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extra 1 (e) > Nervous System > Flashcards

Nervous System Flashcards

1
Q

What is cerebral palsy?

A

A group of disorders in which there is developmental delay and disorder of posture and movement resulting from a non-progressive, permanent, fixed cerebral lesion in developing/immature brain

May or may not also present with other neurological symptoms eg learning difficulties / epilepsy

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2
Q

How common is cerebral palsy?

A

Most common motor impairment in children

1/500

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3
Q

What proportion of cerebral palsy are caused by damage to the immature brain antenatally, perinatally and postnatally?

A 
Antenatal = 80%
Perinatal = 10%
Postnatal = 10%
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4
Q

What are some antenatal causes of cerebral palsy?

A

1) Maternal infection = TORCH
2) Radiation exposure
3) Intraventricular haemorrhage (IVH)
4) Chorioamnionitis
5) Multiple births eg twins
6) Maternal resp or genitourinary infection

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5
Q

What is TORCH?

A 
Toxoplasmosis
Other infections eg syphilis, VZV, parvovirus B19, Listerosis and Coxsackie virus
Rubella
CMV
Herpes simplex
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6
Q

What are some perinatal causes of cerebral palsy?

A

1) Hypoxic-ischaemic encephalopathy (HIE)

2) Intrapartum trauma

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7
Q

What are some postnatal causes of cerebral palsy in the neonate?

A 
IVH
Hyperbilirubinaemia - Kernicterus
Hypoglycaemia
Cerebral infarct
Meconium aspiration
Meningitis
Encephalitis
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8
Q

What are some postnatal causes of cerebral palsy in the infant?

A

Hydrocephalus
Hypoglycaemia
CNS infection

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9
Q

What are some postnatal causes of cerebral palsy in the child?

A

Hypoxic event eg drowning
Head trauma
Lead poisoning
CNS infection

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10
Q

What is the disease progress of cerebral palsy?

A

Lesion is fixed and non-progressive but the symptoms become worse over time

= “circle on an inflating balloon” as child’s brain grows

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11
Q

What are the four classification of cerebral palsy based on type of movement disorder?

A

1) Spastic (80%)
2) Dyskinetic
3) Ataxic

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12
Q

Describe the spastic movement of cerebral palsy

It is caused by damage to what?

A

Intermittently increased tone and pathological reflexes = stiff and tight muscles

Damage of UMN

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13
Q

What are the varying degrees of spastic movement disorder in cerebral palsy?

A

Hemiplegia
Diplegia
Quadriplegia

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14
Q

Describe hemiplegic spastic movement in cerebral palsy

A

Hemiplegia:

  • Unilateral arm and leg affected (arm>leg)
  • Arm = flexed and pronated
  • Leg = cricumducted gate, tiptoe walking, delayed walking
  • Moderate developmental delay and seizure risk
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15
Q

Describe diplegic spastic movement in cerebral palsy

A

Diplegia:

  • Mostly lower limbs affected (less arms)
  • Commando crawl = dragging legs scissored
  • Often normal intellectual development and minimal seizure risk
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16
Q

Describe quadriplegic spastic movement in cerebral palsy

A

Quadriplegia:

  • All four limbs affected
  • Increased tone
  • Swallowing difficulties
  • Significant intellectual delay
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17
Q

Describe the two types of dyskinetic movement of cerebral palsy

It is caused by damage to what?

A

1) Athetoid = writhing movement
- Often normal intellectual development

2) Dytonic = involuntary movements
- Worse on movement
- Unusual posture

Damage to basal ganglia

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18
Q

Describe the ataxic movement of cerebral palsy

It is caused by damage to what?

A

Shaky movements, poor balance and sense of positioning

Ataxic gait = wide base, unsteady trunk, jerky movements

Damage to cerebellum

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19
Q

MOVE CARD

When can the lesion occur in cerebral palsy?

A

At any point from conception - 3yrs

After 3 yrs = acquired brain injury

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20
Q

How may cerebral palsy present?

A

1) Delayed milestones
2) Abnormalities of tone eg hypotonia, spaces or dystonia
3) Abnormal motor development eg late head control, rolling, crawling
4) Feeding difficulties

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21
Q

What are the most common delayed milestones in children with cerebral palsy?

A

1) Not sitting by 8 months
2) Not walking by 18 months
3) Early hand preference before 1 year (should be ambidextrous until 18 months)

Correct for gestational age

22
Q

What are complications of CP?

A

Physical

  • Muscle spasms and contractions
  • Feeding difficulties and nutritional problems
  • incontinence

Social

  • Problems dressing, ADLs
  • Developmental delay
  • Hearing / language impairment

MSK

  • Scoliosis
  • Hip dislocation
  • Inc risk of low bone mineral density = inc risk of osteomalacia / osteoporosis

Neuro
- Epilepsy

Other body systems

  • Recurrent respiratory infections
  • GORD
  • Constipation
  • UTI

NB many children with CP have preserved cognitive function

23
Q

What investigations are done for CP?

A

Diagnosis made clinically

Exclude other causes eg:

  • Thyroid studies
  • Chromosomal analysis
  • CSF etc
24
Q

What may be given to improve movement in CP?

A

Mobility aids eg orthotic devices, wheelchairs

Splinting improve ROM eg ankle joints

25
Q

What may be given to help manage spacisity in CP?

A

Oral diazepam = useful if rapid effect needed eg pain crisis

Baclofen = sustained long term effect eg continuous discomfort

Baclofen can be given via continuous pump-administered intrathecal Baclofen

26
Q

What may be given to help manage dystonia eg problems with posture, function or pain?

A

Trihexyphenidyl
Levodopa
Baclofen

27
Q

When may botulinum toxin type A be given in CP?

A

Focal spasticity eg impeding fine motor function / disturbing sleep

Rapid onset spacisity

Pneol and they alcohol can be given if this fails

28
Q

What professionals involved in MDT approach of CP?

A 
Paeds
OT
SALT
Nutrition
Education
29
Q

What are febrile seizures?

A

aka febrile fit/convulsion

= Seizures occurring in children aged 6 months - 5 years, associated with fever, without an underlying cause such as a CNS infection or electrolyte imbalance

30
Q

What two features must be present in order for a classification of a febrile convulsion?

A

1) Axillary temperature above 37.8 degrees c

2) Clinical hx / examination indicative of febrile seizures

31
Q

What is the emergency treatment of febrile seizures?

A

If child is still convulsing or not fully altert:

  • Recovery position + ABCDE
  • Check blood glucose
  • If still seizing >5min = rectal diazepam OR single dose buccal midazolam OR IV lorazepam

Meningococcal disease suspected:
- benpen or cefotaxime

32
Q

What is a simple febrile seizure?

A

Generalised tonic-clonic seizures
Last <15mins
Do not recur within 24hrs or within the same febrile illness

= most febrile seizures

33
Q

What is a complex febrile seizure?

A

Must have one/more of:

1) Focal features at onset or during seizure
2) Duration >15mins
3) Recurrence within the same febrile illness

= 20% febrile convulsions

34
Q

What is a febrile status epileptics?

A

Febrile seizure lasting more than 30 minutes

= 5% febrile convulsions

35
Q

What are other types of seizures related to acute illness in children?

A

1) Febrile myoclonic seizures
2) Afebrile convulsions in young children with mild gastroenteritis - clusters of seizures with/without fever over several days in those with gastroenteritis = good prognosis

36
Q

How common are febrile convulsions?

A

Common - 2-5% children

37
Q

What are the most common causes of fever in febrile convulsions? (5)

A

Most:

1) Viral infections eg URTI
2) OM
3) Tonsillitis

Others:

4) Gastroenteritis
5) Post-immunisation

38
Q

What are some serious illnesses which need excluding in a febrile child with a seizure?

A

1) Meningitis and septicaemia
2) UTI
3) LFTI
4) Cerebral malaria

39
Q

What features of a seizure are important in a seizure hx?

A

1) Conscious level prior to seizure
2) Duration
3) Focal or generalised
4) Time taken to recover
5) State of child after

40
Q

What other features are important to include in a seizure hx?

A

1) Any symptoms of meningitis or septicaemia
2) Is it a febrile seizure
3) Past or FH of seizure (24% have FH)

41
Q

What features are important to include on examination of a child with a febrile convulsions?

A 
Vital signs
Conscious levels
Rash - blanching or non-blanching
Fontanelle
Meningism
Focus of infection
42
Q

What investigations are performed for a febrile convulsion?

A

Investigate febrile illness rather than seizure, eg:

Bloods: FBC, ESR, glucose, U&Es, coagulation, culture

Urine microscopy/culture

LP

43
Q

Ddx for febrile convulsion?

A 
Rigors
Syncope
Breath-holding spells
Reflex anoxic seizures
Apneoa
Postictal fever
Epilepsy
Hypoglycaemia
Encephalitis
Afebrile seizures with gastroenteritis
44
Q

What are reflex anoxic seizures?

A

A precipitant eg minor bump causes vaguely mediated cardiac asystole lasting many seconds

Child may be pale, floppy and lose consciousness, followed my tonic and clonic movements

45
Q

What makes a posticltal fever more likely?

A

Temp >38

Seizure lasts >10min

46
Q

What is the management of a febrile convulsion?

A

Monitor for a few hours

Send home if child looks well, parents understand how to treat febrile illness and further seizures and can access medical services easily

Arrange review

47
Q

What advice should be given to a parent of a child with febrile convulsions?

A

Give leaflet

Explain what febrile seizures are

How to treat fever at home - remove excess clothing, give fluids, give antipyretics if child uncomfortable

Tepid sponging or cooling not recommended

Check for non-blanching rash, change of alertness, dehydration, fever >5 min - seek medical assistance

Stay with child at night

First aid if child has a fit - position child and do not put anything in their mouth

Call 999 if seizure lasts more than 5 minutes

48
Q

What is the prognosis of febrile convulsions?

A

Good

By definition do not recur beyond 5 yrs (30% do)

Intellect not affected, nor is there an inc risk of death

49
Q

What are some risk factors of recurrence of febrile convulsions? (4)

A

1) FH
2) Onset <18 months
3) Lower temperatures
4) Shorter duration of fever at onset

50
Q

What % of children with febrile seizures go on to develop epilepsy?

A

2-7%

Higher with complicated febrile convulsions

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