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Tesi etd-10312015-084446

Thesis type
Tesi di laurea magistrale LM6
Neurological Assessment of Infants with Cerebral Arterial Ischaemic Stroke
Corso di studi
relatore Prof. Cioni, Giovanni
tutor Prof. Einspieler, Christa
tutor Dott. Guzzetta, Andrea
Parole chiave
  • stroke
  • cerebral palsy
  • general movements
  • GMs
  • neonatal
  • hemiplegia
  • writhing movements
  • fidgety movements
  • segmental movements
Data inizio appello
Riassunto analitico

Arterial Ischaemic Stroke (AIS) occurs in approximately 0.25% of full term infants and around 1% of preterm infants. Up to 60% of perinatal strokes results in neurological deficits, with hemiplegic cerebral palsy (HCP) being a frequent adverse motor outcome. This is a lifelong condition that affects the daily living and the quality of life of these children and their families and often it is diagnosed only after the first year of life or even later, when significant asymmetries in upper extremity function and motor skill development are obvious. This is in contrast to adults who have a stroke who are identified with hemiparesis days not years after the brain injury.
Motor outcomes in neonates with stroke are largely dependent on the location of the injury. The most common presenting feature of neonatal term infants with AIS is seizure and other common presentations include encephalopathy, apnea, tone abnormalities as well as persistent respiratory and feeding difficulties. Physical disability can range from minimal (e.g. weakness in one hand without discernible effects on activities of daily living) to profound (e.g. permanently restricted to a wheelchair and unable to eat or speak independently requiring 24h care).

Today’s neuroimaging techniques such as ultrasound, computed tomography and magnetic resonance imaging, provide the possibility to identify brain lesions that may cause hemiplegia. Together with the classical neurological examination, these tools give us the possibility to perform prospective studies of the neurological development of these infants.
What is still missing is a method that could help us for an early diagnosis of future neurological disabilities. There is actually no proof that early intervention could prevent the development of cerebral palsy in these infants, but it could help prevent secondary defects such as contractures and other forms of immobility, improving their future life.
Many studies have confirmed that Prechtl’s Method of Qualitative Assessment of General Movements of infants is one of the most powerful predictive tools that we have. The General Movements Assessment (GMA) is a non-intrusive, reliable, quick and cost-effective method of functional assessment of the young nervous system developed by Heinz Prechtl and his colleagues of the Department of Developmental Neurology in Groningen (The Netherlands). This assessment is based on the observation of video-recordings showing the child during his spontaneous motility, with nobody neither touching nor stimulating him. By observation we could be able to distinguish between normal and abnormal general movements.
Normal General Movements are gross movements involving the whole body; they may last from a few second to several minutes or longer. What is particular about them is the variable sequence of arm, leg, neck and trunk movements. They wax and wane in intensity, force and speed and they also have a gradual beginning and end. The majority of sequences of extension and flection movements of arms and legs is complex, with superimposed rotations and frequent slight changes in the direction of the movement. These additional components make the movement fluent and elegant and create the impression of complexity and variability.
Abnormal General Movements are movements lacking complexity, variability and fluency. They could be poor in their quality, or cramped synchronised or even chaotic. These features can be related to some neurological deficits, which can range from cerebral palsy to mild neurological disabilities.
Previous studies highlighted the important predictive power of Fidgety movements, which emerge around 6-9 weeks of post-term age. Fidgety movements are small movements of moderate speed and variable acceleration of neck, trunk and limbs, in all directions, continual in the awake infant, except during focused attention, fussing and crying. They may be seen as early as 6 weeks but usually occur around 9 weeks and are present until 20 weeks or even a few weeks longer, at which time intentional, goal directed, and antigravity movements occur and start to dominate. The absence of fidgety movements is highly predictive for later neurological impairments, particularly for cerebral palsy, both the spastic and dyskinetic forms.
General movements can be observed also in fetuses as young as nine weeks postmenstrual age (age of the fetus or infant calculated from the date of the mother’s last period), that is why this method can be of a real support for an early diagnosis.

In our study we tried to use this method on a population of 22 full-term infants, 6 were healthy infants, while 16 have been diagnosed with perinatal arterial ischaemic stroke. The aim of this study was to confirm the predictive value of the qualitative assessment of spontaneous motor activity, together with the evaluation of the Motor Repertoire and the assessment of asymmetries in various body parts.
We wanted to analyse to what extent the long-term neurological outcome of infants diagnosed with neonatal stroke is related to their motor performance at age 3 to 5 months; to confirm the predictive power of the quality of fidgety movements and the significant correlation between asymmetry of segmental movements and the presence of later hemiplegia in infants with neonatal stroke; to find a correlation between severe neurological outcome and asymmetry in hand movements, kicking, trunk bending and foot-foot contact and to confirm or reject the theory of the silent period that would prevent an early diagnosis of unilateral CP.