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.

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 1st yr or 2nd , 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.

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.