Neurological

Question 1

What is cerebral palsy?

Answer 1

Chronic disorder of posture and motor function caused by non-progressive CNS lesions/abnormalities sustained before the age of 2

Question 2

Disturbances in what also accompany the motor and posture abnormalities seen in cerebral palsy?

Answer 2

Disturbance in cognition, communication, behaviour, hearing impairments, gait disturbance, squint development, sensation disturbances, epilepsy and secondary MSK problems

Question 3

How common is cerebral palsy?

Answer 3

2 in 1,000 births

Most common cause of motor impairment in children

Question 4

What are the causes of cerebral palsy, largely speaking?

Answer 4

Mostly antenatal (80%)
Intrapartum (10%)
Postnatal (10%)

Question 5

What are the antenatal causes of cerebral palsy?

Answer 5

Cerebrovascular haemorrhage/ischaemia 
Structural Maldevelopment of the brain
Infection
HIE
Genetic syndromes

Question 6

What are the intrapartum causes of cerebral palsy?

Answer 6

Birth asphyxia/trauma

Question 7

What are the postnatal causes of cerebral palsy?

Answer 7

Intraventricular haemorrhage
Meningitis
Head-trauma

Question 8

What are the symptoms of Cerebral palsy? (CP)

Answer 8

Abnormal limb and/or trunk posture and tone in infancy
Delayed motor milestones (+/- slow growing head)
Feeding difficulties- gagging vomiting, slow feeding, oromotor incoordination
Abnormal gait
Asymmetric hand function before 12 months
Primitive reflexes persisting (need to disappear for normal motor development to progress)

Question 9

How is CP diagnosed?

Answer 9

Clinically- assessing posture, gait, hand function and tone in limbs and trunk

Question 10

What are the types of CP?

Answer 10

Spastic- bilateral and unilateral (90%) - damage to UMN (pyramidal/corticospinal tract) pathway.
Dyskinetic (6%)
Ataxic (4%)

Question 11

What are the characteristics of spastic CP?

Answer 11

Hypertonia: spasticity, hyperreflexia, extensor babinski reflex.

Tends to present early

Question 12

What are the 3 types of spastic CP?

Answer 12

Unilateral
Bilateral quadriplegia
Bilateral diplegia

Question 13

Describe unilateral spastic CP?

Answer 13

On leg and arm affected (usually face sparing).
Flexed arm, pronated forearm, fisting of hand and asymmetric reaching, toe pointing when lifting child.
Tiptoe walk on affected limbs

[severe vascular insults may cause hemianopia of affected side]

Question 14

Describe bilateral quadriplegia spastic CP

Answer 14

all 4 limbs affected, often severely.

Trunk involvement-opisthotonus (extensor posturing).
Poor head control and low central tone

Often associated with seizures, microcephaly and intellectual impairment.

Question 15

Describe bilateral diplegia spastic CP

Answer 15

All 4 limbs but legs to a much greater degree than arms

Abnormal walking

Associated with pre-term births due to periventricular damage

Question 16

What is dyskinetic CP?

Answer 16

Involuntary, uncontrolled movements that are often worse on active moment or stress.

Muscle tone is variable and primitive motor reflexes predominate

Includes:
Chorea
Athetosis
Dystonia

Abnormal movements only appear towards the end of the first year of life.

Signs are due to damage to the basal ganglia and their associated pathways (extrapyramidal)- MRI scan show bilateral changes predominantly in basal ganglia.

Question 17

What is ataxic CP?

Answer 17

Most are genetically determined

Early trunk and limb hypotonia, poor balance and delayed motor development

Uncoordinated movements, intention tremor and ataxic gait may present later

Question 18

How do you manage CP?

Answer 18

MDT approach

Tx for hypertonia

• Botox injections in muscles
• selective dorsal rhizotomy (nerve roots in spinal cord partially cut to reduce spasticity)
• intrathecal baclofen
• deep rain stimulation of the basal ganglia