Cerebral palsy? Cerebral palsies? Cerebral palsy spectrum disorder?

Transcription

1 Teamwork makes the dream work Nationaal symposium van Belgische CP-centra 18/02/2019 Cerebral palsy? Cerebral palsies? Cerebral palsy spectrum disorder? Faes Franny Dienst Kinderneurologie UZ Gent Centrum voor Ontwikkelingsstoornissen Gent

2 History and Origin William John Little ( ) First clinical report of CP Orthopaedic surgeon 1861 : association between abnormal forms of labor, in which the child has been partially suffocated and poor neurological outcomes later in life ( spastic rigidity ) Little s disease 2 /

3 History and Origin William John Little (1861) Sir William Osler ( ) 1889 : numerous case studies and possible causes of impairment primarily attributed to an acquired birth injury to the brain 3 /

4 History and Origin William John Little (1861) Sir William Osler (1889) Sigmund Freud ( ) 1897 Infantile Cerebral Palsy First to unite the wide range of infantile motor impairments caused by abnormal brain development 4 /

5 History and Origin William John Little (1861) Sir William Osler (1889) Sigmund Freud (1897) Michael Shevell pediatric neurologist 5 /

6 Definition child neurology. S 1 Developmental medicine and 6 /

7 Definition 7 /

8 Definition 8 /

9 Definition 9 /

10 Definition 10 / processes or events that in some way interrupt, damage or influence the expected patterns of brain formation, development and maturation it alters the developmental trajectory of the brain and consequently produces a clinical picture that changes over time

11 Definition 11 /

12 Definition 12 /

13 Prevalence 2/1000 live births in high resource settings Last decades little change in prevalence 13 /

14 Etiology and pathogenesis CP is the result of Hypoxic-ischemic encephalopathy (HIE) Intraventricular Hemorrhage (IVH) Periventricular Leukomalacia (PVL) Cerebral dysgenesis 14 /

15 Etiology and Pathogenesis Environmental risk factors Prenatal (70-80%) : prematurity and low birth weight, intra-uterine infections, multiple gestation, pregnancy complications, placental insufficiency Perinatal (10%) : birth asphyxia, complicated labour and delivery, kernicterus Postnatal : NAH, head trauma, meningitis/encephalitis, cardiopulmonary arrest 15 /

16 Etiology and Pathogenesis Environmental risk factors But : little reduction in the incidence/prevalence of CP Improved obstetric practice Better antenatal and perinatal care App. 30 % may be genetic in nature 16 /

17 Etiology and Pathogenesis Environmental risk factors Genetic risk factors (DMCN 2017,59: , Fahey et al.) Small and large effect size 17 /

18 Etiology and Pathogenesis Environmental risk factors Genetic risk factors (DMCN 2017,59: , Fahey et al.) Small and large effect size Susceptibility genes Osteopontin ApoE4 Monogenic causes of CP AP-4 ADD-3 KANK /

19 Etiology and Pathogenesis Environmental risk factors Genetic risk factors (DMCN 2017,59: , Fahey et al.) Small and large effect size Susceptibility genes Monogenic causes of CP Pathogenic copy number variants (Genomic medicine :1-9, Corbett et al.) 19 /

20 Etiology and Pathogenesis Linked to genetic and environmental risk factors Important pathways involved in the pathogenesis Axon guidance Transmission across chemical synapses Protein-protein interactions at synapses Identification of pathways and genes associated with cerebral palsy Genes and genomics (2018) 40: , Zhu et al. 20 /

21 Etiology and Pathogenesis Linked to genetic and environmental risk factors Important pathways involved in the pathogenesis axon guidance transmission across chemical synapses protein-protein interactions at synapses) Can provide useful clues for developing pathwaybased pharmacotherapies 21 /

22 Diagnosis Ongoing challenge in children presenting early in life with motor delay/impairment 22 /

23 Diagnosis Red Flags Normal MRI Imaging abnormalities isolated to the globus pallidus Severe symptoms in the absence of a history of perinatal injury Neurodevelopmental regression, progressively worsening symptomatology Isolated muscular hypotonia Rigidity (as opposed to spasticity) Paraplegia 23 /

24 Diagnosis Systematic literature review to identify all reports of IEM s presenting with CP-like symptoms < 5 y, evidence for effective treatment 54 treatable IEMs reported to mimic CP, +13 expert opinion, no literature report 24 /

25 Diagnosis Genomic analyses identifies masqueraders of full-term cerebral palsy Takezawa et al., Annals of Clinical and Translational Neurology (2018) 5(5): /897 full-term birth and non-specific brain MRI findings array CGH and trio whole-exome sequencing, 17 DNA samples 9/17 pathogenic/likely pathogenic candidate variants 25 /

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27 CP is a chronic neurodevelopmental disorder, heterogenous in many aspects : etiology, presentation, functional severity, comorbidities, treatment options, individual trajectories, and outcomes To use the singular is to miscommunicate and impart a false view of our current understanding In analogy with autism to autism spectrum disorder spectrum : range, can vary across a continuum between extremes and suggests multiple dimensions of variability 27 /

28 Not simply a linguistic modification but A spur to catalyzing or facilitating greater awareness that could lead to enabling directed efforts at multiple levels to improve medical, educational, rehabilitation, vocational, recreational, and community engagements to improve overall health and well-being. 28 /

29 Take home messages The concept of CP as a unifying and defining term remains useful CP should be considered as a descriptive term for affected individuals Before assigning the diagnosis CP do a thorough diagnostic work-up Cerebral palsy spectrum disorder? 29 /

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