What is the management approach for abnormal movements in a cerebral palsy patient following a fever?

Management of Abnormal Movements in Cerebral Palsy Following Fever

In a cerebral palsy patient with abnormal movements following fever, aggressively treat the fever to normothermia (36.0-37.5°C) with antipyretics while simultaneously ruling out seizures with EEG monitoring, as fever can precipitate severe ballistic movements in choreoathetoid CP that require high-dose haloperidol or phenytoin for control. 1

Immediate Assessment and Fever Management

Fever must be treated urgently as it independently worsens neurological outcomes and can trigger paroxysmal movement exacerbations in patients with underlying brain injury 2, 3:

• Monitor temperature every 4 hours initially, increasing frequency if >37.5°C 2
• Administer acetaminophen (paracetamol) or NSAIDs as first-line antipyretics, though efficacy may be limited in severe neurological conditions 2, 3
• Target normothermia of 36.0-37.5°C with temperature variation ≤±0.5°C per hour and ≤1°C per 24-hour period 2, 3
• Investigate infectious sources immediately: obtain chest radiograph, blood cultures (60 mL total from two sites), urinalysis, and consider lumbar puncture if not contraindicated 3, 4

The duration of fever directly correlates with worse prognosis in brain-injured patients, making prompt treatment essential even before identifying the source 2, 3.

Differentiate Movement Type

Critical distinction: Are these movements seizures or fever-induced ballismus? 1

Perform concurrent EEG monitoring to distinguish:

• Seizures: Will show epileptiform discharges on EEG and may require immediate benzodiazepines (lorazepam IV) if not self-limiting 2, 5
• Fever-induced ballismus: EEG will be normal despite dramatic movements; these are paroxysmal episodes lasting hours, specific to choreoathetoid CP patients during febrile illnesses 1

A single self-limiting seizure within 24 hours of fever onset should NOT be treated with long-term anticonvulsants, but recurrent seizures require treatment per standard seizure protocols 2.

Treatment of Fever-Induced Ballismus

If EEG confirms non-epileptic movements in a choreoathetoid CP patient 1:

• Haloperidol in large doses is effective for controlling severe ballistic movements 1
• Phenytoin is an alternative agent that has demonstrated efficacy 1
• These episodes are difficult to control and may last hours despite treatment 1

Important caveat about medication-induced movements:

Screen for recent neuroleptic exposure (haloperidol, metoclopramide) as acute dystonic reactions can mimic other movement disorders and respond rapidly to diphenhydramine 6. This is particularly relevant if the patient received antipsychotics for agitation.

Risk Stratification for Epilepsy Development

Children with cerebral palsy who experience febrile convulsions have substantially elevated epilepsy risk 7:

• Baseline risk: ~6% by age 20 for all children with febrile convulsions 7
• High-risk features in CP patients: Pre-existing neurological impairment (CP, mental retardation) dramatically increases risk to 17% 7
• Additional risk factors: Focal seizures, seizure duration ≥10 minutes, or atypical features 7

Monitor these high-risk patients closely with regular neurological assessments, but do not initiate prophylactic anticonvulsants for a single febrile seizure 2.

Supportive Care During Acute Episode

While managing fever and movements 8:

• Ensure eye protection if facial involvement or altered consciousness impairs eye closure 8
• Maintain adequate hydration 2
• Physical therapy with range-of-motion exercises to prevent contractures during prolonged episodes 8
• Nutritional support assessment if oral intake is compromised 8

Advanced Temperature Control

If fever persists despite antipyretics, consider automated feedback-controlled temperature management devices 2, 3:

• These provide precise control superior to conventional physical cooling methods 2
• Conventional methods (ice packs, cooling blankets) offer poor control and should only be adjuncts 2
• Avoid deep hypothermia (32-34°C) due to high complication rates and risk of rebound intracranial hypertension 3

Monitoring and Follow-Up

• Continuous EEG monitoring if movements persist or mental status is depressed disproportionate to fever 2, 5
• Repeat neurological examination as fever resolves to establish new baseline 2
• Consider repeat MRI if symptoms progress or new deficits emerge, as CP is non-progressive by definition and deterioration suggests alternative pathology 8
• If antipsychotic therapy is required long-term, monitor for dyskinesias every 3-6 months using the Abnormal Involuntary Movement Scale 8

Key Pitfalls to Avoid

• Do not delay antipyretic treatment while searching for fever source—fever duration independently worsens outcomes 3, 4
• Do not assume all movements are seizures—obtain EEG confirmation before escalating antiepileptic therapy 1, 6
• Do not use prophylactic anticonvulsants for single febrile seizures, even in high-risk CP patients 2
• Do not attribute all fever to "neurogenic" causes—thoroughly investigate infectious sources first 3, 4