Paediatric Neurology Flashcards
Migraine/Tension/Epilepsy/NM pathology
How should we approach the neurological history in childhood?
- History taking: interactive
- Hear what was said, not what you thought was said
- Avoid quasi-medical language
- Time course of symptoms crucial
- Distinguishing static from slowly progressive symptoms can be challenging
How does one carry out the neurological examination in childhood?
- Opportunistic approach and observation skills
- Appearance
- Gait
- Head size
- Skin findings
- Real world examination (depends on age)
List some common paeds neurology and their epidemiology:
- Migraine 7.7% of children 10-17
- Traumatic Brain Injury: 180-300/ 100,000 children
- Tourette syndrome: 1% of all children with high frequency in ADHD and OCD
- Epilepsy: 0.7% of all children, 1/3 will have intractable epilepsy
- Brain tumours: second most common cancer in children
What are different types of headache patterns in paeds?
Which ones are more concerning
- Isolated acute
- Recurrent acute
- Chronic progressive
- Chronic non-progressive
What headache questions do we need to ascertain?
- Any warning?
- Location?
- Severity?
- Duration?
- Frequency?
What are elements of headaches examination?
- Growth parameters, OFC, BP
- Sinuses, teeth, visual acuity
- Fundoscopy
- Visual fields (craniopharyngioma)
- Cranial bruit
- Focal neurological signs
- Cognitive and emotional status
Childhood migraine: SSx?
- 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
Tension headache: SSx?
- Diffuse, symmetrical
- Band-like distribution
- Present most of the time (but there may be symptom free periods)
- “Constant ache”
List the main differences between tension and migraine:
write down and use previous to slides to compare
What would suggest raised ICP?
- Aggravated by activities that raise ICP eg. Coughing, straining at stool, bending
- Woken from sleep with headache
What would suggest analgesic overuse headache?
- Headache is back before allowed to use another dose
- Paracetamol/ NSAIDs
- Particular problem with compound analgesics eg. Cocodamol
What are some indications for neuroimaging?
- Features of cerebellar dysfunction
- Features of raised intracranial pressure
- New focal neurological deficit eg. new squint
- Seizures, esp focal
- Personality change
- Unexplained deterioration of school work
Rx for migraine?
- Acute attack: effective pian relief, triptans
- Preventative (at least 1/week):
- Pizotifen, Propranolol, Amitryptyline, Topiramate, Valproate
Rx for tension type headache (TTH)?
- Aim at reassurance: no sinister cause
- Multidisciplinary management
- Attention to underlying chronic physical, psychological or emotional problems
- Acute attacks: simple analgesia
- Prevention: Amitryptiline
- Discourage analgesics in chronic TTH
What comes under bracket of paroxysmal disorders?
Fits, Faints and Funny-turns
What is a convulsion?
Seizure where there is prominent motor activity
What is epilepsy?
A tendency to recurrent, unprovoked (spontaneous) epileptic seizures
What is an epileptic seizure?
An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons
How can we Dx epilepsy?
clinically, with recourse to EEG only for supportive evidence
DDx for non-epileptic seizures and other mimics in children?
- 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 seizures (NEAD)
What is febrile convulsion??
- Event occurring in infancy/ childhood, usually between 3 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 are the 4 different seizure types?
- Jerk/ shake: clonic, myoclonic, spasms
- Stiff: usually a tonic seizure
- Fall: Atonic/ tonic/ myoclonic
- Vacant attack: absence, complex partial seizure
Pathophysiology of 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
What is an epileptic seizure that only affects a small area of brain vs one that affects whole brain?
What are the differences between childhood and adult onset epilepsies?
- Majority are idiopathic in origin (both Focal & Generalised)
- Majority of epilepsies are generalised
- Seizures can be subtle (absences, myoclonus, drop attacks)
What questions should we ask ourselves to diagnose epilepsy?
- Is the paroxysmal event epileptic in nature?
- Is it epilepsy?
- What seizure types are occurring?
- What is the epilepsy syndrome?
- What is the etiology?
- What are the social and educational effects on the child?
What is the role of the EEG?
- An interictal EEG has limited value in deciding when the individual has epilepsy
- Useful in identifying seizure types, seizure syndrome and etiology
Dx procedure for epilepsy?
- History
- Video recording of event
- ECG in convulsive seizures
- Interictal/ ictal EEG
- MRI Brain: to determine etiology eg. Brain malformations/ brain damage
- Genetics: idiopathic epilepsies are mostly familial; also single gene disorders eg. Tuberous sclerosis
- Metabolic tests: esp if associated with developmental delay/ regression
When do we start Mx for epilepsy?
- Only be considered if diagnosis is clear even if this means delaying treatment
- Role of drugs is to control seizures not stop epilepsy
What is Rx for epilepsy?
- Sodium Valproate: first line for generalised epilepsies (not in girls- recent MHRA advice)
- Carbamazepine: first line for focal epilepsies
When would we suspect 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
Anatomical approach:
If affecting muscle: DDx?
If affecting neuromuscular junction: DDx?
If affecting nerve: DDx?
If affecting anterior horn cells: DDx?
- Muscle: muscular dystrophies, myopathies- congenital and inflammatory, myotonic syndromes
- Neuromuscular junction: myasthenic syndromes
- Nerve: Hereditary or acquired neuropathies
- Anterior Horn Cell: Spinal muscular atrophy
What is Duchenne muscular dystrophy?
- Xp21, dystrophin gene, 1/3500 male infants
- Delayed gross motor skills
- Symmetrical proximal weakness
- Waddling gait, calf hypertrophy
- Gower’s sign positive
- Elevated Creatinine Kinase levels
- >1000 in DMD
- Cardiomyopathy
- Respiratory involvement in teens
