Eleven and a half percent of all children in our sample were given a diagnosis of cerebral palsy at approximately 2 years corrected age. The risk of cerebral palsy was 9% if the scan had isolated intraventricular hemorrhage, similar in prevalence to that observed among children with completely normal head ultrasound studied (6%). Forty-three percent (51/120) of children with cerebral palsy had normal cranial ultrasound studies ( and ). In contrast, 34% of those whose scan had isolated echolucency in the cerebral white matter and 39% of those whose scan had isolated ventriculomegaly developed cerebral palsy (). Ultrasound lesions, however, tend not to occur in isolation. For example, 87% of scans with ventriculomegaly and 62% of scans with intraventricular hemorrhage had an additional lesion ().
The Percent of Children Who Had Each Combination of Ultrasound Lesions Listed on the Left Who Developed the Cerebral Palsy Type or Severity Rating Listed at the Head of Each Column. These are row percents.
Among children who had ventriculomegaly or echolucency, the risk of quadriparesis was 3 to 5 times higher than the risk of diparesis. In contrast, among those with no head ultrasound study abnormality, the risk of quadriparesis and diparesis were comparable (). Viewed differently, 34% (22/64) of children who developed quadriparesis and 60% (22/37) of children who developed diparesis did not have intraventricular hemorrhage, echolucency, or ventriculomegaly (). Nearly half of those with cerebral palsy had a Gross Motor Functional Classification System of 2 or greater, and 85% of these children had quadriparesis.
Table 1 The Percent of Children Who Had the Ultrasound Lesion Listed on the Left Who Developed the Cerebral Palsy Type or Severity Rating Listed at the Head of Each Column. These Are Row Percents (ie, the percent of an item with a particular characteristic listed (more ...)
The Percent of Infants Whose Scan Had a Hemorrhage (probable or definite) in the Location Listed on the Left, Who Were Also Given the Cerebral Palsy Diagnosis or Severity Rating at the Top of Each Column. These are Row Percents.
Nine percent of children who had a unilateral intraventricular hemorrhage and 28% of children who had bilateral intraventricular hemorrhage developed cerebral palsy. Also, blood in the third and fourth ventricles, a correlate of ventriculomegaly, predicted quadriparesis better than blood in the lateral ventricle. Of the 10 children who had bilateral cerebellar hemorrhages, 3 developed quadriparesis and 3 developed hemiparesis.
Moderate/Severe Ventriculomegaly ()
Early studies (examinations performed during the first 14 postnatal days)
Of children who had unilateral ventriculomegaly, 21% developed hemiparesis and 7% developed quadriparesis. In contrast, those who had bilateral ventriculomegaly were more likely to develop quadriparesis than hemiparesis (23% versus 6%). Diparesis occurred in 13% to 14% of children with ventriculomegaly, whether unilateral or bilateral.
Late studies (examinations performed between postnatal day 15and expected date of confinement)
Ventriculomegaly on the third protocol scan was a better predictor of cerebral palsy than ventriculomegaly on an early scan. For example, the rate of cerebral palsy among the 19 subjects who had early ventriculomegaly, but never had late ventriculomegaly, was 21% (5% with quadriparesis, 5% with hemiparesis, and 11% with diparesis; data not shown), compared to 50% of children with ventriculomegaly on a late scan. Unlike early unilateral ventriculomegaly, late unilateral ventriculomegaly predicted quadriparesis even better than it predicted hemiparesis. Nearly half of those with bilateral late ventriculomegaly had the quadriparetic form of cerebral palsy and a third had more severe impairment (Gross Motor Functional Classification System >2). Diparesis occurred in less than 8% of cases among those with late ventriculomegaly regardless of location or laterality of the ventricular enlargement.
Table 4 The Percent of Infants Whose Scan Had Ventriculomegaly (moderate or severe) Identified Either on the First or Second Study (early scan) or on the Third Study (late scan) Unilaterally or Bilaterally, Who Were Also Given the Cerebral Palsy Diagnosis or (more ...)
Laterality of Echolucent Lesions and Empiric Diagnoses
Seventy-one children had an echolucency on head ultrasound study, and one third with a unilateral lesion and two thirds with bilateral lesions developed cerebral palsy. Unilateral lesions predicted similar rates of quadriparesis and hemiparesis (17% and 15%), whereas bilateral lesions were 7 to 13 times more likely to predict quadriparesis. Diparesis occurred in only 4% of those with either unilateral or bilateral echolucency.
Approximately 45% of children whose scan was given a diagnosis of cystic periventricular leukomalacia or periventricular hemorrhagic infarction developed cerebral palsy, which, in over 60% of cases, was classified as quadriparesis. Less than a third of those with cerebral palsy and periventricular hemorrhagic infarction, which is a predominantly unilateral lesion, had hemiparesis. Fewer yet with either periventricular hemorrhagic infarction (19%) or cystic periventricular leukomalacia (28%) had Gross Motor Functional Classification System level of 2 or greater.
Extent of Echolucent Lesions
Each hemisphere was divided into 16 zones on the ultrasound data collection form. Although no linear trend was seen between the number of zones involved and the risk of cerebral palsy, cerebral palsy type or severity, 85% of the 13 children whose scan had 5 or more echolucency zones developed cerebral palsy.
Location of Echolucent Lesions
Only 5 children with diparesis had echolucency and none of the lesions were seen in posterior regions. The echolucency lesions seen in hemiparetics and quadriparetics were seen equally frequently in the anterior and posterior aspects of the cerebral hemispheres. Those with hemiparesis were more than twice as likely to have unilateral lesions as bilateral lesions, whereas those with quadriparetics were more than 3 times more likely to have bilateral lesions as unilateral lesions (data not shown).
Infants deemed to have cystic periventricular leukomalacia were as likely to have echolucency lesions placed anteriorly as placed posteriorly. Among scans with periventricular hemorrhagic infarction, echolucency lesions were more likely to occur anteriorly. More than half of scans with periventricular hemorrhagic infarction also had lesions along the more posteriorly placed body of the lateral ventricles.
Ultrasound Lesions as Predictors of Cerebral Palsy ( and )
Echolucency, ventriculomegaly, and intraventricular hemorrhage were strongly and significantly associated with quadriparesis (risk ratio: 24, 17, 5.1) and hemiparesis (risk ratio: 29, 17, and 5.8). Diparesis also was significantly associated with all 3 head ultrasound study findings, but less strongly (risk ratio: 5, 5.7, and 2.3).
Among infants with ventriculomegaly, 44% developed cerebral palsy, and among infants with echolucency, 52% developed cerebral palsy (positive predictive value). Ventriculomegaly and echolucency predicted more severe cerebral palsy (Gross Motor Functional Classification System of 2 or greater) and quadriparesis in approximately half of children with cerebral palsy. For quadriparesis and hemiparesis, the sensitivity of ventriculomegaly and echolucency ranged from 38 to 47%, whereas for diparesis it was 14 and 24%. All negative predictive values and specificities were 92% or higher.
Table 5 Risk Ratios and Their 95% Confidence Intervals for Each Cerebral Palsy Diagnosis and for a Gross Motor Function Classification Scale (GMFCS) of 2 or Higher Associated With Each Ultrasound Lesion or Diagnosis. The Referent Group for Each Ultrasound Lesion (more ...)
Measures of the Ability of Head Ultrasound Abnormalities Evident Before Discharge From the Neonatal Intensive Care Unit to Predict a Cerebral Palsy Diagnosis at 24 Months Corrected Age.