Neurology Flashcards

1
Q

What is epilepsy?

What are seizures and how can they be classified?

A

Disease characterised by the enduring predisposition to generate epileptic seizures and the neurobiological, cognitive, psychological and social consequences of the condition

Seizures are a transient occurrence of signs and symptoms resulting from abnormal excessive or asynchronous brain activity

May be focal (partial) - start in 1 part of the brain
Or may be generalised - more distributed affecting both brain hemispheres

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2
Q

What are the RF for epilepsy ?

A
  • Genetic predisposition
  • Trauma
  • Perinatal asphyxia
  • Structural CNS abnormalities
  • Metabolic disorders
  • Complex febrile seizures
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3
Q

How can epileptic seizures be categorised? [International League against Epilepsy 2017]

A
  1. Where they begin in the brain:
    - Focal
    - Generalised
    - Unknown
    - Focal to Bilateral (AKA secondary generalised - where starts focally then becomes generalised)
  2. Level of awareness:
    - Focal aware
    - Focal impaired
    - Awareness unknown (unwitnessed)
    - Generalised (presumed to affect awareness)
  3. Other features of the seizure (motor vs non-motor):
    - IF Focal onset: MOTOR onset (jerking, twitching, stiffening) or NON-MOTOR (cognitive, emotional, sensory)
    - IF Generalised onset: MOTOR (tonic/stiffenining and clonic/jerkining) or NON-MOTOR (absence, brief changes in awareness +/- automatic/repeated movements)
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4
Q

What are the signs and symptoms of:

- Absence/generalised non-motor seizure?

A

Absence/generalised non-motor:

  • Brief impairment of consciousness (5-10 secs)
  • Behavioural arrest or staring, interrupting normal activity
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5
Q

What are the signs and symptoms of a:

- Tonic-clonic seizure?

A

Tonic-clonic/’Grand Mal’:

  • Patient falls unconscious and may have a preceding aura
  • Violent muscle contractions and shaking
  • Eyes may roll back, tongue biting, incontinence
  • Post-ictal phenomena (confusion, drowsiness, headache, nausea)
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6
Q

What are the signs and symptoms of a:

  • Myoclonic seizure?
  • Different types (BRE, JME, PME)
A

Myoclonic:

  • Brief, arrhythmic muscular jerking movements
  • Last a few seconds, sudden jerking or twitching

Benign Rolandic Epilepsy (BRE):

  • Most common childhood epilepsy affecting 3-12yo, but outgrow by puberty
  • Seizures of face/upper limbs DURING SLEEP with hyper salivation and speech arrest (AKA sylvan seizures)

Juvenile myoclonic epilepsy (AKA ‘fly in cornflakes’):

  • Begin around puberty (12-18yo)
  • Usually involve neck, shoulders, upper arms occurring mostly AFTER WAKING up)

Progressive myoclonic epilepsy:

  • Rare syndromes
  • Combination of myoclonic and tonic-clonic
  • Pt deteriorates over time
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7
Q

How would you manage a patient with epilepsy (Ix/Mx)?

note: think about AEDs + SEs/CI

A

[EEGs are not that useful so mainly clinical?/Mx]

  • MDT based –> paediatrician, neurologist, epilepsy nurse, GP, schools
  • Urgent referral to neurologist if 1st fit; whilst waiting for a referral then advise:
  • -> how to recognise a seizure + what to do
  • -> avoiding dangerous activities e.g. swimming
  • -> video other seizures
  • -> seek help if another event before referral

Treatment:
- Not all children require AEDs as weight vs risk of drug SE and severity/freq/type of seizures (i.e. BRE is not usually treated pharmacologically)

Appropriate AED choices:

Generalised:
–>TC - Valproate > Lamotrigine (or carbemapzepine/ oxcarbazepine)

–>Absence - Ethosuximide (girls) or Valproate, > lamotrigine (note: carbamazepine exacerbates absence seizures!)

–>Myoclonic - Valproate > levetiracetam, topimerate (note: lamotrigine + carbemazepine exacerbates myoclonic seizures!)

Focal seizures:
–> Carbemazepine, Lamotrigine (or consider adjuncts of valproate, topimerate or alternatives like levetirectam)

note:

  • AEDs may be discontinued after 2y free of seizures
  • monotherapy at lowest possible dose; can use adjuncts but try to limit dose
  • ++ rescue therapy for status epilepticus >5 mins (buccal midozalam)
  • monitoring only for carbamazepine

SE of drugs:

  • Valproate (weight gain, hair loss, idiosyncratic liver failure)
  • Carbemazepine - hyponatremia (SIADH), rash, neutropenia, drug-inducer
  • Lamotrigine (severe skin rash - Steven Johnson syndrome)
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8
Q

What other treatments may be available for intractable epilepsies?

A
  • Ketogenic diets
  • Vagal nerve stimulation
  • Surgery (if well localised structural cause)
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9
Q

What is Status Epilepticus?

A
1 epileptic seizure lasting >5 minutes 
OR 
at least 2/+ seizures within a 5 minute period without the person returning back to normal in-between
OR
1 febrile seizure lasting >30 mins
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10
Q

How would you manage a child with status epilepticus?

A

A to E assessment:

Airway - high flow oxygen and don’t ever forget glucose

Circulation - if vascular access/can get quickly then IV/IO Lorazepam - if not then Buccal Midozalam (or rectal Diazepam) - in first 5 mins!

Then if not, try I/IO Lorazepam again and call for senior help

  • reconfirm it is an epileptic seizure
  • prepare phenytoin (IV/IO over 20 min)
  • alert ICU and anaesthetist
  • consider rectal paraldehyde
  • if already on phenytoin, then give phenobarbitone IV/IO over 5mins

Final step - Anaesthetist must be present; rapid sequence induction of anaesthesia with thiopental

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11
Q

What are infantile spasms and who do they affect?

A

Epilepsy syndrome presenting in infancy (<1y, 3-8mo peak incidence)

  • Characteristically part of West Syndrome (infantile spasms, developmental plateau and hypsarrhythmia - characteristic disordered brain activity on EEG)
  • more common in males
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12
Q

Causes of infantile spasms?

A
  • Any disorder causing brain damage
  • Genetic syndromes
  • Congenital infections
  • Prenatal conditions
  • HIE/Trauma
  • Idiopathic
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13
Q

How would a child with infantile spasms present?

A
  • Spasms: sudden, rapid, tonic contractions of trunk and limb muscles with gradual relaxation over 0.5-2 seconds
  • ‘Salaam attacks’ - head goes down and arms up [looks like colic]
  • Contractions last 5-10 seconds
  • Can be gentle nodding of head –> powerful body movements
  • Occurs in clusters; usually when WAKING or BEFORE sleeping
  • Psychomotor delay
  • Hypopigmented skin lesions (tuberous sclerosis)
  • Growth restriction
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14
Q

How would you manage (Ix+Mx) a child with infantile spasms?

A

Ix:

  • EEG - characteristic hypsarrhythmia (“random high-voltage spike and slow waves of varying amplitude, arising from multiple foci that vary over time. The background is asynchronous and generally chaotic” - BMJ)
  • Others (glucose, Mg, Ca) to rule out other aetiology

Mx:
- Vigabatrin or corticosteriods
[Poor prognosis]
note: vigabatrin associated with visual field defects

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15
Q

What are Muscular Dystrophies and what is the most common one?

A

Progressive generalised diseases of muscles, often caused by defective/absent glycoproteins e.g. dystrophin in the muscle membrane.
–> Duchenne is the most common (DMD)

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16
Q

When does Duchennes normally present + continue and how is it inherited/acquired?
EXTRA: What is the pathophysiology of this mutation?

A

1:3000-6000 infants

X-linked recessive (males mainly affected) but 1/3 have denovo mutations (must check FHx!!)
- [dystrophin gene deletion means no connection of muscle fibre cytoskeleton to ECM through cell membrane and so Ca influx –> calmodulin breakdown + excess free radicals –> myofibre necrosis

Presents around 1-3yo with symptoms and diagnosed at 5; no longer walking by~10 with median LE ~35yo but on increase now

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17
Q

How may a child with DMD present?

A

Presents 1-3yo:

  • Developmental delay (persistent waddling gait, some language delay)
  • toe-walking
  • decreased tone and power (flexors stronger > extensors therefore may also have lumbar lordosis, scoliosis also)
  • Gower’s sign - need to turn prone to rise
  • Pseudohypertrophy of calves due to fat+fibrous tissue replacing muscle
  • Primary dilated cardiomyopathy
  • Risk of aspiration pneumonia with infections also
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18
Q

What Ix would you do in a child with suspected DMD?/MD

A
  • Plasma CK (creatine kinase) - elevated (~50-100x normal) due to myofibre necrosis
  • genetic testing (Xp21),
  • other: EMG, biopsy
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19
Q

How would you manage a child with DMD?

A

Note: no cure, just symptomatic treatment

  • Physiotherapy (to clear lungs) + exercise (to reduce contractures)
  • Psychological support
  • Dietician for gastric feeding if indicated + VitD + Ca supplements
  • Medical
  • -> CPAP overnight for respiratory support (weakness of intercostal muscles may cause nocturnal hypoxia)
  • -> Glucocorticoids to delay need for wheelchair
  • -> Ataluren - drug that restores dystrophin synthesis and may be used if 5/+yo
  • -> Cardio protective drugs e.g. carvedilol for preservation of LVEF

Surgery if needed (tendoachilles lengthening, scoliosis surgery)

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20
Q

What happens in Becker MD?

A

Same signs and symptoms as DMD but often LESS SEVERE and progresses SLOWER (also X-linked)

  • learn to walk later than usual
  • muscle cramps after exercise, struggle with sport at school
  • as age increases, struggle with lifting objects
  • can walk into their 40-50s but then need wheelchair
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21
Q

What happens in Myotonic MD? Inheritance mode + how they present?

A

Autosomal dominant trinucleotide repeat disorder (CTG)

  • most common adult onset (20-30s) MD
  • exhibits genetic anticipation (gets worse/earlier onset as gene passed down generations)
  • variable LE (neonatal death-normal)

Sx:

  • muscles contract but unable relax
  • progressive muscle loss + weakness in smaller muscles>larger muscles (opposite to DMD)
  • heart problems, cataracts, abnormal intellectual functional, myotonia
22
Q

What are the indications for CT scanning in children after head injury? Why are these important?

A

Children are at high risk for contusion + intracerebral haemorrhage after head injury BUT also at risk from CT radiation to the head causing cancer

Therefore:

Head injury + 2/+ of:
- LOC>5mins
- Abnormal drowsiness
- 3/+ vomiting episodes
- Dangerous mechanism/high impact injury
- Amnesia>5 mins (anterograde and retrograde)
= CT SCAN <1h, if just 1 of those listed then observe for minimum 4h

Head injury with 1/+ of:
- NAI
- Post-traumatic seizure (no epilepsy Hx)
- GCS<14
- GCS <15 2h+ post injury
-Suspected open/depressed skull fracture/tense fontanelle
- Basal skull fracture signs (racoon eyes, battle sign [postauricular bruising], CSF rhinorrhoea)
- Focal neurological deficit
- Child <1y and bruise/swelling/laceration >5cm on head
= CT SCAN <1h

23
Q

What are the 4 main TBI classifications and how may they present (not IVH)? How would you Ix + Mx these patients?

A

Extradural:

  • Usually following direct trauma
  • May have skull fracture (pterion, MMA tear) - battle sign and racoon eyes for basal fracture
  • LUCID interval followed by deterioration of consciousness + seizures
  • May have focal signs (dilation of ipsilateral pupil, paresis of contralateral limb, shock and anaemia)
  • Ix: CT head (lemon sign)
  • Mx: Fluid resus to correct hypvolaemia + neurosurgery to evacuate the haematoma and stop the bleeding

Subdural
- Results from tear of vein crossing the subdural space
- GCS GRADUALLY decreases i.e. no lucid interval like EDH
- Characteristically NAI e.g. shaken baby syndrome (triad of subdural haematoma, retinal haemorrhages and brainswelling/encephalopathy) or direct trauma
Ix: CT Head (banana sign)

Subarachnoid

  • rare in children, often caused by aneurysm or arteriovenous malformation
  • acute onset head pain, neck stiffness, fever +/or seizures/coma
  • CT head, avoid LP due to risk of increased ICP
  • Mx = neurosurgery or IR

Intraventricular (see other flashcard)

24
Q

How may a patient with intraventricular haemorrhage present (note: grading + risks)? How would you Ix + Mx them? What is the aetiology and epidemiology? What are the risks?

A

Intraventricular haemorrhage:

  • bleeding into ventricles
  • occurs more in premature babies (LBW + VLBW)
  • caused by changes in perfusion to growing brain, e.g. from ECMO in premature babies with severe RDS or congenital CMV infection

Graded:
o Grade I – bleeding just in germinal matrix
o Grade II – intraventricular bleeding (but no enlargement)
o Grade III – intraventricular bleeding with enlargement ventricles
o Grade IV – bleeding extends into brain tissue around ventricles
[I+II –> most common; no further complication
III+IV –> Can lead to long-term brain injury; also after GIII/IV, clots can form leading to secondary hydrocephalus

note: 50% of those with progressive post haemorrhage ventricular dilation go on to develop cerebral palsy

If there is bilateral multiple cysts then = PVL (periventricular leukomalacia) - 80-90% risk of spastic CP
(can only potentially see cystic lesions 2-4w later on USS)

presents - sleepiness, lethargy, apnoea, low tone, no moro reflex, tense fontanelle

Ix - trans-fontanelle USS
Mx - fluid replacement, anticonvulsants, acetazolamide (reduce CSF) +/- LP
- ventriculo-peritoneal shunt if hydrocephalus

25
Q

Outline the criteria for each part in GCS scoring?

A

Score ranges from 3 - 15

this is the adult one below but differences, mainly in verbal response, for paediatric criteria

Eyes:
4 - spontaneously open
3 - open to verbal
2 - open to pain
1 - no opening of eyes
Verbal:
5 - orientated to TPP
4 - confused 
3 - inappropriate words
2 - incomprehensible sounds
1 - no response 

Motor:
6 - obeys/spontaneous
5 - moves to localised pain
4 - withdrawal to pain (flexion)
3 - abnormal flexion (decorticate - arms up)
2 - extension response (decerebrate - arms down)
1 - no response

26
Q

What is vasovagal syncope - how does it present, how would you investigate and manage it?

A

LOC which is caused by either emotional trigger (fear/shock/pain/sudden sounds or sights) or orthostatic (prolonged standing, crows, hot)

Sx:
-> Brief LOC with spontaneous recovery, no signs of seizure activity and link to trigger

Ix:

  • > Lying and standing BP
  • > FBC (rule out anaemia and bleeding)
  • > ECG if indicated/cardiac cause queried

Mx:

  • > Avoid triggers
  • > Lie down flat to avoid fainting (when feel sensation close to occurring)
27
Q

What is a febrile convulsion? In who and how does it present? Simple vs Complex?

A

Seizure and fever in the absence of an intracranial infection

  • > Occurs in children 6m to 3y
  • > Genetic predisposition (30% get further seizures)

Sx:
-> Brief, generalised tonic-clonic seizure
-> fever
NOTE: simple febrile seizure = cause no brain damage and no increased risk of epilepsy
complex febrile seizure = focal, >15 mins, repeated in same illness and associated with a 4-12% increased risk of epilepsy

28
Q

What investigations would you do after a febrile seizure?

A

Ix:

  • > Identify and manage the cause of fever (check ears, throat, listen to chest)
  • > Consider screening for meningitis/encephalitis, urine MC&S, blood glucose
29
Q

How would you manage a febrile seizure?

A

Mx:

  1. During a seizure:
    - > protect from injury (cushion head, remove nearby objects and don’t restrain)
    - > if <5 mins, do nothing UNLESS 1st seizure, severe cause, breathing problems
    - > if >5 mins - call ambulance OR rescue meds: buccal midozalam or PR diazepam (repeat PR after 5 mins if still not stopped). IF >10 mins after 1st dose then call an ambulance
    - > IF ongoing seizure in hospital then status epileptics guidelines (IV Lorazepam)
    - > Midozalam = 2.5mg 6m-11m, 5mg 1-4y and 7.5mg 5-9y
    - > Diazepam = 5mg 6m-1y and 10mg 2-11y

AFTER the seizure:

  • > Immediately after check ABCs and place in recovery position
  • > Admission + immediate assessment by paeds only if 1st febrile seizure, <18m old, uncertain diagnoses of cause, currently on Abx and complex febrile seizure
  • > Check blood glucose if child can’t be roused/convulsing
  • > Otherwise managed at home with advice:
  • 33-50% may have another FC, not same as epilepsy just due to fever and they are common in children but nonetheless worrying for parents
  • safety net (>5 mins and don’t have meds etc)
  • don’t try to cool the child, ensure adequate fluids, regular paracetamol and ibuprofen, seek advice if fever lasting a long time
  • keep getting immunisations
30
Q

What is hydrocephalus? What are the 2 types and causes?

A

Hydrocephalus is an increased volume of CSF occupying the ventricles. Can be differentiated into:

-> Communicating = flow of CSF is obstructed AFTER it exists the ventricles i.e. a failure to resorb CSF due to e.g. Meningitis (TB, pneumococcal) and SAH

-> Non-communicating = flow of CSF is obstructed WITHIN the ventricles. May be due to a congenital cause:
- Aqueduct stenosis
- Dandy-Walker malformation (enlarged 4th ventricle with no outlets)
- Chiari malformation (Cerebellar tonsils displaced down through foramen magnum)
Acquired causes:
- Aqueduct stenosis from IVH (preterm infants) or tumours

31
Q

How does hydrocephalus present?

A

Sx -
Acute = vomiting, irritable, impaired consciousness

Chronic = FTT, developmental delay

Other = increased head circumference, tense fontanelle, increased tone, papillodema and sunset sign (eyes driven down bilaterally), ataxic gait, 6th nerve palsy

32
Q

How would you Ix and Mx hydrocephalus?

A

Ix:

  • Measure head circumference
  • Cranial USS

Mx:

  • 1st line = Ventriculoperitoneal shunt (may fail due to blockage or infection and require replacement/removal of blockage)
  • Medical tx = furosemide to inhibit CSF production
33
Q

What are Tics? What is Tourette’s? Who does it affect?

A

Fast, repetitive muscle movement that result in sudden, difficult to control body jolts/sounds

  • appear around 5yo, most disappear by adulthood
  • 1/3 rules (1/3 won’t have it as an adult, 1/3 have mild tics and 1/3 have severe tics)
  • genetic component - can occur alongside OCD and ADHD

Tourette’s = chronic and multiple tics

  • No cure, same Tx as tics
  • Tics must begin before 18y and persist for >1y
  • Exclude any other cause
34
Q

How may someone with tic disorder present?

A

Sx:

  • brought about by triggers, focussing on them can make it worse
  • Types of tic = blinking, coughing/grunting, clicking fingers, repeating sound or phrase
35
Q

How would you manage a patient with tic disorder?

A

Mx: (+Ix)

  • Self-help - stress and sleep management, don’t draw attention to it or tell child off for it
  • If very debilitating:
  • -> HABIT REVERSAL THERAPY (learn movements to ‘compete’ with tics so tic’s can’t occur at the same time)
  • -> EXPOSURE WITH RESPONSE PREVENTION (ERP) (help the child get used to the unpleasant pre-tic sensation which can stop the tic from occurring)
  • Medications:
  • -> 1st line = antipsychotics (risperidone - SE include weight gain, blurry vision, constipation, dry mouth)
  • -> 2nd line = Clonidine (treats ticks and ADHD simultaneously), Clonazepam, Botulinum toxin into certain muscle (last 3m only) and Tetrabenazine (for tics caused by an underlying condition such as Huntington’s)
  • > Surgery (e.g. severe Tourette’s) - deep brain stimulation therapy
36
Q

What is developmental delay and how may it present? What are some causes?

A

Developmental delay is where a child takes longer to reach developmental milestones that would be expected for their age

Causes:

Sx:

  • > Isolated DD in 1 domain i.e. gross motor, fine motor and hearing, speech and language and social
  • > Global DD
  • > FHx of delay or syndromes
  • > Dysmorphic features or PMH of syndrome
37
Q

What are some Ix and Mx of developmental delay?

A

Ix:

  • [Would’ve done a full developmental assessment +/- hearing + sight tests]
  • Metabolic, genetic, infection screening
  • ASD/ADHD testing
  • IQ test

Mx:

  • Referral + MDT based with SALT, OT, PT, family counselling, behavioural intervention and educational assistance
  • Manage social issues
  • Isolated has a better prognosis; global has a high association with poor prognosis syndromes
38
Q

What is somatisation? What are some common ways it may present?

A

Somatisation = manifestation/communication of emotional distress, troubled relationships and personal predicaments through bodily symptoms

Sx:

  • > Recurrent abdominal pain (peak at 9yo) - affects 10% school age children, around umbilicus (Apley’s rule)
  • > Recurrent headaches (peak at 12yo)
  • > Limb pain, aching muscles, neurological symptoms (>12yo)
39
Q

How would you Ix and Mx somatisation?

A

Ix:

  • Dx of exclusion so must exclude other cuases
  • Full physical examination
  • Full detailed history, collateral from school and family if possible

Mx:

  • 1st line = promote communication between child and family (+school if needed) and pain coping techniques like relaxation for headaches
  • 2nd line = if fails/family or general dysfunction then referral to CAMHS
40
Q

State some neurocutaneous syndromes?

A
  • Neurofibramatosis type 1
  • Tuberous Sclerosis
  • Sturge Weber syndrome
41
Q

What is NF1, how does it present and what are some associations with it? What is NF2?

A

NF1 - autosomal dominant and has variable expression

  • > mutation in the NF1 gene, 50% are de novo mutations
  • > Associated with MEN2, Pulmonary HTN, pheochromocytoma and RAS with HTN

NOTE: NF2 is like NF1 but less common, seen in adolescence with bilateral acoustic neuromas + deafness, and other cerebellar symptoms

Sx: [requires at least 2/+ of the following for Dx]

  • at least 6/+ cafe au last spots (>5mm pre-puberty, >15mm post puberty)
  • > 1 neurofibroma (firm nodular overgrowth of nerve)
  • axillary freckles
  • optic glioma +/- visual impairment
  • Hamartoma of iris (Lisch nodule - brown dots in iris)
  • First degree relative with NF1
  • Bony lesions +/- eye protrusion
42
Q

What is Tuberous Sclerosis? How does it present and how would you Ix it?

A

TS is also AD with 70% cases from new mutations. Causes mainly benign tumours to develop in the body

Sx:
-> Cutaneous features - Shagreen patches (rough skin on lumbar spine). ‘Ash leaf’ hypo pigmented patches under Wood’s lamp, angiofibromata (butterfly facial distribution)
-> Neurological - infantile spasms, focal epilepsy, intellectual disability-often with ASD
-> Other - angiomyolipoma (kidney tumour), dense white areas on retina, sublingual fibromata
-> NC Hydrocephalus if a nodule in brain (subependymal giant cell astrocytoma)
[ASHLEAFS] - ash leaf spots, shagreen patches, heart rhabdomyomas, lung lymphangioleiomyomatosis, epilepsy due to tubers (+DD/InfSpasms/ASD), angiomyolipoma in kidney, facial angiofibromas and subependymal giant cell astrocytoma–>NC hydrocephalus
Ix:
- CT scan (can see calcified subependymal nodules and tubers from 2+ years)
- MRI scan (more sensitive and clearly identify other lesions/tubers)

43
Q

What is Sturge-Weber syndrome and how does it present? What is an investigation necessary?

A

Sporadic disorder + not inherited

  • -> Haemangiomatous facial lesion (port-wine stain) in the distribution of the TRIGEMINAL NERVE
  • Lesion may be intracranial (ipsilateral leptomeningeal angioma)
  • Ophthalmic branch of trigeminal nerve always involved

Sx:

  • Epilepsy
  • Contralateral hemiplegia
  • Pheochromocytoma
  • Intellectual disability
  • Glaucoma in 50%
  • Port wine stain

Ix -> MRI; assess depths of lesions

44
Q

What are 4 types of headaches?

A

Primary

  • Migraine = main
  • Tension type
  • Cluster

Secondary - due to underlying pathology e.g. SOL, raised ICP, alcohol

45
Q

How would tension headaches present?

A

Symmetrical

Gradual onset

Feels like tight band

46
Q

How would migraine present?

A

90% without aura, 10% with aura

  • Aura may be visual (or less often sensory/motor)
  • Uni or bilateral throbbing pain, pulsatile temporal, GI sx, worse with physical activity
  • Photophobia
  • FHx of migraine
  • Vomiting/pallor
  • Triggers e.g. certain foods, stress
47
Q

How would a cluster headache present?

A

Unilateral, near the eye or side of face
Sharp/burning/throbbing pain
Watery/swollen eye
Occurs in clusters

48
Q

How would a secondary headache present?

A

Focal neurological signs - gait/CN etc

Visual field defects

Growth failure

Papillodema

Early morning headache

49
Q

How would you Dx migraines (criteria)?

A

Migraines must:

  • 5 or more headache attacks lasting 4-72h
  • Lasts 4-72h
  • At least 2 of the following: bilateral/unilateral location, pulsating, moderate-severe intensity, aggravated by routine physical activity
  • At least 1 of: N+/vomiting, photophobia or phonophobia
50
Q

How would you Ix and manage headaches in children?

A

Good history and examination

  • -> If suspect meningitis then bloods/LP etc
  • -> Imaging if red flag Sx e.g. early morning headache
  • -> Consider headache diary for trigger identification

Mx:

  • Medical education that they are common and no long-term harm
  • analgesia = ibuprofen > paracetamol
  • anti-emetics (anti-histamines) = prochlorperazine
  • Triptans in 12+ (nasal sumatriptan)
51
Q

How would you specifically manage migraines in children?

A

Mx:

  • Medical education on safety and common
  • Obviouly causes distress however - assess this impact and patterns noted
  • Identify cause (emotional problems) –> consider psychiatry referral, headache diary for 8w, optician referral, weight, height and BP

Acute Mx: in 12-17yo

  • -> 1st = Simple analgesia (paracetamol and ibuprofen but not aspirin, unless 16+, due to risk of Reye’s syndrome = liver and brain swelling)
  • -> 2nd = nasal sumatriptan (oral not licensed for <18yo)
  • -> 3rd = Combined nasal triptan and NSAID/paracetamol; consider anti emetics and f/u in 1m or if Sx worsen
  • -> Prophylaxis = Topiramate (no pregnancy), propanalol (not in asthma) BUT requires specialist referral