Proxy-reported quality of life in adolescents and adults with dyskinetic cerebral palsy is associated with executive functions and cortical thickness.

PURPOSE: Quality of life (QOL) is a key outcome for people with cerebral palsy (CP), and executive functioning is an important predictor of QOL in other health-related conditions. Little is known about this association in CP or about its neural substrate. We aim to analyze the influence of executive functioning (including cognitive flexibility) as well as that of other psychological, motor, communication and socioeconomic variables on QOL and to identify neuroanatomical areas related to QOL in adolescents and adults with CP. METHODS: Fifty subjects diagnosed with dyskinetic CP (mean age 25.96 years) were recruited. Their caregivers completed the primary caregiver proxy report version of the CP QOL-Teen questionnaire. Motor status, communication, IQ, four executive function domains, anxiety/depression and socioeconomic status were evaluated. Correlations and multiple linear regression models were used to relate CP QOL domains and total score to these variables. Thirty-six participants underwent an MRI assessment. Correlations were examined between cortical thickness and CP QOL total score and between cortical thickness and variables that might predict the CP QOL total score. RESULTS: Executive functions predict scores in four domains of CP QOL (General well-being and participation, Communication and physical health, Family health and Feelings about functioning) in the regression model. Among the cognitive domains that comprise executive function, only cognitive flexibility measured in terms of performance on the Wisconsin card sorting test (WCST) predicts the CP QOL total score. Monthly income, fine motor functioning and communication ability predict scores on the domains Access to services and Family Health, Feelings about functioning and School well-being, respectively. The clusters resulting from the correlation between cortical thickness and both CP QOL total score and WCST performance overlapped in the posterior cingulate and precuneus cortices. CONCLUSIONS: Cognitive flexibility predicts proxy report CP QOL-Teen total score in dyskinetic CP. This relationship has its anatomical correlate in the posterior cingulate and precuneus cortices.

Response to creatine analogs in fibroblasts and patients with creatine transporter deficiency.

Creatine transporter (CRTR) deficiency is one of the most frequent causes of X-linked mental retardation. The lack of an effective treatment for this disease, in contrast to creatine (Cr) biosynthesis disorders that respond to Cr monohydrate (CM), led us to analyze the efficacy of a lipophilic molecule derived from Cr, creatine ethyl ester (CEE), in fibroblasts and patients with CRTR deficiency. CM and CEE uptake studies were performed in six controls and four fibroblast cell lines from patients. We found a significant increase in Cr uptake after 72 h of incubation with CEE (500 micromol/L) in patients and control fibroblasts compared to incubation with CM. Subsequently, we assayed the clinical effect of CEE administration in four patients with CRTR deficiency. After 1 year of treatment, a lack of significant improvement in neuropsychological assessment or changes in Cr level in brain (1)H MRS was observed, and CEE was discontinued. In conclusion, this 12-month trial with CEE did not increase the brain concentration of Cr. Our in vitro data lend support to the idea of a certain passive transport of CEE in both pathological and control cells, although more lipophilic molecules or other cell systems that mimic the BBB should be used for a better approach to the in vivo system.

[Prognostic factors and profile in traumatic brain injury in the paediatric age]. / Perfil y factores pronósticos en el traumatismo craneoencefálico en la edad pediátrica.

INTRODUCTION: Traumatic brain injury (TBI) is a common cause of death and disability in the paediatric population, although the literature on the Spanish population is scarce. From the perspective of early vulnerability, recent research findings suggest that early brain injury has worse sequelae and a higher risk of impact. AIMS: To analyse the intelligence profile, executive functions and behaviour, and examine the association between age at the time of the injury, severity of the TBI and environmental factors for cognitive and behavioural outcomes. PATIENTS AND METHODS: Seventy-one participants with moderate to severe TBI, from 6 to 16 years of age, were assessed with measures of intelligence (intelligence quotient), executive functions and behaviour. RESULTS: Children with TBI are at increased risk of disability in all aspects of intelligence, executive functions and behaviour. Children who suffered a traumatic brain injury in infancy and the preschool period had more overall effects on intelligence quotient and some aspects of the executive functions. CONCLUSIONS: Socioeconomic and cultural factors are the best predictors for intelligence quotient and behaviour. These findings contribute to a better understanding of the sequelae of TBI in children, which will help in rehabilitation planning and re-adaptation to functional life.

TITLE: Perfil y factores pronósticos en el traumatismo craneoencefálico en la edad pediátrica.Introducción. El traumatismo craneoencefálico (TCE) es una causa común de muerte y discapacidad en la población pediátrica, aunque la bibliografía en población española sea escasa. Desde la perspectiva de la vulnerabilidad temprana, los hallazgos de investigaciones recientes sugieren que la lesión cerebral temprana tiene peores secuelas y un mayor riesgo de impacto. Objetivos. Analizar el perfil de la inteligencia, las funciones ejecutivas y el comportamiento, y examinar la asociación de la edad a la lesión, la gravedad del TCE y los factores ambientales para los resultados cognitivos y conductuales. Pacientes y métodos. Setenta y un participantes con TCE moderado a grave, con edades entre 6 y 16 años, fueron evaluados con medidas de inteligencia (cociente intelectual), funciones ejecutivas y comportamiento. Resultados. Los niños con TCE tienen un mayor riesgo de discapacidad en todos los aspectos de inteligencia, funciones ejecutivas y comportamiento. Los niños que sufrieron una lesión cerebral traumática en la infancia y preescolar registraron más efectos globales en el cociente intelectual y algunos aspectos de las funciones ejecutivas. Conclusiones. Los factores socioeconómicos y culturales son los mejores predictores para el cociente intelectual y el comportamiento. Estos hallazgos contribuyen a una mejor comprensión de las secuelas de TCE en los niños para ayudar en la planificación de rehabilitación y la readaptación a la vida funcional.

Mental retardation and inborn errors of metabolism.

In countries where clinical phenylketonuria is detected by newborn screening inborn errors of metabolism are rare causes of isolated mental retardation. There is no international agreement about what type of metabolic tests must be applied in patients with unspecific mental retardation. However, and although infrequent, there are a number of inborn errors of metabolism that can present in this way. Because of the high recurrence risk and the possibility of specific therapies, guidelines need to be developed and adapted to different populations. The application of a universal protocol may result in a low diagnostic performance in individual ethnic populations. Consideration of associated signs (extraneurological manifestations, psychiatric signs, autistic traits, cerebellar dysfunction, epilepsy or dysmorphic traits) greatly improves the diagnostic fulfilment.

Efficacy of a new parent and school-supported intervention after moderate and severe childhood traumatic brain injury. / Eficacia de una nueva intervencion de apoyo a padres y escuelas despues de un traumatismo craneoencefalico moderado o grave.

INTRODUCTION: Traumatic brain injury is a common cause of acquired disability during childhood. Early interventions focusing on parenting practices may prove effective at reducing negative child outcomes. AIM: To determine the efficacy of a new counselling program aimed at parents and schools compared to a control group. PATIENTS AND METHODS: The main study sample was obtained from a paediatric hospital. The final sample consisted of 42 children aged between 6 and 16 years old. RESULTS: Comparing with normative data, pre-post comparisons between groups showed a significant improvement in the parent group with respect to the control group. CONCLUSIONS: The superiority of the parental intervention group over those of the control group was not only statistically significant, but also clinically substantial and meaningful. The results of this study suggest that children with moderate to severe traumatic brain injury can benefit from an intensive supported family treatment.

TITLE: Eficacia de una nueva intervencion de apoyo a padres y escuelas despues de un traumatismo craneoencefalico moderado o grave.Introduccion. El traumatismo craneoencefalico es una causa habitual de discapacidad adquirida durante la infancia. Las intervenciones tempranas que se centran en la participacion de los padres pueden resultar efectivas para reducir las disfunciones del niño. Objetivo. Determinar la eficacia de un nuevo programa de asesoramiento dirigido a padres y escuelas en comparacion con un grupo control. Pacientes y metodos. La muestra principal del estudio se obtuvo de un hospital pediatrico. La muestra final consistio en 42 niños de 6 a 16 años. Resultados. Comparando con los datos normativos, las comparaciones pre y post intragrupos mostraron una mejora significativa en el grupo de intervencion parental con respecto al grupo control. Conclusiones. La superioridad del grupo de intervencion parental sobre el grupo control no solo fue estadisticamente significativa, sino tambien clinicamente sustancial y relevante. Los resultados del estudio sugieren que los niños con traumatismo craneoencefalico moderado o grave pueden beneficiarse de un tratamiento familiar intensivo de apoyo.

Arginine supplementation in four patients with X-linked creatine transporter defect.

BACKGROUND: Treatment with oral creatine monohydrate has not shown efficacy in patients with creatine transporter deficiency (CRTR-D). Another therapeutic option proposed is L-arginine, the substrate for the enzyme L-arginine:glycine amidinotransferase (AGAT). We evaluate clinical characteristics and cerebral creatine replenishment after L-arginine therapy in four patients with CRTR-D. PATIENTS AND METHODS: Four boys with genetically confirmed diagnosis of CRTR-D (ages 9-16 years) were supplemented with L-arginine (0.4 g/kg per day) for a period of 9 months. Treatment efficacy was evaluated by clinical and neuropsychological assessment and determination of creatine signals by brain proton magnetic resonance spectroscopy ((1)H-MRS). RESULTS: Epileptic seizures remained well controlled with antiepileptic drugs in three cases, both before and after L-arginine supplementation. Vineland Adaptive Behaviour Scale did not show any change in communication, daily living skills, socialization or motor skills, and a lack of improvement in brain (1)H-MRS follow-up was observed. L-Arginine was discontinued at the end of the observation period. CONCLUSIONS: Nine months of L-arginine supplementation did not show effectiveness in the four patients affected with CRTR-D in this protocol.

[Moebius sequence: clinico-radiological findings]. / Secuencia de Moebius: hallazgos clinicorradiológicos.

INTRODUCTION: Moebius syndrome is an infrequent congenital, non-progressive disorder that is defined by facial palsy (usually bilateral) and oculomotor compromise. Its clinical spectrum is variable but it affects other cranial nerves and is associated with multiple malformations. PATIENTS AND METHODS: We report the clinical, neurological and neuroimaging features and the progress of 20 patients (16 males and 4 females) who satisfied diagnostic criteria for Moebius sequence. RESULTS: Ages at the first visit ranged from 9 days to 23 months. Births had been normal in 50% of the patients. Facial nerve compromise was observed in all cases, 70% being bilateral. Cranial nerves VI (85%), XII (40%), VIII (25%) and IX (60%) were also involved. Perinatal respiratory distress was seen in 35% of the patients, apnoeas in 25% and retarded development in 60% of cases. They also presented other associated malformations such as microretrognathia, ogival palate, club foot, hand and foot malformations, and four cases presented unilateral agenesis of the pectoralis major. An electromyogram study showed absence of spontaneous and voluntary activity and muscle evoked potentials on stimulating the facial nerve; magnetic resonance imaging of the brain showed hypoplasia of the trunk, agenesis of the cranial nerves and abnormalities in the posterior fossa in three of the ten cases in which the scan was performed. CONCLUSIONS: The association of multiple malformations and dysfunction of the cranial nerves suggests a disruption in the process of morphogenesis during the embryonic period, and therefore Moebius syndrome is considered to be a malformative sequence.

[Cerebral creatine transporter deficiency: an infradiagnosed neurometabolic disease]. / Deficiencia del transportador de creatina cerebral: una enfermedad neurometabolica infradiagnosticada.

INTRODUCTION: Brain creatine deficiencies are a group of inborn errors of metabolism recently recognized which are caused by arginine: glycine amidinotransferase (AGAT) deficiency, guanidinoacetate metiltransferase (GAMT) deficiency and defects in creatine transporter (CRTR). Although all of them are characterized by a brain creatine deficiency, clinical and biochemical features are different. CASE REPORTS: We present a retrospective study about four patients of masculine sex affected of creatine transporter defects who were recently diagnosed in our centre. We describe the clinical presentation features, the different tests that we used in the diagnosis process (brain magnetic resonance spectroscopy, biochemical analysis of guanidinoacetate and creatine/creatinine ratio in urine), evolution aspects and the response to treatment. The most significative clinical feature was developmental delay mainly in expressive speech, they also presented epilepsy (three cases), autism (three cases), hypotonia (one case) and microcephalia (one case). Brain magnetic resonance spectroscopy showed a low (three cases) or an absence (one case) of creatine level. To confirm the defect we studied the creatine uptake in fibroblasts and molecular analysis of the SLC6A8/creatine transporter gene. Patients with creatine transporter deficiency are being treated with arginine, because a lack of response to creatine. CONCLUSION: Cerebral creatine transporter deficiency can present with different neurological symptoms but developmental and language delay and epilepsy are the most significative; diagnosis is easy and there are some therapeutical options.

[Guidelines for the treatment of child spasticity using botulinum toxin]. / Guía terapéutica de la espasticidad infantil con toxina botulínica.

AIMS: The introduction of botulinum toxin has been a significant step forward in the treatment of spasticity in children and is now considered to be the preferred treatment in focal spasticity. With the aim of optimising this therapeutic resource, a group of Spanish neurologists and specialists in rehabilitation have drawn up these therapeutic guidelines based on the currently available evidence on its use and indications, and on their own experience. DEVELOPMENT: Spasticity in childhood is mainly caused by infantile cerebral palsy. Its natural history is not favourable due to the negative effect of growth and it should be treated before permanent deformities in bones and joints appear. Treatment with botulinum toxin diminishes hyperactivity and muscle tone, and allows the muscle to grow longitudinally, which prevents permanent contractions. The advantages of botulinum toxin are obvious (ease of use and dosing, long-lasting effects, reversibility in case of adverse responses, and so forth) and outnumber by far the few drawbacks it offers. Before it can be used patients, treatment goals and the muscle areas to be treated must all be selected correctly and, at the same time, a tailored rehabilitation scheme must also be developed. The growing body of experience suggests that its early administration is effective in preventing or reducing the severe complications of spasticity. CONCLUSIONS: Botulinum toxin type A is very effective in the treatment of spasticity. These guidelines offer the well-documented experience gained from its use and our knowledge about its indications, effects and safety in clinical practice.

Tocopherol in inborn errors of intermediary metabolism.

Red blood cell tocopherol was measured in a group of 92 children with inborn errors of intermediary metabolism to evaluate the peroxidative damage in different mitochondrial and cytosolic defects, and to consider the need for treatment or vitamin supplementation. Tocopherol was determined by HPLC with UV detection. Results were expressed in nanomoles red blood cell tocopherol per gram protein. Significant differences (Mann-Whitney; P < 0.001) were found between tocopherol levels in untreated patients: 19 with mitochondrial defects versus 23 with cytosolic enzyme or transport defects, and versus 58 age-matched reference values. In conclusion, mitochondrial enzyme deficiencies, either amino and organic acidurias or defects of energy metabolism, seem to produce an excess of free radicals with the consequent utilization of tocopherol as antioxidant. This is not apparent in the cytosolic enzyme defects studied, whose tocopherol levels are in the normal range. Treatment with tocopherol completely corrects the deficient antioxidant status.

Parasagittal cerebral injury: magnetic resonance findings.

Parasagittal cerebral injury is a specific pathologic lesion that can be found in full-term newborn babies suffering from hypoxic-ischemic encephalopathy. It is defined by the presence of cortical and subcortical white-matter necrosis involving the parasagittal and superomedial areas of the cerebral convexities. We report on two patients who showed parasagittal cerebral injury on magnetic resonance imaging. In both cases antecedents of hypoxic-ischemic encephalopathy were noted. In one of the patients basal ganglia involvement was also detected by cranial magnetic resonance imaging. In the follow-up studies the presence of upper-limb pyramidal signs and dyspraxia were two of the more pronounced symptoms. We will discuss the usefulness of neuroimaging, especially magnetic resonance imaging with coronal views, in the diagnosis of the parasagittal cerebral injury.

Rett syndrome in Spain: mutation analysis and clinical correlations.

Rett syndrome (RTT) is an X-linked neurodevelopmental disease that affects girls almost exclusively. In a high proportion of patients the disease is caused by de novo mutations at the MECP2 gene, encoding methyl-CpG-binding protein 2. With the aim to characterize the spectrum of mutations in a series of sporadic RTT patients, including an affected male, and to relate the genetic results to the clinical features of the disease, a clinical checklist and a score system were elaborated to evaluate the clinical severity of the disease. Mutation analysis of the MECP2 coding region was done by direct sequencing. De novo mutations were found in 60% of the patients, including both classic and atypical forms. The change R133H was identified in a 13-year-old boy showing a classic RTT phenotype and normal karyotype. Significant differences were observed among missense and truncating mutations regarding disease severity, age of onset of stereotypies, and the ability of the patients to sit alone and to walk.

[Cerebellar hemorrhage in full-term newborn babies]. / Hemorragia cerebelosa en recién nacidos a término.

INTRODUCTION: Cerebellar hemorrhage (CH) has been observed in 5 to 10% of the autopsies done on newborn babies. Since neuroimaging techniques have become available it is easier to diagnose the condition. In this paper we report on a series of cases of CH in full-term newborn babies. OBJECTIVES: To determine the number of patients with CH diagnosed by neuroimaging, make a descriptive study and analyze their progress. RESULTS: Between 1984 and 1999 six patients had CH, three boys and three girls, five born after their mother's first pregnancy. Four were vaginal births; in two forceps were used and in one a vacuum extractor; two were born by cesarean section. Four showed symptoms within the first 48 hours of life, one on the fourth day and one on the twenty fifth day. The latter had hemorrhagic disease of the newborn. In five patients transfontanellar ultrasound was useful in diagnosis. In all six cases computerized axial tomography scan confirmed the diagnosis. Cerebral magnetic resonance (MR) was done in three cases. No arteriovenous malformations were shown on angio-MR. Two patients had hydrocephalus and both were treated by ventriculo-peritoneal shunts. Three cases had transient ventricular dilatation which improved with medical treatment. The patient with hemorrhagic disease of the newborn had alterations in blood clotting. In three patients metabolic studies were normal. Five patients were treated conservatively and only one neurosurgically. Subsequent evolution was characterized by the presence of psychomotor retardation with mild cerebellar signs. At school age, only observed in two cases, there were learning difficulties with a low intellectual coefficient and problems with reading and writing. In one case there was epilepsy, controlled by use of two antiepileptic drugs. CONCLUSIONS: Half the cases of CH transfontanellar ultrasound is useful in diagnosis. Most patients were managed conservatively. During the clinical course there were psychomotor retardation, cerebellar signs, cognitive deficits with learning problems and epilepsy.

[Magnetic Resonance in children with dyskinetic cerebral palsy secondary to perinatal injury]. / Resonancia magnética craneal en niños con parálisis cerebral discinética de probable origen perinatal.

INTRODUCTION: The incidence of perinatal factors in the dyskinetic cerebral palsy (DCP) is high. The introduction of the magnetic resonance (MR) has improved our understanding of the pathophysiology and early diagnosis of injury. OBJECTIVE: Review the clinical characteristics of a group of patients with DCP and the appearance of their MR. PATIENTS AND METHODS: Retrospective study of 20 patients with DCP from 37 weeks of gestational age and perinatal injury with MR done. RESULTS: The perinatal injury was: fetal distress (15 cases), severe hyperbilirubinaemia (1 case) and neurological symptoms of unknown origin (3 cases). From the 15 patients with fetal distress, 10 had clinical manifestations of neonatal hypoxia ischemia. The rest were clinical healthy. Seventeen patients had abnormal MR. Four of these had fetal distress without neonatal clinical manifestations. MR findings show high intensity areas on T2 weighted images in the nucleus thalamus in 6 cases, putamen in 4, thalamus and putamen in 1, thalamus and pallidus in 2, thalamus and lenticular in 3 and in the lenticular alone in one case. In 5 cases hipointensity areas on T1 weighted images at the same sites were identified and in 1 case prolongation of T1. In the child whose CDP was caused by severe hyperbilirubinaemia the MR was normal. CONCLUSIONS: The fetal distress occurring late in labour without neonatal hipoxic ischemic manifestations can precede the developmental of DCP. Our observations support that in CDP resulting from perinatal injury the MR shows characteristic focal abnormalities in the basal ganglia (putamen and thalamus).

[Course and treatment of progressive subacute encephalopathy caused by human immunodeficiency virus in children. The value of Botulinum toxin]. / Evolución y tratamiento de la encefalopatía subaguda progresiva por virus de inmunodeficiencia humana en el niño. Utilidad de la toxina botulínica.

INTRODUCTION: Progressive subacute encephalopathy due to human immunodeficiency virus (PSE-HIV) is an important cause of morbidity and mortality in perinatal HIV infection. Although current combined antiretroviral therapies do manage to check its progression, they often give rise to severe motor sequelae that are similar to the spastic infantile cerebral palsy resulting from other aetiologies. We present the case reports of four preschool age children suffering from this pathology who have benefited from long term treatment with botulinum toxin type A (BTA). CASE REPORTS: Four patients suffering from early onset PSE HIV, who responded well to combined antiviral therapies, and who had severe motor sequelae (two cases of tetraparesis and two spastic dysplegias), with no cognitive disorders. The multidisciplinary treatment of their motor disorder included six monthly sessions of muscular injections of BTA in the usual doses, with good results from the functional point of view and with no significant side effects. DISCUSSION: PSE-HIV is defined by one of the following criteria: acquired microcephalus, retarded neurological development or symmetrical motor involvement. It constitutes one of the most frequent diagnostic criteria of AIDS in patients infected by vertical transmission. An early diagnosis and treatment are fundamental for the patient's prognosis. Severe motor sequelae in the form of spastic infantile cerebral palsy are frequent. In our experience treatment of the spasticity associated to this entity with BTA has proved to be useful and safe, with a clear improvement in gait functionality.

[Ataxia telangiectasia: review of 13 new cases]. / Ataxia telangiectasia: revisión de 13 observaciones.

We report the review of 13 patients who were diagnosed of ataxia telangiectasia before 6 years of age. All of them manifested cerebelous ataxia, oculocutaneus telangiectasias (11), sinopulmonary infections (9), dystonia (9), oculomotor apraxia (9) and Burkitt linfoma (1). We analyse the most common presentation of the disease in early stages and the complementary studies performed. The prompt diagnosis allow us a better control of infections, malignant process and finally the possibility of genetic counseling.

[Visuo-constructive disorders in periventricular leukomalacia]. / Trastornos visuoconstructivos en la leucomalacia periventricular.

INTRODUCTION: Cerebral palsy involves not only motor impairment but also the impairment of cognitive functions. Visuo spatial impairment has often been reported in preterm children with spastic diplegia due to periventricular leukomalacia. PATIENTS AND METHODS: Eight children with periventricular leukomalacia diagnosis. When examined their ages were between 3 and 13 years. RESULTS: We found visuo spatial anomalies in all subjects. These anomalies don't result in reading and writing learning difficulties. CONCLUSION: Constructional dyspraxia is frequently found in children with periventricular leukomalacia and correlates with reduction of peritrigonal white matter in parietal lobe.

[Infantile spasms in children with Down's syndrome]. / Espasmos infantiles en niños con síndrome de Down.

Two hundred eighty six infants with Down syndrome have been studied. Infantile spasms have been identified in nine of them, in which background, EEG pattern and its evolution, modalities of treatment and its effects, neuroimaging and development course have been revised. None of these patients had either familiar or personal pathological antecedents. The pattern in the first EEG made was hypsarrhytmic in all cases except one which showed a multifocal paroxystical activity, with intermittent and bilateral bursts of spike-waves. The treatment first used was ACTH in four cases, valproate in three cases and phenobarbital in two cases (one of these associated with nitrazepam). The ACTH treatment was effective in seven infants, either was the first or the second choice. An infant in whom the first treatment with ACTH was not successful, responded to the association with valproate+clonazepam. One patient treated initially with phenobarbital+nitrazepam, having no response to different prescriptions, responded finally to the association of carbamacepin+vigabatrin. The first treatment with valproate or phenobarbital had no effect in all patients. The EEG pattern improved in all cases just after the treatment response. Normal tracing was found for a period of two months to three years. Cranial TC was performed to three infants showing one of them a discrete ventricular dilatation and periventricular calcifications that suggested tuberous sclerosis. It is important to point out that, although the good effect of therapy and EEG pattern normalization, the development is below what had been expected in children with Down syndrome. Behavioral problems have been found in seven (77.7%) of these children.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neurological development of very low birth weight infants (<1,501 gr) at two ears of age]. / Evolución neurológica a los dos años de edad en una población de recién nacidos de muy bajo peso (< 1.501 g).

The aim of this study is to analyse different aspects of the psychomotor development, during the first two years of the life, of 56 very low birth weight newborns (less of 1.501 g) that had completed a follow-up program. Of the results we have got, the most important are the following: 4 observations (7%) presented severe sequelae motor disability in a tetraparesis with sensorial defects in 3 of them and behavior disturbance (psychosis) with visual defect in the rest. Three observations (5.3%) presented moderate sequelae: all of them with motor disability (hemi- or tetraparesis) and cognitive deficiency. Me have to point out that in the two groups described above, the pathological signs were detected before the age of 6 months. Nine observations (16%) presented mild sequelae dominating language delayed (7% of whole sample) and transient abnormalities in 7 of them (12.5%). In the subgroup of small for gestational age newborns (21 observations), 28.5% presented mild sequelae, 14% transient abnormalities and no one presented severe or moderate sequelae. Although a long term follow-up is necessary in order to detect learning, cognitive, or behavior disturbances, that can just become evident later, we think that the attention of the deviations of the normality during the two first years of the life, would warn about possible future disturbances.

[Botulinum toxin Type A. Indications and results]. / Toxina botulínica tipo A. Indicaciones y resultados.

INTRODUCTION: Since introduction for clinical in the 80s, the botulinum toxin type A is being used with effectiveness in the treatment of different disorders that goes with exaggerated muscular activity. Numerous studies have been demonstrated useful for focal treatment of spasticity. PATIENTS AND METHODS: Some indications of the botulinum toxin type A for the treatment of the cerebral palsy are reviewed, emphasizing that it use must be in a global planning. The positive results and adverse events are reviewed, of a series of 278 patients with spastic cerebral palsy. RESULTS: 19% of these patients have had a slightly positive answer, with modification of the tone but without functional repercussion, 49% have had a moderate answer, 17.5% have a good improvement and a 5% have presented good improvement for a long time. Of 224 patients with more than a year of evolution, the 9.5% have presented adverse reactions, but they have always been slight and transient. CONCLUSION: The botulinum toxin type A can be considered effective and safe for the treatment of spasticity, whenever the indication is correct and it is accompanied by a treatment of physiotherapy well oriented.