Neurology Flashcards
What is a complex febrile seizure?
seizure longer than 15min
focal features, at least initially
more than 1 febrile seizure occurring in 24 hours
What type of seizure has peak occurance betwen 4-7 months, and has a poor prognosis?
What type of specic movement is associated with this seizure?
Infantile Spasm
►Exaggerated moro-like movement
What is the difference between simple and complex partial seizures?
the intact awareness in patients with simple partial seizures
*partial means focal seizure
both can occur at any age
Describe an Abscence seizure
- age 3-15 years
- 3-10s lapses in awareness, often many per day
- No post-ictal state
- Classic EEG of 3Hz spike/wave pattern
Desscribe a Benign Rolandic seizure presentation.
- 5-15 years, remits in puberty
- Focal motor seizure involving face, hand
- Usually during sleep or upon awakening
- Classic EEG pattern of central temporal spikes
- no imaging or treatment usually needed
What is the acute management for a patient with new-onset simple febrile seizures?
Acute management:
- ensure child doesn’t hurt himself while seizing,
- provide O2,
- call 911 if lasts over 5 min (99% are shorter)
- Education
<6mo needs electrolyte panel and ED eval
<1yo & unimmunized needs lumbar puncture if has seizure
If Hx suggests access→ run urine tox screen on kids >1yo
What counseling and treatment options can you provide to a parent of a child who just had a febrile seizure?
Patient Education: this is our main role as PCP. We want to prevent recurrent ambulance transport to ED. → risk of reoccurrence= 30%
Risk Factors for reoccurrence: FHx febrile seizure, <18mo, febrile seizure threshold, duration of fever prior to seizure
Risk for later epilepsy: FHx epilepsy, neurodevelopmental abnormal, complex febrile seizure, duration of fever prior to sz
**Febrile sz do not cause brain damage
***Anti-pyretics won’t prevent a febrile seizure
****rectal diazepam can be prescribed
What does it mean to say a seizure is “unprovoked”?
It was not caused by fever, illness or trauma.
Who needs to go to the ED with a first unprovoked seizure?
- infant
- prolonged seizure
- ill-appearing
Get Labs, maybe CT, LP
→PCP follow-up
What can a PCP do for evaluation and management of an initial unprovoked seizure?
PCP can order:
- Imaging: non-urgent MRI (CTs not good for seeing small tumors)
- EEG: within 2 weeks, talk to referral clinic 1st so know which type of EEG to order, prescribe sedative for EEG procedure (neurologist will administer)
- False Negatives common (~50% in kids under 4yo)
- send for repeat EEG if additional seizure
Seizure precautions: no SCUBA, no swimming alone, no heights
What are the legal responsibilities of reporting seizure diagnoses as a PCP?
Reporting: state to state but usually need to be seizure-free for 6mo with or without meds to be able to drive
►CO does not have this law, nor a mandatory reporting protocol for pts with seizures
(however we do have a repsonibilty to report patients who are a threat to themselves or others…)
When should a PCP refer a seizure patient to a neurologist?
Refer to neuro for:
abnormal EEG, MRI, or neuro exam
Hx of prematurity, cranial radiation, focal seizures, baseline neuro impairment (eg w/ Cerebral Palsy)
No anti-epileptics (let neuro prescribe these)
What Hx questions do you need to ask for pediatric seizure?
- Alteration in awareness/ consciousness (true seizure)
- Aura
- Witnessed movement
- Length of episode
- Association with fever, illness, trauma (all can provoke seizure, but seizure isn’t the 1° problem)
- Incontinence (suggests true seizure disorder)
- Post-ictal state (confusion, fatigue or H/A→suggests true seizure disorder)
- Previous episodes
- FHx of seizures
- Adolescent- EtOH, drugs, sleep deprivation (can provoke seizure in non-epileptic patient OR a breakthrough seizure in those with seizure disorder)
How reliable are EEGs in a patient with new onset seizures?
False Negatives are common (~50% in kids under 4yo),
►send for repeat EEG if additional seizure
Name/ descibe 3 seizure “fake outs” that occur in infants.
-
Infantile shuddering→ with eating, excitement
- appears to shiver with decrease in awareness, occurs in clusters, NO post-ictal state
- Pressure to extremity should stop movement
-
Benign nocturnal myoclonus→ while asleep/falling asleep, focal or generalized jerking motions
- Pressure to extremity should stop movement
-
Sandifer’s syndrome– can look like focal seizure bc hard to tell awareness level in very young infants
- pain from GER (gastro-esophageal reflux)
What always precipitates breath holding spells (in a 6mo-3yo)?
What do these look like?
-Precipitated by fright or trauma
- stiffening
- tonic/clonic movt
- pallor,
- syncope
What seizure “fake outs” are common in teens and even adults?
Syncope
- MC in teens, females
- some clonic movts possible
- usually preceeded by pallor, NO post-ictal state
- consider: hypoglycemia, anemia, vasovagal, cardiac (if prolonged QT→get stress echo)
Psychogenic seizure
- Teens and adults
- usually have psychiatric Hx
- stiffening, clonic movts, may not be rhythmic
- rarely incontinent or postictal
What are the 2 MCC of pediatric headaches?
- tension H/A– which produces pain in a band-like pattern
-
migraine H/A—usually throbbing, not as unilateral as in adults, may be accompanied by phonophobia and photophobia
- Hx: resting in a dark room causing improvement in the h/a?
- Positive FH for migraine headaches?
- ~50% of kids with migraines will have a +hx for motion sickness
What “red flags” with pediatric headaches are concerning for serious intracranial pathology?
Concerning for intracranial pathology:
- age < 5y (uncommon for this age group to get headaches–unless it accompanies a viral illness
- Recent changes in frequency and/or severity
- H/A which are relieved by vomiting
- H/A that wake child from sleep
What skin findings might make you suspicious for an optic gliomas (a usually benign brain tumor)?
Neurofibromatosis:
Café-au-lait spots are common in children, but if you see more than a few, consider this neurocutaneous disorder. neurocutaneous lesions and axillary freckling are pathognomonic for this disorder
At risk for development of optic gliomas, a usually benign brain tumor, which may manifest with h/a’s
When would imaging be needed in eval of peds H/A?
- CT (in ED) → Helpful for new/acute vomiting, signs of ICP
-
MRI
- H/A’s younger than 5 y/o
- New onset & Progressive H/A’s
- Focal neurologic deficit
- Nighttime or postural H/A
- Neurofibromatosis lesions
- Hemiplegic migraine (also incl head and neck MRA)
-
Sleep study
- Early a.m. H/A’s (bc OSA can cause AM headaches after a night of oxygen deprivation)
What Tx s are useful specifically for peds migraines?
Fluids
NSAID
Triptans, 12+ y/o (no more than 2-3x/wk)
Diphenhydramine (Benedryl)
What should always be on your DDx for chronic H/As (that isn’t the H/A itself)?
depression
school avoidance
With chronic H/As (more than 2/month), we want to taper off NSAIDs and start prophalactic medication.
What medication would you start if the pt is less than 12yo and is not overweight? Dosing instructions?
Cyproheptadine (Periactin)
Start 2mg every night at bedtime, plan 6 month therapy, titrate up until no more H/As and can D/C NSAIDs
after 6mo, taper off and see if H/As have resolved or decreased enough to go back to abortive meds (NSAIDs)
As a PCP, when should we be referring for pediatric H/As?
- Abnormal neurologic exam
- All hemiplegic migraines (transient gait abnormality during a migraine episode)→ neuro consult, MRI, MRA
- have evaluated once, don’t need to send back after every recurrent H/A (unless Hx or PE changing)
- Diagnostic uncertainty
- Not responding to treatment as expected
