Neonatal Cerebral Infarction and Neuromotor Outcome at School Age Eugenio Mercuri, MD*‡; Anna Barnett, PhD*; Mary Rutherford, MD*; Andrea Guzzetta, MD*§; Leena Haataja, MD*; Giovanni Cioni, MD*§; Frances Cowan, PhD*; and Lilly Dubowitz, MD* ABSTRACT. Objective. The aim of this study was to assess neuromotor function at school age in children who had cerebral infarction on neonatal magnetic resonance imaging (MRI). Design. Twenty-two children with evidence of cere- bral infarction on neonatal brain MRI (18 with arterial infarction and 4 with border-zone lesions) were assessed at school age with a structured neurologic examination and the Movement Assessment Battery for Children, a battery of tests designed to assess motor function. Results. Of the 22 children, 6 (30%) had hemiplegia and a further 7 (30%) showed some neuromotor abnor- mality such as asymmetry on the neurologic examination (n  4) or poor scores on the neuromotor test without any sign of asymmetry (n  3). The remaining 9 children had a normal motor outcome. Hemiplegia was found only in children who had concomitant involvement of hemi- sphere, internal capsule, and basal ganglia on brain MRI. Children with involvement of the internal capsule, asso- ciated either with basal ganglia or hemispheric lesions, did not show hemiplegia but still had motor difficulties. Conclusions. Our results suggest that although hemi- plegia occurs in a relatively small proportion of children with neonatal cerebral infarction, other signs of neuro- motor impairment can be present, and these become more obvious at school age when a more specific assess- ment can be performed. These results also suggest that the involvement of the internal capsule on neonatal MRI can predict the presence of these abnormalities. Pediat- rics 2004;113:95–100; Mov ABC, MRI, hemiplegia, neonatal cerebral infarction. ABBREVIATIONS. MRI, magnetic resonance imaging; MCA, mid- dle cerebral artery; Mov ABC, Movement Assessment Battery for Children; PLIC, posterior limb of the internal capsule; ALIC, an- terior limb of the internal capsule. H emiplegia is the most feared and frequent motor sequela associated with neonatal cere- bral infarction. The majority of studies on perinatal focal infarction report a very high incidence of ensuing hemiplegia, 1–5 but in more recent years it has become obvious that not all the infants with such lesions have an abnormal motor outcome (see refs. 6 –10 and, for review, ref. 11). These differences al- most certainly reflect the different populations stud- ied. Although earlier studies mainly included infants with severe neonatal clinical presentation, recent studies have also included infants who had serial cranial ultrasound and/or brain magnetic resonance imaging (MRI) following the onset of seizures in the first days following birth and were found to have an infarction. Our experience, which is largely obtained from infants presenting with seizures, is that only 20% of full-term infants with infarction develop a hemiplegia. 11 Most of the studies published thus far, however, including ours, focused on the presence of hemiple- gia and the length of follow-up has been relatively short. 1–8 We now report the neuromotor follow-up at early school age of 22 children who were found to have cerebral infarction on neonatal MRI. The aims of this study were 1) to evaluate the spectrum of neuromotor difficulties and 2) to correlate the type and extent of motor impairment, when present, with the type, size, and side of infarction on neonatal brain MRI. We have also compared the motor out- come in these children, as assessed at 2–3 years, with that obtained in this study. SUBJECTS AND METHODS Ethical permission for this study was obtained from the Ham- mersmith Hospital (London, United Kingdom) Research Ethics Committee. The children described in this study are part of a large prospective cohort of term infants born at or referred to the Hammersmith Hospital for MRI between 1991 and 1996. As part of this study, all the infants who present with birth asphyxia and/or neonatal seizures undergo neonatal brain MRI. Twenty-four full-term infants who showed evidence of cerebral infarction on neonatal MRI were enrolled. All the infants were investigated following the onset of convulsions between days 1 and 3. In all, the lesions were obvious on both cranial ultrasound and brain MRI by the end of the first week of life. As part of this prospective study, all patients are followed regularly at 6-month intervals until the age of 3 and at yearly intervals after that irrespective of whether they show any sequela on short-term follow-up. The results of the short-term follow-up of these chil- dren have been reported already. 8 We were not able to personally assess 2 of the 24 children at school age, because they moved outside the United Kingdom; however, from clinical letters we know that they do not have hemiplegia. The remaining 22 have been followed until primary school age. They all were tested between 5.6 and 6.6 years, with the exception of one child who was tested at 9 years. MRI The infants were imaged on a 1.0-T Picker HPQ system using conventional T1-weighted spin-echo (860/20 milliseconds) inver- sion recovery (3800/30/950 milliseconds) and T2-weighted spin- echo (3000/120 milliseconds) sequences. Two different classifica- From the *Department of Paediatrics, Imperial College School of Medicine, Hammersmith Campus, London, United Kingdom; ‡Department of Paedi- atric Neurology and Psychiatry, Catholic University, Rome, Italy; §Depart- ment of Paediatric Neurology and Psychiatry, Stella Maris Institute, Pisa, Italy; and Department of Paediatrics and Child Neurology, Turku Univer- sity Central Hospital, Turku, Finland. Received for publication Dec 12, 2002; accepted Mar 7, 2003. Address correspondence to Eugenio Mercuri, MD, Department of Paediat- rics, Hammersmith Hospital, Du Cane Rd, London W12 OHN, United Kingdom. E-mail: e.mercuri@ic.ac.uk PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- emy of Pediatrics. PEDIATRICS Vol. 113 No. 1 January 2004 95