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Brain CT scans Findings in Children with Cerebral Palsy
Abstract
Background
Cerebral palsy (CP) is a major cause of the disability in children. It is considered a neurological disease occurs due to a non-progressive brain injury or anomaly that occurs while the brain is developing.
Intracranial imaging provides a window to see the brain lesion and potentially, provide an insight into the pathogenesis of CP.
Objectives: To reveal the radiological changes of brain using CT scan in different clinical types of CP and in those CP children with functional impairments.
Material and methods
Sixty eight children with previous diagnosis of cerebral palsy were scanned with computed tomography (Philips, brilliance 64) for brain without contrast at Azadi Teaching Hospital/Kirkuk city, from February 2013-July 2016. Clinical information was obtained from the documentation of pediatricians. The images were reviewed by two board certificate radiologists with at least 6 years of experience.
Result: Sixty-eight patients were included in the study, 42 (61.8%) females and 26 (38.2%) males with female to male ratio 1.6:1 and an overall mean age at presentation was 12 months. Most (79.3%) children with cerebral palsy had abnormal neuroradiological findings, Diffuse brain atrophy predominantly involving the cortical –subcortical grey matter with and without white matter hypodensities which indicate grey matter injury (35.4%) was the most common finding and it was more in the pyramidal CP (100%), followed by white matter atrophy and hypodensities with or without ventriculomegaly which indicate white matter injury in (23.5 %) which was the most common CT finding in Cerebeller CP (50%), congenital malformations found in (8.8 %) which include pachygyria, and Dandy-Walker malformation, entirely seen in quadriplegic type, the focal vascular brain insult seen in (5.9%) occurred only in diplegic type, and the least was ventriculomegaly labeled as miscellaneus ( 2.9 %) occurred only in quadriplegic CP. CT scan was normal in (20.7%), predominantly in Cerebeller type. There were significantly more patients with abnormal CT findings among CP children suffering from convulsion (p>0.05) than those without convulsion, this was not true in those with microcephaly (p<0.05).
Conclusion:
CT scan brain is a good modality for detection of structural brain abnormality in cerebral palsy (CP) cases. There was significant correlation between the topographic distribution of motor deficit and brain CT findings. There were significantly more patients with abnormal CT findings among CP children suffering from convulsion but not microcephaly.
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Cerebral palsy (CP) is the most common cause of severe physical disability in childhood, occurring in approximately 2 in 1,000 liveborn infants. Although the prevalence of CP appears to have stabilized in the past 2 decades, recent studies suggest that severe CP may be decreasing. Neuroimaging studies help identify abnormal neuroanatomic findings, which are found in most affected children. Neuropathology identified by magnetic resonance imaging (MRI) corresponds well to clinical descriptions of motor impairment in children who have CP. Clinical risk factors, combined with imaging studies, can help identify a subpopulation of infants who are at high risk for poor neurodevelopmental outcome. Counseling caregivers on future adverse developmental risks can be challenging for the clinician in the neonatal intensive care unit (NICU), especially because the cause of CP remains unexplained in most cases and is typically diagnosed outside the neonatal period. Early counseling of families of at-risk neonates may function as the starting point for parental adaptation to a lifelong condition that requires ongoing services and adjustments to promote the overall health and well-being of their child. © 2011 by the American Academy of Pediatrics. All rights reserved.
Posterior circulation strokes represent approximately 20% of all ischemic strokes (1, 2). In contrast to the anterior circulation, several differences in presenting symptoms, clinical evaluation, diagnostic testing, and management strategy exist presenting a challenge to the treating physician. This review will discuss the anatomical, etiological, and clinical classification of PC strokes, identify diagnostic pitfalls, and overview current therapeutic regimens.
Only few Indian reports exist on neuroimaging abnormalities in children with cerebral palsy (CP) from India.
We studied the clinico-radiological profile of 98 children diagnosed as CP at a tertiary centre in North India. Relevant investigations were carried out to determine the etiology.
Among the 98 children studied, 80.5% were males and 22.2% were premature. History of birth asphyxia was present in 41.9%. Quadriplegic CP was seen in 77.5%, hemiplegic in 11.5%, and diplegic in 10.5%. Other abnormalities were microcephaly (60.5%), epilepsy (42%), visual abnormality (37%), and hearing abnormality (20%). Neuroimaging was abnormal in 94/98 (95.91%). Abnormalities were periventricular white matter abnormalities (34%), deep grey matter abnormalities (47.8%), malformations (11.7%), and miscellaneous lesions (6.4%). Neuroimaging findings did not relate to the presence of birth asphyxia, sex, epilepsy, gestation, type of CP, or microcephaly.
Neuroimaging is helpful for etiological diagnosis, especially malformations.
The cerebral palsies (CP) are a heterogeneous group of non-progressive motor disorders of the developing brain. By convention, brain injuries occurring at any stage antenatally and postnatally to the age of 2 years are included in the definition of CP. Primary disorders of the spinal cord such as neural tube defects, neuropathies, and myopathies are excluded. Cerebral palsy should be viewed as part of a "continuum of reproductive casualty",(1) comprising miscarriages, stillbirths, and severe and minor brain injuries. Consequently, the incidence and causes of CP are a matter of great interest since they provide a benchmark of reproductive health. The incidence of CP in developed countries is stable at about 2-2.5/1000 live births. The risk of CP for premature babies is 5-80/1000 live births, though the majority of cases of CP are term born babies (fig 1).
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.
AimTo describe the development of a novel rating scale for classification of brain structural magnetic resonance imaging (MRI) in children with cerebral palsy (CP) and to assess its interrater and intrarater reliability.Method
The scale consists of three sections. Section 1 contains descriptive information about the patient and MRI. Section 2 contains the graphical template of brain hemispheres onto which the lesion is transposed. Section 3 contains the scoring system for the quantitative analysis of the lesion characteristics, grouped into different global scores and subscores that assess separately side, regions, and depth. A larger interrater and intrarater reliability study was performed in 34 children with CP (22 males, 12 females; mean age at scan of 9y 5mo [SD 3y 3mo], range 4y–16y 11mo; Gross Motor Function Classification System level I, [n=22], II [n=10], and level III [n=2]).ResultsVery high interrater and intrarater reliability of the total score was found with indices above 0.87. Reliability coefficients of the lobar and hemispheric subscores ranged between 0.53 and 0.95. Global scores for hemispheres, basal ganglia, brain stem, and corpus callosum showed reliability coefficients above 0.65.InterpretationThis study presents the first visual, semi-quantitative scale for classification of brain structural MRI in children with CP. The high degree of reliability of the scale supports its potential application for investigating the relationship between brain structure and function and examining treatment response according to brain lesion severity in children with CP.
The syndrome of cerebral palsy encompasses a large group of childhood movement and posture disorders. Severity, patterns of motor involvement, and associated impairments such as those of communication, intellectual ability, and epilepsy vary widely. Overall prevalence has remained stable in the past 40 years at 2-3·5 cases per 1000 livebirths, despite changes in antenatal and perinatal care. The few studies available from developing countries suggest prevalence of comparable magnitude. Cerebral palsy is a lifelong disorder; approaches to intervention, whether at an individual or environmental level, should recognise that quality of life and social participation throughout life are what individuals with cerebral palsy seek, not improved physical function for its own sake. In the past few years, the cerebral palsy community has learned that the evidence of benefit for the numerous drugs, surgery, and therapies used over previous decades is weak. Improved understanding of the role of multiple gestation in pathogenesis, of gene environment interaction, and how to influence brain plasticity could yield significant advances in treatment of the disorder. Reduction in the prevalence of post-neonatal cerebral palsy, especially in developing countries, should be possible through improved nutrition, infection control, and accident prevention.
.... The object of this communication is to show that the act of birth does occasionally imprint upon the nervous and muscular systems of the nascent infantile organism very serious and peculiar evils. When we investigate the evils in question, and their causative influences, we find that the same laws of pathology apply to diseases incidental to the act of birth as to those which originate before and after birth. We are, in fact, afforded another illustration that there exists no such thing as exceptional or special pathology.
Thirty-five years ago the pathology of deformities, if not invested with fable, was wrapped in obscurity; it was then scarcely perceived that the materials for extensive inductive observation existed.
Nearly twenty years ago, in a course of lectures published in the 'Lancet,' and more fully in a 'Treatise on Deformities,' published in 1853, I showed that premature birth, difficult labours, mechanical
Magnetic resonance imaging (MRI) is recommended in all children with cerebral palsy (CP) where the aetiology has not been established, and the major presenting problem in CP is reduced motor capacity. A systematic review of the literature was performed to investigate the relationship between brain structure on MRI and motor outcomes in children with CP. A total of 37 studies met inclusion criteria, and were analysed in terms of (a) population characteristics, (b) MRI data, (c) motor outcome data, and (d) the relationship between MRI data and motor outcomes. All studies used a qualitative system to classify brain lesions; however, few reported information about the location and extent of lesions. Valid and reliable classifications of motor abilities were not always used, and three studies did not link motor findings to MRI features. There was, however, a relationship between the type of brain lesion on MRI and two specific motor outcomes, namely gross motor functional classification (using GMFCS) and motor type. This relationship could aid in the prediction and optimisation of early interventions for children with CP. There is also need for a quantitative MRI classification measure which includes detailed information about the location and severity of lesions.
The aim of this study was to assess overall and gestational age-specific trends in the rate of cerebral palsy (CP) in Victoria, Australia, and to compare these findings with other population data.
Individuals born in Victoria from 1970 to 2004 with non-postneonatally acquired CP were identified from a population register; 3491 were included in the study (1963 males, 1528 females). After a literature review, comparison data were extracted from publications using previously devised inclusion criteria. Rates were calculated per 1000 live births for all CP and by gestational age group: these were tabulated and plotted by year of birth.
Data from nine registries, including the Victorian register, showed an increase in the rates of CP over the 1970s and 1980s, consistently seen in extremely preterm (<28 wks) survivors but also in those born at term (≥37 wks). Since the early 1990s, CP rates either stabilized or decreased, particularly for children born extremely preterm.
Increases in the rates of CP during the 1970s and 1980s are in part because of the increasing survival of extremely preterm infants that occurred without a concomitant improvement in neurological outcomes. Evidence from population samples now suggests that this trend has been reversed since the mid- to late 1990s.
The purpose of this study was to investigate the frequency and spectrum of magnetic resonance imaging (MRI) abnormalities in a population of children with cerebral palsy (CP) who were born in the years 2000 and 2001 in Victoria, Australia. In 2000 and 2001, 221 children (126 males, 95 females; mean age 6y [SD 7mo], range 5-7y) with CP, excluding those with CP due to postneonatal causes (6% of all cases), were identified through the Victorian Cerebral Palsy Register. All medical records were systematically reviewed and all available brain imaging was comprehensively evaluated by a single senior MRI radiologist. MRI was available for 154 (70%) individuals and abnormalities were identified in 129 (84%). The study group comprised 88% with a spastic motor type CP; the distribution was hemiplegia in 33.5%, diplegia in 28.5%, and quadriplegia in 37.6% of children. Overall, pathological findings were most likely to be identified in children with spastic hemiplegia (92%) and spastic quadriplegia (84%). Abnormalities were less likely to be identified in non-spastic motor types (72%) and spastic diplegia (52%). The most common abnormalities identified on MRI were periventricular white matter injury (31%), focal ischaemic/haemorrhagic lesions (16%), diffuse encephalopathy (14%), and brain malformations (12%). Dual findings were seen in 3% of patients. This is the first study to document comprehensively the neuroimaging findings of all children identified with CP born over a consecutive 24-month period in a large geographical area.
Cerebral palsy is the most prevalent cause of persisting motor function impairment with a frequency of about 1/500 births. In developed countries, the prevalence rose after introduction of neonatal intensive care, but in the past decade, this trend has reversed. A recent international workshop defined cerebral palsy as "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain." In a majority of cases, the predominant motor abnormality is spasticity; other forms of cerebral palsy include dyskinetic (dystonia or choreo-athetosis) and ataxic cerebral palsy. In preterm infants, about one-half of the cases have neuroimaging abnormalities, such as echolucency in the periventricular white matter or ventricular enlargement on cranial ultrasound. Among children born at or near term, about two-thirds have neuroimaging abnormalities, including focal infarction, brain malformations, and periventricular leukomalacia. In addition to the motor impairment, individuals with cerebral palsy may have sensory impairments, cognitive impairment, and epilepsy. Ambulation status, intelligence quotient, quality of speech, and hand function together are predictive of employment status. Mortality risk increases incrementally with increasing number of impairments, including intellectual, limb function, hearing, and vision. The care of individuals with cerebral palsy should include the provision of a primary care medical home for care coordination and support; diagnostic evaluations to identify brain abnormalities, severity of neurologic and functional abnormalities, and associated impairments; management of spasticity; and care for associated problems such as nutritional deficiencies, pain, dental care, bowel and bladder continence, and orthopedic complications. Current strategies to decrease the risk of cerebral palsy include interventions to prolong pregnancy (eg, 17alpha-progesterone), limiting the number of multiple gestations related to assisted reproductive technology, antenatal steroids for mothers expected to deliver prematurely, caffeine for extremely low birth weight neonates, and induced hypothermia for a subgroup of neonates diagnosed with hypoxic-ischemic encephalopathy.
The CT findings in 120 cerebral palsied children are analysed. The 72.5% positive findings are correlated with the clinical types, as well as the aetiological basis for the cerebral palsy. The spastic type, 83.3% of the total number of children, had the highest positive findings. The yield was increased in children with seizures (91.3%) and those in the postnatal group (90%), as well as those with birth trauma and neonatal asphyxia (94%). The findings were those of atrophy in 30.8%, hydrocephalus, in 10%, infarct in 11.6%, porencephaly in 8.3% and others. The atropic changes and their patterns are explained. Treatable lesions, such as tumour, hydrocephalus, subdural haematoma, porencephaly and hygroma were identified in 22.5% of cases. It is concluded that CT scan is definitely efficacious in the management of cerebral palsied children.
After the introduction of cranial computed tomography (CT) it is now possible by an atraumatic procedure to evaluate the pathophysiological findings in children suffering from cerebral palsy (CP). The aim of this study is to describe the cranial CT findings in children with CP and relate these to CP-type, grade of handicap, aetiology, and presence of other functional cerebral defects.
The CT-examination was performed in 83 children with spastic CP (44 boys and 39 girls). Fifty-seven children (67 %) had pathological CT. There was no statistically significant difference between the frequencies of pathological CT findings in the groups with tetraplegia, diplegia, and paraplegia. The frequency of pathological CT findings was increasing with increasing severity of the motor handicap (p < 0.05). There were significantly more children with pathological CT findings among CP children suffering from epilepsy, than among CP children without epilepsy (p < 0.05). The CP children with the lowest IQ, had numerical more pathological CT findings but there was no significant difference among pathological CT findings in CP children with oligophrenia compared to the rest of the group. Infarction, its sequelae and hemiatrophy were much more frequent in patients with hemiplegia (p < 0.001) compared to the other CP-types.
The most frequent pathological CT finding was atrophy (44 cases among 56 pathological CT). Central atrophy with enlargement of the ventricular system or parts of this was found in 39 children. A special kind of central atrophy in this paper called isolated atrophy around cella media, was seen more frequently in patients with paraplegia, and in premature children with CP.
The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society develop practice parameters as strategies for patient management based on analysis of evidence. For this parameter the authors reviewed available evidence on the assessment of a child suspected of having cerebral palsy (CP), a nonprogressive disorder of posture or movement due to a lesion of the developing brain.
Relevant literature was reviewed, abstracted, and classified. Recommendations were based on a four-tiered scheme of evidence classification.
CP is a common problem, occurring in about 2 to 2.5 per 1,000 live births. In order to establish that a brain abnormality exists in children with CP that may, in turn, suggest an etiology and prognosis, neuroimaging is recommended with MRI preferred to CT (Level A). Metabolic and genetic studies should not be routinely obtained in the evaluation of the child with CP (Level B). If the clinical history or findings on neuroimaging do not determine a specific structural abnormality or if there are additional and atypical features in the history or clinical examination, metabolic and genetic testing should be considered (Level C). Detection of a brain malformation in a child with CP warrants consideration of an underlying genetic or metabolic etiology. Because the incidence of cerebral infarction is high in children with hemiplegic CP, diagnostic testing for coagulation disorders should be considered (Level B). However, there is insufficient evidence at present to be precise as to what studies should be ordered. An EEG is not recommended unless there are features suggestive of epilepsy or a specific epileptic syndrome (Level A). Because children with CP may have associated deficits of mental retardation, ophthalmologic and hearing impairments, speech and language disorders, and oral-motor dysfunction, screening for these conditions should be part of the initial assessment (Level A).
Neuroimaging results in children with CP are commonly abnormal and may help determine the etiology. Screening for associated conditions is warranted as part of the initial evaluation.
Cerebral palsy (CP) is a common problem, occurring in about 2 to 2.5 per 1000 live births. The diagnosis of CP is based upon a history of abnormal motor development that is not progressive coupled with an examination (e.g. hypertonicity, increased reflexes, clonus) "placing" the lesion in the brain. In order to establish that a brain abnormality exists in children with CP that may, in turn, suggest an etiology and prognosis, neuroimaging is recommended with magnetic resonance imaging preferred to computed tomography. Metabolic and genetic studies should be obtained if there are atypical features in the history or on the examination. Detection of a brain malformation in a child with CP might suggest an underlying genetic or metabolic etiology. As cerebral infarction is high in children with hemiplegic CP, diagnostic testing for coagulation disorders should be considered. However, there is insufficient evidence at present to be precise as to what studies should be ordered. An electroencephalogram is not recommended unless there are features suggestive of epilepsy or a specific epileptic syndrome. As children with CP may have associated deficits of mental retardation, ophthalmologic and hearing impairments, speech and language disorders and oral-motor dysfunction, screening for these conditions should be part of the initial assessment.
Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.
Evaluation of a child with cerebral palsy (CP) requires a multidisciplinary approach with a team of professionals comprising of a pediatrician or pediatric neurologist, occupational therapist, a physiotherapist, child psychologist, and a social worker. The assessment is necessary to confirm the diagnosis, determine the cause, assess the motor function and associated problems. The diagnosis of CP is clinical but selected investigations may be required for ascertaining the cause. Evaluation includes assessment for common medical problems of childhood particularly nutritional disorders and assessment of family functioning. Additional disabilities are common. Routine assessment of vision and hearing is required in children with CP. Since CP is a changing disorder, some limitations may not be evident early in life but manifest in the school age or later. The evaluation of a child with CP is an ongoing process and should be a part of continuing care as the child grows from infancy to adolescence.
MRI can demonstrate and differentiate the various insults and anomalies that can be responsible for cerebral palsy. Recent advances have resulted in techniques and sequences that allow prompt detection of cytotoxic edema and evaluation of brain perfusion. MRI precisely demonstrates the various patterns of injury, distinguishing insults owing to profound asphyxia, partial prolonged asphyxia, and mixed partial prolonged and profound asphyxia. Infants and children can be studied with MRI, and ultrafast MRI permits evaluation of the fetal central nervous system. In the fetus, the cause of ventriculomegaly can be determined, such as cerebrospinal fluid flow obstruction, brain malformation, or brain destruction with or without hemorrhage. Results from fetal MRI have led to better understanding of many brain abnormalities.
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%.
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