Neuro Flashcards
What are gross motor skills
Truncal and major limb muscles which help mobility
What are fine motor skills
Fine movements- using hands mainly
Also encompasses vision
If patient has speech problems what is important to check first
Check auditory system
Which develops first hearing or expressive development
Hearing
What are primitive reflexes
Reflexes we are born with but we lose at 3 months
What are the primitive reflexes
Sucking and rooting
Palmar grasp
Stepping
Asymmetric tonic reflex (ATNR)
mORO
Babinski
Which is worse neonatally hypothermia, hypoglycaemia or hypoxia
Hypoglycaemia is the worst
Then hypoxia and hypothermia
What is the sucking and rooting reflex
If tickle side of mouth, baby will try to suck it
Evolutionary purpose of sucking and rooting
First evolved as means can not go hypoglycaemic
What is the palmar grasp
If stimulate the palm then baby will try to grab it
Disappears by 1 year
What is the stepping reflex
If hold baby up will lift foot up as if taking step
What is the asymmetic tonic neck reflex
If turn babies neck then will get extension on that side of the body
What is the moro reflex
If move baby or hears loud noise will extend arms upwards then move them back to body
Why is babinskis reflex significant in babies
Myelin not formed properly by age of 1 so get positive babinskis
What are the protective reflexes
Head righting and parachute
Need to develop these before can attain motor development
What is head righting
If baby is sat and move the baby it will move neck to make sure its neck remains perpendicular
When should babies develop head righting
4-6 months
What is the parachute reflex
If when try to stand outstretch arms to protect the head
When should develop parachute reflex
7-9 MONTHS
What happens to grip in development in first year of life
Initially develop full hand grip then move to mature pincer but lose full hand grip a bit
Principles of learning development milestones
6wks
6months
12months
18months
24months
36months
When do children normally stand by
10 months
Gross motor development milestones
6wks- head control
6mths- no head lag, sitting
12mths- pulls to stand, walking, cruising
18mths- walks well, run
24mths- climbs stairs (1 step), kicks ball
36mths- standing on one leg, climbs stairs
Fine motor and vision
6wks- fixes and follows
6mths- full hand grip, hand to hand transfer
12 mths- mature pincer, pointing
18mths- build tower of 3 blocks, hand preferance, scribbles
24 mths- build tower of 7 blocks, circular scribbles
36mths- draw circle, imitates bridge
What is cruising
When hold on to furniture
Language and hearing development milestones
6wks- stills to sound
6mths- turn to sound, babbles
12mths- first word, respond to name
18mths- 6-12 words, follow simple instruction
24 mths- 2 words sentence
36mths- speaks in sentences
Socail skill and self care development milestones
6wks- smiles
6 mth- laughs and squeals
12mths- waves and peek-a-boo, drink from cup
18mths- spoon feeding, symbolic play
24mths- start toilet training, remove clothes
36mths- parallel play, interacting play and sharing
When do you get nystagmus
If struggling to focus
What does clenched fist suggest with regard to fine motor
Unable to form pincer grip
What is criteria for global developmental delay
Lack of development in 2 or more fields
Long term management of child with meningitis
Review in 4-6 weeks after discharge
- audiological assessment
- neuro/development assessment
Immediate management of meningitis in a child
Resus
Abx
- If under 3 months IV amoxicillin/ampicillin and cefotaxime
- Over 3 months IV ceftriaxone/cefotaxime
Steroids (dexamethasone)
- if over 3 months
- prurulent CSF
- WCC over 1000
- raised CSF WCC and protein over 1g/L
- bacteria on gram stain
- over 1 month and Hinfluenzae
- non meningococcal
Fluids
What is used to treat contacts of meningitis
Ciprofloxacin
Order of investigations for meningitis
LP first unless contraindicated (not meningococcal!)
Blood culture
FBC, U&Es, CRP and glucose
Coagulation profile
Contraindications for initial LP in meningitis
Meningococcal
Focal neuro
Papilloedema
Bulging of fontanelle
DIC
Signs of cerebral herniation
Most common viruses causing meningitis
Cocksackie B
Echovirus
How to treat viral meningitis
Discharge home after tests to rule out bacterial
Supportive therapy- fluids etc
What is purpura fulminans
Haemorrhagic skin necrosis from DIC
How does purpura fulminans present
Blood spots
Mass discolouration of the skin
Treatment for purprua fulminans
FFP and surgical debridement
What are reflex anoxic seizures
Seizure in response to pain or emotional stimuli. Caused by neurally mediated transient asystole in those with very sensitive vagal cardiac reflexes
Typical features of reflex anoxic seizures
Child goes very pale
Falls to floor- can have seizure
Rapid recovery
Occurs in children aged between 6mths-3 years
DDx for micropcephaly
Normal variation
Familial
Congenital infection - CMV etc
Perinatal brain injury liek HIE
Fetal alcohol syndrome
Patau
Craniosynostosis
What is defined as microcephaly
An occipital-frontal circumfrence under the 2nd centile
How is retinoblastoma inherited
Autosomal dominant
Pathophysiology of retinoblastoma
Loss of function in retinoblastoma tumour suppressor gene chr 13
Causes tumour of retinal cells
Most common presenting symptom of retinoblastoma
Absence of red reflex giving white pupil
What is leukocoria
White pupil
How can retinoblastoma present
Leukocoria
Strabismum- eyes dont line up
Visual problems-
Normally around 18months
How can retinoblastoma occur categorically
Unilateral
Bilateral- ALL hereditary
Treatment of retinoblastoma
Depends on how bad the tumour is, options include;
- enucleation (remove eye but not the muscles)
- other options include external beam, radiation, chemo
Most common type of seizure in febrile convulsion
Tonic-clonic
How are febrile convulsions classified
Simple
Complex
Febrile status epilipticus
What causes febrile convulsion
Temperature rising rapidly early in response to a viral infection
Differences between simple and complex febrile convulsions
Simple
- under 15 mins
- generalised seizure
- does not recur
Complex
- 15-30 mins
- focal seizure
- may repeat in 24 hours
What advice should be given about febrile convulsions if happesn again
Time it
Protect from head injury
If lasts more than 5 mins call ambulacne or is possibility to use emergency benzos if specialist has advised them.
If given anti-epileptics then wait another 5 mins and see if the seizure has not stopped/unconscious give again and call an ambulance
OPtions for emergency benzos in febrile convulsion
Buccal midazolam
Rectal diazepam
Only advised if recurrent seizures
When should febrile seizures be referred for specialist care
1st one
Less than 18mths
Diagnostic uncertainty
Focal neuro deficit
Taken recent antibiotics as can mask CNS infection
Most common cause of headache in children
Migraine without aura
Then tension
What is criteria for diagnosing migraine
At least 5 headaches with 2 of the following
Headache attack lasting 4-72 hours
2 of the following features
- bilateral or unilateral (frontal/temporal) location
- pulsating quality
- moderate to severe intensity
- aggravated by routine physical activity
Is accompanied by 1 of following
- nausea
- photo/phonophobia
What are infatile spasms (WEST syndrome) and how do they present
A type of childhood epilepsy with characteristic salaam attacks- head, trunk and arms flex followed by extension of the arms
Typically 4-8 months
What causes west syndrome
Typically is an underlying condition
- tuberous sclerosis
- HIE
- downs syndrome
- SOL
Investigations for WEST syndrome
EEG- hysparrythmia
CT- underlying condition
Management of WEST syndrome
Refer for tertiary centre assessment within 24 hours
Combination therapy with vigabatrin and prednisolone
Presentation of encephalitis
LOC
Focal neurology
Ataxia
Fever
Seizure
Investigations for encephalitis
CT then LP for viral PCR
Management of encephalitis
IV ceftriaxone and aciclovir
What is arm in waiters tip position diagnosis
Erb palsy
How does Erb palsy present
Reduced tone
Reduced moro reflex
Arm in waitrtd tip position
Management of Erb palsy
Self-limiting
Physiotherapy
Presentation of BPV in a child
Episodes of vomiting and transient ataxia
Can note nystagmus
How do reflex anoxic episodes occur
Precipitated by fear
Stops breathing and LOC
Can be proceeded by bradycardia or a tonic seizure
What is talipes equinovarus
Clubfoot
Fixed defect with sole of foot facing inwards
Causes of talipes equinovarus
Idiopathic
Genetic
Spina bifida
Treatment for talipes equinovarus
Ponseti method
Manipulating the feet into correct position and fixing in cast
Repeated every week for 5-8 weeks and then a minor operation to loosen achilles tendon
What is difference between talipes equinovarus and positional talipes
Talipes equinovarus is permenant and requires ponseti method
Positional talipes is present in newborns where cramped in utero and requires physiotherapy
Why give cefotaxime in under 3months
Ceftriaxone contradindicated as causes hyperbilirubinaemia
What is cerebral palsy
Abnormality in movement and posture which limits activity caused by around birth injury to the brain
Risk factors of CP
Antenatal- preterm birth, chorioamnionitis, maternal infection
Perinatal- LBW, HIE, neo-natal sepsis
Postnatal- meningitis
Causes of CP
Antenatal 80%
- genetic syndromes
- structural maldevelopment
- vascular occlusion
During delivery 10%
- HIE
Postnatal 10%
- PVL
Where is damage in the types of CP
Spastic- UMN
Dyskinetic- basal ganglia
Ataxic- cerebellum
What are the 3 types of spastic CP
Hemiplegia- one side where arm and leg affected (face unaffected)
Quadriplegia- all 4 limbs affected
Diplegia- 4 affected but mianly legs
How does hemiplegic CP present
4-12 months
- fisting of affected side
- flexed pronated arm
- tiptoes walk on affected side
- hand preference before 1
Common features to all spastic CP
- increased tone and reflexes
- extensor plantar
- clasp knife rigidity (velocity dependent)
What is clasp knife rigidity
Increased tone suddenly releases under pressure
How does quadriplegic spastic CP present
All limbs affected ie all arms fisted
Involves trunk
Opisthotonos
Low central tone with associated complications
Complications of quadriplegic CP
Seizures
Microencephaly
Learning disabilities
Causes of spastic unilateral CP
Largely unknown- typically unremarkable PMH and birth
Most likely an antenatal cause
Main associated cause of quadriplegic CP
HIE mainly
Presentation of diplegic CP
Very abnormal gait
Main difficulty in arms comes with fine motor movements
Main associations of diplegic CP
PVL
Preterm birth damage
How does dyskinetic CP present with the different movement types
Involuntary uncontrolled movements
Chorea-> sudden brief non-repetitive movements
Athetosis-> slow writhing movements distally like fanning fingers
Dystonia-> simultaneous contractions of agonist/antagonist muscles giving twisted appearance
Main associations of dyskinetic CP
HIE and kernicterus
Presentation of ataxic CP
Hypotonia
Ataxia
Malcoordination
Delayed motor development and intention tremor
How can unilateral CP present
Neonatal hypotonia
4 development red flags for CP
Cant sit before 8mths
Cant walk before 18mths
Hand preferance before 1 year
Persistent toe walking
What could oromotor miscoordination with slow eating and gagging be
CP
Investigation for CP and when do
MRI
Only if diagnosis uncertain from whole clinical history
Red flags for other neuro conditions
Absence of risk factors
FHx of progressive development issue
Focal neurology developed
MRI findings progressive
Loss of already attained developmental abilities
Management of CP MDT
Paediatrician- will deal with medical problems
Physio- encourage movement, improve strenthy and stop muscles from losing range of movement
Speech and language
Occupational therapist- identify everyday tasks which may be difficult and help make these more accessible
What medication is given in CP if sleep difficulty
Melatonin
What medication is given in CP if stiffness
1st line- diazepam
2nd line- baclofen
What medication is given in CP if consitpation
Movicol
What medication is given in CP if drooling
Anticholinergic
Pre ictal visual disturbance followed by executive disinhibition and odd motor movements
Focal complex seizures
Strange sensation around the face typically in the evening
Can be tonic clonic
Benign rolandic epilepsy
Prognosis of benign rolandic epilepsy
Very good- should resolve by adolescence
EEG findings of benign rolandic epilepsy
Centrotemporal spikes
How are seizures classified
General
- tonic clonic
- myoclonic
- absence
- atonic
- clonic
Focal
- occipital
- parietal
- frontal
- temporal
What happens in tonic clonic seizures
Go stiff and fall to floor shaking
What happens in tonic seizures
Generalised stiffness
What happens in atonic seizures
Transient loss of muscle tone where head drops or fall to floor
What happens in myoclonic seizures
Rapid repetitive jerking movements
What happens in absence seizures
Period where staring into distance and can get flickering of eyelids
What happens in parietal seizures
Can get dyaesthesia contralterally to where abnormal brain activity is
What happens in frontal seizures
Motor abnormalities unilaterally
What happens in temporal seizures
Auditory or olfactory sensations
Automatisms where keep smacking lips etc
What happens in occipital seizures
Positive or negative visual hallucinations
What is dyaesthesia
Where get strange sensations like itching burning etc on skin
Generalised versus focal seizures
Generalised- LOC, both hemispheres affected
Focal- get auras, 1 hemisphere involved but can get LOC and tonic clonic progression
What often precipitates absence seizures
Hyperventilation or stress
EEG finding of absence seizures
Symmetrical 3hz wave and spike pattern
What happens in juvenile myoclonic seizures
Myoclonic seizures in the morning after waking
Difference between reflex anoxic seizuers and breath holding attacks
Both in toddlers
Reflex anoxic- when in pain stops breathing and goes pale with potential seizure
Breath holding- in response to anger/stress. Holds breath and goes blue then limp
Management of meningitis if penicillin allergic
If moderate allergy then can still use ceftriaxone however if anaphylaxis history must use chloramphenicol
What is risk of a second febrile convulsion
1 in 3
What age group do febrile convulsions occur
6 months-6 years
What is common symptom with dyskinetic CP other than movements
Oro-motor problems
Management of migraine
1st line- NSAID/paracetamol
2nd line- nasal sumatriptan
What can be used to prevent migraines
Propanolol or topiramate under specialist supervision
Assessment of headache in a child
Obs
Examination- FUNDOSCOPY
Headache diary
How does benign rolandic epilepsy present
Seizures at time of night or duing sleep
- dyaesthesia in face
- hypersalivation
Can get tonic clonic seizures too
What is plagiocephaly
When baby sleeps more on back meaning occiput on one side can become flattened
Management of plagiocephaly
Reassure
- advise about turning cot around so sleeps facing other way
- supervised time during day on front
Features of benign intracranial hypertension
14
HIgh BMI
Normal MRI and neuro exam
Headache worse on lying down with vomiting
Can be confused/ altered mental state
Management of benign intracranial hypertension
LPs repeatedly
How do MS lesions appear on MRI
Inflammation
Demyelinating
In the white matter
How do tuberous sclerosis lesions appear on MRI
Calcified
Hypointense white matter lesions
Subepednymal lesions
What are sun setting eyes and what are they a sign of
Where eyes are looking down and upwards gaze impaired
Sign of raised ICP
Who is best person to get a written statement about CP for school
Consultant paediatrician
What are ash leaf macules
Where skin in that area hypopigmented
How does tuberous sclerosis present
Ash leaf macules
Brain ependymomal
Lumps under nails
Factors demonstrating will go on to have another febrile seizure
Short precipitating fever
Under 18 months
Over 15 mins
Focal sx
What are raccoon eyes
Under eyes is bruised suggesting raised ICP
Tuberous sclerosis inheritance
AD
Management of juvenile mycoclonic epilepsy
Sodium valproate
Lamotrigine second line
EEG of lennox gastaut syndrome
Slow spike
How does lennox gastaut syndrome present
Continuation of infantile spasms
Variety of different seizures
Severe learning disability and development delay
First line for lennox gastaut syndrome
Sodium valproate
Management of a first time seizure
Refer to paediatric specialist to be seen within 2 weeks
Investigating first time seizures
Bloods - metabolic causes
12 lead ECG
EEG within 72 hours
MRI if suspecct underlying structural cause
First line for tonic clonic seizures
Sodium valproate if male and girl under 10
Lamotrigine if over 10 and will have to be on long term therapy
First line for focal seizures with or without development to tonic clonic seizures
Lamotrigine or levetiracetam
First line for absence seizures
Ethosuximide
First line for myoclonic seizures
Sodium vaproate if male and girl under 10
Levetiracetam if girl over 10 who may need to continue long term
First line for atonic or tonic seizures
Sodium valproate
Lamotrigine if girl over 10 and may need treatment long term
What defines status epilepticus
Over 5 minutes
Management of status epilepticus in community
If no IV access- buccal midazolam or rectal diazepam
If IV access and resus facilities available- IV lorazepam
Order of how manage status epilepticus
Over 5 minutes
Buccal midazolam, rectal diazepam or IV lorazepam
Wait 5 minutes
Give second dose of diazepam
If no response
- phenytoin
- levetiracetam
- sodium valproate
If no response try these again
If no response phenobarbital or general anaesthesia
Side effects of sodium valproate
Hair loss
Weight
Liver damage
What is most common cause of infantile torticollis
Sternocleidomastoid tumour
How does sternocleidomastoid tumour present
Mobile non tender nodule in neck
Reduced movement of neck
Latches only on 1 breast successfully
Management of infantile torticollis
Physio
Surgery if needed
If patient comes in with suspected encephalitis what is first thing do
No investigatinos until give IV aciclovir and ceftriaxone
Pathophysiology of spinal muscle atrophy
Mutations in survival motor neurone 1 causing degeneration of anterior horn cells in spinal chord
What on presentation suggests medulloblastoma
Cerebellar symptoms
Hydrocephalus management
Ventriculoperitoneal shunt
What is scissor walking seen in
Diplegic cerebral palsy
Child presents with feeling light headed, seizes for 30 seconds and then returns to normal
Vasovagal- hypoperfusion can cause the seizure
If febrile seizure repeats within 24 hours what type of febrile seizure is it
Complex
