Paediatric Neurology Flashcards
What is done in a headache examination?
Growth parameter, OFC, BP, sinuses, teeth, visual acuity, fundoscopy, visual fields, cranial bruit, focal neurological sign and cognitive/ emotional status
What are pointers to childhood migraines?
Associated with abdominal pain and N/V
Focal symptoms/ signs before/ during/ after, visual disturbance, paraesthesia and weakness
Relation to stress and fatigue
Aggravated by bright light and noise
What are features of migraine?
Hemicranial pain, throbbing/ pulsatile, abdo pain, N/V, relieved by rest, photophobia/ phonophobia, positive FH and aura
What are some features of tension headaches?
Diffuse and symmetrical
Band-like distribution
Present most of the time and constant ache
What are signs of raised intracranial pressure?
Aggravated by activities - coughing, straining and bending
Woken from sleep with headache and possible vomiting
What are signs of analgesic overuse headache?
Headache is back before allowed to use another dose
Paracetamol and NSAIDs
Particular problem with compound analgesics - co-codamol
What are the indicators for neuroimaging in headaches?
Features of cerebellar dysfunction, raised ICP, new focal neurological deficit, seizures, personality change and unexplained deterioration in school work
What is the management for migraine in children?
Acute attack - effective pain relief or triptans
Preventative - pizotifen, propranolol, amitriptyline, topiramate and valproate
What is the management of tension type headache in children?
Aim at reassurance
Acute attacks - simple analgesia
Prevention - amitriptyline
Discourage analgesics in chronic TTH
What is a convulsion?
Seizure where there is prominent motor activity
What is an epileptic seizure?
An electrical phenomenon
Abnormal excessive hyper synchronous discharge from a group of neurons
Paroxysmal change in motor, sensory or cognitive function
May have clinical manifestations
Describe epilepsy
A tendency to recurrent, unprovoked spontaneous epileptic seizures
Recourse to EEG
What are some non-epileptic seizures and other mimics in children?
Acute symptomatic seizure - due to acute insult
Reflex anoxic seizure - common in toddlers
Syncope
Parasomnias
Behavioural stereotypes
Psychogenic non-epileptic seizures (PNES)
Describe febrile convulsions
A seizure occurring in infancy/ childhood, usually between 2 months and 5 years of age
Associated with fever but without evidence of intracranial infection or defined cause for the seizure
Commonest cause of acute symptomatic seizure in childhood
What is the mechanism of epileptic fits?
Chemically triggered by decreased inhibition, excessive excitation and excessive influx of Na and Ca ions
Chemical stimulation produces an electrical current - summation of multitude of electrical potentials results in depolarisation of multiple neurons
What are the types of epileptic seizures?
Partial and generalised seizures
What is the differences in adult vs childhood epileptic seizures?
Majority are idiopathic and generalised in childhood
Seizures can be subtle and diagnosis can be challenging
What is the role of the EEG?
Has limited value in deciding when the individual has epilepsy
Useful in identifying seizure types, seizure syndrome and aetiology
Sensitivity of first routine - 30-60%
Problematic false positive rates
How is epilepsy diagnosed?
History, video of event occurring, ECG in convulsion seizures, EEG, MRI brain, genetics and metabolic tests
What is the management of epilepsies in children?
Anti-epileptics only considered if diagnosis is clear
Aim is to control seizures
Start with one anti-epileptic
Side effects - CNS related, drowsiness, effect on learning, cognition and behavioural
What is the drug treatment of epilepsy?
Sodium valproate - not in girls - Levetiracetam
Carbamazepine - focal epilepsies
Levetiracetam and lamotrigine
Other therapies - steroids, immunoglobulins and ketogenic diet
Epilepsy surgery - vagal nerve stimulator
What can be some head size problems?
Macrocephaly and microcephaly
What is part of the normal skull of the infant?
Metopic, coronal, sagittal and lambdoid sutures
Anterior and posterior fontanelle
What is the order of fontanelle closure?
Posterior closes first at around 2-3 months after birth and anterior closes between 1-3 years of age
How is head circumference measured?
Occipitofrontal circumference
As routine - birth to 3 years
Look at facial features, fontanelles and shape of head
Measure and plot parental head sizes
Describe microcephaly
OFC <2SD - mild
OFC <3SD - moderate to severe
Usually indicates small brain - microencephaly
Timing of onset may be a clue
Causes - antenatal, post-nantal, genetic and environmental
Describe macrocephaly
OFC >2SD
Check if the crossing centiles move upwards, sutures, fontanelles, hydrocephalus and large brain
Other abnormalities - facial features, hepatosplenomegaly and bony features
What is plagiocephaly?
Flat head
What is scaphocephaly and brachycephaly?
Scaphocephaly - boat shaped skull
Brachycephaly - short head or flat at the back
Describe plagiocephaly
Flat head - deformational
Asymmetry seen
Positional defect
More prominent in first year in life
Describe craniosynostosis
Sutures have fused too early
Some conditions can cause suture to close
Can have characteristic head shapes - indicates the type
CT scans and skull X-rays
When is a neuromuscular disorder suspected?
baby can be floppy after birth, slips from hands, paucity of limb movements, alert but less motor activity, delayed motor milestones, and able to walk but lots of falls
Describe Duchenne muscular dystrophy
Xp21, dystrophin gene and male infants
Delayed gross motor skills, symmetrical proximal weakness, elevated creatinine kinase levels, cardiomyopathy and respiratory involvement in teens
What are some clinical features of Duchenne muscular dystrophy?
Waddling gait, hold their shoulder back, side to side sway, prominent abdomen, hyperextension of knees and walking on toes
Balance is poor
What are some other neuromuscular disorders?
Myopathy facies - weakness, power and tone of face muscles
Myotonia - inability of muscle to relax after contraction
Paskowitz - high arch of the feet
What is the anatomical approach to neuromuscular conditions?
Muscle - muscular dystrophies, myopathies-congenital and inflammatory, myotonic syndromes
Neuromuscular junction - myasthenic syndromes
Nerve - hereditary or acquire neuropathies
Anterior horn cell - spinal muscular atrophy
What are features of neuropathy?
Distal weakness, may have sensory symptoms + signs, reflexes lost early and fasciculations may be present
What are features of myopathy?
Usually proximal weakness, pure motor, reflexes preserved until later, contractures present and may have accompanying cardiovascular problem
