CEREBRAL PALSY

I KOMANG KARI

1. Definition
Cerebral Palsy (CP) is defined : - A group of non progressive motor disorder - Due to abnormal central nervous system (CNS) development as well as injuries in the prenatal, perinatal, and early postnatal period - That result in abnormalities of motor function - Which occur during early brain development - 80 % of cases (CP) due to antenatal factor - The live birth prevalence rate : 2.5 : 1000
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2. Etiology
- Abnormal CNS development - Genetic; if the occurrence of CP more than one in one family. Inherited clotting disorder - Metabolic/ endokrin : Treatment of mother with thipoid hormone, estrogen or progesteron. Metabolic genetic disorder such as mitoshondrial disorder and glutaric aciduria lesion in basal ganglia and thalamus - Ischemia : intrapartum asfiksia 10% - Infection (maternal inspeksion) : - Chorioamniositis

- Inflammation of placental membranes - Umbilical cord inflammation - Foul smelling amniotic fluid - Maternal sepsis - Temperature greater than 38C during labour - Urinary tract infection - Birth weight : - Low birth weight infant < 100 grams < 150 grams 50% CP Intracerebral hemorrhage Periventricular leukomalacia
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- Normal birth weight - Most children of 45.000 children CP - Acquired : Post meningitis, encephalitis

3. The Pathogenesis of CP
Depend on the etiology for instance (for example) a. Asphyxiated baby hypoxemia anoxemia increase permeability of blood vessel edema cerebral infraction CP b. Maternal infection : Umbilical cord inflammation edema of umbilical vein / artery obstruction of blood circulation hypoxemia anoxemia
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 disturb of brain development CP c. Low birth weight Brain Intra cerebral hemorrhage infraction Periventricular leukomalacia CP

4. Clinical manifestation
Classification by distribution Spastic hemiplegia - Decrease spontaneous movement of affected side - Hand preference at very early age (arm > leg) - Delayed walking until 18 24 mos
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- Growth arrest of hand and thumbnail (parietal lobe is abnormal) - Spasticity of affected extremities (ankle) - Walk on tiptoes - Ankle clonus (+) - Babinski sign (+) - Weakness of the hand - The deep tendon reflexes are increased - Foot dorsiflexors - The foot is equinovarus deformity Spastic diplegia - Spastic cerebral palsy 70 80 % - Bilateral spasticity of the legs > the arm - First is suspected when the infant begins to crowl - The movement of the arms are normal - The movement of the legs are weak
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- Spasticity in the legs - Ankle clonus - Babinski sign +/+ - Scissoring posture of the lower extremities is maintained - Walking is significantly delayed - The feet position are equinovarus - Walk on tiptoe - Disuse atrophy - Impaired growth of the lower extremities - Neuropathologic finding is periventriculer leukomalacia Spastic quadriplegia - The most severe form of CP - Supranuclear bulbar palsies swallowing dificulty aspiration pneumonia

- Neuropathologic finding (MRI) - Severe PVL - Multiceptic cortical encephalomalacia - Tone increased - Spasticity of all extremities - Spontaneous movement decreased - Plantar extensor response decreased - Abnormalities of speech, visual

Athetoid CP/ Choreoathetoid CP/ Extrapiramidal CP

- Hypotonic - Poor head control - Marked head lag Over several years the tone increased with rigidity and dystonia
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- Difficulty of feeding - Tongue thrust Prominent - Drooling - Speech disorder due to abnormality of oropharyngeal muscle - Upper motor neuron signs are not present - seizure are uncommon

5. Diagnosis (Based on)

1. History 2. Physical examination 3. Imaging : - Skull CT Dilated ventricle Atropic cerebral hemisphere

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- Skull MRI is more sensitive than CT 4. Test of hearing function 5. Test of Visual function 6. Genetic evaluation : - Congenital malformation - Evidence of metabolic disorder

6. Treatment
A team consist of : 1. Physicians from various specialties 2. Occupational, physical therapist 3. Speech pathologist 4. Social workers 5. Educator

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6. Parent : - Feeding - Bathing - Carrying

1. Physical therapy 2. Occupational

- Dressing - Playing

To facilitate optimal positioning and movement patterns, increasing function of the affected parts Dantrolene sodium

3. Spasticity : - Oral medication

Benzodiazepine Baclofen oral - Botulinum toxin injection intratecal

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4. Rigidity Dystonia Spastic quadriparesis

Levodopa

5. Learning and attention deficit disorder, MR

- Psychologist - Educator

6. Strabismus Nystagmus Optic atrophy

Ophthalmologist

Inisial assesment
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7. Prognosis
- Seizure - Mental retardation - Blindness - Deafness

8. Prevention
Depend on the etiology

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