Central nervous system Flashcards
When is asymmetry of motor skills (i.e. hand dominance) abnormal?
<1 year
What system classifies motor functional ability? e.g. in CP, and what are the levels?
Gross Motor Function Classification System (GMFCS)
1: walks without limitations
2: walks with limitations
3: walks using a handheld mobility device
4: self-mobility with limitations; may use powered mobility
5: transported in a manual wheelchair
Types of CP
- Spastic
- unilateral (hemiplegia)
- bilateral (quadriplegia)
- bilateral (diplegia) - Dyskinetic
- Ataxic (hypotonic)
Features of spasticity in CP
- velocity-dependent: the faster it’s stretched the greater the resistance
- hallmark of spasticity: ‘dynamic catch’
- clasp knife (increase tone may suddenly yield under pressure)
What is unilateral (hemiplegia) spastic CP and the cause?
- damage to UMN
- arm and leg on opposite side to lesion affected
What is bilateral (quadriplegia) spastic CP and the cause?
- damage to UMN
- all 4 limbs affected, often severely
What is bilateral (diplegia) spastic CP and the cause?
- damage to UMN
- all 4 limbs but legs much more affected than arms
What is dyskinetic CP and the cause?
- damage/dysfunction in basal ganglia or associated pathways (extrapyramidal)
- dyskinesia = involuntary, uncontrolled movements
- chorea - irregular, sudden, brief, dance-like movements (non-repetitive)
- athetosis - slow writhing movements distally
- dystonia - simultaneous contraction of agonist and antagonist muscles of trunk and proximal muscles, causing twisting appearance
What is ataxic (hypotonic) CP and the cause?
- mostly genetic
- if acquired: cerebellum or its connections
- signs on same side as lesion
- early trunk and limb hypotonia, poor balance, delayed motor movements
- later incoordinate movements, intention tremor, ataxic gait
What medications are used to relax muscles in CP?
- diazepam
- baclofen (can be given intrathecally)
- botulinum injections
Features of febrile convulsions (consider another diagnosis if these are not present)
- generalised tonic clonic
- <15mins
- without recurrence within next 24h or within same febrile illness
Age range for febrile seizures
6 months - 6 years
What features suggest a focal frontal seizure?
motor phenomena
What features suggest a focal temporal seizure?
auditory or sensory (smell or taste) phenomena
What features suggest a focal occipital seizure?
positive or negative visual phenomena
What features suggest a focal parietal seizure?
contralateral altered sensation (dysaesthesia)
What generalised seizures are there?
- myoclonic
- tonic
- tonic-clonic
- atonic
- absence
Investigations for ?epilepsy
- ECG to rule out convulsive syncope due to arrythmia (if any diagnostic uncertainty)
- EEG
- MRI and CT (unless characteristic Hx of certain type)
- metabolic Ix if related to feeds/fasting or developmental arrest/regression
- genetic tests if indicated
How to provoke absence seizure
hyperventilation e.g. blowing a toy windmill
Long term management of absence seizures
sodium valproate, ethosuxamide or lamotrigine
Which children with epilepsy are given rescue medication and what are they given?
- children with prolonged epileptic seizures (convulsive with LOC >5min)
- buccal midazolam (or rectal diazepam)
Long term management of tonic clonic seizures
sodium valproate, carbamazepine, lamotrigine
Long term management of myoclonic seizures
sodium valproate, levetiracetam, topiramate
Long term management of focal seizures
sodium valproate, carbamazepine, levetiracetam, lamotrigine
Non-pharmacological Mx options for epilepsy
- ketogenic diet
- vagal nerve stimulation
- surgery
Advice/things to discuss RE epilepsy
- avoid situations where seizure would be dangerous
- no driving until 1y seizure free
- SUDEP very rare in childhood
- self-help groups
- liase with school RE managing seizures
What is status epilepticus
epileptic seizure lasting 5 mins or repeated epileptic seizures for 5 mins without full recovery of consciousness
Management of status epilepticus
0 mins: airway, high flow O2, glucose?
5 mins: IV/IO lorazepam, buccal midazolam or rectal diazepam
15 mins: IV/IO lorazepam, call for senior help, reconfirm it is an epileptic seizure
25 mins: senior help and anaesthetist needed, anaesthetist/ICU advice, consider rectal paraldehyde, phenytoin IV/IO over 20 min (or phenobarbitone over 5 min if already on phenytoin)
45 mins: RSI of anaesthesia with thiopental
Who is at risk of developing rebound chronic daily headaches?
people who use analgesics or triptans on >2 days/week
When to do Ix/imaging in children’s headaches
only if red flags present
Prevention of headaches in children
for frequent, intrusive headaches
- propranolol
- topiramate (or valproate)
- amitriptyline
Management of headaches in children
- lifestyle e.g. help with stressors; ensuring adequate rest, food, etc.
- paracetamol + NSAIDs taken asap in an individual episode
- antiemetics e.g. cyclizine
- triptans e.g. sumitriptan - nasal preparation in EARLY migraine attack (with paracetamol and NSAID)
- physical e.g. cold compress, warm pads, etc.
