Download Dr Janice Bothwell, Consultant Paediatrician - Hemiplegia

Introduction
Questions and Answers
Dr Janice Bothwell
Consultant Paediatrician
Belfast HSCT
Objectives
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Role of Paediatrician in management of
children with hemiplegia
Multidisciplinary team
Some questions parents have when told
their child has a hemiplegia
Other questions?
What is the role of the doctor ?
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A Paediatrician is a doctor who specialises in the
care of children.
Neurodevelopmental Paediatricians specialise in
the care of children with developmental disorders
and/or medical conditions such as hemiplegia
which can affect the development of skills in a
growing child
Neurologists specialise in children who present
with neurological conditions such as hemiplegia
Assessment process
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Unidisciplinary
Multidisciplinary
Medical Assessment
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History of pregnancy, birth, family history,
significant illnesses, any injuries sustained,
medications taken, developmental progress,
educational history
Physical examination
- examination of heart, lungs, abdomen, central
and peripheral nervous system, hearing and vision
- height and weight
Developmental Assessment
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Gross Motor Skills
Fine Motor Skills
Speech and Language – ability to both
speak and understand language
Personal and social skills
Cognitive ability
Child development team
Dentist
Doctor
Speech & Language
therapist
Child
Physiotherapist
Occupational
therapist
Social Worker
Investigations
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Neuroimaging
Blood investigations
EEG
Hearing tests
Vision tests
Diagnosis - Hemiplegia
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Congential
Acquired
What questions do parents ask
when their child is diagnosed
with hemiplegia?
What does hemiplegia
mean?
Paralysis of one side
of the body resulting
from disease or injury
to the motor centres of
the brain.
My child has hemiplegia does
this mean he/she has cerebral
palsy?
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Cerebral palsy is an umbrella term covering a
group of non-progressive but often changing
motor-impairment syndromes secondary to
anomalies or lesions in the brain
These anomalies or lesions can be
prenatal/perinatal/postnatal in origin
Hemiplegic CP is classified as a unilateral motor
disability
What is a Congenital
Hemiplegia?
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A congenital hemiplegia is one which occurs
as a result of a prenatal/perinatal or early
postnatal problem (<28 days after birth).
What went wrong?
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Three main processes can occur, each occur at
different developmental stages during
pregnancy/birth
- cerebral malformations originating early in the
pregnancy
- periventricular lesions mainly arising during 24 –
34 weeks (either during pregnancy or after a
preterm birth)
- cortical infarctions occurring just before or
around the time of a term birth
What does a normal brain look
like?
What are cerebral
malformations?
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All malformations originate from early fetal life
Neuronal migration disorder
- agyria or lissencephaly at early stage
- schizencephaly and pachygyria at later stage
- heterotopias and polymicrogyria at later stages
(up to 30 weeks gestation)
What do these conditions look
like on MRI?
lissencephaly
schizencephaly
polymicrogyria
What are periventricular lesions?
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During the period between 24th and 34th
week of gestation the brain is very
vulnerable to bleeding
As a result periventricular leukomalacia or
periventricular haemorrhagic infarctions can
develop which may result in a congenital
hemiplegia
What does this look like on a
scan?
How can this cause
hemiplegia?
A simplified diagram to show how the corticspinal tracts can be affected by PVL and
hydrocephalus
What are cortical infarctions?
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Cortical infarctions occur around term and
are caused by ischaemia (lack of oxygen
and/or blood flow to part/parts of brain
tissue).
This is actually the least common type
What does this look like?
My child has a congenital
hemiplegia – why were there no
signs when he/she was born?
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Clinical signs of a hemiplegia may not be
evident until the child is old enough to use
the affected limb.
The child may show signs such as being
slower to crawl, pull to stand, walk or may
develop hand dominance at a very early
age.
What else can you tell me
about congenital hemiplegia?
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This affects about 4 babies per 10,000
Its more common in males 1.4:1
R sided hemiplegia is more common
What is an acquired
hemiplegia?
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An acquired hemiplegia is a weakness
which develops in a child who has
previously been well
– Acute
– Chronic progressive
What is an acute hemiplegia?
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This is a sudden onset of one sided
weakness which can be associated with
seizures
What causes an acute
hemiplegia?
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An acute hemiplegia can have a number of
causes.
A brief outline of some of the causes will be
given
What is an alternating
hemiplegia?
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This is a hemiplegia which appears and any
time from birth to 54 months.
The initial signs are mild delay in your child’s
development
This may be followed by abnormal
positioning of your child’s limbs or weakness
of one side and can be associated with
jerking movements of the eyes
How long does the hemiplegia
last for?
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In alternating hemiplegia the duration varies
from minutes to days and the seriousness of
symptoms can vary.
The side affected with weakness can
alternate and the arm is usually more
affected than the leg.
Hemiplegia is also noted to disappear with
sleep and reappear on wakening
Will a child recover from
alternating hemiplegia?
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After each episode the child may recover to
a degree, but after multiple episodes the
child may have learning difficulties and
possibly lose some skills
Medications can be used with various
degrees of success
My child has been diagnosed
as having a stroke why?
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There are many reasons why a child will
have a stroke which results in a hemiplegia.
These reasons can include clotting
problems, heart disease, trauma, infections,
vascular problems, tumours
What investigations will
doctors do to identify why?
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Investigations include multiple blood
investigations, urine sampling, heart scans,
brain scans
What do strokes look like on a
scan?
Can infection cause
hemiplegia?
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An acute hemiplegia can be caused by brain
infections such as meningitis or encephalitis
Infection which causes hemiplegia is also
usually associated with seizures
What causes progressive
hemiplegias?
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Progressive hemiplegias can be caused by
– AV malformations
– Brain abscesses
– Tumours
– Demyelinating disease
– Sturge Weber syndrome
What is Sturge Weber
syndrome?
What are the signs of Sturge
Weber syndrome?
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Port wine stain on face (cutaneous
angioma)
Epilepsy in 80%
Hemiplegia evident in 50% affecting limbs
on side opposite to facial signs
We have a diagnosis of
hemiplegia what other
problems may be present?
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Children with hemiplegia may also have
– Learning disability (1 in 5 children)
– Epilepsy present in 25 to 33% of children
– Vision: significant problems rare but squints
and refraction errors are common
– Hearing most often normal
– Speech is well preserved
Who should be involved with
my child after diagnosis?
Paediatrician
Voluntary
agencies
Orthopaedic
surgeon
Neurologist
Child
Occupational
therapist
Physiotherapist
Educational
Psychologist
How do we treat hemiplegia?
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Main treatment aims are
– Child will walk and aims of treatment are to
maximise efficiency and look of walking
– The arm can be very often ignored by the child
so early awareness of its use and encourage
use of this limb is important. This should be
combined with improvement of efficiency and
look
– Monitor spine
Is early treatment important?
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Yes to ensure
– Greater symmetry of posture and movement
– Develop an awareness of affected side
– Prevention of fixed deformity
– Provide support for families
Are there any surgical or
medical treatment available?
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Yes surgical treatments are offered by the
orthopaedic surgeons to correct deformities
or to improve limb function
Medical treatment includes treatment for
spasticity (tight muscles) this includes
baclofen, diazepam
Botulinum toxin now used as injection form
to help spastic limbs
What other therapeutic options
are there?
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Numerous – need to look at evidence base
for effectiveness
Any other questions ????