Making waves: The changing tide of cerebral palsy.

Cerebral palsy (CP) is a broad diagnosis unbound by aetiology and is based on a clinical examination demonstrating abnormalities of movement or posture. CP represents a static neurological condition, provided that neurodegenerative conditions, leukoencephalopathies and neuromuscular disorders are excluded. In paediatrics, the genetic conditions associated with CP are rapidly increasing, with primary and overlapping neurodevelopmental conditions perhaps better categorised by the predominant clinical feature such as CP, intellectual disability, autism spectrum disorder or epilepsy. Progress in molecular genetics may challenge what constitutes CP, but a genetic diagnosis does not negate the CP diagnosis. As clinicians working in the field, we discuss the changing tide of CP. Neuroimaging provides essential information through pattern recognition and demonstration of static brain changes. We present examples of children where a layered clinical diagnosis or dual aetiologies are appropriate. We also present examples of children with genetic causes of CP to highlight the challenges and limitations of neuroimaging to provide an aetiological diagnosis. In consultation with a geneticist, access to genomic testing (exome or genome sequencing) is now available in Australia under Medicare billing for children under the age of 10 with dysmorphic features, one or more major structural organ anomalies, (an evolving) intellectual disability or global developmental delay. We encourage the uptake of genomic testing in CP, because it can be difficult to tell whether a child has an environmental or genetic cause for CP. A specific genetic diagnosis may change patient management, reduce guilt and enable more distinctive research in the future to assist with understanding disease mechanisms.

Deep nuclei injury distribution in isolated "basal ganglia-thalamus" (BGT) versus combined "BGT and watershed" patterns of hypoxic-ischaemic injury (HII) in children with cerebral palsy.

AIM: To compare frequency and distribution of deep nuclei involvement in isolated basal ganglia and ventrolateral thalamus (BGT) versus combined BGT and watershed (BGT-WS) hypoxic-ischaemic injury (HII). MATERIALS AND METHODS: A retrospective review was undertaken of the magnetic resonance imaging (MRI) reports of children (0-18 years) with isolated BGT or combined BGT-WS HII. The location and extent of deep nuclear injuries were compared between groups using Fisher's exact test. RESULTS: Of 762 MRI reports, 435 (57%) had isolated BGT and 327 (43%) combined BGT-WS. Isolated BGT showed basal ganglia involvement in 85.1% (n=370) versus 49.8% (n=163) for combined BGT-WS (p<0.01). Sole putamen lesions were more common in isolated BGT (70.3%; 306) versus combined (19.3%; 63; p<0.01). Thalamic involvement was similar between isolated BGT (93.8%; 408) and combined BGT-WS (96.9%; 317; p>0.05). Sole ventrolateral nucleus involvement was more common in isolated BGT (66.6%; 291) while sole pulvinar lesions (25.1%; 82) and whole thalamus lesions (41.6%; 136) were more common in combined BGT-WS (p<0.01). Putamen and ventrolateral nucleus was the most frequent BGT lesion combination in isolated BGT (55.4%) but not in combined BGT-WS (8.6%; p<0.01). CONCLUSION: Variations in the frequency of deep nuclear lesions between groups may reflect different underlying pathogenetic mechanisms. Therefore, combined BGT-WS patterns may not necessarily indicate a superimposed profound on partial prolonged HII, as other causes such as neonatal hypoglycaemia may cause these.

Can Children With Perinatal Stroke Use a Simple Brain Computer Interface?

Background and Purpose: Perinatal stroke is the leading cause of hemiparetic cerebral palsy resulting in lifelong disability for millions of people worldwide. Options for motor rehabilitation are limited, especially for the most severely affected children. Brain computer interfaces (BCIs) sample brain activity to allow users to control external devices. Functional electrical stimulation enhances motor recovery after stroke, and BCI-activated functional electrical stimulation was recently shown to improve upper extremity function in adult stroke. We aimed to determine the ability of children with perinatal stroke to operate a simple BCI. Methods: Twenty-one children with magnetic resonance imaging­confirmed perinatal stroke (57% male, mean [SD] 13.5 [2.6] years, range 9­18) were compared with 24 typically developing controls (71% male, mean age [SD] 13.7 [3.7] years, range 6­18). Participants trained on a simple EEG-based BCI over 2 sessions (10 trials each) utilizing 2 different mental imagery strategies: (1) motor imagery (imagine opening and closing of hands) and (2) goal oriented (imagine effector object moving toward target) to complete 2 tasks: (1) drive a remote controlled car to a target and (2) move a computer cursor to a target. Primary outcome was Cohen Kappa with a score >0.40 suggesting BCI competence. Results: BCI performance was comparable between stroke and control participants. Mean scores were 0.39 (0.18) for stroke versus 0.42 (0.18) for controls (t[42]=0.478, P=0.94). No difference in performance between venous (M=0.45, SD=0.29) and arterial (M=0.34, SD=0.22) stroke (t[82]=1.89, P=0.090) was observed. No effect of task or strategy was observed in the stroke participants. Over 90% of stroke participants demonstrated competency on at least one of the 4 task-strategy combinations. Conclusions: Children with perinatal stroke can achieve proficiency in basic tasks using simple BCI systems. Future directions include exploration of BCI-functional electrical stimulation systems for rehabilitation for children with hemiparesis and other forms of cerebral palsy.

Risk of cerebral palsy in Chinese children: A N:M matched case control study.

AIM: To estimate epidemiological risk factors for cerebral palsy (CP) in children. METHODS: A N:M matched case control study was conducted in 114 persons with CP and 1286 controls. Relevant data were collected using a maternal self-design questionnaire. Univariate logistic regression and multivariate conditional logistic regression analyses were performed using SPSS. RESULTS: Univariate analysis has yielded 20 significant risk factors for CP. Advanced maternal age (30 years or older) at childbirth (adjusted odds ratio (OR) 1.63, 95% confidence interval (CI) 0.98-2.72), alcohol consumption during pregnancy (adjusted OR 4.17, 95% CI 1.23-14.08), living in the countryside (adjusted OR 1.71, 95% CI 1.18-2.48), father's occupational exposure to harmful substances (adjusted OR 3.34, 95% CI 1.61-6.93) and multiple births (adjusted OR 3.10, 95% CI 1.65-5.84) were found to be risk factors for CP by multivariate analysis. On the other side, high mother's education level (adjusted OR 0.60, 95% CI 0.46-0.76), folic acid supplements (adjusted OR 0.50, 95% CI 0.30-0.82), and high birth hospital level (adjusted OR 0.68, 95% CI 0.52-0.90) were found to be protective factors. CONCLUSION: Although the important risk factors of CP focus on gestation at birth and perinatal events, the incidence could probably be further lowered, if potential risk factors identified in this study are considered.

Spectroscopic biomarkers of motor cortex developmental plasticity in hemiparetic children after perinatal stroke.

Perinatal stroke causes hemiparetic cerebral palsy and lifelong motor disability. Bilateral motor cortices are key hubs within the motor network and their neurophysiology determines clinical function. Establishing biomarkers of motor cortex function is imperative for developing and evaluating restorative interventional strategies. Proton magnetic resonance spectroscopy (MRS) quantifies metabolite concentrations indicative of underlying neuronal health and metabolism in vivo. We used functional magnetic resonance imaging (MRI)-guided MRS to investigate motor cortex metabolism in children with perinatal stroke. Children aged 6-18 years with MRI-confirmed perinatal stroke and hemiparetic cerebral palsy were recruited from a population-based cohort. Metabolite concentrations were assessed using a PRESS sequence (3T, TE = 30 ms, voxel = 4 cc). Voxel location was guided by functional MRI activations during finger tapping tasks. Spectra were analysed using LCModel. Metabolites were quantified, cerebral spinal fluid corrected and compared between groups (ANCOVA) controlling for age. Associations with clinical motor performance (Assisting Hand, Melbourne, Box-and-Blocks) were assessed. Fifty-two participants were studied (19 arterial, 14 venous, 19 control). Stroke participants demonstrated differences between lesioned and nonlesioned motor cortex N-acetyl-aspartate [NAA mean concentration = 10.8 ± 1.9 vs. 12.0 ± 1.2, P < 0.01], creatine [Cre 8.0 ± 0.9 vs. 7.4 ± 0.9, P < 0.05] and myo-Inositol [Ins 6.5 ± 0.84 vs. 5.8 ± 1.1, P < 0.01]. Lesioned motor cortex NAA and creatine were strongly correlated with motor performance in children with arterial but not venous strokes. Interrogation of motor cortex by fMRI-guided MRS is feasible in children with perinatal stroke. Metabolite differences between hemispheres, stroke types and correlations with motor performance support functional relevance. MRS may be valuable in understanding the neurophysiology of developmental neuroplasticity in cerebral palsy. Hum Brain Mapp 38:1574-1587, 2017. © 2016 Wiley Periodicals, Inc.

Optic nerve morphology as marker for disease severity in cerebral palsy of perinatal origin.

BACKGROUND: It is difficult to predict the neurologic outcome and ambulatory status in children with perinatal neurologic insult until 2-5years age. This study aims to correlate clinical optic nerve head (ONH) findings-cupping, pallor and hypoplasia, with gestational period and neurologic (motor) outcomes in patients with cerebral palsy (CP) from perinatal insults. METHODS: 54 consecutive patients with CP from perinatal insults were enrolled. Patients with intraocular disease, retinopathy of prematurity and hydrocephalus were excluded. ONH was labeled as pale, hypoplastic or large cup (cup/disc ratio≥0.5) if 2 ophthalmologists independently agreed after an ophthalmoscopic examination. Inter-rater reliability was excellent. RESULTS: Mean age at examination was 10.98±6.49years; mean gestational period was 33.26±4.78weeks. Abnormal ONH (pallor, cupping or hypoplasia) was seen in 38/54 (70%) patients. Of patients with pallor (n=17), 88% were quadriplegic and 82% non-ambulatory. Mean cup/disc ratio was 0.45±0.22; 50% patients had large cup. Multivariate logistic regression models showed that disc pallor was associated with non-ambulatory status (OR: 21.7; p=0.003) and quadriplegia (OR: 12.8; p=0.03). Large cup was associated with age at examination (OR 1.15; p=0.03). Cup/disc ratio showed positive correlation with age at examination (Pearson's r=0.39; p=0.003). There was no significant association of ONH parameters with gestational age. CONCLUSION: Clinically observed ONH changes (pallor, cupping and hypoplasia) are common in CP. Presence of ONH pallor serves as an indicator for poor motor outcome in patients who develop CP from perinatal causes and should prompt early referral for rehabilitation.

Serial 1- and 2-Dimensional Cerebral MRI Measurements in Full-Term Infants after Perinatal Asphyxia.

OBJECTIVE: Cranial magnetic resonance imaging (MRI) is associated with neurodevelopmental outcome in full-term infants with neonatal encephalopathy (NE) following presumed perinatal asphyxia. The aim of this study is to relate 2-dimensional measurements of the basal ganglia and thalami (BGT) and cerebellum in the first week after birth and after 3 months with neurodevelopmental outcome at 18 months. METHODS: Retrospectively, 29 full-term infants with NE following presumed perinatal asphyxia who had a cranial MRI in the first week after birth were studied serially. One- and 2-dimensional measurements were obtained and related to different patterns of brain injury, and neurodevelopmental outcome at 18 months. A Griffiths developmental quotient <85 or cerebral palsy was considered adverse. RESULTS: On the first MRI, the adverse outcome group showed increased basal ganglia width (42.1 ± 0.1 vs. 40.3 ± 0.3 mm, p < 0.001), thalamic width (40.3 ± 0.1 vs. 39.3 ± 1.0 mm, p < 0.001), and basal ganglia surface (1,230 ± 21 vs. 1,199 ± 36 mm2, p = 0.007) compared to the favorable outcome group. In the BGT lesions group, basal ganglia width and thalamic width were increased compared to the watershed infarction group (42.1 ± 0.1 vs. 40.9 ± 0.8 mm, p < 0.001, and 40.3 ± 0.1 vs. 39.9 ± 0.5 mm, p = 0.01, respectively). On the second MRI, cerebellar width was larger in the favorable outcome group (p = 0.025). There was a greater increase in dimensions between both MRI time points for basal ganglia width (p = 0.014), basal ganglia surface (p = 0.028) and thalamic width (p = 0.012) in the favorable outcome group. CONCLUSIONS: One- and 2-dimensional measurements for basal ganglia surface, BGT width and cerebellar width are associated with neurodevelopmental outcome at 18 months.

Risk factors for cerebral palsy in premature infants identified during the pre and perinatal periods: a case-control study.

BACKGROUND: The aim of this paper was to assess the pre and perinatal risk factors for cerebral palsy in premature infants, comparing them with full-term infants. METHODS: This was a prospective cross-sectional cohort study on 48 infants between four and eight months of life, of whom 20 were born prematurely (<37 weeks of gestational age) and 28 at full term (37 to 42 weeks). A questionnaire was used, which investigated maternal reproductive, obstetric and neonatal factors, along with an evaluation scale for neurosensory-motor development of infants at risk of neuromotor alterations. For the statistical analysis, the Student's t, chi-square, Fisher's exact and Cramer's V tests were used. RESULTS: All the newborns that were small for their gestational age (35%) were in the premature group (P=0.001). Hyperbilirubinemia (P=0.000), anemia (P=0.009), respiratory distress syndrome (P=0.000) and periventricular hemorrhage (P=0.025) were more frequent in the premature newborn group. Phototherapy and blood transfusion were more frequent among the premature infants: 70.0% vs. 25.0% (P=0.002) and 20.0% vs. 0.0% (P=0.025), respectively. Among the premature infants, 50.0% presented neuromotor development alterations, against only 14.3% of the full-term infants. CONCLUSIONS: Prematurity is an important risk factor for the development of neurosensory-motor alterations that are suggestive of cerebral palsy.

Arterial spin-labelling perfusion MRI and outcome in neonates with hypoxic-ischemic encephalopathy.

PURPOSE: Hyperperfusion may be related to outcome in neonates with hypoxic-ischemic encephalopathy (HIE). The purpose of this study was to evaluate whether arterial spin labelling (ASL) perfusion is associated with outcome in neonates with HIE and to compare the predictive value of ASL MRI to known MRI predictive markers. METHODS: Twenty-eight neonates diagnosed with HIE and assessed with MR imaging (conventional MRI, diffusion-weighted MRI, MR spectroscopy [MRS], and ASL MRI) were included. Perfusion in the basal ganglia and thalami was measured. Outcome at 9 or 18 months of age was scored as either adverse (death or cerebral palsy) or favourable. RESULTS: The median (range) perfusion in the basal ganglia and thalami (BGT) was 63 (28-108) ml/100 g/min in the neonates with adverse outcome and 28 (12-51) ml/100 g/min in the infants with favourable outcome (p < 0.01). The area-under-the-curve was 0.92 for ASL MRI, 0.97 for MRI score, 0.96 for Lac/NAA and 0.92 for ADC in the BGT. The combination of Lac/NAA and ASL MRI results was the best predictor of outcome (r(2) = 0.86, p < 0.001). CONCLUSION: Higher ASL perfusion values in neonates with HIE are associated with a worse neurodevelopmental outcome. A combination of the MRS and ASL MRI information is the best predictor of outcome. KEY POINTS: • Arterial spin labelling MRI can predict outcome in neonates with hypoxic-ischemic encephalopathy • Basal ganglia and thalami perfusion is higher in neonates with adverse outcome • Arterial spin labelling complements known MRI parameters in the prediction of outcome • The combined information of ASL and MRS measurements is the best predictor of outcome.

Encefalopatía por Kernicterus. serie clínica / Kernicterus (bilirubin encephalopathy): case reports

Introducción: La ictericia es común en los recién nacidos (RN). Niveles de bilirrubina a partir de 20 mg/dL (en RN de término) pueden causar parálisis cerebral coreoatetósica, hipoacusia sensorioneural, trastornos de la mirada y displasia del esmalte dental, cuadro clínico conocido como kernicterus. Objetivo: Describir 5 casos de kernicterus controlados en una Unidad de Neurología, entre los años 2002-2012. Casos clínicos: Se presentan 5 niños con edades gestacionales entre 35 y 39 semanas, con peso de nacimiento rango 2.580 y 4.250 g y niveles de bilirrubina entre 24 y 47 mg/dL. Dos RN estaban en su domicilio cuando iniciaron la encefalopatía aguda. Todos se trataron con fototerapia y en 3 casos se realizó además exanguineotransfusión. La edad del diagnóstico de kernicterus fluctuó entre los 12 días y 10 años (3 pacientes se diagnosticaron en etapa neonatal) con una resonancia magnética que demostró impregnación de ganglios basales. Todos evolucionaron con trastornos del movimiento de severidad variable. En 3 pacientes se diagnosticó hipoacusia sensorioneural y en dos hubo trastornos de la mirada. Los test psicométricos evaluaron retraso cognitivo en 3 pacientes y desarrollo normal en los restantes. Conclusión: El kernicterus en una enfermedad devastadora que aún está presente en la realidad nacional. Es una causa de parálisis cerebral prevenible, por lo cual es necesario educar a los padres, población y equipo de salud para la detección precoz y tratamiento oportuno de la hiperbilirrubinemia neonatal.

Introduction: Jaundice is common in newborn babies (NB). Bilirubin levels of 20 mg/dL or higher may cause choreoathetoid cerebral palsy, sensorineural hearing loss, eye disorders and enamel dysplasia in term infants; clinical picture compatible with kernicterus. Objective: To describe five cases of kernicterus treated at a Neurology Unit between 2002 and 2012. Case reports: Five cases of babies with gestational ages between 35 and 39 weeks, birth-weight ranging from 2580 to 4250 grams and bilirubin levels between 24 and 47 mg/dL are presented. Two infants were at home when acute encephalopathy developed, all were treated with phototherapy and 3 of them underwent exchange transfusion. The age of diagnosis of kernicterus was between 12 days to 10 years; three patients were diagnosed in neonatal period through MRI that revealed basal ganglia impregnation. All patients evolved presenting movement disorders of varying severity. Three of them were diagnosed with sensorineural hearing impairments and two presented eye disorders. Psychometric tests showed cognitive delay in three patients and normal development in the remaining children. Conclusion: Kernicterus in a devastating disease present in the national reality. It is a preventable cause of cerebral palsy; therefore, it is necessary to educate parents, population and health care professionals about neonatal hyperbilirubinemia early detection and treatment.

Can noninvasive brain stimulation measure and modulate developmental plasticity to improve function in stroke-induced cerebral palsy?

The permanent nature of motor deficits is a consistent cornerstone of cerebral palsy definitions. Such pessimism is disheartening to children, families, and researchers alike and may no longer be appropriate for it ignores the fantastic plastic potential of the developing brain. Perinatal stroke is presented as the ideal human model of developmental neuroplasticity following distinct, well-defined, focal perinatal brain injury. Elegant animal models are merging with human applied technology methods, including noninvasive brain stimulation for increasingly sophisticated models of plastic motor development following perinatal stroke. In this article, how potential central therapeutic targets are identified and potentially modulated to enhance motor function within these models is discussed. Also, future directions and emerging clinical trials are reviewed.

Cochrane Review: Prophylactic phototherapy for preventing jaundice in preterm or low birth weight infants.

BACKGROUND: Low birth weight and premature infants are at major risk for exaggerated hyperbilirubinaemia and jaundice that can lead to bilirubin encephalopathy. Phototherapy is the most common treatment for neonatal hyperbilirubinaemia and could be most effective in preventing the sequelae of hyperbilirubinaemia if initiated prophylactically. OBJECTIVES: To evaluate the efficacy and safety of prophylactic phototherapy for preterm (< 37 weeks gestational age) or low birth weight infants (birth weight < 2500 g). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3) on 31 March 2011, MEDLINE (1950 to 31 March 2011), EMBASE (1980 to 31 March 2011) and CINAHL (1982 to 31 March 2011). SELECTION CRITERIA: Randomised controlled trials or quasi-randomised controlled studies evaluating the effects of prophylactic phototherapy for preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS: Two authors independently obtained data from published articles. We performed fixed-effect meta-analysis for the outcomes: rate of exchange transfusion, cerebral palsy or other neurodevelopmental impairment, peak serum bilirubin level and all-cause mortality. MAIN RESULTS: Nine studies of 3449 participants were included. The rate of exchange transfusion was reduced in one study with liberal transfusion criteria (risk ratio (RR) 0.20; 95% confidence interval (CI) 0.13 to 0.31) but not in the other two more recent studies with stringent criteria (typical RR 0.66; 95% CI 0.19 to 2.28). There was no statistically significant difference in the rate of cerebral palsy (typical RR 0.96; 95% CI 0.50 to 1.85; two studies, 756 participants). However, one large study that reported on neurodevelopmental impairment (a composite outcome including cerebral palsy) found a slightly lower rate of neurodevelopmental impairment with prophylactic phototherapy (RR 0.85; 95% CI 0.74 to 0.99; 1804 participants). The prophylactic phototherapy group had lower peak bilirubin levels (mean difference (MD) -2.73; 95% CI -2.89 to -2.57; six studies, 2319 participants) and had fewer neonates with peak unconjugated serum bilirubin levels > 10 mg/dl (typical RR 0.27; 95% CI 0.22 to 0.33; three studies, 1090 participants) or peak unconjugated serum bilirubin levels > 15 mg/dl (typical RR 0.13; 95% CI 0.07 to 0.23; four studies, 1116 participants). There was no statistically significant difference in the rate of all-cause mortality between the two groups (typical RR 1.08; 95% CI 0.93 to 1.26; four studies, 3044 participants). AUTHORS' CONCLUSIONS: Prophylactic phototherapy helps to maintain a lower serum bilirubin concentration and may have an effect on the rate of exchange transfusion and the risk of neurodevelopmental impairment. However, further well-designed studies are needed to determine the efficacy and safety of prophylactic phototherapy on long-term outcomes including neurodevelopmental outcomes.

Depressed brainstem auditory function in children with cerebral palsy.

Brainstem auditory evoked responses were studied to examine brainstem auditory function in 80 children with cerebral palsy. The response waveform, particularly later waves, tended to be depressed. Thirty-three (41.3%) showed abnormal results. The main abnormality was reduced wave V amplitude. Other abnormalities were decreased V/I amplitude ratio, missing waves, prolonged I-V interval, and increased interaural difference in I-V interval. The abnormalities were persistent during the follow-up. In contrast to common findings in the responses in progressive neurologies, abnormalities in interpeak intervals were rare in children with cerebral palsy. There were some characteristic changes in the responses in certain etiologies. These results suggest that brainstem auditory function in children with cerebral palsy is depressed, which may be owing to decreased or altered neural firing or synchrony in the auditory brainstem. A detailed analysis of central components of the responses is valuable in detecting central auditory dysfunction in children with cerebral palsy.

Thyroxine for transient hypothyroxinemia and cerebral palsy in extremely preterm infants.

BACKGROUND: The relationship of thyroxine supplementation for transient hypothyroxinemia of prematurity to the incidence of cerebral palsy (CP) in infants <28 weeks of gestation is unclear. METHODS: The incidence of CP at a corrected age of 18 months was compared between infants born in a 3-year period in which routine measurement of free T4 (FT4) in the blood was not performed (first period, n= 54), and those born in a later 3-year period in which FT4 was measured (second period, n= 60; mainly at 7 days old), and in which l-thyroxine 5-10 µg/kg per day (mean, 9 µg/kg/day) was administered for FT4 levels <0.8 ng/dL. Incidence of CP at 3 years of age was also compared between the same groups. RESULTS: Background clinical factors between the two groups were comparable except for prenatal steroid administration, which was reduced in the second period. Incidence of CP at a corrected age of 18 months was significantly lower in the second period (3.3%) than in the first period (16.6%). Incidence of CP at 3 years of age was also significantly lower in the second period. Multiple logistic regression analysis using factors except thyroxine supplementation, for the total of 114 infants from both groups, found no perinatal factors related to the development of CP at a corrected age of 18 months. CONCLUSIONS: Thyroxine supplementation for transient hypothyroxinemia of prematurity may reduce the incidence of CP in extremely preterm infants. Large-scale randomized controlled trials are essential to determine the effects of thyroxine supplementation in reducing the incidence of CP among extremely preterm infants.

Prolonged electromyogram biofeedback improves upper extremity function in children with cerebral palsy.

Biofeedback of muscle activity is commonly used as an adjunct to physical therapy, but it has not previously been used for long-term treatment of movement disorders. The authors hypothesized that chronic daily use of biofeedback of muscle electrical activity might promote improved use of the upper extremity in children with cerebral palsy and upper extremity motor deficits. They constructed a portable electromyography (EMG) unit that includes a surface EMG sensor and amplifier, microcontroller-based nonlinear signal processing, and vibration feedback of muscle activity. A total of 11 children ages 6 to 16 years, with cerebral palsy or acquired static brain injury, wore the device at least 5 hours per day for 1 month. Changes in upper extremity function were assessed using an individualized Goal Attainment Scale. Results showed significant clinical improvement in all 10 children who completed the study. These results suggest that further testing of prolonged surface EMG biofeedback is warranted.

[Systematic evaluation of acupuncture for treatment of post-stroke spastic paralysis].

OBJECTIVE: To evaluate the effects of acupuncture on post-stroke spastic paralysis. METHODS: A systematic evaluation including all the relavant randomized controlled trials (RCTs) or quasi-RCTs of acupuncture and moxibustion for treatment of post-stroke spastic paralysis were carried out according to the method recommended by the Cochrane Collaboration. RESULTS: Nine hundred and seventy-eight patients being included in fourteen papers met the enrolled criteria. However, their methodological quality was relatively poor. Meta-analysis of nine trials indicated that there was no significant difference between the treatment groups and the control groups in Ashworth scores, Carr-Shepherd scores, nerve defect scores and hip adductor tension scores. Whereas the Fugel-Meyer scores in one trial and the Barthel scores in three trials were better in the treatment groups than those of the control group. CONCLUSION: A reliable conclusion can not be drawn from the present data because of the defects in methodological quality and insufficient numbers of trials, especially lack the long-term terminal outcomes, although it appears a tedency that acupuncture can improve the conditions of post-stroke spastic paralysis. Therefore, it is necessary to perform more multi-central RCTs of high quality in future.

Neurodevelopmental outcomes of premature infants treated with l-arginine for prevention of necrotising enterocolitis.

AIM: This study aimed to compare the long-term neurodevelopmental outcomes at 36 months adjusted age in preterm infants (birth weight < or = 1250 gm) who received supplementation with L-arginine during the first 28 days of life with controls. METHODS: Surviving infants enrolled in a randomised control study of L-arginine supplementation were prospectively followed longitudinally to determine their neurodevelopmental outcomes at 36 months of adjusted age. Neurologic examination and neurodevelopmental assessments were performed by examiners who were unaware of the original treatment assignments. RESULTS: A total of 132 children (95% of survivors) were evaluated at 36 months adjusted age. In the group given L-arginine, 5 of 61 (8.1%) had major neurodevelopmental disabilities, defined as the presence of one or more of cerebral palsy, cognitive delay (cognitive index <70), bilateral blindness or bilateral hearing loss requiring hearing aids as compared with 9 of 71 (12.6%) in the placebo group (relative risk, 0.64; 95 % confidence interval, 0.22-1.82; P= 0.40). CONCLUSIONS: There is no increase in neurodevelopmental disability in preterm infants who received L-arginine supplementation.

Maternal and infant thyroid disorders and cerebral palsy.

Deficiency of thyroid hormone during critical periods of development can severely damage the nervous system, but the specific effects of thyroid hormones on neuromotor development are less certain. Nonetheless, evidence has accumulated to suggest that thyroid hormone deficiency might be one cause of cerebral palsy (CP). The evidence arises from three sets of observations: first, severely premature infants with transient hypothyroxinemia have elevated risks of CP; second, some children born with endemic cretinism in iodine-deficient areas of the world have motor findings compatible with the diagnosis of CP; and third, several studies of the antecedents of CP have encountered a higher than expected prevalence of maternal thyroidal disorders. The evidence thus far is insufficient to conclusively determine what role, if any, thyroid hormone deficiency plays in CP, although it seems clear that neuromotor abnormalities can be the result of insufficient supply of maternal thyroid hormone in utero. A major research priority should be to assess the effects on CP risk of thyroid supplementation in transient hypothyroxinemia of prematurity. Iodine deficiency can be addressed by inexpensive and well-established public health measures, and thyroid hormone deficiency can be addressed by inexpensive and well-established clinical measures. If a causal chain can be established that links iodine and thyroid hormone to risk of CP, the potential for introducing very cost-effective ways of reducing the burden of CP will be considerable.

Parasagittal lesions and ulegyria in hypoxic-ischemic encephalopathy: neuroimaging findings and review of the pathogenesis.

Hypoxic-ischemic brain injury is a very important neurological problem of the perinatal period and a major cause of chronic disability later in childhood. The subsequent neurological deficits are a variety of motor defects-especially spasticity but also choreoathetosis, dystonia and ataxia, often grouped together as "cerebral palsy," mental retardation, and seizures. The gestational age determines the neuropathology of the brain injury. One of the patterns of hypoxic-ischemic encephalopathy, typically affecting full-term infants, consists of parasagittal lesions and ulegyria. The aim of this study is to describe the magnetic resonance imaging (MRI) features and discuss the "suggested" pathogenetic mechanisms of this pattern, which affects the cortex and the white matter in a mainly parasagittal distribution; in this type of brain injury, the damage usually involves the deeper sulcal portion while sparing the apex, thus resulting in the so-called mushroom gyri characteristic ulegyric pattern. We discuss the MRI findings of parasagittal lesions and ulegyria in the brain examinations of 14 patients with a clinical history of perinatal hypoxia/anoxia presenting with mental retardation, seizures, and cerebral palsy. Differential diagnosis from polymicrogyria is discussed.