Regional cerebral glucose metabolism in clinical subtypes of cerebral palsy

doi:10.1016/0887-8994(91)90024-F

Pediatric Neurology

Volume 7, Issue 6, November–December 1991, Pages 415-425

https://doi.org/10.1016/0887-8994(91)90024-F Get rights and content

Abstract

Twenty-three children with 4 clinical subtypes of cerebral palsy were studied using 2-deoxy-2(¹⁸F)fluoro-d-glucose (FDG) and positron emission tomography (PET). Subtypes included spastic quadriparesis (N = 6), spastic diplegia (N = 4), infantile hemiplegia (N = 8), and choreoathetosis (N = 5). FDG-PET images were correlated with magnetic resonance imaging or computed tomography. Although the location of glucose metabolic abnormalities corresponded, in general, to abnormalities of brain structure demonstrated by structural imaging studies, the distribution of metabolic impairment almost invariably extended beyond the region of anatomic involvement. The following observations in specific subtypes of cerebral palsy were determined with FDG-PET: (1) In spastic diplegic patients, PET revealed focal areas of cortical hypometabolism in the absence of apparent structural abnormality; (2) A relatively normal pattern of cortical metabolism was observed in most patients with choreoathetoid cerebral palsy, despite marked hypometabolism in the thalamus and lenticular nuclei; and (3) In patients with infantile hemiplegia, FDG-PET disclosed symmetric cerebellar glucose metabolism with absence of crossed cerebellar hypometabolism (diaschisis). This finding is contrary to the typical persistence of crossed cerebellar diaschisis in adult patients with acquired cerebral lesions and suggests metabolic recovery due to developmental plasticity. The possibility that FDG-PET may be clinically useful in identifying the cerebral palsy patient with potential learning handicap and in the study of functional recovery or sparing following brain injury should be explored further.

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Other imaging modalities used were computed tomography, diffusion tensor imaging, positron emission tomography, single-photon emission computed tomography, and voxel-based morphometry. In two studies, single-photon emission computed tomography and positron emission tomography appeared to show abnormalities that were not visible on standard MRI.19,20 Almost all studies probed thalamic involvement (21 of 22).
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Thirteen studies specified the involved basal ganglia nuclei (subthalamic nucleus, caudate, putamen, globus pallidus, or lentiform nuclei, comprised by the putamen and globus pallidus). Studies investigating the lentiform nuclei (without distinguishing between the putamen and globus pallidus) showed that all subjects (19 of 19) had lentiform nuclei damage. Studies simultaneously but independently investigating the putamen and globus pallidus also showed that all subjects (35 of 35) had lentiform nuclei damage (i.e., putamen or globus pallidus damage); this was followed in frequency by damage to the putamen alone (70 of 101, 69%), the subthalamic nucleus (17 of 25, 68%), the thalamus (88 of 142, 62%), the globus pallidus (7/35, 20%), and the caudate (6 of 47, 13%). Globus pallidus damage was almost always coincident with putaminal damage.
Noting consistent involvement of the lentiform nuclei in dyskinetic cerebral palsy, these results could suggest two groups of patients with dyskinetic cerebral palsy: those with putamen-predominant damage and those with panlenticular damage involving both the putamen and the globus pallidus. Differentiating between these groups could help predict response to therapies such as deep brain stimulation.
Early hyperglycemia is associated with poor gross motor outcome in asphyxiated term newborns
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Citation Excerpt :
Also, in a newborn piglet model with induced hypoxia but without ischemia, administration of dextrose actually prevents brain cell membrane dysfunction.12 The part of the brain most sensitive to asphyxia in the term infant is the basal ganglia.13-15 A buildup of lactic acid in the basal ganglia as shown in magnetic resonance spectroscopy is one of the strongest predictors of poor outcome in term neonatal asphyxia.16-18
Hyperglycemia after ischemic stroke in adults and after near-drowning in children is associated with a poor neurological outcome. Anaerobic metabolism of glucose leads to buildup of lactic acid, free radical production, mitochondrial failure, and ultimately an increase in neurological injury. In asphyxiated infants, high lactate peaks are seen in the basal ganglia with magnetic resonance spectroscopy. Because motor disability in asphyxiated full-term newborns often relates to injury in the basal ganglia, we hypothesized that hyperglycemia and associated buildup of lactic acid may lead to worse gross motor outcome.
Glucose, blood gas values, and demographic data were abstracted from the medical records of 41 term infants with asphyxia and without confounding diagnoses. Their Gross Motor Function Classification System scores were determined from the medical record or by structured telephone interviews.
The outcomes of 14 infants were considered poor on the basis of death within the first 6 months or moderate-to-severe cerebral palsy (Gross Motor Function Classification System score 1-5). The other 27 infants had no gross motor disability (Gross Motor Function Classification System score 0). The highest recorded blood glucose correlated with poor outcome (P = 0.046 by logistic regression). Infants with hyperglycemia (blood glucose > 150 mg/dL) were more likely to have poor outcome (P = 0.017; odds ratio: 5.9; 95% confidence interval: 1.4-24.7).
High blood glucose in the first 12 hours is associated with poor gross motor outcome in this cohort of asphyxiated term infants. Clinicians should avoid hyperglycemia in managing term infants with asphyxia.
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Positron emission tomography (PET) is a relatively noninvasive imaging test that is able to detect abnormalities in different organs based on derangements in the chemical functions and/or receptor expression at the cellular level. PET imaging of the brain has been shown to be a powerful diagnostic tool for detecting neurochemical abnormalities associated with various neurologic disorders as well as to study normal brain development. Although its use in detecting neurological abnormalities has been well described in adults and pediatrics, its application in the newborn nursery has not been explored adequately. Early detection of brain injury secondary to intrauterine and perinatal insults using PET imaging can provide new insight in prognosis and in instituting early therapy. In this review, the authors describe applications of PET imaging in the newborn nursery specifically related to the detection of metabolic changes seen in hypoxic ischemic encephalopathy, neonatal seizures, and neuroinflammation in the neonatal period.
Single unit "pauser" characteristics of the globus pallidus pars externa distinguish primary dystonia from secondary dystonia and Parkinson's disease
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The presence of high frequency discharge neurons with long periods of silence or “pauses” in the globus pallidus pars externa (GPe) is a unique identifying feature of this nucleus. Prior studies have demonstrated that pause characteristics reflect synaptic inputs into GPe. We hypothesized that GPe pause characteristics should distinguish movement disorders whose basal ganglia network abnormalities are different. We examined pause characteristics in 224 GPe units in patients with primary generalized dystonia, Parkinson's disease (PD), and secondary dystonia, undergoing single unit microelectrode recording for DBS placement in the awake state. Pauses in neuronal discharge were identified using the Poisson surprise method. Mean pause length in primary dystonia (606.8373.3) was higher than in PD (557.4366.6) (p < 0.05). Interpause interval (IPI) was lower in primary dystonia (2331.63874.1) than PD (3646.45894.5) (p < 0.01), and mean pause frequency was higher in primary dystonia (0.140.10) than PD (0.070.12) (p < 0.01). Comparison of pause characteristics in primary versus secondary generalized dystonia revealed a significantly longer mean pause length in primary (606.8373.3) than in secondary dystonia (495.6236.5) (p < 0.01). IPI was shorter in primary (2331.6 ± 3874.1) than in secondary dystonia (3484.5 ± 3981.6) (p < 0.01). The results show that pause characteristics recorded in the awake human GPe distinguish primary dystonia from Parkinson's disease and secondary dystonia. The differences may reflect increased phasic input from striatal D2 receptor positive cells in primary dystonia, and are consistent with a recent model proposing that GPe provides capacity scaling for cortical input.
Walking and periventricular leukomalacia: Locomotor characteristics and brain imaging (MRI)
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The aim of the present study was to compare the walking abilities in infants with and without periventricular leukomalacia and to see whether the severity of the brain damage was related to locomotor outcome of the infants at 12 and 18 months.
47 newborns were included in the study based on white matter abnormalities on ultrasound. Magnetic resonance imaging (MRI) recordings during the neonatal period were used to identify and quantify the location and severity of the brain lesions. Locomotor outcome was assessed in terms of disability at 12 and 18 months. The quality of walking, including global and segmental gait parameters, was measured for the infants who could walk independently at 18 months and compared to a group of healthy control infants. The number of children who could walk was related to the extent of white matter abnormalities seen on the neonatal MRI, but the quality of walking was not.
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Citation Excerpt :
FDG-PET studies have shown that the distribution of metabolic impairment almost invariably extends beyond the region of anatomic involvement. Whereas FDG-PET shows focal areas of cortical hypometabolism in the absence of apparent structural abnormality in spastic diplegic patients, a relatively normal pattern of cortical metabolism is seen in some children with choreoathetoid cerebral palsy, along with marked hypometabolism in the thalamus and lenticular nuclei and relative sparing of the caudate nucleus (see Fig. 15).98 Relative sparing of the cerebral cortex is consistent with the clinical observation that many of these children have relative preservation of cognitive function compared with their severe motor impairment.

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^☆: Supported by Department of Energy contract DE-FCO3-87ER60615, U.S. Public Health Service grant 2P01-NS15654-10, and a grant from the United Cerebral Palsy Research Foundation.

¹: Dr. Chugani is the recipient of Teacher-Investigator Developmental award 1-K07-NS00886 from the National Institute of Neurological Diseases and Stroke.

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Original articleRegional cerebral glucose metabolism in clinical subtypes of cerebral palsy☆

Abstract

Asphyxia in the fetus and cerebral palsy

Cerebral palsy and mental retardation in relation to indicators of perinatal asphyxia: An epidemiologic overview

Am J Obstet Gynecol

Increase in cerebral palsy in normal birth weight babies

Arch Dis Child

Antecedents of cerebral palsy

Am J Dis Child

Antecedents of cerebral palsy: Multivariate analysis of risk

N Engl J Med

Antenatal hypoxia and low IQ values

Am J Dis Child

Intrapartum asphyxia: A rare cause of cerebral palsy

J Pediatr

Cerebral palsy: A pediatric developmentalist's overview

Am J Dis Child

Positron emission tomography: Human brain function and biochemistry

Science

Performance evaluation of a positron tomograph designed for brain imaging

J Nucl Med

A new PET system for high resolution 3-dimensional brain imaging

J Nucl Med

Optimization and standardization of anatomical data in neuro-behavioral investigations using positron computed tomography

J Cereb Blood Flow Metab

The (14C)-deoxy-glucose method for the measurement of local cerebral glucose utilization: Theory, procedure, and normal values in the conscious and anesthetized albino rat

J Neurochem

Tomographic measurement of local cerebral glucose metabolic rate in humans with (18-F)2-fluoro-2-deoxyglucose: Validation of method

Ann Neurol

Noninvasive determination of local cerebral metabolic rate of glucose in man

Am J Physiol

Positron emission tomography study of human brain functional development

Ann Neurol

Neurology of the newborn

Positron emission tomography in the asphyxiated term newborn: Parasagittal impairment of cerebral blood flow

Ann Neurol

Regulation of local cerebral blood flow in normal and hypoxic newborn dogs

Ann Neurol

Granule cell deficit in the mouse cerebellum after total asphyxia

Ann Neurol

Pathology of perinatal brain injury

Clinical risk factors and periventricular leucomalacia

Arch Dis Child

Acquired perinatal leukoencephalopathy

Ann Neurol

Periventricular leukomalacia: A one-year autopsy study

Arch Neurol

Original article
Regional cerebral glucose metabolism in clinical subtypes of cerebral palsy☆