Neurology Flashcards
What are the causes of meningitis?
Child: Strep Pneumoniae, N. meningitidis
>6yo: N. Meningitidis, Strep pneumoniae
Hib
Neonate: E.Coli, Listeria, Strep B/Pneumoniae, TB, Entero
What is the pathophysiology of meningitis?
Colonises in the nasopharyngeal epithelium
Invades the blood stream & spreads to the meninges
Inflammation leads to protein leak and cerebral oedema
Change in blood flow and metabolism - cerebral vasculitis
What are the signs & symptoms of meningitis?
INFANTS DONT GET MENINGISM- low threshold for LP Headache Decreased consciousness Vomiting Visual disturbance (papilloedema) Bradycardia Hypertension (above) 12-24hrs into the illness for older children Fever Neck stiffness Photophobia Irritable Seizure 30% Bulging Fontanelle Focal neuro deficit Kernig's sign: Hip flexed at 90 cannot fully extend knee Brudzinski's sign: Passive flexion of neck= flexion of both legs & thighs
How is meningitis investigated?
LP
Bloods: FBC, Clotting, U&E, LFT, Blood Culture
Whole blood PCR: N.Meningitidis
Ziehl-Neelsen Stain: TB
When is an LP contraindicated?
Raised ICP: Focal neuro signs, papilloedema, bulging fontanelle, signs of cerebral herniation
Skin infection over site
Coagulopathy: DIC or thrombocytopenia
CV instability
How do the results of an LP differ depending on the cause of meningitis?
Bacterial: High opening pressure, Cloudy & turbid, raised neutrophils & WCC, raised protein, low glucose
Viral: Normal/high opening pressure, Normal appearance, raised lymphocytes, normal protein & glucose
Partial Tx bacterial: WCC slightly raised, high neutrophils & protein, normal glucose
How is meningitis managed?
GP Abx: BenzylPenicillin STAT (<1yr 300mg, 1-9 600mg, >10 1200mg) on transfer to hospital
Hospital admission:
<3m: IV Amoxicillin & Cefotaxime 14d
>3m: IV Cefotaxime
Steroids (>1m): IV Dexamethasone 150micro/kg for 4days
Public health notification
IV Aciclovir if seizure, focal neuro or HSV exposure
Prophylaxis for contacts: Ciprofloxacin (Rifampicin for haemophilus)
What are the complications of meningitis?
Cerebral Palsy Deafness Visual problems Epilepsy Cognitive impairment Motor deficits Hydrocephalus Cerebral abscess/ cerebral infarcts
What are the causes of cerebral palsy?
Static injury to the developing brain 80% Antenatal 10% Postnatal 10% Hypoxic birth Meningitis Teratogenic Vascular Prematurity Genetics Metabolic issues Congenital infection
What are the types of cerebral palsy?
Spasticity
Choreoathatosis
Ataxia
Describe Spastic cerebral palsy
Most common Hemi/di/quadriplegic Spasticity: Disruption to spinal reflex arc by upper motor neuron Affects all skeletal muscles Inc tone & reflexes Clasp knife phenomenon
What is the definition of cerebral palsy?
Chronic disorder of movement +/- posture
Presents early <2yr and continues throughout life
Describe Choreoathetosis
4 limb disorder
Greatly inc tone when awake
No stretch related response
Fixed RoM
Describe ataxic cerebral palsy
Extremely rare
Congenital ataxia- striking loss of balance in early years
Mild diplegia
How is cerebral palsy investigated?
MRI (esp pyramidal tracts)
How is cerebral palsy managed?
OT/Speech therapist Adaptive equipment Baclofen: Muscle spasm Botox: Contractures Surgery: Tendon lengthening Mobility aids
What are the different levels in the GMFCS?
Gross Motor Function Classification System
6-12years
Level 1: Able to walk, climb stairs independently, perform gross motor skills, speed & balance & coord limited
Level 2: Walk in most settings, difficulty with long distances, physical assistance/mobility device used, minimal gross motor skills
Level 3: Walk w/ hand-held device, climb stairs w/rail, wheelchair for long distances
Level 4: Require physical assistance/ powered mobility in most settings, walk short distances at home w/assistance
Level 5: Manual wheelchair in all settings, limited ability to maintain antigravity head & trunk postures & control leg & arm movements
What is a febrile seizure?
Must fulfil criteria: Temp >38 Developmentally a normal child 3m-5yr OR <6yr No evidence on intracranial infection/inflammation No prev afebrile seizure No acute metabolic disturbance
What are the signs & symptoms of a febrile seizure?
Tonic-Clonic <15mins Incontinence Rousable afterwards Post-seizure fatigue
What are the causes of a febrile seizure?
Infection: Otitis media, Rhinitis, Tonsilitis, Pneumonia, UTI, Meningitis, Septicaemia
What are the red flag signs for a febrile seizure?
>15mins Repeated Focal signs Incomplete recovery within 1hour <12m or >5yrs
How is a febrile seizure investigated?
Temp Bloods Urinalysis EEG LP CXR CT if no cause found
How is a febrile seizure managed?
Antipyretic: Ibuprofen/Paracetamol
Recovery position afterwards
>5mins: Rectal Diazepam: <1m= 2.35-3.5mg <11yr= 5-10mg
Observe on CAT for 6hrs
Parents worried about recurrence: Don’t routinely offer antipyretics
What are the causes of hypoxic ischaemic encephalopathy?
PERINATAL CEREBRAL HYPOXIA Reduced umbilical flow: Prolapse Reduced placental gas exchange: Abruption Maternal hypoperfusion Maternal hypoxia Shoulder dystocia Inadequate postnatal circulation
What are the grades of presentation of hypoxic ischaemic encephalopathy?
Grade 1: hyperalert, normal tone, brisk reflexes, weak suck, strong moro, tachy
Grade 2:lethargic, hypertonic, overactive reflexes, weak suck& moro, brady, seizures
Grade 3: stuporous baby, flaccid, intermittent decerebration, absent reflexes, absent suck, absent moro, variable hr, difficult seizures.
How is hypoxic ischaemic encephalopathy treated?
Resus at birth Assess: Tone, breathing, HR Gasping/ not breathing: 5 inflation breaths ABOVE WITHIN 60s Re-assess HR slow <60: Ventilate for 30s Re-assess HR still <60: Chest compressions 3:1 Re-assess every 30s Consider: IV & arterial lines & IV drugs BP: Maintain at >30 Fluids: 40ml/kg/day 10% Dextrose
How is hypoxic ischaemic encephalopathy investigated?
Defects depend on area affected IMMEDIATE Resus Bloods: U&E, Ca, Glucose, Hb, Coag ABG Daily cranial USS Doppler MCA/ACA after 24hours MRI/CT 2nd week Sever: EEG >6hours
What are tics thought to be related to?
Some genetic component
Related to dopamine
What signs are seen in someone with a tic?
Sudden, purposeless, repetitive, non-rhythmic movements or vocalisations
Eye blinking
Twitching
Grunting/ throat clearing
Can be suppressed to some extent
Worse: Anxiety, stress, fatigue, excitement
What are tics associated with?
ADHD OCD Learning difficulties Behavioural problems Tourettes
What are the different types of tics?
Chronic: No tick free period of longer than 3m in 1year
Transient: Nearly every day no longer than 18m
Tourettes: Mixed phonic, motor & chronic
Who is affected by tics?
Boys
8-11years
How are tics managed?
Reassurance
Education to avoid triggers
Ignore tics
How common are brain tumours in children?
Most common solid tumour
25% of all childhood malignancies
How are CNS tumours classified?
Infratentorial: >50%
Supratentorial
Primary Spinal
CNS mets
What are the signs & symptoms of a brain tumour?
Raised ICP Headache/Migraine Vomiting Seizures Blurred vision Abnormal eye movements Papilloedema Fatigue Balance problems Cerebellar ataxia Unilateral weakness
How are brain tumours investigated?
Opthalmoscope:Papilloedema MRI/CT Brain angiogram LP Bloods/biopsy
How are brain tumours managed?
Diagnostic imaging: CT, MRI, Spinal imaging for staging
Raised ICP: Referral & transfer, Dexamethasone, Surgery- CSF drainage
Anticonvulsants
RT/Chemo
What are the RFs for a brain tumour?
FHx Leukaemia Cranial irradiation Neurofibromatosis Li-Fraumeni Syndrome
What are the types of brain tumours?
Ependymoma: Periventricular, Obstructive hydrocephalus, Chemo
CNS Germ Cell: Rare, teens, raised AFP & hCG, surgery
Craniopharyingioma: Slow-growing, Rathke’s pouch, Complete resection
Retinoblastoma: Sporadic/familial, bilateral/unilateral disease, absent/abnormal light reflex, squint, surgery, Chemo
Gliomas: Low grade-1, high grade-3,4, brainstem
Medulloblastoma: Cerebellum
What are the complications of brain tumours?
Delayed growth
Endocrine: Hypothalamic-Pituitary damage
Educational/behavioural issues
What are the red flags signs in a headache?
Neck stiffness Photophobia Papilloedema & vomiting Morning headaches Posture related headache Trauma Neurological impairment SOL: visual defects, CN abnormalities, abnormal gait, torticollis, growth failure
Name the causes of primary & secondary headaches
1: Migraine, tension, cluster, paroxysmal hemicranias, trigeminal, post-hepatic
2: Head & neck trauma, raised ICP, space occupying lesion, abscess, meningitis, encephalitis, sinusitis, stroke, GCA
What are the signs & symptoms of a chronic headache?
Regular
Often Frontal
NO: Vomiting, paraesthesia, visual disturbance, abnormal exam
