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Toward a Better Understanding of Cerebral Palsy

Neurologists and pediatricians alike should benefit from new guidelines on diagnosing CP.

Little described it, Nelson defined it, and the recent practice parameter from the American Academy of Neurology and the Child Neurology Society now provides some clarity to the often-confusing process of diagnosing cerebral palsy (CP; Trans Obstet Soc 1862; 3:378; Adv Neurol 1978; 19:421; and Pediatrics 1982; 69:529).

The parameter authors define CP as a "nonprogressive [emphasis added] disorder of posture or movement due to a lesion of the developing brain." They note that CP is a descriptive term and that many etiologies result in the multitude of clinical symptoms that characterize CP. The purpose of the parameter, therefore, was to review data on the role of diagnostic testing for these children and, secondarily, data on associated neurodevelopment problems in affected children.

The reviewers provide four major suggestions:

• They recommend neuroimaging in evaluating a child with CP. The average yield of an abnormal MRI finding in a child with CP (89%) is greater than that of CT (77%). MRI scans are more likely to be abnormal when CP is associated with preterm birth, but MRI has also detected cerebral malformations (not associated with preterm birth) in 12% of CP patients studied. Further, imaging may occasionally identify treatable lesions (5%-22% in reported CT studies) and may suggest an increased risk for associated conditions such as mental retardation and seizures.
  
• Metabolic and genetic studies are not recommended unless neuroimaging provides evidence of a cerebral malformation associated with an underlying neurogenetic or metabolic disorder.
  
• Although approximately 45% of children with CP have seizures, routine EEG studies are not useful for CP diagnosis in children without symptoms that suggest epilepsy.
  
• Particularly important is the recommendation that, because of the high incidence of associated conditions, children with CP should undergo developmental, ophthalmologic, hearing, speech, and language evaluations.
  

Comment: Why study cerebral palsy? The answer is clear. The cost of CP is high -- to the child, the family, and society. A recent estimate of cost per lifetime for each affected child approached U.S. $1 million (MMWR Morb Mortal Wkly Rep 2004; 53:57), and numbers are just the tip of the iceberg. As neurogenetic, neurometabolic, and neuroimaging studies provide a clearer picture of CP, better prevention and treatment will demand fuller understanding of the molecular mechanisms underlying injury to the developing brain (Ment Retard Dev Disabil Res Rev 2001; 7:56, and JAMA 2003 26; 290:2730). Ashwal and his group have provided data and direction for pediatricians and neurologists alike in diagnosing and evaluating children with CP.

— Laura R. Ment, MD

Dr. Ment is Professor of Pediatrics and Neurology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT.

Published in Journal Watch Neurology June 11, 2004

Citation(s):

Ashwal S et al. Practice parameter: Diagnostic assessment of the child with cerebral palsy. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2004 Mar 23; 62:851-63.

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• Medline abstract (Free)

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