Antecedents and neuroimaging patterns in cerebral palsy with epilepsy and cognitive impairment: a population-based study in children born at term

Hemiplegic (unilateral) cerebral palsy in northern Stockholm: Intellectual disability and epilepsy

PURPOSE

The purpose of this study was to describe intellectual disability and its association with epilepsy and brain imaging, in a population-based group of children with hemiplegic (unilateral) cerebral palsy, previously investigated and published in 2020.

MATERIALS AND METHODS

Forty-seven children of school age in northern Stockholm, fulfilling the Surveillance of Cerebral Palsy in Europe-criteria of hemiplegic (unilateral spastic) cerebral palsy, were invited to participate in the study. Twenty-one children consented to participate. A WISC (Wechsler Intelligence Scale for Children)-test was performed by an experienced psychologist.

RESULTS

In the study population of twenty-one children, 57 % (n 12) displayed uneven cognitive profiles, 38 % (n 8) intellectual disability and 62 % (n 13) had a normal IQ. 43 % (n 9) developed epilepsy. Children with extensive brain lesions had more severe intellectual disability.

CONCLUSIONS

In this study intellectual disability and/or epilepsy were associated with the type and extent of the underlying brain lesion. Intellectual disability and uneven cognitive profiles were common. We therefore recommend individual cognitive assessment to ensure an optimal school start.

Clinical features associated with epilepsy occurrence, resolution, and drug resistance in children with cerebral palsy: A population-based study

AIM

To investigate clinicoradiological features associated with epilepsy, its resolution, and drug resistance in children with cerebral palsy (CP).

METHOD

Data were gathered from the New South Wales/Australian Capital Territory CP Register, encompassing children with CP born between 2003 and 2015 (n = 1916). Clinical features and the severity of impairments were compared among three groups: children with current epilepsy (n = 604), those with resolved epilepsy by age 5 years (n = 109), and those without epilepsy (n = 1203). Additionally, a subset of the registry cohort attending Children's Hospital Westmead (n = 256) was analysed to compare epilepsy and treatment characteristics between drug-responsive (n = 83) and drug-resistant groups (n = 147) using logistic regression and hierarchical cluster analysis.

RESULTS

Manual Ability Classification System levels IV and V, intellectual impairment, and vision impairment were found to be associated with epilepsy in children with CP on multivariable analysis (p < 0.01). Moderate to severe intellectual impairment and bilateral spastic CP were independent positive and negative predictors of epilepsy persistence at the age of 5 years respectively (p < 0.05). Microcephaly and multiple seizure types were predictors of drug-resistant epilepsy (area under the receiver operating characteristic curve of 0.83; 95% confidence interval 0.77-0.9). Children with a known genetic cause (14%) and CP epilepsy surgery group (4.3%) formed specific clinical subgroups in CP epilepsy.

INTERPRETATION

Our study highlights important clinical associations of epilepsy, its resolution, and treatment response in children with CP, providing valuable knowledge to aid in counselling families and identifying distinct prognostic groups for effective medical surveillance and optimal treatment.

WHAT THIS PAPER ADDS

Severe motor and non-motor impairments in cerebral palsy (CP) increase epilepsy risk. Epilepsy more likely resolves in bilateral spastic and milder CP impairments. Epilepsy in CP often manifests at an early age with multiple seizure types and high drug resistance. Children with a known genetic cause and CP epilepsy surgery group represent distinct clinical subgroups.

The Profile of Epilepsy and its characteristics in Children with Cerebral Palsy

PURPOSE

To determine the characteristics of epilepsy in children with Cerebral Palsy (CP) visiting the Pediatric Outpatient Department (OPD) of a tertiary care hospital.

METHODS

This cross-sectional study was carried out at a tertiary care pediatric hospital. All children with CP aged between 1 and 12 years seen at this hospital during an 18 months period (January 2018 to July 2019) were included. Children with CP who had seizures were studied in detail. Seizure semiologies were classified according to the International League Against Epilepsy (ILAE) 1981 and 2017 classifications. The severity of seizures was assessed with the Early Childhood Epilepsy Severity Scale (E-Chess). Functional impairment was characterised using the Gross Motor Function Classification System (GMFCS) score.

RESULTS

Of 300 children with CP, 207 (69%) were male and 93 (31%) female. The mean age was 45.17±31.12 months. Seizures were present in 79 (26%) children. 89.9% of children had drug-responsive epilepsy, and 10.1% had refractory epilepsy. Seizures were present in 30.4% of children with a spastic hemiplegia CP subtype, 28.7% with spastic quadriplegia, 26.3% with spastic diplegia, 24% with mixed type CP, and 6.3% with dyskinetic CP. On E-Chess assessment, the median score was 8 (4-14). The majority had poor Gross Motor Function Classification System (GMFCS) scores (>III).

CONCLUSION

The prevalence of epilepsy in the studied population of children with CP was 26%. The highest incidence of seizures was in the spastic hemiplegia subtype (30.4%). The severity of cortical damage is positively correlated with the risk of having epilepsy. The primary determinant of severity of the GMFCS score was the type of CP and not the presence or absence of epilepsy.

Cognitive, academic, executive and psychological functioning in children with spastic motor type cerebral palsy: Influence of extent, location, and laterality of brain lesions

PURPOSE

To investigate, in spastic motor-type cerebral palsy, the association between 1) the location and extent of brain lesions and numerous psychological outcomes; 2) the laterality of brain lesions and performance of verbal-related cognitive functions.

METHODS

The semi-quantitative scale for MRI (sqMRI) was scored for 101 children with cerebral palsy. Non-verbal and verbal proxy intelligence quotients (IQ), word reading, spelling, numerical operations skills, executive functioning, and psychological adjustment were assessed. Relationships between global and regional sqMRI scores and clinical scores were examined. The best multivariable linear regression model for each outcome was identified using the Bayesian Information Criteria. Regional sqMRI scores, gross motor functioning, manual ability, and epilepsy status were considered for inclusion as covariables. Where sqMRI scores made statistically significant contributions to models of verbal-related functioning, data were reanalysed including these sqMRI scores' laterality index. Verbal-related outcomes were compared between participants with left-sided versus bilateral brain lesions.

RESULTS

Medial dorsal thalamus and parietal lobe lesions significantly accounted for poorer verbal proxy-IQ. Left-hemisphere lateralization of temporal lobe lesions was associated with poorer verbal proxy-IQ. Participants with bilateral lesions performed significantly better than those with unilateral left-sided lesions in verbal cognitive functions. Controlling for epilepsy diagnosis, participants with ventral posterior lateral thalamus lesions presented with better Behaviour Rating Inventory of Executive Function scores, although within the normal range. sqMRI scores were not significantly associated with some psychological outcomes or these only bordered on significance after accounting for relevant control variables.

CONCLUSION

The laterality of early-life lesions influences the development of verbal-related cognitive functions.

Associations between antenatal and perinatal risk factors and cerebral palsy: a Swedish cohort study

OBJECTIVES

To investigate known and suggested risk factors associated with cerebral palsy in a Swedish birth cohort, stratified by gestational age.

SETTING

Information on all births between 1995 and 2014 in Skåne, the southernmost region in Sweden, was extracted from the national birth register.

PARTICIPANTS

The cohort comprised a total of 215 217 children. Information on confirmed cerebral palsy and subtype was collected from the national quality register for cerebral palsy (Cerebral Palsy Follow-up Surveillance Programme).

PRIMARY AND SECONDARY OUTCOME MEASURES

We calculated the prevalence of risk factors suggested to be associated with cerebral palsy and used logistic regression models to investigate the associations between potential risk factors and cerebral palsy. All analyses were stratified by gestational age; term (≥37 weeks), moderately or late preterm (32-36 weeks) and very preterm (<32 weeks).

RESULTS

In all, 381 (0.2 %) children were assigned a cerebral palsy diagnosis. Among term children, maternal preobesity/obesity, small for gestational age, malformations, induction, elective and emergency caesarian section, Apgar <7 at 5 min and admission to neonatal care were significantly associated with cerebral palsy (all p values<0.05). Among children born moderately or late preterm, small for gestational age, malformations, elective and emergency caesarian section and admission to neonatal care were all associated with cerebral palsy (all p values <0.05), whereas among children born very preterm no factors were significantly associated with the outcome (all p values>0.05).

CONCLUSION

Our results support and strengthen previous findings on factors associated with cerebral palsy. The complete lack of significant associations among children born very preterm probably depends on to the small number of children with cerebral palsy in this group.

Hemiplegic (unilateral) cerebral palsy in northern Stockholm: clinical assessment, brain imaging, EEG, epilepsy and aetiologic background factors

BACKGROUND

The purpose of this study was to describe clinical presentation, epilepsy, EEG, extent and site of the underlying cerebral lesion with special reference towards aetiologic background factors in a population-based group of children with hemiplegic cerebral palsy.

METHODS

Forty-seven children of school- age, fulfilling the SPCE (Surveillance of Cerebral palsy in Europe)-criteria of hemiplegic cerebral palsy, identified via the Swedish cerebral palsy register, were invited and asked to participate in the study.

RESULTS

Fifteen boys and six girls participated. Of the sixteen children born at term, five had no risk factors for cerebral palsy. Two out of five preterm children presented additional risk factors. Debut of motor impairment was observed in the first year of life in sixteen children. Age at diagnosis varied from 2 months to 6 years. Epilepsy was common and associated with grey- and white matter injury.

CONCLUSIONS

Recognizing the importance of risk factors for cerebral palsy, any child with these risk factors should be offered a check-up by a paediatrician or a paediatric neurologist. Thereby reducing diagnostic delay. Epilepsy is common in hemiplegic cerebral palsy and associated with grey- and white matter injury in this cohort.

[Clinical experience of using zonisamide in structural focal epilepsy in children with cerebral palsy]

AIM

To evaluate the efficacy and safety of zonisamide as an add-on therapy in structural focal epilepsy in children with cerebral palsy (CP).

MATERIAL AND METHODS

Sixty-four patients (36 boys and 28 girls) with spastic CP and structural focal epilepsy with refractory seizures were followed up. Patients received zonisamide in a dose of 6-8.8 mg/kg/day for ≥6 months. Treatment efficacy was assessed by the reduction of seizures depending on CP form, type of epileptic seizures, combination of zonisamide with other drugs and adverse-effects.

RESULTS AND CONCLUSION

A reduction of seizures by ≥50% was identified in 60.9% of children, 10.9% showed a better recovery. The best efficacy (35.9%) was demonstrated in the treatment of generalized seizures with focal onset and in the combination with levetiracetam (35.9%). Adverse effects of mild to moderate severity were noted in 26.5% of children. The treatment was discontinued in 7.8%. Therefore, zonisamide is an effective treatment for refractory structural focal epilepsy in children with CP and comorbid pathology, which reduces the frequency of seizures without severe side-effects.

Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study

Background

Motor outcomes of children with unilateral cerebral palsy are clearly documented and well understood, yet few studies describe the cognitive functioning in this population, and the associations between the two is poorly understood. Using two hands together in daily life involves complex motor and cognitive processes. Impairment in either domain may contribute to difficulties with bimanual performance. Research is yet to derive whether, and how, cognition affects a child’s ability to use their two hands to perform bimanual tasks.

Methods/Design

This study will use a prospective, cross-sectional multi-centre observational design. Children (aged 6–12 years) with unilateral cerebral palsy will be recruited from one of five Australian treatment centres. We will examine associations between cognition, bimanual performance and brain neuropathology (lesion type and severity) in a sample of 131 children. The primary outcomes are: Motor - the Assisting Hand Assessment; Cognitive - Executive Function; and Brain – lesion location on structural MRI. Secondary data collected will include: Motor - Box and Blocks, ABILHAND- Kids, Sword Test; Cognitive – standard neuropsychological measures of intelligence. We will use generalized linear modelling and structural equation modelling techniques to investigate relationships between bimanual performance, executive function and brain lesion location.

Discussion

This large multi-centre study will examine how cognition affects bimanual performance in children with unilateral cerebral palsy. First, it is anticipated that distinct relationships between bimanual performance and cognition (executive function) will be identified. Second, it is anticipated that interrelationships between bimanual performance and cognition will be associated with common underlying neuropathology. Findings have the potential to improve the specificity of existing upper limb interventions by providing more targeted treatments and influence the development of novel methods to improve both cognitive and motor outcomes in children with unilateral cerebral palsy.

Trial registration

ACTRN12614000631606; Date of retrospective registration 29/05/2014.

Stem cells and cell-based therapies for cerebral palsy: a call for rigor

Cell-based therapies hold significant promise for infants at risk for cerebral palsy (CP) from perinatal brain injury (PBI). PBI leading to CP results from multifaceted damage to neural cells. Complex developing neural networks are injured by neural cell damage plus unique perturbations in cell signaling. Given that cell-based therapies can simultaneously repair multiple injured neural components during critical neurodevelopmental windows, these interventions potentially offer efficacy for patients with CP. Currently, the use of cell-based interventions in infants at risk for CP is limited by critical gaps in knowledge. In this review, we will highlight key questions facing the field, including: Who are optimal candidates for treatment? What are the goals of therapeutic interventions? What are the best strategies for agent delivery, including timing, dosage, location, and type? And, how are short- and long-term efficacy reliably tracked? Challenges unique to treating PBI with cell-based therapies, and lessons learned from cell-based therapies in closely related neurological disorders in the mature central nervous system, will be reviewed. Our goal is to update pediatric specialists who may be counseling families about the current state of the field. Finally, we will evaluate how rigor can be increased in the field to ensure the safety and best interests of this vulnerable patient population.