Neurology Flashcards
1
Q
Difference between seizure and epileptic seizure?
A
Epileptic seizure is an excessive and hypersynchronous self-limiting activity of neurons in the brain
2
Q
Taking a history of a seizure, what do you ask about before the event?
A
Time of day What were you doing at the time? Any triggers Any warnings like behavioural changes Was it sudden or gradual Well before the episode? were they feeling funny? Chances of being poisoned?
3
Q
When taking a history of a seizure, what do you ask about the event itself?
A
Movement - eyes, head, which limbs, symmetrical, flex or extend, hypertonic or hypotonic, jerking (clonic), sudden jerks Pallor Cyanosis Eyes open or closed Awareness Tongue biting Incontinence
4
Q
When taking a history of a seizure, what do you ask about after the event?
A
When did it stop? Gradual/sudden? How long till returned to normal? Post-ictal confusion sleepy?
5
Q
What is it always important to have before epilepsy diagnosis can be made?
A
Eye witness
6
Q
What is the differential diagnosis to epilepsy?
A
Non-epileptic paroxysmal events
7
Q
List 10 types of non-epileptic paroxysmal events?
A
Vasovagal syncope Cardiogenic syncope Breath holding Reflex anoxic spells Blank spells/day dreaming Sandifer Syndrome fabricated illness sleep phenomena self gratification benign neonatal sleep myoclonus benign paroxysmal vertigo and torticollis Tics Pseudoseizures
8
Q
Cardiogenic syncope often is found to have what? Triggers?
A
QT prolongation
FH of sudden death
Triggered by exercise and sleep
9
Q
What is Sandifer syndrome?
A
Present in complex neurodisability triggered by feeding and leaves patients with GORD and pain
10
Q
2 examples of idiopathic generalised seizures in children?
A
CAE (childhood absence seizures)
JME (juvenille myoclonic epilepsy)
11
Q
A type of idiopathic focal epilepsy in children?
A
BREC (benign rolandic epilepsy of chidhood)
12
Q
2 epileptic encephalopathies that can develop in children?
A
Wests syndrome
Dravet Syndrome
13
Q
Describe benign neonatal sleep myoclonus?
A
Brief jerks whilst asleep that don’t bother neonate
Grows out of it in 6-8 months
14
Q
Infantile spasms - when do they present? symptoms? cry? assocaited to what syndrome? 2 underlying causes?
A
Presents 2 months-1year
Symptoms = myoclonic jerks of head, limbs or trunk, clusters on waking
Cry between spasms whereas colic cry during
Assocaited to Wests syndrome - infantile spasms, developmental delay and Hips arrythmia on EEG
underlying causes can be Down’s Syndrome or Tuberous Sclerosis
15
Q
How do you treat infantile spasms?
A
Steroids
16
Q
How do you treat infantile spasms if the underlying cause is tuberous sclerosis?
A
Vigabatrin
17
Q
2 things that make a febrile illness become complex?
A
More than 2 seizures in a 24 hours period
Seizure for longer than 15 minutes
18
Q
Age group usually effected by febrile seizures?
A
6 months to 5 years
19
Q
When do you treat febrile illness?
A
If they enter status epilepticus which is prolonged seizure for 15-20 minutes then treat with buccal Midazolam
20
Q
Describe the typical picture of breath holding spells? resolves by what age?
A
child crying, louder then collapses and seizes, return to normal
Resolve by age 2/2.5
21
Q
What causes reflex anoxic seizures? typical picture?
A
Hypoxic drive for seizure activity
Suddenly go limp then clonic jerks
pallor
22
Q
Usual age onset of CAE? features during and after?
A
4-8 years old eye or mouth flickering Little finger movements Peri-orbital and periocular flickering Last 20 seconds No post-ictal confusion
23
Q
How do you diagnose CAE alongside clinical appearance?
A
2 second spike and wave on EEG
24
Q
Key feature of BREC? age?
A
facial or periorbital onset of focal epilepsy
3-13 years
25
What are the 2 classic prodromal symptoms of BREC do children tend to suffer?
Other potential prodromes?
Unilateral numbness and paraesthesia of the lips, gums, cheek
Involuntary movements of the jaw
Expressive speech arrest
26
4 post-ictal features of BREC?
guttural sounds
speech arrest
hypersalivation
difficulty swallowing
27
EEG characteristic feature of BREC?
bilateral or unilateral centrotemporal spikes
28
Prognosis of BREC?
90% remission by 16 years old
29
Juvenille myoclonic epilepsy? age of onset? EEG findings? treatment options? prognosis in comparison to CAE?
onset at 12 years old
Absence seizures, GTC, myoclonic
EEG sees 3 per second spike and wave
Treatment with sodium valproate and lamotrigine
30
Juvenile myoclonic epilepsy onset age? type of seizure? often confused with what? EEG shows what? Treatment? Prognosis?
12-18 years onset
GTC seizures
Often confused with daydreaming - clumsy, dropping stuff in morning
EEG shows polyspike waves with irregular slow waves
Treatment is with sodium valproate and lamotrigine
Prognosis is lifelong disorder
31
Conditions that relate to development of cerebral palsy?
Prematurity
Hypoxic ischaemic encephalopathy
metabolic disease
Acquired brain injury
32
Define cerebral palsy
Non-progressive non changing disorder due to malformations in brain development
33
What are common comorbidities suffered from those with cerebral palsy?
```
Difficulties feeding
Epilepsy
Sensorineural deafness
Visual impairment
Gut motility issues
Retinopathy of prematurity
```
34
GMFCS 1 vs GMFCS 5 in terms of cerebral palsy classification
GMFCS 1 = no walking aids needed
| GMFCS 5 = wheelchair and poor head control
35
Which cause of cerebral palsy is most likely to end up as a quadriplegiac?
CP caused by prematurity
36
Cardinal features of cerebral palsy?
dystonia
spasticity
pain
37
What is dystonia and which type of cerebral palsy cause usually presents with it?
involuntary movements of the limbs
| Usually in full term hypoxic events that damage the basal ganglia
38
Dystonia causes that arent caused by damage to the basal ganglia?
```
Dopa responsive dystonia
Biotinidase deficiency
Methyl malonic aciduria
Glutaric aciduria type 1
GLUT 1 deficinecy
Inherited DYT1/DYT11
```
39
How does spasticity form in cerebral palsy and what does it present as?
Damage to motor pathways
High tone movement disorder
Increased reflexes
Clonus
40
3 main forms of pain in cerebral palsy?
dental pain, bone pain and gastric pain
41
What can the pain in cerebral palsy impact the persons life?
```
Seizures become worse
dystonic positioning
difficult sleeping
poor feeding
irritable and challenging behaviour
```
42
What kind of MDT team is involved in CP?
```
Paediatrician
Physiotherapist
OT
GP
Respite
SLT
Neurologist
SW
```
43
4 main MSK issues suffered by patients with CP?
scoliosis
Hip dislocation
Muscle contracture
Plantar flexed feet and toe walking
44
Main prevention methods of worsening MSK issues in children with CP?
Prevention schemes - walking and moving
Medication to decrease tone
Postural management - chairs, beds
45
Common sites for Botulinum toxin injections to be administered? Who needs to be involved in management of patients recieving them? Benefit? How long do they last?
Iliopsoas, hamstrings, adductors
OT - train antagonist muscle whilst the agonist are paralysed
last for 3-4 months with peak at 1 month
46
What is the CDC input in post injection therapy for cerebral palsy patients?
```
8 weeks once a week treatment sessions, monitoring, review
Goal setting
Liaison with school
Ongoing monitoring
2/3 review sessions in months 3/4
```
47
What GABA agonist is commonly used to treat cerebral palsy that presents as a high tone disorder such as spasticity?
Intra-thecal baclofen
48
What is the gold standard trio of medication for managing dystonia in cerebral palsy? alternative?
Haloperidol + tetrabenazine + trihexyphenidyl
| Deep brain stimulation
49
How is a Baclofen pump placed in situ and who is it administered to?
Placed inside abdomen with leads into spinal cord
Spasticity and dystonia indications in older ambulatory children with either severe spasticity in upper and lower extremities or spinal injury
50
In deep brain stimulation what the rods target?
Basal Ganglia
51
Define Neural tube defect?
developmental disorder of the brain, spine or spinal cord occurring in the first trimester of pregnancy
52
3 types of spina bifida?
Spina bifida occulta, meningocele, myelomeningocele
53
How does spina bifida occulta present?
dimples in back, hair tuft, lipoma, adhesions can potentially cause sensory or motor disturbances
54
Meningocele?
Vertebral cleft and meninges in CSF
55
Myelomeningocele?
Vertebral cleft with meninges and nervous tissue
56
Antenatal USS reveals what signs of spina bifida?
Lemon sign
Banana sign
Ventriculomegaly
Posterior vertebral arch defects
57
What screening blood test can be done in early pregnancy to assess for spina bifida? how many weeks gestation?
AFP in maternal blood
58
Preventable causes of spina bifida?
Folic acid deficiency
AEDs - sodium valproate, phenytoin, carbemazepine
Maternal diabetes
59
Why do AEDs cause spina bifida?
Reduce folate stores
60
If the spina bifida occurs at the S2-S4 level what are the symptoms?
can usually walk with shoe inserts
61
If the spina bifida occurs at the level L5-S1 level what are the symptoms?
Walk with short ankle braces
| Crutches
62
If the spina bifida occurs at the L4 level what are the usual symptoms?
Can use braces that go above the knee
Wheelchair often preferred for long distances
Braces for short distances
63
If the spina bifida occurs at the level L2-L3 what are the usual symptoms?
Can have braces above knee/hip
| Usually end up using wheelchair majority of time
64
is the spina bifida occurs at the level T12-L1 what are the usual symptoms?
Younger may walk with braces above hip
| Usually end up just using wheelchair
65
Why is surgical intervention often needed with higher lesion spina bifida?
Scoliosis
66
Apart from walking, what other complications does spina bifida often come with?
Sensory issues
Neuropathic bowel
Neuropathic bladder
67
Management of neuropathic bowel?
laxatives
suppositories
bowel training
rectal washouts
68
2 main types of neuropathic bladder that can develop in spina bifida? complications associated?
sphincter tight shut - reflux, renal damage, CKF
| Sphincter loose and open - incontinence, stagnant bladder, UTI
69
80% of myelomeningocele patients will suffer with what?
Associated with what?
What is needed as treatment?
Hydrocephalus
Chiari 2 malformation
Ventriculoperitoneal shunt
70
Infant presenting with shunt malformation?
```
Lethargy
Poor feeding
Vomiting
Irritable
Seizure
LOC
```
71
Child presenting with shunt malformation?
```
Headache
Visual loss
Dizzy
Vomiting
Personality changes
developmental delay
LOC
Seizure
```
72
High AFP on 15-20 week screen of mother suggests what 2 possibilities?
Myelomeningocele and anencephaly
73
How does USS determine spina bifida?
Lemon and banana sign - ventriculomegaly and microcephaly
74
In motor defects of spina bifida where are the main referrals made to?
OT
Physio
Orthopaedics
Child development clinic
75
Urinary issues in spina bifida investigated and managed how?
MCUG
USS
Videourodynamics
Self-catheterisation and UTI prophylaxis
76
What is given for bowel problems suffered in spina bifida patients?
Glycerol suppositories
77
In spina bifida, what support group is a good one to suggest?
SHINE charity
78
Symptoms of VP shunt blockage in baby?
```
Lethargy
Poor feeding
Vomiting
Seizure
LOC
```
79
Symptoms of VP shunt blockage in child?
```
Developmental delay
Headache
Visual loss
Dizziness
Vomiting
Seizures
LOC
Unsteady
Irritable
```
80
How do you diagnose shunt malfunction?
CT brain
| Shunt series
81
AFO? KAFO? HKAFO?
Ankle foot orthoses
Knee ankle foot orthoses
Hip knee ankle foot orthoses
82
Child with spina bifida is starting to hate having to self-cathetrise, who do you refer to?
Specialist continence nurse
| SHINE
83
If a child with spina bifida presents with incontinence every day what are investigations performed?
MRI spine - tethering
Videourodynamics - pressures, compliance
CT brain - shunt malformations
84
Symptoms suggestive of cord tethering?
Progressive limb deterioration
Change in urinary habits
Progressive scoliosis
Pain
85
Associated symptoms to ask about in headache history?
```
nausea
vomiting
aura
visual disturbances
balance
fever
personality changes
numbness or paraesthesia
```
86
In terms of the pattern and time course to a headache what questions do you want to ask?
Morning? night?
| after exercise? argument? eating? trauma? travel?
87
What relieving factors do you want to ask about with headache history?
```
Lying down
Dark room
Paracetamol
Sitting down
Eating
```
88
What questions can you ask to assess how much headaches are effecting a childs quality of life?
If they have to leave school? how many times?
Sleep effected?
Daily activities effected?
89
Medication history of a child with a headache what is it important to ask about?
Anticoags, antoplatelet, contraception
Allergies
Vaccines up to date
OTC - eye drops, nasal decongestants, herbal
90
FH questions to ask about migraines?
```
headaches, migraines
kidney problems, high BP
eye problems - any one wear glasses?
Familial tumours
Blood vessel abnormalities - aneurysms, malformations, coagulopathy
```
91
SH questions to ask about migraine?
```
Who lives at home?
Any social worker?
Pets?
School? progress? enjoy? any developmental concerns?
Hobbies and activities?
```
92
Things to assess in a neurology exam to assess headaches?
Gait
Coordination
CNS - power, tone, coordination, reflex, sensation
PNS - cranial nerve 1-12
Eye exam - movements, acuity, nystagmus, diplopia, pupils, fundoscopy
93
What symptoms make you worried about a space occupying lesion with a headache?
Headache worse in morning, vomiting, sleep disturb
94
If CT is performed for papilloedema and finds no brain abnormality, what 2 tests can you perform?
Lumbar puncture for pressure reading
| MRI brain for more accurate imaging
95
Differential diagnosis of seizures in children?
Epilepsy - idiopathic or secondary to damage
Metabolic - dka, hypocalcaemia, hypomagnesaemia, hypo or hypernatraemia
Trauma - intracranial haemorrhage, NAI
Infection - meningitis, encephalopathy
Cardiac - arrhythmia, long QT syndrome
Breath holding
Toxins
Poisoning
Causes of a seizure - febrile illness, reflex anoxic attacks, sleep apnoea, pseudoseizures, fabricated illness
96
Difference between simple and complex febrile illness?
Simple - 6 months to 5 years, fever, GTCS, less than 15 minutes, full neuro in an hour, no CNS infection
Complex - Focal onset, does not fully recover in an hour, more than 15 minutes, reoccurrence within 24 hours
97
When do you admit a child to hospital for a seizure?
```
Complex seizure
First seizure
Hasn't been assessed by paediatrician
Parental anxiety
Fever not present
More serious infection suspected
Child is on antibiotics
```
98
2 deficiencies that can lead to increased risk of febrile seizures?
Zinc and iron
99
What infection can predispose a child to their first febrile seizure?
Herpes virus 6
100
Dose of paracetamol given to children under 1 years old? 1-3 years old? 4+ years old?
120mg
240mg
360mg
101
rectal and buccal rescue treatments for febrile seizures?
Rectal diazepam
| Buccal midazolam
102
What physical examinations need to be performed for a child experiencing seizures? (including one examiantion with light)
```
Facial dysmorphic features
cafe au lait spots, woods light
HC
fundoscopy
Bruits
BP
Neurodevelopmental exam
Mental state
```
103
What investigation should never be forgotten in a child presenting with seizure?
Blood glucose
104
Epilepsy support groups?
British epilepsy association and epilepsy action
105
If buccal midazolam isnt working what can be given IV in hospital setting?
IV lorazepam 0.1mg/kg
106
If IV lorazepam isnt working then what is given IV to resolve seizure?
Phenytoin 20mg/kg over 20 minutes
