Neurology Flashcards
A child presents complaining of headaches, what would you want to ask?
- Recurrence?
- More than 1 type?
- Warning?
- SOCRATES
- Use of analgesia?
What would you examine on a kid with a headache?
Growth parameters (height, weight, OFC, BP) Sinuses & teeth Visual acuity, fields and fundoscopy Listen for cranial bruit Focal neurological signs Cognitive/emotional status
Headaches in kids fall into 4 groups:
- Migraines
- TTHs
- Raised ICP
- Analgesic Overuse
How would you make the diagnosis of a migraine?
Hemicranial, throbbing & pulsatile headache
Relieved by rest
Often photo/phonophobic
Presence of an aura
Also useful to look for FH
How would you diagnose a tension type headache?
If a child sufferes from a constant diffuse, symmetrical (band-like distribution) headache
How would you treat a migraine?
Give them simple analgesics for acute attacks
Maybe Triptans if bad enough
If atleast 1/wk give preventative drugs:
- Propranolol
- Amitriptyline
- Valproate
How do you manage a tension type headache?
Reassure the parent it’s nothing sinister
Attend to chronic underlying physical/psychological/emotional stressors
Discourage chronic use of analgesics
If necessary you can use simple analgesics acutely and amitriptyline preventatively
How would you spot a medication overuse headache
High use of PCM/NSAIDs (more problematic if with compound analgesics e.g. cocodamol)
Pain returns before they can have another dose
What would be red flags of a raised ICP headache?
- Wakens them from sleep
- Aggravated by raising ICP e.g. coughing, toilet straining or bending over
Headaches are diagnosed clinically, when would you want to use imaging?
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
What are the major causes of fits/falls/funny turns in kids?
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
What causes reflex anoxic seizures?
Trigger e.g. pain or fright –> Vagal overactivity –> bradycardia –> hypoxia & seizure
It’s not abnormal in toddlers
What is an Acute Symptomatic Seizure?
A response to an acute insult e.g. hypoglycaemia, infection or hypoxia
The most common form is a Febrile Convulsion (very common, ~1in20 kids). Seizure ass with fever but with no intracranial inf or defined cause
What can you use to diagnose epilepsy?
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
What causes epilepsy in kids?
Mostly it’s idiopathic
Is childhood epilepsy generalised or focal?
Mostly generalised
What factors are important when determining drug treatment for epilepsy?
- Age
- Gender
- SEizure type
- Epilepsy type
What drugs do we use for childhood epilepsy?
Generalised = Sodium Valproate Focal = Carbamazepine
New better tolerated drugs e.g. Lamotrigine
What are the major SEs of Anti-Epileptic Drugs (AEDs)?
CNS - Drowsiness, impacted learning, cognition & behaviour
Others include rashes & bone marrow problems
Other than AEDs how can you treat epilepsy?
Some forms respond to Vagus Nerve Stimulation or Surgery
What signs would raise concern of a neuromuscular disorder in a pre-walking child?
- Floppy
- Slips from hands
- Paucity of limb movements
- Alert but low motor activity
- Delayed motor milestones
- Myopathic facies
What signs would suggest a neuromuscular disorder in a walking child?
- Frequent falls
- Awkward/clumsy positioning e.g. holding shoulders back, belly out, walking on toes
- Gait e.g. waddling
- Pes Cavus & hammer toes
What is pes cavus and hammer toes indicative of?
Charcot Marie Tooth Disease
How can you differentiate a neuropathy from a myopathy?
Myopathy:
- Proximal weakness
- Purely motor
- Preserved reflexes
- Contractures
- ~Myocardial dysfunction
Neuropathies:
- Distal weakness
- ~sensory involvement
- Loss of reflexes
- ~Fasciculations
List some of the major neuromuscular disorders in kids?
Muscular dystrophies e.g. Duchenne’s
Spinal Atrophy
Myasthenia Gravis
How is Duchenne’s MD inherited?
X-linked –> female carriers and male suffers
Xp21 - the dystrophin gene
How would you expect Duchenne’s MD to present?
Delayed gross motor skills Symmetrical proximal weakness Waddling gait Calf hypertrophy Gower's Sign
~ Cardiomyopathy & Resp involvement in teens
How do you confirm Duchenne’s?
Gower’s sign (required but not specific)
Raised Creatinine kinase CK (>1000)
How do we treat Duchenne’s?
Steroids, thanks to this sufferers can stay on their feet etc much longer and live into early 30s
What’s the most common cause of collapse in kids/adolescents?
Vasovagal Syncope
What questions would you ask about a collapse/fit/fall to ascertain cause?
- Any precipitant?
- Any prodromal symptoms?
- Timescale
- Time to recover
- Fh of epilepsy, syncope etc
- H/o collapse
- Fever/illness
3rd party:
- Eye movement
- Limb movement
- Colour
- Response/consciousness
What can cause vasovagal syncope?
- Missing meals (hypoglycaemia)
- Dehydration
- Stress
- Posture change
- Heat
- Straining
- Blood taking
- Arrythmia e.g. Long QT
What can you test in syncope?
Glc at the time
ECG for arrhythmia
BP for hypotension
What advice would you give someone who suffers from syncope?
- Reassure that it’s not something serious
- Drink lots
- Have proper meals
- Take care on changing posture
- Return if it recurs
- Exercise legs (improves venous return)
What is the second most common cancer in children?
brain tumour
how many children present with migraines?
7.7% of children 10-17
pointers (other than typical symptoms) which suggest childhood migraine?
Associated abdominal pain, nausea, vomiting
Focal symptoms/ signs before, during, after attack: Visual disturbance, paresthesia, weakness
‘Pallor’
Aggravated by bright light/ noise
Relation to fatigue/ stress
Helped by sleep/ rest/ dark, quiet room
Family history often positive
seizure/fit def?
Any sudden attack from whatever cause
Syncope def?
Faint (a neuro-cardiogenic mechanism)
convulsion def?
Seizure where there is prominent motor activity
Epileptic seizure def?
An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons
It may have clinical manifestations
Paroxysmal change in motor, sensory or cognitive function
Depends on seizure’s location, degree of anatomical spread over cortex, duration
examples of non-epileptic seizures?
Acute symptomatic seizures: due to acute insults eg. Hypoxia-ischaemia, hypoglycemia, infection, trauma
Reflex anoxic seizure: common in toddlers
Syncope
Parasomnias eg. night terrors
Behavioural stereotypies
Psychogenic non-epileptic seizures (PNES)
what is Microcephaly?
OFC <2 SD: mild
OFC <3 SD: moderate/ severe
what does microcephaly indicate?
small brain
‘micranencephaly’
causes of microcephaly?
antenatal, postnatal, genetic and environmental
definition of macrocephaly?
OFC > 2SD
what is Plagiocephaly
‘flat-head’
what is Brachycephaly
‘short head or flat at back’
what is scaphocephaly?
‘boat shaped skull’
Craniosynostosis
baby’s skull join together too early.
Deformational plagiocephaly
a flat spot on one side of the head or the whole back of the head.
Craniosynostosis
a condition in which one or more of the sutures close too early, causing problems with normal brain and skull growth.
what chemically triggers an epileptic seizure?
epilepsy is caused by excessive for cortical neurones
- Decreased inhibition (gama-amino-butyric acid, GABA)
- Excessive excitation (glutamate and aspartate)
- Excessive influx of Na and Ca ions
resulting in large scale depolarisation
how does chemical stimulation cause an epileptic fit?
Chemical stimulation produces an electrical current
Summation of a multitude of electrical potentials results in depolarization of many neurons which can lead to seizures, can be recorded from surface electrodes (Electroencephalogram)
why is an epilepsy diagnosis challenging?
Non-epileptic paroxysmal disorders are more common in children
Difficulty in explaining (Children are not young adults)
Difficulty in interpretation (witness)
Difficulty in interpretation and synthesising information(physician)
pros and cons with EEG and epilepsy?
limited value in deciding when the individual has epilepsy
Problematic false positive rates: paroxysmal activity seen in 30%, frankly epileptiform activity in 5% of normal children
BUT good at identifying seizure types
How do a Childs frontage’s close?
- the posterior frontalles usually close 2-3 months after giving birth
- The anterior frontalles closes between 1-3 years
when measuring head size need to plot on graph with weight and heigh..
…
what exactly do you measure? OFC?
occipital frontal circumference
when do you measure OFC?
when is it important to measure?
do u measure parents?
as routine- between birth and 3 years of age
VERY important
v important if neurological or developmental symptoms
also measure parents head size tp see if it is going along with families
most common weird head shape?
Deformational plagiocephaly
looks like from the top parallels gram shape
flattering at the back and frontal bone more prominent
how does craniocinositis look like?
-fusing too early
caronal, saggitol or lambdoid
