Motor outcome after perinatal stroke and early prediction of unilateral spastic cerebral palsy

https://doi.org/10.1016/j.ejpn.2020.09.002Get rights and content

Highlights

  • One-third of the infants with perinatal stroke developed cerebral palsy (CP).

  • General movement assessment must be interpreted cautiously after perinatal stroke.

  • The Hand Assessment for Infants is highly predictive for unilateral CP.

Abstract

Background

Unilateral spastic cerebral palsy (USCP) occurs in 30%–68% of infants with perinatal stroke. Early detection of USCP is essential for referring infants to early intervention. The aims of this study were to report motor outcomes after perinatal stroke, and to determine the predictive value of the General Movements Assessment (GMA) and Hand Assessment for Infants (HAI) for detection of USCP.

Materials and methods

This was a prospective observational study involving infants with perinatal stroke. GMA was conducted between 10 and 15 weeks post term-age (PTA). The HAI was performed between 3 and 5 months PTA. Motor outcome was collected between 12 and 36 months PTA.

Results

The sample consisted of 46 infants. Fifteen children (32.6%) were diagnosed with CP, two children with bilateral CP and 13 with USCP. Abnormal GMA had a sensitivity of 85% (95% confidence interval [CI] 55–98%) and a specificity of 52% (95% CI 33–71%) to predict USCP. When asymmetrically presented FMs were also considered as abnormal, sensitivity increased to 100%, hence the specificity declined to 43%. A HAI asymmetry index cut-off of 23, had both a sensitivity and a specificity of 100% to detect USCP.

Conclusion

Using GMA and HAI can enable prediction of USCP before the age of 5 months in infants with perinatal stroke. Nevertheless, GMA must be interpreted with caution in this particular population. The HAI was found to be a very accurate screening tool for early detection of asymmetry and prediction of USCP.

Introduction

Perinatal stroke is defined as a group of heterogeneous conditions in which a (multi)focal disruption of blood flow secondary to arterial (perinatal arterial ischaemic stroke [PAIS]) or venous (cerebral sinovenous thrombosis [CSVT]) thrombosis or embolization occurred between 20 weeks postmenstrual age and the 28th postnatal day [1]. Haemorrhagic stroke (HS) is also included under the umbrella of perinatal stroke [2]. Primary HS tends to affect near-term and term infants, whereas periventricular haemorrhagic infarction (PVHI) is a lesion that primarily affects preterm infants and is a serious complication of germinal matrix-intraventricular haemorrhage [3,4]. The overall incidence of perinatal stroke is approximately 1:1600–1:2300 live births [5].

After perinatal stroke, 30–68% of the infants develop cerebral palsy (CP), of which unilateral spastic CP (USCP) is the most common form due to the focal nature of the brain injury [[6], [7], [8], [9]]. However, large variations exist between studies and there remains some uncertainty about the outcome according to the type of brain lesion.

CP is typically diagnosed between the ages of 12 and 24 months [10]. However, due to significant activity-dependent cortical plasticity predominantly occurring early in life, it is important to diagnose CP as early as possible to benefit from intervention during this limited time-window [11]. Recently, it has been recommended to combine neonatal magnetic resonance imaging (MRI), a standardized neurological examination with the Prechtl General Movements Assessment (GMA) to predict CP before five months corrected age [11]. Regarding the GMA, in particular, the absence of fidgety movements (FMs) predicts CP with a sensitivity of 98% and a specificity of 94% in high-risk infants [12]. Moreover, other motor signs predictive for USCP may occur at an early age. For example, asymmetric hand function has been identified as one of the earliest clinical signs of USCP [13]. Recently, a new assessment tool was developed for detecting upper limb asymmetry in infants at risk of developing USCP. The Hand Assessment for Infants (HAI) quantifies hand function, both bimanually and for each hand separately, in infants between 3 and 12 months post-term age (PTA) [14]. It has been demonstrated that a unilateral HAI score of the affected hand, in combination with gestational age and gender, predicts USCP before 5 months of age with an accuracy of 93% (95% CI 0.86–100) [15].

Numerous studies have reported outcomes after perinatal stroke or unilateral brain lesions, however, studies on early detection of USCP based on the GMA and HAI are few [[15], [16], [17], [18]]. To our knowledge, no studies have yet compared both tests for early prediction of USCP.

The aims of this study were (1) to report on motor outcomes after perinatal stroke, taking into consideration brain lesion type and timing of injury; (2) to investigate whether there is a difference in early spontaneous movements and motor patterns (as determined using GMA and HAI) between infants who later developed USCP and those who did not; and (3) to determine the predictive value of the GMA and HAI for detection of USCP.

Section snippets

Patients

This was a prospective observational study involving infants with perinatal stroke. The study comprised newborns who were admitted to the neonatal intensive care unit (NICU) of hospitals in Flanders, Belgium (UZ Gent, AZ Sint-Jan Brugge, UZ Leuven, UZ Brussel, UZ Antwerpen and ZNA Middelheim), between October 2015 and October 2018. Inclusion criteria were a diagnosis of perinatal stroke confirmed by neonatal brain imaging and having a video recording for the GMA during the fidgety movements

Patients and stroke characteristics

In total, 46 infants were enrolled in the study. Motor outcome was available for 45 infants, resulting in a sample of 45 infants. All infants had one video recording available for GMA and in 35 children, a HAI evaluation was also performed. However, one infant's HAI evaluation was performed at 27 weeks PTA (outside the time frame); thus, these results were not included. The flowchart is depicted in Fig. 1 and the characteristics of the infants are shown in Table 1. Gestational age ranged from

General findings

The present study explored the outcome of perinatal stroke and the possibly early diagnosis of USCP in high-risk infants. To our knowledge, this is the first study to evaluate the predictive value of the GMA and HAI in a sample of patients at high risk of USCP. Our results showed that GMA (absent/sporadic FMs) and the HAI had a good predictive value (≥85% sensitivity) for detecting USCP.

The first aim of this article was to the report motor outcomes after perinatal stroke. Overall, 33% of the

Conclusion

Early diagnosis of CP is important and can lead to early intervention. This study emphasizes that early detection of USCP is possible before the age of 5 months PTA. GMA is feasible in a population with perinatal stroke for early prediction of USCP. However, it is important to note that normal GMA must be interpreted with caution in this particular population, considering the high rates of false positive cases. Furthermore, asymmetrical FMs might be observed, which could be an indicator for

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors wish to thank all of the infants and families who participated in this study and the physicians who helped recruit the infants. We also wish to thank Randi Tynes Vågen for her input as the third tie-breaking observer for the GMA classification.

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