12. Neurology

Question 1

What is key to note about a child’s brain?

Answer 1

As it continues to develop lesions may not become apparent for many years.

Question 2

What sort of neurological pathologies may a child get

Answer 2

Congenital abnormalities
Neurogenetic diseases and syndromes
Nuerometabolic diseases and syndromes
Acquired disease: infection, trauma, tumour, ischeamia

Question 3

What are you looking to find out in a developmental history?

Answer 3

Motor milestones:gross and fine motor
Speech and language development
Early cognitive development 
Play esp symbolic play and social behaviour
Self help skills
Vision and hearing assessment

Question 4

What is involved in a neurological assessment of a child?

Answer 4

Opportunistic approach and observation skills
Appearance
Gait
Head size
Skin findings
Real world examination

Question 5

What are the different types of headaches a child might have?

Answer 5

Finding out the type of headache is very important:

Isolated acute- worrying
Recurrent acute
Chronic progressive- worrying 
Chronic non progressive 
New onset daily persistent headache

Question 6

What other information is good in a headache history?

Answer 6

Any warning?
Location
Severity?
Duration?
Frequency?

Question 7

What are your two differrent types of headaches?

Answer 7

Primary

Secondary- caused by a structural abnormality

Question 8

What are red flags for examination?

Answer 8

Growth parameters slowing (OFC, FB)-cranial pharyngoma

Sinuses, teeth, visual acuity defects- optic chiasm disruption

Cranial Bruit

Focal neurological signs (specific deficits in an area of the body)

Cognitive and emotional status

Question 9

How does a migraine present in children

Answer 9

Associated abdominal pain, nausea, vomiting

Focal symptoms (parenthesis, weakness)

Aura

Aggravated by bright light/noise

Helped by sleep

Family history

Pain on one side

Question 10

How do tension type headaches present?

Answer 10

No aura, nausea, vomiting
Tight band around head
Constant headache
No localised point of pain

Question 11

What indicated a raised intracranial pressure headache?

Answer 11

Aggravated by activities that raise ICP e.g. coughing, straining at stools bending

Woken from sleep with headache/ vomiting

Question 12

How does analgesic overuse headache present?

Answer 12

Headache is back before they are allowed another dose
Paracetamol/NSAIDS
Particular problem with compound analgesics e.g. co-codamol

Question 13

When would you send for a scan?

Answer 13

Features of cerebellar dysfunction

Features of raised ICP

New focal neurological deficit e.g. new squint

Seizures esp. focal

Personality change

Unexplained deterioration in school work

Question 14

How do you treat a migraine?

Answer 14

Acute attack- pain relief, triptans (somatriptin, vasotriptin)

Preventative (more than one migraine a week) propranolol, amitriptyline, valproate

Question 15

How do you treat a tension type headache?

Answer 15

Reassurance 
MDT approach
Attention to underlying chronic physical, psychological or emotional problems
Acute attacks- simple analgesia 
Prevention- amitriptyline 
Discourage analgesics in chronic TTH

Question 16

What is a seizure?

Answer 16

And sudden attacks from whatever cause

Question 17

What is syncope?

Answer 17

A faint

Question 18

What is convulsion?

Answer 18

Seizure with prominent motor activity

Question 19

What is an epileptic seizure?

Answer 19

Abnormal hyper synchronised discharge from a group of cortical neurons

It may or may not have clinical manifestations

Paroxysmal change in motor sensory or cognitive function

Depends on site of seizure and neurological spread

Epilepsy refers to recurrent episodes of seizures

Question 20

What can mimic epileptic seizures?

Answer 20

Hypoglycaemic seizure
Infection, traumatic seizure
Reflex anoxic seizure- vagally mediated seizure- common in stressed toddlers
Syncope
Parasomnias- nightmare
Behavioural stereotypes

Question 21

What is a febrile convulsion?

Answer 21

Very common in childhood, usually between 3 months and 5 years of age
Associated with fever but without evidence of intracranial infection or defined cause for the seizure
Commonest cause of acute symptomatic seizure in childhood

Question 22

What are the different types of epileptic seizures?

Answer 22

Jerk/shake- clinic, myoclonic spasms
Stiff- usually a tonic seizure
Fall- atonic/tonic/myoclonic
Vacant attack: abscence, complex partial seizure
Tonic clonic- two stages, kid goes tonic (seizes up) then clonic (ryhymthic jerking of both sides)

Question 23

What is the physiology behind epilepsy?

Answer 23

Chemically triggered by decreased inhibition (GABA)
Excessive excitation (glutamates and aspartate)
Excessive influx of Na and Ca

Question 24

What are the two different types of seizures?

Answer 24

Partial- starts in one area of the brain

Generalised- involves all areas of the brain, both hemispheres

Question 25

How do you conform epilepsy?

Answer 25

History
Video
ECG in convulsive seizures 
EEG
MRI brain to look for abnormalities
genetics
metabolic tests- esp if associated with regression

Question 26

What is the role of an EEG?

Answer 26

Interictal EEG has limited value
Sensitivity is around 30-60%
Problematic false positives as well
Useful for seizure types
Seizure syndromes and aetiology

Question 27

How do you treat epilepsy in children?

What should you consider with treatment?

Answer 27

Anti epileptic drugs in diagnosis is clear
Used to control seizures not cure epilepsy
Start with one drug and titrations up
Watch out for side effects ( drowsiness, effect on learning ad cognition)
Consider age, gender, type of seizures

Question 28

What drugs are used for epilepsy?

Answer 28

Sodium valporate (first line)- not in girls,
Levetiracetam- first line for general epilepsies
Carbamazepine- first line for focal epilepsies