‫اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ‬ ‫ﺑﺴﻢ ا‬

Cerebral palsy
Dr Muhammad Zaki
MBBS, FCPS, PGPN

Assistant Professor

Department of Paediatrics
Learning objectives
• Define cerebral palsy.
• Describe causes of cerebral palsy.
• Describe various types of cerebral palsy.
• Describe clinical features of cerebral palsy.
• Describe various treatment modalities for management of a patient with cerebral
palsy
 Note: This lecture is an overview of topic, for further detail read the book.
Introduction
• “A permanent disorder of posture and movement resulting from damage
to the developing brain.”

• Group of nonprogressive, but often changing, motor impairment

syndromes secondary to brain insult in the early stages of development.

• Caused by Non-progressive damage to the developing brain before,

during or shortly after birth.
• 2-2.5 of every 1000 live-born children in developed countries have CP

• Nearly 50% of children with CP have no identifiable risk factors.

• In <10% cases with CP have evidence of intrapartum asphyxia

Etiology
Before Pregnancy
• Maternal thyroid disorder
• Family history of mental retardation
• Low socioeconomic status
• Maternal seizures / seizure disorder
Pregnancy and Birth
• Polyhydramnios
• Eclampsia
• Maternal infections (chorioamnionitis, hyperpyrexia)
• Cerebral malformations.
• Intra uterine infections…..TORCH.
• Placental insufficiency.
• Autoimmune disorders.
• Chromosomal anomalies.
• Third trimester bleeding (including placenta abruption and placenta
previa)
• Low birth weight (<1000gm)
• PVL & intra cerebral hemorrhage
• Multiple births
• Fetal growth retardation
• Abnormal fetal presentation
Postnatal Period
• Newborn hypoxic-ischemic or

• ↑ Bilirubin (kernicterus encephalopathy)

Infancy
• Trauma
• CVA
• Infections…Meningitis, Encephalitis etc.
Classification
1. Spastic: (monoplegia, diplegia, hemiplegia, Quadriplegia)
2. Dyskinetic: (extrapyramidal) athetosis, chorea, Rigidity, dystonia.
3. Ataxic/Atonic
4. Mixed
Spastic Cerebral Palsy
• The most common form of CP, occurring in 70%-80%.
• It results from injury to the upper motor neurons of the pyramidal tract.
• It is characterized by at least two of the following:
Abnormal movement pattern
Increased tone
Pathologic reflexes (e.g., babinski response, hyperreflexia)
• Spasticity is apparent in the affected extremities, particularly the ankle,
causing an equinovarus deformity of the foot.
• An affected child often walks on tiptoes because of the increased tone
• If arms is involved  difficulty in hand manipulation, obvious by one year
of age
• There may be growth arrest particularly in the hand and thumbnail
Spastic Hemiplegia
• 1/3rd have seizures.

• 1/4th have cognitive impairment.

• Mental retardation.
• Ankle clonus and a Babinski positive
• The deep tendon reflexes are increased
• Circumductal gait
Spastic diplegia
• Commando crawl.
• Normal intellect, no seizures usually.
• Scissoring of legs due to adductors spasm.
• May have contracture at hip, knee and
• Talipes equinovarus
Spastic Quadriplegia
• PVL, Congenital malformations of brain, Multicystic
EncephalomalaciaHIE
• Feature:
• Highest incidence of mental retardation, seizures.
• Speech, vision impairment.
• Swallowing difficulties.
Dyskinetic CP (choreoathetoid
extrapyramidal)
• Hypotonic with poor head control initially
• Marked increased variable tone with rigidity and dystonia over several
years
• Seizures not common.
• Intellect preserved.
• Kernicterus secondary to high level of bilirubin
• Lesions in the basal ganglia, globus pallidus and thalamus
Ataxic/Atonic CP
• Accounts for <5% of CP cases.
• This form of CP results from cerebellar injury.
• Features:
• Abnormal posture or movement
• Poor balance and co-ordination with increase
tendency to fall.
• Marked hypotonic, brisk reflex, wide-based
gate
Mixed cerebral palsy
• Rare
• Term used when more than one type of motor pattern is present and
when one pattern does not clearly dominate another.
• Associated with more complications, including sensory deficits, seizures
and cognitive-perceptual impairments.
Comorbidities

• Motor impairment syndromes

• Epilepsy 60%
• Learning difficulties/mental retardation 25-50%
• Behavioral disorders
• Cranial neuropathy (hearing visual and speech)
• Sensory impairments.
Differential diagnosis
• Degenerative brain disorder
• Post meningitic /congenital hydrocephalus
• Brain tumor.
• Spinal cord lesions.
• Muscular dystrophy
• Congenital hypotonic(spinal muscular atrophy)
Diagnosis
• Thorough history and physical examination
• Antenatal problems
• Maternal illness
• Intrauterine infections (chorioamnionitis, umbilical cord inflammation)
• Gestational age
• Mode of delivery (prolong labour, APGAR score, resuscitation)
• Birth weight less than 1500gm
• Neonatal sepsis
• IVH
• Kernicterus
• Seizures
• Developmental history
Examination
• Dysmorphic features
• Microcephaly
• Tone
• Reflexes
• Cranial nerves
• Abnormal movements
• Contractures
• Nutritional status
Investigation
Ultra sound MRI
• From neonatal period upto 18 • Structural lesions
months
• Congenital malformation
• Ventricular size, hydrocephalus,
hemorrhage, calcification EEG

CT scan • In case of epilepsy

• Hemorrhage, calcification Visual/Hearing assessment

• Ventricular size
Management
Various specialties
• Occupational
• Physical therapists
• Speech therapist
• Social workers, educators
• Psychologists
• Orthopedic procedures
• Parents should be taught how to handle their child in daily activities such
as feeding, carrying, dressing, bathing, and playing
• Prevent the development of contractures, especially at Achilles tendon
• Assistance of adaptive equipment, such as walkers, poles, and standing
frames.
If a patient has marked spasticity of the lower extremities or evidence of
hip dislocation
• Adductor tenotomy or psoas transfer and release.
• A tight heel cord in a child with spastic hemiplegia may be treated
surgically by tenotomy of the Achilles tendon.
• Learning and attention deficit disorders and mental retardation are
assessed and managed by a psychologist and educator.
• Strabismus, nystagmus, and optic atrophy are common in children with
CP; thus, an ophthalmologist should be involved.
• Bowel and bladder care
• Drugs used to treat spasticity are
Dantrolene sodium
Benzodiazepines
Baclofen.
Thanks