CEREBRAL PALSYHOW AND WHEN TO IMAGE

WHAT TO EXPECT

Nathan DemeyereZiekenhuis Netwerk Antwerpen, Belgium

• Diagnostic role of Neuro-imaging in Cerbral Palsy (CP)

• Predictive role of Neuro-imaging on neurodevelopmental outcome in CP

• Conclusion

Cerebral palsy: how and when to image what to expect

Diagnostic role of Neuro-imaging in CP

• detect brain injuries in neonate (nn) at risk -> clinical management

• majority of childeren CP -> abn. MRI 88.3%abn. US 57-94%

importance of neuro-imaging

Bax & al. JAMA 2006Kuban & al. J Child Neurol 2009/ De Vries & al. J Pediatr 144

Diagnostic role of Neuro-imaging: Casus

boy term (39 we): hypotonia, hyporeactivityconvulsions d 2

pregnancy: hypertensiondelivery: strangulation umbilical cord

Selective neuronal necrosis: deep nuclei and brainstem

DAY 1

DAY 2 & 3 US: negative

DAY 7

DAY 7

6 MONTHS: comprehensive assessment: Cerebral Palsy

Diagnostic role of Neuro-imaging: Modality

• US: - most widely used technique in neonates in NICU- practical (bedside, independent of stability patient)- availability (no waiting list, no direct acces to MRI)- cost

• MRI: gold standard for brain imaging at all ages

US still a role to play? US replaced by MRI?

Diagnostic role of Neuro-imaging: Modality

Miller & al. AJNR 2003Leijser & al. Neuroradiology 2010

Comparison US & MRI

- GA: 27-38 we- WM injuries- sequential US - MRI 32 we & TEA-MRI (Term Equivalent Age)

-sensitivity for detection *more severe WM lesion = similar *more subtle WM lesion: MRI>US - good corr. for intraventricular hemm. & ventriculomeg.

- GA: < 32 we - WM injuries - sequential US- TEA-MRI (predic. value of US for MRI)

- predictive value of US for TEA-MRI findings was *high for more severe WM lesions *less reliable for mild & moderate lesions

Diagnostic role of Neuro-imaging: Modality

Leijser & al. Early Human Development 2009Horsch & al. Arch.Dis.Child.Fetal 2009

Comparison US & MRI- GA < 32 we- TEA-US & TEA-MRI

- majority: US & MRI comparable accuracy-> US > calcifications, germinolytic & plexus cyst, lenticulostriatale vasculop. (LSV)-> MRI > more subtle WM injuries (punctate WM lesions (PWML), DEHSI)

- GA < 27 we- TEA-US & TEA-MRI

- detection severe WM abn. MRI = US- normal US -> normal MRI (64%) or mild abn. MRI (36%): TEA-MRI no relevant clinical info -> no change in clinical decision

Diagnostic role of Neuro-imaging: Modality

• TEA-MRI & TEA-US: majority comparable or equal accuracy

• TEA-MRI & US correlate well for severe WM lesions, intraventr. hemmorhagic lesions, ventriculomegalie

• TEA-MRI > more subtle WM lesion ( PWML, DEHSI)

• TEA-US > specific lesions (cyst, LSV, calcifications)

Summarize

Diagnostic role of Neuro-imaging: Timing

• variability in practice models

• standardised practice model for preterm in France:- 1-3 first 2 weeks of life- follow-up: * once in 2 weeks if no previous lesions* once every week if previous lesions

Beaino & al. Dev Med Child Neurol 2010

US

Diagnostic role of Neuro-imaging: Timing

• practice model for preterm function GA:

Leijsera & al. Early Hum Dev 2006

US

23-26 we d1, d2, d3, weekly untill 31 we, 33we, 35we, term

27-29 we d1, weekly untill 31 we, 36we, term

29-35 we d1, 3we, term

Diagnostic role of Neuro-imaging: Timing

• method of choice as follow-up examination starting at TEA• routine TEA-MRI in extreme preterm?• routine TEA-MRI in preterm with abn. US?

• diagnostic tool in NICU• first few days after birth: clinical management• between week 1-2 after birth: extent• improvement of technical equipement• sequences valuable in acute phase

Mirmiran & al. Pediatrics 2004/ Leijser & al. Neuroradiology 2010Rutherford & al. Pediatr Radiol 2010

MRI

Predictive role of Neuro-imaging in CP

• detect motor & neurodevelopmental impairement asap based on type & extent of brain injuries at or prior to term

• advantages of early detection of CP:• improve parental counseling and direct appropriate therapy before

discharge• evaluate short/long term effects of therapies in nn care• stimulate application of early intervention therapy

- pos. effect on motor development: start therapy < 6 mo

Koldewijn & al. J Pediatr 2010

Predictive role of Neuro-imaging: Modality

Bos & al. J Pediatr 2010

Neurodevelopmental assessement

- assess. 9-20 we & 3-4 mo: quality of spon. GM & concurr. motor repertoire- asses. 4we: NICU Netw. Neurobehav. Scales

reliable and valid predictor for major individual motordeficits

only predictive tool? role for neuro-imaging?

Predictive role of Neuro-imaging: Modality

Broitman & al. J Pediatr 2007Beaino & al. Dev Med & Child Neurol 2010

Clinical data vs. neuro-imaging

- GA 24-28 we- <28d US & near term US- clinical data <28d or discharge

clinical variables stronger predictor than US findings for CP at 18-22 mo

- GA 22-32 we- sequential US- WM inj. & intraventr. hemm.- neonat & obst. risk fact.

cerebral lesions are a very important predictor > neonat. & obstetrc risk factors for CP at 5 yrs.

Predictive role of Neuro-imaging: Modality

Spittle & al. Pediatrics 2009

Functional assessment vs. neuro-imaging

- GA < 30 we - TEA-MRI -> WM abn. - funct. assess (GM). 1 & 3 mo

TEA-MRI beter accuracy in predicting motor dysfunction for CP at 12 mo

Predictive role of Neuro-imaging: Modality

Himpens & al. Eur J Pediatr 2010/ Kuban & al. J Child Neurol 2009

Neuro-imaging: US

- GA 23- ≥37 we/ < 28 we- sequential US- assess. 4-6 mo,12 & 24 mo

specific perinataly acq. brain lesions predict specific types or severity of cerebral palsy in early childhood

Predictive role of Neuro-imaging: Modality

Dyet & al. Pediatrics 2006Jyoti & al. Pediatr Radiol 2006

Neuro-imaging: MRI

- GA 23-30 we - sequential MRI & TEA-MRI - assess. 18 mo

abnormalities TEA-MRI good relation reduced development

- term- TEA-MRI, HIE- assess. 1 yrs

high predictive value of mild to minor & severe brain abnorm.

Predictive role of Neuro-imaging: Modality

Woodward & al. New Eng J Med 2006Twomey & al. Pediatr Radiol 2010

Neuro-imaging: US & MRI

- GA ≤ 30 we, WMA, GMA- sequential US, TEA-MRI - assess. 2 yrs

predictive value of cerbral anomalies for CP: TEA-MRI > seq. US

- term - closest seq. US & TEA-MRI - MRI 2 yrs - assess. 2 yrs

- TEA-MRI significant predictor of outcome > US - good correlation TEA-MRI & late MRI (80%)

Predictive role of Neuro-imaging: Modality

• predictive value for CP:• TEA-MRI > neurodevelopmental assess.• TEA-MRI > US• TEA-MRI > preterm-MRI• US > ? < clinical data

Summarize

Conclusion

• MRI > US

in overall detection of the majority of brain lesions in term en preterm neonate

• US remains first choice evaluating preterm brain inNICU

• MRI is mainly a complementary investigation method

Conclusion

• predictive vallue of MRI > neurodevelopmental assess. > US

• comprehensive assess. remains the standard in evaluation of the child at risk

• still no standard practice to perform MRI at term equivalent age solely for the purpose of prognostic information