1. Cerebral Palsy Dr. Shabir Ahmad
Assistant Professor
Department of Paediatrics
ANMC

2. Cerebral palsy
CP refers to a group of nonprogressive, but often changing, motor impairment syndromes secondary to brain insult in the early stages of development.
A total of of every 1000 live-born children in developed countries have CP

3. Causes premature and twin births perinatal asphyxia
kernicterus are causes, occult infection or inflammation is increasingly implicated

4. Nearly 50% of children with CP have no identifiable risk factors.
In 80% cases antenatal factors, causing abnormal brain developmental are identified
In <10% cases with CP have evidence of intrapartum asphyxia

5. Risk Factors for Cerebral Palsy
Before Pregnancy
Maternal thyroid disorder
History of fetal wastage
Family history of mental retardation

6. Pregnancy and Birth
Low socioeconomic status
Maternal seizures / seizure disorder
Pregnancy complications
Polyhydramnios
Eclampsia
Maternal infections (chorioamnionitis, hyperpyrexia)

7. Low birth weight (<1000gm) PVL & intra cerebral hemorrhage
Multiple births
Fetal growth retardation
Abnormal fetal presentation
Congenital malformation
Postnatal Period
Newborn hypoxic-ischemic or
bilirubin (kernicterus encephalopathy)

8. Descriptions of Cerebral Palsy By Site of Involvement
Hemiparesis (hemiplegia)
Predominantly unilateral impairment of the arm and leg on the same (e.g., right or left side)
Diplegia
Motor impairment primarily of the legs (often with some limited involvement of the arms
Quadriplegia
All four limbs (whole body) are functionally compromised.

9. Classification of Cerebral Palsy by Type of Motor Disorder
Spastic Cerebral Palsy
The most common form of CP, occurring in 70%-80%.
it is characterized by at least two of the following:
Abnormal movement pattern
Increased tone
Pathologic reflexes (e.g., babinski response, hyperreflexia)

10. Arms is often more involved than the leg and more difficulty in hand manipulation is obvious by one year of age
walking is delayed until18-24 months, and a circumductive gait is apparent
There may be growth arrest particularly in the hand and thumbnail if contraletral parietal lobe is abnormal

12. Spasticity is apparent in the affected extremities, particularly the ankle, causing an equinovarus deformity of the foot.
An affected child often walks on tiptoes because of the increased tone

19. Ankle clonus and a Babinski positive
The deep tendon reflexes are increased
Weakness of the hand and foot dorsiflexors
About one third of patients with spastic hemiplegia have
A seizure disorder
Cognitive abnormalities
Mental retardation.

20. Spastic Diplegia
Bilateral spasticity of the legs greater than In the arms.
Identified when an infant begins to crawl
Infant uses arms in a normal reciprocal fashion but tends to drag the legs behind more as a rudder (commando crawl) rather than using the normal four-limbed crawling movement.

21. Excessive adduction at hip joints leads to scissoring when child is suspended by the axillae walking is delayed
Equinovarus deformity of both lower limbs
Intellectual development is normal seizures are less likely associated

23. MOTOR IMPAIRMENT SYNDROMES
Comorbidities
Epilepsy
Learning difficulties
Behavioral disorders
Cranial neuropathy (hearing visual and speech)
Sensory impairments.

24. Spastic Quadriplegia Most sever form of CP
High association with mental retardation and seizures
Bullbar palsies

26. Athetoid CP
(choreoathetoid extrapyramidal)
Hypotonic with poor head control initially
Marked increased variable tone with rigidity and distonia over several years
Athetoid CP can be caused by kernicterus secondary to high level of bilirubin
MRI scan shows lesions in the globus pallidus bilaterally
Lesions in the basal ganglia and thalamus

27. Diagnosis Thorough history and physical examination Antenatal problems
Maternal illness
Intrauterine infections (chorioamnionitis, umbilical cord inflammation)
Gestational age
Mode of delivery (prolong labour, APGAR score, resuscitation)

28. Birth weight less than 1500gm
Neonatal sepsis
IVH
Kernicterus
Seizures
developmental history

29. Examination Dysmorphic features Microcephaly Tone Reflexes
Cranial nerves
Abnormal movements
Contractures
Nutritional status

30. Diagnosis Ultra sound From neonatal period upto 18 months
Ventricular size, hydrocephalus, hemorrhage, calcification
CT scan
Hemorrhage, calcification
Ventricular size

31. MRI
Structural lesions
Congenital malformation
EEG
In case of epilepsy
Visual
Hearing assessment

32. Management Various specialties Occupational Physical therapists
Speech therapist
Social workers, educators

33. Psychologists
Parents should be taught how to handle their child in daily activities
such as feeding, carrying, dressing, bathing, and playing in ways that limit the effects of abnormal muscle tone.

34. Prevent the development of contractures, especially at Achilles tendon
Assistance of adaptive equipment, such as walkers, poles, and standing frames.

35. If a patient has marked spasticity of the lower extremities or evidence of hip dislocation
Adductor tenotomy or psoas transfer and release.
A tight heel cord in a child with spastic hemiplegia may be treated surgically by tenotomy of the Achilles tendon.

36. Learning and attention deficit disorders and mental retardation are assessed and managed by a psychologist and educator.
Strabismus, nystagmus, and optic atrophy are common in children with CP; thus, an ophthalmologist should be involved.

37. Bowel and bladder care
Drugs used to treat spasticity are
Dantrolene sodium
Benzodiazepines
Baclofen.

38. Dyskinetic Cerebral Palsy
Occurs in 10%-15% of cases of CP. It is dominated by abnormal patterns of movement and involuntary, uncontrolled, recurring movements.
Ataxic Cerebral Palsy
Accounts for <5% of CP cases. This form of CP results from cerebellar injury and Features abnormal posture or movement and loss of orderly muscle coordination or both

39. Dystonic Cerebral Palsy
Also uncommon. It is characterized by reduced activity and stiff movement (hypkinesia) and hypotonia)
Choreoathetotic Cerebral Palsy
Rare now that excessive hyperbilirubinemia is aggressively prevented and treated. This form is dominated by increased and stormy movements (hyperkinesia) and hypotonia.

40. Mixed Cerebral Palsy
(10%-15% of all cases) term used when more than one type of motor pattern is present and when one pattern does not clearly dominate another.
It typically is associated with more complications, including sensory deficits, seizures and cognitive-perceptual impairments.

42. Hydrocephalus
Hydrocephalus is the buildup of too much cerebrospinal fluid in the brain
Normally, this fluid cushions your brain hydrocephalus can be congenital, or present at birth. Causes include genetic problems and problems with how the fetus develops.
An unusually large head is the main sign of congenital hydrocephalus.

43. Hydrocephalus can also happen after birth
This is called acquired hydrocephalus.
It can occur at any age. Causes can include head injuries, strokes, infections, tumors, and bleeding in the brain. Symptoms include

44. Symptoms include
Headache
Vomiting and nausea
Blurry vision
Balance problems
Bladder control problems
Thinking and memory problems

45. How is hydrocephalus diagnosed
Typically hydrocephalus is discovered by the child’s parents or pediatrician when the child’s head begins to rapidly swell and enlarge
Depending on child’s age (before six months),
pediatrician will probably order a series of X-rays and possibly a CT scan and refer you to a pediatric neurologist and/or neurosurgeon
Sometimes an ultrasound of the brain is also performed

46. If child is older than six months, an MRI may be ordered, as a better diagnosis can be made at that time through MRI

47. Treatment for hydrocephalus
Most often, hydrocephalus is treated surgically with the placement of a shunt to bypass the blockage that is causing the buildup, or to create a better flow of CSF

48. Follow-up care is extremely important in tracking the progress of a child’s recovery.
Pediatric neurosurgeon will schedule follow-up appointments to make sure your child is making a full recovery.

51. Spina bifida
Spina bifida (Latin: "split spine") is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube
Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open
If the opening is large enough, this allows a portion of the spinal cord to protrude through the opening in the bones

52. Spina bifida malformations fall into three categories: spina bifida occulta
spina bifida cystica with meningocele
spina bifida cystica with myelomeningocele
The most common location of the malformations is the lumbar and sacral areas

53. Physical signs of spina bifida may include:
Leg weakness and paralysis
Orthopedic abnormalities (i.e., club foot, hip dislocation, scoliosis)
Bladder and bowel control problems, including incontinence, urinary tract infections, and poor renal function
Pressure sores and skin irritations
Abnormal eye movement

54. Treatment
There is no known cure for nerve damage caused by spina bifida
To prevent further damage of the nervous tissue and to prevent infection, pediatric neurosurgeons operate to close the opening on the back

55. The spinal cord and its nerve roots are put back inside the spine and covered with meninges
In addition, a shunt may be surgically installed to provide a continuous drain for the excess cerebrospinal fluid produced in the brain, as happens with hydrocephalus.

56. Physiatrists
Neurosurgeon
Neurologist
Urologist
Opthalmoiogist
Physical and occupational therapists