NEURO peds Flashcards
What is the most important diagnostic tool in neurology?
History
- headache fails to respond to therapy
- focal neurologic findings in first 2-6 months (palsy, diplopia, new onset strabismus, papilledema, hemiparesis, ataxia)
- progressively increasing frequency/ severity of HA , HA worse with valsalva
- HA awaken from sleep, worse in AM , AM vomiting,
- at -risk hx or condition : neurocutaneous disorder
Headache RED Flags
brought on by fatigue, exertion, stress, poor hydration
- sx: constant, aching, tight, occipital, frontal or constricting band around head
- may occur with vascular headache
- TX: rest, analgesics
Tension-type headache (TTH)
symptom of depression and or anxiety
- pain is: b/l diffuse, dull aching, present with awakening, not associated with n/v or neuro problems
- Evaluate : CT or MRI
- TX is difficult, ANTIDEPRESSANTS help
Chronic Tension Headache
- severe, pulsatile (pounding)
- u/l, can be b/l
- frontal or temporal regions, retro orbital or cheek
- sx: N/V, photophobia, phonophobia, vertigo, fatigue, mood alteration
- vomiting may be only sx in younger children (abdominal migraines)
Migraine Headache
when are neuro studies warranted in someone with migraine ha?
worse with an awakening, awaken pt, cough or bending over
what can also cause migraines in children?
allergies
treatment for migraines?
1 avoid triggers
- ibuprofen or acetaminophen early in attack
- caffeine + ergot
- triptans
- rest and quiet
- avoid narcotics
TCA, beta blockers (propranolol), CCB (verapamil)
prevent migraines
Mainly male
-
Cluster Headache
a sudden, transient disturbance of brain function manifested, or psychic phenomena
Seizure
2 or more seizures not provoked by particular event or cause
eiplepsy
a benign condition of childhood with u/l focal seizures and speech abnormalities , often hereditary
Rolandic seizures
What is the most common type of seizure in children?
Partial
Children present with what in their first seizure?
Status Epilepticus
who has seizures in the first 28 days of life (first few days), sometimes benign familial , secondary may progress (HIE, infection, IVH, thrombus)
Neonatal Sz
What are 6mo -6 year old seizures, usually 2-5 /o
Febrile Seizure
Seizure >30 min, sequential seizures without regain LOC > 30 mins
Status Epilepticus
What is an adjunctive test to clinical history for seizures?
eeg
what % of children “out grow” their seizures?
70-80%
Absent (petit mal)
- Generalized tonic clinic (grand mal)
- Tonic
- Clonic
- Atonic
Generalized seizures
Simple partial (focal)
- Complex partial (psycho- motor)
- Benign rolandic epilepsy
Partial seizures
- Infantile spasms (West syndrome)
- Febrile sz
- Juvenile myoclonic
Other types of seizures
- Onset of seizures begins in one area of cerebral hemisphere
- simple = no LOC
- complex = LOC (staring)
- Secondarily generalized = simple or complex partial seizure that ends in a generalized convulsion
- 40-60% of childhood epilepsies
Partial (focal) Epilepsy
a simple or complex partial seizure that ends in a generalized convulsion
secondarily generalized partial focal epilepsy
Duration : 90 seconds
Sx: sudden jerking, sensory phenomena , no LOC
Post ictal Sx: transient weakness or loss of sensation
Simple Partial
Duration: 1-2 mins
Sz: aura, automatism (lip smack, pick at clothes, fumbling)
unaware of envt, may wander
Post ictal Sx: amnesia of sz, mild to moderate confusion, sleepiness
Complex Partial
tingling of contralateral limb, face or side of body
- tonic clonic movements if upper limb
- head and eyes turn to opposite side
- see flashes of light, blurring
- sweat, flushing , pallor
Simple Partial seizure
in impaired consciousness
- hears music (hallucinations)
- olfactory hallucination
- chewing movements, picking at clothing
Complex Partial Sz
- Seizures arise from both hemispheres simultaneously
- Typical Absence : 6-20% children
- Myoclonic, tonic, atonic, atypical absence sz= 10-15% of childhood epilepsies
- Associated with underlying structure brain dz
- DIFFICULT TO TREAT AND CLASSIFY
Generalized seizures
Duration - 2-15 seconds
- Sx: stare, eyes fluttering, automatism (lip smack, pick clothes) help if needed
- Post ictal sx: amnesia for seizure events, no confusion, resume activity
Absence (petit mal)
Duration - 1- 2 mins
- Sz: cy, fall, tonicity, clonicity, may have cyanosis
- post itcal symptoms L amnesia for seizure , confusion, deep sleep
Generalized tonic - clonic (grand mal)
- Clinical spasms (1-2 seconds)
- occurs in clusters with drowsy
- brain insult : birth, malformation , tuberus sclerosis, metabolic origin ( hard to control, poor neurocog outcome)
- Cryptogenic = NO underlying cause –> best outcome
infantile spasms (west syndrome)
- Onset 3-13, males more
- 15% epileptic children
- Normal IQ, normal exam, normal MRI
- May have + FHx sz
Description: when awake, twitching or tingling on one side, speech arrest , my drool
Benign Roldandic Epilepsy
What is this treatment for?
indicated if : seizures are frequent, socially stigma if occurs in wakefulness, anxiety provoking for parents if occur in sleep
Benign rolandic epilepsy
Treatments
Avoidance for sleep deprivations
- Medications : carbamazepine, oxcarbazepine
- Time (outgrow by adolescence)
Benign Rolandic Epo epilepsy
- > 30 minutes or more continuouse seizures, recurrent seizures without regaining consciousness
- medical emergency : structural damage, hypoxia, hypotension, death
- most children in children under 5 (85%) especially
Status Epileptics
structural damage, hypoxia, hypotension and death are associated with what sz?
status epilepticus
Use this in every case of suspected seizure disorder (not febrile) , abnormal in 60-80%
EEG
These are generally NOT helpful , only based on presentation and hx
Blood tests
Generalized - abnormal exam or difficult to control
Focal - not benign rolandic epilepsy, all others
Seizure Evaluation
WBC > 20 k = bacterial infection, left shift is seen d/t adrenocortical surge
- Blood culture, Urine C&S
- Lumbar puncture : under age 2 , any suggestion of meningitis
- Electrolytes
- Glucose
- Neonates : consider metabolic (lactate, amonia, urine ketones)
Seizure Workup (mostly look for secondary sources)
This test CANT make diagnosis of epilepsy.
- MOST USEFUL for classifying types and guiding therapy (absence [petit mal], psychomotor [temporal lobe], generalized tonic clonic [grand mal] , infantile spasms, mixed seizure disorder
- Useful in evaluating worsening seizures or projecting recurrence of seizures if medicine were to be stopped
EEG
- Cannot make diagnosis of epilepsy
- most useful for classifying types and guiding therapy
- Useful in evaluating worsening seizures or projecting recurrence of seizures if medicines were to be stopped
EEG
- Antipyretic ineffective in febrile seizures
Treatment
Only diazepam indicated for abortive tx if prolonged complex
Febrile Seizure TX
Phenobarbital
Neonatal Sz
Phenytoin, phenobarbital, carbamazepine, valproic acid, primidone
Generalized TC
Ethosuximide, valproic acid
Absent sz
Felbamate , gabapentin, lamotrigine, topiramate, tiagabine, vigabatrine
New anti-epileptics
-2-4% of children age
Febrile Seizures
type of febrile seizure
- generalized convulsion (whole body shaking)
- brief (
Simple febrile seizure
type of febrile seizure
- focal seizure (one side of the body shaking, staring)
- prolonged ( >15 mins)
- multiple in 24 hours
- often post-ictal state
Complex febrile seizure
what seizures are usually harmless?
febrile
how often to febrile recurrences occur?
30% rate , does not change prognosis
is the progression to epilepsy common or uncommon?
uncommon ( no more than 1.3% )
febrile seizure treatment
usually none
rectal diazepam
abort prolonged complex febrile seizure
- prevent complex febrile seizure clusters
phenobarbital and valproic acid
effective in prevention of febrile seizures
spells that mimic seizures?
migraine variants, benign breathholding spells, syncope, pseudoseizures
Common features
- involuntary, children
Breath-Holding Spells
Precipitated by anger, frustration, fear
- crys, stops breathing in expiration, becomes cyanotic
Cyanotic Spells
- Transient LOC and postural tone d/t cerebral ischemia and anoxia
- prodrome : dizzy, lighthead, nausea, sweating, pallor
- MAY HAVE JERKING MOTIONS while LOC, tonic clonic
- Family hx + in 90%
Syncope
- neurally mediated
- transient hypotension from vasodilation and or decreased heart rate
- arousal 1-2 minutes up to 1 h
Vaso-vagal or neurocardiogenic 95%
D/t cerebral edema, mass lesion
- S/S : infants –> bulging fontanelle, increased head circumference , separating sutures, lethargy, vomiting, FTT, “SETTING-SUN SIGN”
Children –> HA, diplopia/strabismis, papilledema, herniation syndromes
Increased ICP
- cystic formation on the cns tract on the 4th ventricle, end up with hydrocephalus as a result
Location
- supratentorial - eye forehead temple
- infratentorial - occiput, neck
- worse in AM , standing up, night
- worsened by cough sneeze straining
- OFTEN WITH VOMIT WITHOUT NAUSEA
- subarachnoid hemorrhage : worse headache of life, suspect abuse in kids
Headache from Elevated ICP
increased ICP without identifiable mass or hydrocephalus
- obese teen girl
- HA, tinnitus, papilledema, visual loss (normal MRI)-
- MRI to exclude hydrocephalus or intracranial mass
- LP : elevated opening pressure (Essential to dx)
Pseudotumor Cerebri
- brief LOC or stunned for minutes to hours
- no localize neuro signs
- amnesia is common and transient
- Diagnostic - CT if hemorrhage
- observe and hospital –> suspect abuse, abnormal vital signs
- implications for sports- second impact syndrome
head injury concussion
- all children with amnesia or who were LOC should be evaluated in er
concussion
post ___ : complain of headahce, dizziness, forgetfulness, inability to concentrate, slowing of response time, mood swing, irritable
- resolve spontaneously
- weeks to months
post concussive syndrome
what is second impact syndrome?
kid isnt recovered from first concussion and gets second concussion which can worsen sx
what are congenital malformations?
meningomyelocele, encephalocele, lissencephaly, pachygyria, absent corpus callosum
neural tube forms and closes during days 0-28 of gestation
meningomyelocele, encephalocele
cell proliferation and migration after 28 days
lissencephaly, pachygryia, absent corpus callosum
smooth brain
lissencephaly
gyri too thick and overdeveloped
pachygyria
often identified on US likely to have elevated alpha fetoprotein on prenatal screen.
- Folate during pregnancy
meningomyelocele,
