Cerebral Palsy- Etiology & Pathophysiology

Question 1

Cerebral Palsy =

Answer 1

describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain

Question 2

motor disorders of cerebral palsy are often accompanied by:

Answer 2

disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems

Question 3

Key Points for Definition of CP

Answer 3

1) Non-progressive lesion

2) Developing brain

3) Disorder of posture and movement (accompanied by other problems)

Question 4

Non-progressive lesion:

Answer 4

CP is caused by a static injury to the brain that does not worsen over time

brain damage that leads to CP does not get progressively worse, although the effects and symptoms can change as the child grows

Question 5

Developing brain:

Answer 5

The injury or damage occurs to the brain during its development, which can be before, during, or shortly after birth

This disruption during critical periods of brain development leads to the motor and coordination difficulties characteristic of CP

Question 6

Disorder of posture and movement:

Answer 6

CP primarily affects posture and movement control

Often leads to difficulties with motor functions and coordination, and it may be accompanied by other issues such as sensory impairments, cognitive challenges, and musculoskeletal problems

Question 7

Most common childhood motor disability =

Answer 7

Prevalence: About 2 – 3 children out of every 1,000 will be diagnosed with CP

Question 8

Anatomical Sites:

Answer 8

basal ganglia
cerebellum
motor cortex
multiple areas

Question 9

Basal ganglia:

Answer 9

dyskinesia
involuntary movement

Damage to this area can result in movement disorders such as dystonia (involuntary muscle contractions) and chorea (involuntary, irregular movements)

often presents with problems like muscle rigidity and abnormal postures

Question 10

Cerebellum:

Answer 10

ataxia
shaky movement
poor balance

role in fine-tuning motor control and maintaining balance

Damage to this area can lead to ataxia, which is characterized by lack of coordination and balance issues

difficulties with motor planning and execution, affecting coordination and precision of movements

Question 11

Motor cortex:

Answer 11

spasticity
muscles appear stiff
most common site of lesion

responsible for planning, controlling, and executing voluntary movements

Damage to the motor cortex, often seen in spastic CP, can lead to spasticity (muscle stiffness and exaggerated reflexes) and weakness in specific muscle groups

damage impacts the ability to control precise and coordinated movements

Question 12

Multiple areas:

Answer 12

mixed = combination of types

symptoms from different types of CP, such as spasticity, ataxia, and dyskinesia, depending on the areas affected

multifocal damage can complicate the clinical presentation and impact various aspects of motor and sensory function

Question 13

Time of Brain Insult:

Answer 13

congenital vs acquired

Question 14

Congenital Brain Insult

Answer 14

damage that occurs before, during, or shortly after birth, while the brain is still developing

injuries that occur from prenatal through perinatal periods (before and around the time of birth)

Symptoms typically become noticeable in early infancy or early childhood

presents with a more stable pattern of motor impairment, as the brain damage is static, though its effects can evolve as the child grows

Question 15

Prenatal causes:

Answer 15

Infections (e.g., cytomegalovirus, toxoplasmosis), exposure to toxins (e.g., drugs, alcohol), maternal conditions (e.g., diabetes, preeclampsia), or genetic factors

Question 16

Perinatal causes:

Answer 16

Complications during labor and delivery, such as oxygen deprivation (hypoxia or ischemia), premature birth, or traumatic delivery

Question 17

Acquired Brain Insult

Answer 17

damage that occurs after birth, usually during the first few years of life when the brain is still maturing

injuries that occur after birth, during the postnatal period

symptoms may appear suddenly or develop over a short period following the insult

presentation might vary depending on the timing and extent of the injury, and there may be more fluctuation in the progression of symptoms compared to congenital CP

Question 18

postnatal causes:

Answer 18

Infections: Postnatal infections (e.g., meningitis, encephalitis) can lead to brain injury

Trauma: Physical injury to the brain (e.g., accidents, falls) can result in CP

Stroke: An acquired stroke or vascular event can cause localized brain damage, leading to CP

Toxic Exposure: Exposure to harmful substances after birth can affect brain development

Question 19

Inversely related with gestational birth weight 
=

Answer 19

much higher risk of CP during the
prenatal and perinatal period

Question 20

prenatal risk factors:

Answer 20

Genetics
Infections (TORCH)
Placental complications
Prematurity

Question 21

Genetics =

Answer 21

through inherited conditions or mutations

genetic mutations or abnormalities can affect brain development or lead to congenital conditions that increase the risk of CP

neurogenetic disorders or chromosomal abnormalities may predispose a fetus to neurological damage

Question 22

Infections =

Answer 22

TORCH complex refers to a group of infections that can affect fetal development and increase the risk of cerebral palsy

can cause inflammation, damage to brain cells, or interfere with normal brain development, increasing the risk of CP

Question 23

TORCH =

Answer 23

Toxoplasmosis: An infection caused by the parasite Toxoplasma gondii, which can be transmitted from mother to fetus.

Other Infections: This category includes various infections such as syphilis, varicella-zoster virus, and more.

Rubella: Also known as German measles, rubella can lead to congenital rubella syndrome, affecting multiple organs, including the brain.

Cytomegalovirus (CMV): A common virus that can cause developmental issues and neurological damage if contracted by the mother during pregnancy.

Herpes Simplex Virus (HSV): Genital herpes can be transmitted to the infant during delivery, potentially causing serious complications.

Question 24

Placental Complications =

Answer 24

Issues with the placenta can impair the supply of oxygen and nutrients to the fetus, leading to potential brain injury

Placental Abruption: Premature separation of the placenta from the uterus, which can lead to bleeding and reduced oxygen supply to the fetus.

Placental Insufficiency: Inadequate blood flow through the placenta can result in oxygen deprivation and nutritional deficiencies for the developing brain.

Placenta Previa: A condition where the placenta covers the cervix, which can lead to complications during delivery.

Question 25

Prematurity =

Answer 25

being born before 37 weeks of gestation, is a significant risk factor for cerebral palsy

Spontaneous Preterm Labor: Labor that begins prematurely without an obvious cause.

Medical Interventions: Induction or cesarean delivery due to maternal or fetal health concerns.

underdeveloped brain structures, making them more vulnerable to injury and infection

higher risk for complications such as intraventricular hemorrhage (bleeding in the brain) and periventricular leukomalacia (damage to white matter)

Question 26

perinatal risk factors:

Answer 26

Infections (TORCH)

Birth complications resulting in lack of oxygen

Hypoxic-Ischemic Encephalopathy (HIE): This condition occurs when the brain is deprived of adequate oxygen and blood flow during birth. It can lead to significant neurological damage and increase the risk of CP.

Umbilical Cord Complications: Issues such as umbilical cord compression, prolapse, or knotting can reduce blood flow and oxygen to the fetus.

Prolonged Labor: Extended labor can increase the risk of oxygen deprivation, especially if there are complications such as uterine contractions that affect blood flow.

Placental Abruption: Premature separation of the placenta from the uterine wall can reduce oxygen supply to the fetus, leading to potential brain damage.

Question 27

postnatal risk factors:

Answer 27

Head trauma
Near drowning
Strokes
Meningitis

Question 28

Head Trauma =

Answer 28

resulting from accidents or falls

Falls, vehicle collisions, or other traumatic events can lead to concussions, contusions, or more severe brain injuries

Physical abuse or non-accidental head trauma (e.g., shaken baby syndrome) can result in serious brain damage

can cause direct injury to brain tissues, leading to motor and cognitive impairment

Question 29

Near Drowning =

Answer 29

resulting hypoxia (lack of oxygen) can have severe effects on the brain

Complications from near drowning, such as infection or prolonged hypoxia, can further impact brain health

Question 30

Strokes =

Answer 30

interruption of blood supply to the brain, leading to brain cell damage

Ischemic Stroke: Caused by a blockage in a blood vessel supplying the brain, leading to reduced blood flow and oxygen.

Hemorrhagic Stroke: Results from bleeding within the brain, which can damage brain tissue.

can cause localized damage to brain areas responsible for motor control and coordination

can lead to different types of CP, including spastic, dyskinetic, or mixed types

Question 31

Meningitis =

Answer 31

infection of the protective membranes covering the brain and spinal cord, known as the meninges

Bacterial Meningitis: This type of meningitis is often severe and can lead to significant brain injury if not treated promptly.

Viral Meningitis: Generally less severe but can still cause complications.

can cause inflammation and swelling in the brain, potentially leading to brain damage

Question 32

CP Pathogenesis

Answer 32

periventricular leukomalacia (PVL)
brain hemorrhage
lack of oxygen
brain malformation

Question 33

periventricular leukomalacia (PVL)

Answer 33

Primary known cause

Damage to the white matter of the brain from lack of blood flow

More sensitive to injury between 26 weeks and 34 weeks of pregnancy

death of white matter cells, which are crucial for transmitting nerve signals

most commonly seen in premature infants due to their underdeveloped vascular systems and vulnerability to ischemic events

can lead to spasticity (muscle stiffness), motor control issues, and sometimes cognitive impairments

Question 34

brain hemorrhage

Answer 34

Intraventricular or Periventricular hemorrhage

Most occur within the first 48 hours after birth

bleeding within the brain, which can occur in different regions and at varying severities

can cause immediate damage to brain tissue, leading to motor deficits, spasticity, or other types of CP

Hemorrhages can lead to complications such as hydrocephalus (accumulation of cerebrospinal fluid), which can further exacerbate motor and cognitive impairments

Infants with very low birth weight are at higher risk

Question 35

Intraventricular Hemorrhage (IVH):

Answer 35

Bleeding into the ventricles of the brain, often seen in premature infants.

Question 36

Intracerebral Hemorrhage (ICH):

Answer 36

Bleeding within the brain tissue itself, which can result from trauma or other causes.

Question 37

Periventricular Hemorrhage

Answer 37

bleeding around the ventricles, particularly in the periventricular white matter

closely related to periventricular leukomalacia (PVL), where the white matter near the ventricles is damaged.

Question 38

Lack of Oxygen (Hypoxia-Ischemia)

Answer 38

Hypoxic-Ischemic Encephalopathy (HIE)

Symptoms typically evolve over period of 72 hours after birth

can cause widespread damage to brain tissue, leading to various forms of CP, including spastic, dyskinetic, or ataxic types

damage to whole brain = generalized area of lack of oxygen

Question 39

Hypoxic-Ischemic Encephalopathy (HIE):

Answer 39

A condition resulting from inadequate oxygen and blood flow to the brain, often occurring during or shortly after birth due to complications such as umbilical cord compression or placental insufficiency.

Question 40

Brain Malformation =

Answer 40

abnormal development of brain structures during fetal development

Infections, fever, trauma, or gene mutations can cause the brain to develop abnormally

Abnormalities in the cortical structure of the brain, such as schizencephaly (abnormal clefts or gaps) or lissencephaly (smooth brain surface)

Includes conditions like agenesis of the corpus callosum (absence of the structure connecting the two hemispheres) or hydrocephalus

can disrupt normal motor pathways and brain function, leading to motor impairments and other neurological deficits characteristic of CP

Question 41

Intraventricular Hemorrhage (IVH)

Answer 41

critical condition, particularly in premature infants, characterized by bleeding within the brain’s ventricles—the fluid-filled spaces that cushion and protect the brain

Question 42

Grade I IVH

Answer 42

isolated to the germinal matrix

Bleeding is confined to the small blood vessels in the germinal matrix, a region of the brain responsible for neuronal development

Question 43

Grade II IVH

Answer 43

bleeding occurs in ventricles, ventricles maintain normal-size

but does not cause ventricular enlargement

Question 44

Grade III IVH

Answer 44

when bleeding causes acute ventricular dilation

Bleeding fills the ventricles and causes ventricular enlargement (hydrocephalus)

Question 45

Grade IV IVH

Answer 45

hemorrhage spreads into the periventricular white matter

resulting in more severe brain damage

Question 46

While PVL can affect both sides of the brain, it often presents with:

Answer 46

more pronounced motor issues on one side of the body, resembling the effects of a stroke
> this is because the damage can be asymmetric

Question 47

A hemorrhage will often affect multiple areas of the primary motor cortex and myelination of tracks

Answer 47

primary motor cortex, located in the frontal lobe, is crucial for voluntary motor control

damage the neurons and glial cells in the primary motor cortex, disrupting the pathways responsible for voluntary motor control

Hemorrhage can cause necrosis of the white matter, leading to delayed or abnormal myelination = impairs the ability of nerve fibers to conduct signals efficiently

*the larger the bleed - the more involvement of other parts of the body

Question 48

Hypoxic Ischemic Encephalopathy (HIE) Risk Factors:

Answer 48

Maternal hypotension/hypertension
Placental/Uterus complications
Injury from the umbilical cord
Fetal heart problems
Trauma
Fetal infections

Question 49

Maternal hypotension/hypertension

Answer 49

Low blood pressure in the mother can reduce blood flow to the placenta and fetus, leading to decreased oxygen and nutrient delivery

High blood pressure in the mother can lead to placental insufficiency and reduced blood flow to the fetus

Question 50

Placental/Uterus complications

Answer 50

Placental Insufficiency: When the placenta does not deliver enough oxygen and nutrients to the fetus, it can result in hypoxia and ischemia.

Placental Abruption: Premature separation of the placenta from the uterine wall can lead to significant bleeding and reduced oxygen delivery to the fetus.

Uterine Contractions: Excessive or abnormal uterine contractions can compress the umbilical cord and reduce blood flow to the fetus.

Uterine Rupture: This rare but serious complication can cause significant bleeding and oxygen deprivation to the fetus.

Question 51

Injury from the Umbilical Cord

Answer 51

Umbilical Cord Compression: Compression of the umbilical cord can reduce or block blood flow to the fetus, leading to oxygen deprivation.

Umbilical Cord Prolapse: When the umbilical cord slips ahead of the presenting part of the fetus during labor, it can become compressed, impairing blood flow.

Umbilical Cord Knotting: A tight knot in the umbilical cord can reduce blood flow and oxygen supply.

Question 52

Fetal Heart Problems

Answer 52

Bradycardia: Abnormally slow fetal heart rate can indicate compromised oxygenation and is a potential sign of fetal distress.

Tachycardia: An unusually fast heart rate may also be indicative of underlying issues affecting oxygen delivery.

Question 53

Trauma

Answer 53

Physical Injury: Trauma during delivery, such as from instrumental delivery (forceps or vacuum extraction), can cause bruising or direct injury to the fetus.

Delivery Complications: Difficult or prolonged labor can increase the risk of trauma and subsequent oxygen deprivation.

Question 54

Fetal Infections

Answer 54

Maternal-Fetal Transmission: Infections acquired by the mother can be transmitted to the fetus, leading to inflammation and complications affecting oxygenation.

Types: Common infections include TORCH infections (Toxoplasmosis, Other, Rubella, Cytomegalovirus, and Herpes Simplex Virus), which can cause significant fetal distress and contribute to HIE risk.

Question 55

Diagnosis of CP- Diagnosis made by combining findings from:

Answer 55

1) neurological assessment
2) neuroimaging
3) assessment of movement and posture

Question 56

Diagnosis of CP < 5 months corrected age

Answer 56

MRI (86-89% sensitivity)

General Movement Assessment (GMA, 98% sensitivity)

Hammersmith Infant Neurological Examination (HINE, 90% sensitivity

diagnosis is often based on early signs of motor delays and abnormal tone

Lack of typical motor milestones such as rolling over, reaching for objects, or head control

poor muscle tone, either too high (hypertonia) or too low (hypotonia)

asymmetric limb movements or posture

Persistent primitive reflexes beyond the expected age, or abnormal responses to reflex testing

Question 57

Diagnosis of CP > 5 months corrected age

Answer 57

MRI (86-89% sensitivity)

HINE (90% sensitivity)

Developmental Assessment (83% sensitivity, eg: TIMP, AIMS)

diagnosis can be made through detailed assessments of motor skills, tone

Detailed assessment of motor skills, including sitting, crawling, standing, and walking

Comparison of motor and cognitive milestones to age-appropriate norms

Question 58

Nature of CP:

Answer 58

Non-Progressive Lesion: CP involves brain damage that does not worsen over time but leads to permanent changes in motor function and posture.

Immature Brain: CP typically affects the developing brain of infants, particularly those born prematurely.

Disorder of Posture and Movement: CP is characterized by difficulties with posture, movement, and motor control, often accompanied by other developmental challenges.

Question 59

Susceptibility of Periventricular White Matter:

Answer 59

Vulnerability: The periventricular white matter is especially susceptible to damage from hemorrhagic (bleeding) or ischemic (lack of blood flow) injuries.

Question 60

Factors Influencing Severity and Topography of CP:

Answer 60

Time of Injury: The timing of the brain injury (prenatal, perinatal, or postnatal) affects the extent and type of motor and developmental impairments.

Degree of Injury: The severity of the injury influences the range and impact of symptoms.

Cause of Injury/Damage: The specific cause of the brain injury (e.g., hypoxia, hemorrhage, infection) affects the clinical presentation and outcomes of CP.

Question 61

Diagnosis of CP:

Answer 61

Neurological Assessment: Includes evaluating muscle tone, motor function, and reflexes to identify motor impairments and developmental delays.

Neuroimaging: Utilized to detect structural abnormalities in the brain, such as lesions or areas of damage.

Posture and Movement Assessment: Observing the child’s posture, movement patterns, and functional abilities helps in diagnosing CP and understanding its impact.