DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

MRI classification system (MRICS) for children with cerebral

palsy: development, reliability, and recommendations
KATE HIMMELMANN 1 *
| VERONKA HORBER 2 * | JAVIER DE LA CRUZ 3 | KAREN HORRIDGE 4 |
€
VLATKA MEJASKI-BOSNJAK 5 | KATALIN HOLLODY 6 | INGEBORG KR AGELOH-MANN 7
|
ON BEHALF OF THE SCPE WORKING GROUP †

1 Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, G€oteborg, Sweden. 2 Department of Child Neurology,
University Children’s Hospital T€ubingen, T€ubingen, Germany. 3 Biomedical Research Institute Imas12-Ciberesp, 12 Octubre University Hospital, Madrid, Spain. 4 City
Hospitals Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland, UK. 5 Department of Neuropediatrics, Children’s Hospital Zagreb, School of
Medicine, University of Zagreb, Zagreb, Croatia. 6 Department of Paediatrics, University of Pecs, Pecs, Hungary. 7 Department of Paediatric Neurology, University
Children’s Hospital T€ubingen, T€ubingen, Germany.
Correspondence to Kate Himmelmann at Regional Rehabilitation Centre, Queen Silvia Children’s Hospital, Box 210 62, SE 418 04 G€oteborg, Sweden. E-mail: kate.himmelmann@vgregion.se

*These authors contributed equally to this study.

†
SCPE members listed in Acknowledgements.
This article is commented on by Ditchfield on page 9 of this issue.

PUBLICATION DATA AIM To develop and evaluate a classification system for magnetic resonance imaging (MRI)
Accepted for publication 25th April 2016. findings of children with cerebral palsy (CP) that can be used in CP registers.
Published online 21st June 2016. METHOD The classification system was based on pathogenic patterns occurring in different
periods of brain development. The MRI classification system (MRICS) consists of five main
ABBREVIATIONS groups: maldevelopments, predominant white matter injury, predominant grey matter injury,
MRICS MRI classification system miscellaneous, and normal findings. A detailed manual for the descriptions of these patterns was
PVL Periventricular leukomalacia developed, including test cases (www.scpenetwork.eu/en/my-scpe/rtm/neuroimaging/
SCPE Surveillance of Cerebral Palsy cp-neuroimaging/). A literature review was performed and MRICS was compared with other
in Europe classification systems. An exercise was carried out to check applicability and interrater reliability.
Professionals working with children with CP or in CP registers were invited to participate in the
exercise and chose to classify either 18 MRIs or MRI reports of children with CP.
RESULTS Classification systems in the literature were compatible with MRICS and
harmonization possible. Interrater reliability was found to be good overall (k=0.69; 0.54–0.82)
among the 41 participants and very good (k=0.81; 0.74–0.92) using the classification based on
imaging reports.
INTERPRETATION Surveillance of Cerebral Palsy in Europe (SCPE) proposes the MRICS as a
reliable tool. Together with its manual it is simple to apply for CP registers.

Surveillance of Cerebral Palsy in Europe (SCPE) has,
through agreement in definitions and classifications of cere-
bral palsy (CP), developed a common language in the
domain of CP.1,2 This has been a prerequisite for compara-
tive studies,3,4 and for studies which necessitate a large popu-
lation basis.4,5 This common language has generated a lot of
interest even beyond Europe: the definitions and classifica-
tions are widely used, and SCPE papers extensively cited.
CP is a clinical diagnosis, based upon neurological
symptoms and a motor disorder causing an activity limita-
tion.6 SCPE does not consider neuroimaging a prerequisite
for the diagnosis of CP.2 Up to now, normal magnetic res-
onance imaging (MRI) does not exclude the diagnosis of
CP. Moreover, neuroimaging, especially MRI, is not avail-
able nor used in all countries to the same extent. In addi-
tion, the use of MRI, as well as knowledge of its role in
the understanding of CP pathogenesis, has dramatically
increased during the last 15 years, which would make com-
parison between countries and time periods difficult. Most
importantly, there is no commonly agreed neuroimaging
classification for CP at this time.
Although neuroimaging is not part of the CP definition,
neuroimaging findings are abnormal in more than 80% of
children with CP,7–9 disclosing the pathogenic pattern
responsible for the CP. Neuroimaging may also help to
understand the structure–function relationship.10,11
National guidelines recommend MRI as the first diag-
nostic step after history taking, neurological examination,
and examination of additional impairments.12 Therefore, a
need was expressed for the development of a classification
system for neuroimaging findings in CP, which could be
introduced into the standard CP evaluation form to be
prospectively used in registers. For this purpose, a simple
system is needed, which can be applied easily not only by

© 2016 Mac Keith Press DOI: 10.1111/dmcn.13166 57

clinicians, but also by epidemiologists or other profession-
als who work in CP registers. In CP registers, in most
cases only a written description of the imaging findings is
available and not the image itself. The classification there-
fore has to be applicable also for the written descriptions.
With the aim to develop such a classification, SCPE had
as a first step identified MRI patterns known to be associ-
ated with a high risk of CP. CP is defined as a disorder
due to a non-progressive interference or lesion or abnor-
mality of the developing or immature brain.1 Thus, it
seemed important to identify patterns according to their
time of occurrence during brain development, on the basis
that the human brain undergoes complex organizational
changes during intra- and extrauterine development; the
patterns of abnormalities or lesions found will depend on
the stage of brain development at the time of insult.13
Thus, the brain pathology of CP is dependent on the time
of occurrence of noxious events interfering with brain
development or actually damaging it. MRI has good poten-
tial to visualize this pathology. During the first and second
trimesters, predominantly cortical neurogenesis takes place,
characterized by proliferation, migration, and organisation
of neuronal precursor cells, then neuronal cells. Distur-
bances in this process result in maldevelopments such as
lissencephaly, pachygyria, or polymicrogyria. When affect-
ing the motor cortex, CP may be the result. Some of these
disorders may be of genetic origin, especially when
symmetrical in distribution.14
During the third trimester, when the ‘gross architecture’
of the brain (neural cyto- and histogenesis) is largely estab-
lished, growth and differentiation events are predominant
and persist into postnatal life (axon, dendrite and synapse
formation, myelination). Disturbances of brain develop-
ment during this period mainly result in clastic lesions.
The causes are multiple and key factors are inflammation
with excessive cytokine production, oxidative stress, and
excess release of glutamate triggering the excitotoxic cas-
cade, factors that are induced by hypoxic–ischaemic and/or
infectious mechanisms, whereby a potentiation of single
effects can be assumed.15 Early in the third trimester white
matter is especially affected. The major neuropathology
potentially damaging the motor tracts and thus leading to
CP includes periventricular leukomalacia (PVL) or compli-
cations of intraventricular haemorrhage: predominant
white matter injury. This pathology has been called ‘en-
cephalopathy of prematurity’ and is accompanied by ‘neu-
ronal/axonal disease’. This may also involve the thalamus,
basal ganglia, cortex, brainstem, and cerebellum,16
although the pathology that is related to CP and identifi-
able by visual inspection is mainly that of white matter
injury.
Lesional patterns that can occur in central motor
domains and thus cause CP in the late third trimester con-
cern the cortical grey matter, basal ganglia, and thalamus:17
predominant cortical or deep grey matter injury. Infarcts
of the middle cerebral artery are reported mainly in chil-
dren born at or near term with unilateral spastic CP.18
58 Developmental Medicine & Child Neurology 2017, 59: 57–64
What this paper adds
• MRI Classification System (MRICS) is a mainly qualitative classification
system for children with cerebral palsy (CP).
• MRICS describes pathogenic neuroimaging patterns related to timing of
brain compromise.
• The classification system proved to be reliable and easy to use for CP regis-
ters.
• MRICS was compared with other classification systems and harmonization
was feasible.
They may also occur in the very-preterm child, then
involving more the lenticulostriate arteries.19
Thus pathological patterns, characterizing disturbance of
early brain development and likely to cause CP, can be
summarized as maldevelopments, predominant white mat-
ter injury, and predominant grey matter injury; we called
these patterns ‘pathogenic patterns’ because they character-
ize specific timing periods of disturbance/insult to the
developing brain.
In a second step, we had systematically searched in the
literature for these pathogenic patterns in children with
CP.7 In this earlier review, MRI was reported to be abnor-
mal in 86% of the CP cases and indicated the pathogenesis
in 83%. Periventricular white matter injury was the most
frequent finding (56%), followed by deep grey matter
injury (18%), and brain maldevelopment (9%). Thus, this
earlier review indicated that the classification based on
pathogenic patterns covers the main brain pathology in
children with CP and seems a useful approach also for CP
registers.
The aim of this study was to develop an MRI classifica-
tion for CP research, registers, and clinicians, compare it
with other classification systems used in the literature, and
test its reliability.
METHOD
The development of a classification system was based on
the concept of the underlying pathogenic MRI patterns in
children with CP. Typical illustrations of these patterns
including subgroups and descriptions in the context of
clinical cases were searched for and agreed on by the
authors. A manual was developed in the process and tested
with respect to comprehensibility and applicability during
several SCPE workshops. Type of CP and gross motor
function according to Gross Motor Function Classification
System (GMFCS)20 were described together with MRI
findings.
A literature review was performed, searching for other
classification systems of MRI findings in CP, with the
question of compatibility with the MRI classification sys-
tem (MRICS), and whether harmonization between classi-
fications was possible. This review covered the time period
January 2007 to March 2013. The following keywords
were used for the search: cerebral palsy, neuroimaging,
MRI, classification.
A workshop with SCPE participants aimed at harmoniz-
ing the findings of the different classifications with the
MRICS.
 A reliability study of the suggested classification system
was done using 18 MRIs and their written reports; these
illustrated maldevelopments (3 cases), predominant white
matter injuries (7), predominant grey matter injuries (5),
miscellaneous (2), or normal findings (1). Age at examina-
tion and CP subtype were indicated. The test case exam-
ples were not part of the MRICS manual. These examples
together with the manual were sent to all SCPE centres
asking for participation of members involved in collecting
neuroimaging results for the register. The participants
were asked to do the study either with the images, or with
the written reports, using the MRICS manual as reference.
They were asked to classify at least the main pathogenic
group (A, B, C, D, E), and in the case of more than one
pattern, to classify the predominant pattern or the pattern
that most probably caused CP. MRICS interrater reliabil-
ity was estimated with kappa statistics (and 95% confidence
intervals [95% CI]) and interpreted according to usual
ordinal categories.
RESULTS
The classification system based on the pathogenic patterns
including subgroups is described in Table I, and was called
MRICS.
A manual exemplifying and illustrating these patterns,
including clinical cases for training, was established (www.
scpenetwork.eu/en/my-scpe/rtm/neuroimaging/cp-neuroi-
maging/). Examples and definitions – such as unilateral or
bilateral involvement, or mild versus severe extent of a
lesion – were included. All examples indicated the age at
imaging, the CP subtype and severity according to
GMFCS, and the topography of the lesion and its
Table I: The harmonized classification of magnetic resonance imaging,
based on pathogenic patterns (MRI classification system) proposed by
the SCPE network. For categories A.2. and D, the findings are to be given
as free text. Severity categories of B.1. and C.1. are defined according to
previous publications10,30
A. Maldevelopments
A.1. Disorders of cortical formation (proliferation and/or
migration and/or organization
A.2. Other maldevelopments (examples: holoprosencephaly
Dandy–Walker malformation, corpus callosum agenesis,
cerebellar hypoplasia)
B. Predominant white matter injury
B.1. PVL (mild/severe)
B.2. Sequelae of IVH or periventricular haemorrhagic infarction
B.3. Combination of PVL and IVH sequelae
C. Predominant grey matter injury
C.1. Basal ganglia/thalamus lesions (mild/moderate/severe)
C.2. Cortico-subcortical lesions only (watershed lesions in
parasagittal distribution/multicystic encephalomalacia) not
covered under C3
C.3. Arterial infarctions (middle cerebral artery/other)
D. Miscellaneous (examples: cerebellar atrophy, cerebral atrophy,
delayed myelination, ventriculomegaly not covered under B,
haemorrhage not covered under B, brainstem lesions,
calcifications)
E. Normal
IVH, intraventricular haemorrhage.
relation to the CP subtype were explained. The aspect of
topography and functional consequence was highlighted
in a specific chapter. Figure 1 gives an overview on brain
development and timing in relation to the pathogenic
patterns described. Figures 2 to 4 exemplify MRI findings
in the A, B, and C categories respectively; in the B cate-
gory, also with respect to morphology–function. In a sec-
ond part of the manual, concrete case reports of children
with CP integrated the MRI in the clinical context. Thus,
the classification system is primarily qualitative (patterns
of different timing). To some degree it is also quantita-
tive, because parameters are introduced such as unilater-
ality or bilaterality, and for some patterns – such as PVL
or diencephalic lesions – also aspects of lesion extent.
Specific pitfalls were highlighted, such as the importance
of age of the child at MRI. Incomplete myelination may
make it difficult or impossible to identify mild PVL or
mild deep grey matter lesions.
The cases in the manual can be studied primarily as
illustrations of specific patterns, or without revealing the
MRI classification, so that the user can train themselves.
This manual was included in the Reference and Training
Manual of the SCPE (www.scpenetwork.eu/en/rtm/).2
The literature review for other classification systems of
MRI findings in CP identified 49 publications, 10 of which
qualified for further analysis because they used specific
classification systems: two were reviews,8,9 five population
based studies,11,21–24 and three focused on a specific CP
subtype.25–27 All these studies had in common a high pro-
portion of abnormal MRIs (83–87%). Most of the items
used in the different classifications could be easily allocated
to one of the groups suggested in the SCPE classification
system as they referred to comparable pathogenic patterns.
Minor differences concerned the wording of an item such
as maldevelopment versus malformation; harmonization
thus seemed unproblematic. Major differences concerned
patterns without a corresponding term in the SCPE classi-
fication. An important category here refers to enlargement
of intra- and/or extracerebral spaces such as ventricu-
lomegaly, atrophy, cerebrospinal space abnormalities, cere-
bellar atrophy, diffuse cortical atrophy, thin corpus
callosum, and enlargement of the lateral ventricles. Other
items without correspondence were infection and
hypomyelination (Table II).
Multiple lesions (e.g. more than one abnormality where
it is difficult to decide which one is predominant or caus-
ing CP) were not dealt with unanimously and were gener-
ally considered to be problematic for classifying. The age
at MRI varied considerably and there was no consensus on
how to deal with the problem of incomplete myelination.
There was a tendency however, to include MRI performed
at a younger age and even neonatal MRI into the analysis.
Harmonization of classifications
Ten SCPE partners (clinicians dealing with CP, epidemiol-
ogists, and experts who work with CP registers) from eight
countries (Sweden, UK, Hungary, Croatia, Germany,
MRI Classification in CP Kate Himmelmann et al. 59
 Cortical neurogenesis

Conception 6wks 20wks 30wks 40wks

Proliferation, migration, organization Synapse formation, dendritic growth,

of neuronal cells start of myelination

Pathogenic events cause

A. Maldevelopments B. Predominant C. Predominant

white matter injury grey matter injury

Figure 1: Systematic overview on brain development, pathogenic patterns, and timing.

Figure 2: Illustrations of category A: Maldevelopments. Left: lissencephaly with broad, agyric cortex especially in the parietooccipital domain (T2w axial; age
16y, bilateral spastic CP, GMFCS level V, LIS1 gene mutation). Right: unilateral schizencephaly on the left side, a polymicrogyric cortex band borders the cleft
(arrow, T2w axial; age 12y, unilateral spastic CP on the right side, GMFCS level I). CP, cerebral palsy; GMFCS, Gross Motor Function Classification System.

Spain, Australia, France) participated in a workshop on
MRICS, which resulted in the following suggestions for
harmonization, summarized in Table II. Classification
systems of four papers differed more substantially from
the classification proposed by the SCPE, and Table II
indicates suggested allocation to categories used in
MRICS.7,23,24,27 It was suggested that patterns which could
not be allocated to one of the SCPE categories and which
referred to cerebrospinal space abnormalities – for example
ventriculomegaly, atrophy, cerebellar atrophy, diffuse corti-
cal atrophy, enlargement of the lateral ventricles or thin
corpus callosum – should be allocated to D (miscellaneous).
Only if there was evidence of intraventricular haemorrhage
grade III or IV in the neonatal period, then ventricu-
lomegaly or enlargement of the lateral ventricles would cor-
respond to B.2. (sequelae of intraventricular haemorrhage
or periventricular haemorrhagic infarction). It was sug-
gested that hypomyelination should be classified as
miscellaneous. The term ‘infection’ could not be allocated
because it is not a pathogenic pattern but an aetiological
term, and can cause various patterns (for example, cytome-
galovirus can cause polymicrogyria or white matter injury
dependent on timing). MRICS aims at classifying MRI pat-
terns related to timing and pathogenesis, not aetiology.
The interrater reliability exercise
The interrater reliability exercise was performed on 18
cases by 41 raters. The raters were from CP registers in 10
European countries with a background in neuropaediatrics
(9/41), radiology (4/41), paediatrics/child development/re-
habilitation (22/41), or other background (6/41). Fifteen
raters chose to classify based on images, and 26 performed
the exercise reading reports of the same images. The over-
all kappa statistic was 0.69 (95% CI 0.54; 0.82), which is
considered substantial or good. The interrater reliability
statistic was 0.57 (95% CI 0.38; 0.72) for ratings of images,

60 Developmental Medicine & Child Neurology 2017, 59: 57–64

Figure 3: Illustrations of category B: Predominant white matter injury. B.1. Periventricular leukomalacia is exemplified in three different forms of sever-
ity. Left: a mild, but very asymmetrical form, involving the motor tract only on the right side, indicated by the big arrow, while the small arrow indicates
frontal gliosis (age 6y, unilateral spastic CP on the left side, GMFCS level I); (middle) a mild symmetrical form, involving motor tracts on both sides, the
arrow indicates the periventricular gliosis (age 3y, bilateral spastic CP, GMFCS level I). Right: a severe form with not only bilateral gliosis, indicated by
the arrows, but also tissue loss (age 6y, bilateral spastic CP, GMFCS level V). The upper row shows T2w axial images. The lower row shows T2w coro-
nal images in the domain of the motor tracts, illustrating the lesions with respect to the motor tracts. CP, cerebral palsy; GMFCS, Gross Motor Function
Classification System.

and 0.81 (95% CI 0.66; 0.92) for rating of reports of
images. Normal and miscellaneous findings proved to
cause a major difficulty, especially when rating images.
The highest reliability was achieved for predominant white
matter injury (k=0.83: k=0.78 for images, 0.87 for descrip-
tions); maldevelopments and predominant grey matter
injury achieved a kappa of 0.71 and 0.68 respectively (see
also Table SI, online supporting information, for details).
DISCUSSION
There is a consensus on an international basis that neu-
roimaging is of great importance in the diagnosis of CP.7–
9,12
Neuroimaging is abnormal in more than 80% of chil-
dren with CP. Neuroimaging helps understanding of patho-
genesis and, to a minor extent, also aetiology of the
underlying brain disorder. It may also help to understand
the structure–function relationship.10,11 Thus a classification
system for MRI findings in children with CP seems to be of
high importance. Especially for CP registers, there is a great
need for consensus on classification. In the literature, the
need for a standardized classification system is expressed in
every study dealing with MRI in children with CP. In most
of the studies, some kind of classification is indeed used.
Brain abnormalities in CP arise at different times during
brain development. The same cause, for example, an infec-
tious agent or a hypoxic–ischaemic event, may give rise to
different patterns depending on the timing of interference
with brain development. Therefore, it seemed logical to
describe pathogenic patterns related to timing rather than
use a classification based on aetiology, especially because
aetiology is often not clear.
After having agreed on definitions concerning CP and its
subtypes as well as additional impairments, pre-, peri-, and
neonatal data and denominators,28 SCPE now suggests a

MRI Classification in CP Kate Himmelmann et al. 61

Figure 4: Illustrations of category C: Predominant grey matter injury. Upper: C.1. Basal ganglia and thalamus lesions: T2w axial images illustrate involve-
ment of deep grey nuclei on the left (medio-lateral thalamus, posterior part of nucleus lentiformis, arrows) associated with additional cortico-subcortical
lesions in the central region (arrows, right) (age 7y, born at term, hypoxic–ischaemic encephalopathy, dyskinetic CP with spastic features, GMFCS level
IV). Middle: C.2. Parasagittal lesion, T2w images in axial (left) and coronal orientation (right) showing cortico-subcortical injury in parasagittal distribu-
tion, the temporal lobe is relatively spared (age 10y, born at term, severe hypoxic–ischaemic encephalopathy, bilateral spastic CP, GMFCS level V).
Lower: C.3. Infarction of the middle cerebral artery with cortico-subcortical and basal ganglia/thalamus defects, indicating endstage after tissue
destruction, axial T2w image (left), coronal T2w image (right) (age 18mo, unilateral spastic CP, GMFCS level I). CP, cerebral palsy; GMFCS, Gross Motor
Function Classification System.

62 Developmental Medicine & Child Neurology 2017, 59: 57–64

Table II: Allocation of the categories of four other classification
the more extensive the lesion); information on topography
systems7,23,24,27 into categories used in the MRI classification system
is given when subscores are considered, but lesion type
(MRICS)
itself is not addressed. Thus, the systems appear comple-
mentary. When comparing MRICS to other classification
Other magnetic resonance imaging MRICS (main categories) systems used in the literature, harmonization seemed feasi-
classifications in the
literature A B C D E ble because, usually, similar patterns were addressed,
although with a somewhat different wording, and some
8
Korzeniewski et al.
aspects had to be allocated to the miscellaneous group
Congenital malformations x
White matter injury x (e.g. hypomyelination, cerebellar atrophy, or unspecified
Grey matter injury x atrophy). So, in a next step, we would like to test MRICS
Ventriculomegaly, atrophy, or x
also at an international level to see whether consensus on
cerebrospinal space abnormalities
Miscellaneous abnormalities not x the classification can be achieved.
included above MRI findings are increasingly introduced into CP regis-
Normal x
ters; usually the imaging report is used, but some registers
Benini et al.23
Cerebral malformation x have direct access to images. For both, rating images
Periventricular white matter injury x directly and ratings of imaging reports, we could show a
Cerebral vascular accident x
very good interrater reliability.
Deep brain grey matter injury x
Superficial grey matter injury x Several questions turned up repeatedly in this context
Diffuse grey matter injury x which led to the following recommendations noted in the
Intracranial haemorrhage x
SCPE guideline for data submission and in the Reference
Infection
Non-specific x and Training Manual (www.scpenetwork.eu/en/my-scpe/
Normal x rtm/neuroimaging/cp-neuroimaging/recommendation-for-
Reid et al.24
performing-mri-in-cp/):
Brain malformations x
White matter injury x
Focal vascular insult
Grey matter injury
x
x
• If there are several patterns, the predominant pattern
that is believed most likely to have led to the CP
Miscellaneous x
Normal x should be classified first; if there is another pathogenic
Numata et al.27 pattern (A, B, or C), this should be classified separately.
Malformation
Periventricular leukomalacia
x
x • Patterns should be classified as a minimum at headline
Hypomyelination x level (A, B, C, D, E); if feasible, patterns should be fur-
Cerebellar atrophy x ther classified at the subgroup level.
Diffuse cortical atrophy
Enlargement of the lateral ventricles
x
x • Ideally, an MRI performed after the age of 2 years
Border-zone-infarction x should be used for classification purposes, because of
Porencephaly/periventricular x developing myelination during the first years. If MRI
venous infarction
performed before 2 years of age is normal, patterns such
Thin corpus callosum x
Unclassifiable x as mild periventricular or basal ganglia/thalamus lesions
Normal x may have been be missed; and MRI should be repeated.
If a clear pathogenic pattern (A, B, C) is found before the
age of 2 years, this MRI is appropriate for classification.
classification system for the reporting of brain abnormali-
ties identified by means of MRI in children with CP: the In a longer process involving clinicians and non-clini-
MRI classification system, MRICS. A manual developed cians, SCPE has developed a classification system for MRI
under continual feedback of the SCPE group illustrates in CP, which proved easy to use and reliable. In compar-
these brain abnormalities in three major groups and their ison with other classification systems described in the liter-
subgroups, including morphology–function aspects, and can ature, harmonization appeared feasible. MRICS is a mainly
be used as a training tool. MRICS is primarily a qualitative qualitative classification system for cerebral palsy describ-
system based on pathogenic patterns related to timing, but ing pathogenic neuroimaging patterns related to timing of
it does take into account different pathologies within one brain compromise. A web-based manual is available for
timing period, which are partly also related to the extent of training purposes.
a lesion. Thus, MRICS has some simple quantitative
aspects (e.g. uni- vs bilaterality, severity of a pattern such as A CK N O W L E D G E M E N T S
basal ganglia/thalamus lesions). More sophisticated quanti- This study was performed on behalf of the SCPE collaboration
tative systems, such as the scoring system for MRI in CP,29 and was funded by the European Union Health Programme –
could be used in addition to describe the extent of lesions grant numbers DG SANCO EAHC 2008–1307/2013–3211 –
within the pathogenic groups. This system analyses the ‘Surveillance of Cerebral Palsy in Europe: best practice in
brain injury in children with CP semi-quantitatively, in monitoring, understanding of inequality and dissemination of
scoring the extent of a lesion (the higher the score, knowledge’.

MRI Classification in CP Kate Himmelmann et al. 63

 We wish to thank the members of the SCPE who in many
ways have contributed to the development of the MRICS. List of
SCPE participants: C Cans, M Van Bakel (RHEOP, Grenoble,
France); C Arnaud, M Delobel (RHE31, Toulouse, France); J
Chalmers (ISDSHS, Edinburgh, UK); V McManus, A Lyons
(Lavanagh Centre, Cork, Ireland); J Parkes, H Dolk (Belfast,
UK); K Himmelmann, M Pahlman (G€ oteborg University, G€
ote-
borg, Sweden); V Dowding (Dublin, Ireland); A Colver, L Pen-
nington (University of Newcastle, Newcastle, UK); K Horridge
(NECCPS, UK); J Kurinczuk, G Surman (NPEU, Oxford, UK);
MJ Platt (University of Liverpool, Liverpool, UK); P Udall, G
Rackauskaite (NIPH, Copenhagen, Denmark); MG Torrioli, M
Marcelli (Lazio Cerebral Palsy Register, Rome, Italy); G Ander-
sen, S Julsen-Hollung (CPRN, Tonsberg, Norway); M Bottos
(Bologna, Italy); G Gaffney (Galway, Ireland); J De La Cruz, C
Pallas (DIMAS-SAMID, Madrid, Spain); D Neubauer, M Jeko-
vec-Vrhovsek (Ljubljana, Slovenia); D Virella, M Andrada
(Lisbon, Portugal); A Greitane (Riga, Latvia); K Hollody (Pecs,
Hungary); S Sigurdardottir, I Einarsson (Reykjavik, Iceland); M
Honold, K Rostasy (Innsbruck, Austria); V Mejaski-Bosnjak
(Zagreb, Croatia). We also wish to thank the participants in the
reliability exercise and Wolfgang Grodd MD, Prof. of Neuroradi-
ology, as well as Peter-Michael Weber, DTP laboratory, Univer-
sity Hospital T€ ubingen, Germany, for their support in the initial
development of the neuroimaging chapter of the SCPE Reference
and Training Manual.
The authors have stated that they had no interests which might
be perceived as posing a conflict or bias.
SUPPORTING INFORMATION
The following additional material may be found online:
Table SI: Interrater reliability for the main categories of the
harmonized classification of magnetic resonance imaging, based
on pathogenic patterns

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