Cerebral Palsy Workup
- Author: Hoda Z Abdel-Hamid, MD; Chief Editor: Amy Kao, MD more...
The 2003 American Academy of Neurology (AAN) practice parameter on cerebral palsy suggests laboratory studies if : (1) the clinical history or findings from neuroimaging do not indicate a specific structural abnormality, (2) additional and atypical features are present in the history or clinical examination, or (3) a brain malformation is detected in a child with cerebral palsy. In addition, diagnostic testing for coagulation disorders is recommended if a cerebral infarction is seen; however, available data were insufficient for guiding what precise studies should be ordered.
If a diagnosis of a hereditary or neurodegenerative disorder is suspected, screening for an underlying metabolic or genetic disorder should be performed. However, specific studies were not recommended by the AAN practice parameters, as such studies should be guided by the clinical picture.
The AAN practice parameter did not recommend an electroencephalogram (EEG) unless suspicion for epilepsy or an epileptic syndrome is present, but it did recommend neuroimaging "to establish that a brain abnormality exists in children with cerebral palsy, that may, in turn, suggest an etiology and prognosis." Note that a normal brain imaging study does not mean that the child does not have cerebral palsy, because the diagnosis is always based only on physical examination findings.
Potentially Helpful Laboratory Tests
There are no definitive laboratory studies for diagnosing cerebral palsy, only studies to rule out other symptom causes, such as metabolic or genetic abnormalities, as deemed necessary based on clinical examination. Such studies may include the following:
Thyroid function studies - Abnormal thyroid function may be related to abnormalities in muscle tone or deep tendon reflexes or to movement disorders.
Lactate and pyruvate levels - Abnormalities may indicate an abnormality of energy metabolism (ie, mitochondrial cytopathy).
Ammonia levels - Elevated ammonia levels may indicate liver dysfunction or urea cycle defect.
Organic and amino acids - Serum quantitative amino acid and urine quantitative organic acid values may reveal inherited metabolic disorders.
Chromosomal analysis - Chromosomal analysis, including karyotype analysis and specific DNA testing may be indicated to rule out a genetic syndrome, if dysmorphic features or abnormalities of various organ systems are present.
Cerebrospinal protein - levels may assist in determining asphyxia in the neonatal period. Protein levels can be elevated, as can the lactate-to-pyruvate ratio.
Cranial Imaging Studies
Neuroimaging studies can help to evaluate brain damage and to identify persons who are at risk for cerebral palsy. Data to support a definitive diagnosis of cerebral palsy are lacking.
Cranial ultrasonography performed in the early neonatal period can be helpful in medically unstable infants until they are able to tolerate transport for more detailed neuroimaging. Ultrasonography can delineate clear-cut structural abnormalities and show evidence of hemorrhage or hypoxic-ischemic injury. For example, neonatal cranial ultrasonography provides information about the ventricular system, basal ganglia, and corpus callosum, as well as diagnostic information on intraventricular hemorrhage and hypoxic-ischemic injury to the periventricular white matter. Periventricular leukomalacia initially appears as an echodense area that converts to an echolucent area when the patient is approximately age 2 weeks. Periventricular leukomalacia is strongly associated with cerebral palsy.
In infants, computed tomography (CT) scanning of the brain helps to identify congenital malformations, intracranial hemorrhage, and periventricular leukomalacia more clearly than ultrasonography.
Magnetic resonance imaging (MRI) of the brain is most useful after 2-3 weeks of life and is the diagnostic neuroimaging study of choice for older children, because this modality defines cortical and white matter structures and abnormalities more clearly than any other method. MRI also allows for the determination of appropriate myelination for a given age. In children with spasticity of the legs and worsening of bowel and bladder function, a spine MRI may help identify a tethered spinal cord.
Although the precise role for MRI in the diagnosis and workup of children with cerebral palsy or suspected cerebral palsy has not been fully elucidated, the literature suggests that MRI should be strongly considered in all cases; in one study, 89% children with cerebral palsy were found to have abnormal MRIs. Additionally, MRI may have a role in predicting neurodevelopmental outcomes in preterm infants. See the following images.
Head ultrasonography, CT scanning, and MRI may be helpful for diagnosing and monitoring findings of hydrocephalus.
Patients who present clinically with cerebral palsy may have normal results from brain imaging studies. Normal results from a neuroimaging studies do not exclude a clinical diagnosis of this disorder. However, in these cases, other underlying metabolic and genetic etiologies should be considered and excluded before diagnosing a child with cerebral palsy.
Electroencephalography (EEG) is useful in evaluating severe hypoxic-ischemic injury. This study is important in the diagnosis of seizure disorders; findings initially show marked suppression of amplitude and slowing, followed by a discontinuous pattern of voltage suppression, with bursts of high-voltage sharp and slow waves at 24-48 hours. However, EEG is not indicated if seizures are not suspected along with cerebral palsy.
EMG and Nerve Conduction Studies
Electromyography (EMG) and nerve conduction studies are helpful when a muscle or nerve disorder is suspected (eg, a hereditary motor or sensory neuropathy as a basis for equinus foot deformities and toe walking).
Evoked potentials are used to evaluate the anatomic pathways of the auditory and visual systems.
Simpson DM, Gracies JM, Graham HK, Miyasaki JM, Naumann M, Russman B, et al. Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2008 May 6. 70(19):1691-8. [Medline].
Scholtes VA, Dallmeijer AJ, Knol DL, Speth LA, Maathuis CG, Jongerius PH, et al. The combined effect of lower-limb multilevel botulinum toxin type a and comprehensive rehabilitation on mobility in children with cerebral palsy: a randomized clinical trial. Arch Phys Med Rehabil. 2006 Dec. 87(12):1551-8. [Medline].
Dai AI, Wasay M, Awan S. Botulinum toxin type A with oral baclofen versus oral tizanidine: a nonrandomized pilot comparison in patients with cerebral palsy and spastic equinus foot deformity. J Child Neurol. 2008 Dec. 23(12):1464-6. [Medline].
Yang EJ, Rha DW, Kim HW, Park ES. Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy. Arch Phys Med Rehabil. 2008 Nov. 89(11):2108-13. [Medline].
Pascual-Pascual SI, Pascual-Castroviejo I. Safety of botulinum toxin type A in children younger than 2 years. Eur J Paediatr Neurol. 2009 Nov. 13(6):511-5. [Medline].
Hoving MA, van Raak EP, Spincemaille GH, Palmans LJ, Becher JG, Vles JS. Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial. Eur J Paediatr Neurol. 2009 May. 13(3):240-6. [Medline].
Trost JP, Schwartz MH, Krach LE, Dunn ME, Novacheck TF. Comprehensive short-term outcome assessment of selective dorsal rhizotomy. Dev Med Child Neurol. 2008 Oct. 50(10):765-71. [Medline].
Mutch L, Alberman E, Hagberg B, Kodama K, Perat MV. Cerebral palsy epidemiology: where are we now and where are we going?. Dev Med Child Neurol. 1992 Jun. 34(6):547-51. [Medline].
Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Aug. 47(8):571-6. [Medline].
Shevell MI, Bodensteiner JB. Cerebral palsy: defining the problem. Semin Pediatr Neurol. 2004 Mar. 11(1):2-4. [Medline].
Stanley F, Blair E, Alberman E. Cerebal Palsies: Epidemiology and Causal Pathways. London, United Kingdom: MacKeith Press; 2000.
Jacobsson B, Hagberg G. Antenatal risk factors for cerebral palsy. Best Pract Res Clin Obstet Gynaecol. 2004 Jun. 18(3):425-36. [Medline].
Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006 Feb 28. 28(4):183-91. [Medline].
Russman BS, Ashwal S. Evaluation of the child with cerebral palsy. Semin Pediatr Neurol. 2004 Mar. 11(1):47-57. [Medline].
Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev. 2009 Jan 21. CD004661. [Medline].
Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. N Engl J Med. 2008 Aug 28. 359(9):895-905. [Medline]. [Full Text].
Conde-Agudelo A, Romero R. Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeks' gestation: a systematic review and metaanalysis. Am J Obstet Gynecol. 2009 Jun. 200(6):595-609. [Medline].
Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, Pa: WB Saunders; 2001. 4.
Moster D, Wilcox AJ, Vollset SE, Markestad T, Lie RT. Cerebral palsy among term and postterm births. JAMA. 2010 Sep 1. 304(9):976-82. [Medline].
Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978 Apr. 92(4):529-34. [Medline].
Nelson KB. Can we prevent cerebral palsy?. N Engl J Med. 2003 Oct 30. 349(18):1765-9. [Medline].
American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology. Washington, DC: American College of Obstetricians and Gynecologists; 2003. [Full Text].
Capute AJ, Accardo PJ, eds. Developmental Disabilities in infancy and Childhood. 2nd ed. Baltimore, Md: Brookes Publishing; 2001. Vol 2.:
Majnemer A, Mazer B. New directions in the outcome evaluation of children with cerebral palsy. Semin Pediatr Neurol. 2004 Mar. 11(1):11-7. [Medline].
Vincer MJ, Allen AC, Joseph KS, Stinson DA, Scott H, Wood E. Increasing prevalence of cerebral palsy among very preterm infants: a population-based study. Pediatrics. 2006 Dec. 118(6):e1621-6. [Medline].
Ancel PY, Livinec F, Larroque B, Marret S, Arnaud C, Pierrat V, et al. Cerebral palsy among very preterm children in relation to gestational age and neonatal ultrasound abnormalities: the EPIPAGE cohort study. Pediatrics. 2006 Mar. 117(3):828-35. [Medline].
Dolk H, Pattenden S, Johnson A. Cerebral palsy, low birthweight and socio-economic deprivation: inequalities in a major cause of childhood disability. Paediatr Perinat Epidemiol. 2001 Oct. 15(4):359-63. [Medline].
Strauss D, Shavelle R, Reynolds R, Rosenbloom L, Day S. Survival in cerebral palsy in the last 20 years: signs of improvement?. Dev Med Child Neurol. 2007 Feb. 49(2):86-92. [Medline].
Hemming K, Hutton JL, Colver A, Platt MJ. Regional variation in survival of people with cerebral palsy in the United Kingdom. Pediatrics. 2005 Dec. 116(6):1383-90. [Medline].
Hemming K, Hutton JL, Pharoah PO. Long-term survival for a cohort of adults with cerebral palsy. Dev Med Child Neurol. 2006 Feb. 48(2):90-5. [Medline].
Verrall TC, Berenbaum S, Chad KE, Nanson JL, Zello GA. Children with Cerebral Palsy: Caregivers' Nutrition Knowledge, Attitudes and Beliefs. Can J Diet Pract Res. 2000 Autumn. 61(3):128-134. [Medline].
Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study. JAMA. 2006 Oct 4. 296(13):1602-8. [Medline].
Woodward LJ, Anderson PJ, Austin NC, Howard K, Inder TE. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med. 2006 Aug 17. 355(7):685-94. [Medline].
Wyatt K, Edwards V, Franck L, Britten N, Creanor S, Maddick A, et al. Cranial osteopathy for children with cerebral palsy: a randomised controlled trial. Arch Dis Child. 2011 Jun. 96(6):505-12. [Medline].
Edwards P, Sakzewski L, Copeland L, Gascoigne-Pees L, McLennan K, Thorley M, et al. Safety of Botulinum Toxin Type A for Children With Nonambulatory Cerebral Palsy. Pediatrics. 2015 Nov. 136 (5):895-904. [Medline].
Blackmore AM, Boettcher-Hunt E, Jordan M, Chan MD. A systematic review of the effects of casting on equinus in children with cerebral palsy: an evidence report of the AACPDM. Dev Med Child Neurol. 2007 Oct. 49(10):781-90. [Medline].
Delgado MR, Hirtz D, Aisen M, et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010 Jan 26. 74(4):336-43. [Medline].
Muthusamy K, Recktenwall SM, Friesen RM, Zuk J, Gralla J, Miller NH, et al. Effectiveness of an anesthetic continuous-infusion device in children with cerebral palsy undergoing orthopaedic surgery. J Pediatr Orthop. 2010 Dec. 30(8):840-5. [Medline].
Du RY, McGrath CP, Yiu CK, King NM. Oral health behaviors of preschool children with cerebral palsy: a case-control community-based study. Spec Care Dentist. 2014 Nov-Dec. 34 (6):298-302. [Medline].
Anderson P. FDA Clears Stimulation System for Foot Drop in Children. Medscape Medical News. Jan 25 2013. Available at http://www.medscape.com/viewarticle/778221. Accessed: February 5, 2013.
Dabney KW, Lipton GE, Miller F. Cerebral palsy. Curr Opin Pediatr. 1997 Feb. 9(1):81-8. [Medline].
Girard S, Kadhim H, Roy M, Lavoie K, Brochu ME, Larouche A, et al. Role of perinatal inflammation in cerebral palsy. Pediatr Neurol. 2009 Mar. 40(3):168-74. [Medline].
Jones MW, Morgan E, Shelton JE, Thorogood C. Cerebral palsy: introduction and diagnosis (part I). J Pediatr Health Care. 2007 May-Jun. 21(3):146-52. [Medline].
Mattern-Baxter K. Effects of partial body weight supported treadmill training on children with cerebral palsy. Pediatr Phys Ther. 2009 Spring. 21(1):12-22. [Medline].