Revision - Cerebral Palsy, Hydrocephalus & Head Shapes Flashcards
CP can be caused in the antenatal, intrapartum or postnatal period.
Which is most common?
Antenatal (80%)
Give some antenatal causes of cerebral palsy (CP)
1) Chorioamnionitis
2) TORCH
3) Trauma during pregnancy
4) Cerebral malformation
What congenital/maternal infections can cause CP?
TORCH –> toxoplasmosis, rubella, CMV, HSV
Give 4 intrapartum risk factors for CP
1) Birth asphyxia/trauma
2) Prematurity
3) Low birth weight
4) Neonatal sepsis
Give 4 postnatal causes of CP
1) Interventricular haemorrhage
2) Meningitis
3) Head trauma
4) Severe hyperbilirubinaemia (neonatal jaundice)
What are the 4 types of CP?
1) Spastic
2) Dyskinetic
3) Ataxic
4) Mixed
What is the most common type of CP?
Spastic
What is spastic CP?
1) velocity dependent hypertonia (spasticity)
2) hyperreflexia
When a limb is moved quickly the muscle can suddenly increase in tone and stop further movement (a spastic catch).
What is damaged in spastic CP?
UMNs
What characterises dyskinetic CP?
This involves involuntary, uncontrolled, recurring movements, fluctuating muscle tone and persistent primitive reflexes.
Associated with hypertonia and hypotonia.
Can cause athetoid movements and oro-motor problems.
What is damaged in dyskinetic CP?
Basal ganglia
What type of CP causes athetoid movements?
Dyskinetic
What type of CP causes oro-motor problems?
Dyskinetic
Whaty kind of oro-motor problems may be seen in dyskinetic CP?
Drooling, difficulties with sucking, swallowing, and chewing
What is ataxic CP?
This involves problems with coordinated movement - characterised by loss of muscular coordination resulting in ataxia and tremor.
What is damaged in ataxic CP?
Cerebellum
What is mixed CP?
A mix of spastic, dyskinetic and/or ataxic features
Does spastic CP involve hypo- or hypertonia?
Hyper
Does dyskinetic CP involve hypo- or hypertonia?
Both
Cerebral palsy can also be classified by which part of the body is most affected.
What are the 4 classifications?
1) Monoplegic –> affects one limb
2) Hemiplegic –> affects one side of body
3) Diplegic –> cerebral palsy is symmetrical, with the lower limbs more affected than the upper limbs
4) Quadriplegic –> indicates all four limbs are severely affected.
How does CP typically present?
Delayed motor milestones:
1) Not sitting by 8 months
2) Not walking by 18 months
3) Hand preference before 12 months
Children with cerebral palsy often have associated non-motor problems.
What are some examples?
1) learning difficulties (60%)
2) epilepsy (30%)
3) squints (30%)
4) hearing impairment (20%)
What medication can be used for muscle spasticity & contractures in CP?
Baclofen
What medication can be used for excessive drooling in CP?
Glycopyrronium bromide or hyoscine hydrobromide
What does a hemiplegic/diaplegic gait indicate?
UMN lesion
What does a broad based/ataxic gait indicate?
Cerebellar lesion
What does a high stepping gait indicate?
Foot drop or LMN lesion
What does a waddling gait indicate?
Pelvic muscle weakness due to myopathy
Patients with cerebral palsy may have a hemiplegic or diplegic gait.
What is this caused by?
This gait is caused by increased muscle tone and spasticity in the legs.
How will a hemiplegic or diplegic gait present?
The leg will be extended with plantar flexion of the feet and toes.
This means they have to swing the leg around in a large semicircle when moving their leg from behind them to in front. There is not enough space to swing the extended leg in a straight line below them.
What are the 2 types of squints?
1) Concomitant squints (common)
2) Paralytic squints (rare)
Cause of concomitant squints?
Due to differences in the control of the extraocular muscles.
Cause of paralytic squints?
Due to paralysis of one or more of the extraocular muscles
What 2 tests can be used to diagnose a squint?
1) Hirschberg’s test
2) Cover test
When does treatment for squints need to start?
<8 years (as up until 8 years, the visual fields are still developing).
Delayed treatment increases the risk of the squint becoming permanent.
1st line management of a squint?
1) referral to 2ary care
2) an occlusive patch can be used to cover the good eye and force the weaker eye to develop
What is an alternative to an occlusive patch for a squint?
Atropine drops (causes eye to become blurred)
What is CSF produced by & absorbed by?
Produced by 4 choroid plexuses (1 in each ventricle).
Absorbed by arachnoid granulations back into venous system.
What is the most common cause of congenital hydrocephalus?
Aqueductal stenosis –> leads to insufficient drainage of CSF
What is aqueductal stenosis?
Narrowing of cerebral aqueduct that connects the 3rd and 4th ventricle.
This blocks the normal flow of CSF out of the third ventricle, causing CSF to build up in the lateral and third ventricles.
What are the 2 types of congenital hydrocephalus?
1) obstructive (non-communicating)
2) non-obstructive (communicating)
What type of hydrocephalus does aqueductal stenosis cause?
Obstructive (non-communicating)
What is non-obstructive hydrocephalus?
Due to an imbalance of CSF production and absorption.
give 4 causes of congenital hydrocephalus
1) aqueductal stenosis
2) arachnoid cysts: can block the outflow of CSF if they are large enough
3) Arnold-Chiari malformation
4) chromosomal abnormalities and congenital malformations can cause obstruction to CSF drainage
What is the Arnold-Chiari malformation?
When the cerebellum herniates downwards through the foramen magnum, blocking the outflow of CSF.
1st line imaging in hydrocephalus?
CT head
What is the mainstay of treatment for hydrocephalus?
Ventriculoperitoneal shunt
When should a LP not be done in hydrocephalus?
In obstructive hydrocephalus –> the difference of cranial and spinal pressures induced by the drainage of CSF will cause brain herniation.
What is craniosynostosis?
Premature fusion of the skull sutures –> abnormal head shapes and restriction to growth of brain.
Can lead to raised ICP.
1st line investigation in craniosynostosis?
Skull XR
What needs to be excluded in any baby with an abnormal head shape?
Exclude craniosynotosis with a thorough history and properly palpating the sutures.
Where there is doubt refer for specialist assessment and imaging.
