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  1. 1. CEREBRAL PALSY Dr Sachin Soni DNB Pediatrics Resident Indraprastha Apollo Hospital New Delhi
  2. 2.  Topic  Definition  Etiology and Classification  Classification  Clinical manifestation  Diagnosis and D/D  Management
  3. 3. Definition  A group of non-progressive but changing motor impairment syndromes characterized by abnormalities of movement, posture and tone  Its not a specific disease, but a symptom complex
  4. 4. Etiology PRENATAL(MATERNAL/FETA L/PLACENTAL) PERINATAL POST NATAL • Iodine deficiency, iron deficiency and poor nutrition • Intrauterine infections, high fever,UTI • Chorioamnionitis • Maternal disease- Diabetes, hypertension, Hyperthyroidism • Teratogens-drugs, Radiation,smoking, alcohal,intrauterine environmental toxins • Fertility problems- Advanced age at conception, history of infertility, recurrent fetal wastage • Prematurity/VLBW • Birth asphyxia • IUGR • Hyperbilirubinemia • intravenricular and intra cerebral bleed • Hypoglycemia, Dyselectrolytemias • Sepsis, peumonia and meningitis • Poor Antenatal care • poor socioeconomic status • Premature separation of placenta • CNS infections such as viral encephalitis, tubercular meningitis and pyogenic meningitis • Head injuries • Seizure • Hypoxic damage • Hyperpyrexic damage • Twins/abnormal fetal presentation • Fetal thrombotic vasculopathy • Genetic causes • Functional polymorphism in interleukin-6 gene has recently been associated with term infants.
  5. 5. Clinicopathological correlation of cerebral palsy
  6. 6. Suspected Cerebral palsy - Child with motor dysfunction-Abnormal muscle tone, abnormal posture and movement. - Clinical expression of the case depends on the extent and area of brain damage, growth of the child, coexisting problems - Include- Mental retardation - - Seizure - - Behavioral problem - - Speech, Hearing and Language disorders - Ocular- Strabismus, refractory error, field defect - Extra pyramidal abnormalities, sensory impairment/integrative - dysfunction - Feeding difficulties
  7. 7. Spastic  Most common type  Increased muscle tone  Develop deformities, contractures  Associated problems-Squint, oral motor dysfunction, perceptual and learning disorder Quadriplegic CP-  All limbs are affected, Arms> legs  Absent bladder bowel control  Difficulty in speech and feeding  Intelligence deceased  Epilepsy is common
  8. 8.  Hemiplegic CP: - Term baby - Rt hemiplegia twice as common as left hemiplegia, arm> legs - Persistent fisting and cortical thumb on affected side - Absent pincer grasp ,hemiplegic gait, loss of cortical sensation  Diplegic CP: - In Preterm baby wih IVH and PVL - Lower limb> Upper limb - Increased Abductor tone – later Ambulatory problem - Seizure is uncommon
  9. 9. Dyskinetic  Uncontrolled and purposeless movements  Dystonic: - Infants are hypotonic with poor head control - Dystonia evolve gradually, truncal twisting, facial grimacing, extremity rigidity  Choreo athetoid : Characteristically seen in babies with hyperbilirubinemia - Associated problem- high tone hearing loss, upward gaze palsies - Seizures are uncommon - Speech difficulty but intelligence is normal
  10. 10.  Hypotonic: - Marked motor delay, deceased tone, mental retardation - Preserved or brisk DTR differentiate it from LMN  Ataxic: - Uncommon form, defective postural function, disturbed equilibrium, in coordinated movement for all major task - Tremor on use of hand are common - Associated problem- spasticity, athetosis, dysarthria and Nystagmus
  11. 11.
  12. 12. Diagnosis  Early diagnosis of CP: - Warning symptoms: - Lack of alertness, deceased spontaneus motility - Inceased abnormal movements,seizure - Feeding problem, drooling - Poor quality of sleep - Fisting after 2 months of age
  13. 13. Family counseling  Its not a mental illness  Cause need to be identified  Holistic evaluation and care needed  Not inherited  Not curable Management aims at minimizing the disability to improve quality of life
  14. 14. Abnormal signs:- - Reduced head circumferance or fall in its growth - Delayed social smile - Poor head control at 3 months of age - Delayed appearance of postural reflexes and developmental milestones - Persistence of primitive reflexes - Increased tone , scissoring or assumption of equinus position of feet - Visual problem: roving of eyes, no visual following, poor hand regard after 6 month , persistant squint - Lack of auditory response
  15. 15. Conditions which mimic CP  Paraplegia,Quadriplegia due to trauma  Neural tube defects  Mental retardation, speech disorder  Slowly progressive degenerative brain disorders:- Metabolic disease, Mitochondrial disorder  Neuromuscular disorder
  16. 16. Assement of muscle tone and neonatal reflexes  Popliteal angle  Scarf sign  Abductor angle Modified Ashworth scale- Abnormal developmental reflexes - Absence of parachute response and landau reflex and persistence of other infantile automatism beyond the ages mentioned Reflexes Persistance beyond Rooting 3 month Moro 5-6 months Palmar grasp 6 month Tonic neck 5-6 months
  17. 17. Role of Investigations  Brain imaging- Useful in evaluating etiology of CP and suggesting prognosis  USG- To detect IVH And Periventricular Leucomalasia  CT and MRI- To detect other disease that may confused with CP  Visual and hearing assessment  Tests to detect inherited thrombophilic disorders - Patients in which an in utero or neonatal stroke is suspected as the cause of CP.
  18. 18. Management  Multidisciplinary approach:  A recent study indicates that prenatal treatment of mothers with magnesium lowers the prevalence of CP in their children at corrected age of 2 yr.
  19. 19.  Rehabilitation therapy: Two major goal 1- To decease complication of CP 2- To enhance or improve acquisition of new skills (A) Physical therapy (B) Occupation therapy (c) Speech and language Therapy  Physiotherapy and motor atraining  Prevention of contractures  Management of feeding difficulties  Educational problem  Drug treatment: - Diazepam - Baclofen - Dantrolane - Tizanidine  Visual problem  Communication problem  Epilepsy
  20. 20.  Alcohal and Phenol blocks  Botulism toxinType – A  Plaster casting and orthdoses  Adaptive equipment/Assistive devices  Orthopedic procedure: - Selective posterior rhizotomy  Rehablitation
  21. 21. Thank You