Neurology Flashcards
What is a febrile seizure?
An epileptic seizure accompanied by a fever in the absence of intracranial infection
They usually occur early in a viral infection as the temperature rises rapidly
What is an epileptic seizure?
The nature of the underlying electrical activity in the brain
Excessive and hypersynchronous electrical activity
When do febrile seizures usually occur?
- With regards to age group of the child
- With regards to viral infection
In children between the ages of 6 months to 6 years
They usually occur early in a viral infection when the temperature is rising rapidly
Increased risk (10%) if the child has a first degree relative with febrile seizures
What advice should parents of a child with febrile seizures be given?
If a febrile convulsion lasts >5 minutes they should call an ambulance
If the parents want to treat the fever at home (for reduction of the child’s anxiety) they should not carry out ‘active cooling’ - e.g putting in a cold bath but they could carry out cooling in the form of removing the child’s clothing, giving fluids and giving anti-pyretics
Reducing the child’s temperature, however, does not prevent febrile seizures from re-occuring
How common are febrile convulsions?
They are seen in around 3% of children
What features are considered to be a ‘complex’ febrile seizure?
15-30 minutes in duration
Focal seizure
May have repeat seizures in 24 hours
What features are considered to be a ‘simple’ febrile seizure?
Less than 15 minutes in duration
Generalised (most commonly tonic clonic)Typically no recurrence within 24 hours
Should be complete recovery within an hour
What is cerebral palsy?
It is an umbrella term for a permanent disorder of movement and/or posture and of motor function due to a non-progressive abnormality in the developing brain.
What are some of the different causes of cerebral palsy?
Up to what age is brain damage called cerebral palsy? After that age what is it then known as?
Causes:
- Antenatal (80%)- cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV)
- Intrapartum (10%) - birth asphyxia/trauma
- Post natal (10%) - intraventricular haemorrhage, meningitis, head-trauma
After the age of 2 the brain injury is diagnosed as acquired brain injury.
What are the different types of cerebral palsy?
- Spastic - cerebral cortex affected - stiff muscles
Spastic can be hemiplegia, diplegia or quadriplegia - Dyskinetic - damage to the basal ganglia - uncontrollable movements
- Ataxic - cerebellum affected - poor balance and co-ordination
- Mixed
What are reasons for involvement of medics with patients with cerebral palsy (e.g describe management of cerebral palsy)
Medicine for muscle tightness Surgery to reduce muscle tightness Orthopaedic surgery Surgery to correct spinal deformity Medication to reduce muscles spasticity Management of associated conditions
What are some of the (non-motor) complications associated with cerebral palsy?
Learning difficulties
Epilepsy
Squints
Hearing impairment
What treatments may people with cerebral palsy be given for muscle spasticity/tightness?
Oral diazepam
Oral and intrathecal baclofen
Botulinum toxin type A
Orthopaedic surgery and selective dorsal rhizotomy
What are some early features of cerebral palsy?
- Abnormal limb and/or trunk posture and tone
- Delayed motor milestones
- Feeding difficulties (with oromotor inco-ordination, slow feeding, gagging and vomiting)
- Abnormal gait once walking is achieved
- Asymmetric hand function before 12 months
What pathway is damaged in spastic cerebral palsy?
What are the 3 main types of spastic cerebral palsy? What is affected in each?
Pyramidal and corticospinal tract
- Hemiplegia (one half) where the arm is usually affected more than the leg
- Diplegia - all 4 limbs are affected by the legs are affected more than the arms. Hand function may appear relatively normal and difficulties are most apparent with functional use of the hands
- Quadriplegia - all 4 limbs are affected, often severely.
Which type of cerebral palsy is most common in premature babies?
Which type of cerebral palsy is often associated with seizures, micro-encephalopathy and moderate or severe intellectual impairment?
Diplegia is one of the patterns associated with preterm birth
Quadriplegia can be associated with seizures, micro-encephalopathy and moderate or severe intellectual impairment
What is dorsal rhizotomy?
Who is it suitable for?
When a proportion of the nerve roots in the spinal cord are selectively cut to reduce spasticity
Children with a gross motor function of 2 or 3
At what age does childhood absence epilepsy usually present at?
4-12 years
What is the difference between a primary headache and a secondary headache?
A primary headache is thought to be due to a primary malfunction of neurons and their networks. A secondary headache is symptomatic of some underlying pathology e.g from raised intracranial pressure or space-occupying lesions.
Given some examples of primary headaches
Migraine
Tension-type headache
Cluster headache
Trigeminal neuralgia
Give some examples of secondary intracranial headaches
Meningitis
Temporal arteritis
Intracranial haemorrhage - subarachnoid haemorrhage, subdural, intracerebral
Raised ICP - e.g tumour, benign intracranial HTN
Intracranial venous thrombosis
Give some examples of secondary extracranial headaches
Glaucoma
Sinusitis
Other than the causes for primary and secondary headaches what are some other differentials for a headache?
Infections (abscess, encephalitis, meningitis)
Hypoxia/hypercapnia
Malignant hypertension
Viraemia
Cervical spondylosis
Pre-eclampsia
Drugs (e.g nitrates, PPI, caffeine, analgesia overuse, hormones)
What are some features (in the Hx) suggestive of a tension headache?
Bilateral tight band sensation
Recurrent
Occurs late in the day
Association with stress
What are some features (in the Hx) suggestive of a cluster headache?
Short painful attacks around one eye
Last between 30 mins - 3 hours
Occur once/twice a day for 1-3 months
May be lacrimation and flushing
What are some features (in the Hx) suggestive of a migranous headache?
Unilateral pulsating headache in trigeminal nerve distribution
Last between few hours-days
May be aura (usually visual - can also be sensory or motor)
Need to lie down in dark room (photophobia)
What are some features (in the Hx) suggestive of a trigeminal neuralgia
2 second paroxysms of stabbing pain in unilateral trigeminal nerve distribution
Face screws up with pain
What are some features (in the Hx) suggestive of a headache secondary to meningitis?
Photophobia
Neck stiffness
Systemic symptoms e.g fever, non blanching rash
What are some features (in the Hx) suggestive of a headache secondary to temporal arteritis?
Unilateral throbbing pain
Scalp tenderness and jaw claudication
>55 years
May be visual problems
What are some features of a headache secondary to subarachnoid haemorrhage?
Very sudden onset severe headache
‘Like someone hit me with a brick over my head’
Meningismus
What are some features of a headaches secondary to raised ICP?
Worse in the morning
Worse on coughing/bending
Vomiting and reduced GCS
May be neurological symptoms and seizures if a tumour
What are some features of a headache secondary to glaucoma?
Pain around one eye
Swollen red eye
Visual blurring and halos
What are some features of a headache secondary to sinusitis?
Facial pain exacerbated by leaning head forwards
What are some of the unpleasant symptoms that can be associated with migraine?
What may aggravate migraines?
Unpleasant gastrointestinal disturbance e.g N&V, abdo pain, photophobia and phonophobia (sensitivity to sounds)
May be aggravated by physical activity and relieved by sleep
Describe the visual disturbances which may occur before a migraine
Negative phenomena - e.g hemianopia (loss of half the visual field) or scotoma (small areas of visual loss)
Positive phenomena e.g fortification spectra (seeing zigzag lines)
What is the definition of status epilepticus? (e.g in books)
Continuous seizures lasting >30 minutes OR
Intermittent clinical or EEG seizures lasting >30 minutes without full recovery of consciousness between seizures
Why is it crucial to terminate seizures as soon as possible?
Because seizures of a longer duration are associated with a worse outcome and can be more treatment resistant
When is a seizure considered to be ‘prolonged’?
If it last 5 minutes or longer
The aim is to prevent the prolonged seizure from developing into convulsive status epilepticus (this is why parents are advised that if (any) seizure lasts >5 minutes to contact hospital
How is GCS assessed?
Movements(6), Eyes (4), Verbal (5)
Eyes - 4 Alert 3 Open to voice 2 Open to pain 1 Unresponsive
Verbal - 5 -orientated to time, place and person 4-confused 3-inappropriate words 2-incomprehensible sounds - No response
Movements - 6 - Normal 5 - Localise to pain 4 - Withdraw from pain 3- Decorticate 2- Decerebrate
1 - No response
What are some reversible causes of seizures?
Hypoglycaemia
Electrolyte disturbances
Infection
What drugs can be given in the treatment of status epilepticus?
If there is vascular access: LORAZAPAM is given IV/IO
If no vascular access MIDAZOLAM (buccal), DIAZEPAM (rectal)
What is a convulsion?
A seizure with motor components
What is the definition of status epilepticus that is a more practical definition?
> 5 minutes of continuous seizure or ≥2 discrete seizures between which there is incomplete
recovery of consciousness
If the seizure doesn’t terminate followed administration of medication what should be done?
Initial medication can b repeated if there is no termination at 10 minutes
Anaesthetists, PICU and Paeds SpR should be called
Require IV infusion of phenytoin /Phenobarbitone (need cardiac monitoring). RSI with Propofol/Midazolam/Thiopental. Transfer to PICU
When can epilepsy be diagnosed?
Diagnosed when at least 2
unprovoked seizures occur >24 hours apart
What are acute symptomatic epileptic seizures?
When epileptic seizures are provoked by acute brain injury e.g cortical ischaemia, intracranial infection, hypoglycaemia
They do NOT constitute an epilepsy
What should always be considered in a patient having a seizure with a temperature?
Who must you be particularly careful with?
Meningitis MUST be excluded. Classical features = photophobia, neck stiffness
Classical features may not be present in children <18 months so infection screen may be necessary
What does an infection screen for meningitis entail?
Blood cultures
Urine culture
Lumbar puncture for CSF
What is the difference between central and peripheral hypotonia on examination?
CENTRAL: ‘strong floppy’ - e.g truncal weakness but sustained limb strength, global developmental delay, may have syndromic features e.g trisomy 21
PERIPHERAL - ‘weak floppy’ - weak cry and cough, frog leg position, decreased tendon reflexes, social development may be normal
A drowsy child following a FEBRILE convulsion is not consistent if it is longer than what time period?
A child still being drowsy after 1 hour is not consistent with a ‘simple’ febrile convulsion.
What are some of the size effects of baclofen?
Because the drug is not selective is leads to decreased tone of all of the muscles in the body- this can mean threat the central/core muscles that do not have increased tone are more floppy/less functiona
