European Journal of Cardiovascular Medicine

Magnetic Resonance Imaging (MRI) has revolutionized the field of neuroimaging, offering a non-invasive and highly detailed method for visualizing the brain. In pediatric neurology, MRI plays a crucial role in diagnosing and understanding cerebral palsy (CP), a group of permanent movement and posture disorders caused by non-progressive disturbances in the developing fetal or infant brain.¹ Given the complexity of CP and its varied clinical manifestations, MRI serves as an essential tool for identifying structural abnormalities, evaluating the extent of brain injury, and guiding therapeutic interventions. The use of MRI in children with CP has not only enhanced diagnostic accuracy but has also provided valuable insights into the underlying neuropathological mechanisms contributing to motor impairments, cognitive deficits, and associated comorbidities. ^2,3

Cerebral palsy is one of the most common neurodevelopmental disorders in children, affecting approximately 2 to 3 per 1,000 live births worldwide. The condition is primarily attributed to perinatal brain insults, including hypoxic-ischemic events, periventricular leukomalacia, intracranial hemorrhage, infections, and genetic factors. Despite advancements in neonatal care, a significant proportion of children diagnosed with CP exhibit varying degrees of motor dysfunction, intellectual disabilities, epilepsy, and sensory impairments. ³ These diverse clinical presentations necessitate a thorough neuroimaging assessment, where MRI has emerged as the gold standard for detecting brain abnormalities associated with CP. Unlike other imaging modalities such as computed tomography (CT), which is limited in its ability to differentiate soft tissue structures, MRI provides superior contrast resolution, enabling the detailed visualization of white matter, gray matter, and subcortical structures. ^2,3

The role of MRI in cerebral palsy extends beyond structural imaging to functional and metabolic assessments. Conventional MRI sequences, including T1-weighted and T2-weighted imaging, allow for the identification of brain lesions, while advanced techniques such as diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI), and functional MRI (fMRI) offer insights into white matter integrity, cortical reorganization, and neural connectivity⁴. These modalities have been instrumental in differentiating the various subtypes of CP, including spastic, dyskinetic, and ataxic forms, each of which is associated with distinct neuroanatomical findings. For instance, periventricular leukomalacia, a hallmark of hypoxic-ischemic injury in preterm infants, is frequently observed in children with spastic diplegia, whereas basal ganglia and thalamic lesions are more commonly associated with dyskinetic CP. ^3,4

Despite its numerous advantages, the use of MRI in children with CP is not without challenges. One of the primary limitations is the requirement for sedation or general anesthesia in young children who may be unable to remain still during the procedure. While recent advancements in fast imaging techniques and motion-correction algorithms have improved the feasibility of awake MRI in pediatric populations, the need for sedation remains a concern due to potential risks associated with anesthetic exposure in developing brains. Additionally, MRI accessibility and cost can be significant barriers, particularly in resource-limited settings where advanced neuroimaging facilities may not be readily available. ^,5,6

Recent developments in MRI technology continue to expand the scope of neuroimaging in CP. Techniques such as magnetic resonance spectroscopy (MRS) provide metabolic information about brain tissue, offering insights into neuronal function and energy metabolism. Additionally, machine learning and artificial intelligence-driven image analysis are being explored to enhance the automated detection and classification of brain abnormalities in CP. These advancements hold promise for improving diagnostic accuracy, predicting functional outcomes, and personalizing treatment strategies based on neuroimaging biomarkers. ^6,7

The aim of this study was to evaluate spectrum of findings of magnetic resonance imaging of brain in children with cerebral palsy- a hospital based cross sectional study

The hospital-based cross-sectional observational study was conducted in the Department of Radiodiagnosis at S. Nijalingappa Medical College and HSK Hospital, located in Navanagar, Bagalkot. This is a tertiary care teaching hospital equipped with advanced diagnostic imaging facilities, including a 1.5 Tesla MRI scanner. The department served as a referral center for pediatric neuroimaging, ensuring an adequate number of relevant cases for the study. The study was carried out over a duration of 18 months.  Ethical approval for the study was obtained from the Institutional Ethics Committee of S. Nijalingappa Medical College and HSK Hospital, Bagalkot.

Inclusion Criteria:

• Children of either sex aged 15 years or younger.
• Children referred for MRI brain with a clinical diagnosis or suspicion of cerebral palsy.
• Children presenting with symptoms such as delayed milestones or seizures.

Exclusion Criteria:

• Children diagnosed with inborn errors of metabolism.
• Children with a history of developmental regression.
• Children with inflammatory brain diseases such as meningitis or encephalitis.
• Cases with space-occupying lesions like brain abscesses, tuberculomas, neurocysticercosis, or intracranial neoplasms.
• Children with cochlear or stent implants that could interfere with MRI imaging.

These criteria ensured a homogenous study population specifically diagnosed with cerebral palsy, free from confounding neurological or metabolic disorders.

Study Sampling

A non-probability purposive sampling technique was employed. Children meeting the inclusion criteria and attending the Department of Radiodiagnosis for MRI evaluation were consecutively enrolled until the desired sample size was achieved. This method was appropriate for an observational study with a well-defined target population.

Sample Size

The sample size was calculated using Open Epi software version 2.3.1. At a 95% confidence interval and an absolute precision of 15%, and based on prior evidence indicating that periventricular white matter changes occurred in 47% of CP cases, the sample size was estimated to be 50 children. The following formula was used for estimation:

n = [DEFFNp(1-p)] / [(d²/Z²₁–α/2(N–1) + p(1–p))]*

This calculation ensured adequate power to detect the prevalence of common MRI abnormalities in children with CP.

Study Groups

As this was a cross-sectional study, no control or intervention groups were established. However, the enrolled participants were grouped and analyzed according to their clinical subtype of CP (e.g., spastic, dyskinetic, ataxic) and the MRI findings. Subgroup analyses were conducted to assess any significant associations between imaging patterns and clinical variables.

Study Parameters

The following parameters were assessed during the study:

• Demographic details (age, sex, consanguinity, birth weight).
• Perinatal history (mode of delivery, gestational age, prenatal complications).
• Clinical subtype of CP (noted from pediatric assessment).
• MRI characteristics, including structural abnormalities, signal intensity changes, and specific pathological findings such as:
• Periventricular leukomalacia (PVL)
• Cortical and subcortical atrophy
• Basal ganglia involvement
• Hypoxic-ischemic encephalopathy (HIE)
• Brain malformations
• Myelination patterns

Each MRI scan was reviewed to correlate with the clinical findings and determine potential etiological implications.

Study Procedure

After obtaining ethical clearance and informed consent, each child underwent a comprehensive clinical and radiological evaluation. Initially, demographic data and perinatal history were collected through interviews with the child’s caregivers. Additional clinical data were retrieved from hospital records using a predesigned proforma.

Subsequently, MRI scans of the brain were performed using a 1.5 Tesla Philips scanner. Sedation (pedicloryl syrup) was administered orally under the supervision of an anesthesiologist in cases where the child was uncooperative. Imaging was carried out using standard protocols which included sequences such as:

• T1-weighted
• T2-weighted
• Fluid-attenuated inversion recovery (FLAIR)
• Diffusion-weighted imaging (DWI)
• Coronal T2
• Sagittal T1 inversion recovery

Scan parameters were optimized with a field of view (FOV) of 14–24 cm, slice thicknesses of 3 mm, 5 mm, and 10 mm, and a matrix size of 256 × 256. The final MRI images were interpreted by experienced radiologists, and the results were compared with clinical evaluations conducted by pediatric neurologists.

Study Data Collection

Data collection was systematically carried out using a structured format. Patient history was gathered through caregiver interviews, while clinical classification and neurological assessments were extracted from existing medical records. All findings were meticulously recorded in an anonymized data sheet.

MRI findings were documented based on specific anatomical and pathological features. These included changes in white matter, cortical thinning, ventricular dilatation, basal ganglia involvement, and evidence of malformations. Each case was then classified under the relevant imaging subtype. The clinical and imaging findings were subsequently correlated and categorized for statistical analysis.

Data Analysis

Statistical analysis of the collected data was performed using SPSS software version 19.0. Descriptive statistics such as mean, standard deviation, median, and range were used for quantitative variables. Categorical variables were expressed in frequencies and percentages.

The chi-square test was used to compare proportions of qualitative variables, such as the frequency of MRI abnormalities among CP subtypes. Student’s unpaired t-test was applied to compare continuous variables between groups where applicable. A p-value of <0.05 was considered statistically significant. All results were presented in tabulated and graphical forms for clarity and interpretation. The source of data included direct interviews, hospital medical records, and MRI imaging studies conducted at the Radiodiagnosis Department. All collected information was used exclusively for academic and research purposes, with no commercial intent.

The sample comprised a total of 50 participants, with a slight majority identifying as male (58.0%) compared to female participants (42.0%). The participants ranged in age from 1 to 5 years, with the largest age group being 3-year-olds (32.0%), followed by 2-year-olds (24.0%).  Out of 50 participants, 12 (24.0%) were reported to exhibit abnormal movements, while the remaining 76.0% did not show such signs. Abnormal posture was reported in 36.0% of participants, indicating that more than one-third of the children showed deviations from typical postural development.

Seizures were reported in 34.0% of the participants, reflecting a relatively high prevalence of seizure activity in the cohort. Hyperactivity was observed in only 4.0% of participants.

A substantial proportion of participants (44.0%) had a history of neonatal intensive care unit (NICU) follow-up. Among the 50 participants, 8.0% were born to parents in a consanguineous relationship (rcm), while the vast majority (92.0%) were from non-consanguineous marriages (ncm).  Intellectual disability (referred to here as "mental retardation") was observed in 20.0% of the participants.

Only 8.0% of mothers experienced systemic illness during pregnancy, indicating a relatively low prevalence of such maternal complications.  Antenatal care was received by 96.0% of mothers, reflecting excellent prenatal coverage within the sample.  The majority of pregnancies (86.0%) were term (TM), while 14.0% were preterm (PT).  Multiple pregnancies were rare in this cohort, occurring in only 4.0% of cases. Singleton pregnancies predominated (96.0%).

Participants' birth weights ranged from 1.5 kg to 2.1 kg, with the most common weight being 1.5 kg (30.0%). Per vaginal bleeding was reported in 16.0% of pregnancies. Urinary tract infections were noted in 26.0% of pregnancies. Gestational diabetes was reported in 16.0% of the pregnancies. Most deliveries occurred at home (62.0%), while the remainder (38.0%) took place in hospital settings. PROM was reported in 28.0% of cases, suggesting a considerable incidence of this perinatal complication. Instrumentation was used in only 6.0% of deliveries, indicating that the vast majority of births occurred without assisted techniques. Exactly half the participants were born via LSCS (50.0%), indicating a balanced split between cesarean and vaginal deliveries.

The distribution of crying status at birth shows 42.0% with weak cry (w), 34.0% with normal cry (N), and 24.0% with delayed cry (d). Resuscitation was needed in 36.0% of cases, highlighting a significant proportion of neonates requiring immediate medical intervention. A total of 38.0% of participants required NICU stay, suggesting a considerable burden of neonatal complications. Septicemia was identified in 16.0% of neonates, a meaningful finding given its potential to cause systemic complications and influence long-term development. Seizures in the neonatal period occurred in 12.0% of participants, suggesting early neurological insult or dysfunction. RDS was noted in 26.0% of neonates, reflecting a moderate prevalence of respiratory compromise in the immediate postnatal period. Feeding difficulties were experienced by 34.0% of neonates, indicating that over one-third of the cohort faced challenges with basic postnatal nutrition.

Hemiplegia was present in 6.0% of children, indicating localized cerebral involvement.  Diplegia was seen in 24.0% of participants. This type, commonly associated with prematurity, predominantly affects the lower limbs. It often reflects periventricular leukomalacia or white matter injury. Quadriplegia was identified in 8.0% of participants, suggesting diffuse and severe cerebral involvement affecting all four limbs. This form often results from global hypoxic-ischemic injury or severe congenital abnormalities.

Triplegia was noted in 4.0% of cases. Dyskinesia was present in 2.0% of the participants, indicating a rare occurrence in this cohort.  Spasticity was the most common cerebral palsy phenotype, present in 80.0% of the children.

Dystonia was observed in 6.0% of cases. This condition is marked by sustained or intermittent muscle contractions causing abnormal postures or movements.  Choreoathetoid features were noted in 12.0% of participants. This movement disorder, involving both chorea (brief, irregular movements) and athetosis (slow writhing movements), can significantly impair voluntary motor control. Ataxia was identified in 14.0% of children, reflecting cerebellar dysfunction. This subtype is characterized by poor coordination, imbalance, and unsteady gait. White matter involvement varied across multiple regions, with the most frequent patterns being normal (26.0%), posterior (20.0%), and anterior (18.0%) predominance. These distributions suggest a heterogeneity in white matter pathology among participants, with some exhibiting diffuse patterns (e.g., anterior–mid–posterior, 10.0%). This information is vital in classifying types of cerebral injury and may correlate with clinical presentation, particularly in spastic and diplegic forms of cerebral palsy.

Table 1. Patterns of White Matter Involvement

Radiological Appearance Categories

Imaging revealed that nearly half (48.0%) of participants showed normal appearance, while others exhibited hypodensity (28.0%), gliosis (18.0%), or cystic degeneration (6.0%). These findings provide key structural correlates to functional deficits and assist in classifying the type and severity of cerebral injury, which may guide prognosis and intervention.

Cerebral Cortex Involvement

Cortical abnormalities were present in 10.0% of participants. Cortical damage can underlie severe functional impairments including intellectual disability and motor deficits. While not the predominant site affected, its involvement warrants consideration in relation to seizure activity and cognitive profiles.

Table 2. Cerebral Cortex Abnormalities

Periventricular White Matter Involvement

Periventricular white matter changes were observed in 22.0% of children, which is consistent with periventricular leukomalacia — a common etiology in preterm infants. This type of injury is often associated with spastic diplegia and motor coordination deficits.

Table 3. Periventricular White Matter Involvement

Internal capsule changes were found in 18.0% of participants.

Figure 1:Neuropathological Changes Associated with CP

Caudate nucleus abnormalities were found in 6.0% of participants. Although infrequent, this structure plays a role in motor and cognitive regulation, and its involvement is often associated with dyskinetic or mixed forms of cerebral palsy.

Putaminal lesions were noted in 34.0% of cases, representing a significant subset. As part of the basal ganglia, the putamen is integral to motor control, and its involvement is commonly seen in dystonic and dyskinetic CP.

Globus pallidus abnormalities were observed in 16.0% of the sample. As with the putamen, this structure is involved in voluntary movement regulation. Thalamic Involvement

Thalamic changes were found in 12.0% of children. Given the thalamus’s role in sensory and motor signal relay, its dysfunction may contribute to mixed or atypical presentations of CP.

Figure 2: Brain Abnormalities in CP

Corpus callosum abnormalities were present in 30.0% of the sample. These findings may reflect structural underconnectivity between hemispheres, which could explain certain cognitive and motor coordination deficits. Corpus callosum integrity is also a prognostic indicator in many developmental disorders.

Figure 3. Proportion of participants with corpus callosum involvement.

Cerebellar Cortex Abnormalities

Cerebellar cortex involvement was observed in 24.0% of participants. This is highly relevant in cases of ataxic CP, where the cerebellum is the primary site of dysfunction. Abnormalities here contribute to coordination deficits, balance issues, and delayed motor milestones.

Cerebellar White Matter Abnormalities

White matter lesions in the cerebellum were found in 16.0% of the cohort. These findings may overlap with cerebellar cortical pathology and are often associated with motor coordination deficits. Their presence further reinforces the cerebellum's role in CP pathophysiology in this sample.

Malformations in Neuroimaging

Malformations were observed in 6.0% of cases, indicating the presence of structural anomalies that may be congenital. While rare, these abnormalities can have significant implications for neurodevelopment and clinical outcomes, particularly if they affect cortical or midline structures. Their presence often suggests an early gestational insult and may be associated with syndromic features or genetic conditions. Early identification is crucial for comprehensive evaluation, including genetic counseling and developmental monitoring.

Focal Infarcts

Focal infarcts were identified in 14.0% of participants. These localized ischemic injuries often result from vascular events during the perinatal period. Their presence is highly relevant to unilateral or asymmetric clinical presentations such as hemiplegia. Depending on the region involved, infarcts may affect motor, sensory, or cognitive domains and often correlate with adverse developmental trajectories.

Table 4. Focal Infarcts Detected on Imaging

Porencephalic Cysts

Porencephalic cysts were seen in 16.0% of the sample. These cystic cavities within brain parenchyma are often post-ischemic and may communicate with the ventricular system. They are associated with seizures, cognitive impairment, and hemiparesis depending on size and location. This imaging finding suggests a history of significant prenatal or early postnatal brain injury.

Intracranial Hemorrhage

Hemorrhagic lesions were found in 14.0% of participants, often linked with birth trauma or prematurity. Intracranial hemorrhage increases the risk for hydrocephalus, seizures, and subsequent cerebral palsy. Its identification has both diagnostic and prognostic implications, necessitating close follow-up and early intervention.

Ventricular Enlargement

Ventricular enlargement was observed in 42.0% of participants, categorized as mild (18.0%) or severe (24.0%). This finding suggests potential hydrocephalus or atrophy-related ex vacuo dilation. Enlargement may influence intracranial pressure and is associated with developmental delays, particularly when severe.

Table 5. Patterns of Ventricular Enlargement

Enlargement of Subarachnoid Space

Subarachnoid space (SA) enlargement was rare, seen in only 8.0% of cases. It can reflect cortical atrophy or benign external hydrocephalus. While not always pathological, persistent enlargement may require further evaluation for developmental implications.

Cerebellar Atrophy

Cerebellar atrophy was identified in 14.0% of participants, supporting the presence of ataxic symptoms or global motor delays. Cerebellar volume loss can be congenital or acquired and may impact coordination, balance, and motor planning. Its detection justifies inclusion in rehabilitation plans focused on postural control and gait training.

Myelination Status

Delayed myelination was present in 38.0% of the cohort, suggesting either prematurity or disrupted brain maturation. Normal myelination was observed in 62.0%. Myelination patterns are key indicators of neurological development and are useful in interpreting global developmental delay or cognitive outcomes.

Final Clinical Diagnosis

The final clinical diagnosis varied across participants. Hypotonic CP (22.0%) was most common, followed by spastic hemiplegia and combined types. The diagnostic diversity reflects the heterogeneity of cerebral palsy presentations and highlights the importance of individualized treatment strategies. Accurate phenotyping aids in prognosis and therapy planning.

Figure 4. Final clinical diagnoses among children with cerebral palsy.

MRI-Based Diagnosis

Periventricular leukomalacia (PVL) was the most common MRI diagnosis (38.0%), followed by cortical dysplasia (19.0%) and basal ganglia involvement (11.5%). These findings validate clinical observations and provide anatomical correlates to CP subtypes. MRI remains a crucial diagnostic tool in identifying etiology and guiding prognosis.

Association Between MRI Diagnosis and Types of Cerebral Palsy

This cross-tabulation examines the relationship between specific MRI-diagnosed brain lesions and different clinical subtypes of cerebral palsy. A statistically significant association was found between MRI findings and the hemiplegic type of CP (p = 0.025), suggesting that specific structural lesions such as infarcts and cortical dysplasia may underlie unilateral motor deficits. Other CP subtypes—including diplegia, quadriplegia, dyskinesia, and spastic or ataxic presentations—did not show significant associations with MRI categories (p > 0.05). These results indicate that neuroimaging may be more predictive in identifying etiology in focal presentations like hemiplegia than in more diffuse CP types.

In this study, abnormal MRI findings were present in a substantial majority of the cerebral palsy (CP) cohort, with periventricular leukomalacia (PVL) emerging as the most common abnormality (38%), followed by cortical dysplasia (19%), basal ganglia involvement (11.5%), brain atrophy (5.5%), infarcts (5%), and porencephalic cysts (16%). These findings confirm the dominant role of structural brain injuries in the etiology of CP and reinforce the diagnostic utility of MRI in delineating lesion patterns.

The predominance of PVL in this cohort aligns with numerous previous studies. Krägeloh-Mann^,8 reported white matter lesions—particularly periventricular injury—as the most prevalent MRI abnormality, especially among preterm infants, accounting for over 50% of cases. Similarly, Prasad et al. ⁹ and Magesh et al. ¹⁰ found that PVL was the leading MRI finding in their Indian CP populations, observed in 47.1% and 38% of cases respectively. These studies support the present data and emphasize PVL’s strong correlation with spastic diplegia and prematurity, even though prematurity accounted for only 14% of the present sample—suggesting that other perinatal insults (e.g., hypoxia) may also contribute to PVL in term infants.

The relatively high incidence of cortical and deep grey matter involvement in the present study is also consistent with global findings. Robinson et al^,11 identified focal ischemic or hemorrhagic lesions and diffuse encephalopathy in a notable proportion of children with CP, particularly those born at term. Ara et al. ^,12 further differentiated lesion types by gestational age, observing that grey matter injuries predominated in term-born infants. In our cohort, cortical dysplasia and basal ganglia lesions were common in children with quadriplegia and dyskinetic CP, suggesting a strong link between these lesion locations and the severity of motor dysfunction.

Basal ganglia involvement, noted in 11.5% of cases here, is of particular interest given its association with dyskinetic CP. Wei^,13 demonstrated that high T2 signal intensities in the globus pallidus are a hallmark of kernicterus-induced dyskinetic CP. Although bilirubin levels were not evaluated in the present study, the relatively high rate of neonatal jaundice (32%) suggests that bilirubin toxicity may have contributed to basal ganglia injury in a subset of cases.

Brain atrophy and porencephalic cysts, though less prevalent, remain critical markers of severe cerebral injury, often associated with early global hypoxic events or ischemic infarction. Their presence typically correlates with extensive motor and cognitive impairment, as corroborated by Magesh et al. ^,10 and Pradeep et al. ^,14 who identified cystic degeneration and infarcts as secondary yet important contributors to the CP lesion spectrum.

The frequency of dual or complex lesions in this study also merits attention. Although not explicitly categorized as “mixed,” several children presented with multiple concurrent findings (e.g., PVL with cortical dysplasia or infarcts with porencephalic cysts). Such overlaps complicate clinical classification but reflect the reality that CP often arises from multifactorial and temporally layered insults. As highlighted by Himmelmann et al. ^,15 bilateral and combined lesions are often associated with more severe functional outcomes, a finding echoed in our sample.

In conclusion, the current study confirms that MRI detects structural abnormalities in the vast majority of CP cases, with PVL and grey matter injury forming the cornerstone of neuroimaging diagnoses. These findings align closely with international literature, reinforcing MRI's role as both a diagnostic and prognostic tool. The lesion patterns observed also reflect the timing and nature of perinatal brain insults, further underlining the importance of early MRI evaluation in children with suspected CP.

The present study demonstrated that MRI abnormalities were found in the vast majority of children with cerebral palsy (CP), with radiological findings correlating strongly with clinical subtypes. These results underscore the diagnostic power of MRI in delineating the underlying neuropathology of CP and support its routine use in clinical evaluation. Specifically, the study revealed that periventricular leukomalacia (PVL), cortical and deep grey matter lesions, infarcts, and porencephalic cysts were prominent MRI features, all of which contributed to subtype classification and etiological understanding.

This aligns with the seminal findings of Krägeloh-Mann^,8, who reported that MRI abnormalities were present in 85% of CP cases and could establish a pathogenetic pattern in over 80%. The present study’s similar detection rate reaffirms MRI’s role as the gold standard for anatomical confirmation of brain injury in CP. Importantly, MRI enabled distinction between acquired lesions (e.g., PVL, infarcts) and developmental anomalies (e.g., cortical dysplasia, malformations), facilitating targeted management strategies.

MRI’s diagnostic relevance also extends to timing and pattern recognition. Ara et al. ^,12 highlighted MRI’s ability to differentiate injuries occurring in the prenatal, perinatal, and postnatal periods based on lesion type and distribution. This distinction is critical for medico-legal evaluation and counseling, particularly in contexts where perinatal asphyxia or delayed intervention may be questioned. In the current study, white matter injury was common in preterm cases, while deep grey matter and cortical injuries predominated in term infants—supporting Ara et al.’s observation that lesion type can indicate timing of insult.

Moreover, the correlation between MRI findings and CP severity has been repeatedly emphasized in the literature. Gunawan et al. ¹⁶ and Nel et al. ^,17 both reported that grey matter lesions, particularly when bilateral, were associated with higher Gross Motor Function Classification System (GMFCS) levels and more severe motor dysfunction. The present findings are consistent with this, as children with extensive basal ganglia or cortical involvement exhibited more severe clinical presentations, including quadriplegia and hypotonia.

Beyond motor outcomes, MRI has diagnostic utility in identifying predictors of comorbidities such as epilepsy, intellectual disability, and visual impairment. Himmelmann et al. ^,15 in their large-scale application of the MRI Classification System (MRICS), found strong associations between imaging abnormalities and secondary impairments. While the current study did not directly evaluate comorbidities, the high prevalence of structural lesions in functionally critical areas (e.g., basal ganglia, thalamus, cerebellum) implies a similar pattern and supports early MRI for prognostic planning.

Despite its advantages, the present findings also echo limitations highlighted by Leonard et al. ^,18, who observed that 9–16% of children with CP have normal MRI scans. Although only 12% of the current sample fell into this category, such cases point to the possible presence of non-structural etiologies, including metabolic, genetic, or synaptic dysfunction. In such instances, MRI should be supplemented by biochemical and genetic investigations to avoid diagnostic oversight.

Finally, several studies have recommended expanding MRI’s role through standardized classifications and quantitative analysis. Belova et al. ¹⁹ advocated for integrating advanced techniques such as diffusion tensor imaging (DTI) and functional MRI (fMRI) to improve diagnostic sensitivity and link imaging findings more directly to functional outcomes. While these techniques were not employed in the present study, the high correlation between MRI and clinical presentation provides strong justification for future incorporation of these modalities in CP assessment protocols.

This study affirms that cerebral palsy, though clinically diverse, often presents with distinct and recognizable patterns on MRI. The integration of neuroimaging into the diagnostic framework allows for better understanding of pathophysiology, more accurate classification, and improved prognostic clarity. MRI serves as a critical bridge between clinical observation and anatomical evidence, enabling more precise, effective, and personalized care for children with CP. Future research should focus on combining advanced imaging techniques with long-term functional data to refine diagnostic precision and enhance intervention strategies in this vulnerable population

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