Cerebral palsy

Case history #1

An 18-month-old child with a history of prematurity (28 weeks' gestation, 1200 grams) presents with failure to meet developmental milestones. The child sat independently at 1 year, has few words vocally, does not pull to stand, and exhibits increased deep tendon reflexes in the lower extremities, and sustained clonus at both ankles. There is good upper-extremity function. A magnetic resonance imaging scan of the brain reveals periventricular leukomalacia. The child is diagnosed with spastic diplegic CP.

Case history #2

A 2-year-old boy, born after a normal pregnancy and delivery, presents with an asymmetric gait. Examination reveals mild spasticity of the left upper and lower extremity, hyperactive left knee and ankle deep tendon reflexes, and decreased dorsiflexion of the left ankle compared with the right. When walking, the patient walks on his left toes, and his left arm is held mildly flexed at the elbow with the palm facing the floor (pronated forearm). The left calf is smaller in girth than the right, leading to the diagnosis of hemiplegic CP.

Other presentations

Patients with severe spastic quadriplegic CP have total body involvement, are typically fed via a gastrostomy if there is oropharyngeal involvement and risk of aspiration, and may have a history of birth complications, seizures, and GORD. Initial hypotonia evolves to a spastic or dyskinetic state over 14 months or longer. These patients require a wheelchair with a specialised seating system and are dependent for mobility, transfers, and all activities of daily living.

Some patients may present with non-spastic forms including dystonia (intermittent, but sustained involuntary posturing with sudden shifts of muscle tone and primitive reflex activity), athetosis (distal writhing motions, typically with hyperextension of the fingers), chorea (quicker, more jerky, more proximal muscular involvement), and/or ataxia (impaired balance with wide-based gait, tremor, and falling tendencies).

Some patients have features of both spastic and non-spastic elements; this is referred to as mixed CP.