Neurology Flashcards
By which age is most of the brain/head growth complete?
2y
Any head injury before what age may lead to serious impact on brain function?
2y
Are babies born with neurological signs?
Neurological signs develop as brain develops
These are not necessarily present at birth
What things do you want to ensure to ask about in the history of a patient with a suspected neurological deficit?
Time course of symptoms
Perinatal, developmental and family history
What do you want to ask about in the developmental history?
Gross and fine motor skills - have they met the milestones?
Speech and language and eaerly cognitive development
Play esp. symbolic play/copying/social behaviour
Self help skills
Vision and hearing
What does a neurological examination in a child involve?
Appearance, e.g. facial features
Gait - walking normally? Sitting? Posture?
Head size
Skin findings, e.g. café au lait spots
How common is headache?
40% have had one by age 7, 75% by age 15
What are the 4 types of headache pattern?
Isolated acute
Recurrent acute
Chronic progressive
Chronic non-progressive
Where IA & CP are more likely to be sinister
What things do you want to ask in a headache history?
Is there more than 1 type of headache?
Typical episode duration? warning? frequency? severity? location?
What is involved in headache examination?
Growth parameters, OFC, BP (e.g. craniopharyngioma may affect only growth & give headache, OFC for hydrocephalus, BP for HTN encephalopathy)
Fundoscopy (RICP)
Visual fields (craniopharyngioma)
Cranial bruit (AV fistula, aneurysm)
Focal neurological signs, e.g. nystagmus
Emotional/cognitive status
What things might make you think migraine?
Ab pain, N/V Visual disturbance, paraesthesia, weakness Phono/photophobia Relation to stress/fatigue Helped by sleep/rest/dark quiet room FH often +ve
How does migraine differ from TTH?
Migraine - hemicranial, throbbing/pulsatile, abdo pain, NV, other features prev mentioned
TTH - diffuse, symmetrical, band like, constant ache
What features are typical of a RICP headache?
Made worse by activities that raise ICP, e.g. coughing, straining at stool, bending
Woken with headache
What features are typical of a analgesic overuse headache?
Headache back before next dose
Paracetamol/NSAIDs
Particular problem with compound analgesics
What are indications for neuroimaging?
Features of cerebellar dysfunction/RICP New neurological deficit, e.g. new squint Seizures, esp focal Personality change Unexplained deterioration n school work
What is Mx for migraine?
Acute: pain relief, triptans
Preventative (if 1+/wk): pizotifen, propranolol, amitriptyline, topiramate, valprotate
What is Mx for TTH?
Reassurance, consider physical/psychological/emotional problems
Acute attack: analgesia
Prevention: amitryptilline
Define seizure/fit
Any sudden attack from whatever cause
Define syncope
Faint, usually due to vagal overactivity
Define convulsion
Seizure where there is prominent motor activity
Define epileptic seizure
Abnormal excessive hyper synchronous discharge from a group of cortical neurons –> paroxysmal changes in motor/sensory/cognitive function, depending on site of discharge
Define epilepsy
A tendency to recurrent, unprovoked spontaneous epileptic seizures CLINICAL diagnosis (EEG supportive)
What are non-epileptic seizures that mimic epilepsy in children?
Acute symptomatic seizures - due to acute insults, e.g. hypoxia/ischaemia, hypoglycaemia, infection, trauma
Reflex anoxic seizure (vagal mediated brachycardia due to painful stimulus)
Syncope
Parasomnias, e.g. night terrors
Behavioural stereotypies, e.g. rocking
Psychogenic seizures (NEAD)
Define febrile convulsion
An event occurring usually between 3m-5y, assoc with fever but without evidence of intracranial infection/defined cause for seizure
What is a clonic seizure?
One in which there is repeated jerking of the muscles
What is a myoclonic seizure?
Uncontrolled jerking
What is a tonic seizure?
Patient goes really stiff
What is an aclonic seizure?
Patient goes floppy and falls
What is an absence seizure?
Patient loses awareness, may be assoc with eye flickering, upward gaze of eyes etc.
What is the mechanism of an epileptic fit?
Decreased inhibitory NTs (e.g. GABA), increased excitatory NTs (e.g. glutamate & aspartate) –> xs influx of Na and Ca ions –> uncontrolled firing of neurons
This can be picked up on EEG
What is the difference between a partial and a generalised seizure?
Generalised - affecting both hemispheres
Partial - affecting 1 hemisphere or 1 lobe
What are the main differences between childhood and adult onset epilepsies?
Maj idiopathic and generalised
Seizures can be subtle
What is the role of the EEG in diagnosing epilepsy?
Supportive - interictal EEG only 30-60% sensitive
Also see paroxysmal activity in 30% & frankly epileptiform activity in 5% of normal children
But may help in finding the underlying cause & seizure type/syndrome
What things can help you reach a diagnosis of epilepsy?
Hx, EEG during seizure, MRI (?brain malformations/damage)
Genetics - idiopathic epilepsies mostly familial & single gene disorders (e.g. tuberous sclerosis)
Metabolic tests, esp if assoc with developmental delay/regression
How do you Mx epilepsy?
Only start anti-epileptics if sure of diagnosis & titrate up
Sodium valprotate for GE (not in girls)
Carbamazepine for focal epilepsy
New AEDs with less SEs - levetiracetam lamotrigine, perampanel
Resistant epilepsies: ketogenic diet, steroids, Ig
Vagal nerve stimulator (disrupts epileptic circuit)
Epilepsy surgery (removal of causative part of brain)
What are the side effects of anti-epileptics?
Drowsiness, effect on learning, cognition & behaviour
Supression of bone marrow
When should you suspect a NM disorder?
Floppy baby Slips from hands Paucity of limb movements Alert, but less motor activity Delayed milestones Able to walk, but frequent walls
What are the signs of NM disorder?
Pelvic waddle due to pelvic weakness Exaggerated lumbar lordosis (protuberant belly) Wasting of muscles Swaying of shoulders Foot drop Poor balance
What is Charcot-Marie-Tooth disease?
Sensorimotor polyneuropathy where there is calf atrophy and pes cavus
What are the conditions affecting the NMJ?
Muscle: muscular dystrophies, myopathies - congenital & inflammatory, myotonic syndromes
NMJ: myasthenic syndromes
Nerve: hereditary or acquired neuropathies
Anterior horn cell: spinal muscle atrophy
What are the typical features of a myopathy?
Usually proximal, pure motor, reflexes preserved till late, contractures may be present, may have accompanying cardiac dysfunction
What are the typical features of a neuropathy?
Distal weakness, with sensory symptoms, reflexes lost early, fasiculations
What is Duchenne muscular dystrophy caused by?
Mutation in Xp21, dystrophin gene
What are the typical features of Duchenne muscular dystrophy?
Delayed gross motor skills
Symmetrical proximal weakness - waddling gait, calf hypertrophy, Gower’s sign positive
Elevated CK >1000
Cardiomyopathy
Resp involvement in teens
What is CK a marker of?
Muscle breakdown
