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PPC2 Exam 3 > Neuro 2 > Flashcards

Neuro 2 Flashcards

1
Q

Concerns after first seizure (4)

A
  1. It is a brain tumor
  2. He stopped breathing and we want oxygen at home
  3. We do not want to start drugs–
    a. Asking why you will find they read the package insert
    b. Drug is not FDA approved for children
    c. The Internet
  4. Things to remember about seizures and parental concerns
    a. All children look terrible during the seizure but they are breathing
    b. Seizures are common 1 in 200
    c. Children with seizures are normal children
    d. They need to sleep in their own beds, go to school, take out the garbage and do most sports except
    i. Sky diving
    ii. Archery
    iii. Hunting
    iv. Scuba diving
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2
Q

Generalized Absence, Typical (5)

A
  1. 3-8 year old, common at 6-7
  2. May present with convulsion
  3. Usually several months of staring and unresponsive spells
  4. 3 hz spike wave
  5. Strong genetic disposition
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3
Q

Generalized Absence, Typical Treatment (3)

A
  1. Ethosuximide (Zarontin) is excellent
  2. Valproate
  3. Lamotrigine (Lamictal) → Steven Johnsons Syndrome
    * Always worry* start slow and watch for skin rashes
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4
Q

Generalized Tonic-Clonic Seizure: Benign Rolandic Epilepsy (8)

A
  1. School aged child 5-10
  2. Boys >girls
  3. Usually nocturnal, strong genetic disposition
  4. High voltage centrotemporal spike
  5. Brief seizure after falling asleep with face and shoulder twitching occasionally with preserved awareness
  6. Can have migraines and learning disability
  7. Seizures are sporadic and remit in puberty
  8. Most AED work but you can wait to see if a second seizure reoccurs
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5
Q

Juvenile Myoclonic Epilepsy (9)

A
  1. Adolescent (12-18) with seizure on wakening
  2. Reports early am arm and body jerks which resolve by breakfast
  3. Tend to recur
  4. Lifelong disease
  5. Normal Intelligence
  6. Will not usually remit without anticonvulsants
    a. Valproate (Depekene)
    b. Levetiracetam (Keppra)
    c. Zonisamide (Zonagran)
  7. Does not go away, adolescent, first thing in the morning when they have seizure, sleep deprivation
  8. Keppra is a nice safe drug, push levels high* drug of choice for generalized epilepsy
  9. Need to monitor blood levels before you renew prescription
    a. Every 3 months for the first few then every 6 months
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6
Q

Treatment Considerations (5)

A
  1. Potential risks of additional seizures
  2. Likelihood of seizure recurrence
  3. Likelihood of multiple recurrences
  4. Risk factors for recurrence
  5. Efficacy of treatment for prevention of recurrences
    a. Which drug
    b. Adverse effects
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7
Q

Focal Epilepsy Anticonvulsants (3)

A
  1. Oxcarbazepine (trileptal) 20 mg/kg/day bid
  2. Carbamazepine (tegretol, carbatrol) is acceptable alternative
  3. Levetiracetam 20 mg/kg/kay bid
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8
Q

Generalized Epilepsy Anticonvulsants (2)

A
  1. Valproate 20mg/kg/day bid – increase side effects and monitor liver function
  2. Lamotrigine (Lamictal) 1mg/kg/day
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9
Q

Systemic Side Effect of Antiepileptic drugs (4)

A
  1. Rash, hirsutism, and weight gain.
  2. Severe reactions such as hepatic toxicity, bone marrow toxicity, and Stevens–Johnson syndrome
  3. Side effects of AED include effects on behavior and higher cortical function, which are often dose related
  4. Under-recognized
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10
Q

Differential Diagnosis for Epilepsy (14)

A
  1. Night terrors
  2. Apnea
  3. Breath holding spells
  4. Syncope
  5. Vertigo
  6. Migraine confusional state
  7. Nightmares
  8. Hyperventilation
  9. Daydreaming attentional disorder
  10. Hyperplexia (exaggerated startle
  11. Paroxysmal behavior outburst*** weird things
  12. Psychogenic seizure
  13. GER
  14. Arrhythmia (long QT)

*ALL PATIENTS W SEIZURES DESERVE AN ECG

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11
Q

Paroxysmal Non-Epileptic Disorders (8)

A
  1. Diverse Group
  2. Breath holding spells
    * Pallid
    * Cyanotic Breath holding spells
  3. Sandifer syndrome
  4. Tics
  5. Spasmus Nutans
    a. Differential = optic glioma
    b. Nystagmus and head tilt
    c. Head tilt = always differential for head tumor
  6. Benign Neonatal myoclonus = when they are going to sleep or sucking body will jump
  7. Shudder Attacks – paroxysmal event
  8. Paroxysmal dystonic dyskinesia
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12
Q

Tics (5)

A
  1. Common 5-24% with stereotypic repetitive movements or vocalization
  2. Increase with anxiety, frustration
  3. Diminishes with sleep
  4. Most common tick = eye blinker, or lip smacking
  5. A lot of times the kids are under stress
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13
Q

Spasmus Nutans (6)

A
  1. Age 4-12 months
  2. Benign, self-limited
  3. Clinical triad
    a. Head tilt
    b. Head nodding
    c. Nystagmus-asymmetric
  4. Differential Optic glioma
  5. Anterior visual pathway disease
  6. Referred to ophthalmology or neurology = need to get MRI
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14
Q

Benign Neonatal Myoclonus (4 with 4 clinical features)

A
  1. Infants
  2. Benign, self limiting
  3. Clinical Features
    a. Paroxysmal myoclonic jerks
    b. May cluster
    c. Primarily of upper body
    d. Occurs during sleep
  4. Normal infant development
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15
Q

Landau Reflex (2)

A
  1. Infant will lift head and extend the neck and trunk

2. Present by 6 months

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16
Q

Parachute Reflex (2)

A
  1. Present by 6-8 months

2. Look for symmetric response

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17
Q

Propping Reflex (2)

A
  1. Anterior propping when sitting up

2. Lateral propping to maintain balance

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18
Q

Headache (5)

A
  1. Common pediatric disorder which has become more common in adolescents
  2. Overall, prevalence is between 37-51% in 7 year olds with an increase to as high as 82% in 15 year olds
  3. Males have slightly higher prevalence pre-puberty
  4. Reeldx case 434
    a. Post-inflammatory hyperpigmentation
    b. Sandpaper acne; papules of acne
  5. Not drinking water in schools
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19
Q

Location of headaches

A

Bitemporal frontal headache is common in migraine whereas tension headache is around the head. Occipital headaches are an ominous sign

20
Q

Red signs with headache (8)

A

THESE REQUIRE IMMEDIATE REFERRAL

a. Sudden onset of headache
b. Occipital headache
c. Worsening pattern of headache
d. Headache with systemic illness
e. Focal neurologic signs other than typical aura
f. Papilledema
g. Headache triggered by Valsalva, cough or exertion
h. Headache during pregnancy or postpartum

21
Q

Worrisome symptoms with headache (9)

A
  1. Early morning headaches
  2. Progressive headache
  3. Persistent vomiting
  4. Changes in language skills
  5. Changes in motor skills
  6. Headaches that get worse with sneezing, coughing, or straining
  7. Diplopia (double vision)
  8. Visual field defects
  9. Impaired school performance
22
Q

Worrisome signs with headache (9)

A
  1. Ataxia
    i. Need to do a tandem walk for a kid with headache
  2. Macrocephaly
  3. Neurocutaneous syndrome
  4. Difficulties with upward gaze
    i. Intact EOM?
  5. Changes in mental status
  6. Growth abnormalities including precocious puberty
  7. Nuchal rigidity
  8. Hemiparesis
  9. Seizure
23
Q

Types of Headache (5)

A

Least common
1. Organic BRAIN TUMOR

Somewhat common
2. Associated with viral illness, tooth pain, sinuses

Most common

  1. Tension
  2. Migraine
  3. Psychogenic
24
Q

Differential Dx for Acute Headache (7)

A
  1. Fever = #1 reason for headache
  2. Sinusitis
  3. Viral illness
  4. First migraine
  5. Acute bleed
  6. Increase in intracranial pressure
  7. Pseudotumor cerebri
25
Q

Primary Headaches: Tension Type Headaches (3)

A
  1. Infrequent episodic TTH with headaches occurring less than one day a month
  2. Frequent episodic TTH with headache episodes occurring one to 14 days a month
  3. Chronic TTH with headaches 15 or more days a month.
    * Feel like a band around the kids head
26
Q

Primary Headaches: Migraine (3)

A
  1. Migraine with aura
  2. Migraine without aura
  3. Childhood periodic syndromes that are commonly precursors of migraine
27
Q

Tension type headaches definition (2)

A
  1. Described as a tightening feeling (non- pulsating) with or without associated photophobia or phonophobia, but without nausea, vomiting, or exacerbation with activity
  2. In the absence of other symptoms, recurrent headaches of more than 3 months’ duration are rarely due to an organic cause
28
Q

Tension type headaches pathophysiology (3)

A
  1. Most common type of headache; now believed to have a neurobiological basis
  2. Central pain mechanisms play a role in frequent tension headaches
  3. Peripheral pain mechanisms play a role in infrequent episodic tension headaches
29
Q

Tension type headaches treatment (2)

A
  1. Nonpharmacologic – avoid precipitating factors

2. Pharmacologic – NSAIDS

30
Q

Features of Migraine in Children (6)

A
  1. Attacks may last 2–72 hours
  2. Headache is more often bilateral than in adults; an adult pattern of unilateral pain usually emerges in late adolescence or early adulthood
  3. Occipital headache is rare and raises diagnostic caution for structural lesions → tumor or sinusitis
  4. Photophobia and phonophobia may be inferred by behavior in young children → referred by behavior
  5. Unilateral = late childhood
  6. Bilateral = adolescent/adult
31
Q

Migraine without Aura (Adolescent) (4)

A
  1. At least 5 attacks fulfilling criteria B–D
  2. Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated)
  3. Headache has ≥2 of the following characteristics:
    a. Unilateral location
    b. Pulsating quality
    c. Moderate or severe pain intensity
    d. Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
  4. During headache ≥1 of the following:
    a. Nausea, vomiting, or both
    b. Photophobia and phonophobia
32
Q

Migraine with Typical Aura (Adolescent) (3)

A
  1. At least 2 attacks fulfilling criteria B–D
  2. Aura consisting of visual, sensory, and/or speech/ language symptoms, each fully reversible, but no motor, brainstem, or retinal symptoms
  3. At least 2 of the following 4 characteristics:
    a. At least 1 aura symptom spreads gradually over ≥5 minutes, and/or ≥2 symptoms occur in succession
    b. Each individual aura symptom lasts 5– 60 minutes
    c. At least 1 aura symptom is unilateral
    d. The aura is accompanied, or followed within 60 minutes, by headache
33
Q

Migraine with Aura (Adolescent) (6 and 4)

A

One or more of the following fully reversible aura symptoms:

  1. Visual
  2. Sensory
  3. Speech and/or language
  4. Motor
  5. Brainstem
  6. Retinal

At least 2 of the following 4 characteristics:

  1. At least 1 aura symptom spreads gradually over ≥5 minutes, and/or ≥2 symptoms occur in succession
  2. Each individual aura symptom lasts 5–60 minutes
  3. At least 1 aura symptom is unilateral
  4. The aura is accompanied, or followed within 60 minutes, by headache
34
Q

Headache Pearls (2)

A
  1. Secondary headaches – due to variety of injuries, illnesses or disorders
  2. In children, it may be difficult to distinguish between migraine and tension due to the developmental level of the child
35
Q

Factors that Precipitate Migraine: Common factors (8)

A
  1. Stress/anxiety
  2. Menstruation
  3. Oral contraceptives
  4. Physical exertion/ fatigue
  5. Lack of sleep
  6. Glare
  7. Hunger
  8. Dietary – LACK OF FLUIDS
36
Q

Less common factors that trigger migraines (4)

A

a. Reading/refractive error
b. Cold foods
c. High altitude
d. Drugs - Nitroglycerin, indomethacin, hydralazine

37
Q

Migraine

A
  1. Usually frontotemporal and can be bilateral in children
  2. Occipital headaches are rare and require immediate evaluation
  3. School age children may also present without headaches, but with temporal or visual aura lasting ten minutes and resolving within one hour
38
Q

Migraine Manifestations (7)

A

In children, a migraine headache is a recurrent headache with symptom-free intervals and at least 3 of the following signs or symptoms:

  1. Visual, sensory or motor aura
  2. Abdominal pain
  3. Nausea or vomiting
  4. Throbbing headache
  5. Unilateral location
  6. Relief after sleeping
  7. Positive family history
39
Q

Abdominal Migraine (4)

A
  1. Age: School-age children
  2. Main symptom: abdominal pain which is crampy and located in periumbilical or epigastric areas
  3. Associated symptoms: Vague headaches with motion sickness
  4. Time: Self-limiting and is gone within two to three years
40
Q

Migraine to Refer (4)

A
  1. Complicated: Transient neurological symptoms
  2. Hemiplegia: abrupt in onset Ophthalmologic: cranial nerve 3,4 or 6
  3. Basilar (migraine with brainstem aura):
    a. Must have two of the following: dysarthria, vertigo, tinnitus, hypoacusis, diplopia, ataxia, and decreased level of consciousness
  4. Acute Confusional Migraine
    a. Acute onset of confusion manifesting as agitation, memory deficit, disorientation, increased alertness, dysarthria, or perceptual disturbance
41
Q

Diagnostic tests for migraines (3)

A
  1. Guidelines show no value in routine lumbar puncture or EEG
  2. EEG is recommended if there are motor or sensory components to the headache
  3. Guidelines do not recommend neuroimaging for patients with recurrent headaches and normal neurological exams Neuroimaging is recommended if there are the following changes in headache history
    a. Worsening headaches
    b. Changes in types of headaches
    c. Changes in neurological function including changes in school performance
    d. Onset of severe headaches
    e. Occipital headaches
42
Q

Analgesia for Migraines (6)

A

a. Acetaminophen: 15mg/kg/dose
b. Ibuprofen: l0 mg/kg/dose
c. Naproxen sodium
d. Ketorolac
e. Codeine
f. Migraine Excedrin

43
Q

Aborative treatment for migraines (2)

A

a. Sumatriptan/naratriptan (not approved in children)

b. Isometheptane (Midrin)

44
Q

Prophylactic for migraines (5)

A

a. Beta-blockers (propanolol, nadolol)
b. Tricyclics (amitriptyline, nortriptyline)
c. Cyproheptadine
d. Antiepileptic drugs (valproic acid, toprimax)
e. Verapamil

45
Q

Benign Paroxysmal Torticollis (5)

A
  1. Age: infants 2-8 months of age
  2. Main symptom: Torticollis
  3. Associated Symptoms: Pallor, vomiting, changes in behavior
  4. Time: Resolves by ages 2-5 with decreasing intervals. Episodic and nonprogressive
  5. Can evolve into benign paroxysmal vertigo
46
Q

Cyclic vomiting (4)

A
  1. Age: 4-10 years of age
  2. Main symptom: Vomiting with nausea associated with migraine.
  3. Associated symptoms: May be triggered by something with associated pallor
  4. Length of time: Occurs frequently and regularly and can last for several hours
47
Q

Benign paroxysmal vertigo symptoms (3)

A
  1. Characterized by recurrent episodes of a head tilt and/or vertigo and ataxia.
  2. Torticollis typically occurs during the first year while the vertigo occurs in young children (usually aged 2 to 3 years)
  3. Cyclic vomiting and recurrent abdominal pain
    * Primary gastrointestinal diseases must be excluded.

PPC2 Exam 3 (14 decks)

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