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Children With CP Should Receive MRI Scans
Susan Jeffrey
October 4, 2006 ? A new cohort study suggests MRI scans can help to establish the pathologic basis of cerebral palsy (CP) in individual patients and correlate strongly with clinical findings. The researchers maintain that all children with CP should be scanned to help parents and clinicians in planning for their future.
"I think people in the past have tended to think that it's not much use to do scans; in fact, in North America it's been hard to get scans done on cerebral palsy children, because they say, 'Well, what can you do about it?' " first author Martin Bax, DM, from the department of pediatrics at Imperial College London, United Kingdom, told Medscape.
This study, he feels, shows that MRI images can help doctors to guide families on expected outcomes for their children and help parents to see and better understand the actual damage that has occurred. "It's not new, but the fact that we've done it systematically in a whole clinical population is what's significant about this," Dr. Bax said. "Because of the good clinical correlations, we feel very happy in saying that [scans] should be done."
Their report of results from the European Cerebral Palsy Study appears in the October 4 issue of the Journal of the American Medical Association.
Large Study Population
This cross-sectional population-based study was carried out in 8 centers in Europe in England, Scotland, Ireland, Portugal, Sweden, Germany, and Finland. A total of 585 children with CP born between 1996 and 1999 were identified. Of these, 431 were assessed clinically using a standardized exam. Parents answered a questionnaire, and obstetric, genetic, and metabolic data were taken from medical records. Of the children, 351 had a brain MRI done.
Important findings include a high rate of infections reported by mothers, occurring in 158, or 39.5%, of them, the authors note. More than half of the children, 54%, were born at term, while only 47 children, or 10.9%, were very preterm, born at 28 weeks or less. There was a high rate of twin births in this population, with 51 children, or 12%, known to be from a multiple pregnancy.
Clinically, more than half of the children had hemiplegia or diplegia; less than 20% had quadriplegia, the most severe involvement.
European Cerebral Palsy Study: CP Type
CP Type
% of Cohort
Hemiplegia
26.2
Diplegia
34.4
Quadriplegia
18.6
Dyskinesia
14.4
Ataxia
3.9
Other CP types
2.6
MRI scans showed that white-matter damage of immaturity, including periventricular leukomalacia (PVL), was the most common finding, they note; only 11.7% had normal scans.
European Cerebral Palsy Study: MRI Findings
MRI Findings
% of Cohort
Normal scan
11.7
White-matter damage, including PVL
42.5
Basal ganglia lesions
12.8
Cortical/subcortical lesions
9.4
Malformations
9.1
Focal infarcts
7.4
Miscellaneous lesions
7.1
"Not only do MRI scans help reveal the pathologic basis of the condition, but the findings have a strong correlation with clinical findings," they conclude. "This may be useful in helping parents, clinicians, and others involved in the care of children with CP to understand the nature of the children's condition and to predict their needs in the future. Therefore, all children with CP should have an MRI scan."
The researchers also developed a standardized MRI scoring system for this study that can be used clinically, Dr. Bax said. "It allows you to decide not only the nature of what's going on but also the severity."
Their findings have implications for litigation, where CP outcomes are often alleged to relate to obstetric malpractice, they note. Only 70 children had either cortical/subcortical damage or basal ganglia damage and were born after 34 weeks of gestational age. "Thus, in our study, only 19.9% of a population with CP might be considered on the basis of their MRI scan as having a possibility of some type of obstetric mishap as the cause of their brain damage," Dr. Bax and colleagues write.
Preventive strategies suggested by their findings include the systematic identification and treatment of maternal infections and close monitoring of multiple pregnancies, they note.
Complex Causes
In an editorial accompanying the paper, Michael E. Msall, MD, from the Pritzker School of Medicine, University of Chicago, Illinois, calls the report by Dr. Bax and colleagues "a major advance," with a large population-based sample where subjects underwent both clinical and MRI evaluation.
"Similar to research findings in coronary artery disease and adult stroke, pediatric investigators have recognized that the clustering of multiple risks affects the developmental vulnerability of the brain," Dr. Msall writes. "The current task is to understand the pathways of risk and protection for specific groups of children with CP."
These groups include twins and high-order multiples, children with intrauterine growth restriction or malformations, those undergoing congenital heart surgery, and those with neonatal seizures and encephalopathy, he writes.
"By focusing efforts on white-matter injury in preterm infants and neuroprotection of term infants with the highest risk of encephalopathy, as well as realizing that a substantial number of term and near-term children do not have a simplistic cause for their motor disability, families can be helped and the general public can understand the need for addressing shortcomings in current knowledge," Dr. Msall concludes.
JAMA 2006;296:1602-1608, 1650-1652.