Neurology: Cerebral Palsy Flashcards
How is cerebral palsy defined?
A disorder of movement and posture due to a non- progressive lesion of the motor pathways in the developing brain
Although the lesion does not progress, why do symptoms appear gradually?
It is not usually noticed at birth as the child is not expected to perform various motor movements, but as the child ages normal development does not occur - symptoms more pronounced
Can any part of the brain be affected?
Yes e.g cerebellar disorder, basal ganglia disorder, cerebral etc
In 1000 live births, how many are affected by CP?
2
It is the most common cause of major motor impairment
Children with cerebral palsy often have associated non-motor problems such as…
Learning difficulties 60% Epilepsy 30% Squint 30% Visual impairment 20% Hearing impairment 20%
Also speech and language disorders, behavioural disorders, joint disorders - contractures, subluxation, scoliosis, hip displacement
Bladder problems, sleep disorder
What percentage of causes occur during the antenatal period?
80%
What are some antenatal causes of cerebral palsy?
Vascular malformation
Structural maldevelopment of brain
Antenatal infection - rubella, CMV, toxoplasmosis, chickenpox
Maternal illness
Hypoxia - may be due to placental problems
Radiation exposure
10% of causes occur during birth period. This is primarily due due..
Birth asphyxia/ trauma
Also: low birth weight, neonatal sepsis
10% of cause occur post natal for example…
Head injury Pre term babies particularly at risk - more likely to suffer from Periventricular leucomalacia (PVL) Meningitis Encephalitis Hypoglycaemia Hydrocephalus Hyperbilirubinaemia (kernicterus)
What are the different types of CP?
Spastic
Dyskinetic
Ataxic
Mixed
Which classification of cerebral palsy is most common?
Spastic = 70%
Cerebral palsy is considered to be what type of disorder?
Neurodevelopmental
Something happens to an area of brain during its development - a very sensitive time
Does cerebral palsy get worse over time?
No = a non progressive disease
What is periventricular leukomalacia?
A type of brain injury most common in babies born too soon or low birthweight
The white matter surrounding ventricles is deprived of blood and oxygen leading to softening (malacia).
Damaging white matter can cause cause problems with movement
Difficult to say why this happens - may be linked to intraventricular haemorrhage
Babies with PVL are at high risk of CP
How can cerebral palsy present?
May present at birth and most commonly seen in infancy as milestones are missed, but sometimes diagnosis can be delayed
What can be see in a neonate with CP?
Floppy baby - REDUCED muscle tone in the neonate
This contrasts to the increased tone seen older children with CP
How can CP present in infancy?
Feeding difficulties due to poor coordination - may be slow feeding, vomiting, gagging
Delayed motor milestones - late crawler/walker, may have abnormal gait when they do walk
Asymmetric hand movement - in those without CP hand preference not seen until at least 12 months, hand preference before this is always pathological
Persistence of primitive reflexes
Pattern of symptoms depends on type of CP
Describe spastic cerebral palsy
UMN lesions
Pyramidal
UMN signs - hypertonia, brisk reflexes, extensor plantar response, weakness
Muscles feel stiff and movements look stiff and jerky. The faster the limb moves, the stiffer it seems
Scissor gait
What are the types of spastic cerebral palsy?
Hemiplegic
Quadriplegic
Diplegic
What are the characteristics of spastic hemiplegic cerebral palsy?
Unilateral - one arm and one leg involved
Arm usually affected more than leg
Face unaffected
Flexed arm, possibly extended leg
Asymmetrical
Abnormal gait may be present as the child grows - toe heel (tip-toe) gait on affected side
Typically not associated with a birth or post natal injury, although a neonatal stroke might be cause
What are the characteristics of spastic quadriplegic cerebral palsy?
All four limbs affected
Usually severe
Arms may be affected more than legs
Poor head control
Typically associated with seizures, microcephaly and mod to severe intellectual impairment
May be history of hypoxic - ischaemic encephalopathy
What are the characteristics of spastic diplegic cerebral palsy?
All four limbs usually affected but legs usually much worse than arms
Hand function may appear normal
Abnormal gait
What are the characteristics of ataxic hypotonic cerebral palsy?
Involves cerebellum
Typically symmetrical signs Hypotonia Poor balance and delayed motor development Uncoordinated movement Intention tremor Wide based gait
What are the characteristics of dyskinetic cerebral palsy?
Due to basal ganglia or associated extra pyramidal tract damage
Dyskinesia - fluctuating muscle tone giving rise to involuntary limb movements (especially noticeable when person attempts to move)
Abnormally slow movement
Usually affects all four limbs
Types of involuntary movement include:
- chorea - irregular, sudden, dance like
- dystonia - twisting and repetitive or abnormal posture
- athetosis - slow, continuous, writhing, fluctuations in muscle tone so hard to maintain posture
Dystonia - involvement of trunk and proximal limbs
Athetosis - involvement of distal limbs
Intellectual ability may be unaffected
Exacerbated by stress, no sleep
Is there a curative treatment?
No
How can cerebral palsy be managed?
Aim is quality of life and full integration into society
Once child diagnosed, taken care of by type of MDT called child development services - comprises paediatricians, social workers, physiotherapists, OTs, psychologists, dieticians, GP, paediatric nurse
Statemented - status awarded to some special needs children to allow extra funding for education and other needs e.g adaptations to house
Specific management:
- physio therapy of affected limbs
- splinting of contractured joints
- Botox injections into spastic muscles to allow relaxation
- oral or intrathecal baclofen
- SALT
- treat co morbidities e.g epilepsy
How is cerebral palsy diagnosed?
Clinical
MRI if cause unknown
How can an orthopaedic specialist help?
Help with motor problems, scoliosis
Use of braces
How does OT help?
Improve self care skills
Adaptations
Increase independence
How does physio help?
Optimise function
Build strength
Improve walking
Stretching to reduce contracture - permanent shortening of muscle tissue
Why can people with CP experience pain?
Tight muscles
Abnormal posture
Stiff joints
How can surgery help?
Loosen muscles
Straighten bones (from abnormal forces)
Cut nerves to reduce their associated movements or spasms
What risk factors are there?
Low birth weight
Preterm
Multiple births
Assisted reproductive technology - due to increased risk of multiple births/ preterm
Infection during pregnancy
Kernicterus
Medical conditions in mother: thyroid problems, intellectual disability or seizures
Birth complications - detachment of placenta, uterine rupture (disrupting oxygen supply)
What is acquired CP?
Brain damage that occurs more than 28 days after birth
- usually associated with an infection or head injury
If cerebral ischaemia occurs at less than 20 weeks gestation, what is likely to occur?
Neuronal migrations deficit
If cerebral ischaemia occurs between 26-34 weeks, what is likely to occur?
PVL
If cerebral ischaemia occurs between 34-40 weeks, what is likely to occur?
Focal or multi focal cerebral injury
Which areas of the brain are vulnerable if hypoxia/hypotension occurs?
The end of arterial supply e.g border zones
What is leukomalacia?
When bleeding occurs in neonate it can cause holes in the white matter
If leukomalacia occurs next to the ventricles, what can happen to them?
They can enlarge
CP can be classified according to severity. What tool can be used to assess gross motor skills?
Gross Motor Function Classification System (GMFCS)
Describe a scissor gait
Hip flexion, adduction and internal rotation
With knee extension and feet plantar flexed
What can swallowing difficulties lead to?
Aspiration pneumonia
