Neurology 6 (cerebral palsy) Flashcards
What is cerebral palsy?
an abnormality of movement & posture causing activity limitation attributed to non- progressive disturbances that occurred in the developing foetal or infant brain- motor disturbances are often accompanied by disturbances in cognition, communication, perception, sensation, behaviour and seizure disorder and secondary musculoskeletal problems
2 per 1000 live births
What are the antenatal origins of cerebral palsy (80%)?
o Vascular occlusion o Cortical migration disorders o Structural maldevelopment of the brain during gestation o Genetic syndromes o Congenital infection
What is the most common cause of CP during delivery (10%)?
hypoxic-ischaemic injury
What are the postnatal origins of CP (10%)?
o Meningitis o Encephalitis o Encephalopathy o Head trauma from accidental or non-accidental injury o Symptomatic hypoglycaemia o Hydrocephalus o Hyperbilirubinaemia brain damage from periventricular leukomalacia (PVL) secondary to ischaemia and/or severe intraventricular haemorrhage (preterm)
What are the early features of CP?
o Abnormal limb and/or trunk posture and tone in infancy with delayed motor milestones may be accompanied by slowing of head growth
o Feeding difficulties, with oromotor incoordination, slow feeding, gagging & vomiting
o Abnormal gait once walking is achieved
o Asymmetric head function before 12 months of age
Primitive reflexes may persist and become obligatory
What are the types of CP?
o Spastic- 90%
o Dyskinetic- 6%
o Ataxic- 4%
What is spastic CP?
damage to the upper motor neurone pathways (pyramidal or corticospinal)
limb tone is persistently increased (spasticity) with associated brisk deep tendon reflexes and extensor plantar responses
limb involvement is described as unilateral or bilateral to acknowledge asymmetrical signs
spasticity tends to present early and may even be seen in the neonatal period- sometimes there is initial hypotonia, particularly of the head & trunk
What is hemiplegia CP?
unilateral involvement of the arm & leg - the arm is usually affected more than the leg, with the face spared
affected children often present at 4-12 months of age with fisting of the affected hand, a flexed arm, a pronated forearm, asymmetric reaching or hand function
subsequently a tiptoe walk on the affected side may become evident
affected limbs may be initially flaccid & hypotonic, but increased tone soon emerges as the predominant sign
neonatal stroke
What is quadriplegia CP?
all four limbs are affected, often severely
the trunk is involved with a tendency to opisothonus (extensor posturing), poor head control and low central tone
often associated with seizures, microcephaly and moderate or severe intellectual impairment there may have been a history of perinatal hypoxic-ischaemic encephalopathy
What is diplegia CP?
all four limbs, but the legs are affected to a much greater degree than the arms, so that hand function may appear to be relatively normal
motor difficulties in the arms are most apparent with functional use of the hands, but walking is abnormal
associated with preterm birth due to periventricular brain damage
What is dyskinetic CP?
dyskinesia refer to movements which are involuntary uncontrolled, occasionally stereotyped, and often more evident with active movements or stress
muscle tone is variable and primitive motor reflex patterns pre-dominate
How can dyskinetic CP be described as?
o Chorea- irregular, sudden and brief non-reptitive movements
o Athetosis- slow writhing movements occurring more distally, such as fanning of the fingers
o Dystonia- simultaneous contraction of agonist & antagonist muscles of the trunk and proximal muscles often giving a twisting appearance
What are the features of dyskinetic CP?
Intellect may be relatively unimpaired
floppiness, poor trunk control and delayed motor development in infancy
abnormal movements may only appear towards the end of the 1st year of life
the commonest cause was previously hyperbilirubinaemia (kernicterus) due to rhesus disease, but it is now hypoxic-ischaemic encephalopathy
What is ataxic (hypotonic) CP?
most are genetically acquired, but when due to acquired brain injury (cerebellum or its connection), the signs occur on the same side as the lesion but are usually relatively symmetrical
early trunk and limb hypotonia, poor balance and delayed motor development
incoordinate movements, intention tremor and an ataxic gait may be evident later
What are the features fo abnormal development in CP?
Unable to lift head or push up on arms, stiff extended legs
Pushing back with head, difficulty moving out of this position
Floppy trunk, stiff arms, extended legs
Arms flexed and held back, stiff crossed legs
Can’t crawl
Not interested in weight bearing
