Computed tomography in spastic cerebral palsy

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.

Computerized tomography scan of the brain in a community study of neurological impairment in Kenya

Neurological impairment is common in resource-poor countries, but its causes are not clear. Computerized tomography (CT) of the brain has been used to determine the cause of brain insults that may manifest as neurological impairments. The authors conducted a community survey in Kilifi of 10 218 children aged 6 to 9 years to detect neurological impairment. From this survey, 34 children were identified, of whom 16 had motor deficits, 11 complex partial seizures, 4 microcephaly or macrocephaly, and 3 severe developmental delay. These children were assessed with elicitation of history, physical examination, and CT scan of the brain. Sixteen (47%) of the scans showed abnormalities: cerebral atrophy (n = 9), schizencephaly (n = 3), periventricular leukomalacia (n = 2), porencephalic cyst (n = 1), and agenesis of the corpus callosum (n = 1). The minimum prevalence of abnormalities on the CT scan of the brain is 1.56 of 1000, and the prevalence of schizencephaly is 0.29 of 1000. Motor impairments were more likely to show abnormality than the other indications. CT abnormalities are common in children with neurological impairment in Kenya, but the appearances did not identify a major cause.

Epilepsy in children with cerebral palsy

To study the spectrum of epilepsy in children with cerebral palsy, 105 consecutive children with cerebral palsy and active epilepsy, between 1 and 14 years of age, were studied prospectively. A detailed history and examination, electroencephalography (EEG), and computed tomography (CT) were done in all cases. The social quotient was assessed using the Vineland Social Maturity Scale. A retrospective cohort of 452 cases of cerebral palsy was studied to find the prevalence of epilepsy in cerebral palsy. A control group of 60 age-matched children with cerebral palsy but no epilepsy was also studied for comparison of the social quotient. Of the 105 children, 65 were male, 40 of 105 (38%) had a history of birth asphyxia. The mean age of onset of seizures was 18.9 months; 64 (60.95%) had seizure onset before 1 year of age. Children with myoclonic seizures (P < .05) and infantile spasms (P < .01) had seizure onset significantly early in life. Generalized seizures were the most common, followed by partial seizures, infantile spasms, and other myoclonic seizures. Seizures were controlled in 45 (58.1%) children, and polytherapy was required in 40 children. EEG and CT abnormalities were seen in 70.5% and 61% of the children. Seizure control was achieved in 74% of the patients with a normal to borderline social quotient compared with 48.7% with a social quotient less than 70. Social quotient values had a positive correlation with age of onset of seizures (P < .01) and with better control of seizures (P < .01). Of the cohort of 452 children, 160 (35.4%) had epilepsy. The maximum incidence (66%) was seen in children with spastic hemiplegia, followed by quadriplegia (42.6%) and diplegia (15.8%). Epilepsy in cerebral palsy is seen in about one third of cases; it is often severe and difficult to control particularly in children with mental retardation.

Is computerized tomography ventricular abnormality related to cycloid psychosis?

Twenty-eight psychiatric patients with computerized tomography (CT) findings of ventricular abnormality most likely to result from prenatal/perinatal lesions (VA group) were compared to 28 sex- and age-matched psychiatric patients with normal neuroradiological findings (NCT group). The neuroradiological rater was blind to clinical psychiatric diagnoses and, vice versa, clinical diagnoses were established without knowledge of neuroradiological findings. A polydiagnostic approach (DSM-III-R, ICD-10, Leonhard Classification) was used for psychiatric diagnostic workup. Significantly more patients with cycloid psychoses (according to Leonhard's original description) were found in VA as compared to NCT patients. According to DSM-III-R and ICD-10, VA and NCT groups did not differ significantly regarding diagnostic distribution. Ventricular abnormalities that may reflect sequels of birth complications and/or adverse events during pregnancy may constitute one of the risk factors for developing cycloid psychosis as originally described by Leonhard.

Value of brain CT scan in children with febrile convulsions

Studies specifically dealing with the value of brain CT scans in different types of febrile convulsion are lacking when compared to the large amount of studies on other favorable convulsive disorders. This study is correlation study between children who presented with febrile convulsions (n = 38) and the results of their brain CT scans. Twenty four patients had risk factors for subsequent epilepsy (group A), 3 of them had abnormal CT scans in the form of mild diffuse brain atrophy, and all 3 patients were found to have prior neurodevelopmental deficits. The other 14 patients did not have such risk factors (group B) and had normal brain CT scans. Despite the small size of the study, the results are unequivocal, and it can be concluded that brain CT scan is not indicated in the management of simple or complex febrile convulsions. Brain CT may be justifiable, but may not be clinically useful in the management of febrile convulsion patients with prior neurodevelopmental deficits.

Surgical indication in children with congenital hemiparesis

Nine children with perinatal occlusion of the middle cerebral artery, resulting in unilateral enlargement of one lateral cerebral ventricle associated with cortical atrophy and subcortical cavity formation, were operated on because of intractable epilepsy. All subjects exhibited mild to severe hemiparesis, localized in the right side of the body in six instances and in the left side in the three cases. All but one patient presented with some degree of psychomotor retardation. The surgical treatment consisted of the removal of the atrophic cerebral cortex. One child died after surgery because of disseminated intravascular coagulation. All the remaining eight children benefited from the operation, with a decrease in the hypertonia of the affected limbs and an improvement in dexterity and gait as well as in intellectual performance. Five patients could be considered seizure-free following the surgical treatment, and the remaining three experienced a significant reduction in the frequency of the seizures.

Cerebral palsy--an etiological study

Five hundred and forty four cases of cerebral palsy were studied to find the etiology. Male to female ratio was 1.9:1. Prenatal, natal and postnatal factors were found in 42 (7.72%), 238 (43.75%) and 142 (26.1%) cases respectively. Only 79 (14.52%) cases were found to have more than one factor which could have contributed to brain damage. In 43 (7.9%) cases the prenatal, natal and postnatal history were normal and the cause was not known. Toxemia (1.29%) cases and microcephaly (1.84%) cases were the most common etiological factors in the prenatal category. Among the natal causes, birth anoxia was the most common etiological factor and was observed in 24.45% cases. Infections of the central nervous system comprised the major etiopathogenetic factors of the postnatal causes--11.95% cases had encephalitis, while 5.15% cases had meningitis. In cases where more than one etiology was present, the most frequent causes were a combination of prematurity or birth anoxia in association with toxemia, antepartum hemorrhage, prolonged labour, twins, forceps or caesarean delivery. Anoxia was consistently the most common etiological factor in those cases of monoplegia paraplegia, quadriplegia, diplegia, and ataxia, i.e. in 0.55%, 1.29%, 11.76%, 6.07% and 0.55% cases respectively. The present study reveals that majority of the cases were found to have natal or post natal etiology.

Visuo-perceptual impairment and cerebral lesions in spastic diplegia with preterm birth

Eighteen cases of spastic diplegia (SD) ranging in age from 5 year 4 month to 9 year 5 month with preterm birth were studied to clarify the relationship between visuo-perceptual impairment and their cerebral lesions. All underwent neuropsychological examinations including the Frostig developmental test of visual perception, Tanaka-Binet or Suzuki-Binet intelligence test, and MRI examination. Cerebral lesions were detected in all subjects, and the volume of the peritrigonal white matter of the parietal and occipital lobes was significantly correlated with the visuo-perceptual impairment (r = 0.74, in the axial plane; r = 0.64, in the coronal plane). We propose that visuo-perceptual impairment is caused by cerebral lesions and that the measurement of peritrigonal white matter by MRI is useful for detecting potential visuo-perceptual impairment at an early age.

Morphology of cerebral lesions in children with congenital hemiplegia. A study with computed tomography

This study has analysed the results of CT scans of the brains in children with congenital hemiplegia. The material consists of 111 out of a total of 151 children with this cerebral palsy syndrome in a population-based series. We have classified the morphological findings in five groups. The groups are designed to reflect the phase of maturation of the brain when the insult happened. The groups are: 1. Maldevelopment, 2. Periventricular atrophy, 3. Cortical-/subcortical atrophy, 4. Miscellaneous, 5. Normal. In contrast to previous reports we found a high proportion (17%) with maldevelopment. However the dominating morphological pattern was periventricular atrophy, consistent with a hypoxic-ischemic insult to the immature brain, seen in 42%. Cortical and/or subcortical atrophy was found in 12%. Three children (3%) presented with morphological patterns not possible to classify. The group with no pathology according to CT was 26%.

Computed tomographic (CT) scans in cerebral palsy (CP)

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.

Computed tomographic findings in children with spastic diplegia: correlation with the severity of their motor abnormality

Computed tomographic findings of 46 children with spastic diplegia examined at nine months to three years of age corrected for preterm births were analyzed. Both the size of the lateral ventricles measured by the width of the anterior horns, and the volume of the extracerebral low-density areas were enlarged in some patients. Both enlargements did not, however, correlate to the severity of the motor abnormality in the patients. The low-density areas of the periventricular white matter, especially adjacent to the trigone, were reduced in many children, probably due to the atrophy of the cerebral white matter having periventricular leukomalacia. The anterior expansion of the white matter reduction from the trigone corresponded to the severe motor abnormality in the children with spastic diplegia.

Lobar holoprosencephaly presenting as spastic diplegia

A child with lobar holoprosencephaly presented with spastic diplegia and mild mental retardation, compounded by attention deficits and hyperactivity. His facial features were normal, and except for borderline microcephaly, there were no other predictors of holoprosencephaly. This patient represents the mild end of the spectrum of the holoprosencephaly malformation complex, which seems to be under-represented in the medical literature. Holoprosencephaly does not appear to have been described previously in association with spastic diplegia. This patient also illustrates the value of CT scans of the head of patients with neurological findings, without specific etiology.

Hemiplegic cerebral palsy. Aetiology and outcome

Hemiplegic cerebral palsy (CP) was studied in a retrospective population-based series of 169 cases from the South-western Swedish health care region covering the birth years 1969-78. The purpose was to analyse the prevalence, aetiology and neuro-developmental outcome in children born preterm and at term, and to correlate pathogenetic periods, aetiological factors and clinical parameters to neuroradiology. The prevalence at the ages 6-15 years was 0.66 per 1000. Postnatally acquired hemiplegia, mainly postinfectious, iatrogenic or posttraumatic, constituted 11%. Among term children with congenital hemiplegia (pre and perinatally derived) the aetiology was considered prenatal, mainly circulatory brain lesions and maldevelopments, in 42%, combined pre and perinatal in 9%, perinatal (cerebral haemorrhage, hypoxia) in 16% and untraceable in 34%. The corresponding distribution among preterm children was 29%, 47%, 25% and 6%, respectively. The rate of preterm birth among congenital cases was 24%. Birth asphyxia was shown to be a poor indicator of pathogenetic period, whereas a cascade of postpartum complications suggested perinatal brain damage. Clinical follow-up of 152 children revealed that 50% had mild, 31% moderate and 19% severe motor dysfunction. Stereognostic sense was impaired in 44% of the children (astereognosia in 20%). Additional impairments (mental retardation, epilepsy, impaired vision, hearing and speech, severe behavioural/perceptual problems) were present in 42%. Term children with congenital hemiplegia tended to be more severely affected than preterm children. The resulting total handicap was considered mild in 40%, moderate in 44% and severe in 16%. The prevalence of severe total handicap was highest among postnatal cases. Computerised tomography (CT), performed in 109 congenital cases, was normal in 26%, showed unilateral ventricular enlargement in 36% and revealed cortical/subcortical cavities in 20%. In the remaining 18% CT findings were classified as "other". With the classification so far used, correlations between CT findings and aetiologies were unsatisfactory and disappointing. In contrast, CT findings showed a strong correlation with clinical degree of severity and magnitude of associated handicap. As a rule, normal CT implied mild disability and unilateral ventricular enlargement moderate, whereas cortical/subcortical cavities were frequently associated with severe handicap, including mental retardation and epilepsy.

Porencephaly and schizencephaly in adopted infants. Frequency ascertainment in a risk group

A formal inquiry on the health state of 1206 legally adopted children from Indonesia revealed cerebral palsy in 9 (0.9% of 1029 responses obtained), including two who had died. CT examination performed in 7 cases was abnormal in all. Four types of lesions were seen: 1. Bilateral full thickness porencephalies (BFTP lesion) in 4 cases, amounting to 0.4% of the total population on which response was obtained. 2. Full thickness porencephaly of the area of one internal carotid artery in 1 case. 3. Schizencephaly-like lesion in 1 case, confirmed by magnetic resonance imaging. 4. Supratentorial midline cyst resulting in hydrocephalus. The frequency of the BFTP lesion found in 4 out of 7 cerebral palsied investigated by CT is remarkable in view of its rarity in radiological studies on cerebral palsy and because of its relationship to prenatal rather than perinatal damage according to previous pathological studies. This is the first systematic study on the neurodevelopmental outcome of a group of adopted babies which indicates an increased risk to specific prenatal brain damage.

Temporal evolution of hypoxic-ischaemic brain lesions in asphyxiated full-term newborns as assessed by computerized tomography

Hypoxic-ischaemic brain lesions may be detected as low density (LD) areas by means of computerized tomography (CT), but the clinical significance of such LD areas has been controversial. Since timing might be a critical factor, we studied the temporal evolution of LD areas in 9 asphyxiated term babies who had had two or more CT, and compared the changes to the neurodevelopmental outcome. Scans were classified according to the elapsed time after asphyxia as early (day 1-7, n = 6), intermediate (week 2-4, n = 7; week 4-7, n = 3) and late CT (3 months or more, n = 7). In early scans, no, or only ill defined, LD areas were seen in the periventricular region. In intermediate CT's, LD-zones were further diminished in those babies who later were normal. Sharply accentuated LD areas, however, appeared in those who later suffered from neurodevelopmental disorders. These LD areas, probably representing hypoxic-ischaemic lesions, were located periventricularly, extending into the subcortical white matter and the cortex, and usually involved both hemispheres symmetrically. They began to disappear at 4 to 7 weeks in some regions, possibly because of glial proliferation. LD persisting more than 4-7 weeks tended to transform into cyst-like lesions, or marked atrophy. We conclude (1) that hypoxic-ischaemic lesions appear as zones of low density on CT scans performed after the first week and (2) that the extent of such lesions can best be assessed between 9 to 23 days after asphyxia.

Familial porencephalic white matter disease in two generations

We report the pedigree of a family in which a mother and her two children, a boy and a girl, all suffer from a similar, though variably expressed cerebral disorder, seen on CT as uni- or bilateral cavities within the supratentorial white matter in communication with the ventricular system. Additional white matter hypodensity around the lateral ventricles without ventricular widening provides preliminary evidence of a primary disease of myelination, in the absence of histopathological confirmation. This is probably the first report of "porencephaly" which shows a pattern of autosomal dominant inheritance.