21 - Neurology 1 Flashcards
What are some causes of seizures in neonates?
- HIE
- Infection (meningitis/encephalitis)
- Intracranial haemorrhage/infarction
- Structural CNS lesions (focal cortical dysplasia/tuberous sclerosis)
- Metabolic disturbance (hypoglycaemia, Ca)
- Neonatal withdrawal from maternal drugs or substance abuse
- Kernicterus
- Idiopathic seizures eg benign 5th day fits.
What drugs are needed to treat neonatal seizures if they are recurrent?
Phenobarbital or Phenytoin
What are some causes of non-epileptic seizure like activity in children?
- Non-epileptic attack disorder (pseudo seizure)
- Benign neonatal sleep myoclonus
- Breath holding attacks
- Night terror
- Febrile seizures
- Day dreaming (looks like absence)
- Syncope with myoclonic jerks
- Munchausen’s
What is the definition of epilepsy?
Tendency to have chronic recurrent unprovoked seizures
What are the different types of epileptic seizures that children can have?
- Tonic/clonic
- Absence
- Infantile Spasms/West syndrome
- Myoclonic
- Atonic
What antiepileptics are used in focal seizures?
Reverse of tonic clonic seizures
What antiepileptics are used in generalised seizures?
Tonic Clonic
- First line: sodium valproate
- Second line: lamotrigine or carbamazepine
Absence
Ethosuximide or Sodium Valproate
Myoclonic
- First line: sodium valproate
- Other options: lamotrigine, levetiracetam or topiramate
Atonic (drop attacks)
- First line: sodium valproate
- Second line: lamotrigine
What is West syndrome?
- Brief full body spasms beginning around 6 months (jack-knife)
- Flexion of head, trunk, limbs and extension of arms for 1 to 2 seconds
- Usually due to serious neurologic abnormality (e.g. TS, encephalitis, birth asphyxia)
- Poor prognosis, progressive handicap and ⅓ die by age 25
How is West syndrome (infantile spasms) diagnosed and managed?
EEG: Hypsarrhythmia
Treatment: Prednisolone or Vigabatrin
When do absence seizures occur in children, what do they show on EEG and what is the prognosis?
- Onset 4-8 yrs
- <30 secs with no warning, quick recovery and many per day
- EEG: 3Hz generalized, symmetrical
- 90-95% become seizure free in adolescence
What is Lennox-Gastaut syndrome?
- May be extension of infantile spasms
- Onset 1-5 yrs
- Atypical absences, falls, jerks
- 90% moderate-severe mental handicap
- EEG: slow spike
What are Rolandic seizures?
- Infrequent, brief partial fits with unilateral facial or oropharyngeal paralysis, speech arrest ± hypersalivation
- Common on waking
- Treatment is rarely needed
What investigations are done after a child has a seizure to diagnose or rule out epilepsy?
- If definitely febrile convulsion or vasovagal syncope then no Ix
- EEG: after second seizure
- Videos of seizures
- MRI brain: look for structural abnormalities in certain situations
- ECG to exclude problems in the heart.
- U+Es: including calcium and magnesium
- Blood glucose: hypoglycaemia and diabetes
- Blood/urine cultures,lumbar puncture if sepsis, encephalitis/meningitis suspected
What is the criteria for an MRI brain in children with seizures?
- The first seizure if child under 2 years
- Focal seizures
- No response to first line anti-epileptic medication
What advice do you need to give parents after a child has a seizure?
Recognising, managing and reporting further seizures
Safety Precautions
- Take showers rather than baths
- Be very cautious with swimming
- Be cautious with heights
- Be cautious with traffic
- Be cautious with any heavy, hot or electrical equipment
- Older teenagers with epilepsy will need to avoid driving
What safety advice should you give to parents on how to manage their child when they are having a seizure?
What are the side effects for sodium valproate and carbamazepine?
Sodium Valproate
- Teratogenic
- Liver damage and hepatitis
- Hair loss
- Tremor
Carbamazepine
- Agranulocytosis
- Aplastic anaemia
- Induces the P450 system so there are many drug interactions
What are the side effects for phenytoin, ethosuximide and lamotrigine?
What is a reflex anoxic seizure? (pallid breath holding spell)
Syncopal episode (or presyncope) due to temporary lack of blood flow to the brain, in response to pain or emotional stimuli
Transient asystole in children with very sensitive vagal cardiac reflexesIt
Young children aged 6 months to 3 years
How does a reflex anoxic seizure present?
- Child goes very pale
- Falls to floor
- Secondary anoxic seizures are common
- Rapid recovery and no post-ictal confusion
No specific treatment and prognosis is good. Often misdiagnosed as epilepsy
What are cyanotic breath holding spells?
Young children hold their breath during periods of crying to the point that they faint
The faint can even be accompanied by turning blue and jerking of the limbs
The child recovers quickly with no post-ictal confusion
How are breath holding spells treated?
- After excluding other pathology and making a diagnosis, educate and reassure parents
- Check for iron deficiency anaemia and treat
How is status epilepticus in children managed? (seizure >5 minutes or 2 or more seizures without regaining consciousness)
- Secure the airway A to E
- Give high-concentration oxygen
- Assess cardiac and respiratory function
- Check blood glucose levels and temperature
- Gain IV access
- IV lorazepam, repeated after 10 minutes if the seizure continues
- IV phenytoin if after 5 minutes of second lorazepam not worked. Contact PICU and anaesthetist for intubation/rapid sequence induction at 45 minutes as this is refractory status epilepticus
Medical options in the community:
- Buccal midazolam
- Rectal diazepam
What are some complications of status epilepticus?
(recap image)
- Focal neurological deficit (normally temporary)
- Memory loss
- Behavioural problems
- Hypoxic brain injury
- Epilepsy
- Encephalopathy
What are some differentials for a febrile convulsion?
- Epilepsy
- Meningitis, encephalitis
- Intracranial SOL, for example brain tumours or intracranial haemorrhage
- Syncopal episode
- Electrolyte abnormalities
- Trauma (always think about NAI)
What is the typical history of a child with syncope?
Prodrome
- Hot or clammy
- Sweaty
- Heavy
- Dizzy or lightheaded
- Vision going blurry or dark
- Headache
During
- Suddenly losing consciousness and falling to the ground
- Unconscious on the ground for a few seconds to a minute
- May be some twitching, shaking which can be confused with a seizure
- No prolonged confusion, drowsiness or irritability
- May be incontinence
What are some causes of syncope in children?
Primary
- Dehydration
- Missed meals
- Extended standing in a warm environment, such as a school assembly
- Sudden surprise, pain or the sight of blood
Secondary
- Hypoglycaemia
- Dehydration
- Anaemia
- Infection
- Anaphylaxis
- Arrhythmias
- Valvular heart disease
- Hypertrophic obstructive cardiomyopathy
What are some important questions to ask in the history when suspecting a syncope in a child?
- Features that distinguish a syncopal episode from a seizure
- After exercise?
- Triggers?
- Concurrent illness? Do they have a fever or signs of infection?
- Injury secondary to the faint?
- Associated cardiac symptoms, such as palpitations or chest pain?
- Associated neurological symptoms?
- Seizure activity?
- Family history, particularly cardiac problems or sudden death?
What examination and investigations should you do for a child with syncope?
Examination
- Any physical injuries as a result of the faint?
- Is there a concurrent illness, for example an infection or gastroenteritis?
- Neurological examination
- Cardiac examination: pulses, heart rate, rhythm and murmurs
- Lying and standing blood pressure
Investigations
- ECG: arrhythmia and long QT
- 24 hour ECG if paroxysmal arrhythmias suspected
- Echocardiogram if structural heart disease suspected
- Bloods: FBC (anaemia) U+Es, (arrhythmias and seizures) and blood glucose (diabetes)
If you exclude seizures and secondary causes for syncope, what advice can you give to parents and patients on discharge?
- Avoid dehydration
- Avoid missing meals
- Avoid standing still for long periods
- When experiencing prodromal symptoms such as sweating and dizziness, sit or lie down, have some water or something to eat
If a child has a extradural or subdural haemorraghe, what do you need to consider?
Head injury - is this abuse?
What are causes of subarachnoid hameorraghe in children?
- Trauma
- Aneurysms
- AV malformations
- Tumours
What are causes of raised ICP in children?
- Meningitis
- Encephalitis
- Traumatic brain injury (accidental or NAI)
- Subdural/Extradural bleeds
- Tumours
- DKA
- Reye’s
- Hydrocephalus
How may a child with raised ICP present?
- Relative bradycardia with hypertension
- Focal neurological signs
- Bulging fontanelle
- Abnormal posture
- Unequal pupils, dilated or poorly responsive
- Abnormal eye movement/ persistent eye deviation
- Seizures
- Reduced GCS= 8
- Papillodema (late sign)
- Vomiting
How is raised ICP in children managed acutely?
- Start resuscitation, ABC approach
- Check glucose and treat hypoglycaemia
- Elevate head 30 degrees in midline
- Give hypertonic saline or mannitol
- Treat shock if present cautiously, avoid hypotension
- Call for help and call anaesthetist early on
- Urinary catheter for fluid chart
- Neuro observation every 15 minutes
You shouldn’t do an LP in a child with raised ICP until what point?
- Intubated
- Stabilised
- Had a CT
What are some causes of hydrocephalus?
Either too much CSF production or problem draining/absorbing CSF
Non-Communicating (Obstruction)
- Aqueductal stenosis (most common, between 3rd and 4th ventricle)
- Arachnoid cysts
- Intraventricular haemorraghe (premature neonates)
- Arnold-Chiari malformation (cerebellum herniation in to F.Magum)
- Chromosomal abnormalities and congenital malformations
Communicating (issue with reabsorption)
- SAH
- Meningitis
How may hydrocephalus present in an infant?
- Rapidly enlarging head circumference
- Bulging anterior fontanelle
- Poor feeding and vomiting
- Sunsetting of eyes
- Distension of veins on scalp
- Papilloedema
How is hydrocephalus diagnosed?
- Cranial US through anterior fontanelle
- MRI or CT
LP must not be used in obstructive hydrocephalus since the difference of cranial and spinal pressures induced by drainage of CSF will cause brain herniation
How is hydrocephalus managed?
- External ventricular drain (EVD): Acute, severe hydrocephalus. Inserted into right lateral ventricle and drains into a bag
- Ventriculoperitoneal shunt (VPS): long-term drains CSF from ventricles to peritoneum
- Obstructive hydrocephalus: surgically treat obstructing pathology
What are some ventriculoperitoneal shunt complications?
Teach parents how to recognise blockage and infection
- Infection
- Blockage
- Excessive drainage
- Intraventricular haemorrhage during shunt related surgery
- Outgrowing them (need replacing every 2 years as child grows)
What are the complications of untreated hydrocephalus?
- Severe neurological deficit
- Death due to coning
What are some differentials for headaches in children?
- Tension
- Migraines
- ENT infection
- Analgesic headache
- Problems with vision
- Raised ICP
- Brain tumours
- Meningitis
- Encephalitis
- Carbon monoxide poisoning
- Hypertension (always take BP)
- Sinusitis
How do tension headaches appear in children and what are some triggers?
- Pain or pressure in a band-like pattern around the head
- Symmetrical
- No visual changes
- Come on gradually
Young children: quiet, stop playing, turn pale or become tired
How are tension headaches managed in children?
- Reassurance
- Analgesia
- Regular meals
- Avoid dehydration
- Reduce stress
What are the different types of migraine that children can have?
- Migraine without aura
- Migraine with aura
- Silent migraine (migraine with aura but without a headache)
- Hemiplegic migraine
- Abdominal migraine
How do migraines present in children?
- Usually unilateral
- Visual aura
- Photophobia and phonophobia
- Nausea and vomiting
- Abdominal pain
- Last between 2 and 72 hours
How are acute migraines in children managed?
- Rest, fluids and low stimulus environment
- Paracetamol
- Ibuprofen
- Sumatriptan
- Antiemetics, such as domperidone (unless contraindicated)
What migraine prophylaxis is given to children?
Give if migraines are regularly disrupting social activity or schooling
- Reduce stress, improve sleep, avoid skipping meals
- Propranolol (avoid in asthma)
- Pizotifen (often causes drowsiness)
- Topiramate (girls with child bearing potential need highly effective contraception)
How does abdominal migraine present in children?
Central abdominal pain>1hour with normal examination
- Nausea and vomiting
- Anorexia
- Headache
- Pallor
What simple infections can cause headaches in children?
Always check throat and ears
- Otitis media
- Viral URTI
- Tonsilitis
- Sinusitis
What is a cause of cortical blindness in neonates?
HYPOGLYCAEMIA!!
What is squint (a.k.a strabismus) and some causes of this?
Misalignment of the eyes, can lead to amblyopia if not corrected
- Idiopathic
- Hydrocephalus
- Cerebral palsy
- Space occupying lesions, for example retinoblastoma
- Trauma
What examination should you do if a child has a squint?
- General inspection
- Eye movements
- Fundoscopy (or red reflex) to rule out retinoblastoma or cataracts
- Visual acuity
-Hirschberg’s test: reflection of the light source on their cornea
-Cover test
How is a squint in children managed and what age does this need to be done before?
Manage before 8 because visual fields are still developing until then
- Occlusive patch or Atropine drops in good eye
- Corrective lenses
- Surgery
