CEREBRAL PALSY HOW AND WHEN TO IMAGE WHAT TO EXPECT Nathan Demeyere Ziekenhuis Netwerk Antwerpen,...
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Transcript of CEREBRAL PALSY HOW AND WHEN TO IMAGE WHAT TO EXPECT Nathan Demeyere Ziekenhuis Netwerk Antwerpen,...
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