CEREBRAL PALSY

I KOMANG KARI

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1. Definition
Cerebral Palsy (CP) is defined : - A group of non progressive motor disorder - Due to abnormal central nervous system (CNS) development as well as injuries in the prenatal, perinatal, and early postnatal period - That result in abnormalities of motor function - Which occur during early brain development - 80 % of cases (CP) due to antenatal factor - The live birth prevalence rate : 2.5 : 1000
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2. Etiology
- Abnormal CNS development - Genetic; if the occurrence of CP more than one in one family. Inherited clotting disorder - Metabolic/ endokrin : Treatment of mother with thipoid hormone, estrogen or progesteron. Metabolic genetic disorder such as mitoshondrial disorder and glutaric aciduria → lesion in basal ganglia and thalamus - Ischemia : intrapartum asfiksia ≤ 10% - Infection (maternal inspeksion) : - Chorioamniositis

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- Inflammation of placental membranes - Umbilical cord inflammation - Foul smelling amniotic fluid - Maternal sepsis - Temperature greater than 38◦C during labour - Urinary tract infection - Birth weight : - Low birth weight infant < 100 grams < 150 grams → 50% CP Intracerebral hemorrhage Periventricular leukomalacia
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- Normal birth weight - Most children of 45.000 children → CP - Acquired : Post meningitis, encephalitis

3. The Pathogenesis of CP
Depend on the etiology for instance (for example) a. Asphyxiated baby → hypoxemia → anoxemia → increase permeability of blood vessel → edema → cerebral infraction → CP b. Maternal infection : Umbilical cord inflammation → edema of umbilical vein / artery → obstruction of blood circulation → hypoxemia → anoxemia
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→ disturb of brain development → CP c. Low birth weight Brain Intra cerebral hemorrhage infraction Periventricular leukomalacia CP

4. Clinical manifestation
Classification by distribution • Spastic hemiplegia - Decrease spontaneous movement of affected side - Hand preference at very early age (arm > leg) - Delayed walking until 18 – 24 mos
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- Growth arrest of hand and thumbnail (parietal lobe is abnormal) - Spasticity of affected extremities (ankle) - Walk on tiptoes - Ankle clonus (+) - Babinski sign (+) - Weakness of the hand - The deep tendon reflexes are increased - Foot dorsiflexors - The foot is equinovarus deformity • Spastic diplegia - Spastic cerebral palsy 70 – 80 % - Bilateral spasticity of the legs > the arm - First is suspected when the infant begins to crowl - The movement of the arms are normal - The movement of the legs are weak
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- Spasticity in the legs - Ankle clonus - Babinski sign +/+ - Scissoring posture of the lower extremities is maintained - Walking is significantly delayed - The feet position are equinovarus - Walk on tiptoe - Disuse atrophy - Impaired growth of the lower extremities - Neuropathologic finding is periventriculer leukomalacia • Spastic quadriplegia - The most severe form of CP - Supranuclear bulbar palsies → swallowing dificulty → aspiration pneumonia

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- Neuropathologic finding (MRI) - Severe PVL - Multiceptic cortical encephalomalacia - Tone increased - Spasticity of all extremities - Spontaneous movement decreased - Plantar extensor response decreased - Abnormalities of speech, visual

• Athetoid CP/ Choreoathetoid CP/ Extrapiramidal CP
- Hypotonic - Poor head control - Marked head lag Over several years the tone increased with rigidity and dystonia
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- Difficulty of feeding - Tongue thrust Prominent - Drooling - Speech disorder due to abnormality of oropharyngeal muscle - Upper motor neuron signs are not present - seizure are uncommon

5. Diagnosis (Based on)
1. History 2. Physical examination 3. Imaging : - Skull CT → Dilated ventricle Atropic cerebral hemisphere

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- Skull MRI is more sensitive than CT 4. Test of hearing function 5. Test of Visual function 6. Genetic evaluation : - Congenital malformation - Evidence of metabolic disorder

6. Treatment
A team consist of : 1. Physicians from various specialties 2. Occupational, physical therapist 3. Speech pathologist 4. Social workers 5. Educator

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6. Parent : - Feeding - Bathing - Carrying
1. Physical therapy 2. Occupational

- Dressing - Playing

To facilitate optimal positioning and movement patterns, increasing function of the affected parts Dantrolene sodium

3. Spasticity : - Oral medication

Benzodiazepine Baclofen oral - Botulinum toxin injection intratecal
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4. Rigidity Dystonia Spastic quadriparesis

Levodopa

5. Learning and attention deficit disorder, MR

- Psychologist - Educator

6. Strabismus Nystagmus Optic atrophy

Ophthalmologist

→ Inisial assesment
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7. Prognosis
- Seizure - Mental retardation - Blindness - Deafness

8. Prevention
Depend on the etiology

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