Background: In an attempt to uncover strategies that might prevent cerebral palsy, investigators of the European Cerebral Palsy Study reviewed the clinical findings of cerebral palsy at eight European centers. Bax and colleagues observed these findings and correlated them with magnetic resonance imaging (MRI) findings.
The Study: Cerebral palsy occurs at a rate of two per 1,000 live births. For this study, children older than two years who had cerebral palsy were examined by physicians familiar with the disorder. Information about family and birth history was collected from the parents. MRI scans were obtained and analyzed according to a standardized scoring system. There was a total of 585 eligible children, of whom 431 participated in the study.
Results: Prenatal findings included a high rate of reported infection (39.5 percent) during pregnancy. About one half of these were urinary tract infections. Overall, excluding minor upper respiratory illnesses, 29.6 percent of women had significant infection. A higher rate of multiple pregnancies was reported in the study group than in the general population—12.0 compared with 1.5 percent.
More than one half of the children were born at term. About the same percentage (around one fifth) in each gestational age group, including infants born at term, were small for gestational age. Regarding type of delivery, 32.2 percent of infants were born by emergency cesarean delivery, 44.8 percent had normal vaginal deliveries, and 12.6 percent had instrumented deliveries.
MRI scans were performed on 81.4 percent of infants, with white matter damage of immaturity (WMDI) being the most common finding (occurring in 42.5 percent). WMDI was associated with diplegia, hemiplegia, and quadriplegia. Basal ganglia damage was associated with dystonic cerebral palsy. Focal infarcts correlated with hemiplegia. Cortical and subcortical damage was associated with all cerebral palsy manifestations except ataxia. Malformations were associated for the most part with hemiplegia but were also found in all other clinical subtypes. Of note, 11.7 percent of children had normal MRI findings.
Conclusion: The authors conclude that there is a high correlation between MRI findings and clinical findings and that MRI in patients with cerebral palsy might help predict future medical needs. A high rate of white matter damage suggests that genetic factors, nutritional factors, and infections damage the placenta and lead to ischemic events that are unrelated to management issues during labor and delivery.
The authors postulate a genetic cause of cerebral palsy in children with normal MRI findings. They indicate that in 19.9 percent of the children (those with cortical/subcortical damage or basal ganglia damage) the cerebral palsy could conceivably have had an obstetric cause. Of these children, at least one fourth were born by cesarean delivery, indicating that the obstetrician was responding to a problem in labor. In short, the authors find that malpractice is unlikely to be a cause of most cerebral palsy cases. In addition, urinary tract infection rates were higher in mothers with children who had cerebral palsy, and this may be an area where more aggressive intervention could have a preventive effect.