To the Editor A systematic review and clinical practice guideline on early, accurate diagnosis and early intervention in cerebral palsy (CP), as undertaken by Novak et al,1 is a timely addition to the literature. However, it is unclear why the authors restricted their search criteria to only systematic reviews/meta-analyses and CPGs. By doing so, they overlooked several relevant, well-conducted prognostic studies.2- 5 Unfortunately, this casts significant doubt on their recommendation to combine structural brain magnetic resonance imaging (MRI) with general movements assessment (GMA) for accurate diagnosis of CP before age 5 months. They report MRI to possess a sensitivity of 86% to 89%. However, these data were derived from a clinical practice guideline that examined cross-sectional MRI studies (reference 27 in the Novak et al article),1 which are unable to determine prognostic test properties, and from a systematic review that found only 1 eligible cohort study of 61 preterm infants (reference 21 in the Novak et al article).1 They excluded the largest MRI study in preterm infants (N = 445),2 which yielded a sensitivity of 48% and likelihood ratio for a positive test result (LR+) of 2.8 for CP prediction. A 2015 meta-analysis,3 also excluded, reported a similarly low LR+ of 3.7 for MRI. When applied to a very preterm infant (assuming 10% CP prevalence) with an abnormal MRI, a LR+ of 3.7 only increases this infant’s probability of developing CP to 29%.
Parikh NA. Are Structural Magnetic Resonance Imaging and General Movements Assessment Sufficient for Early, Accurate Diagnosis of Cerebral Palsy?. JAMA Pediatr. 2018;172(2):198–199. doi:10.1001/jamapediatrics.2017.4812
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