Examkin

Question

Difficulty: EasyPediatric Neurologic Disorders

An 11-month-old girl is evaluated in the pediatric clinic for a follow-up appointment. The parents happily report that she is already strongly right-handed, consistently reaching for toys, feeding herself, and interacting with objects almost exclusively with her right hand. They note she often keeps her left hand clenched in a tight fist. She was born at 31 weeks gestation and required continuous positive airway pressure for two weeks due to respiratory distress. On physical examination, vital signs are within normal limits. Neurologic examination reveals increased muscle tone and brisk deep tendon reflexes in the left arm and left leg compared to the right. Which of the following is the most appropriate next step in management?

  1. Magnetic resonance imaging of the brainAnswer
  2. B
    Reassurance that early handedness indicates advanced motor development
  3. C
    Reassurance that a persistently fisted hand is a normal palmar grasp reflex for this age
  4. D
    Reassurance that asymmetric motor tone is a normal transient finding in premature infants
  5. E
    Postponement of neurologic evaluation until the independent walking milestone at 15 months

Answer

Magnetic resonance imaging of the brain
Magnetic resonance imaging of the brain is the most appropriate next step. This patient's history of prematurity, combined with early hand preference, a persistently fisted hand, and asymmetric hypertonia/hyperreflexia, is highly concerning for hemiplegic cerebral palsy. Normal infants are ambidextrous; hand preference before 18 to 24 months of age is a major developmental red flag indicating a contralateral motor deficit. A brain MRI is required to evaluate for underlying structural lesions, such as periventricular leukomalacia, perinatal stroke, or congenital brain malformations.

Step-by-Step Solution

1
Evaluate the developmental milestones and physical exam findings.
The patient demonstrates early handedness at 11 months, a persistently fisted left hand, and asymmetric upper motor neuron signs (hypertonia, hyperreflexia) on the left side.
Identifying abnormal neurologic signs is necessary to differentiate normal developmental variations from pathological processes.
2
Correlate the findings with the patient's medical history.
The history of prematurity (31 weeks gestation) places the infant at high risk for perinatal brain injury, such as periventricular leukomalacia or intraventricular hemorrhage.
Prematurity is the most significant risk factor for cerebral palsy.
3
Determine the clinical significance of early hand preference.
Hand preference developing before 18 to 24 months of age is a developmental red flag that strongly suggests a contralateral focal motor deficit, such as hemiplegic cerebral palsy.
Normal infants use both hands symmetrically until toddlerhood.
4
Select the appropriate diagnostic intervention.
Magnetic resonance imaging (MRI) of the brain is indicated.
MRI is the diagnostic modality of choice to identify structural brain abnormalities underlying suspected cerebral palsy.

Key Concept

Early hand preference (before 18-24 months of age) combined with upper motor neuron signs is a developmental red flag that suggests a focal structural brain lesion (e.g., hemiplegic cerebral palsy) and requires evaluation with a brain MRI.
Rate this question

Topics

Pediatric Neurologic Disorders

More questions from this topic