Comparisons of right and left hemiparetic cerebral palsy

Comparisons of Right and Left Hemiparetic Cerebral Palsy Wojciech Kulak, PhD, and Wojciech Sobaniec, PhD The purpose of this study was to compare right and left hemiparetic cerebral palsy. Sixty children (34 males, 26 females) with hemiparetic cerebral palsy were recruited. Thirty-two children manifested left hemiparetic cerebral palsy and 28 right hemiparetic cerebral palsy. Low birth weight, seizures, a family history of epilepsy, severity of cerebral palsy, and computed tomographic findings were analyzed. No significant differences were found between the clinical patterns of hemiparesis in both groups. Gestational history, low birth weight, and perinatal pathologies were present in similar percentages in the left and the right hemiparetic cerebral palsy children. Significantly greater numbers of pregnancies (P ⴝ 0.003) and deliveries (P ⴝ 0.01) were observed in the left hemiparetic cerebral palsy group as compared with the right hemiparetic cerebral palsy group. Similarly, significantly (P ⴝ 0.03) lower values of the Apgar score were recorded in the left hemiparetic cerebral palsy group than the right hemiparetic cerebral palsy group. A similar percentage of neuroradiologic abnormalities was detected in both groups. Twenty-six (43.3%) children with hemiparetic cerebral palsy had epilepsy. The incidence of intractable epilepsy was similar in both groups. The results of this study are comparable with earlier reports on hemiparetic cerebral palsy. © 2004 by Elsevier Inc. All rights reserved. Kulak W, Sobaniec W. Comparisons of right and left hemiparetic cerebral palsy. Pediatr Neurol 2004;31:101-108.

Introduction Hemiparetic cerebral palsy is a form of spastic cerebral palsy in which one arm and leg on either the right or left side of the body is affected. Hemiparetic cerebral palsy is

From the Department of Pediatric Neurology and Rehabilitation, Medical University of Bialystok, Bialystok, Poland.

© 2004 by Elsevier Inc. All rights reserved. doi:10.1016/j.pediatrneurol.2004.01.009 ● 0887-8994/04/$—see front matter

the most common cerebral palsy syndrome in children born at term, and is second in frequency only to spastic diplegia among preterm infants [1]. Patients with hemiparetic cerebral palsy have unilateral prehensile dysfunction as a consequence of lesions in the sensorimotor cortex and corticospinal tract [2]. Children whose hemiparesis involves the upper limb to a greater extent than the lower (arm-dominant hemiparesis) are much more likely to experience learning difficulties than those whose clinical pattern is leg-dominant [2]. They more often develop recurrent, unprovoked seizures. Those whose clinical pattern affects the upper and lower limbs to an approximately equal extent (sometimes referred to as “proportional” hemiparesis) appear to fall between the arm-dominant and leg-dominant groups in terms of outcome [3]. Brain damage early in life is associated with a greater potential for recovery of function than lesions acquired later in life [4]. In children with hemiparetic cerebral palsy, remarkable motor reorganization can often occur by relocating or preserving motor representations of the affected arm in the undamaged ipsilateral hemisphere, which plays an essential role in motor control. In normal individuals, the left hemisphere is responsible for verbal, sequential, temporal, logical, analytical and rational processes [5]. The right hemisphere support nonverbal, visuospatial, spatial, analogical, synthetic, and intuitive processes. Epilepsy and cognitive deficits are common in the arm-dominant and rare in the leg-dominant. Some authors have recommended routine imaging studies in children with hemiparetic cerebral palsy as an assessment of etiology and a predictor of outcome [6,7]. The present study compares risk factors, clinical patterns, electroencephalogram, and computed tomography in predicting epilepsy and cognitive disabilities in children with left hemiparetic cerebral palsy and right hemiparetic cerebral palsy.

Communications should be addressed to: Dr. Kulak; Department of Pediatric Neurology and Rehabilitation; Medical University of Bialystok; 15-274 Bialystok ul. Waszyngtona 17; Poland. Received July 17, 2003; accepted January 23, 2004.

Kulak and Sobaniec: Right vs Left Hemiparetic Cerebral Palsy 101

Patients and Methods

based on a characteristic radiologic picture, also referred to in the literature as perisylvian polymicrogyria [12].

We reviewed the medical records of children with cerebral palsy referred to our Pediatric Neurology Department in Bialystok from October 1994 to December 2002. Sixty children (34 males and 26 females) with hemiparetic cerebral palsy were investigated. Of these children, 32 had a left hemiparetic cerebral palsy, and 28 had a right hemiparetic cerebral palsy. Children with classically defined hemiparetic cerebral palsy [8] were included in the present study. During the initial assessment, function of the upper limb on the hemiparetic side was graded according to the following modified Humphreys’ [6] simple scale: grade 4 –fisted hand, wrist drop, no useful function; grade 3– crude grasp only, no pincer; grade 2– clumsy hand with poor rapid finger movement but preserved pincer grasp; grade 1–normal hand function. The degree of cerebral palsy severity was assessed in the patients according to Arguelles et al. [9]: 4 –very severe; when patients do not have any postural control; 3–severe: can walk with maximum support; 2–moderate: can walk with some support or when the patient uses the paretic hand but without the ability to make individual movements of the fingers; 1–mild: can walk unaided. At the completion of the assessment, the patients were assigned to one of three groups for the purposes of analysis: arm-dominant–spasticity and functional impairment clearly greater in the upper limb; leg-dominant– lower limb primarily involved with relative sparing of the upper limb, whose functional grade was always 2 or 3; proportional–the patients without clear-cut arm or leg predominance, regardless of the upper limb functional grade. In addition, the following variables were analyzed: sex, age, Apgar score, birth weight, prenatal pathology (preeclampsia, premature disruption of placenta, bleeding, sepsis) pregnancy, delivery, severity of hemiparetic cerebral palsy, types of epilepsy [10], onset of epilepsy, neonatal seizures, status epilepticus, computed tomographic brain scan, electroencephalogram, use of antiepileptic drugs, and seizure outcome.

Electroencephalogram Electroencephalographic signals were recorded from scalp electrodes (according to the International 10/20 System), all correlated with the vertex reference. The signals were recorded, amplified, and filtered by a Medelec DG Compact 32 (Surrey, Great Britain). Ag/AgCl electrodes with an impedance less than 5 k⍀ were used. Frequencies below 1 Hz and above 70 Hz were eliminated by digital filtering. The investigational protocol was approved by the Local Committee of the Medical University of Bialystok.

Cognitive Function The patients were assigned to one of three groups, depending upon their level of academic achievement, supplemented by results of formal psychological testing: (1) Normal–normal school performance to at least first grade level, with no evidence of specific learning difficulties. All the children in this group had one or more formal psychological assessments (the typical Wechsler Intelligence Scale for Children, Polish version). (2) Mentally handicapped–formal psychological testing results indicated function in the mentally deficient range. (3) Mental retardation was divided into the following: mild: 70-84 intelligence quotient (IQ); moderate: 50-69 IQ; severe: ⬍50 IQ. Normal children had IQ ⬎90.

Definitions Cerebral palsy was defined as motor disabilities caused by nonprogressive damage to the developing brain [8]. Epilepsy was defined as a separate occurrence of two or more apparently unprovoked seizures [10]. The seizure outcome was defined as good if the patient was seizure-free for more than 2 years. Intractable epilepsy was defined as two seizures per month despite appropriate drug therapy [13]. The epileptic seizures were divided into the following three groups: (1) partial (including simple partial, complex partial, and partial with secondary generalization); (2) generalized (generalized seizures other than infantile spasms (IS), including tonic, tonic clonic, myoclonic, and atypical absence seizures); and (3) the Lennox-Gastaut syndrome. Prematurity was defined by the World Health Organization as an infant with a gestation of less than 37 weeks from the first day of the last menstrual period. Prenatal pathology included preeclampsia, premature disruption of the placenta, bleeding, and sepsis. Diagnosis of mental abnormality was based on clinical assessment, supplemented by standard tests if available at the time of diagnosis, and need for special education.

Statistical Analysis The differences between the groups were determined by the parametric t test and nonparametric statistical tests: Fisher’s Exact Test or chi-square test where appropriate. All P values were two-tailed. Statistical significance was defined as P ⱕ 0.05. Spearman’s rank-sum correlation test was applied. Statistics were calculated using Statistica 5.1.

Results Computed Tomography A routine computed tomographic scan of all the patients’ heads was made with 10-mm axial slices. All computed tomographic studies were performed at the Children’s Hospital of Bialystok. The computed tomographic results were first analyzed by the pediatric radiologists, and carefully reviewed by the authors (W.K., W.S.). The computed tomography was divided into five subgroups according to Wiklund and Uvebrant [7]: 1–normal; 2– unilateral ventricular enlargement (periventricular leukomalacia); 3– cortical/subcortical cavities (infarct); 4 – hemispheral atrophy and other findings (porencephaly); 5– central nervous system malformations (polymicrogyria). For the analysis, the percentage of abnormal computed tomographic findings in the cerebral palsy patients with right hemiparetic cerebral palsy and left hemiparetic cerebral palsy was evaluated. Periventricular leukomalacia was established according to the criteria of Flodmark et al. [11]: Infarct– encephaloclastic lesion involving the territory of a major cerebral artery, in whole or in part. Porencephaly–a single cystic lesion of cerebral white matter which may or may not connect with the lateral ventricle. Polymicrogyria–a pathologic inference

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The clinical data are summarized for all patients in Table 1. Sixty patients (34 males, 26 females) with hemiparetic cerebral palsy were recruited. Thirty-two children had left hemiparetic cerebral palsy and 28 had right hemiparetic cerebral palsy. Of the three clinical patterns of hemiparesis, 10 (31.2%) in right hemiparetic cerebral palsy 11 (39.2%) in left hemiparetic cerebral palsy were arm-dominant. The leg-dominant forms of hemiparetic cerebral palsy were present in 13 (40.6%) of the children with left hemiparetic cerebral palsy and in 12 (43.8%) right hemiparetic cerebral palsy children. Nine (28.1%) patients of the left hemiparetic cerebral palsy group and 5 (17.8%) of the right hemiparetic cerebral palsy had a proportional hemiparesis. No significant differences between the clinical patterns of hemiparesis in the groups were observed. Significantly greater numbers of

Table 1. Characteristics of subjects with left hemiparetic cerebral palsy (LHCP) and right hemiparetic cerebral palsy (RHCP)

Variable Gestation (wk) Female/Male Arm-dominant Leg-dominant Arm-leg Number of pregnancies Number of deliveries Apgar score at 1 minute Weight at birth Severity of CP (n 4 score scale)

LHCP (n ⴝ 32)

RHCP (n ⴝ 28)

28-42 38.70 ⫾ 2.95 14/18 10 13 9 1-7 2.64 ⫾ 1.76 1-7 2.32 ⫾ 1.64 1-10 6.33 ⫾ 3.67 1650-4400 3030 ⫾ 736 1-4

30-41 37.80 ⫾ 2.74 12/16 11 12 5 1-4 1.50 ⫾ 0.86 1-4 1.42 ⫾ 0.79 1-10 8.17 ⫾ 2.53 1550-4100 3032 ⫾ 682 1-4

1.28 ⫾ 0.53

1.33 ⫾ 0.76

NS

10 12 8 2 14

7 16 4 1 12

NS NS NS NS NS

Mental development Normal Small delay Mild Severe Epilepsy

P Value* NS NS NS NS NS 0.003 0.01 0.03 NS NS

* P value from t test and Fisher’s Exact Test between groups. Abbreviations: CP ⫽ Cerebral palsy NS ⫽ Not significant

pregnancies (P ⫽ 0.003) and deliveries (P ⫽ 0.01) were observed in the left hemiparetic cerebral palsy group as compared with the right hemiparetic cerebral palsy group. Similarly, a significantly (P ⫽ 0.03) lower value of the Apgar score was recorded in the left hemiparetic cerebral Table 2.

palsy group than in the right hemiparetic cerebral palsy group. No differences in birth weight between the groups were observed. The severity of hemiparetic cerebral palsy on the in 4 - score scale did not differ between the groups. The mental development was similar in the left hemiparetic cerebral palsy patients and the right hemiparetic cerebral palsy patients. Comparable percentages of epilepsy in left hemiparetic cerebral palsy and right hemiparetic cerebral palsy were documented. No significant differences in milestones (sitting, standing, walking, and speaking) of the children with left hemiparetic cerebral palsy and in the right hemiparetic cerebral palsy children were evident (data not shown). Sex, asphyxia, gestational history, caesarean section, birth weight, and perinatal pathology as risk factors for hemiparetic cerebral palsy are presented in Table 2. Forty-five (75%) children with hemiparetic cerebral palsy were born term, and in preterm 15 (25%). The prenatal risk factors of low birth weight and asphyxia were observed in 15 (25%) and 12 (20%) patients, respectively. Perinatal risk factors (prelabor rupture, abruptio placenta, fetal distress, preeclampsia, respiratory distress syndrome, and sepsis) ranged from 3% to 25% in hemiparetic cerebral palsy children. Male sex was not associated with an increased risk of left hemiparetic cerebral palsy or right hemiparetic cerebral palsy, nor was gestational history related to an increased risk of left hemiparetic cerebral palsy or right hemiparetic cerebral palsy. The percentages of caesarean sections in both groups were comparable. Low birth weight (⬍2500 gm) was not significantly associated with an increased risk of left hemiparetic cerebral palsy or right hemiparetic cerebral palsy. The perinatal pathologies (prelabor rupture, abruptio placenta, fetal distress, preeclamp-

Risk factors of children with left hemiparetic cerebral palsy (LHCP) and right hemiparetic cerebral palsy (RHCP)

Variable Male sex Asphyxia Gestational history Preterm Term Postterm Caesarean section Low birth weight ⬍2500 gm Prelabor rupture of membranes Abruptio placenta Fetal distress Preeclampsia RDS Sepsis

LHCP N (%) (n ⴝ 32)

RHCP N (%) (n ⴝ 28)

LHCP vs RHCP OR (95% CI)

P Value

18 (56) 8 (25.8)

16 (57.1) 4 (14.3)

0.98 (0.42-2.28) 1.75 (0.47-6.44)

NS NS

8 (25.8) 24 (75.0) 0 (0) 10 (32.2) 7 (21.8) 6 (18.7) 4 (12.5) 11 (34.3) 1 (3.1) 5 (15.6) 3 (9.3)

7 (25.0) 21 (75.0) 0 (0) 9 (32.1) 8 (28.5) 9 (32.1) 3 (10.7) 9 (32.1) 2 (7.1) 7 (25.0) 2 (7.1)

1.08 (0.32-3.10) 1.0 (0.46-2.17) 0 0.97 (0.34-2.73) 0.76 (0.24-2.37) 0.58 (0.18-1.84) 1.16 (0.24-5.66) 1.06 (0.38-2.95) 0.43 (0.03-5.08) 0.62 (0.17-2.19) 1.31 (0.20-8.42)

NS

NS NS NS NS NS NS NS NS

Abbreviations: 95% CI ⫽ 95% confidence interval NS ⫽ Not significant OR ⫽ Odds ratio RDS ⫽ Respiratory distress syndrome

Kulak and Sobaniec: Right vs Left Hemiparetic Cerebral Palsy 103

Table 3. Degree of severity (locomotion and hand function) in hemiparetic cerebral palsy (HCP) and HCP with epilepsy

Types of CP Hand function LHCP LHCP and epilepsy RHCP RHCP and epilepsy Locomotion LHCP LHCP and epilepsy RHCP RHCP and epilepsy

Very Severe

Severe

Moderate

Mild

Table 4.

Total (n)

0 3 1 4

5 7 3 6

5 4 3 1

8 0 9 1

18 14 16 12

2 1 0 0

2 0 1 0

7 5 2 5

7 8 13 7

18 14 16 12

Abbreviations: CP ⫽ Cerebral palsy HCP ⫽ Hemiparetic cerebral palsy LHCP ⫽ Left hemiparetic cerebral palsy RHCP ⫽ Right hemiparetic cerebral palsy

sia, respiratory distress syndrome, and sepsis) were present in similar proportions in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy groups. The degrees of severity of impaired locomotion and function in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy children are presented in Table 3. More children with very severe and severe dysfunction of the hand manifested epilepsy, 10 vs 5 in the left hemiparetic cerebral palsy group and 10 vs 4 in the right hemiparetic cerebral palsy group. On the other hand, moderate and mild forms of hemiparetic cerebral palsy were observed in a higher percentage of the children without epilepsy. The locomotion function was affected in similar proportions in the hemiparetic cerebral palsy children with or without epilepsy. Significant abnormalities relevant to the hemiparesis were evident on imaging in 51 (85%) (Table 4). Nine children had normal computed tomographic scans. A similar percentage of the computed tomographic abnormalities were detected in both groups, 26 (83.3%) in patients with left hemiparetic cerebral palsy and 25 (89.2%) in patients with right hemiparetic cerebral palsy. The most common finding on computed tomography was periventricular leukomalacia in 23 (38.3%) patients, with a similar proportion in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy groups. Periventricular leukomalacia was observed more frequently in the children with the leg-dominant and arm⫽leg hemiparesis than in arm-dominant, 18 vs 5 patients (P ⫽ 0.02). It is significant that 83% of the patients with periventricular leukomalacia were born at term with no history suggestive of perinatal asphyxia and low birth weight (⬍2500 gm). Only five children born prematurely had a history of perinatal asphyxia, low birth weight, and neonatal respiratory distress syndrome. Infarcts were observed in six children in similar proportions in the three groups. Porencephalic cysts were evident in 13 patients. Of the 13 cysts,

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Neuroimaging findings in hemiparetic cerebral palsy*

Variable Arm-dominant Normal PVL Infarct Porencephaly Polymicrogyria Leg-dominant Normal PVL Infarct Porencephaly Polymicrogyria Arm-leg Normal PVL Infarct Porencephaly Polymicrogyria Total CT abnormalities Score CT abnormalities in nonepileptic HCP Score CT abnormalities in epileptic HCP Sum of score CT abnormalities

LHCP N (%) Cases (n ⴝ 32)

RHCP N (%) Cases (n ⴝ 28)

0 2 (6.4) 1 (3.2) 5 (16.1) 1 (3.2)

0 3 (10.7) 2 (7.1) 4 (14.3) 1 (3.6)

5 (15.6) 6 (19.3) 0 1 (3.2) 0

4 (14.3) 4 (14.3) 2 (7.1) 0 0

0 5 (16.1) 1 (3.2) 0 1 (3.2)

0 3 (10.7) 0 2 (10.7) 0

26 (83.3%) 32

25 (89.2%) 30

39

35

71

65

* Fisher’s test, LHCP vs RHCP. Abbreviations: CT ⫽ Computed tomography HCP ⫽ Hemiparetic cerebral palsy LHCP ⫽ Left hemiparetic cerebral palsy PVL ⫽ Periventricular leukomalacia RHCP ⫽ Right hemiparetic cerebral palsy

nine were present in patients with arm-dominant hemiparesis, one in a leg-dominant patient, and three in the arm⫽leg group. Porencephalic cysts were observed more often in term children 9 (69%) than in preterm infants 4 (31%). Premature infants with porencephaly manifested asphyxia and low birth weight. Polymicrogyria was observed in three patients. All of these patients were born at term, and two had arm-dominant, one leg-dominant, and one arm⫽leg hemiparesis. No significant differences in a sum of the computed tomography abnormalities score were observed between the groups. Similarly, no significant differences were found between the epileptic and the nonepileptic hemiparetic cerebral palsy patients. Table 5 summarizes the relationships between the computed tomographic abnormalities, the severity of hemiparetic cerebral palsy, mental retardation, and epilepsy. Significant correlations between the computed tomographic findings and hand function, and epilepsy in the left hemiparetic cerebral palsy patients were found. No correlations between the computed tomographic abnormalities, locomotion defects, and mental retardation in the left hemiparetic cerebral palsy group were observed. Significant relationships between the computed tomographic

Table 5. Relation between the CT abnormalities and the severity of hemiparetic cerebral palsy (hand and locomotion functions), mental retardation, and epilepsy Types of CP Variable

r Value

P Value

LHCP (n ⫽ 32) CT abnormalities CT abnormalities CT abnormalities CT abnormalities

vs vs vs vs

hand function locomotion mental retardation epilepsy

0.676 0.293 0.298 0.488

0.00004 0.108 NS 0.109 NS 0.006

RHCP (n ⫽ 28) CT abnormalities CT abnormalities CT abnormalities CT abnormalities

vs vs vs vs

hand function locomotion mental retardation epilepsy

0.679 0.327 0.651 0.488

0.00007 0.086 NS 0.0002 0.006

Abbreviations: CP ⫽ Cerebral palsy CT ⫽ Computed tomography LHCP ⫽ Left hemiparetic cerebral palsy NS ⫽ Not significant r ⫽ Spearman’s rank sum correlation coefficient RHCP ⫽ Right hemiparetic cerebral palsy

LHCP n ⴝ 32

RHCP n ⴝ 28

Nonepileptic N ⫽ 18

Nonepileptic N ⫽ 16

Normal Multifocal* Focal left hemisphere* Focal left centro-parietal* Focal right centro-parietal

4 5 4 4 1 Epileptic N ⫽ 14

3 2 6 5 0 Epileptic N ⫽ 12

Normal Paroxysmal generalized Multifocal* Focal right hemisphere* Focal left hemisphere Focal left centro-parietal*

0 3 3 4 3 1

0 2 2 3 5 0

Abbreviations: LHCP ⫽ Left hemiparetic cerebral palsy RHCP ⫽ Right hemiparetic cerebral palsy

Neonatal seizures Seizures during the first year of life Status epilepticus Types of epilepsy PSG Generalized Lennox-Gastaut syndrome Intractable epilepsy Monotherapy Polytherapy

LHCP N (%) (n ⴝ 14)

RHCP N (%) (n ⴝ 12)

1 3 (21.4) 0 (0)

0 (0) 2 (16.6) 2 (16.6)

10 (71.4) 0 2 (14.2) 4 (28.5) 9 (64.2) 5 (35.7)

10 (83.3) 1 (8.33) 1 (8.33) 4 (33.3) 8 (66.6) 4 (33.3)

P Value* NS NS NS NS NS NS NS NS NS NS

Abbreviations: LHCP ⫽ Left hemiparetic cerebral palsy NS ⫽ Not significant PSG ⫽ Partial seizures secondary generalized RHCP ⫽ Right hemiparetic cerebral palsy

Table 6. Visual analysis of EEG in children with hemiparetic cerebral palsy

* Sharp and slow waves.

Characteristics of epilepsy in children with LHCP and

* Fisher’s Exact Test between groups.

findings and hand function, mental retardation, and epilepsy in the right hemiparetic cerebral palsy children were documented. No correlation between the computed tomographic abnormalities and locomotion in the right hemiparetic cerebral palsy patients was observed. We found the abnormalities to be predominantly focal in the electroencephalographic recordings (Table 6). The electroencephalographic abnormalities in the nonepileptic hemiparetic cerebral palsy patients included focal changes (slow or sharp waves) in the left hemisphere in 10, in the left centro-parietal area in 9, and multifocal changes in 7.

EEG Findings

Table 7. RHCP

Seven electroencephalographic recordings were normal. In the epileptic hemiparetic cerebral palsy children, no normal electroencephalograms were evident. Paroxysmal changes were present in five hemiparetic cerebral palsy patients, multifocal in five with similar percentages in both groups. Focal changes in the right hemisphere were detected in seven children and in the left in eight patients. Similar percentages of the electroencephalographic abnormalities were present in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy patients. Twenty-six children with hemiparetic cerebral palsy had epilepsy; frequency of epilepsy was similar in the left hemiparetic cerebral palsy patients (14 [43.7%]) and the right hemiparetic cerebral palsy patients (12 [42.8%]) (Table 1). Other factors associated with the occurrence of epilepsy in children with hemiparetic cerebral palsy were also analyzed. The mean duration of monitoring was 7.42 ⫾ 3.75 years (range 4-15 years). The mean age of the onset of epilepsy was 4.19 ⫾ 3.23 years in the hemiparetic cerebral palsy children. Neonatal seizures occurred only in one child with left hemiparetic cerebral palsy (Table 7). Status epilepticus affected two children (16.6%) with right hemiparetic cerebral palsy but none from the left hemiparetic cerebral palsy group. Epilepsy attacks in the left hemiparetic cerebral palsy group included partial seizures secondarily generalized in 10 children, and the LennoxGastaut syndrome in 2. In the right hemiparetic cerebral palsy patients, partial secondarily generalized seizures were observed in 10 children, generalized affected 1 child, and Lennox-Gastaut 1. Four (35.7%) of the left hemiparetic cerebral palsy children had poor seizure control and were on polytherapy. Similarly, four (33.3%) of the right hemiparetic cerebral palsy group manifested intractable epilepsy. Nine (64.2%) of the left hemiparetic cerebral palsy children had epilepsy well controlled by mono-

Kulak and Sobaniec: Right vs Left Hemiparetic Cerebral Palsy 105

therapy. Eight (66.6%) of the right hemiparetic cerebral palsy patients had monotherapy. In this study, polytherapy with no more than two first-line antiepileptic drugs (carbamazepine or valproate) and second-line antiepileptic drugs (vigabatrin, lamotrigine, gabitril, clonazepam, nitrazepam) was administered. In the left hemiparetic cerebral palsy group, polytherapy was applied in five cases, and it was applied in four cases in the right hemiparetic cerebral palsy group. In our department, antiepileptic drugs are discontinued after the child with cerebral palsy is free of seizures for at least 3 years. The antiepileptic drugs were discontinued in only two patients with left hemiparetic cerebral palsy (data not shown). Discussion In this study, no significant differences were observed between the clinical patterns of hemiparesis in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy groups. Gestational history was not related to an increased risk of left hemiparetic cerebral palsy or right hemiparetic cerebral palsy. Similar proportions of caesarean sections were documented in both groups. Similar percentages of low birth weight, perinatal pathologies (prelabor rupture, abruptio placenta, fetal distress, preeclampsia, respiratory distress syndrome, and sepsis) were present in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy patients. These findings are in accordance with the study of Khaw et al. [14]. They compared right and left hemiplegia in 66 children with cerebral palsy. There were slightly more right hemiplegics than left hemiplegics. The authors found minor differences in the frequency of associated problems, but overall there were no major differences between right and left hemiplegics. On the other hand, in the present study, significantly greater numbers of pregnancies and deliveries were observed in the left hemiparetic cerebral palsy compared with the right hemiparetic cerebral palsy children. Similar significantly lower values of the Apgar score were recorded in left hemiparetic cerebral palsy vs right hemiparetic cerebral palsy. We are unable to explain these observations; no similar reports could be located. Motor and mental development was similar in the children with left hemiparetic cerebral palsy and right hemiparetic cerebral palsy. No differences in the milestones between the groups were evident. The severity of hemiparetic cerebral palsy did not differ between the children of the two types. These findings are in accordance with previous studies [14,15]. A weakness of this study, particularly with respect to the possible predictive value of neuroimaging in cerebral palsy, is the fact that it utilized computed tomography, whereas magnetic resonance imaging is widely available and potentially more revealing [16,17]. Yet the detection by magnetic resonance imaging of subtle changes in the

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cortex or white matter not documented by computed tomography would likely not change the results significantly. In this study, computed tomographic findings were used in the comparison of the two forms of hemiparetic cerebral palsy. Although computed tomography is an older neuroradiologic procedure, there is a good concordance level of 0.849 between computed tomography and magnetic resonance imaging based on the Kappa test according to Piovesana et al. [16]. Periventricular leukomalacia is a form of hypoxicischemic damage typical of the immature brain and most commonly observed as a complication of preterm birth. As this lesion was evident in children born at term, it was considered to reflect a cerebral injury that had occurred in utero. Cerebral maldevelopment resulting from an early in utero lesion (cortical/subcortical lesions) is also considered to be of major importance in hemiplegia [7]. In the present report, the most common finding on computed tomography was periventricular leukomalacia in 49.1% of the patients, the proportions of which were similar in the left hemiparetic cerebral palsy and the right hemiparetic cerebral palsy groups. Periventricular leukomalacia was observed more frequently in children with the leg-dominant and arm⫽leg hemiparesis than in armdominant. It is important to note that 82.7% of the hemiparetic cerebral palsy children with periventricular leukomalacia were born at term with no history suggestive of perinatal asphyxia and low birth weight. Porencephalic cysts were observed more often in full-term children than in preterm infants. Premature infants with porencephaly had asphyxia and low birth weight. Our findings are in accordance with earlier studies [6,7]. In the study by Wiklund and Uvebrant [7], the most common finding (37%) was periventricular atrophy considered to represent periventricular leukomalacia. Humphreys et al. [6] described principal imaging findings among the arm-dominant patients: large arterial infarcts and porencephalic cysts; in the leg-dominant, brain malformations; whereas periventricular leukomalacia and porencephaly were documented in the “proportional” group. Patients with armdominant hemiparesis tend to have relatively large lesions involving cortex and subcortical white matter and would therefore be more likely to develop learning difficulties and epilepsy [6,7]. Conversely, children with leg-dominant hemiparesis tend to have smaller lesions involving central and periventricular white matter and would be expected to do relatively well. In contrast to our findings, Miller et al. [18] reported 12 term children with periventricular leukomalacia to delineate its long-term clinical correlates. The reason for the assessment was developmental delay in 10 (83.3%) patients, seizure in one, and attention-deficit hyperactivity disorder in one. Three children had normal motor examinations, three were hypotonic, three had spastic diplegia, two manifested spastic quadriplegia, and one had finemotor abnormalities. Nine children (75%) manifested developmental delay (severe global delay in six), and two

children (16.7%) had epilepsy; electroencephalograms were abnormal in six (50%). They concluded that periventricular leukomalacia in term children presented with a spectrum of neurologic abnormalities, particularly developmental delay and heterogeneous motor findings not limited to classic spastic diplegia. We observed that more hemiparetic cerebral palsy children with very severe and severe dysfunction of hand had epilepsy. On the other hand, higher percentages of the moderate and mild forms of hemiparetic cerebral palsy were observed in the children without epilepsy. The locomotion function was affected in similar proportions in the hemiparetic cerebral palsy children with or without epilepsy, which is in accordance with earlier reports [6,7]. An overall percentage of electroencephalographic abnormality of 88.3% of the hemiparetic cerebral palsy children was found. Electroencephalographic abnormalities were detected in all of the epileptic hemiparetic cerebral palsy children. Only seven nonepileptic hemiparetic cerebral palsy patients had normal electroencephalographic recordings. Focal and multifocal changes were observed among both nonepileptic and epileptic hemiparetic cerebral palsy children. Similar proportions of the electroencephalographic abnormalities were observed in the left hemiparetic cerebral palsy and right hemiparetic cerebral palsy patients. Epileptiform activity was observed more frequently in the epileptic than in the nonepileptic group of hemiparetic cerebral palsy. The present study is in agreement with Al-Sulaiman’s report [19]. He studied 151 patients with different forms of cerebral palsy. The electroencephalographic abnormalities in the seizure group included slow waves, epileptiform activity (including isolated sharp waves, isolated spikes, and spike-wave and polyspike-wave complexes). Only six electroencephalographic recordings were normal, giving an overall percentage of abnormality of 92.6%. Epilepsy affected 46.6% of the children with hemiparetic cerebral palsy in the present study. The frequency of epilepsy did not differ with the two forms of hemiparetic cerebral palsy (43.7% for left hemiparetic cerebral palsy and 42.8% for right hemiparetic cerebral palsy). Our results are similar to those of earlier reports [4,15,17,20]. Zafeiriou et al. [21] studied 178 patients with cerebral palsy and epilepsy and compared them with a control group of 150 epileptic patients without cerebral palsy. The overall prevalence of epilepsy was 36.1%. Patients with hemiplegic cerebral palsy had an epilepsy incidence of 42%. In the present study, the mean age of the onset of epilepsy was 4.19 ⫾ 3.23 in spastic hemiplegia. Neonatal seizures are more commonly observed in patients with cerebral palsy and epilepsy than in cerebral palsy alone [21]. The presence of neonatal seizures is considered to be a factor for subsequent development of neurologic disabilities. In this study, neonatal seizures were observed in only one case of left hemiparetic cerebral palsy. Status epilepticus is more common in patients with neurologic abnormalities [22]. Acquired brain damage

after status epilepticus was well documented, and even nonconvulsive status epilepticus might produce long-term memory and intellectual disturbances [23,24]. In the present study, only two of the right hemiparetic cerebral palsy children with epilepsy had a history of status epilepticus. Partial seizures secondarily generalized were present in most of our patients, which is in accordance with previous studies [24,25]. Aksu [26] and Delgado et al. [27] both reported that focal or secondarily generalized seizures were common in children with cerebral palsy, whereas primary generalized epilepsies were less frequent. The present study demonstrated that epilepsy in children with hemiparetic cerebral palsy was associated with a relatively poor prognosis. Only two epileptic children with hemiparetic cerebral palsy were seizure-free for more than 3 years. This finding could be related to the higher percentage of intractable epilepsy in our study. In Kwong’s study [24], 16% of epileptic children with cerebral palsy were seizure-free for more than 2 years, and the figure was 12% in Aksu’s study [26]. Several reports mentioned a significant relationship between mental retardation, motor impairment, and epilepsy [28,29]. Vargha-Khadem et al. [28] reported that, in patients with hemiplegia, the presence of epilepsy was clearly associated with more severe cognitive difficulties. In the present study, a significant number of the right hemiparetic cerebral palsy children with epilepsy had mental retardation as compared with the left hemiparetic cerebral palsy group. Furthermore, the mental retardation positively correlated with computed tomographic abnormalities in right hemiparetic cerebral palsy. The present study demonstrated a higher proportion of computed tomographic abnormalities in children with hemiparetic cerebral palsy and epilepsy compared with hemiparetic cerebral palsy. Our findings are comparable with those of Senbil’s [29] study. In Kwong’s study [24], computed tomographic abnormalities were detected in 74% of cerebral palsy with epilepsy and in 77% with cerebral palsy. This study leads us to conclude that left hemiparetic and right hemiparetic forms of cerebral palsy had comparable clinical patterns, although we detected some differences. Significantly greater numbers of pregnancies and deliveries were observed in the left hemiparetic cerebral palsy group as compared with the right hemiparetic cerebral palsy group. Similarly, significantly lower values of the Apgar score were documented in the left hemiparetic cerebral palsy group than the right hemiparetic cerebral palsy group

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