neurology

Question 1

why is child neurology considered dynamic?

Answer 1

• brain continues to grow and function evolves

- static lesions produce evolving features

Question 2

give examples of common neurological problems in childhood

Answer 2

• headache
• fits, faints, funny turns
• unusual head
• neuromuscular disorders

Question 3

what is assessed in a developmental history?

Answer 3

• motor milestones: gross and fine motor skills
• speech and language
• vision and hearing
• play
• self-help skills
• cognitive development

Question 4

what is looked at in a paediatric neurological examination?

Answer 4

• appearance
• gait
• head size
• skin findings

Question 5

what is the epidemiology of headache disorders?

Answer 5

• 40% of children by age 7

- 75% of children by age 15

Question 6

what are the 4 classifications of headache?

Answer 6

• isolated acute
• recurrent acute
• chronic progressive
• chronic non-progressive

Question 7

what do you want to know about the typical episode of chronic headache?

Answer 7

• warning
• location
• severity
• duration
• frequency

Question 8

what does a headache examination consist of

Answer 8

• growth parameters, OFC, BP
• sinuses, teeth, cranial bruit
• visual acuity, visual fields (craniopharyngioma), fundoscopy
• focal neurological signs
• cognitive and emotional status

Question 9

what features would suggest childhood migraine?

Answer 9

• abdominal pain, nausea, vomiting
• focal signs: visual disturbance, paraesthesia, weakness
• pallor
• photophobia, phonophobia
• relation to fatigue/stress
• relieved by sleep/rest/ dark, quiet room
• family history

Question 10

what is the typical presentation of migraine?

Answer 10

• hemicranial pain
• throbbing/pulsatile
• abdo pain, nausea, vomiting
• relieved by rest
• photophobia/phonophobia
• visual, sensory, motor aura
• positive family history

Question 11

what is the typical presentation of tension headache?

Answer 11

• diffuse, symmetrical
• band-like distribution
• present most of the time (but there may be symptom free periods)
• “constant ache”

Question 12

what type of headache would suggest raised intracranial pressure?

Answer 12

aggravated by activities that raise ICP eg. coughing, straining at stool, bending

woken from sleep with headache +/- vomiting

Question 13

what type of headache would suggest analgesic overuse headache?

Answer 13

headache is back before allowed to use another dose

- paracetamol/NSAIDs, compound analgesics eg cocodamol

Question 14

what are the indications for neuroimaging in headache?

Answer 14

• cerebellar dysfunction
• raised intracranial pressure
• new focal neurological deficit eg. new squint
• seizures, esp focal
• personality change
• unexplained deterioration of school work

Question 15

how is migraine treated in children?

Answer 15

acute attack: effective pain relief and triptans

preventative: pizotifen, propranolol, amitryptiline, topiramate, valproate

Question 16

how are tension type headaches treated in children?

Answer 16

• acute attacks: simple analgesia
• prevention: amitryptiline
• discourage analgesics in chronic TTH

Question 17

what are paroxysmal events

Answer 17

• seizure/fit
• syncope
• convulsion

Question 18

what is a seizure/fit

Answer 18

sudden attack from whatever cause

Question 19

what is epilepsy?

Answer 19

tendency to recurrent, unprovoked (spontaneous) epileptic seizures

Question 20

what is an epileptic seizure

Answer 20

abnormal excessive hypersynchronous discharge from a group of (cortical) neurons

paroxysmal change in motor, sensory or cognitive function

depends on seizure’s location, degree of anatomical spread over cortex, duration

Question 21

what non-epileptic seizures and mimics can occur in children?

Answer 21

• acute symptomatic seizures: hypoxia-ischaemia, hypoglycemia, infection, trauma
• syncope
• reflex anoxic seizure
• parasomnias eg. night terrors
• behavioural stereotypies
• psychogenic seizures (NEAD: Non-epileptic attack disorder)

Question 22

what is febrile convulsion?

Answer 22

a seizure occurring in infancy/childhood (3 months - 5 years)
associated with fever but without evidence of intracranial infection or defined cause for the seizure

Question 23

what are the different seizure types?

Answer 23

jerk/shake: clonic, myoclonic, spasms

stiff: tonic seizure
fall: atonic/ tonic/ myoclonic

vacant attack: absence, complex partial seizure

Question 24

what is the mechanism of epileptic fits?

Answer 24

chemical stimulation produces an electrical current

summation of a multitude of electrical potentials results in depolarisation of many neurons which can lead to seizures

can be recorded from surface electrodes (electroencephalogram)

Question 25

what are the types of epileptic seizures

Answer 25

partial seizure

generalised seizure

Question 26

what are epileptic fits chemically triggered by

Answer 26

• decreased inhibition (gama-amino-butyric acid, GABA)
• excessive excitation (glutamate and aspartate)
• excessive influx of Na and Ca ions

Question 27

what is a focal seizure?

Answer 27

seizure restricted to one hemisphere or one part of the one hemisphere

Question 28

what is a generalised seizure?

Answer 28

abnormal activity in both hemispheres

Question 29

what are EEGs useful in?

Answer 29

identifying seizure types, syndrome and aetiology

Question 30

What are the disadvantages of using EEG for diagnosis of fits?

Answer 30

Problematic false positives

• Paroxysmal activity seen in 30%
• Frankly epileptiform activity in 5% of normal children

Question 31

how are seizures/fits diagnosed?

Answer 31

• history
• video recording of event
• ECG in convulsive seizures
• interictal/ ictal EEG
• MRI Brain: to determine aetiology
• genetics
• metabolic tests

Question 32

when should anti-epileptic drugs be considered for use in children?

Answer 32

if diagnosis is clear even if this means delaying treatment

Question 33

what should be considered when choosing anti-epileptics drugs?

Answer 33

• age
• gender
• type of seizures
• epilepsy

Question 34

what are the possible side effects of anti-epileptic drugs?

Answer 34

CNS related

• drowsiness
• effect on learning
• cognition and behavioural effects

Question 35

describe the management of epilepsy

Answer 35

sodium valproate (not in girls)/ levetiracetam
carbamazepine (focal)
other: steroids, immunoglobulins, ketogenic diet

Question 36

what is microcephaly and macrocephaly

Answer 36

microcephaly: OFC < 2 SD
macrocephaly: OFC > 2SD

OFC - occipitofrontal circumference

Question 37

what do neuromuscular disorders affect?

Answer 37

disorders of the peripheral nervous system from the anterior horn cells down

Question 38

when should you suspect a neuromuscular disorder?

Answer 38

• baby ‘floppy’ from birth
• slips from hands
• paucity of limb movements
• alert, but less motor activity
• delayed motor milestones
• able to walk but frequent falls

Question 39

what is Duchenne muscular dystrophy?

Answer 39

delayed gross motor skills

symmetrical proximal weakness: waddling gait, calf hypertrophy, gower’s sign

elevated creatine kinase levels

complications: cardiomyopathy, respiratory involvement

Question 40

give examples of neuromuscular conditions

Answer 40

muscle: muscular dystrophies, myopathies (congenital and inflammatory), myotonic syndromes

neuromuscular junction: myasthenic syndromes

nerves: hereditary or acquired neuropathies

anterior horn cells: spinal muscular atrophy