Neurology Flashcards
What is important in a neurological consultation in paediatrics?
Interactive
Avoid medical language
Time course of symptoms CRUCIAL
Perinatal, developmental, Fox
What is important in a developmental Hx in neurology?
Motor milestones: gross and fine motor Speech and language Early cognitive development Play - symbolic play and social behaviour Self-help skills Vision and hearing assessment
What should you observe in a neurological examination of a child?
Appearance Gait Head skin Skin findings Observe
What is the second most common cancer in children?
Brain
What are the different types of headache disorder in children?
Isolated acute
Recurrent acute
Chronic progressive
Chronic non-progressive
What are the two worrying headache disorders in children?
Isolated acute
Chronic progressive
What should you ask in a recurrent or chronic headache Hx?
More than one type of headache?
Typical episode: warning, location, severity, duration, frequency
What should you examine in a headache exam?
Growth parameters, OFC, BP Sinues, teeth, visual acuity Fundoscopy Visual fields Cranial bruit Focal neurological signs Cognitive and emotional status
What is the OFC?
Occipitofrontal Circumference (OFC)
What are indicators of childhood migraine?
Associated abdominal pain, nausea, vomiting Focal symptoms Signs before/during/after: visual disturbance, parenthesis, weaknes Pallor Aggravated by bright light/noise Relation to fatigue/stress Helped by sleep/rest/dark, quiet room FHx positive
What are signs it is a migraine as opposed to a tension headache?
Hemicranial pain Throbbing/pulsatile Abdo pain, nausea, vomiting Relieved by rest Photophobia/phonophobia Visual, sensory, motor aura FHx positive
What are signs it is a tension headache as opposed to migraine?
Diffuse, symmetrical
Band-like distribution
Present most of the time
Constant ache
What is suggestive of raised intracranial pressure?
Aggravated by activities that raise ICP: coughing, straining at stool, bending
Woken from sleep with headache +/- vomiting
What is suggestive of an analgesic overuse headache?
Headache back before allowed another dose
Paracetamol/NSAIDs
Compound analgesics - cocodamol
What are activities that can raise ICP?
Coughing, straining at stool, bending
What are indications for neuroimaging?
Features of cerebellar dysfunction Features of raised ICP New focal neurological deficits e.g. squint Seizures (esp. focal) Personality change Unexplained deterioration of school work
What is the management for an acute attack migraine?
Pain relief
Triptans
What is the preventative management for migraines?
Pizotifen Propranolol Amitryptyline Topiramate Valproate
What is the management for tension headaches?
Reassure no sinister cause MDT management Underlying problems Acute attacks: analgesia Discourage analgesics in chronic TTH
What is a preventative treatment for TTH?
Amitriptyline
What is a convulsion?
Seizure where there is prominent motor activity
What is an epileptic seizure?
An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons
What is epilepsy?
A tendency to recurrent, unprovoked (spontaneous) epileptic seizures
How is epilepsy diagnosed?
Clinically - with EEG for supportive evidence
What is a seizure not necessarily?
Epileptic
What are examples of non-epileptic seizures and other mimics in children?
Acute symptomatic seizures Reflex anoxic seizure Syncope Parasomnias Behaviour stereotypies Psychogenic non-epileptic seizures (PNES)
What can acute symptomatic seizures be due to?
Hypoxia-ischaemia
Hypoglycaemia
Infection
Trauma
What is a febrile convulsion?
A seizure occurring in infancy/childhood usually between 3mo-5yr associated with fever but no evidence of intracranial infection or defined cause for seizure
What is the commonest cause of acute symptomatic seizure in childhood?
Febrile convulsion
How can you distinguish between different seizure types?
Jerk/shake: clonic, myoclonic, spasms
Stiff: tonic
Fall: atonic/tonic/myoclonic
Vacant attack: absence, complex partial seizure
What are epileptic fits chemically triggered by?
Decreased inhibition
Excessive excitation
Excessive influx of Na and Ca ions
What are the two main types of epileptic seizure?
Partial seizure
Generalised seizure
What type of seizure are the majority of seizures?
Generalised
What are the subtle types of seizure?
Absences, myoclonus, drop attacks
What questions should you ask when diagnosing epilepsy?
Is the paroxysmal event epileptic in nature? Is it epilepsy? What seizure type is it? What is the epilepsy syndrome? What is the ethology? What are the effects on the child?
Why does the EEG have limited value in diagnosing epilepsy?
Low sensitivity
False positives
What is the EEG useful for in diagnosing seizures?
Seizure type
Seizure syndrome
Etiology
What do you use for a diagnosis of epilepsy?
History Video EEG in convulsive seizures Interictal/ictal EEG MRI brain Genetics Metabolic tests
What is the management of epilepsy in children?
Anti-epileptic drugs (AED)
What is the role of AED?
To control seizures
How should you start children on AED’s?
Slow upward titration until side-effects manifest of drug inefficient
What should be considered when selecting AEDs?
Age
Gender
Type of seizures and epilepsy
What can some of the side effects of AEDs be?
CNS
Drowsiness
Effect on learning, cognition, behaviour
What are first line AEDs for generalised epilepsies?
Sodium valproate
Levetiracetam
What are first line AEDs for focal epilepsies?
Carbamazepine
What are other therapies for seizures/epilepsy?
Steroids
Immunoglobulins
Ketogenic diet (drug-resistant epilepsies)
What are epilepsy management options which are not drugs?
Vagus nerve stimulation (VNS)
Surgery
What are examples of head size problems?
Macrocephaly
Microcephaly
When does the posterior fontanelle usually close?
2-3 months after birth
When does the anterior fontanelle usually close?
1-3 years
What is the head measurement roughly down between birth-3yrs in any child with neurological/developmental symptoms?
Occipitofrontal circumference (OFC)
When is microcephaly diagnosed as mild?
OFC <2 SD
When is microcephaly diagnosed as moderate/severe?
OFC <3 SD
What should you consider when diagnosing microcephaly?
Prenatal or postnatal onset?
Timing of onset?
Causes? (genetic/environmental)
What is the definition of macrocephaly?
OFC >2 SD
What should you consider when diagnosing macrocephaly?
Is it crossing gentiles upwards? Sutures? Fontanelles? Familial? Hydrocephalus? Large brain? Development? Other physical abnormalities?
What is the term for ‘flat head’?
Plagiocephaly
What is the term for ‘short head or flat at back’?
Brachycephaly
What is the term for ‘boat shaped skull’?
Scaphocephaly
What is craniosynostosis?
The bones in a baby’s skull join together too early
When should you suspect a NM disorder?
Baby floppy from birth Slips from hands Paucity of limb movements Alert, but less motor activity Delayed motor milestones Able to walk but frequent falls
What gene does Duchenne Muscular Dystrophy affect?
Xp21
Dystrophin gene
What are the signs/symptoms of Duchennes?
Delayed gross motor skills Symmetrical proximal weakness Elevated creatinine kinase levels Cardiomyopathy Respiratory involvement in teens
What are the levels of creatinine kinase usually like in Duchennes?
High
>1000
What are the signs of symmetrical proximal weakness in Duchenne’s Muscular Dystrophy?
Waddling gait
Calf hypertrophy
Gower’s sign positive
What is Gower’s sign?
The sign describes a patient that has to use their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength.
What are physical signs of Duchenne’s?
Shoulders/arms back when walking Sway back Weak butt muscles Knees may bend back to take weight Thick lower leg muscles - fat not strong Tight heel cord (contracture) Belly sticks out Poor balance Falls often Clumsy walking Weak muscles in front leg cause foot drop Tip toe contractures
What are examples of muscle neuromuscular conditions?
Muscular dystrophies
Myopathies - congenital and inflammatory
Myotonic syndromes
What is an example of a neuromuscular junction problem?
Myasthenic syndromes
What are examples of nerve neuromuscular conditions?
Hereditary or acquired neuropathies
What is an example of a anterior horn cell neuromuscular condition?
Spinal muscular atrophy
Where is the site of weakness in a neuropathy?
Distal weakness
Where is the site of weakness in a myopathy?
Usually proximal
What are the reflexes like in a neuropathy?
Reflexes lost early
What are the reflexes like in a myopathy?
Reflexes preserved until late
Are fasciculations common in neuropathies?
May be present
Are fasciculations common in myopathies?
Not typical
Are contractures a feature of neuropathies?
Not a feature
Are contractures a features of myopathies?
Yes
Is myocardial dysfunction a feature of neuropathy?
Not a typical feature
Is myocardial dysfunction a feature of myopathy?
May have accompanying cardiac dysfunction with dystrophies
