neurology Flashcards
why is child neurology considered dynamic?
- brain continues to grow and function evolves
- static lesions produce evolving features
give examples of common neurological problems in childhood
- headache
- fits, faints, funny turns
- unusual head
- neuromuscular disorders
what is assessed in a developmental history?
- motor milestones: gross and fine motor skills
- speech and language
- vision and hearing
- play
- self-help skills
- cognitive development
what is looked at in a paediatric neurological examination?
- appearance
- gait
- head size
- skin findings
what is the epidemiology of headache disorders?
- 40% of children by age 7
- 75% of children by age 15
what are the 4 classifications of headache?
- isolated acute
- recurrent acute
- chronic progressive
- chronic non-progressive
what do you want to know about the typical episode of chronic headache?
- warning
- location
- severity
- duration
- frequency
what does a headache examination consist of
- growth parameters, OFC, BP
- sinuses, teeth, cranial bruit
- visual acuity, visual fields (craniopharyngioma), fundoscopy
- focal neurological signs
- cognitive and emotional status
what features would suggest childhood migraine?
- 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
what is the typical presentation of migraine?
- hemicranial pain
- throbbing/pulsatile
- abdo pain, nausea, vomiting
- relieved by rest
- photophobia/phonophobia
- visual, sensory, motor aura
- positive family history
what is the typical presentation of tension headache?
- diffuse, symmetrical
- band-like distribution
- present most of the time (but there may be symptom free periods)
- “constant ache”
what type of headache would suggest raised intracranial pressure?
aggravated by activities that raise ICP eg. coughing, straining at stool, bending
woken from sleep with headache +/- vomiting
what type of headache would suggest analgesic overuse headache?
headache is back before allowed to use another dose
- paracetamol/NSAIDs, compound analgesics eg cocodamol
what are the indications for neuroimaging in headache?
- cerebellar dysfunction
- raised intracranial pressure
- new focal neurological deficit eg. new squint
- seizures, esp focal
- personality change
- unexplained deterioration of school work
how is migraine treated in children?
acute attack: effective pain relief and triptans
preventative: pizotifen, propranolol, amitryptiline, topiramate, valproate
how are tension type headaches treated in children?
- acute attacks: simple analgesia
- prevention: amitryptiline
- discourage analgesics in chronic TTH
what are paroxysmal events
- seizure/fit
- syncope
- convulsion
what is a seizure/fit
sudden attack from whatever cause
what is epilepsy?
tendency to recurrent, unprovoked (spontaneous) epileptic seizures
what is an epileptic seizure
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
what non-epileptic seizures and mimics can occur in children?
- 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)
what is febrile convulsion?
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
what are the different seizure types?
jerk/shake: clonic, myoclonic, spasms
stiff: tonic seizure
fall: atonic/ tonic/ myoclonic
vacant attack: absence, complex partial seizure
what is the mechanism of epileptic fits?
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)
what are the types of epileptic seizures
partial seizure
generalised seizure
what are epileptic fits chemically triggered by
- decreased inhibition (gama-amino-butyric acid, GABA)
- excessive excitation (glutamate and aspartate)
- excessive influx of Na and Ca ions
what is a focal seizure?
seizure restricted to one hemisphere or one part of the one hemisphere
what is a generalised seizure?
abnormal activity in both hemispheres
what are EEGs useful in?
identifying seizure types, syndrome and aetiology
What are the disadvantages of using EEG for diagnosis of fits?
Problematic false positives
- Paroxysmal activity seen in 30%
- Frankly epileptiform activity in 5% of normal children
how are seizures/fits diagnosed?
- history
- video recording of event
- ECG in convulsive seizures
- interictal/ ictal EEG
- MRI Brain: to determine aetiology
- genetics
- metabolic tests
when should anti-epileptic drugs be considered for use in children?
if diagnosis is clear even if this means delaying treatment
what should be considered when choosing anti-epileptics drugs?
- age
- gender
- type of seizures
- epilepsy
what are the possible side effects of anti-epileptic drugs?
CNS related
- drowsiness
- effect on learning
- cognition and behavioural effects
describe the management of epilepsy
sodium valproate (not in girls)/ levetiracetam
carbamazepine (focal)
other: steroids, immunoglobulins, ketogenic diet
what is microcephaly and macrocephaly
microcephaly: OFC < 2 SD
macrocephaly: OFC > 2SD
OFC - occipitofrontal circumference
what do neuromuscular disorders affect?
disorders of the peripheral nervous system from the anterior horn cells down
when should you suspect a neuromuscular disorder?
- 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
what is Duchenne muscular dystrophy?
delayed gross motor skills
symmetrical proximal weakness: waddling gait, calf hypertrophy, gower’s sign
elevated creatine kinase levels
complications: cardiomyopathy, respiratory involvement
give examples of neuromuscular conditions
muscle: muscular dystrophies, myopathies (congenital and inflammatory), myotonic syndromes
neuromuscular junction: myasthenic syndromes
nerves: hereditary or acquired neuropathies
anterior horn cells: spinal muscular atrophy
