Practice Parameter: Diagnostic assessment of the child with cerebral palsy
Jonathan W.Mink, MD, PhD, Dept. of Neurology, University of Rochester, 601 Elmwood Ave., Box 673, Rochester, NYjonathan Mink_urmc.rochester.edu
Mary E. Jenkins, MD
Submitted June 19, 2004
We read with interest the recent article by Ashwal et al. [1] The
Practice Parameter represents a thorough review of the current literature
on an important issue that has diagnostic, prognostic, management and
research implications. We view the final recommendations as clinically
sound and feasible. However, we were struck by the paucity of evidence
supporting these recommendations.
The guidelines focused on MRI and CT as a method of determining both
etiology of cerebral palsy and timing of the lesion (Level A, class I
evidence). There are five class I references 2-6 that evaluate
neuroimaging in children with CP. The evidence from these studies support
the recommendation that neuroimaging in conjunction with clinical history
may determine etiology of cerebral palsy in many children.
The recommendations suggest that timing of the cerebral injury may be
determined by CT or MRI imaging (Level A, class I evidence). This
recommendation does not seem to be supported by the evidence. In Table 3
and Table 4 of the guidelines, the original references are listed with
classification of cases based on CT or MRI into 1) prenatal, 2) perinatal
and 3) postnatal events. In all four of the original class I studies 2, 3,
5, 6, the etiologies are determined to be either 1) prenatal or 2)
prenatal / perinatal. There are no data from any of the class I studies
that support the premise that an isolated perinatal etiology can be
determined from neuroimaging.
Recommendations on evaluation of metabolic, genetic and coagulation
studies are reported to be Level B and Level C. However, the evidence
does not support this level of recommendation. The authors clearly state
that no prospective studies have evaluated these issues. The studies cited
concern the incidence of different etiologies and any diagnostic studies
are small series or case reports, making the recommendations Level U.
The evidence reviewed in this paper is worthwhile and informative.
However, the current literature is not adequate to develop Practice
Parameters in this area. We question whether the American Academy of
Neurology should be endorsing Practice Parameters on topics with such weak
evidentiary support. We agree that the role of imaging in the diagnosis
of disorders presenting as cerebral palsy is an important question in need
of further research. However, a goal of a Practice Parameter should be to
set evidence-based guidelines rather than to illustrate the need for
additional research.
References
1. Ashwal S, Russman BS, Blasco PA, et al. Practice Parameter:
Diagnostic assessment of the child with cerebral palsy: Report of the
Quality Standards Subcommittee of the American Academy of Neurology and
the Practice Committee of the Child Neurology Society. Neurology 2004;
62:851-63.
2. Wiklund LM, Uvebrant P, Flodmark O. Computed tomography as an adjunct
in etiological analysis of hemiplegic cerebral palsy. I: Children born
preterm. Neuropediatrics 1991; 22:50-6.
3. Wiklund LM, Uvebrant P, Flodmark O. Computed tomography as an adjunct
in etiological analysis of hemiplegic cerebral palsy; II: Children born at
term. Neuropediatrics 1991; 22:121-8.
5. Krageloh-Mann I, Petersen D, Hagberg G, Vollmer B, Hagberg B, Michaelis
R. Bilateral spastic cerebral palsy--MRI pathology and origin. Analysis
from a representative series of 56 cases. Dev Med Child Neurol 1995;
37:379-97.
6. Yin R, Reddihough D, Ditchfield M, Collins K. Magnetic resonance
imaging findings in cerebral palsy. J Paediatr Child Health 2000; 36:139-
44.
We read with interest the recent article by Ashwal et al. [1] The Practice Parameter represents a thorough review of the current literature on an important issue that has diagnostic, prognostic, management and research implications. We view the final recommendations as clinically sound and feasible. However, we were struck by the paucity of evidence supporting these recommendations.
The guidelines focused on MRI and CT as a method of determining both etiology of cerebral palsy and timing of the lesion (Level A, class I evidence). There are five class I references 2-6 that evaluate neuroimaging in children with CP. The evidence from these studies support the recommendation that neuroimaging in conjunction with clinical history may determine etiology of cerebral palsy in many children.
The recommendations suggest that timing of the cerebral injury may be determined by CT or MRI imaging (Level A, class I evidence). This recommendation does not seem to be supported by the evidence. In Table 3 and Table 4 of the guidelines, the original references are listed with classification of cases based on CT or MRI into 1) prenatal, 2) perinatal and 3) postnatal events. In all four of the original class I studies 2, 3, 5, 6, the etiologies are determined to be either 1) prenatal or 2) prenatal / perinatal. There are no data from any of the class I studies that support the premise that an isolated perinatal etiology can be determined from neuroimaging.
Recommendations on evaluation of metabolic, genetic and coagulation studies are reported to be Level B and Level C. However, the evidence does not support this level of recommendation. The authors clearly state that no prospective studies have evaluated these issues. The studies cited concern the incidence of different etiologies and any diagnostic studies are small series or case reports, making the recommendations Level U.
The evidence reviewed in this paper is worthwhile and informative. However, the current literature is not adequate to develop Practice Parameters in this area. We question whether the American Academy of Neurology should be endorsing Practice Parameters on topics with such weak evidentiary support. We agree that the role of imaging in the diagnosis of disorders presenting as cerebral palsy is an important question in need of further research. However, a goal of a Practice Parameter should be to set evidence-based guidelines rather than to illustrate the need for additional research.
References
1. Ashwal S, Russman BS, Blasco PA, et al. Practice Parameter: Diagnostic assessment of the child with cerebral palsy: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2004; 62:851-63.
2. Wiklund LM, Uvebrant P, Flodmark O. Computed tomography as an adjunct in etiological analysis of hemiplegic cerebral palsy. I: Children born preterm. Neuropediatrics 1991; 22:50-6.
3. Wiklund LM, Uvebrant P, Flodmark O. Computed tomography as an adjunct in etiological analysis of hemiplegic cerebral palsy; II: Children born at term. Neuropediatrics 1991; 22:121-8.
4. Miller G, Cala LA. Ataxic cerebral palsy--clinico-radiologic correlations. Neuropediatrics 1989; 20:84-9.
5. Krageloh-Mann I, Petersen D, Hagberg G, Vollmer B, Hagberg B, Michaelis R. Bilateral spastic cerebral palsy--MRI pathology and origin. Analysis from a representative series of 56 cases. Dev Med Child Neurol 1995; 37:379-97.
6. Yin R, Reddihough D, Ditchfield M, Collins K. Magnetic resonance imaging findings in cerebral palsy. J Paediatr Child Health 2000; 36:139- 44.