Overview

• Cerebral Palsy → permanent neurological problems resulting from damage to the brain around the time of birth (non-progressive disease).
  • Hypoxic-Ischaemic Encephalopathy → lack of oxygen to brain before or shortly after birth. May lead to cerebral palsy.
    • Therapeutic cooling at 33-35 degrees attempts to reduce the chances of severe brain damage in neonates with hypoxic injury.
• Causes
  • Antenatal (80%) → maternal infections (chorioamnionitis), trauma during pregnancy.
  • Intrapartum (10%) → birth asphyxia/trauma, pre-term birth.
  • Postnatal (10%) → intraventricular haemorrhage (periventricular leukomalacia - bilateral multiple cysts, 80-90% risk of spastic CP), meningitis, head-trauma.
• Classification of Cerebral Palsy
  • Spastic (70%) → hypertonia and reduced function resulting from damage to upper motor neurons (MOTOR CORTEX).
    • Subtypes → monoplegia (one limb affected), hemiplegia (one side of body affected), diplegia (all four limbs are affected, but mostly the legs), quadriplegia (four limbs affected severely, often with seizures and speech disturbance).
  • Dyskinetic → problems controlling muscle tone, with hypertonia and hypotonia, causing athetoid movements and oro-motor problems. A result of damage to the basal ganglia.
    • (1) Athetoid Movements → slow writhing movements of his hands and feet and also the difficulty of holding onto objects (due to fluctuating muscle tone).
    • (2) Oro-Motor Problems → eg. drooling.
    • (3) Chorea → uncontrolled repetitive movements.
  • Ataxic → problems with coordinated movement resulting from damage to the cerebellum.
  • Mixed → mix of spastic, dyskinetic and/or ataxic features.

Making Diagnosis

Clinical Features

• Failure to meet milestones.
• Increased or decreased tone.
• Hand preference before 12 months → may suggest neuromuscular problems with other limb (ie. cerebral palsy).
• Abnormal gait.
• Problems with coordination, speech or walking.
• Feeding or swallowing problems.
• Learning difficulties.
• NICE Guidelines suggest the following delayed motor milestones should elicit suspicion of CP (= URGENT REFERAL):
  • Not sitting by 8 months (corrected for gestational age)
  • Not walking by 18 months (corrected for gestational age)
  • Hand preference before 1 year (corrected for gestational age)
  • Persistent toe-walking

Investigations

• MRI Head → gold-standard for diagnosis. Difficult to achieve practically as young children may need sedation to stay still during MRI.
• If child has risk factors for CP → offer MDT follow-up for 2 years.