Neurology Flashcards
What is the most common cause of childhood headaches.
a. Migraine
b. Myopia
c. Sleep disorder
Migraine
14 year old girl with asthma has throbbing headaches associated with nausea, photophobia. Her mother has a history of migraines. What treatment do you offer for prophylaxis? A. Amitriptyline B. Propranolol C. Phenytoin D. Sumatriptan E. Ergotamine
Amitriptylline
No propranolol!!
Flunarazine would also be an option
7 year old migraine, 3-4 x/month. Management: A. Ibuprofen as needed B. Propranalol prophylaxis C. Referral to neurologist D. Brain MRI
Ibuprofen PRN
Consider preventative Tx if >1 H/A per week or >1 disabling H/A per month
To stop H/A: NSAIDs and triptans. Limit use
No obvious red flags to warrant neuroimaging
If had >1 H/A/wk then prophylaxis: flunarazine,
amitriptylline, topiramate, propranolol
A 14 year old girl presents to the ER with abdominal pain rated 8/10. Soft abdomen on exam, no rebound, tender but not worse with palpation. She is also complaining of a headache. She states she’s had 4 similar episodes in the past which resolved over hours. Likely diagnosis?
a. abdominal migraine
b. appendicitis
c. PID
- ————–
58) Kid vomiting recurrently, missing lots of school, mom has headaches. Most likely cause?
a. abdominal migraines
b. benign paroxysmal vertigo
c. separation anxiety
Abdominal migraine
arome IV
- > =2 episodes in 6mo
- midline, periumbilical or diffuse abdo pain. Abdo pain is most severe + distressing Sx. Lasts >=1H. Interferes with normal activities
- at time of abdo pain, >=2 of:
1) N
2) V
3) anorexia
4) pallor
5) H/A
6) Photophobia - Personal/Fhx of migraines
Tx A. nonpharm - explain + reassure - avoid triggers - modified diet (high fibre, probiotics) - psychotherapy B. Pharm 1. Abortive (INH sumitriptan, IV VPA) 2. PPx: 1) propranolol, 2) cypraheptadine, flunarizine
Prognosis
- predicts cephalic migraines later in life
A girl presents with severe abdominal pain 8/10 in the periumbilical area. She is also complaining of a severe frontal headache. She has had five of the episodes previously and they have self-resolved in two to three days. Her mother suffers from migraines. Which of the following is the underlying diagnosis?
a. Familial Mediterranean fever
b. Abdominal migraine
Abdominal migraine
Rome Criteria
- > =2 in 6mo
- midline, periumbilical or diffuse abdo pain. Abdo pain is most severe + distressing Sx. Lasts >=1H. Interferes with normal activities
- at time of abdo pain, has >=2
1. N
2. V
3. anorexia
4. pallor
5. H/A
6. Photophobia - Personal/FHx of migraines
Mgmts A. Nonpharm - reassure - avoid triggers - improve diet (high fibre, probiotics) - psychotherapy
B. Pharm
- Abortive: INH sumatriptan, IV VPA
- Ppx: flunarazine, propranolol, cypraheptadine
Predicts future cephalic migraines
A picture of child showing the parachute reflex is shown. What is true?
a. This is a primitive reflex that disappears by 4 months
b. This is a voluntary reflex which disappears when child starts walking
c. This is an involuntary reflex that appears at 7-9 months and does not disappear
Involuntary reflex that appears at 7-9mo and does not disappear
Myelomeningocele – what associated abnormality is most likely to need surgical intervention? a. Chiari malformation b. Diastematomyelia c. Hydrocephalus -------- Most common need for surgery in a patient with myelomeningocele? a. Syrinx b. Tethered cord c. Hydrocephalus
Hydrocephalus (though most are in association with Chiari II malformation)
Child with brachial plexus injury. How long before if no change in exam is prognosis poor?
a. 1 mo
b. 3 mo
c. 6 mo
d. 12 mo
1 month (CPS)
Brachial plexus injury-extended hand, pronated, but can grip. Which nerve roots
a) C3-C4
b) C5-C6
c) C7-C8
d) C8-T1
C5-C6, Erb’s
- likely asymmetric Moro +ATNR
- No brachial reflexes
A 1 month old has a droopy lower left lip. The forehead moves normally. What is the problem:
a. centrally mediated facial nerve palsy
b. peripherally mediated facial nerve palsy
c. congenital absence of the mouth angle depressor muscle
d. Mobius syndrome
—————
Baby with facial droop. Normal frontal muscle, can close eyes and normal nasolabial fold:
a. absence of depressor angularis oris
—————
Drooping mouth but eyes were able to close, normal nasolabial folds. Diagnosis?
a. Mobius syndrome
b. congenital absence of the depressor anguli oris muscle
c. CN VII lesion
d. upper lobe lesion
Congenital absence of the mouth depressor anguli oris muscle
- Kid presents with 3rd febrile seizure in the past month. Otherwise well, no post-ictal. What do you do?
a) Reassure
b) EEG
c) Admit
d) MRI brain
- ———— - An 18 month-old female presents to the emergency department with a febrile seizure secondary to an acute otitis media. This is her third febrile seizure in three months. What is the next step in management?
a. EEG
b. CT head
c. Neurology consult
d. Reassure parents, and no further investigations
Reassure
- 30% recur if 1st episode
- 50% recur if >2 episodes
- 50% recur if <1yo
- no routine investigations
- LP if <12mo to r/o meningitis. consider in 12-18mo. Only if SSx if 18mo.
- EEG not routinely indicated
RFs of epilepsy
- simple febrile sz (1%)
- complex febrile sz (6%)
- recurrent febrile sz (4%)
- focal complex feb sz
- neurodvptal abN
- FHx of epilepsy
- fever <1H before feb sz
18-month-old boy presents with fever, AOM, and febrile seizure. This is his third recurrent febrile seizure in the past few months. What is your next step?
a) EEG
b) CT head
c) Neuro consult
d) Reassure parents
Reassure parents
A child with epilepsy presents unwell with findings of hepatotoxicity and pancreatitis and thrombocytopenia. Which medication is this likely related to? A. Valproic acid B. Carbamazepine C. Topiramate D. Keppra
VPA
Serious: hepatic + pancreatic toxicity
Nuisance: wt gain, alopecia, menstrual irregularities, hyperammonemia tremor
9y boy w episodic r side face twitching and drooling at night with preserved consciousness. What is the most likely diagnosis?
a. Rolandic epilepsy
b. Juvenile myoclonic epilepsy
c. Tourette syndrome
Rolandic epilepsy
- rolling in bed awake
- AD, 3-13yo (usually stop after puberty)
- Typical sz: wake from sleep, mouth twisted, IL twitching of mouth/face/pharynx, speech arrest or dysarthria, drooling preserved consciousness
- lasts 1-2min
Normal neuro exam
EEG: centrotemporal spikes
Mgmt: keppra, oxcarbazepine. Most AED effective
9 year old has woke 3 times now….each time the same. Right sided facial twitching, ? limb involvement, but after few minutes well. What is the diagnosis?
a. rolandic epilepsy
b. absence seizures
c. sleep-walking (ambusomnulence or something)
d. juvenile myoclonus
Rolandic epilepsy
10 year old boy previously healthy has been waking up the parents at night with symptoms of mouth twitching, and drooling. He has a normal neurological exam and a normal MRI. Which of the following is most likely on his EEG?
a. Centrotemporal Spikes
b. 3 Hz spike and wave
c. high amplitude waves and a background of irregular spikes
Centrotemporal spikes
A 7 year old girl has had episodes over the past couple months where she awakes from sleep, has twitching of her right lip and is unable to verbalize. The episodes last 1-2 minutes. You suspect seizure activity and order and EEG. What is it likely to show?
a. spikes in the centrotemporal (rolandic) region
b. Generalized slow waves
c. 3 Hz generalized spikes over a normal background
d. normal
- ————–
55) History of child waking up with garbled, confused speech. What would you expect on EEG?
a. normal EEG
b. 3 spikes/wave
c. centrotemporal spikes
d. hypsarrhymia
Centrotemporal spikes
Benign rolandic epilepsy
- rolling in bed awake
- AD
- 3-13yo (disappear by puberty)
- Typical sz: awake from sleep, pulling of face on one side, speech arrest or dysarthria, drooling, consciousness preserved
Normal neuro
EEG centrotemporal spike
No routine MRI
Tx: keppra, oxcarbamazepine. Most AED work
Kid with facial twitch in the middle of the night. Seizure pattern?
a. Centro-temporal
b. 3 hz spike and wave
- ———–
45) 5 yo child wakes up to tell mom that he has been drooling, and facial movements in the middle of the night. Aware of events. What likely finding on EEG?
a. Centrotemporal spikes
Centro-temporal spikes
11 month old baby boy is admitted because yesterday morning before breakfast he had two episodes where he “flopped back” and seemed hypotonic. This resolved. This morning after breakfast, he had another episode where he flopped back, became hypotonic, and had irregular breathing. His blood glucose is normal, as was a CBC and electrolytes. Which of the following would be next step?
a) EEG
b) Lumbar puncture
c) Pyruvate, lactate, fasting blood glucose
EEG
- repeated loss of tone, which suggests atonic Sz
- no fever or infectious Sx to warrant LP
- no red flags for metabolic disease based on initial normal BW
5 month old boy with episodes of head flexion and limb extension lasting a few seconds. His EEG shows a disorganized background with multifocal spikes. What is the most likely diagnosis?
a) Benign familial neonatal convulsions
b) Infantile spasms
c) GERD
d) Benign myoclonus
Infantile spasms
- first year of life
- Cause: Cryptogenic vs symptomatic (tuberous sclerosis!)
- clusters of brief body spasms, Q2-10s x 2-3min
- may have DD +/ regression
EEG: hypsarrhythmia
MRI to look for brain injury + abN
Mgmt
- Vigabatrin for Tub Scler (SE: tunnel vision!)
- ACTH IM for cryptogenic. (SE: high BP, glycosuria, irritability, facial edema, immunosuppression)
3 month old with myoclonic jerks. No skin lesions. Eeg shows disorganized background with intermittent discharges. What is the most likely diagnosis?
a. infantile spasms
b. benign myoclonus of infancy
- —————
38) 5 month old baby who has intermittent flexion of arms/legs for several seconds and in between that, has normal behavior. EEG – abnormal background with polyspikes. What is diagnosis?
a. benign neonatal myoclonus
b. infantile spasms
c. benign sleep myoclonus
- —————–
39) Kid with myoclonic spasms. Well in between spasms. No regression. They also describe seizure pattern in questions. I think they did describe hypsarrythmia. Ask for dx?
a. Infantile spasms
b. Benign myoclonic epilepsy
Infantile spasms
Infant w hypopigmented macules and repeated flexion movements of the entire body. EEG shows a disorganized pattern. What is the diagnosis?
a. Infantile spasms
b. Benign myoclonus of infancy
c. Benign sleep myoclonus
Infantile spasms
50) Infant with hypopigmented lesions over body and brief flexion/extension of upper and lower body periodically throughout the day. Baby is mildly developmentally delayed. How would you confirm the underlying diagnosis:
a. EEG
b. Urine OA
c. Head MRI
EEG to look for hypsarrhythmia in context of infantile spasm
A 12 month old child has had several episodes of crying, followed by cyanosis and then a few seconds of generalized convulsions. These convulsions resolve spontaneously and his behaviour is normal post-ictally. What is the most likely etiology?
a. infantile spasms
b. breath holding spells
c. febrile seizures
d. myoclonic epilepsy
Breath holding spells
1) cyanotic (most common): d/t expiratory apnea, can have brief LOC + very brief tonic-clonic sz
2) pallid: d/t reflex vagal bradycardia + asystole
- can be mixed
- assoc’d with IRON DEFICIENCY ANEMIA
- Tx: reassurance + education. Will outgrow
Teenage girl with asthma has frontal headaches associated with nausea, photophobia. Her mom has a history of migraines. What treatment do you offer for prophylaxis?
a. sumatriptan
b. propranolol
c. amitriptyline
d. phenytoin
Amitriptyline
- Prophylactic treatment for migraines in child with asthma
a. Propranolol
b. Amitriptyline
c. Sumatriptan
- ———- - Teenager with a history of asthma presents with migraine headaches interfering with daily life. Which medication for prophylaxis?
a. Propanolol
b. Amitryptiline
Amitryptyline
A 14 year old girl presents to the ER with abdominal pain rated 8/10. Soft abdomen on exam, no rebound, tender but not worse with palpation. She is also complaining of a headache. She states she’s had 4 similar episodes in the past which resolved over hours. Likely diagnosis?
a. abdominal migraine
b. appendicitis
c. PID
- ————–
58) Kid vomiting recurrently, missing lots of school, mom has headaches. Most likely cause?
a. abdominal migraines
b. benign paroxysmal vertigo
c. separation anxiety
Abdominal migraine
A girl presents with severe abdominal pain 8/10 in the periumbilical area. She is also complaining of a severe frontal headache. She has had five of the episodes previously and they have self-resolved in two to three days. Her mother suffers from migraines. Which of the following is the underlying diagnosis?
a. Familial Mediterranean fever
b. Abdominal migraine
Abdominal migraine
15 yr old girl has a headache, then syncope at school for several minutes. She is brought to hospital. Can’t walk because of numbness in her legs. Exam is normal, plantar reflexes normal, DTR normal. Initial loss of sensation to L4, the next day she has sensation to her ankles. Able to walk without ataxia leaning heavily on your hands, feet spaced 8 cm apart. What is your next step in management?
a. EEG
b. MRI head and spine
c. Confrontation and explanation that her symptoms are not organic
d. Refer to PT
Refer to PT
15 yo obese girl lives in group home, and was sexually assaulted by her father 3 years ago. Acute onset headache, and syncope but neurological exam detailing fundoscopy, DTR, tone, cerebellar reflexes are normal. Complains of difficulty walking, and difficulty urinating. Manages to urinate in bedpan. Yesterday had sensation to thigh, and today sensation at ankles. Absent plantar reflex. Walks requiring assistance, leans heavily on you. Feet are 8cm apart. Management:
a) confront her with the fact that physical findings do not correlate with symptoms
b) MRI - ?absent plantar reflex
Confront her?
Leans heavily = good strength
Feet 8cm apart = not ataxic gait
?absent plantar reflex = babinski not present?
Conversion disorder
- > =1 Sx/deficit affect voluntary motor or sensory fxn
- Sx not compatible with recognized neuro or medical conditions
- Not better explained by another medical or mental d/o
- Causes clinically significant distress or impairment in social, occupation, or other important area of functioning or warrants medical evaluation
43) . CT head with a bleed (can’t remember what the image showed). Choices were
a. Epidural
b. subdural
c. intraventricular
d. subgaleal
Epidural = rounded, meningeal artery, lucid period then decompensate rapidly Subdural = linear, ruptured bridging veins. Immediately unconscious. Inflicted trauma!
Player experiences brief, transient loss of consciousness (<5min) during a sporting event accident; what do you advise the coach to do?
a. Player must sit out for at least one week
b. May return to game after 15 minutes if asymptomatic
c. Go home with parents with head injury instructions
d. Out for the season
—————
A child playing a sports game has a head injury with transient loss of consciousness. What to do:
a. Have him do mental tasks. If he succeeds, have him return to game
b. Sit out for 1 week
c. Sit out for 15 minutes
Go home with parents with head injury instructions
Concussions
- in adol, Sx can resolves in 7-10d
- in children, can take weeks to months
