Cerebral palsy, paediatrics long case, Dr tamimul Ansari

1. Cerebral Palsy

2. Definition
• Cerebral palsy is defined as a
non-progressive disorder involving posture and
movement due to an insult to the growing
brain. It is often associated with co morbid
conditions like seizures, disorders of speech,
vision, hearing and mental retardation.

3. Etiology of Cerebral Palsy
Prenatal Perinatal Postnatal
Age < 16 & > 35
years
Intrauterine
Infections
Drugs
Radiation
Maternal conditions
eg eclampia
GDM
Anemia
Cerebral
malformations
Birth asphyxia
Birth trauma
Prematurity
Low birth weight
Neonatal
Hyperbilirubinemia
Neonatal sepsis
Neonatal meningitis

4. Neuropathology - CP
Type of lesion Site of lesion Sequelae
Periventricular
leukomalacia
White fibres in internal
capsule
Spastic diplegia
Multicystic
encephalomalacia
Cerebral cortex Spastic Quadriplegia
Status marmaratus Basal ganglia Athetiod CP

5. Classification of Cerebral palsy
Physiologic Topographic Etiological Functional
Spastic
Atonic
Athetoid
Ataxic
Mixed
Quadriplegic
Diplegic
Hemiplegic
Prenatal
Perinatal
Postnatal
Mild cases - ambulant
Moderate cases -ambulant
with help
Severe cases - no useful
activity

6. Early pointers for diagnosis of CP
• Lack of alertness
• Reduced head circumference
• Delayed social smile
• Persistent fisting beyond 2 months
• Primitive (neonatal ) reflexes beyond 6 months

7. Spastic Cerebral Palsy

8. Clinical features
Spastic quadriplegia – all 4 limbs equally involved
Most severe form
Most common in term babies
Tone increased in all four limbs
Mental retardation is common
Microcephaly
Wind swept deformity
Co morbid conditions

9. Examination of the Motor System
• Bulk: disuse atrophy
• Tone: increased - hypertonia – spasticity
• Power: the best observed power is 3 by 5 if he is able to
lift the limbs away from the bed
• Reflexes: DTR – exaggerated and clonus may be present
Superficial reflexes: Plantar extensor (Babinski sign
positive)

10. Clinical features
Spastic diplegia – all 4 limbs involved but the lower limbs are more
involved than upper limbs.
• More common in preterm babies
• Pathology – periventricular leukomalacia
• Brisk DTR
• Tendency to contracture
• Commando crawl
• Tip toe walking
• Scissoring gait

11. Clinical features
Spastic hemiplegic
Paucity of movements & persistent fisting of the
affecting side
Definite hand preference ( < 1 year )

12. Clinical features
Athetoid CP – extrapyramidal CP
Usually follows kernicterus
Athetosis, chorea, dystonia, tremors may be associated
Deafness is usually associated
Ataxic CP
Cerebellar involvement
Hypotonia & hyporeflexia
Cerebellar signs

13. Co morbid conditions - CP
• Mental retardation – ranges from borderline to severe MR
• Seizures – almost all have seizures
• Eyes – strabismus, gaze palsy
• Ears – hearing loss common in athetoid CP
• Speech defects
• Behavioral problems
• Feeding difficulties
• Recurrent pulmonary infections

14. Diagnosis
There is no specific test to diagnose CP.
The investigation plan is to
- reveal the possible etiology & plan for genetic counseling
- assess the prognosis
Investigations
• Complete neurologic & development assessment
• Visual assessment
• Hearing assessment
• Metabolic screening for IEM (to rule out inborn errors of metabolism)
• EEG for seizures
• Neuroimaging

15. Diagnosis
Neuro imaging
• CT Scan – no role for routine CT
• MRI – Imaging modality of choice in many cases of CP
• MRI can pick up structural lesion like
neuro migrational disorder such as lissencephaly,
schizencephaly &
agenesis of corpus callosum

16. Management
Aim of treatment
• To make the child as independent as possible
• To prevent deformity

17. Management
Multidisciplinary approach involving
• Pediatrician
• Neurologist
• Orthopedic surgeon
• Ophthalmologist
• ENT surgeon
• Physiotherapist
• Speech therapist
• Occupational therapist
• Psychologist
• Social worker
• Parents.
CP child

18. Management - Medical
 Physiotherapy
 Aim: abolish primitive reflexes and promote postural
reflexes
- Prevents the development of muscle contractures
- Improves the strength of muscles

19. Management – Medical
 Drugs
- Diazepam , baclofen & dantrolene sodium to relieve spasticity
 Management of seizures
 Management of behavioral problems- tranquilisers
 Feeding & Nutrition management
 Occupational therapy
 Emotional support
 Special school education for children with borderline intelligence

20. Management - Surgical
Role of surgery
Orthopedic procedures - for fixed deformities
• Tendon transfer / lengthening procedures done for release of contractures at
tendo achilles, hip adductors
• Arthrodesis– unstable joints
Neuro surgical procedures
- Selective dorsal Rhizotomy
Newer strategies
• Botulinum toxin injection (Botox) – every 3 to 4 months
expensive.

21. Prognosis
• Hemiplegic & Diplegic CP are associated with good
prognosis
• Quadriplegic CP have a relatively poor prognosis

22. Prevention of Cerebral Palsy
• Good antenatal care
• Prevention of maternal infection
• Institutional delivery & conduct of delivery by trained personnel to
prevent birth asphyxia
• Prevention of perinatal insults by prompt resuscitation & management
• Good postnatal care