Neurology Flashcards
What is meant by syncope?
Syncope is the term used to describe the event of temporarily losing consciousness due to a disruption of blood flow to the brain, often leading to a fall. Syncopal episodes are also known as vasovagal episodes, or simply fainting.
What happens in a vasovagal episode?
Strong stimulus to vagus nerve (emotional event, pain, change in temperature)
Stimulation of the parasympathetic nervous system, counteracting the sympathetic nervous system
Smooth muscle in blood pressure relax including those delivering blood to the brain
Cerebral circulation blood pressure drops
Hypoperfusion of the brain tissue, this causes the patient to lose consciousness and ‘faint’
Patients often remember the event and can recall how they felt prior to fainting. This is called the prodrome, and involves feeling how?
Hot or clammy
Sweaty
Heavy
Dizzy or lightheaded
Vision going blurry or dark
Headache
A collateral history from someone that witnessed a syncope is essential to get an accurate impression of what happened. During a vasovagal episode they may describe the person how?
Suddenly losing consciousness and falling to the ground
Unconscious on the ground for a few seconds to a minute as blood returns to their brain
There may be some twitching, shaking or convulsion activity, which can be confused with a seizure
Seizure vs syncope - after the episode
The patient may be a bit groggy following a faint, however this is different from the postictal period that follows a seizure.
Postictal patients have a prolonged period of confusion, drowsiness, irritability and disorientation.
There may be incontinence with both seizures and syncopal episodes
Primary syncope causes
Dehydration
Missed meals
Extended standing in a warm environment, such as a school assembly
A vasovagal response to a stimuli, such as sudden surprise, pain or the sight of blood
Secondary causes of syncope?
Hypoglycaemia
Dehydration
Anaemia
Infection
Anaphylaxis
Arrhythmias
Valvular heart disease
Hypertrophic obstructive cardiomyopathy
Key points to focus on during history of a syncopal episode?
Features that distinguish a syncopal episode from a seizure
After exercise? Syncope after exercise is more likely to be secondary to an underlying condition.
Triggers?
Concurrent illness? Do they have a fever or signs of infection?
Injury secondary to the faint? Do they have a head injury?
Associated cardiac symptoms, such as palpitations or chest pain?
Associated neurological symptoms?
Seizure activity?
Family history, particularly cardiac problems or sudden death?
Syncope vs seziure - pre episode
Syncope: prolonged upright posture, lightheaded, sweatting, blurring or clouding of vision
Seziure: aura (smells, tastes, deja vu)
Syncope vs seizure - during the event
Syncope: reduced tone during the episode, return of conicouness shortly after fall
Seziure: tonic clonic activity, head turning or abnormal limb positions, tongue biting, cyanosis, lasts more than five mins
?syncope key points to elicit on examination
Are there any physical injuries as a result of the faint, for example a head injury?
Is there a concurrent illness, for example an infection or gastroenteritis?
Neurological examination
Cardiac examination, specifically assessing pulses, heart rate, rhythm and murmurs
Lying and standing blood pressure
?syncope investigations
ECG, particularly assessing for arrhythmia and the QT interval for long QT syndrome
24 hour ECG if paroxysmal arrhythmias are suspected
Echocardiogram if structural heart disease is suspected
Bloods, including a full blood count (anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)
Management of fainting in children
Fainting is common in children, particularly in teenage girls. They usually resolve by the time they reach adulthood. The most important aspect of management is making a confident diagnosis and excluding other pathology.
Seizures or underlying pathology need to be managed by an appropriate specialist.
Once a simple vasovagal episode is diagnosed, reassurance and simple advice can be given to:
Avoid dehydration
Avoid missing meals
Avoid standing still for long periods
When experiencing prodromal symptoms such as sweating and dizziness, sit or lie down, have some water or something to eat and wait until feeling better
What is epilepsy?
Epilepsy is an umbrella term for a condition where there is a tendency to have seizures - transient episodes of abnormal electrical activity in the brain.
Features of Generalised Tonic-Clonic Seizures
These are what most people think of with an epileptic seizure. There is loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements. Typically the tonic phase comes before the clonic phase. There may be associated tongue biting, incontinence, groaning and irregular breathing.
After the seizure there is a prolonged post-ictal period where the person is confused, drowsy and feels irritable or low.
Management of tonic-clonic seizures?
First line: sodium valproate
Second line: lamotrigine or carbamazepine
Features of focal seizures
Focal seizures start in the temporal lobes. They affect hearing, speech, memory and emotions. There are various ways that focal seizures can present:
Hallucinations
Memory flashbacks
Déjà vu
Doing strange things on autopilot
Where do focal seziures start?
Temporal lobes
Focal seizure management
One way to remember the treatment is that the choice of medication is the reverse of tonic-clonic seizures:
First line: carbamazepine or lamotrigine
Second line: sodium valproate or levetiracetam
What do absence seizures look like?
The patient becomes blank, stares into space and then abruptly returns to normal.
During the episode they are unaware of their surroundings and won’t respond.
These typically only lasts 10 to 20 seconds
Which patients are typically affected by absence seizures?
Children
More than 90% of these patients will stop having them as they get older
Management of absence seizures
First line: sodium valproate or ethosuximide
How are atonic seizures characterised?
Brief lapses in muscle tone
They usually last more than 3 minutes
Atonic seizures/drop attacks typically begin in childhood. What might they be indicative of?
Lennox-Gastaut syndrome
How are atonic seizures managed?
First line: sodium valproate
Second line: lamotrigine
How are myoclonic seizures managed
First line: sodium valproate
Other options: lamotrigine, levetiracetam or topiramate
How are myoclonic seizures characterised?
Myoclonic seizures present as sudden brief muscle contractions, like a sudden “jump”. The patient usually remains awake during the episode.
Myoclonic seizures occur in various forms of epilepsy but typically happen in children as part of what?
juvenile myoclonic epilepsy
What is also known as West syndrome?
Infantile spasms
When does West syndrome start?
In infancy, around 6 months of age
What is West syndrome characterised by?
Clusters of full body spasms
Infantile spasms/West syndrome prognosis
There is a poor prognosis: 1/3 die by age 25, however 1/3 are seizure free. It can be difficult to treat but first line treatments are:
What are febrile convulsions
Febrile convulsions are seizures that occur in children whilst they have a fever. They are not caused by epilepsy or other underlying neurological pathology (such as meningitis or tumours).
By definition, febrile convulsions occur only in children of what ages?
between the ages of 6 months and 5 years
Consequences/prognosis of febrile convulsions
Febrile convulsions do not usually cause any lasting damage.
One in three will have another febrile convulsion.
Having febrile convulsions slightly increases the risk of developing epilepsy in the future.
Do all children with ?seizures require investigation?
A good history is the key to a diagnosis of epilepsy. It is important to establish that any episodes were seizures, as opposed to vasovagal episodes or febrile convulsions.
Try to identify the type of seizure. Patients with a clear history of a febrile convulsion or vasovagal episode do not require further investigations.
Children are allowed one simple seizure before being investigated for epilepsy.
When should an EEG be performed on children?
An electroencephalogram (EEG) can show typical patterns in different forms of epilepsy and support the diagnosis.
Perform an EEG after the second simple tonic-clonic seizure.
When should an MRI brain be performed in children with seizures
An MRI brain can be used to visualise the structure of the brain. It is used to diagnose structural problems that may be associated with seizures and other pathology such as tumours. It should be considered when:
The first seizure is in children under 2 years
Focal seizures
There is no response to first line anti-epileptic medications
Additional investigations can be considered to exclude other pathology that may cause seizures
ECG to exclude problems in the heart.
Blood electrolytes including sodium, potassium, calcium and magnesium
Blood glucose for hypoglycaemia and diabetes
Blood cultures, urine cultures and lumbar puncture where sepsis, encephalitis or meningitis is suspected
Patients and families presenting with seizures need to be given advice about safety precautions, recognising, managing and reporting further seizures. It is important to avoid situations where a seizure may put the child in danger, what advise can be given?
Take showers rather than baths
Be very cautious with swimming unless seizures are well controlled and they are closely supervised
Be cautious with heights
Be cautious with traffic
Be cautious with any heavy, hot or electrical equipment
Older teenagers with epilepsy will need to avoid driving unless they meet specific criteria regarding control of their epilepsy
Action of sodium valproate in epilepsy?
It works by increasing the activity of GABA, which has a relaxing effect on the brain.
Sodium valproate is a first line option for most forms of epilepsy except for what?
Focal seizures
Notable side effects of sodium valporate?
Teratogenic, so patients need careful advice about contraception
Liver damage and hepatitis
Hair loss
Tremor
There are a lot of warning about the teratogenic effects of sodium valproate and NICE updated their guidelines in 2018 to reflect this how?
It must be avoided in girls unless there are no suitable alternatives and strict criteria are met to ensure they do not get pregnant.
Carbamazepine is the first line therapy for what?
focal seizures
Notable side effects of carbamazepine
Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions
Phenytoin notable side effects
Folate and vitamin D deficiency
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitamin D deficiency)
Two notable side effects of ethosuximide?
Night terrors
Rashes
Two notable side effects of lamotrigine?
Stevens-Johnson syndrome or DRESS syndrome. These are life threatening skin rashes.
Leukopenia
Immediate management of a seizure?
Put the patient in a safe position (e.g. on a carpeted floor)
Place in the recovery position if possible
Put something soft under their head to protect against head injury
Remove obstacles that could lead to injury
Make a note of the time at the start and end of the seizure
Call an ambulance if lasting more than 5 minutes or this is their first seizure.
What is status epilepticus?
It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.
Management of status epileptics in the hospital
Secure the airway
Give high-concentration oxygen
Assess cardiac and respiratory function
Check blood glucose levels
Gain intravenous access (insert a cannula)
IV lorazepam, repeated after 10 minutes if the seizure continues
If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin. At this point intubation and ventilation to secure the airway needs to be considered, along with transfer to the intensive care unit if appropriate.
For managing status epilepticus in the community
Buccal midazolam
Rectal diazepam
What are simple febrile convulsions?
Simple febrile convulsions are generalised, tonic clonic seizures. They last less than 15 minutes and only occur once during a single febrile illness.
What are complex febrile convulsions?
Febrile convulsions can be described as complex when they consist of partial or focal seizures, last more than 15 minutes or occur multiple times during the same febrile illness.
Febrile convulsion - differntials
Epilepsy
Meningitis, encephalitis or another neurological infection such as cerebral malaria
Intracranial space occupying lesions, for example brain tumours or intracranial haemorrhage
Syncopal episode
Electrolyte abnormalities
Trauma (always think about non accidental injury)
Diagnosing febrile convulsions
In order the make a diagnosis of a febrile convulsion, other neurological pathology must be excluded.
Typical presentation of febrile convulsions
A typical presentation is a child around 18 months of age presenting with a 2 – 5 minute tonic clonic seizure during a high fever.
The fever is usually caused by an underlying viral illness or bacterial infection such as tonsillitis.
What should be done following the diagnosis of a febrile convulsion?
Once a diagnosis of a febrile convulsion has been made, look for the underlying source of infection.
What advice should you parents advice on managing a seizure if a further episode occurs following a febrile convulsion?
Stay with the child
Put the child in a safe place, for example on a carpeted floor with a pillow under their head
Place them in the recovery position and away from potential sources of injury
Don’t put anything in their mouth
Call an ambulance if the seizure lasts more than 5 minutes
The first seizure should always result in a trip to hospital for assessment, however if parents are confident in subsequent events and can safely manage the child at home then they can visit their GP at the next available opportunity.
Risk of developing epilepsy following a febrile convulsion?
1.8% for the general population
2-7.5% after a simple febrile convulsion
10-20% after a complex febrile convulsion
What are breath holding spells?
Breath holding spells are also known as breath holding attacks. They are involuntary episodes during which a child holds their breath, usually triggered by something upsetting or scaring them.
Between what ages do breath holding spells typically occur?
6 and 18 months of age
What to reassure parents about breatholding spells
Child cannot control it - not deliberate
Not harmful in long term
Do not lead to epilepsy
Most children outgrowth them by 4 or 5 years
What are the two types of breath holding spells?
cyanotic breath holding spells
pallid breath holding spells (also known as reflex anoxic seizures).
What are cyanotic breath holding spells?
Cyanotic breath holding spells occur when the child is really upset, worked up and crying. After letting out a long cry they stop breathing, become cyanotic and lose consciousness. Within a minute they regain consciousness and start breathing. They can be a bit tired and lethargic after an episode.
What are reflex anoxic seziures?
Reflex anoxic seizures occur when the child is startled.
The vagus nerve sends strong signals to the heart that causes it to stop beating. The child will suddenly go pale, lose consciousness and may start to have some seizure-like muscle twitching.
Within 30 seconds the heart restarts and the child becomes conscious again.
Management of breath holding spells
After excluding other pathology and making a diagnosis, educating and reassuring parents about breath holding spells is the key to management.
Breath holding spells have been linked with iron deficiency anaemia. Treating the child if they are iron deficiency anaemic can help minimise further episodes.
Causes of headaches in children?
Tension headaches
Migraines
Ear, nose and throat infection
Analgesic headache
Problems with vision
Raised intracranial pressure
Brain tumours
Meningitis
Encephalitis
Carbon monoxide poisoning
How do tension headaches present in children?
Tension headaches are very common.
Classically they produce a mild ache across the forehead and pain or pressure in a band-like pattern around the head.
Tension headaches comes on and resolve gradually and don’t produce visual changes or pulsating sensations.
They are typically symmetrical.
Symptoms may be very non-specific in younger children.
They may become quiet, stop playing, turn pale or become tired.
They tend to resolve more quickly in children compared with adults, often within 30 minutes.
Specific triggers for tension headaches in children
Stress, fear or discomfort
Skipping meals
Dehydration
Infection
Management of tension headache
Management is with reassurance, analgesia, regular meals, avoiding dehydration and reducing stress.
Types of migraine
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
Abdominal migraine
What complex neurological condition causes headaches and other associated symptoms occurring in ‘‘attacks’’ following a typical pattern?
Migraine
Characteristic of migraine headaches
Unilateral
More severe
Throbbing in nature
Take longer to resolve
Saggittal Synostosis
Saggital suture
Long and narrow from front to back
Coronal Synostosis
Coronal suture
Bulging on one side of the forehead
Metopic Synostosis
Metopic suture
Pointy triangular forehead
Lambdoid Synostosis
Lambdoid suture
Flattening on one side of the occiput
What is plagiocephaly
Common condition of abnormal head shape in otherwise normal health babies
Plagiocephaly refers to flattening of one area of the baby’s head.
What is brachycephaly?
Common condition of abnormal head shape in otherwise normal health babies
Brachycephaly refers to flattening at the back of the head, resulting in a short head from back to front.
What is Gower’s sign?
Children with proximal muscle weakness use a specific technique to stand up from a lying position. This is called Gower’s sign.
To stand up, they get onto their hands and knees, then push their hips up and backwards like the “downward dog” yoga pose. They then shift their weight backwards and transfer their hands to their knees. Whilst keeping their legs mostly straight they walk their hands up their legs to get their upper body erect. This is because the muscles around the pelvis are not strong enough to get their upper body erect without the help of their arms.
What type of SOL is more common in children and what signs might you expect subsequently
Posterior fossa, cerebellar signs
