/neonatal events at term or near term. Maldevelopment comprised 9 per cent, all but one found in term-born children. MRI morphology correlated strikingly with outcome. Periventricular leukomalacia was associated with more severe disability in term- than preterm-born children.

Motor function of infants with spastic hemiplegia

The motor function of 25 children with spastic hemiplegia was examined retrospectively using videotapes recorded at 2-8 months of age. Many infants showed deficient forward movement of the arm and deficient opening of the hand on the affected side. At 7 and 8 months of age, whether the hand was semiflexed or clenched was correlated with the later upper extremity function. In the prone position, most could support their weight on the flexed arm on the affected side. In the supine position, half of the infants could not extend the knee on the affected side. At 2 months of age, asymmetry of the upper and lower extremity movements was not identified. Persistent primitive reflexes and abnormal truncal muscular tone were not recognized in the hemiplegic infants, and did not seem to be signs predicting hemiplegic cerebral palsy.