Comparison of Clinical Profile in Spastic Diplegic and Quadriplegic Cerebral Palsy
Adel A. Kareem *
Abstract
Background and aim: Cerebral palsy refers to a group of non progressive, but often changing motor impairment syndrome.
This study compares clinical profile & neuroimaging findings in children with spastic diplegic cerebral palsy &
spastic quadriplegic cerebral palsy
Methods: One hundred & seventy one (171) children with spastic cerebral palsy , aged 12-60 mo.(median 30 mo.) were
classified into 2 groups; Spastic diplegic (n=78) & Spastic quadriplegia (n=93). Risk factors of cerebral palsy, gross
motor function classification system, associated neurological diseases & neuroimaging finding were analyzed.
Result: Risk factors were mainly prematurity & birth asphyxia were present in similar percentage in both groups .The
children with spastic quadriplegia were classified more frequently into level 4 & 5 of gross motor function
classification system while children with spastic diplegia were classified level more frequently into level 2 & 3.
Global delay, epilepsy & speech delay were observed more frequently in the children with spastic quadriplegia.
Cerebral atrophy occurred more frequently in the quadriplegic cerebral palsy.
Conclusion: These findings suggest different cerebral palsy subtypes demonstrate various clinical profiles.
Key word: cerebral palsy, Spastic diplegia, Spastic quadriplegia.
Cerebral palsy was classified as spastic quadriplegia
sq (spasticity of all four limbs & of similar
involvement), & spastic diplegia SD (spasticity of
lower limbs being greater than upper) (7).
Epilepsy was defined as a separate occurrence of
two or more apparently unprovoked seizures (8). The
diagnosis of epilepsy was based on history from
reliable
eye
witness
account
and
electroencephalogram (EEG) finding.
Term delivery was defined as birth occurring at 37
weeks or more of gestation, preterm delivery defined
as birth occurring of less than 37 weeks gestation,
low birth weight ; weight less than 2500 gms(9).
Any complication occurring within the intrapartum
period until the 1st 24 hours would define the
perinatal period as abnormal or (birth asphyxia), an
abnormal or worrisome intrapartum fetal heart
tracing such as fetal bradycardia & variable or late
decelerations, was defined as fetal distress, when
available, Apgar scores were included and asphyxia
is defined as any Apgar score ≤ 4 .
Introduction
Cerebral palsy refers to a group of non progressive,
but often changing motor impairment syndrome
secondary to lesions or anomalies of the brain
arising in the early stages of development (1).
One of the most common congenital or acquired
neurological diseases is primarily motor with or
without mental or other developmental deficits (2).
Spastic diplegia (sd) is one of the most common
clinical subtypes of cerebral palsy regardless of birth
weight & gestation, occurring in 53% of patients in
one series(3).
Spastic quadriplegia (sq) is the most severe type of
cerebral palsy with pareses of the upper limbs being
& the same degree or more severe than those of the
lower limbs (4), recently some studies have compared
two forms of hemiparetic cerebral palsy (5).
The diversity of individuals with cerebral palsy
together with the range of severity & complications
make this condition a challenge for health care
system (6).
The aim of this study is to compare clinical profile,
associated condition, neurological images, risk
factors & gross motor function abnormalities in
children with SD cerebral palsy versus sq cerebral
palsy.
Motor function (10)
The gross motor function classification system
(GMFCS) was used to classify severity of limitation
in gross motor function.
Level 1 - walking without restriction.
Level 2 - walking without restriction but with
support.
Level 3 - walking with support & restriction to the
activity outdoor.
Level 4 - mobility only with wheel chair.
Level 5 - complete immobility.
Patients & methods
Neurosciences teaching hospital is the first &largest
hospital having paediatric neurology department
with rehabilitation department and professional
management. From Feb. 2010 to Oct. 2010 a total
of 171children were involved in this study 97male
and 74 female with SD and qd children, 93
quadriplegia & 78 were diplegic cerebral palsy.
The study is a cross-section study with analytic
purpose.
The diagnosis of cerebral palsy was confirmed in
each case in paediatric neurology department.
Children with neurodegenerative disorder were
excluded from the study.
Associated conditions
Co-morbid conditions were recorded if they were
present at intake or observed subsequently on follow
up. These conditions included global developmental
delay, mental retardation, attention deficit
hyperactivity disorder, learning disabilities &
epilepsy. Global delay was defined as significant
delay in two or more of the following developmental
253
Iraqi J. Comm. Med., July. 2012 (3)
Comparison of Clinical Profile in Spastic Diplegic and Quadriplegic Cerebral Palsy
domains, gross or fine motor, speech/language,
social/interpersonal & activities of daily living.
Adel A. Kareem*
mainly preterm &birth asphyxia constitute mainly of
them in both, these findings are partially in
agreement with the study of Hagberg B. &Hagberg
G. which was done in Sweden at 21june 1996 (12) &it
is coincide with Kulak study which was done in
Bialystok, Poland department of paediatric
neurology & rehabilitation 28 April 2005. (13)
The GMFCS for cp makes clinical sense as away to
describe motor activities of children with cp. That is,
it is face validity in present study GMFCS mostly
level 2 & 3 in sd while it is level 3 & 4 in sq, that is
indicate sd cp children more likely to be ambulatory,
can walk independently at present time or in future
& this partially in agreement with the study of Kulak
which is done in Bialystok, Poland, department of
paediatric neurology & rehabilitation 28 April 2005.
Neuroimaging
Most of children already have brain computed
tomography (C-T) &/ or brain magnetic resonance
imaging (MRI) or if not done we arrange for that for
indicated cases, the controversial images were
assessed by the neuroradiologists who were unaware
of child history & examination, cerebral atrophy was
diagnosed when diffuse sulcal widening of the
cerebrum with symmetrical ventricular dilatation
without periventricular signal abnormalities was
observed (11)
The following information was obtained on each
patient, sociodemographic data, age at first
presentation, history of neonatal seizure gestational
age at & place of delivery, the underlying risk
factor&/or cause of cerebral palsy & appropriate
topographic (sd &qd) most .
The difference between the groups determined by
non parametric statistical Chi-square test was used
when appropriate.
(13)
The more interesting finding of present study is the
presence of associated condition, that is the
probability of presence of associated of neurological
condition with sq much more than sd.
Global delay, epilepsy & speech delay constitute the
main associated neurological condition &it is
present only in 9 cases of sd, but it is present in
about 60 cases of sq. Our result is similar to many
studies. (13, 14, 15) Zafeirion et al (15) had studied 178
patient with cp & epilepsy. He compared them to a
control group of 150 epileptic patients without cp,
the overall prevalence of epilepsy was 36.1%,
almost 56% of children with sq had epilepsy.
Several studies had been mentioned a significant
relationship between global delay, cerebral palsy &
epilepsy. (16, 17, 18, 19)They found children with sq had
a delay in all the development functions than those
with sd.
About 75% of sd & 94% of sq already under given
neuroimaging, the probability of associated
significant brain insult sign which is mostly brain
atrophy seen in brain neuroimaging were recorded in
patients with sq the brain atrophy reflect strong
evidence for acute brain injury occurring around the
time of birth.
In present study brain atrophy found in 43% in sd &
it is in 77% of cases with sd & it is partially
agreement with previous study. (20)
Result
Of 171 selected cases with spastic cerebral palsy
78(45 males&33 females) had SD & 93(52
males&41 females) had sq (table 1). The age
mean±SD (median) in months were 35.23±20.82
(30) and 41.12±28.17 (30) of diplegic and
quadriplegic patients respectively; with male/female
ratio 1:1.36 and 1:1.26 respectively.
Male gender was not associated with an increase risk
of SD and sq (p value >0.05).
Table-1 shows presence of risk factor between SD
and sq and it is mainly preterm delivery and birth
asphyxia and there is no significant difference
between them in subdivision of risk factor.
A significantly greater number of children with sd
were classified into level 2&3 of the gross motor
function classification system compared with the
quadriplegia group, on the other hand ,the patient
with sq were classified more frequently into level
4&5 of the gross motor function classification
system than were patients with sd(table- 2).
The total of 70 child with spastic cerebral palsy had
associated neurological condition ,60 of them were
from sq & global delay, epilepsy & speech delay
constitute high proportion in (sq) were documented
( table-3).
Of total cases 145 had neuroimaging & mostly brain
C-T (table- 4). Significant abnormalities relevant to
the spastic cp were evident in 92 cases &it is mostly
sq (67cases) &it is mainly brain atrophy.
Conclusion
This study leads us to conclude that quadriplegic cp
& diplegic cp forms of cp have comparable risk
factor, but different clinical pattern,
sq more likely to have GMFCS 4 & 5, global delay,
epilepsy & speech delay were observed more
frequently in a children with sq than in children with
sd.
Discussion
In present study 171 cases with spastic cp, 78 were
sd & 93 were sq, some significant differences were
found between them, although the risk factor were
254
Iraqi J. Comm. Med., July. 2012 (3)
Comparison of Clinical Profile in Spastic Diplegic and Quadriplegic Cerebral Palsy
Adel A. Kareem*
Table 1: Distribution of patients according to the risk factors.
With risk factors
No risk
(n)
(%)
factors (n)
LBW
NNJ
Preterm
Birth
%
asphyxia
13
2
1
39
23
Diplegic
16.6
3.0
1.5
60.0
35.5
18
1
7
40
27
Quadriplegic
19.3
1.3
9.3
53.4
36.0
Odds ratio =1.20
Table 2: The distribution of patients according to the GMFCS.
Types of GMFCS
Diplegic (n)
1
1
(1.28)
2
27
(34.61)
3
36
(60.0)
4
13
(17.9)
5
1
(1.28)
Total
78
(100)
%
All with risk
factors
65
83.4
75
36.0
Quadriplegic (n)
------------1
(1.07)
7
(7.52)
43
(36.0)
42
(47.2)
93
(100)
Table 3: distribution of patients according to the types of associated conditions.
Diplegic
Development delay (n) %
1 (10.0)
global(n)%
2 20.0)
Epilepsy(n)%
4 (40.0)
Speech delay(n)%
3 (30.0)
Total(n)%
10 (100)
Total
(n)
%
78
100
93
100
%
Quadriplegic
---------18 (30.0)
21 (35.0)
21 (35.0)
60 (100)
Table 4: distribution of patients according to the types of neurological image finding
Diplegic
Quadriplegic
Normal (n)%
33
(56.89)
20
(22.98)
Brain atrophy (n)%
25
(43.11)
67
(77.02)
Total (n)%
58
(100)
87
(100)
Total
35
92
145
(100)
(100)
(100)
7. Much L., Alberman E., Hagberg B., Kadama K.
& perat M.V., cerebral palsy epidemiology:
Where are we now &where are we going 2.Dev
Med Child neurology 34(1zxcv m, 992). Pp547555.
8. Commission on Classification & Terminology of
the International league Against Epilepsy,
proposal for revised classification of epilepsies
&epileptic syndrome, Epilepsy 30 1989, pp309399.
9. Richard Tang. Wai, Richard I. Webste &
Michael I. Shevell. A clinical &Etiologic Profile
of Spastic diplegia pediatric neurology 34 (2006)
no.3, pp (212-218).
10. Palisano RJ, Rosenbaum P, Walter S, Russell D
Wood E, Galappi B. Developmental & reliability
of a system to classify gross motor function in
child with cerebral palsy. Dev. med. child
neurology 1997; 39:214-223.
11. Hayakawa K., Kanada T., Hashimoto K., Okuno
Y. & yamori Y., MR of spastic tetraplegia. A.
JNR AMJ Neuroradiology 18(1997) pp.247-253.
References
1. Mutchl, Albermane, Hagberg B et al. Cerebral
palsy epidemiology; where are we now &where
are going? Dev. Med child neurology, 1992;
34:547-551.
2. Christos P. Panteliadis,Thessaloniki/Greece HanMichael strassburg, Würzburg/Germany cerebral
palsy principles & management, Geeorg Thieme
Verlag ,Stuttggart, New York 2004.p3.
3. Mc Donald AD. Cerebral palsy in children of
very low birth weight .Arch Dies child
1963;38:579.
4. Hagberg B., Olow &L. Van Vent, The changing
panorama of cerebral palsy in Sweden :Analysis
of general changes, Acta Paediatr Scand 64
(1996),pp547-555.
5. Kulak W. & Sobaniec W., comparisons of right
&left hemiparetic cerebral palsy, pediatric neural
31(2004) pp.101-108 Article.
6. Crichton J U, Mackinon M, white. The life
expectancy of person with cerebral palsy. Dev
Med child neurology 1995; 37: 567-576.
255
Iraqi J. Comm. Med., July. 2012 (3)
Comparison of Clinical Profile in Spastic Diplegic and Quadriplegic Cerebral Palsy
12. Hagberg B. & Hagberg G. The changing
panorama of cerebral palsy-bilateral spastic
forms in particular Acta pediatr suppl 416(1996).
pp 48-52.
13. Kulka W, Sobaneic W, Smigielska-Kuzia J,
Kubas B, Walecki j. a comparison of spastic
diplegic & tetraplegic cp. Pediatr neurol. 2005,
32:311-317.
14. Ellenberg J.H., Hirtz D. G. & Nelson K. B.,
Age at onset of seizures in young children, Ann.
Neurol 15 (1984) PP289-294.
15. Zafeirion D. I, Kontopolous E.E. & Tsikoulas I.,
Characteristics & prognosis of epilepsy in
children with cerebral palsy, J. child neurol. 14
(1999); PP 289-294.
16. Senbil N., Sonel B., Aydin O. F. & Gurer Y. K.,
Epileptic cerebral palsy EEG &cranial imaging
finding, Brain Dev 24 (2004). pp 166-169.
Adel A. Kareem*
17. Okumura A., Hayakawa F, Kato T., Kuno K &
Watanab K., Epilepsy in patients with spastic cp;
correlation with MRI finding at 5 years of age,
Brain Dev 21(1999); pp540-543.
18. Chen C L et al., Comparison of developmental
pattern change in preschool children with spastic
diplegic &quadriplegic cerebral palsy Chang
Gug Med. J. 33 (2010);PP407-14.
19. Lee YC et al, Development profiles of preschool
children with spastic diplegic &quadriplegic
cerebral palsy Kaohsiung J Med Sci 26(2010);
pp 341-9.
20. Adel A. Kareem, Mohammad A. S Kamel risk
factors &clinical profiles in Iraq children with
cerebral palsy, Iraqi med j ; 5(2009) pp64-68.
* Pediatric Neurology Department, Neurosciences
Hospital, E-mail;[email protected]
256
Iraqi J. Comm. Med., July. 2012 (3)