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

Population-Level Analysis of Appropriateness of End-of-Life Care for Children with Neurologic Conditions

OBJECTIVE

The objective of this study was to measure the appropriateness of end-of-life care for children who died with neurologic conditions.

STUDY DESIGN

Based on linked routinely collected databases, we conducted a population-level decedent retrospective cohort study of children with neurologic conditions who died in Belgium between 2010 and 2017. We measured a set of 22 face-validated quality indicators. The set concerns 12 indicators of potentially appropriate end-of-life care (eg, specialized comfort medication, physician contact, continuous care) and 10 indicators of potentially inappropriate end-of-life care (eg, diagnostic tests, phlebotomy). We performed ANOVA for predictors (age, sex, disease category, nationality, having siblings, year of death) for scales of appropriate and inappropriate care.

RESULTS

Between 2010 and 2017, 139 children with neurologic conditions died in Belgium. For potentially appropriate care, in the last 30 days, 76% of children received clinical care, 55% had continuous care relationships, 17% had contact with a general physician, 8% of children received specialized comfort medication, and 14% received care from a palliative care team. For potentially inappropriate care, in the last 14 days, 45% had blood drawn and 27% were admitted to intensive care unit.

CONCLUSIONS

Our study found indications of appropriate as well as inappropriate end-of-life care for children who died with neurologic conditions. These findings reveal a substantial margin for potential quality improvement, in regard to palliative care provision, multidisciplinary care, financial support, specialized comfort medication, clinical follow-up, general physician contact, diagnostics, and blood drawing.

Effects of Dopamine on Motor Recovery and Training in Adults and Children With Nonprogressive Neurological Injuries: A Systematic Review

BACKGROUND

The strong link between dopamine and motor learning has been well-established in the animal literature with similar findings reported in healthy adults and the elderly.

OBJECTIVE

We aimed to conduct the first, to our knowledge, systematic review of the literature on the evidence for the effects of dopaminergic medications or genetic variations in dopamine transmission on motor recovery or learning after a nonprogressive neurological injury.

METHODS

A PubMed search was conducted up until April 2018 for all English articles including participants with nonprogressive neurological injury such as cerebral palsy, stroke, spinal cord injury, and traumatic brain injury; quantitative motor outcomes; and assessments of the dopaminergic system or medications.

RESULTS

The search yielded 237 articles, from which we identified 26 articles meeting all inclusion/exclusion criteria. The vast majority of articles were related to the use of levodopa poststroke; however, several studies assessed the effects of different medications and/or were on individuals with traumatic brain injury, spinal cord injury or cerebral palsy.

CONCLUSIONS

The evidence suggests that a brain injury can decrease dopamine transmission and that levodopa may have a positive effect on motor outcomes poststroke, although evidence is not conclusive or consistent. Individual variations in genes related to dopamine transmission may also influence the response to motor skill training during neurorehabilitation and the extent to which dopaminergic medications or interventions can augment that response. More rigorous safety and efficacy studies of levodopa and dopaminergic medications in stroke and particularly other neurological injuries including genetic analyses are warranted.

A population-based study and systematic review of hearing loss in children with cerebral palsy

AIM

The aims of this study were to estimate the frequency of hearing loss in children with cerebral palsy (CP), to examine factors associated with hearing loss, and to describe aspects of hearing in a population sample of children with CP and hearing loss.

METHOD

A systematic review of the international literature was undertaken, and data on the frequency of hearing loss or severe hearing loss were extracted from 14 data sets based on previously devised criteria. Six hundred and eight-five children with CP (406 males, 279 females) born in Victoria, Australia, between 1999 and 2004 were identified from the Victorian Cerebral Palsy Register. Children were included if they had an established post neonatal cause for their CP before the age of 2 years. Additional information was collected on 48 children with documented hearing loss based on a four-tone pure tone average in the better ear.

RESULTS

There was considerable variation in the definitions and proportions of hearing loss (range 4-13%) and severe hearing loss (range 2-12%) reported by CP registries in developed countries. In Victoria, 7% of individuals with CP had bilateral hearing loss of a moderate to profound degree, whereas the subgroup with a severe-profound degree of loss constituted 3% to 4% of the CP population.

INTERPRETATION

These population-based data are likely to more accurately reflect the true frequency of defined hearing loss in children with CP than previous reviews.

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.

Evaluation of the child with cerebral palsy

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.

Cerebrovascular disorders in children with the factor V Leiden mutation

Since 1995, at least 128 children with a cerebrovascular disorder, cerebral palsy, or both and the factor V Leiden mutation have been reported. The majority of these strokes were in the first year of life, many of them in the perinatal period. Two thirds had an additional exogenous risk factor for thrombosis, and 42% had another recognized endogenous prothrombotic risk factor in combination with the mutation. We review the association of the factor V Leiden mutation and a cerebrovascular disorder in children younger than 16 years of age and describe the clinical features of 8 children with cerebral palsy and the Leiden mutation. This mutation should be considered in the evaluation of children with a stroke or its sequelae, including infants with perinatal stroke.

MRI in motor delay: important adjunct to classification of cerebral palsy

Cranial magnetic resonance imaging (MRI) was performed prospectively in 45 children (ages 3-27 months) with clinically documented motor delay to evaluate the ability of MRI to determine etiologic factors, to determine whether myelination correlated with motor delay, and whether the clinical category corresponded with the imaging findings. Of the 22 children diagnosed clinically as having major motor delay (i.e., cerebral palsy), 77% had magnetic resonance imaging abnormalities. In 23%, etiologic associations were established from MRI alone and in 32% a clinically suspected etiology was supported. No children had myelination delay as the sole abnormality. In 23 children with minor motor delay, only 17% had abnormal scans. Clearly, MRI provided useful information in the majority of children with cerebral palsy; therefore, a classification system is proposed in which MRI can be used in conjunction with clinical assessment to specify more precisely the etiologic factors in cerebral palsy.