Neuro Flashcards
Classify CP (8)
Pyramidal (cortex involved)
- spastic
>quadriplegic (all 4 limbs)
> hemiplegic (one side)
> double hemiplegic (arms > legs)
> diplegic (legs > arms)
Extrapyramidal (subcritical: basal ganglia, cerebellum, +/- cortex)
- dyskinesia (basal ganglia)
> chorio-atethoid (alternating flexor/extensor dystonia-faster)
> dystonic (may be transient - slower)
- ataxic-hypotonic (cerebellum)
-mixed
Name 5 prenatal aetiology of cerebral palsy
- toxaemia of pregnancy (pre-eclampsia)
- genetic factors!
- antenatal bleeding
- cerebral malformations
- valproate use!
- hydrocephalus
Name 10 perinatal aetiology of cerebral palsy
- prematurity
- SGA
- birth asphyxia!
- hypoxic/ischaemic encephalopathy
- cerebral birth trauma
- kernicterus (hyperbilirubin)
- metabolic eg hypoglycaemia
- infections!
- cerebral haemorrhages (IVH)
- perinatal strokes
Hydrocephalus, warfarin, TORCHES
Describe neurological exam (12)
- Introduce, explain, consent, comfort.
- general impression
- Vitals
- anthropometry
1. Neurodevelopmental: Milestones
2. Level of consciousness: avpu
3. Cranial nerves
4. Motor (power)
5. Tone: central and peripheral
6. Reflexes
7. Sensory (tickle)
8. Cerebellar and gait
How do cranial nerve examination?
- Cn I (olfactory): ask about smell and change, smell with eyes closed (impossible in baby )
- cn ii (optic- vision, afferent light reflex): visual acuity by reaching / snellen chant; peripheral vision ; near vision; visual fields by confrontation (count fingers while cover 1 eye) ; fundoscopy for red reflex, optic disc, retinal vessels, macula; afferent pupil reflex
- cn iii (oculomotor ): efferent pupil reflex; cover test; eye movements ( up, medial, down and in); accommodation reflex
- Cn iii, iv (trochlear), vi (abducens): eye movements
- cn v (trigeminal): chewing and mastication; jaw jerk, light touch face; corneal reflex
- cn vii (facial): expressions and symmetry
- cn viii (vestibulocochlear): hearing, balance
- cn ix (glosopharyngeal),x (vagus), xi (accessory): swallow; gag reflex; say ‘ah’ and check uvula central,
- cn xi: neck and shoulder movements
- cn xii (hypoglossal): stick out and move tongue,
Name 2 sign raised intracranial pressure
- Bradycardia
- vomiting getting progressively worse
Name 4 milestones at 3 months
Gross motor: lifts head in prone/ventral suspension
Fine motor: hands open, follows 180°
Communication: coo
Social: enjoys watching own hands
3AM: You wake up, and LIFT YOUR HEAD FROM PRONE. You WATCH your OPEN HANDS to wake yourself up. You FOLLOW the horizon 180º out the window and COO because you get to go back to sleep.
Name 4 milestones at 6 months
- Gross motor: roll over both ways, sit in tripod position (with support)
- fine motor: transfer from hand to hand and hand to mouth, reach for toys with palmar grasp
- communication: babbles
- social: express emotion
6 AM: when your alarm goes off, you BABBLE unhappily and EXPRESS DISPLEASURE. You ROLL OVER and SIT IN TRIPOD POSITION. You REACH for alarm, (palmar) GRASP it and TRANSFER it to the other hand to turn it off.
Name 4 milestones at 1 year
- gross motor: bear walks, walk around furniture
- fine motor: release, throws away, pincer grasp
- communication: can say nouns (mommy), knows name, knows 1-3 word phrases
- social: finger eats, likes pictures
1 PM: it’s lunch time and you’re hungry like a BEAR. You PINCER GRASP your lunch box with FINGER FOODS and find a note. It says, CARLA (knows name) MOMMY (can say nouns) LOVES YOU (understand 1-3 word phrases). You RELEASE the note, eat and THROW AWAY the trash.
Name 4 milestones at 2 years
- Gross motor: jumps, walks upstairs with both feet
- fine motor: can make train with blocks, hand preference , build tower of 6 blocks
- communication: can name 1 body part and point at 4, knows pronouns and verbs
- social: can dress, possessive
2 PM: exercise time. You DRESS in YOUR exercise clothes. You JUMP up the STAIRS WITH 2 FEET. You should gym FOUR body parts but you only gym ONE. Your RIGHT hand is sore afterwards.
Name 4 milestones at 3 years
Gross motor: walk up stairs one foot per stair
Fine motor: can draw circle, use scissors, turn individual pages
Communication: count to 10, knows gender, use sentences
Social: uses fork, bowel trained, empathy, interactive and cooperative play
3PM: study. You reluctantly walk ONE FOOT PER STAIR to the desk. You FEEL SORRY for yourself. You TURN INDIVIDUAL PAGES to page TEN, where you’ll study BOWEL TRAINING in FEMALES.
Name 4 milestones at 4 years
Gross motor: jumps on one foot, walk down stairs one foot at time
Fine motor: 12 block tower, draw cross, draw person with head, chest, legs
Communication: knows age, points at colours
Social: can button clothes, make believe play
4 PM: Break time. You JUMP ON ONE FOOT because you’re excited it’s break time. You UNBUTTON your pants and MAKE BELIEVE you are EIGHTEEN on a beach DRAWING A YELLOW STICKMAN.
Name 4 milestones at 5 years
Gross motor: walk straight line
Fine motor: draw square and triangle, cut along lines,
Communication: recites alphabet, fluent speech
Social: use knife and fork, chooses own friends
5PM: You had a big party to celebrate finishing studying with your OWN FRIENDS. You drank quite a bit. When the cops stop you, your SPEECH is too FLUENT, you struggle to RECITE ALPHABET, you can’t DRAW SQUARE/TRIANGLE, you can’t WALK IN STRAIGHT LINE.
Name 7 causes microcephaly
- chromosomal abnormalities
- teratogenic
- syndromic
- perinatal hypoxia
- Intrauterine infections
- familial microcephaly
- Severe metabolic disorders
Name 5 causes macrocephaly
- Isolated macrocephaly
- associated growth disturbances
- neurocutaneous syndrome
- chromosomal abnormalities
- hemi - megalencephaly
- hydrocephalus
- storage disorders
- Space occupying lesions
- familial
- Sotos syndrome
At what age should child be able to stand
10 months
At what age should child be able to walk
15 months
How assess higher functions in children? (2)
< 5: developmental level
> 5: school performance and behaviour
How do neurological motor examination? (11)
Inspect:
- abnormal posturing,
- muscle size, shape, symmetry
- abnormal movements and fasciculation’s
Tone
- central (head lag and control)
- peripheral
- hypo/hyper/ clonus; spasticity (velocity dependent clasp knife) / rigidity (lead pipe)
Reflexes
- upper limb: biceps, triceps, supinator
- lower limb: knee jerk, ankle jerk
- babinski: abnormal after 2 years age - Cortico spinal tract region
- grade 0-5
Power
- grade 0-5
How classify abnormal involuntary movements? (6)
Slow
- dystonias (sustained twisting contractions)
- athetosis (writhing)
Fast
- stereotyped (able to mimic)
→ rhythmic → tremor (specific frequency/speed and amplitude coarse/fine); stereotypies eg head banging, rocking. Can be distracted!
→ non-rhythmic → tics (sudden twitch/movement, involuntary but can be suppressed. Tourette’s = 2 motor and 1 vocal tic at least 1 year)
- non-stereotyped
→ chorea (periphery, continuous, jersey, purposeless, arrhythmical, asymmetric )
→ myoclonus (jerk)
How do sensory neurological examination? (4)
- Light touch (dorsal column)
- pain (spinothalamic)
- tuning fork vibration (128 hz) (dorsal column)
- proprioception hands + toes (dorsal column)
How do cerebellar examination? (12)
- Inspect standing posture
- inspect resting tremor
- test eye movements for nystagmus
- orientation tremor (hands out)
- dysdiadochokinesis
- finger to nose test both sides (intention tremor)
- fine finger movements
- repeat “baby hippopotamus”
- observe gait and arm swing
- heel to toe test
- Romberg’s test (stand with feet together and close eyes)
- heel to shin test
Name 2 signs of meningeal irritation
- Kerning sign: extend knee on flexed hip at 90 - cause pain and restriction beyond 135°
- Brudzinski neck sign: reflex flexion of patient’s hips and knees on passive flexion of the neck
Name 7 types gait and what they indicate
- Spastic: crouching and scissoring (umn)
- high steppage: foot drop, left leg high, exaggerated hip flexion (nerve palsy)
- broad based : unsteady, poor coordination (cerebellar ataxia)
- Hemiparetic circumduction: swing leg in semicircle (cp)
- apraxic: small hesitant steps (frontal lobe)
- waddling: weak proximal muscles (myopathy eg duchenne )
- antalgic: pain, weight bear more on one side, limp
- slapping: distal extremity weakness
How grade reflexes?
O: no response
1: contraction without movement
2: slight movement (normal)
3: brisk
4: clonus
How grade power?
0: no contraction
1: flicker
2: active movement. gravity excluded
3: against gravity
4: against resistance
5: normal, can’t overcome
Name 3 characteristics umn lesion
- Loss muscle strength distal to injury
- hypertonia
- hyperreflexia
Name 3 characteristics LMN lesion
- Muscle fasciculation’s
- atrophy and loss strength
- decreased tone
- absent reflexes
Most likely long term outcome of severe bacterial meningitis with hydrocephalus
Spastic quadriplegic cp
When should child sit
6 months
When should child crawl
9 months
Name 4 sign cenebellar pathology
- Ataxia
- nystagmus
- dysmetria
- dysarthria
Name features turner syndrome
Webbed neck
Early sign cp?
Poor or high pitched cry
Where is lesion in patient with chorea
Basal ganglia
How is rett syndrome characterised
Hand stereotypes
Which test helps diagnose proximal weakness
Ck (creatine kinase) level
What type cp suspected in very premature baby with grade 3-4 Intraventricular haemorrhages
Spastic diplegic cp
Most common cause status epilepsy?
Abrupt withdrawal anti-epileptic drugs
Define epilepsy (3)
- At least 2 unprovoked seizures > 24 hours apart
- one unprovoked/reflex seizure + a probability (60% or more) of further seizures over next 10 years
- diagnosis epilepsy syndrome
Name 9 symptoms and signs raised intracranial pressure
- Headache
- vomiting
- diplopia
- bulging fontanel
- diastasis of sutures
- sun setting sign
- mcewan “cracked pot”
- Cushing response,
- Papilloedema
Define microcephaly
Skull circumference less than 2 standard deviations of mean for age, race, sex
Define macrocephaly
Skull circumference more than 2 standard deviations of mean for age, race, sex
Define Sydenham’s chorea and what it indicates
- Major sign rheumatic fever (Jones criteria) - late symptom
- girls > boys; hypotonia and emotional lability can occur
- ESR can be normal and antibodies negative. Cardiac involvement in 1/3 - check heart!
- antineuronal antibody mediated post group A Bh strep infection
- duration weeks to months, usually good outcome
- require penicillin prophylaxis as for rheumatic fever
Name 4 causes dystonia
Primary
- Genetic eg primary torsion dystonia (normal imaging! )
Secondary
- metabolic
- Drug
- brain injury: stroke / tumour / dystonic cp
Differential diagnosis ataxia? (9)
Acute
- cerebellitis /inf
- intoxication
- tumour (MRI)
Chronic non-progressive
- “ataxic” / hypotonic cp (rare)
- congenital malformation
- early injury eg prematurity
Chronic progressive neurodegenerative (genetic)
- Sca
- ataxia telangiectasia!
- Friedrich’s ataxia
Name 5 dyskinetic disorders that mimic cp
- neurotransmitters
- glucose transporter defects
- brain iron accumulation
- organic acid disorders
- mitochondrial disorders
Name 5 spasticity disorders that mimic cp
- Pelizaeus - merzbacher
- hereditary spastic paraplegias
- lysosomal storage disorders
- migrational disorders
- disorders of forebrain cleavage
How classify stroke? (4)
Haemorrhagic
- vascular: abnormal vessels eg aVm
- intravascular: bleeding disorder eg ITP
Ischaemic
- arterial: occlusion with focal cerebral infarction
- venous: cerebral vein or venous sinus occlusion with or without infarct
Name 8 causes childhood stroke
- Heart disease! (25%): congenital cyanotic; rheumatic, SBE; cardiomyopathy
- bleeding tendencies
- hypercoagulable states: increased viscosity (sickle cells, polycythaemia; dehydration); fv Leyden, prot C+S deficiency
- trauma: carotid thrombosis (falling with pen in mouth); vertebral artery thrombosis (after minor neck trauma)
- vasculopathies: Moyà - Moyà, avm/ aneurysms; Sturge Weber syndrome
- vasculitis: connective tissue disorders (sle, RA); auto-immune vascalitis; varicella! (30%)
- infections: varicella! (30.%), HIV, mastoiditis
- metabolic/ syndromic
Clinical presentation arterial ischaemic stroke of the anterior circulation (3)
- Hemiparesis
- facial palsy
- seizures common
Clinical presentation arterial ischaemic stroke of the posterior circulation (3)
- Dysphasia
- headache
- nausea
Clinical presentation cerebral bleed stroke (4)
Dramatic onset!
- severe headache
- hemiplegia
- seizures
- coma
Clinical presentation venous thrombosis stroke (5)
Children > adults!
- headache
- vomiting
- seizures
- altered mental state
- focal deficit ( hemiplegia either side)
Complication neonatal (prenatal) stroke?
Hemiplegic cp
Most common cause hemiplegic cp?
Neonatal (prenatal) stroke
Highest risk = 20 weeks gestation → 28 days post birth
Name 10 risk factors neonatal (prenatal) stroke
Foetal
- twin pregnancy
- polycythemia
Maternal
- auto -immune
- drug abuse
- clotting problems
- infection
Placental
- abruptio
- chorio -amnionitis
- placental thrombosis
Birth
- injury to carotid injury (traction on neck)
- resuscitation / hypotension
2 most common neuromuscular diseases in children?
- Muscular dystrophy: Duchenne’s
- sma
Name 2 epilepsy syndromes neonates
- Benign familial neonatal epilepsy
- ohtahara syndrome
Name 3 epilepsy syndromes infancy
- West syndrome
- myoclonic epilepsy in infancy
- dravet syndrome
Name 4 epilepsy syndromes childhood
- Benign epilepsy with centro-temporal spikes
- Lennox - gastaut syndrome
- landau - kleffner syndrome
- childhood absence epilepsy
Name 4 epilepsy syndromes adolescence
- Juvenile absence epilepsy
- Juvenile myoclonic epilepsy
- generalized tonic - clinic seizures
- other familial temporal lobe epilepsies
Define febrile seizures (4)
- Seizures age 6 months and 3-5 years in association with fever but without evidence intracranial infection
- most before age 3, average age 18-22 months
- boys > girls
- younger = higher risk recurrence, 2% risk of developing epilepsy
Simple vs complex febrile seizures? (3)
- Generalised tonic clinic vs focal
- < 15 vs > 15 minutes
- no recurrence within 24h vs 2 or more within 24h
Epileptic seizures vs paroxysmal non-epileptic events?
- <3 vs > 3 minutes
- brief cry, no emotional content vs complex weeping, yelling
- synchronous movements vs failing, thrashing
- eyes usually open vs closed
- acute onset/offset vs slow
- medication improves us no change
- frequent injury us uncommon
- frequent incontinence us occasional
- rare provocation vs common
- Occurs awake or asleep vs day, audience
- post-ictal lethargy / confusion vs none
Treatment absence epilepsy?
Sodium valproate (increase GABA, reduce GHB, inhibit NMDA rs)
Not carbamazepine! Exacerbates.
Treatment focal and generalised tonic clonic seizures?
Carbamazepine (blocks Na channels)
Treatment status epilepsy children? (3)
Step 1: lorazepam 0,1 mg/ kg iv (12-15 h effect ) (repeat X1)
Step 2: phenytoin 20 mg/kg in saline, 20-30 min slow infusion (can give extra 5 -10mg/kg)
Step 3: thiopentone infusion until 48 hours seizure free. Intubate, ICU, EEG.
Treatment status epilepsy neonates and infants? (3)
Step 1: phenobarbitone 20 mg / kg
Step 2: phenytoin 20 (never valproate!)
Step 3: thiopentone
Define cp (4)
GROUP of disorders of the development of movement and posture causing activity limitation that are attributed to NON-PROGRESSIVE distibunces (single event/ insult) that occurred in developing brain (prenatal → 2 years age)
Name 7 early warning signs for cp
- No head control at 3 months
- early handedness
- Thumb across palm in newborn
- Fisting (hand held closed ) at 4 months
- reaching with dystonic posturing
- abnormal primitive reflexes: poorly developed initially or persistence
- Scissoring on vertical suspension
