Neuro Flashcards
Antenatal risk factors of CP?
- Chorioamnionitis
- GU/ resp maternal infection
Perinatal risk factors of CP?
- Pre-term birth
- HIE
- LBW
- Neonatal encephalopathy
- Neonatal infection
- Maternal infection
Post-natal risk factors of CP?
- TBI <3 years old
- Meningitis
Spastic CP?
70% of CP
- UMN lesion
- Reduced GABA sensitivity (reduced inhibition)
- Increased tone from UMNs
Dyskinetic/ athetoid CP?
- Damage to basal ganglia
- Lack of movement regulation
- Dyskinesia/ chorea
Ataxic CP?
- Cerbellar damage
- Clumsy, poor coorination
Early motor signs of CP?
- Fidgeting
- Lack of/ abnormal movement (head control, crawling, walking)
- Feeding difficulties
- Tone abnormalities
Delayed milestones CP?
- Not sitting 8 months
- Not walking 18 months
- Hand preference before 1 year
Red flags for other neuro conditions, not CP?
- No CP risk factors
- Family hx of degenerative neuro disease
- Loss developmental milestones
- Focal neurology
What is the follow up for patients at risk of CP?
Follow-up programme by MDT for children up to 2 years
Surgical management CP?
- Dorsal rhizotomy - Electical stimulation reveals nerve root causing spastic symptoms, nerve root is severed (spasticity)
- Intrathecal baclofen (GABA agonist) (spasticity)
- Deep brain stimulation (dystonia) - electrodes placed in the brain, neurostimulator placed under the skin of the abdomen, regulates movements
SALT management CP?
Eating/ drinking/ swallowing
- Individualised plan for eating, drinking and swallowing
Language
- Posture
- Breath control
- Voice production
- Rate of speech
- Augmented and alternative communication systems (eg. pictures, symbols, speech generation etc)
Management of saliva control CP?
- Anticholinergics (eg. glycopyrronium bromide, transdermal hyoscine hydrobromide)
- If Anti-Ach contraindicated botox A injection salivary glands (refer to specialist)
Management bone mineral denisty CP?
- Dietary intake Ca2+ and vit D
- Active movement/ weight bearing programme (physio)
- Dietarty advice (dietician)
Pain mx CP?
- Stepped approach simple analgesia (WHO pain ladder)
- Specialist referral
Sleep disturbance CP?
- Sleep hygiene
- Trial melatonin
Visual impairment mx CP?
- 1/2 children
- Opthalmological assessment
What % CP hearing impaired?
10%
What % CP chronic constipation?
60% (3/5), give laxatives
What % CP epilepsy?
33% (1/3) give anticonvulsants
Simple febrile seizure?
- <15 minutes
- Generalised tonic-clonic
- No repeats within 24 hours of the seizure
What are the excitatory and inhibitory neurotransmitters in the brain?
Excitatory: glutamate, binding to NMDA receptors causing Ca2+ influx
Inhibitory: GABA, binding to GABA receptors causing Cl- influx
What are the theorised mechanisms of febrile convulsion?
- Increase in body temperature increases neuronal excitability
- Increased temperature causes hyperventilation leading to respiratory alkalosis which increases neuronal excitability
- Cytokines IL-1 stimulate NMDA receptors
Risk factors febrile convulsion
- Genetics (family hx)
- Age (6m-5yrs peaking at 12-18 months)
- Rapidly increasing fever
- High temperature (always >38)
- HHV-6 (roseola)
- Vaccines (MMR, stimulate immune system)
Why don’t antipyretics decrease the risk of febrile convulsion recurring?
Theorised due to the rapid increase in temperature, when temperature is high and antipyretics given the rapid increase has already happened
Management during febrile convulsion
- Protect head (cushion)
- Once seizure stops, put in recovery position
- Time seizure
- > 5 minutes, call ambulance
Rescue medication for seizure?
- Buccal midazolam
- Rectal diazepam
When can doses of rescue medication be given seizure?
- > 5 mins
- 10 mins after 1st dose
When is ambulance called when rescue medication given for seizure?
10 mins after first dose:
- Seizure ongoing
- Twitching ongoing
- Another seizure started before child regains consciousness
Measure blood glucose if child can’t be roused/ is convulsing
Doses of midazolam
- 6-11 months: 2.5mg
- 1-4 years: 5mg
- 5-9 years: 7.5mg
Dose of rectal diazepam
- 6 months - 1 year: 5mg
- 2-11 years: 5-10mg
When is immediate hospital assessment by paediatrician indicated for febrile seizure?
- 1st seizure/ 2nd seizure in child not assessed
- <18 months (signs of CNS infection may be subtle)
- Diagnostic uncertainty
- Complex seizure
- Focal neurology
- Decreased consciousness prior to seizure
- Seizure in same illness
- Child taken abx (can mask CNS infection)
- Anxious parents
- No obvious focus of infection
When is febrile seizure referred to paediatric neurologist?
- Neurodevelopmental delay
- Signs of neurocutaneous syndrome
- Signs of metabolic disorder
Which children with a headache should be referred?
- All children under 4 (urgent neuro assessment)
- Children under 12 with red flag symptoms
What are the red flag symptoms for headache under 12?
- Waking at night or present on waking in the morning
- Features of meningism
- Vomiting or ataxia
- Aggravated by coughing, sneezing, bending down
- Progressively worsening
- Change in consciousness or lethargy
- Within 5 days of head injury
- Squint or failure of upwards gaze
- New onset cognitive dysfunction
What is the managment of extradural haemorrhage in children?
- Correct hypovolaemia
- Urgent evacuation of haematoma
- Arrest bleeding
When do breath holding attacks resolve?
4-5 years old
(Common in children between 6 months and 6 years)
Management breath holding attacks?
- Behaviour modification therapy with distraction
- Consider IDA as a cause and investigate with bloods
What are the behavioural modifications with distraction techniques for breath holding attacks?
Behavioural modification
- Positive reinforcement eg. reward when the child manages frustration without holding breath
- Ignoring behaviour
- Consistency, ensuring all caregivers respond to BHA the same way
Distraction techniques
- Engaging the child (conversation, toys and objects)
- Physical diversion (tickling etc)
What are partial epileptic seizures?
One hemisphere/ lobe
- Simple partial = conscious during the seizure
- Complex partial = impaired consciousness/ unconscious during seizure
What is a Jacksonian March?
Type of epileptic seizure where contractions start in one muscle group and spread throughout the body (usually one side)
What are generalised seizures?
Affecting both hemispheres, usually unconscious
What are the types of generalised seizures?
- Tonic
- Atonic
- Clonic
- Tonic-clonic (most common)
- Myoclonic (short muscle twitches, patient remains conscious)
- Absence
What is the difference between tonic and myotonic seizures?
Tonic - sudden sustained stiffening of the body, lasts 20s, usually unconscious
Myotonic - jerking of specific muscles or muscle groups, shock like contractions, 2-3s
What is Todd’s paralysis?
Weakness/ paralysis following a seizure
- Usually one side of the body
- Lasts a few minutes - hours (average 15 hours)
- Self-resolves
When should patients with suspected epilepsy be referred?
When first epileptic seizure is suspected, refer to first fit clinic
Who can assist families with epilepsy in the community?
Epilepsy specialist nurse
Which type of epilepsy is treatment not usually given for?
Childhood rolandic epilepsy
(seizures involving twitches, numbness, tingling of the face or tongue)
What is the treatment for childhood absence epilepsy?
Maximise educational potential and support social development
Which seizures can carbamazepine worsen?
Absence and myoclonic seizures
Which children with epilepsy are given rescue therapy?
Children with prolonged epileptic seizures (>=5 minutes)
When can anti-epileptic drugs be discontinued?
After 2 years free of seizures
What is the first line management for tonic-clonic seizures?
- Sodium valproate (not of childbearing potential)
- Lamotrigine or levetiracetam
What can lamotrigine exacerbate?
Myoclonic seizures
What is the first line managment for absence seizures?
Ethosuximide
(2nd line valproate or lamotrigine in females CBA)
What is the first line management for myoclonic seizures?
Valproate or levetiracetam
What is the first line management for focal seizures?
Levetiracetam, lamotrigine
Side effects of sodium valproate
- Weight gain
- Hair loss
- Rare idiosyncratic liver failure
Side effects of carbamazepine
- Rash
- Neutropaenia
- Hyponatraemia (SIADH)
- Ataxia
- Liver enzyme induction
Side effects of lamotrigine
Rash
Side effects of ethosuximide
Nause and vomiting
Side effects of levetiracetam
Sedation (rare)
Side effects of benzodiazepines
(Facilitate binding of GABA to GABA receptors to inhibit neuronal impulses)
- Sedation
- Tolerance
- Increased secretions
What are the management options for children with intractable epilepsy?
- Ketogenic diets
- Vagal nerve stimulation (regulates neurotransmitter release)
- Surgery (if there is a well localised structural cause)
When is driving allowed in epilepsy?
After 1 year free of seizures
