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 is one presentation that would be reassuring against intracranial pathology? (with regards to timeline)
presentation to your office > 3 months after the onset of recurrent H/A is reassuring because a focal neuro deficit is usually apparent within 2mo (and so your patient would have come in earlier)
What Hx questions do you need to know for a pediatric headache?
- Age
- Length of H/A episodes
- Duration of H/A history
- Location/ Character of pain
- Timing of H/A
- Recent changes in frequency, severity
- Associated symptoms
- Vomiting, phonophobia/photophobia
- Viral symptoms
- Neurologic symptoms
- FH- Migraine H/A
EVERY child with complaint of seizure or headache should have a focused neuro exam. What needs to be included (listed in descending order of most to least likely to find a deficit in case of a brain lesion)?
**What is added for headaches only?
- coordination/ gait (42-78% of patients with a brain tumor have deficits here within 2 months of onset of headache)
- pupillary response, extra ocular movements
- vision
- fundoscopic- unreliable for ICP in kids—send to ophthalmology for dilated fundoscopic exam
- development
- finger-to-nose
- balancing, hopping, heel-to-toe gait
- deep tendon reflexes
**include skin exam if child has a headache
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)
