CEREBRAL PALSY

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• CEREBRAL PALSY

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• CP is not a single diagnosis but an umbrella
  term describing nonprogressive brain lesions
  involving motor or postural abnormalities that
  are noted during early development

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Age of onset

• The brain lesions of CP occur from the fetal or
  neonatal period to up to age 3 years. Insults to
  the brain after age 3 years through adulthood may
  manifest clinically as similar or identical to
  CP, but, by definition, these lesions are not CP.

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Etiology

• The etiology of CP is not well understood, and
  brain lesions are thought to be associated with
  prenatal, perinatal, or postnatal events of
  varying causes.

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Risk factors

• preterm birth
• multiple gestation
• intrauterine growth restriction
• male sex
• birth asphyxia

• low Apgar scores
• intrauterine infections
• maternal thyroid abnormalities
• prenatal strokes

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Typical types of CP

• Spastic hemiplegia affecting one side of the body
  
• Spastic diplegia - CP affecting bilateral lower
  extremities more than upper extremities
• Spastic quadriplegia - CP affecting all 4
  extremities (full body)

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• Dyskinetic CP (athetoid CP, choreoathetoid CP,
  and dystonic CP)
• Mixed CP - CP with no single specific tonal
  quality predominating typically characterized by
  a mixture of spastic and dyskinetic components
• Hypotonic CP - CP with truncal and extremity
  hypotonia with hyperreflexia and persistent
  primitive reflexes

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• DIAGNOSIS OF CEREBRAL PALSY

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History

• CP diagnosis begins with a history of gross motor
  developmental delay in the first year of life
• CP frequently manifests as early hypotonia for
  the first 6 months to 1 year of life, followed by
  spasticity.

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Prenatal history

• Thorough history for maternal diseases ,
  medications , irradiation , prenatal care ,
  previous abortions

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Perinatal history

• gestational age ,presentation of the child and
  delivery type, birth weight, Apgar score, and
  complications in the neonatal period...

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Developmental history

• This should review gross motor, fine motor,
  language, and social milestones from birth until
  the time of evaluation.

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Current medical history

• This should include a review of systems to
  evaluation for the multiple complications that
  can occur with CP

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• CLINICAL PICTURE OF DIFFERENT TYPES

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Spastic hemiplegic CP

• One-sided upper motor neuron deficit
• Arm generally affected more than leg
• Specific learning disabilities
• Oromotor dysfunction
• Possible unilateral sensory deficits
• Visual-field deficits and strabismus
• Seizures

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Spastic diplegic CP

• Upper motor neuron findings in the legs more than
  the arms
• Scissoring gait
• Learning disabilities and seizures less commonly
  than in spastic hemiplegia

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Spastic quadriplegic CP

• All limbs affected, either full-body hypertonia
  or truncal hypotonia with extremity hypertonia
• Oromotor dysfunction
• Increased risk of cognitive difficulties
• Seizures
• Legs generally affected equally or more than arms
  
• Categorized as double hemiplegic if arms more
  involved than legs

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Dyskinetic (extrapyramidal) CP

• Early hypotonia with movement disorder emerging
  at age 1-3 years
• Arms more affected than legs
• Deep tendon reflexes usually normal to slightly
  increased
• Some spasticity
• Oromotor dysfunction
• Gait difficulties
• Truncal instability
• Risk of deafness in those affected by kernicterus

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INVESIGATIONS

• The diagnosis of CP is generally made based on
  the clinical picture.
• The 2004 American Academy of Neurology (AAN)
  practice parameter on CP suggests laboratory
  studies if certain findings are present

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• These findings include
• 1) the clinical history or findings from
  neuroimaging do not indicate a specific
  structural abnormality
• 2) additional and atypical features are present
  in the history or clinical examination
• 3)brain malformation is detected in a child with
  CP

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The investigations may include

• Metabolic screen
• Neuroimaging MRI is preferred over CT scanning
• EEG
• EMG and NCV
• Chromosomal studies
• Hormonal assay

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Complications

• Gastrointestinal and nutritional
• Failure to thrive
• Gastroesophageal reflux and associated aspiration
  pneumonia
• Constipation
• Dental caries

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• Respiratory
• Increased risk of aspiration pneumonia because of
  oromotor dysfunction
• Chronic lung disease/bronchopulmonary dysplasia
• Bronchiolitis/asthma

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• Skin Decubitus ulcers and sores
• Orthopedic
• Contractures
• Hip dislocation
• Scoliosis

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• Neurologic
• Epilepsy
• Visual-field abnormalities due to cortical injury
  
• Strabismus
• Hearing loss

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• Cognitive/psychological/behavioral
• Mental retardation (30-50)
• Attention-deficit/hyperactivity disorder
• Learning disabilities
• Impact on academic performance and self-esteem
• Increased prevalence of depression
• Sensory integration difficulties
• Increased prevalence of progressive development
  disorder or autism

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CARE OF CEREBRAL PALSY PATIENTS
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• Diet Oromotor dysfunction may require
  limitations in the texture of food and liquid,
  feeding only by gastrostomy or jejunostomy tube,
  supplemental feedings via gastrostomy or
  jejunostomy tube to increase energy intake, and
  aspiration precautions.

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• Activity Regular physical therapy and
  occupational therapy are crucial. The goal should
  be to maximize the functional use of limbs and
  ambulation and to reduce the risk of
  contractures.

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Rehabilitation

• Cooperation between pediatric neurologists ,
  psychiatrists , orthopedists , gastroenterologists
  , neurosurgeons . ENT specialist and pulmonogists
  is crucial for any intercurrent problem and for
  rehabilitation.

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• Drug therapy
• Indicated for
• Control of epilepsy
• Control of abnormal movements
• Botulinium toxin injection
• Muscle relaxants
• To treat intercurrent problems

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• THANK YOU