Cerebral Palsy

Question 1

Definition

Answer 1

Non-progressive disease of the brain originates during the antenatal perinatal or early postnatal period.
- results in motor or postural disorders with spasticity.
- Less commonly Px can develop chorea, ataxia or dystonia

Question 2

Aetiology

Answer 2

Antenatal (80%)
Perinatal (10%)
Postnatal (10%)

Question 3

Antenatal Risk Factors

Answer 3

• Premature birth
• Multiple births
• Maternal illness: chorioamnionitis, TORCH infections, thyroid disease
• Foetal brain malformation
• Lower socioeconomic status

Question 4

Perinatal Risk Factors

Answer 4

• Asphyxia
• Birth trauma
• Non-vertex presentation
• Placental abruption
• Uterine rupture
• Prolonged/obstructed labour

Question 5

Postnatal Risk Factors

Answer 5

• Neonatal sepsis
• Meningitis
• Respiratory distress
• Hyperbilirubinaemia
• Intraventricular haemorrhage: spontaneous, head injury, NAI

Question 6

Classification

Answer 6

Spastic (70%):
- subtypes include hemiplegia, diplegia or quadriplegia
- increased tone resulting from damage to upper motor neurons
Dyskinetic
- caused by damage to the basal ganglia and the substantia nigra
- athetoid movements and oro-motor problems
Ataxic
- caused by damage to the cerebellum with typical cerebellar signs
Mixed

Question 7

Signs

Answer 7

Gross motor delay:
- not sitting by 6 m
- not walking at 12-18 m
Delayed speech development: talking in short sentences by 2 years
Cognitive impairment
Retention of primitive reflexes: moro, neck righting reflex
Spasticity/clonus: usually after 2 years of age
Scoliosis: as spasticity increases

Question 8

Symptoms

Answer 8

• Abnormal movements: persistent cramped synchronous movements <3 months
• Toe walking/knee hyperextension: unilateral if hemiplegia, bilateral in diplegia
• Scissoring: hip adductor spasticity causing legs to cross
• Contractures
• Muscle weakness
• Joint dislocation: as spasticity increases

Question 9

Diagnosis

Answer 9

MRI Brain:
- periventricular leukomalacia,
- congenital malformation,
- stroke or haemorrhage,
- cystic lesions
Consider:
- CT brain: suspected trauma
- USS brain: less sensitive than MRI
- Coagulation screen: if thrombotic cause suspected
- Metabolic screen: if inborn errors of metabolism suspected
- Gait analysis: toe-walking, scissoring gait

Question 10

Treatment

Answer 10

• Physiotherapy: mobility training, strength training, orthotics
• Occupational therapy: manual and cognitive therapy exercises, adaptive equipment
• Speech therapy: aiming to reach developmental milestones, swallow assessment
• Dietician: to ensure adequate intake

Question 11

Symptom control

Answer 11

• Sialorrhea: Glycopyrronium bromide, hyoscine hydrobromide
• Spasticity: Botulinum toxin A, phenol
• Constipation: Laxatives
• GORD: Antacids, proton pump inhibitors
• Mental health: SSRIs, anxiolytics
• Insomnia: Melatonin, sedative e.g. zopiclone
• Epilepsy: antiepileptics

Question 12

Complications

Answer 12

• Intellectual disability
• Feeding difficulties
• Increased aspiration risk
• Behavioural problems
• Epilepsy
• Constipation
• Sleep disturbances
• GORD
• Incontinence
• Siallorhoea: excess saliva formation
• Low visual acuity
• Hydrocephalus
• Microcephaly
• Mental health problems: anxiety and depression