Cerebral Palsy

Question 1

Cerebral palsy (CP) definition

Answer 1

group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.

• injury typical occurs prenatal

Question 2

Age of CP diagnosis

Answer 2

No specific upper age limit - generally up to 3 years old.

Question 3

CP is a clinical diagnosis that generally includes:

Answer 3

• clinical diagnosis = based on observable behavior (not diagnosed in utero)
• formal neurodevelopmental examination
• history of activity limitations
• MRI (frequent findings: white matter damage, cortical or subcortical lesions (particularly involving the basal ganglia), brain malformations, and postnatal injuries (including focal infarction)

Question 4

Where does CP originate? (Which systems?)

Answer 4

In either or both of the two semi-independent motor systems of the brain

pyramidal (70-85%)

extrapyramidal (15-30%)

Question 5

Pyramidal motor system

Answer 5

• travel through pyramids of medulla
• responsible for voluntary muscle control

Corticospinal tract:
Cerebral cortex -> internal capsule -> midbrain -> pons -> medulla (75% decussate) -> lower motor neuron (ventral horn)

Injury: spastic CP (upper motor neuron)

Corticobulbar tract (voluntary control of face, head, neck):
Cerebral cortex -> internal capsule -> lower motor neuron (brainstem/CN: 5, 7, 9-12)

Bulbar = medulla, pons, cerebellum

Injury: dysphasia, dysarthria

Question 6

Extrapyramidal motor system

Answer 6

• do not travel through pyramids of medulla
• responsible for involuntary control (tone, balance)
• “fine tunes” movement of pyramidal system by making adjustments to posture and coordination
• originate in brainstem, cerebellum, and basal ganglia - not cortex (pyramidal)
• results in non-spastic CP
• typically involves all extremities (upper>lower)
• normal IQ

Question 7

Pyramidal motor system damage results in:

Answer 7

Spastic CP

Question 8

Spastic CP (general definition)

Answer 8

• results from damage to pyramidal system
• characterized by abnormally high muscle tone (tightness)
• children born preterm > full-term
• often associated with underlying periventricular leukomalacia (PVL) and/or intraventricular hemorrhage (IVH)

Question 9

Spastic CP subtypes

Answer 9

Spastic hemiplegic (“half”) CP - arm and leg on one side of body
- arm>leg
- most common in full term children
- cause: perinatal MCA stroke
- can learn to walk and have normal IQ

Spastic diplegic CP - lower extremities, lesser degree of upper extremities
- most common in preterm children
- cause: periventrical leukomalacia (damage to white matter around ventricles)
- cognitive impairment is correlated with severity of motor disability

Spastic quadriplegic CP - ll four extremities and the trunk and neck (i.e., full body)
- caused by a generalized event such as anoxia
- injury to brain occurs prenatally (50%), perinatally (30%), and postnatally (20%)
- most severe subtype; frequently accompanied by epilepsy and cognitive impairments

Question 10

Spasticity

Answer 10

increased muscle tone

Abnormally increased muscle tone or muscle stiffness that can interfere with functional movement and daily activities.

When severe, spasticity is characterized by uncontrollable muscle spasms.

Question 11

extrapyramidal CP subtypes

Answer 11

Dyskinetic CP
- basal ganglia dysfunction
- trouble controlling muscle movement (twisting, abrupt movements)
- difficulty sitting comfortable and coordinating muscles for walking and speaking
- caused by hypoxic-ischemic injury typically in full-term infants

Ataxic CP
- cerebellar dysfunction
- lack of coordination during voluntary gross and fine motor movements
- poor balance, unsteadiness,
a wide-based gait, and shakiness or tremors during activities involving manual dexterity.

Question 12

Mixed CP

Answer 12

• 20% of cases
• abnormalities of both the pyramidal and extrapyramidal motor systems.

Question 13

CP risk factors

Answer 13

• preterm birth (most important - though ~50% of CP are full-term)
• low birth weight (second)
• prenatal factors (low SES, maternal infections/toxic exposure, multiple birth, IUGR, brain malformations)
• perinatal (anoxic damage during delivery (10%), low Apgar at 5 mins)
• postnatal (infections-e.g., meningitis)

Injury after age 3 = CP diagnosis not accurate, rather should reflect underlying cause (e.g., TBI, stroke)

Question 14

Physical outcomes in CP

Answer 14

1/2 = walk unaided, 1/3 = cannot walk, rest = need assistance

spasticity can result in scoliosis and/or hip dislocation

chronic pain

increased risk of epilepsy

oral motor impairments; if severe can increase aspiration

bladder control

poor sleep d/t positioning issues and discomfort

Question 15

Cognitive outcomes in CP

Answer 15

ID (30-50%) - most common in quadriplegic CP

Question 16

CP classifications of severity

Answer 16

mild (i.e., minimal functional limitations)

moderate (i.e., some assistance is required to accomplish ambulation and daily activities)

severe (i.e., non-ambulatory and extensive assistance is required to accomplish daily activities)

Question 17

Early motor attainment and CP

Answer 17

Precocious acquisition of certain motor skills can also be a harbinger of CP:

standing well before the age of 12 months can reflect hypertonia (stiffness and rigidity) in the legs

strong hand preference in the first 12 to 18 months can indicate weakness in the other hand

Question 18

% of children ultimately diagnosed with CP who have unremarkable pre- and perinatal history.

Answer 18

50%

Question 19

Most children do not manifest full motor signs of CP until how many years?

Answer 19

2 years of age or beyond - a definitive diagnosis usually is made in the second or third year of life

Question 20

Neuropsychological expectations of CP

Answer 20

CP is not associated with a prototypical neuropsychological profile, however:

language > visually-based is common

ID to BIF (50%)

SLD (25%)

Attention deficits (d/t periventricular white matter and subcortical damage, and/or epilepsy)

Question 21

Medications for CP reduce …?

Answer 21

spasticity

does not do well to address muscle weakness, incoordination, or movement abnormalities.

Question 22

Periventricular leukomalacia (PVL)

Answer 22

Cerebral white matter necrosis around the ventricles that interrupts the output of motor tracts.

Periventricular leukomalacia results from interrupted blood flow and oxygen to the area, particularly in preterm babies of less than 32 weeks. In fact, PVL is sometimes referred to as “white matter damage of prematurity.”

Question 23

For a child with cerebral palsy, a favorable prognostic indicator is:

Answer 23

sitting by 24 months

Question 24

The medical history most typical of spastic diplegic cerebral palsy is:

Answer 24

premature birth and neuroimaging findings of periventricular leukomalacia

Question 25

The foremost risk factor for cerebral palsy is

Answer 25

premature birth.

Question 26

Most robust neuropsychological findings of CP

Answer 26

: Average IQ with visuospatial impairment and attention weaknesses

Question 27

Describe typical MRI finding in (1) hemiplegic CP, (2) dyskinetic CP, and (3) spastic diplegic CP

Answer 27

(1) MCA stroke,
(2) hypoxic-ischemic injury,
(3) PVL