1
Fifth stage
Pediatric
Lec. 3
.د
اروى
29/3/2017
Cerebral palsy
Cerebral palsy (CP) is a diagnostic term used to describe a group of permanent disorders of
movement and posture causing activity limitation that are attributed to non-progressive
disturbance in the developing fetal or infant brain.
EPIDEMIOLOGY AND ETIOLOGY
CP is the most common and costly form of chronic motor disability that begins in childhood
with a prevalence of 2/1000 .
٭In 80% of cases, features were identified pointing to antenatal factors causing abnormal
brain development. ٭substantial number of children with CP had congenital anomalies
external to the central nervous system (CNS).
٭Fewer than 10% of children with CP had evidence of intrapartum asphyxia.
٭Intrauterine exposure to maternal infection (chorioamnionitis, inflammation of placental
membranes, umbilical cord inflammation, foul-smelling amniotic fluid, maternal sepsis,
temperature >38°C during labor, urinary tract infection) is associated with a significant
increase in the risk of CP in normal birthweight infants.
٭About 10% are postnatal in origin.
Preterm infants are especially vulnerable to brain damage from periventricular
leucomalacia (PVL) secondary to ischaemia and/or severe intraventricular haemorrhage.
٭The rise in survival of extremely preterm infants has been accompanied by an increase in
survivors with cerebral palsy, although the number of such children is relatively small.
٭Other postnatal causes are meningitis/encephalitis/encephalopathy, head trauma from
accidental or non-accidental injury, symptomatic hypoglycaemia, hydrocephalus and
hyperbilirubinaemia.
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CLINICAL MANIFESTATIONS
CP is generally divided into several major motor syndromes that differ according to the
pattren of neurologic involvement, neuropathology and etiology.
*Spastic hemiplegia (25%) : has decreased spontaneous movements on the affected side,
the infant show hand preference at very early ag. It affect upper limbs more than lower
limbs which may show growth arrest that especially affect distal part of the limbs, walking
is delayed with circumductive gait. A seizure disorder usually develops in the 1
st
yr or 2
nd
,
approximately 25% have cognitive abnormalities.
*Spastic diplegia (35%): bilateral spasticity of the lower limbs that is greater than upper
limbs , it is usually appear when the infant begin to crawl (commando crawl), the prognosis
for normal intellectual development is good and the likehood of seizure is minimal.
*Spastic quadriplegia (20%): the most sever one, it affect all extrimities and the high
association with mental retardation and seizure. Swallowing difficulties are common as a
result of supranuclear bulbar palsies, often leading to aspiration pneumonia.
*Athetoid ( choreoathetoid, extrapyramidal, or dyskinetic) (15%) :due to the lesion in the
basal ganglia causing hypotonia & head lag early in life, then the tone will be increased&
associated with rigidity & dystonia over several yrs. the speech is typically affected & the
feeding is also difficult due to tongue thrusting and drooling.
POSTER criteria:
Posturing /abn movement
Oropharngeal proplems (e.g. swallowing).
Stabismus
Tone (hyper-hypotonia)
Evolutional mal development(e.g. primitive reflexes persist or parachute reflex fall to
develop).
Reflexes (e.g. increased deep tendon).
Abnormal 4⁄6strongly point to c.p.
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Investigations:
1-MRI of brain: is indicated to determine the location and extent of structural lesion or
associated congenital malformation.
2-genetic evaluation
3-metabolic screen (e.g amino acid,organic acid)
4-additional studies may include tests of hearing and visual function.
Treatment:
CP management require a team of physicians from various specialties ,occupational and
physical therapists, speech pathologists, social workers ,educators and developmental
psychologists.
It also involve teaching of patient& his family to optimize functional ability in order to
achieve their potential. The use of some device e.g. wheelchair will help in adaptation.
Some patients also may benefit from orthopedic procedures to treat deformities of limbs or
contrature of joints.
*
Measures to decrease spasticity in patient with CP include:-
~ muscle relaxant agents e.g. oral benzodiazepines , dantrolene, or baclofen ( which also
can be given intrathecally).
~Botulinum toxin injected in to the affected muscles
~Selected dorsal Rhizotomy procedure on spinal nerves can be used in selected patients
with sever spasticity.
*Rigidity , dystonia & spastic quadriparesis may respond to levodopa , carbamazepine.