Neurological Presentations

Question 1

Define SEIZURE.

Answer 1

A seizure is a rapid and irregular firing of neurons within the brain, leading to abnormal electrical activity.

In children, seizures are of two main types:

1. afebrile
2. febrile

Question 2

Define FEBRILE SEIZURE.

Answer 2

A febrile seizure is a seizure that occurs in a child, typically between 6 months to 6 years, in the context of a febrile illness (e.g. gastroenteritis, URTI, UTI).

Question 3

Define AFEBRILE SEIZURES.

Answer 3

An afebrile seizure is a seizure that occurs in a child in the absence of a fever.

Question 4

Describe key characteristics of FEBRILE SEIZURES.

Answer 4

✔️ key age is between 6 months to 6 years
✔️ benign
✔️ very common in normal, healthy children
✔️ risk of going on to develop epilepsy is 1% (if no other risk factors are present)
✔️ risk of recurrence is 50% in the first 12 months and 30% in the second twelve months

Question 5

Outline the diagnostic criteria for the different types of febrile seizures:

1. simple febrile seizure
2. complex febrile seizure
3. afebrile febrile seizure

Answer 5

SIMPLE FEBRILE SEIZURE
Presence of a fever plus ALL of the following:
✔️ generalised tonic-clonic seizure
✔️ seizure duration < 15 minutes
✔️ complete recovery within 60 minutes
✔️ only a single seizure occurs within the one disease episode

COMPLEX FEBRILE SEIZURE
Presence of a fever plus at least ONE of the following:
✔️ focal neurological deficit either during or after the seizure
✔️ seizure duration > 15 minutes
✔️ recovery takes longer than 60 minutes
✔️ multiple seizures within the one disease episodes

AFEBRILE SEIZURE
✔️ symptoms consistent with febrile seizure, however, NO fever present

Question 6

Outline some differentials for SEIZURE in a child, that must be considered when taking seizure history.

Answer 6

✔️ febrile seizure –> presence of fever (e.g. gastro, UTI, URIT), generalised tonic-clonic, duration < 15 mins, recovers within 60 mins
✔️ epilepsy –> previous seizure episodes; previous diagnosis
✔️ head trauma
✔️ meningitis –> fever, rash, headache, lethargy, sepsis
✔️ encephalitis –> fever, rash, headache, altered consciousness
✔️ hypoxia
✔️ malignancy –> headache, nausea, projectile vomiting
✔️ stroke –> ongoing neurological deficits
✔️ hypoglycaemia / hyponatremia –> missed meals, dehydration

Question 7

Outline appropriate investigations for SEIZURE in a child.

Answer 7

Bedside Ix
✔️ urine dipstick + MCS
✔️ blood glucose level
✔️ ECG (to check for electrolyte abnormalities)

Laboratory Ix
✔️ FBC + WCC
✔️ Inflammatory markers
✔️ UECs
✔️ Blood culture
✔️ Lumbar puncture (only if meningitis / encephalitis suspected) --> contraindicated if raised ICP 

Imaging Ix
✔️ non-contrast brain CT

EEG is usually NOT required for the diagnosis of febrile seizures in children.

Question 8

Define BRIEF UNEXPLAINED RESOLVED EVENT (BRUE).

Answer 8

A BRUE is an episode that occurs in a child < 12 months of age in which there is reduced tone, changes to colour (e.g. pallor, cyanosis), reduced breathing and / loss of consciousness which lasts for < 60 seconds, resolves spontaneously and cannot be attributed to an underlying cause.

Question 9

Describe key features of BRUE.

Answer 9

✔️ occurs in a child < 12 months of age
✔️ lasts < 60 seconds
✔️ spontaneous recovery and return to baseline
✔️ no underlying medical cause found
✔️ characterised by at least ONE of the following: 
1. cyanosis / changes to colour
2. abnormal / reduced breathing
3. hypotonia 
4. loss of consciousness

Question 10

Identify factors that characterise a LOW RISK BRUE.

Answer 10

✔️ child age > 60 days
✔️ child born at least 32 weeks gestation or is at least 45 weeks corrected age
✔️ first episode
✔️ duration < 60 seconds
✔️ no CPR required

Low risk BRUE does not require admission to hospital. If the parents wish for admission for one night to allow for observation, this is acceptable.

Question 11

Define CEREBRAL PALSY.

Answer 11

Cerebral palsy is the consequence of a non-progressive brain lesion / insult that results in a permanent deficit in movement or posture.

Question 12

What are some risk factors for CEREBRAL PALSY?

Answer 12

✔️ extreme prematurity
✔️ IUGR
✔️ placental abnormalities 
✔️ thrombophilia
✔️ significant hypoxic event (e.g. birth trauma, trauma)
✔️ RhD or ABO incompatibility 
✔️ maternal infection (e.g. TORCH infections) early in pregnancy
✔️ severe jaundice

Question 13

Outline ways in which CEREBRAL PALSY may present in a child.

Answer 13

1. Follow up of high-risk infants (e.g. extreme prematurity, neonatal encephalitis / meningitis, congenital hydrocephalus)
2. Concerns with development; developmental delay (e.g. unable to sit by 6 months, trouble standing at 12 months, unable to walk by 18 months)
3. Abnormal tone (hypotonic initially, progresses to hypertonia)
4. Persistent primitive reflexes (e.g. Moro reflex, grasp reflex)
5. Early hand preference / asymmetrical movements
6. Severe feeding problems or prolonged irritability

Question 14

Identify some common complications of CEREBRAL PALSY.

Answer 14

✔️ vision and hearing problems
✔️ speech and language problems
✔️ cognitive impairment
✔️ seizures (~50%)
✔️ recurrent respiratory tract infection –> chronic lung disease
✔️ aspiration –> aspiration pneumonia
✔️ gastrointestinal problems (e.g. GOR, GORD, constipation)
✔️ hip displacement (subluxation )
✔️ knee contracutres
✔️ increased osteoporosis and fracture risk
✔️ poor dentition

Equinis deformity of the foot