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

2. 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

3. 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 2006 Kuban & al. J Child Neurol 2009/ De Vries & al. J Pediatr 144

4. Diagnostic role of Neuro-imaging: Casus boy term (39 we): hypotonia, hyporeactivity convulsions d 2 pregnancy: hypertension delivery: strangulation umbilical cord Selective neuronal necrosis: deep nuclei and brainstem

5. DAY 1 DAY 2 & 3 US: negative

6. DAY 7

7. 6 MONTHS: comprehensive assessment: Cerebral Palsy

8. 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?

9. Diagnostic role of Neuro-imaging: Modality Miller & al. AJNR 2003 Leijser & 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

10. Diagnostic role of Neuro-imaging: Modality Leijser & al. Early Human Development 2009 Horsch & 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

11. 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

12. 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

13. Diagnostic role of Neuro-imaging: Timing practice model for preterm function GA: Leijsera & al. Early Hum Dev 2006 US 23-26 wed1, d2, d3, weekly untill 31 we, 33we, 35we, term 27-29 wed1, weekly untill 31 we, 36we, term 29-35 wed1, 3we, term

14. 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 2010 Rutherford & al. Pediatr Radiol 2010 MRI

15. 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

16. 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?

17. Predictive role of Neuro-imaging: Modality Broitman & al. J Pediatr 2007 Beaino & 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.

18. 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

19. 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

20. Predictive role of Neuro-imaging: Modality Dyet & al. Pediatrics 2006 Jyoti & 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.

21. Predictive role of Neuro-imaging: Modality Woodward & al. New Eng J Med 2006 Twomey & 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%)

22. 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

23. 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

24. 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