- Spastic: Characterized by muscle stiffness and increased reflexes.
- Dyskinetic: Involves involuntary and uncontrolled movements, such as dystonia or choreoathetoid movements.
- Ataxic: Impairs balance and coordination, leading to unsteady movements.
- Mixed: Presents a combination of spastic and dyskinetic features.
Among these, Spastic quadriplegia is the most common type observed in India. It is often caused by perinatal asphyxia or neonatal illness and can be associated with various comorbidities, including intellectual disability, seizures, pseudobulbar palsy, microcephaly, squint or visual disturbances, speech abnormalities, and deformities.
The second most common type is Spastic diplegia, which is linked to prematurity. This form usually preserves intellect, and neuroimaging studies reveal periventricular leucomalacia.
Spastic hemiplegic palsy typically results from a vascular insult or perinatal stroke. Early hand preference can serve as a clue to its diagnosis. Neuromaging usually shows focal changes or a porencephalic cyst. These children are often mobile, and their intellect may be preserved or impaired.
Dyskinetic or extrapyramidal palsy may result from asphyxia or kernicterus. It is characterized by prominent rigidity, dystonia, dyskinesia, and drooling, while the intellect is relatively preserved. Radiology may indicate abnormalities in the basal ganglia or thalamus.
Ataxic palsy is caused by cerebellar malformations and may be associated with other cerebellar signs.
Mixed CP refers to a presentation that includes features of both spastic and extrapyramidal types. Each type of cerebral palsy presents unique challenges and requires tailored management and care.
EPIDEMIOLOGY
In a hospital-based study conducted at a tertiary care hospital in Delhi, researchers examined 160 children with cerebral palsy, ranging from 2 to 15 years of age. Each patient underwent a thorough assessment, including a detailed history and examination, and underwent appropriate investigations.
The study encompassed a review of various prospective, retrospective, cross-sectional, and cohort studies focused on cerebral palsy in the Indian population. Data were carefully extracted from these studies, and a meticulous quality assessment was conducted to ensure the reliability of the findings.
The results of the study revealed that a significant proportion, approximately 64.4%, of the affected children were below the age of 5, and 72.5% of the cases were found in males. Birth asphyxia was identified as the most common cause of cerebral palsy, accounting for about 41.9% of the cases.
Among the different types of cerebral palsy, spastic quadriplegic CP (bilateral spastic) was the most prevalent, comprising 43.1% of the cases. The most common comorbidity across all subtypes of cerebral palsy was intellectual disability, followed by epilepsy.
Moreover, the study noted that certain specific comorbidities were more prevalent in particular types of cerebral palsy. For instance, spastic quadriplegic CP showed a higher incidence of epilepsy and various visual problems, while dyskinetic CP had a greater frequency of hearing and speech impairment, along with optic atrophy. Additionally, chewing, swallowing, and drooling
difficulties were more commonly observed in children with spastic quadriplegic CP. These findings underscore the diverse clinical manifestations of cerebral palsy and emphasize the importance of individualized care for affected children.
The pathophysiology of cerebral palsy
involves a complex interplay of factors contributing to its development.
One of the main factors is poor oxygen supply to the fetus or brain asphyxia.
Additionally, multiple factors during different stages of pregnancy (ante-, peri-, and postnatal) could be responsible for cerebral palsy syndromes.
These may include interactions between environmental factors and genetic vulnerabilities, leading to brain injuries that can be detected through imaging techniques like ultrasonography or MRI.
Notably, these injuries are observed in the white matter of preterm infants and the gray matter and brainstem nuclei of full-term newborns.
These factors act on the developing brain and may alter the sequence of developmental events.
In cases of cerebral palsy, cell death or loss of cell processes leads to the release of biochemical key factors in hypoxic-ischemic and inflammatory conditions.
This results in an excessive production of proinfl ammatory cytokines, deprivation of maternal growth factors, oxidative stress, changes in the extracellular matrix, and the release of excessive glutamate, ultimately triggering an excitotoxic cascade that can cause periventricular leukomalacia. This condition poses a high risk for developing spastic diplegic or quadriplegic cerebral palsy.
During the early stages of pregnancy, particularly until the 24th week of gestation, cortical neurogenesis is a critical process.
This involves various stages like proliferation, migration, and organization of neuronal precursor cells, followed by the formation of neurons.
However, genetic deficits or acquired factors, such as exposure to viruses or toxins, during this period can interfere with proper brain development, leading to difficulties associated with cerebral palsy.
The primary cause of cerebral palsy
is abnormal brain development or damage to the developing brain, which can occur before birth, during birth, or in early infancy. In some cases, the cause remains unknown, referred to as idiopathic. Various factors can contribute to problems with brain development, including:
- Infections during pregnancy can affect the developing fetus and lead to brain damage.
- Gene mutations can result in genetic disorders or hinder normal brain development.
- Insufficient blood supply to the developing brain, known as fetal stroke, can cause damage.
- Bleeding into the brain, occurring in the womb or as a newborn, can also be detrimental.
- Certain infections contracted by the infant can cause inflammation in or around the brain.
- Traumatic head injuries from falls, accidents, or physical abuse can damage the infant’s brain.
- Difficult labor or birth-related asphyxia, causing a lack of oxygen supply to the brain, is another significant cause.
Various risk factors play a role in the development of cerebral palsy, categorized as prenatal, perinatal, and postnatal factors:
Prenatal factors include:
- Hemorrhage or bleeding during pregnancy.
- Abruptio placenta, a condition where the placenta separates from the uterus prematurely.
- Infections such as Rubella, cytomegalovirus, and toxoplasmosis.
- Environmental factors.
- Maternal characteristics like age, difficulty in conceiving or carrying a baby to term, multiple births, history of fetal deaths/miscarriages, excessive smoking, alcoholism, drug addiction, and the mother’s medical condition.
Perinatal factors encompass:
- High or low blood pressure during birth.
- Umbilical cord complications, such as coiling around the baby’s neck.
- Breech delivery, where the baby is positioned feet-first instead of head-first.
- Over sedation of drugs during delivery.Trauma during delivery, often due to forceps or vacuum extraction.
- Complications arising during birth.
Postnatal factors involve:
- Traumatic head injuries occurring after birth.
- Infections contracted after birth.
- Lack of oxygen supply to the brain (hypoxia).
- Stroke in young infants.Tumors, cysts, or bacterial infections affecting the brain.
Certain factors related to pregnancy and birth increase the risk of cerebral palsy, including:
- Low birth weight (babies weighing less than 2.5 kilograms).
- Multiple births, where the risk increases with the number of babies sharing the uterus.
- Premature birth, with babies born before the due date being at higher risk.
- Delivery complications during labor and birth, which can elevate the risk of cerebral palsy. These complications may include various problems that occur during labor and delivery.
Clinical signs and symptoms of cerebral palsy
can vary significantly from person to person, ranging from affecting the entire body to being limited to specific limbs or one side of the body. Common signs and symptoms include difficulties with movement, coordination, speech, eating, and overall development. Some specific manifestations of cerebral palsy include:
- Stiff muscles and exaggerated reflexes (spasticity), which is the most common movement disorder associated with cerebral palsy.
- Variations in muscle tone, leading to either excessive stiffness or floppiness.
- Muscle rigidity with normal reflexes.
- Poor balance and muscle coordination.
- Jerky involuntary movements and tremors.
- Slow movements on one side of the body, like reaching with one hand or dragging a leg while crawling.
- Gait abnormalities, such as walking on toes, crouched gait, scissors-like gait with knees crossing, wide gait, or asymmetrical gait.
- Difficulty with fine motor skills, such as buttoning clothes or picking up utensils.
- Delay in speech development and difficulty with speaking.
- Challenges with sucking, chewing, or eating.
- Swallowing difficulties and excessive drooling.
