Cerebral Palsy

• Definition
• Etiology
• Types
• Evaluation
• Diagnosis
• Prevention
• Management
Definition
• Nonprogressive neuromotor disorder of cerebral origin.
• Affects muscle tone, posture, and movement.
• Additional symptoms include altered sensation or perception,
intellectual disability, communication and behavioral difficulties,
seizure disorders, and musculoskeletal complications.
• Although the etiology is not progressive, the clinical expression may
change over time as the brain matures.
• Incidence 1-2 per 100 live births.
• Ghai: Essential pediatrics ed 8. Central Nervous System
uptodate.com/contents/clinical-features-and-classification-of-cerebral-palsy
Etiology
The etiology of CP is multifactorial.
The multifactorial etiology was illustrated in a series of 213 children diagnosed with CP in
Australia. Major CP-associated pathologies were identified; some children had more than one
associated pathology:
 Acute intrapartum hypoxia (1%)
 Prematurity (78%)
 Intrauterine growth restriction (34%)
 Intrauterine infection (28%)
 Antepartum hemorrhage (27%)
 Severe placental pathology (21%)
 Multiple pregnancy (20%)
uptodate.com/contents/epidemiology-etiology-and-prevention-of-cerebral-palsy
ncbi.nlm.nih.gov/pubmed/16738164
http://www.pathophys.org/cerebralpalsy/
Types of cerebral palsy
• Spastic CP
Spastic Quadriparesis
Spastic Dysplagia
Spastic Hemiplegia
• Hypotonic (Atonic) CP
• Extrapyramydal CP
• Cerebellar Involvement
• Mixed type
Spastic CP
• Commonest form (65%)
• Early diagnostic features of neural damage include abnormally
persistent neonatal reflexes, feeding difficulties, persistent cortical
thumb after 3 months age and a firm grasp.
• The stretch tendon reflexes are always brisk.
• They have variable degrees of mental and visual handicaps, seizures
and behavioral problems.
On vertical suspension, the infant
goes into scissoring due to adductor
spasm with an extensor posture and
does not flex his knees or thigh.
• Spastic quadriparesis
More common in term babies
Signs including opisthotonic posture, pseudo­bulbar palsy, feeding
difficulties, restricted voluntary movements and motor deficits.
• Spastic diplegia
Commoner in preterm babies
Associated with periventricular leukomalacia.
The lower limbs are more severely affected with extension and adduction
posturing, brisk tendon jerks and contractures.
• Spastic hemiplegia
Recognized after 4-6 months age.
Early hand preference, abnormal persistent fisting, abnormal posture or gait
disturbance may be the presen­ting complaint. Vascular insults, porencephaly
or cerebral anomalies may be associated.

Opisthotonic posture
 Hypotonic (Atonic) Cerebral Palsy
• Despite pyramidal involvement, these patients are
atonic or hypotonic.
• Tendon reflexes are normal or brisk. Babinski
response is positive. They are often severely mentally
retarded.
• In cerebellar involvement, hypotonia is not associated
with exaggerated reflexes.
• Muscles may show fiber disproportion and delayed
CNS maturation is common.
Extrapyramldal CP

• This form accounts for 30% of cases.

• The clinical manifestations include athetosis, choreiform movements,
dystonia, tremors and rigidity. Arms, leg, neck and trunk may be
involved.
• Mental retardation and hearing deficits may be present.
• Cerebral damage following bilirubin encephalopathy is one of the
causes.
Cerebellar Involvement

• Seen in less than 5% of the patients.

• There is hypotonia and hyporeflexia.
• Ataxia and intention tremors appear by the age of 2 yr. Nystagmus is
unusual; mental status may be near normal in some of these patients.
Mixed Type

• A proportion of the patients have features of diffuse neurological

involvement of the mixed type.
Types: a summary

simplifiedmed.weebly.com/cerebral-palsy.html
Evaluation
• Eyes. strabismus, paralysis of gaze, cataracts, coloboma, retrolental fibroplasia,
perceptual and refractive errors.
• Ears. Partial or complete loss of hearing is usual in kernicterus. Speech. Aphasia,
dysarthria and dyslalia are common among dyskinetic individuals.
• Sensory defects. Astereognosis and spatial disorientation
• Seizures. Spastic patients usually have generalized or focal tonic seizures. Seizures
are more common in disorders acquired postnatally.
• Intelligence. About a quarter of the children may have borderline intelligence (IQ
80-100); and about half of them are severely mentally retarded.
• Miscellaneous. Inadequate thermoregulation and problems of social and
emotional adjustment are present in many cases. These children may have
associated dental defects and are more susceptible to infections.
Diagnosis

• The diagnosis of cerebral palsy should be suspected in a child with

low birthweight and perinatal insult;
• clinically has an increased tone, feeding difficulties and global
development delay.
• Abnormalities of tone posture, involuntary movements and
neurological deficits should be recorded.
• Evaluation includes perinatal history, detailed neurological and
developmental examination and assessment of language and learing
disabilities.
Diagnostic evaluation
The diagnosis of CP is made clinically. No specific test confirms or excludes the
diagnosis of CP. However, a diagnostic evaluation should be performed in all children
with CP to identify the underlying cause of CP and to exclude other conditions.
1. The diagnostic evaluation of infants and children with CP should always include
MRI.
2. Screening for thrombophilia is performed in children with MRI evidence of
cerebral infarction.
3. Other testing is dependent on clinical and historic concerns and may include:
4. Metabolic and genetic testing if there are atypical symptoms or if no etiology is
identified by clinical history and neuroimaging
5. Electroencephalogram (EEG) if seizure activity is suspected
6. Infectious work-up (TORCH titers) if pre- or perinatal history is suggestive
uptodate.com/contents/
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Differential Diagnosis
• Neurodegenerative disorders.
• Hydrocephalus and subdural lesion.
• Brain tumors or space occupying lesions.
• Muscle disorders.
• Ataxia-telangiectasia.
Prevention

• Prevention of maternal infection, fetal or perinatal insults, good

maternal and neonatal care reduces prevalence.
• Early diagnosis, prompt adequate management plans can reduce the
residual neurological and psychosocial emotional handicaps for the
child and his family.
Management
• The management plan should be holistic
• Stress on improving posture, reducing tone, preventing contractures and early stimulation is
necessary.
• Symptomatic treatment is prescribed for seizures. Tranquilizers are administered for behavior
disturbances and muscle relaxants may be used for improv­ing muscle function
• Plastic orthoses may help to prevent contractures, surgical procedures for spasticity and
contractures may be required in selected patients.
• Occupational therapy. The beginning is made with simple movements of self-help in feeding and
dressing with progressive development of more intricate activities like typing.
• Educational. The defects of vision, perception, speech and learning are managed by adequate
special education experiences.
• Orthopedic support. Tendon, muscle and bony surgeries may be required. Light weight splints may
be required for tight tendo-Achilles and cortical thumb.
• Social. The family should be given social and emotional support to help it to live with the child's
handicap.
• Rehabilitation and vocational guidance. Parents should help the child to adjust in the society and if
possible to become
https://www.shelteringarms.com/cerebral-palsy-awareness-day-march-25-2017/
References
• ncbi.nlm.nih.gov
• Ghai: Essential pediatrics ed 8. Central Nervous System
• uptodate.com