Jan 16, 2019 in Health

Cerebral Palsy Essay

Predicting Cerebral Palsy And Its Motor And Cognitive Consequences

Executive Summary

Despite non-progressive nature of Cerebral Palsy, children with CP diagnosis often face cognitive deterioration during the first year of life. This tendency is associated with wrong diagnosis of cerebral palsy among height risk infants, whose cognitive disorder usually explained by small gestational age and fetal infections as the main reasons of cerebral palsy. However, unidentified CP reasons, brain damage and mental regression noticed along with paralytic disability leads to significant regression in cognitive and intellectual state.

Urgent clinical and etiological diagnosis of neonatal brain damage analysis leads to adequate treatment, along with the use of neuroimaging techniques, neurosonography of a child for the first year of his or her life. The magnetic resonance of brain can visualize and show the level and area of brain damage and help to treat the problem. However, several prenatal diseases lead to the rapid brain damage, which can be fatal if treated too late. Depending on the type of brain damage, the future consequences can be treatable or irreversible, conspicuous or inconspicuous. Moreover, existing brain trauma can continue brain damage without proper treatment. Therefore, neonatal and fetal MRI of the brain is the main innovation in cerebral palsy diagnosis, which should be used in the Clinic for all high-risk infants for more detailed prognosis of CP causes on further development of the child.  

Clinical Problem

The difficulties of diagnosis among the high-risk infants with cerebral palsy have become very urgent task, since the prognosis of cerebral palsy in each case have its own critical time period after birth. 

Preterm infants are number one high-risk infants group for majority of clinics. Major changes in neuron morphology of preterm infants differ due to different sensitivity to hypoxia of the brain cells, and depending on the gestational age. Especially this group of children usually suffers from hypoxia ischemia of brain lesions in preterm characteristic, worsened by small body weight and less than 32 weeks gestation term, in 57% artificial lungs’ ventilation causes serious brain oxygen deficiency. These children are among high-risk group infants. Therefore, these patients usually are tested on MRI and CT apparatus. In the process of MRI diagnostics, doctors usually identify white matter necrosis. During the first year of life, majority of necrotic areas are substituted by cystic lesions. The further control of placement and organization of cysts in preterm infants’ brain will influence further cognitive and motor development. Among motor disorders, future development of motor dysfunction usually leads to lower limb paralysis - spastic diplegia, since the most common location of cyst in such cases is pyramidal tract. Moreover, cognitive development in such cases can be characterized by motor and mental retardation.  

Among clinical practice of patients with cerebral palsy of the first year of life, is that the level of brain damage can hardly be identified due to the absence intellectual activity among children younger than one year. Whereas the motor disability and level of motor functions damage can be identified on the third week of postnatal period, the brain damage can be predicted only by predicting reasons of sickness. For example, full-term infants who are not identified as the high-risk group might also suffer from neurons necrosis, which can be diagnosed only after one-year age after identifying status marmoratus - spots on the child’s body. These spots characterize changes in thalamus, which leads to motor and mental retardation by the end of the first year

Cognitive regression process might progress without identification, unless proper MRI or CT diagnostics measures are conducted. Therefore, it is important to diagnose all representatives of high-risk group infants and patients with possible changes in motor activity during the first year of life, since minor motor and body disorder can eventually be a symptom of uncontrolled unidentified necrosis and cyst formation. 

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Decision Support Approach

According to Wiley (2014) Prenatal or fetal MRI can identify cerebrospinal fluid flow obstruction, brain malformation, or brain destruction with or without hemorrhage. In this case, the doctor will be able to make immediate decisions on fetal treatment or decision to hold caesarean section operation. 

Motor dysfunctions during CP can be identified by examining spinal reflexes and automatic reflexes, reflex symmetric chain, average degree of motor development delay of children under 7 months, whereas  mental retardation can stay unnoticed by the age of 12 months. Due to the fact that the first year of life is the most impotent for the mental disorder of cerebral paralysis treatment, the cognitive state might face regression due to the improper diagnosis (Aneja 2002).

The most serious and undetected reason for CP is intraventricular hemorrhage, complex brain bleeding which can either be completely recovered, or, if not identified, leads to comatose state and complete inconvertible mental retardation. In cases when massive brain bleeding to the caudal cranial fossa is not treated properly, it leads to breathing, conscious disorder and death.

Computer diagnosis of neonatal convulsions can improve the efficiency of their recognition by 30%, allowing the appointment of timely and adequate therapy. The most dangerous age for the development of children with cerebral palsy is the first two years of life. The appointment of treatment and determining prognosis physician should consider the possibility of a child with cerebral palsy is not only symptomatic. (Beckung 2002).

Computed tomography of the brain (CT) during cerebral palsy is used to clarify the nature of the morphological defect. CT is a harmless method that reveals malformation of brain structure and identify the reason for seizures. It can help you detect congenital malformations of the brain cysts, calcifications, objective evidence of hydrocephalus, determine the degree of expansion of the cerebral ventricles 

Children who have suffered from brain trauma or children whose mothers had intrauterine infection usually suffer from CP. However, these traumas can also lead to intrauterine growth retardation, premature infants, congenital malnutrition, encephalopathy of different genesis, children who have suffered birth trauma, asphyxia, hemolytic disease of the newborn distress syndrome and any other pathology.

The invention relates to medicine, in particular for pediatric neurology, and can be used as a means for predicting forms spastic cerebral palsy in premature infants. The method consists in determining gestational age, nutrition (Han, 2002).

Comprehensive assessment of the nervous system of the newborns using a dynamic study of the neurological status of the newborn using scale and neuroimaging (MRI, CT) helps to identified among children in the first months of life at risk for the formation of cerebral palsy (Beckung 2002).

MRI allows early diagnosis of structural changes and prognosis of GM form of cerebral palsy. Character revealed structural changes in the brain correlates with the form and severity of cerebral palsy. However, Glen and Coakley (2009) stressed that MRI fetal tomography can be conducted only after 20th week of gestation. 

Application scoring scale allows for the earliest stages objectively identify the most significant problems with motor functions. Violations of motor activity identified using a scale, are significant criterion prognosis of cerebral palsy. Persistent changes in brain activity, recorded in the follow formation age in children with neonatal seizures are at risk factor for cerebral palsy (Gaggero, 2002).

On the other hand, Brody (2014) emphasize the importance of postnatal MRI rather than prenatal. According to Brody, each reason of cerebral palsy have its own critical period of estimation. For example, brain hypothermia for newborn babies who suffer oxygen deficiency demands cooling therapy during first 72 hours after birth. 

The professor believes that brain it might take not less than 10 days before brain injuries will be visualized on the M.R.I., while encephalopathy is visualized three days after the birth.

Nevertheless, Brody consider several diagnoses urgent enough for cesarean delivery. Among such factors, Brody identify fetal growth retardation and placental lesions in combination with unusual heart rate increase of the fetus.

Evaluation

Professor Wiley who specializes on fetal magnetic tomography explained that that grey and white matter injury noticed by doctors during fetal tomography shows brain damage of fetus. In case if the process of damaging and its source (free radicals) (Wiley 2013). Wiley predicted postnatal indicated oxidative stress of fetus after prenatal M.R.I. He also exemplified that reperfusion-reoxygenation affects motor deficits of fetus (Wiley 2013).

Professors Bax and Tydeman (2006) held another fetal MRI investigation

They showed that among 358 women 39.5% had intrauterine infection, whereas 54% of children were born after full-term pregnancy. Nevertheless, 28% of children had paralysis 34.4% had diplegia, 18.6% had quadriplegia, 14.4% had dyskinesia, 3.9% had ataxia, and 2.6% had other types of CP. 

Brain MRI scans showed that white-matter damage of immaturity, including periventricular leukomalacia notices as the most common diagnosis reflected on MRI (42.5%), followed by basal ganglia lesions (12.8%), cortical and subcortical lesions (9.4%), malformations (9.1%), focal infarcts (7.4%), and miscellaneous lesions (7.1%) (Bax &Tydeman 2006). However, the MRI still suggested 11% of normal results, whereas other mentioned disorders were clearly reflected on MRI (Appendix 1, Bax and Tydeman research).

Appendix 1

Due to the results suggested by doctors and tomography specialists who analyzed correlation between cerebral palsy among newborn babies, pregnancy factors and results of MRI gave evidences that cerebral palsy can be diagnosed in prenatal period with the use of magnetic tomography. However, the diagnostics do not always influence the treatment of the fetus, since in majority of cases, the white and grey matter damage cannot be treated. Nevertheless, fetal MRI gives much better picture of CP that computer tomography, since it displays brain near bone tissue. MRI can identify brain bleeding, after with a quick surgery might save the fetus from death or future paralysis.  

Glen and Coakley (2009) emphasize the importance of the body MRI, but not only brain tomography. According to their researches, 10 of 11 fetuses who were born with mental retardation diagnosis had noticeably small liver size during body tomography. However, Glen and Coakley studied development disorder, whereas cerebral palsy became a target interest for MRI tomography in more recent works. 

Among practical utilization of CP fetal diagnosis, Glen and Coakley (2009) identify fetal surgery as a treatment used in cases when MRI diagnosis reveal internal bleeding of the fetus. 

Cognitive disorder prognosis during cerebral palsy usually can be identified as fatigue, emotional liability, insomnia, loss of function of active attention. These symptoms may appear after 3-4 years, whereas positive prognosis of handling these defects possible in early diagnostic before one-year age.  

Motor defects among CP patients include prognosis of increased neuron reflex excitability, tremor, restlessness, increased muscle tone and periosteal reflexes. However, preservation of physiological neonatal reflexes make identification and further prognosis complicated.

The CP is characterized by motor disorders, muscles dystonia, hyper and hypo muscle tonus, asymmetry tone based on which further forms of cerebral palsy. CP also contribute to the development of long-term preservation of tonic neck reflexes, lack of timely support formation of reflexes. In future motor disorder usually leads to hyperkinesias, ataxia and paresis.

Success Factors

Despite the fact that prenatal MRI does not perform 100% efficacy, it can perform important results in diagnosis of CP on early stages of pregnancy. In certain cases, such diagnosis appears vital, in other cases, it will provide additional acknowledgment for mothers whose children will have CP after birth. 

The prognosis in such cases highly depends on early diagnose. The early identification of prenatal brain trauma can lead to complete recovering, since mental retardation in not a permanent state, but temporal disorder that can be treated on early stages. 

Mental and preverbal retardation can be treated by nootropic agents before one year age However, this retardation must be identified much earlier and whereas intra-uterine fetal infection can be identified and treated during prenatal period, hypoxic ischemic brain disorder and prenatal traumas may be hard to identify. On the one hand, mental disorder cannot be noticed when patient is not old enough for diagnostic communication analysis. On the other hand, some of mental disorder reasons during PC should be treated earlier than at one-year old age. 

Therefore, MRI tomography should be suggested to all representatives of risk group, including hard prenatal period cases, mild cases of TORCH infection, and infants with motor abnormality – too active and too passive newborn babies. 

In cases when high-risk group diagnosis will be broaden to more numerous cases, it will be easier to identify unobservable CP mental disorder symptoms, recommend early treatment for further positive prognosis.

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