Cerebral Palsy

Question 1

What is cerebral palsy (CP)?

Answer 1

Describes a 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. Motor disorders are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary MSK problems.

Question 2

At what ate is the diagnosis made?

Answer 2

Age 2, at most 3

Question 3

What are the key points of the definition of CP?

Answer 3

Non-Progressive Lesion
Immature brian
Disorder of posture, movement, and sensation

Question 4

What are the three time frames when CP is caused? What percentage of CP occurs during each?

Answer 4

Prenatal (35%)
Perinatal (35-40%) - right around birth/during the birth process
Postnatal (4-6%)

• There is a high percentage of cases that time of lesion can not be determined*

Question 5

What are the prenatal causes of CP?

Answer 5

Early - genetic or acquired impairments

Later: infectious or hypoxic-ischemic mechanisms that result in lesions

Question 6

What are perinatal causes of CP?

Answer 6

Obstructed labor, cord prolapse, hypoxic-ischemic encephalopathy, neonatal stroke, severe hypoglycemia, untreated jaundice, severe neonatal infection

Question 7

What are postnatal causes of CP?

Answer 7

Metabolic encephalopathy
Infections
Cerebral vascular eves - esp. first 28 days after birth
Injuries: near-downing, trauma, MVA, shaken baby syndrome
Lung disease requiring mechanical ventilation

Question 8

What are risk factors for CP at birth?

Answer 8

Low birth weight
Prematurity
Poor intrauterine growth
Low APGARS

Question 9

What are APGAR scores?

Answer 9

A quick test performed on a baby at 1 and 5 minutes after birth. Determines how well the baby tolerated the birthing process (1 min) and how well the baby is doing outside the womb (5 min)
Lower score is worse (out of 10)

Question 10

What are the 5 categories of the APGAR score?

Answer 10

Breathing effort
Heart Rate (most important assessment!)
Muscle tone
Reflexes
Skin color

Question 11

What is considered a normal APGAR score?

Answer 11

7, 8, or 9. A score of 10 is unusual typically lose one point for blue hands/feet which is common.
Any core below 7 is a sign that the baby needs medical attention.

Question 12

What are LBW, VLBW, and ELBW?

Answer 12

Low Birth weight = < 2500g
Very low birth weight = < 1500g
Extremely low birth weight = <1000g

Question 13

What is commonly seen with approximately 50% of surviving children with ELBW?

Answer 13

Subsequent moderate to severe neurodevelopment disabilities.

Question 14

What are three types of lesions found in children with CP?

Answer 14

• Pervientricular leukomalacia (PVL) - ischemic
• Focal germinal matrix intraventricular hemorrhagic lesions (GM_IVH)
• Diffuse hypoxic ischemic encephalopathy (HIE)

Question 15

What is a periventricular leukomalacia lesion? What are the associated characteristics?

Answer 15

• Leading known cause of CP and cognitive impairments in premature infants
• White matter damage
• Usually symmetrical, bilateral nonhemorrhagic lesion caused by ischemia
• Cellular necorsis (sometimes there is calcification seen) and cavitation around the ventricles

Question 16

What areas are effected by periventricular leukomalacia lesions?

Answer 16

Can effect multiple areas of primary motor cortex

• Closer the lesion is to the center of the brain the more LEs are effected
• More extensive lesion results in greater involvement of the trunk and UEs

Question 17

What is a subependymal germinal matrix/intraventricular hemorrhagic lesion? What are the associated characteristics?

Answer 17

• Most common type of brain lesion in the premature infant
• Neonates < 32 weeks, <1500g
• Starts in the germinal matrix and extends into the intraventricular space of lateral ventricles

Question 18

What is the Germinal Matrix?

Answer 18

• Very fragile area during 2nd trimester
• Source of germinal cells for the cerebrum
• Premature infant poor auto-regulation of blood pressure

Question 19

How is a subependymal germinal matrix/intraventricular lesion graded?

Answer 19

Graded I-IV by severity level
Grade I = isolated to germinal matrix
Grade IV = hemorrhage that involves ventricles and periventricular white matter

Question 20

What are complications associated with subependymal germinal matrix/intraventricular lesions?

Answer 20

Hydrocephalus

Cyst formation

Question 21

What is hydrocephalus?

Answer 21

The excessive accumulation of CSF resulting in an abnormal widening of spaces in the ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

Question 22

What does a grade IV subependymal germinal matrix/intraventricular lesion look like? What else is it referred to as?

Answer 22

• Sometimes referred to as Perventricular Hemorrhagic Infarction (PHI)
• Large region of hemorrhagic necrosis in the periventricular white matter
• Impeded venous return leading to increased pressure and rupture
• 35-90% have significant neurological conditions

Question 23

What is hypoxic ischemic encephalopathy (HIE)?

Answer 23

• Lack of O2 and substrate delivery to the brain from decreased blood flow
• High neonatal mortality and neurologic morbidity

Question 24

What are clinical signs of hypoxic ischemic encephalopathy (HIE)?

Answer 24

Lethargy
Decreased activity
Hypotonia
Weak suck
Incomplete Moro
Bradycardia

Question 25

What are associated factors/comorbidities of HIE?

Answer 25

Cognitive delays
Behavioral issues
Speech difficulties
Auditory problems
Seizure disorders/Epilepsy
Visual Problems
Urinary incontinence
Constipation
Sensory Impairment
Growth disturbances
Sleep disturbances

Question 26

What is seen with 30+% of children with moderate HIE?

Answer 26

Spastic quadriparesis and cognitive impairment is common with this lesion

Question 27

What are types of CP classified by topographic distribution?

Answer 27

Diplegia
Hemiplegia/Hemiparesis
Quadriplegia/Tetraplegia

Question 28

What is diplegic CP?

Answer 28

d