Neurology Flashcards
Cranial Nerve I
Olfactory
Smell
Sensory
Cranial Nerve II
Optic
Vision
Sensory
Cranial Nerve III
Oculomotor
Most EOMs, opening eyelids, papillary constriction
Motor
Cranial Nerve IV (4)
Trochlear
Down and inward eye movement
Motor
Cranial Nerve V (5)
Trigeminal
Muscles of mastication; sensation of face, scalp, cornea, mucus membranes and nose
Sensory and Motor
Cranial Nerve VI (6)
Abducens
Lateral eye movement
Motor
Cranial Nerve VII (7)
Facial
Moves face, closes mouth and eyes; taste (anterior 2/3)’ saliva and tear secretion; Bells palsy
Sensory and Motor
Cranial Nerve VIII (8)
Acoustic
Hearing and equilibrium
Sensory
Cranial Nerve IX (9)
Glossopharyngeal
Phonation, (1/3), gag reflex, carotid reflex swallowing; taste (posterior 1/3)
Sensory and Motor
Cranial Nerve X (10)
Vagus
Talking, swallowing, general sensation from the carotid body, carotid reflex
Sensory and Motor
Cranial Nerve XI (11)
Spinal accessory
Movement of trapezius and sternomastoid muscles (shrug shoulders)
Motor
Cranial Nerve XII (12)
Hypoglossal
Moves the tongue
Motor
Pneumonic for remembering the type of Cranial Nerve
Some Say Marry Money But My Brother Says Big Bras Matter Most
S = sensory M = motor B = both
Cranial Nerve responsible for eye movement
III, IV, VI
Headache
May present for a multitude of reasons and can be difficult to evaluation
Proper evaluation of the history of the HA, and associated symptoms, are essential to making an accurate diagnosis
4 primary mechanisms of headache pain
- Vascular dilation: Cranial artery distention (ie migraine, fever, vasodilator drugs, metabolic disturbance, systemic infection
- Muscular contraction: HA and neck muscle contraction (ie tension or psychogenic HA - stress HAs)
- Traction: Space occupying lesions (ie brain tumors, mass lesions, abscess, hematoma, increased ICP)
- Inflammation: Infection (meninges, sinuses, and teeth)
Pneumonic for HA evalation
OLDCARTS Onset Location Duration Characteristics Aggravating factors Remedial/alleviating factors Treatments tried Severity
HA considerations for the febrile patient
- Meningits: bacterial, viral, tubercular, ascetic
- Brain abscess or other intracranial infection
- Encephalitis
- Sinusitis
- Associated infection: strep throat, influenza, mononucleosis, rubeola
Meningitis
- Viral meningitis more common in infants
- Bacterial meningitis occurs only in up to 2%.
- T > than 101.8F (38.8C)
- Causative agents: Group B streptococcus, S. pneumonia, Haemophilus influenza, Salmonella, Nesseria meningitis, Protozoa, and E. coli
- Infants between 6-12 months are at the highest risk
- 90% of cases occur in children ages 1 month - 5 years***
S/S of Meningitis
Most are behavioral responses
Differ from newborns and older children
S/S of Meningitis in newborns and young infants
Mimic septicemia T instability Irritability, lethargy Poor feeding Vomiting Bulging fontanel No stiff neck
S/S of Meningitis in older infants and children
N/V Irritability, confusion HAs, back pain, nuchal rigidity Hyperesthesia, cranial nerve palsy, ataxia Photophobia \+ Kernig's and Brudzinski's signs
Kernig’s sign
Flexion of the hip at 90 degrees
Pain on extension of leg
*bend knee forward, hurts at head and want to pull head up
starts with Knee = Kernig
Brudzinkski’s sign
Involuntary flexion of legs when neck is flexed
*pull head forward, patient pulls knees up
Diagnostic tests for Meningitis
Cerebrospinal fluid (CSF) analysis via lumbar puncture
- CSF is usually clear
- cloudy b/c WBC are in there
- WBCs present
- increased protein
- decreased glucose
*bugs are eating the sugar = increased protein and decreased glucose
HA considerations in the afebrile patient
- Subarachnoid hemorrhage
- Intraparenchymal hemorrhage
- Postictal HA
- Cerebral ischemia
- Severe hypertension
- Space-occupying conditions (ie brain tumor, hydrocephalies)
- Acute dental disease
- Acute glaucoma, inflammatory disease of the eye/orbit
Brain tumors
1 solid tumor in children
Etiology is unknown
Infratentorial, brainstem, tumors predominate: most common ages 4-11 years (these are below the tentorium, herniate quickly)
S/S of brain tumors in infants
- increased head circumference, tense bulging fontanel
- irritability
- head tilt
- loss of developmental milestones
S/S of brain tumors in older children
- HA: worst in the morning followed by vomiting; usually increases in frequency
- Abnormal neurologic or ocular findings
- atatxia, hemiparesis, cranial nerve palsies
- somnolence
- seizures
- head tilt, FTT, diabetes insidious
- papilledema
- loss of fine motor control
- positive Babinski’s sign
- behavioral changes
Diagnostic tests for brain tumors
- CT scan — then REFER
- MRI
- LP - only after CT scan has been done to show safety
Migraine Headaches (Vascular HAs)
d/t dilation and excessive pulsation of branches in the external carotid artery
2 categories:
- classic migraine (with aura)
- common migraine (w/o aura)
Causes/Incidence of Migraine Headaches
- Common migraine (no aura) < 10 yo at onset
- Classic migraine (with aura) > 10 yo
- Often, there is a family history
- Females > males
- A variety of “triggers” are a/w migraine
- emotional or physical stress
- lack or excess sleep
- missed meals
- nitrate-containing foods
- alcoholic beverages
- mensuration
- use of oral contraceptives
S/S Migraine Headaches
- Unilateral, lateralized dull or throbbing HA that occurs episodically
- Insidious onset
- Focal neurologic disturbances may precede or accompany classic migraines (field defects, luminous visual hallucinations)
- Aphasia, numbness, tingling, clumsiness or weakness may occur
- N/V
- Photophobia and phonophobia
Confusional Migraine
Period of confusion and disorientation followed by vomiting and deep sleep, waking feeling well
HA may not be described
More common in younger children
Abdominal Migraine
Episodic abdominal pain with nausea, vomiting followed or accompanied by HA
Treat with ibuprofen and HA goes away
Labs/diagnostics for Migraine HA
Baseline studies:
- Blood chemistries, BMP
- CBC
- Venereal disease research laboratory test
- ESR
- CT scan of head !!!
- Other studies as indicated by the history and physical exam
Management of Migraine Headaches
- Avoidance of trigger factors is very important - have the patient keep a HA diary
- Improve general health: balanced diet, aerobic exercise, regular sleep
- Relaxation/stress management techniques (counseling, biofeedback)
- Eliminate monosodium glutamate and nitrates or nitrites from diet
- Stabilize or wean caffeine intake
- Prophylactic therapy if attacks occur more than 3-4 times per month, or if migraines interfere with daily functioning or school
- Manage acute attacks
Prophylactic therapy for Migraine Headaches
- If attacks occur more than 3-4 times per month, or if migraines interfere with daily functioning or school
- NSAIDs for chronic cases: low doses daily
- Propanolol (Inderal)
- Amitriptyline (Elavil)
- Topiramate (Topamax)
- Imipramine (Tofranil): 10-150 mg daily
- Verapamil (Calan): 15-30 mg/kg/24 hours PO BID
Management of an acute attack of Migraine HAs
- Rest in a dark, quiet room
- A simple analgesic such as Tylenol or ibuprofen (preferred) taken right away may provide some relief.
* Ibuprofen 7.5mg-10mg/kg dose in younger children
* May use up to 800 mg/dose in older teens - Antiemetics
- When OTC analgesics are not enough, use triptans
Triptans for Migrane HAs
- Almotriptan (Axert): 6.25 mg (approved for children 12 and older
- Rizatriptan (Maxalt): 5mg
- Sumatriptan (Imitrex): Nasal 5mg; Tablets are less expensive but may not work as well d/t slower absorption
- Zolmitriptan (Zomig): Nasal 5mg
Most evidence in adolescent: All triptans above
Most evidence age 6-11yo: Maxalt 5mg or Imitrex nasal 5mg
May take at first sign of HA, then repeat in 2 hours if needed
Avoid in children at risk for heart disease
Seizure disorder
A transient disturbance of cerebral function d/t an abnormal paroxysmal neuronal discharge in the brain
*an electrical disturbance
There are severe types seizures with different presentations, diagnostic findings, and treatments.
The term epilepsy = any disorder characterized by recurrent seizures.
Causes/Incidence of Seizures
- Congential abnormalities and perinatal injuries may result in seizures presenting in infancy and early childhood.
- Metabolic disorders: Hypocalcaemic, hypoglycemia, pyridoxine deficiency, renal failure, acidosis, and others.
- Trauma is an important cause of seizures in adolescents.
- Tumors and other space occupying lesions
- Infectious diseases: Bacterial meningitis, herpes encephalitis, neurosyphilis
- Seizure threshold is lowered with a fever (aka it is easier for them to have a seizure if febrile
Seizure categories
Partial seizures: 1 hemisphere
- Simple partial seizures
- Complex partial seizures
Generalized seizures: bilateral, involving both hemispheres
- Absence (petit mal) seizures
- Tonic seizures
- Tonic-clonic (grand-mal seizures)
- Atonic
Simple partial seizures
No loss of consciousness
A variety of other symptoms (motor, autonomic, and sensory)
Complex partial seizures
Impaired consciousness: Staring > 20s before, during, or after the symptoms (motor, autonomic, and sensory)
*loses consciousness
Absence (petit mal) seizures
Brief “staring” episodes (10-20s)
Onset and termination are very brief
Almost always begin in childhood
Tonic seizures
Sudden increase in muscle tone producing a number of characteristic postures
Consciousness is usually partially or completely lost
Postictal alteration of consciousness is usually brief, may last several minutes
Tonic-clonic (grand mal) seizures
Sudden loss of consciousness w/ arrested respirations
The clonic phase involves increased muscle tone followed by bilateral rhythmic jerks lasting 2-3 minutes, followed by flaccid coma
Urinary and/or fecal incontinence may occur
The postictal state is characterized by deep sleep for up to an hour, followed by HA, disorientation, muscle discomfort and nausea, which can last minutes to hours
Atonic seizures
Sudden loss of muscle tone
May result in head drop or falling to the ground
An eyewitness account is extremely helpful
Labs/diagnostics for Seizures
- Investigate the underlying cause.
- CBC with differential, glucose, renal function test, liver function test, and a serologic treat for syphilis should be performed.
- Other test to rule out suspected etiology as indicated by the history and age of the patient (CT scan, LP, CT or MRI of the head for all new onset seizures)
- EEG: most IMPORTANT test to determine seizure classification**
Management of acute attack of seizures
- Initial management is supportive as most seizures are self-limiting.
- maintain open airway
- protect patient from injuries
- administer oxygen if patient is cyanotic - Do NOT force artificial airways or objects between teeth/mouth.
- Parenteral anticonvulsants to stop convulsive seizures.
- Lorazepam (Ativan)
- Benzodiazepines (Valium) - Refer is needed
- Primary care follow-up
Consider referral for seizures if
- Seizures continue despite therapeutic monitoring through anticonvulsant levels
- Regression of developmental skills occurs **
- Regression of cognitive function occurs **
- Side effect profile is unacceptable
Febrile Seizures
Seizures occurring during the course of and as a result of a fever
5% of children, peak incidence between 1-3 yo
Risk factors: family history of seizure disorder, tobacco use by mother during pregnancy, prematurity, neonatal hospitalization > 28 days, and/or frequent infections in the first year
If seizure occurs > 24 hours after fever onset, it is likely d/t infection
S/S Febrile Seizures
- majority are tonic-clonic
- most episodes last < 5 minutes
- physical exam to rule out infectious cause of seizure
- rule out meningitis
Labs/diagnostics for Febrile Seizures
- LP if meningitis is suspected (fever + seizure = rule out meningitis)
- EEG, chemistries, and serologies are NOT indicated
Management of Febrile Seizures
- Protect airway, place in side-lying position
- Cooling measures
- Acetaminophen
***do NOT prophylactically treat with anticonvulsants
Neurofibromatosis (von Recklinghausen Disease)
A neurocutaneous syndrome characterized by numerous cafe-au-lait (CLS) spots on the body, and nerve tumors on the skin and in the body
A progressive disorder
Does NOT affect intelligence
Severity is highly variable:
NF1 = von Recklinghausen Disease (most common)
NF2
Schwannomatosis (rare)
S/S of Neurofibromatosis
- Multiple CLS
2. Seizures
Diagnostic criteria for Neurofibromatosis
Must have at least 2:
- 6 or more CLS > 5 mm in prepubertal child or > 15 mm post pubertal
- 2 or more cutaneous neurofibromas (fast skin tags)
- Axillary or inguinal freckling
- 2 or more iris Lisch nodules (black sports on iris of the eye)
- Distinctive osseous lesions
- Autosomal dominant; present in a first-degree relative (parents, aunt/uncle)
Management of Neurofibromatosis
Refer to neurology
Tic Disorders
Brief, abrupt, non-purposeful movements or utterances
- most common: Tourette’s syndrome (only one you refer)
Movements usually involve the face, neck, or shoulders and sometimes, muscles of the limbs or other parts of the body
Other psychobehavorial problems (ie ADHD, obsessive-compulsive behaviors)
Etiology/Incidence of Tic Disorders
- Frequency unrecognized as a movement disorder in children
- Onset is between 6-12 yo
- Cause is unknown
- Family predisposition
- Associated with medications (methylphenidate, pemoline, amphetamines)
Types of Tic Disorders
Simple motor tics
Complex motor tics
Clinical manifestations of complex motor tics
- Copropraxia (obscene gestures) and coprographia (obscene writing)
- Vocal tics
- oropharyngeal, nasopharyngeal, or laryngeal sounds
- consonants or syllables
- meaningful or nonsense words or phrases
- coprolalia (obscene speech)
- palilalia (repeating one’s own words) and echolalia (repeating another’s words)
Management of Tic Disorders
Collaboration with neurology
