Paediatric Neuro Flashcards
What is cerebral palsy
A condition of permanent neurological problems resulting from damage to the brain around the time of brith
Are the symptoms of cerebral palsy progressive?
No however they may change over time with development
Causes of cerebral palsy
Birth asphyxia- hypoxic ischaemic encephalopathy
Maternal infections
Postnatal infections (e.g. meningitis, encephalitis)
Head injury
Types of cerebral palsy
Spastic
Dyskinetic
Ataxic
Mixed
Describe what spastic cerebral palsy is
Damage to the upper motor neurones leading to increased tone (spasticity) and brisk reflexes
What different types of spastic cerebral palsy are there?
Hemiplegia (unilateral involvement of arm and leg, usually the arm worse than leg)
Bilateral quadriplegia (all 4 limbs are affected, often severely)
Bilateral diplegia (all 4 limbs are affected however legs are much more severe than arms)
Explain dyskinetic cerebral palsy
Occurs due to damage of the basal ganglia and substantia nigra
Patients present with problems of muscle tone and movement - may include chorea, athetosis and dystonia
‘ slow writhing movements’
Explain ataxic cerebral palsy
Occurs due to damage to the cerebellum and often genetic.
Leads to uncoordinated movements
How may patient with cerebral palsy present?
Hemiplegic gait (due to increased muscle tone)
Delayed motor milestones
Feeding difficulties
Treatment approach of cerebral palsy
MDT
Physiotherapy
Muscle relaxants- baclofen
Describe the presentation of benign rolandic epilepsy
partial seizures at night- hemifacial paraesthesias, oropharyngeal and hypersalivation
when should an ambulance be called in patients with febrile convulsions
if lasting >5 misn
Treatment for spasticity in cerebral palsy
baclofen
What is a seizure
a paroxysmal abnormality of motor, sensory, autonomic and/or cognitive function due to transient brain dysfunction
Causes of epilepsy
genetic
structural
metabolic
cerebral malformation
cerebral tumours
cerebral tumours,
Causes of non-epileptic seizures
-cardiac syncope- e.g. prolonged QT
-neurally mediated syncope- e.g. reflex anoxic seizures
-expiratory apnoea syncope- breath holding spells
-hypovolaemic syncope- can occur in haemorrhagic, dehydration, anaphylaxis
-sudden rise in intracranial pressure (hydrocephalus, haemorrhage)
- sleep disorders
- functional/ medically unexplained/ dissociative seizures
How do focal frontal seizures present?
motor features such as posturing or peddling
Jaksonian march
motor arrest
post-ictal todds palsy
dysphagia or speech arrest
How do temporal lobe focal seizures present?
automatisms- lip smacking, chewing
dysphagia
deja vu
emotional disturbances (sudden terror)
hallucinations of smell, taste or sound
What is an absence seizure
transient loss of consciousness with abrupt onset and termination.
No accompanied motor phenomena except some eyelid flickering and minor alterations in muscle tone
What is a generalised seizures
electrical activity is discharged from both hemispheres of the brain
associated with a loss of consciousness
what is a focal seizure
seizures arise from one or part of a hemisphere
consciousness maintained
Treatment of tonic-clonic seizures
males- sodium valproate
females- lamotrigine or levetiracetam
treatment of absence seizures
1st line: ethosuximide
2nd line: sodium valproate (male), lamotrigine or levetiracetam (women)
what antiepileptic can exacerbate absence seizures
carbamazepine
first line treatment of focal seizures
lamotrigine or levetiracetam
second line treatment of focal seizures
carbamazepine
What are infantile spasms
a type of epilespy syndrome which onsets 3-12 months
Seizures are characterised by violent flexor spass of the head trunk and limbs followed by extension of the arms (Salaam attack).
There will often be multiple bursts - 20-30
What does the EEG of infantile spasms show
hypsarrhythmia
How are infantile spasms treated
vigabatrin and/or corticosteroids
underlying aetiology of infantile spasms
often underlying serious neurological cause
e.g. tuberous sclerosis, encephalitis
What is Lennox-Gastaut syndrome?
a type of epilepsy syndrome that presents around 1 to 3 years
Can be an extension of infantile spasms
Seizures are mainly atonic, atypical absence seizures and tonic seizures in sleep.
how does Lennox-Gastaut syndrome present on EEG
low generalised spike and wave
What is childhood absence epilespy
a type of paediatric epilepsy syndrome that presents around 4-12 years.
Characterised by momentary unrresponsive stares with motor arrest which child cannot recall
May be induced by hyperventilaiton
treatment is ethosuximide
good prognosis
What is benign rolandic epilepsy
an epilepsy syndrome that onsets at 4-10 years
Characterised by tonic clonic seizures in sleep and simple focal seizures with awareness of abnormal feeling in the tongue and distortion of the face
How does juvenile myoclonic epilepsy present
myoclonic seizures, generalised tonic seizures and absence seizures.
Often right after waking- history suggests throwing drinks or spilling things in the morning
How is epilepsy diagnosed?
detailed history- video if available
ECG- checks for arrhythmias
EEG
Brain imaging- CT or MRI. checks for structural abnormalities, not needed if characteristic epilepsy syndrome (e.g. absence seizures)
- metabolic investigations
what might trigger breath holding spells
emotional pain or upset
What is encephalitis
inflammation of the brain parenchyma- due to infectious or non-infectious cause
What is the most common cause of encephalitis
HSV infection
in neonates HSV-2 acquired at birth is the most common cause
in children HSV-1 from cold sores is the most common cause
What part of the brain does HSV most commonly affect?
the temporal lobe
What are two examples of autoimmune encephalitis
NDMA-receptor-antibody - associated encephalitis
GABA-receptor- antibody encephalitis
how does encephalitis present in children ?
altered consciousness
altered cognition
unusual behaviour
acute onset of neurological symptoms
acute onset of focal seizures
fever
peripheral signs of HSV- cold sores
HSV affecting the temporal lobe may cause aphasia
How does encephalitis present in neonates
poor feeding, irritability, seizures, lethargy, temperature instability
How is encephalitis in children diagnosed?
LP- viral PCR (not if raised ICP)
- CT scan if LP is contraindicated
How is encephalitis treated
IV aciclovir if HSV or VZV
ganciclovir in cytomegalovirus
what are the most common causes of meningitis in children under 3 months
Group B streptococcus
Listeria monocytogenes
E.coli
what are the most common causes of meningitis in children 3 months to 6 years
Strep. pneumoniae
Neisseria meningitidis
Haemophilus influenzae
What are the most common causes of meningitis in those over 6 years
neisseria meningitidis
strep. pneumoniae
What are viral causes of meningitis
enteroviruses
HSV
HIV
How does meningitis present
fever
headache
neck stiffness
purpuric non-blanching rash
drowsiness
nausea and vomiting
seizures
how can meningitis present in babies
bulging fontanelles, reduced feeding, irritability, lethargy, unusual behaviour, high pitched weak cry
When would you not perform a LP for the investigation of meningitis ?
focal neurological signs
papilledema
significant bulging fontanelle
disseminated intravascular coagulation
signs of cerebral herniation
How does bacteria meningitis present on LP
polymorphs
cloudy CSF
low glucose
high protein
how does viral meningitis present on LP
lymphocytes
clear CSF
glucose normal/ slightly low
normal or raised protein
what is found in the CSF of TB meningitis
fibrin web
What should be done if a CSF is contraindicated in meningitis
blood cultures
PCR
What is given to treat menginitis in community
IM benzylpenicillin
Treatment of meningitis in <3months
IV cefotaxime + IV amoxicillin/ampicillin
Treatment of meningitis in over 3 months
IV cefotaxime/ ceftriaxone
should you given steroids in the treatment of meningitis in someone under 3 months
no
what are some indications to give dexamethasone in meningitis
CSF is frankly purulent
CSF WCC is > 100 per microlitre
CSF has protein concentration > 1g/l
CSF shows bacteria on gram stain
Overview of treatment of meningitis
- Broad spectrum anitbiotics (IV cefotaxime +/- IV amoxicillin)
- consider dexamethasone in > 3months
- fluids
- notify public health england
what is given to contacts of meningitis
ciprofloxacin
Who is most commonly affected by febrile convulsions?
children under 3 (most common in under 6 months)
What are the two types of febrile convulsions?
simple and complex
describe simple febrile convulsions
primary generalised seizures lasting less than 15 mins, resolving spontaneously with complete recovery in <1 hour, and not recurring again within 24 hours
describe complex febrile convulsions
prolonged seizures (15-30 minutes)
focal seizures
recurrence within 24 hours or within the same illness
what defines febrile status epilepticus
> 30 minutes
After what duration should parents phone 999 for a febrile convulsion and when should they administer rescue therapy
after 5 minutes
what might rescue therapy consist of for febrile convusions?
buccal midazolam or rectal diazepam
what factors increase the risk of having further febrile convulsions? (4)
age of onset less than 18 months
occuring with temperatures < 39
shorter duration of fever before convulsion
a family history
What RF for febrile convulsions increase the likelihood of having epilepsy?
family history of epilepsy
complex febrile convulsions
having a background of a neurodevelopmental disorder
