Cerebral palsy

Question 1

An 18 month old was brought to your clinical due to concerns of difficulty walking. He was an ex-prem (28 wks) baby and was admitted to NICU for 2 months after birth. His mother has noticed that he has always had a strong preference for using his right hand. You examine him and find that his left arm and leg have increased tone and brisk reflexes. His left sided plantar reflex is up-going.

A 3 year old with quadriplegic CP has severe weakness and developmental abilities of a 2-month-old child. She comes to clinic for review. How would you manage this patient? [CP is SAD – SPASTIC, ATAXID, DYSKINETIC]

Answer 1

Impression
Given walking difficulties and hyperreflexia in setting of referencing R side of body, am suspicious of spastic cerebral palsy.

CP is a persistent but not unchanging disorder of movement and posture, due to insult to the developing brain. CP is SAD;
- spastic
- ataxic
- Dyskinetic (hypotonic)

DDx
- Intracerebral mass (neoplasia, abscess, vascular)
- Angelmans syndrome
- spinal cord injury
- neuromuscular disorders (spinal muscular atrophy, duchesses MD): can have hypotonic(dyskinetic) CP.

Question 2

CP - History

Answer 2

History
- sx: Characterise walking difficulties, any developmental regression? (red flag), any other associated abnormalities (speech, vision, hearing, etc), drooling, incontinence, ling problems, reflux
- HPI: obstetric complications, ante, intra, and postpartum, medications/drugs.
- RISKS: pre-term birth, hypoxia ischaemic, resp distress, feeding problems encephalopathy, meningitis, etc
- complications: failure to thrive, reflux, failure to meet milestones
- Fam Hx
- assess for carer fatigue, functional impact on family

Question 3

CP - Examination

Answer 3

Examination
- observe in play for developmental milestones
at 18 months:
- single word sentences, follow simple instructions
- walking

Neurological examination for gait and other movement abnormalities, tone, reflexes.

Question 4

CP - Investigations

Answer 4

Investigations
Nil indicated if clear obstetric cause of CP, diagnosis is made on clinical basis of history and examination findings.

Otherwise if unclear;
- MRI Brain
- Bloods for metabolic masquerading causes

Question 5

CP - Management

Answer 5

Management
- MDT required: paeds neuro, gastro, clinical geneticist, ophthalmology if visual manifestations
- Key complications to consider and treat accordingly
o hearing and vision
o epilepsy
- establish treatment goals
- patient education about condition, expected course, expectations
- aim for supportive and holistic care

Social
- supportive management for additional psychosocial issues
o drooling: speech path
o incontinence: anticholinergics
o spasticity: muscle relaxants
- NDIS input
- allied health referral: physiotherapy
- community support groups