Neurology Flashcards
what is the best dx tool for neuro?
History
where is LP done?
22 gauge needle at L3-L4 intervertebral space
what is LP used for measuring?
Opening pressure, cell count (red and white), glucose, protein, culture, gram stain, PCR for viruses
what does CT find?
bleeding and masses
what does MRI show?
Myelination and demyelenation
Can see posterior fossa best
what can US show?
Eval for hydro, hemorrhage, gross structures, calcification
Routine neuroimaging is or is not indicated for children presenting with recurrent headaches unless
is there is an abnl neuro exam, coexistence of seizures or other red flags.
when do you do CT or MRI for HA?
rarely necessary/appropriate
Concern about sub-arachnoid, subdural hematoma
Concern about increased IC pressure or hemorrhage
when should you do labs for HA
if suspect infectious origin
CBC, blood cultures, lumbar puncture etc for meningitis
what are 5 red flags of HA
- Headache fails to respond to therapy
- focal neurologic findings appear (in first 2-6 months)
- progressively increasing frequency / severity of headache, headache worse with valsalva
- headache awakens from sleep, worse in the morning, AM vomiting
- at-risk hx or condition: neurocutaneous disorder
(brain tumor, hemorrhage, hydrocephalus, pseudotumor, meningitis,) may cause
increased ICP
(intracerebral hemorrhage, vasculitis, or AVM) may cause
vascular HA
(postictal or ictal) may cause what 2ndary HA?
epilepsy
(sinusitis, dental abscess, trigeminal neuralgia, TMJ pain, carotid dissection) may cause what 2ndary HA
h and neck patho
(HTN, DM, cardiac disease-source of emboli/stroke) may cause
2ndary HA
what drugs may cause 2ndary HA
(analgesic overuse/rebound, drug abuse-cocaine, psychostimulants, OCPs, steroids)
what psych do may cause 2ndary HA?
depression
HA that is Severe, pulsatile (pounding)
unilateral, can be bilateral
Frontal or temporal regions, retro orbital or cheek
Migraine
May be only symptom in younger children (cyclic vomiting)
Vomiting may herald the end of the headache
Migraine
Assoc symptoms
N/V photophobia, phonophobia, vertigo, fatigue, mood alteration
Vomiting
Migraine
children have what kind of aura for HA
visual
when are studies warranted for migraines?
focal neurologic signs
HA worse on awakening , or awakens pt , or with a cough or bending over.
how do you treat migraines
Ibuprofen or acetaminophen early in the attack
Caffiene, caffiene+ergot
Triptans (sumatriptan, rizatriptan, etc.) and DHE (dihydroergotamine)
Rest and quiet
Avoid narcotics
how do prevent migraines?
Tricyclic antidepressants
Beta Blockers ie propranolol
Calcium channel blockers, such as verapamil
how do you dx a migraine?
Hx
what are TTH brought on by?
Brought on by fatigue, exertion, stress
which of the following is not for migraines?
narcotic - morphine
what is Pain described as
Constant, aching, tight
Occipital, frontal or constricting band around head
May occur simultaneously with vascular headache
TTH
how do you treat TTH?
Relieved by rest, analgesics
who gets cluster HA
Predominantly male
Unusual in children under 10
what is HA that is Unilateral, severe pain
Periorbital or retro-orbital
May have ipsilateral autonomic dysfunction (flushing, tearing, sweating, nasal congestion)
Patient can’t sit still due to the pain
Cluster HA
how long does cluster HA last
Lasts minutes to hours – typical 30 min to 2 hrs
t or f cluster ha Occur in clusters, often seasonal
T
how do you treat cluster HA?
O2 - 100%
A sudden, transient disturbance of brain function manifested by involuntary motor, sensory, autonomic, or psychic phenomena.
seizure
2 or more seizures not provoked by particular event or cause.
epilepsy
sz can be d/t
Metabolic, truamatic, anoxic, infectious insult to brain
a benign condition of childhood with unilateral focal seizures and speech abnormalities, often hereditary.
rolandic epilepsy
sz that is in first 28 days (typically first few days)
Benign familial ( outgrow )
Secondary may progress ( HIE,Infex, IVH, thrombus)
neonatal sz
sz in 6 mo – 6 yrs, w no evidence of intracranial infection or defined cause
febrile
what is status epilepticus
Seizure > 30 min
Sequential seizures without regain LOC > 30min
do children out grow sz?
70-80% do
what are partial sz types
simple partia (focal) Complex partial (psycho-motor) Benign rolandic epilepsy
what are generalized sz types
Absence (petit mal) Generalized tonic clonic (grand mal) Tonic Clonic Atonic
what sz are unique to kids?
Infantile spasms (West syndrome)
Febrile seizures
Juvenile myoclonic
what is simple partial sz
No LOC
what is complex partial sz?
LOC (staring) – altered consciousness
what is 2ndarily gen sz?
: a simple or complex partial seizure that ends in a generalized convulsion
what is a partial sz?
Onset of seizure begins in one area of one cerebral hemisphere (apparent clinically or via the EEG)
can eeg tell us if someone has epilepsy?
No -
what is a generalized sz?
Seizures arise from both hemispheres, simultaneously
what szs are Frequently associated with underlying structural brain disease and
Difficult to treat and classify
Myoclonic,Tonic, Atonic and Atypical absence
symptoms of Stare Eyes fluttering Automatisms (such as lip smacking, picking at clothes, fumbling) if prolonged
Absence (petit mal)
what has symptoms of A cry Fall Tonicity (rigidity) Clonicity (jerking) May have cyanosis
Generalized tonic-clonic (Grand mal)
what has post-ictal of Amnesia for seizure eventsNo confusionPromptly resumes activity
absence
what has post-ictal of Amnesia for seizure eventsConfusionDeep sleep
tonic-clonic
what is are infantile spasms? (west syndrome?
Clinical Spasms ( 1-2 seconds)
Mistaken for colic, reflux, startle
Occur in clusters when drowsy
what could cause infantile spasm? and out comes of both?
-Brain insult at birth, malformation ,Tuberous Sclerosis, metabolic origin
Hard to control
Poor neurocognitive outcome
Cryptogenic = no identifyable cause.
Best outcome
Seizure description:
-When awake:
twitching and/or tingling on one side of body
speech arrest, speech difficulty, may drool / gag
no loss of consciousness, usually
Benign Rolandic EpilepsyBenign Focal Epilepsy of Childhood
what is the IQ of someone with rolandic epi?
normal
what is the Fhx of someone with rolandic epi
positive for
who gets rolandic epilepsy?
Boys>girls
when do you treat rolandic epi?
frequent (which is unusual)
Socially stigmatizing if occur in wakefulness
Anxiety provoking for parents if occur in sleep
what is status epilepticus?
30 minutes or more of continuous seizures or recurrent seizures without regaining consciousness
Medical emergency
Prolonged seizure may cause structural damage, hypoxia, hypotension, death
who is status epi common Most common in?
children under 5 (85%) , especially < 12 mo
how do you treat status epi?
ABCs, then IV anticonvulsants (Valium)
what are most common causes of status epi?
Infection and metabolic disorders are most common causes in children.
how do you work up sz?
EEG CT or MRI
EEG
Every case of suspected seizure disorder (but not necessary for febrile seizures)
Abnormal in 60-80%
Blood tests
Generally not helpful
Only if specifically suggested by presentation, history
CT scan or MRI
Generalized - Abnormal exam or difficult to control
Focal – Not for benign Rolandic epilepsy, but all others
what specimens should be collected for Sz eval?
-CBC WBC > 20k may suggest bacterial infection Left shift often seen due to adrenocortical surge -Blood cultures , Urine C+S , -Lumbar puncture Some under age 2(younger the child, the more important) Any suggestion of meningitis -Electrolytes Na,K,Cl,HCO3,BUN,Cr,Ca,Phos,Mag Glucose -Neonates – consider metabolic Lactate, Amonia, Urine ketones
who should get labs for sz?
Neonatal,abnormal mental status persistent, diabetics, renal disease, diuretic use, Dehydration, malnourishment
what is EEG most used for?
–>Most useful for classifying types and guiding therapy
Absence (petit mal), psychomotor (temporal lobe),
generalized tonic clonic (grand mal)
Infantile spasms
Mixed seizure disorders
–>Useful in evaluating worsening seizures or projecting recurrence of seizures if medicines were to be stopped
how do you treat febrile sz
diazepam, phenobarbital, valproic acid
how do you tx neonate sx
phenobarbital
do you tx febrile sz
no - if you have to for continual sz - diazepam
is a febrile sz epilepsy?
NO
if a child presents with complex febrile sz
more likely will have epilepsy but as a whole does not progress they just have the increased risk
lots of things that mimic seizure
Apnea / ALTE
GER
Sleep disorders (nocturnal myoclonus, night terrors, narcolepsy/cataplexy)
Migraine variants (esp. aura)
Benign breathholding spells
Syncope
Movement Disorders (tics, tremor, dystonia)
Pseudoseizures (psychogenic seizures)
-Strange posturing, back arching, writhing
-Alternating L and R limb shaking during same
seizure
-Psychosocial stressor
what are the 3 common features of breath-holding spells?
-Involuntary:
Children < 4 can’t voluntarily hold breath
Most start before 18 mo
Resolve usually by 4, definitely by 8
-Brief loss of consciousness
-May have “seizure” activity while unconscious
what are cyanotic spells precipitated by?
anger frustration and fear
how does cyanotic spells occur?
Cries, stops breathing in expiration, becomes cyanotic
what sz has symptoms of No loss of consciousness.Sudden jerkingsensory phenomena
simple partial
what sz symptoms of May have auraAutomatisms (such as lip smacking, picking at clothes, fumbling)Unaware of environmentMay wander
complex partial
what sz has postictal of transient weakness or loss of sensation
simple partial
what sz has a postictal of Amnesia for seizure eventsMild to moderate confusion, sleepiness
complex partial
what HA often has symptoms of depression and/or anxiety. Secondary gain is common (e.g., school avoidance)
chronic tension
what HA has pain Bilateral and diffuse
Dull and aching
Often present upon awakening
Not associated with nausea, vomiting, neurologic problems
chronic tension
how do you tx chronic tension HA?
Treatment is difficult but antidepressants seem helpful
what may work up include for chronic tension HA
a CT scan or MRI
syncope has prodrome T or F?
May have prodrome
Dissiness, lightheadedness, nausea, sweating, pallor
what is Transient LOC and postural tone due to cerebral ischemia or anoxia.
syncope
syncope absolutely does not have jerking motions when unconscious, T or F
F
what is link in syncope
Family history + in 90% of patients
what syncope is Neurally mediated
Transient hypotension from vasodilation and/or decreased heart rate
Arousal 1-2 min up to 1h
Vaso-vagal or neurocardiogenic
what is the most common syncope type
Vaso-vagal or neurocardiogenic
what syncope has CP and palpitations with it? and occurs during exercise?
cardiac
how do you work up syncope?
Vitals , BP, Hgb, EKG
how do you treat syncope?
Direct management of any cardiac cause
Reassurance and avoidance of triggers for vaso-vagal stimulation
what may cause inc ICP?
Cerebral edema
Mass lesion
Infant with symptoms of
Bulging fontanelle
Increasing head circumference, separating sutures
Lethary, vomiting, FTT, “setting-sun sign”
inc ICP
Children with symptoms of Headaches Diplopia/Strabismus Papilledema Herniation syndromes
increased ICP
what does setting sun sign go with?
hydrocephalus
where is HA from elevated ICP located?
Supratentorial – eye, forehead, temple
Infratentorial – occiput, neck
Generalized
when does the pain occur for elevated ICP
Worse in morning on awakening and standing up, or at night
Worsened by maneuvers that transiently increase ICP: Coughing, sneezing, straining
what occurs along with pain d/t inc ICP? describe pain?
Often also have vomiting without nausea
Constant and unremitting
what is assoc with Well person who suddenly experiences “worst headache in my life”
SAH
classic pt who is girl obese with HA, tinnitus, papilledema,visual loss normal MRI increased opening pressure
psuedotumor cerebri
what is Increased intracranial pressure without identifiable mass or hydrocephalus
pseudotumor cerebri
what is cause of pseudotumor cerebri?
unknown (dx of exclusion)
what are the most common causes of childhood stroke?
Cyanotic heart disease
Sickle cell anemia
Meningitis
Hypercoagulable states
what presents as hemiplegia, unilateral weakness, seizures.
childhood stroke
what hx do you want for childhood stroke?
Assess for history of infections, head/neck truma, familial clotting disorders, CHD
what studies should you do for childhood stroke?
CBC, ESR, Chemistries, BUN/Cr , clotting studies, CXR, EKG,Urine tox, UA ( CSF not usually helpful unless eval infection)
CT or MRI
how do you tx stroke?
No treatment to repair damage
Preventive management
Underlying disease , anticoagulants
What is the most common cause of concussion in children?
Fall
Brief loss of consciousness or stunned for minutes to hours No localizing neurologic signs
Amnesia is common and transient
concussion
what is the major diagnostic for concussion?
CT
All children with amnesia or who were unconcscious should be evaluated in ER t or f?
T
what is post concussive syndrome and when does it resolve
Many children complain of headache, dizziness, forgetfulness, inability to concentrate, slowing of response time, mood swings, irritability
Resolve spontaneously
Can take weeks to months
what are congenital malformations of neuro? 6
Meningomyelocele, encephalocele, Lissencephaly, pachygyria, absence of corpus callosum
what is MMC identified by and is d/t?
Often identified on US, likely have elevated alpha fetoprotein on prenatal screen.
Folate during pregnancy
what is displaced cerebellum through foramen magnum into spinal canal –
arnold chiari I
how do you treat arnold chiari i?
posterior laminectomy
what has sx of progressive ataxia or vertigo
arnold chiari I
what is displaced cerebellum plus meningomyelocele
arnold chiari II
which chiari has Varying degrees of paralysis depending on site/level of defect
hydroceph and sz
II
how do you treat AC II
surgical repair and shunt
what has low lying tonsils alone and asympt
chiari I
what has low lying tonsils + hydrocephalus and diffuse HA
chiari II
smooth brain
Severe delay, seizures. Associated with syndromes
lissencephaly
Most common disorder of neuronal migration
lissenecephaly
what is Premature closure of sutures
Craniosynostosis
most common craniosynostosis?
saggital suture > coronal suture
what limits lateral growth and has Elongated (scaphoid) head
saggital suture craniosyn
what Limits AP growth Short wide (brachycephalic) head
coronal suture craniosyn
does craniosyn affect brain
Doesn’t constrict brain unless many sutures involved (↓ head size)
how do you dx craniosyn
Diagnosed on basis of palpable, raised, fixed suture lines and/or changing shape of head Skull Xrays
how do you treat craniosyn?
Treatment is surgical excision of fused suture line – best done prior to 6 months of age
Impairment of coordination and balance of voluntary movement
ataxia
where is the problem in the brain with ataxia?
cerebellar problem
what is the most common cause of ataxia?
post infectious or drug intox
what are other causes of ataxia?
Brain lesions or tumors
Infection (CNS ; encphalitis, meningitis)
Hereditary Ataxic (Friedreich Ataxia )
Metabolic
what illness may cause ataxia?
usually viral (varicella, mono, URI, GI )
what has symptoms of Sudden onset of ataxia,staggering, frequent falls
Nystagmus, vomiting, irritaility, lethargy possible
Sensory and reflexes preserved
No evidence increased ICP
post infectious acute cerebellar ataxia
what is the prognosis of post infectious cerebellar ataxia
– 90% of children with acute cerebellar ataxia have complete recovery in 1-4 weeks
disease at the Anterior Horn Cells
SMA – spinal muscular atrophy
nerve NM d/o?
Guillian Barre – post viral autoimmune
NMJ NM d/o?
Myasthenia Gravis
neouromuscular d/o at the muscle
Muscular dystrophy
Myotonic dystrophy
progressive weakness and wasting of skeletal muscles Normal mental, language and social skills
Eventual respiratory failure and death
anterior horn cell spinal musc atrophy (AR)
muscle weakness, which may manifest with floppiness, delayed motor milestones, unsteady gait or muscle fatiguability you should think…
NM d/o
Acute post-infectious polyneuropathy
often follows URI / GI infection (autoimmune)
GB syndrome
ascending symmetrical weakness; starts as numbess or tingling in hand / feet… heavy feeling in legs
bulbar palsy and respiratory depression
Autonomic dysfunction –hyper/hypotension , tachycardia
GB syndrome
> 10 years old, ophthalmoplegia and ptosis, loss of facial expression and difficulty chewing
Juvenile myasthenia
presents later in life, less severe
Death usually in adulthood
Becker Muscular Dystrophy
X-Linked recessive Onset at 2-6 yrs Proximal muscles affected before distal Waddling gait, difficulty with stairs pseudohypertrophic calf
duchenne MD
what has +Gower Sign (pelvic weakness)
Elevated CPK , Rx Steroids
DMD
in MD weakness starts…
proximal and goes distal
when does death occur in duchenne
DMD
what is the most common CP
spastic - Monoplegia, paraplegia, hemiplegia, quadraplegia,
what is Muscular – motor problem,
Non-progressive and originated before or at or near birth
CP
what is an Autosomal Dominant
with Café au lait spots - >6 of 5mm prepubertal pt
NF
AD, rare , characterized by benign tumors in vital organs such as the brain, eyes, kidneys, heart and skin.
tuber-like growths in the brain which calcify with age and become hard, or sclerotic.
tuberous sclerosis
-Unilateral port wine stain over upper face
Follows cranial nerve V
-Intracranial leptomeningeal vascular anomaly and calcifications
-Buphthalmos with enlarged globe, corneal clouding
-Mental Retardation
Embryonal developmental anomaly
sturge weber
