Neurology Flashcards

1
Q

What would you examine on a kid with a headache? [6]

A
Growth parameters (height, weight, OFC, BP)
Sinuses & teeth
Visual acuity, fields and fundoscopy
Listen for cranial bruit
Focal neurological signs
Cognitive/emotional status
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2
Q

Headaches in kids fall into 4 groups:

A
  • Migraines
  • TTHs
  • Raised ICP
  • Analgesic Overuse
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3
Q

Pointers to childhood migraine
Site, character, duration
Associated sx [4]
Relieving [1]

A

Hemicranial, throbbing & pulsatile headache lasting 0.5-few hours
Associated abdominal pain, nausea, vomiting
Presence of an aura
Relieved by rest and quiet, often photo/phonophobic
Also useful to look for FH

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4
Q

How would you diagnose a tension type headache? [3]

A

Constant ache
Diffuse and symmetrical
Band like distribution

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5
Q

Management migraine
Acute attacks [2]
Preventative drugs if occurs 2 or more times a month [2]

A

Give them simple analgesics for acute attacks

  • NSAID
  • Nasal triptan in 12-17 yo

Preventative

  • Propranolol
  • Topiramate
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6
Q

TTH Mx
Principles [3]
Acute treatment, give 3 options
Prophylaxis [2]

A

Reassure the parent it’s nothing sinister. MDT: attention to underlying chronic physical, psychological or emotional problems. Encourage use of simple analgesia in acute attacks. Discourage chronic use of analgesics

  1. acute treatment: aspirin, paracetamol or an NSAID are first-line
  2. prophylaxis: NICE recommend ‘up to 10 sessions of acupuncture over 5-8 weeks’
  3. low-dose amitriptyline is widely used in the UK for prophylaxis against tension-type headache.
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7
Q

How would you spot a medication overuse headache [2]

A

High use of PCM/NSAIDs (more problematic if with compound analgesics e.g. cocodamol)

Pain returns before they can have another dose

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8
Q

What would be red flags of a raised ICP headache? [5]

A
  • Wakens them from sleep
  • Aggravated factors (these raise ICP) e.g. coughing, toilet straining or bending over
  • Altered conscious level, memory loss, cognitive loss
  • Focal neuro signs
  • Papilloedema
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9
Q

Headaches are diagnosed clinically, when would you want to use imaging? [6]

A

1) Cerebellar dysfunction e.g. ataxia
2) Raised ICP
3) New focal deficit e.g. new squint
4) Seizures
5) Personality change
6) Unexplained deterioration in schoolwork

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10
Q

Presentation of fits/falls/funny turns - differentials? [6]

A

1) Epilepsy
2) Acute Symptomatic seizures e.g. febrile convulsion
3) Reflex Anoxic Seizures
4) Syncope
5) Parasomnias e.g. night terrors
6) Psychogenic Seizures

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11
Q
Reflex anoxic seizures
Ep 
Define
Triggers [3]
Symptoms and signs [3]
Ix [2]
Mx
A

Ep: 6m/o-2y/o

Brief (15s) periods of asystole
Triggers: pain, anxiety, fear

Sy/Si:

  • Pallor +/- hypotonia
  • rigidity, upward eye deviation, clonic movements, urinary incontinence
  • but NOT tongue biting

Ix:

  • serum ferritin (ensure >50ng/mL)
  • if unsure of dx can refer to specialist for vagal excitation tests under continuous ECG and EEG monitoring

Mx: reassurance benign

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12
Q

What is an Acute Symptomatic Seizure or non-epileptic seizure?

Name 6 and indicate which is most common

A

A response to an acute insult e.g. hypoglycaemia, infection or hypoxia

Reflex anoxic seizure
Syncope
Parasomnias
Psychogenic seizures 
*Febrile Convulsion
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13
Q

What can you use to diagnose epilepsy? [7]

A

Mostly a clinical diagnosis!!!

  • History
  • Video recordings
  • ECG
  • Interictal/Ictal EEG
  • MRI (For malformations)
  • Genetics (Familial & single gene disorders e.g. Tuberous Sclerosis)
  • Metabolic tests if ass with developmental delay
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14
Q

Which cause and type of epilepsy is most common

A

Mostly it’s idiopathic

Mostly generalised

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15
Q

What factors are important when determining drug treatment for epilepsy? [4]

A
  • Age
  • Gender
  • Seizure type
  • Epilepsy type
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16
Q
Anti-epileptic drugs (AED) should only be considered if diagnosis is clear even if this means delaying treatment. What are the AEDs given for:
Tonic clonic [2]
Absence [2]
Myoclonic [2]
Partial
A
  1. Tonic clonic
    - Sodium valproate or lamotrigine
  2. Absence
    - Sodium valproate or ethosuximide
  3. Myoclonic
    - Sodium valproate or levetiracem

Partial: carbamazepine

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17
Q

What are the major SEs of Anti-Epileptic Drugs (AEDs)? [4]

A

CNS - Drowsiness, impacted learning, cognition & behaviour

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18
Q

Invasive procedures for epilepsy [2]

A

Some forms respond to Vagus Nerve Stimulation or Epilepsy surgery

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19
Q

What signs would suggest a neuromuscular disorder in a walking child? [4]

A
	Baby ‘floppy’ from birth
	Alert but paucity of limb movements
	Delayed motor milestones
•	Slips from hands
•	Able to walk but frequent falls
	Pes cavus (hammer) and waddling gait
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20
Q

What is pes cavus and hammer toes indicative of?

A

Charcot Marie Tooth Disease

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21
Q
How can you differentiate a neuropathy from a myopathy?
Site of weakness
Motor/sensory involvement
Reflexes
\+ 2 other distinguishing factors
A

Myopathy:

  • Proximal weakness
  • Purely motor
  • Preserved reflexes
  • Contractures
  • ~Myocardial dysfunction

Neuropathies:

  • Distal weakness
  • ~sensory involvement
  • Loss of reflexes
  • ~Fasciculations
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22
Q

List some of the major neuromuscular disorders in kids? [4]

A

Muscular dystrophies e.g. Duchenne’s
Spinal Atrophy
Myasthenia Gravis

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23
Q

How is Duchenne’s MD inherited? What gene mutation is involved?

A

X-linked –> female carriers and male suffers

Xp21 - the dystrophin gene

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24
Q

How would you expect Duchenne’s MD to present? [6]

Specific manifestation in teens [1]

A
Delayed gross motor skills
Symmetrical proximal weakness
Waddling gait
Calf hypertrophy
Gowers sign
~ Cardiomyopathy
Resp involvement in teens
25
How do you confirm Duchenne's? [2]
Gower's sign (required but not specific) Raised CK (>1000)
26
How do we treat Duchenne's?
Steroids
27
Febrile convulsions Define [2] Ep Ax [3]
Define: - Event occurring in infancy or childhood associated with fever [1] but without evidence of intracranial infection or defined cause of seizure [1] Ep: 3m/o-5y/o Ax: viral infection, otitis media, tonsillitis
28
Febrile convulsions | Describe the 2 forms that it can present with
• Simple: - single tonic-clonic seizure lasting <15mins - occurring as temperature rises rapidly in acute febrile illness - brief post-ictal period of drowsiness/irritability/confusion - full recovery within 1h • Complex: - partial onset or focal features (movement limited to 1 side of body or 1 limb) - >15mins duration - recurrence in 24h or within same febrile illness, seizure recurrence within 1h or prolonged post-ictal drowsiness or transient hemiparesis (Todd’s palsy)
29
Management of febrile convulsions Immediate [4] Examinations [4]
o Monitor duration, protect from injury by cushioning head, check airway and place in recovery position when seizure stopped o If seizure >5mins, give IM lorazepam? o Observe until recovered and examine and manage any injury Ex: - GCS, focal neuro deficit - temp post seizure (>38oC) - fluid status - signs of underlying febrile illness
30
Febrile convulsions Ix [5]
``` FBC, ESR Glucose U&E Coagulation screen Blood cultures and urine MC&S if no source found ```
31
Mx when confirmed dx febrile convulsion [6]
Parental advice and education - Not the same as epilepsy; risk child developing subsequent epilepsy - About 1 in 3 have another febrile seizure - Rare beyond 6 yo - First aid advice and call ambulance if >5min - PCM will not reduce seizure reccurrence but can make child more comfortable
32
Features of seizures in a history Preceding During seizure [5] Post seizure [2]
o Pre-ceding events and epileptic aura (olfactory or gustatory hallucinations, visual hallucinations (flashing lights, blurred vision), déjà vu feeling, sensory disturbance (numbness, tingling, burning)) o Eyewitness account of seizure: movements, duration (>20s), lateral tongue biting, incontinence, cyanosis (arrhythmias) o Post-seizure: post-ictal confusion or agitation, secondary injuries
33
Causes of epilepsy [6]
``` Idiopathic Genetic Brain malformation Brain damage Metabolic defects Brain tumour ```
34
Presentation of different types of epilepsy: 1. Generalised - Name 3 types 2. Focal - what are 3 clinical features?
Generalised - Tonic clonic - Absence - Myoclonic Focal - Signs assoc to one hemisphere - Reduced consciousness - Automatisms eg lip smacking, running, rubbing face 1. focal aware (previously termed 'simple partial') 2. focal impaired awareness (previously termed 'complex partial') 3. awareness unknown
35
Describe the difference in presentations of generalized seizures - Tonic clonic - Absence [3] - Myoclonic [2]
- Tonic clonic: limbs stiffen and jerk forcefully - Absence: 4-8yo, brief 10s pauses with loss of awareness, eyes may roll back - Myoclonic: 1-4 yo, fall to floor
36
``` Brain tumour Ax [2] Sxs [3] Ix Mx [3] ```
Ax: brainstem astrocytoma, medullablastoma Sy/Si: unexplained headache, nausea and vomiting Ix: MRI brain Mx: surgical resection, chemotherapy, RT
37
Brain tumour: describe presentation of raised ICP [3]
Diplopia Papilloedema Headache aggravated by Valsalva or wakes up
38
What are other more long term symptoms that can point to a brain tumour [4]
diabetes insipidus (polydipsia and polyuria), growth disturbance or failure, delayed, arrested or precocious puberty
39
Red flags (meningitis or encephalitis) [7]
* Irritability * Neck stiffness * Petechial rash * Headache * Photophobia * Prolonged post-ictal period * Focal neurological deficit >1h
40
Encephalitis What is the main presenting symptom? Aetiology can be divided into infective [11] and non-infective causes [8]
Main presenting symptom: altered consciousness Ax: • Infective: HSV, mumps, VZV, rabies, parvovirus B19, toxoplasmosis, TB, malaria, Lyme disease, Rikettsia, Dengue o Immunocompromised: CMV, EBV, HHV-6 • Non-infective: hypoglycaemia, DKA, kernicterus, hepatic failure (Reye’s syndrome), lead or other poisoning, SAH, malignancy, SLE
41
Encephalitis Presentation Symptoms [3] Signs [2] Management Complications [4]
Flu like prodrome Odd behaviour Vomiting, fever Focal neurological deficits Reduced GCS Mx: antimicrobials target at causative organism eg aciclovir for HSV Cx: Kluver-Bucy syndrome (hyper sexuality, rage, visual agnosia), auditory agnosia, autism, amnesia
42
Infant presents with abnormal head size and shape. What are your 2 top differentials
Hydrocephalus | Microcephaly
43
Hydrocephalus Congenital causes [5] Acquired causes [5]
Congenital: - Arnold-Chiari malformation type 1 and 2 - Bickers-Adams syndrome, - Dandy-Walker malformation - agenesis of foramen of Monro, Vein of Galen aneurysm - congenital toxoplasmosis Acquired: - brain tumour - intraventricular haemorrhage - meningitis - increased venous sinus pressure (e.g. in achondroplasia) - iatrogenic, idiopathic
44
Hydrocephalus Classifications [2]` Ix [2]
* Communicating: failure to reabsorb CSF e.g. post bleed/infection, Arnold-Chiari malformation * Non-communicating: obstruction to CSF flow e.g. tumour, congenital malformation Investigations: - USS through anterior fontanelle in infants - CT head
45
Hydrocephalus | Presentation infants: signs [5], symptoms [3], name 2 special signs
``` Infants: Signs - Rapid increase in OFC or OFC > 98th centile - Suture disjunction - Dilated scalp veins - Tense fontanelle - increased limb tone Symptoms - irritability - poor feeding - seizures ``` Setting sun sign: both globes deviated downwards, upper lids retracted and white sclera visible above iris (failure of upward gaze) Macewan’s sign: cracked pot sound on percussing head
46
Hydrocephalus Presentation in children: - Describe an acute onset [4] - Describe a chronic onset [4] Mx Complications [4]
Acute onset: - headache and vomiting - papilloedema - impaired upward gaze - seizures Chronic onset: - unsteady gait (leg spasticity) - large head (although sutures closed - skull still enlarges due to chronic increased ICP) - unilateral or bilateral VI palsy due to increased ICP Mx: ventriculopertitoneal shunt insertion Cx: LD and epilepsy if untreated; shunt infection; CSF over-drainage
47
Causes of microcephaly [7] | Definition
OFC <2nd centile * Normal variation (small child w/ small head) * Familial (parents w/ small head) * Congenital infection: toxoplasmosis, rubella, cytomegalovirus * Fetal alcohol syndrome * Hypoxic ischaemic encephalopathy (association w/ cerebral palsy) * Patau syndrome * Craniosyntosis
48
Cerebral palsy Definition [3] Prenatal causes [4]
Def: - Permanent non-progressive (lesion static, clinical picture not) motor disorder - due to brain damage - before birth or before 2y/o Prenatal: - Placental insufficiency - Toxaemia - Smoking, alcohol, drugs - TORCH2 infection
49
Cerebral palsy Perinatal causes [4] Postnatal causes [2]
Perinatal: - Prematurity - Anoxia - Kernicterus - Erythoblastosis fetalis Postnatal: - CMV or rubella infection - Head trauma
50
Classification of CP [4] | State the affected part of the nervous system
- Spastic (pyramidal system and motor cortex) - Athetoid/dyskinetic (extrapyramidal system (basal ganglia) - Ataxia (cerebellum and brainstem) - Other: rigid (basal ganglia and motor cortex), hemi ballistic, mixed
51
Describe the gross motor function classification score (GMFCS)
* I: walks w/out limitations * II: walks w/ limitations * III: walks using hand held mobility device * IV: self-mobility w/ limitations, may use powered wheelchair * V: transported in manual wheelchair
52
Types of spastic CP [3]
Spastic CP: - Hemiplegia - Diplegia - Quadriplegia
53
Presentation of: hemiplegia spastic CP [3] diplegia spastic CP [1] quadriplegia [2]
o Hemiplegia: delayed walking, hand preference <1y/o, increased deep reflexes of affected limb o Diplegia: scissor legs on picking up o Quadriplegia: associated with seizures and reduced IQ
54
Presentation of athetoid CP [4] Presentation of ataxia CP
Athetoid: - unwanted movements and poor posture control - spasticity and hypotonia - reduced hearing, dysarthria - kernicterus association Ataxia CP: hyper or hypotonia
55
General clinical features of CP [4] Investigations [3]
1. Spasticity, contractures 2. Lack of voluntary control, poor co-ordination 3. Delayed walking 4. Sensory impairment XR, MRI, gait analysis
56
Types of contractures [2] and the difference between them
Dynamic - Increased muscle tone - Hyperreflexia - No fixed deformity Fixed muscle contracture - Persistent spasticity - Shortened tendon muscle units cannot be overcome - Fixed contractures with joint subluxation - Secondary bone changes
57
Management of CP 1. MDT [3] 2. For spasticity [3] 3. Ortho review [2]
MDT: Physiotherapy and OT, ortho scoliosis correction, posture management of hips and spine Spasticity: - Medication: Baclofen or diazepam - Botulinum toxin injections - Surgery: soft tissue release of adductors or hamstrings, bony realignment, osteotomy Ortho review: - Annual exam - Hip XR
58
Management of CP | Prognosis
persistence of >2 primitive reflexes suggests child will be non-ambulatory (moro startle reflex, parachute reflex, tonic neck reflex, neck righting reflex, extensor thrust)