Paediatric Neurology - Head Injury, Migraines and Cerebral Palsy

Question 1

How can primary head injuries be split?

Answer 1

Focal

Diffuse

Question 2

What are the causes for focal head injuries?

Answer 2

Haematoma

Contusion

Question 3

What are the causes for diffuse head injury?

Answer 3

Diffuse axonal injury

Concussion

Question 4

Describe the pathophysiology of a contusion

Answer 4

Microhaemorrhages and small vessel leaks lead to cerebral oedema

Question 5

What happens in diffuse axonal injury?

Answer 5

Shearing of grey/white matter interfaces damages the axons leading to cerebral oedema

Question 6

What happens in a concussion?

Answer 6

Axon injury means there is impaired neurotransmission, ion regulation and cerebral blood flow

This causes temporary brain dysfunction

Question 7

When would you request an immediate CT head?

Answer 7

LOC > 5mins
Amnesia >5mins
Drowsy
3+ episodes of vomiting
Suspect non-accidental injury
GCS <14 or <15 if <1yo
Suspicion of open or depressed skull injury
Signs of basal skull fracture
Focal neurological deficit
Bruise, swelling or laceration >5cm if <1yo
Dangerous mechanism of injury

Question 8

Why is a CT of the cervical spine not ideal in children?

Answer 8

Ionising radiation damage the thyroid gland

Children at lower risk of C spine injuries

Question 9

When do you CT the cervical spine in children?

Answer 9

GCS < 13
Intubation needed
Focal peripheral neurological signs
Limb paraesthesia

Question 10

What investigation would you request for neck pain and tenderness?

Answer 10

3 view cervical spine X-Ray

Question 11

Where can children get intracranial haemorrhages?

Answer 11

Subdural
Extradural
Intraventricular
Subarachnoid
Lobar intracerebral
Deep intracerebral

Question 12

What is the mechanism of a subdural haematoma?

Answer 12

Shearing force on cortical bridging veins

Question 13

How quickly do subdural haematoma’s present?

Answer 13

Slow onset of symptoms

Chronic subdural haematoma seen in infants due to fragile bridging veins

Question 14

How do extradural haematoma’s happen?

Answer 14

Acceleration-deceleration

Blow to side of head

Question 15

What causes an extradural haematoma?

Answer 15

Middle meningeal artery bleed (normally)

Question 16

Over what timeframe do extradural haematoma’s present?

Answer 16

Lucid interval first

Rapid deterioration follows

Question 17

Who gets intraventricular haemorrhages?

Answer 17

Children with premature periventricular vasculature

Neonates

Question 18

How do intraventricular haemorrhages appear on CT?

Answer 18

Hyperdense ventricles on CT

Question 19

When and why do neonates get intraventricular haemorrhages?

Answer 19

Occur within 72 hours of birth

Combination of:
Delicate neonatal structures
Birth trauma
Cerebral hypoxia

Question 20

What complications are associated with head injuries?

Answer 20

RICP
Seizures
Infection

Question 21

What is a migraine?

Answer 21

Recurrent headache +- aura lasting 30 minutes to 48 hours

Question 22

How many migraine attacks does a child need to have before diagnosis?

Answer 22

5

Question 23

What are the types of migraines?

Answer 23

Migraine without aura (most common)

Aura without headache

Hemiplegic migraine (hemiplegia accompany/precede)

Basilar migraine (Aura followed by dizziness and syncope + minor headache)

Periodic syndromes - cyclical vomiting, abdominal migraines (often precursor to migraines)

Question 24

How do migraines present?

Answer 24

Pre-monitory symptoms of mood and appetite change

Photophobia and phonophobia common

Tiredness and depression following attack

Question 25

What are the types visual aura?

Answer 25

Fortification spectra - see picture Micropsia - things appear smaller than they are Macropsia - things appear larger than they are

Question 26

What other types of aura can you get?

Answer 26

``` Sensory Motor Speech Confusion Brainstem dysfunction - LOC and vertigo ``` Visual most common

Question 27

What investigations do you do for migraines?

Answer 27

Fundoscopy Head circumference Neurological exam

Question 28

Describe the headache felt in migraines

Answer 28

Frontotemporal Bilateral Doesn't always throb

Question 29

Who is more likely to get migraines?

Answer 29

Boys until menarche, then more common in girls

Question 30

How do very young children with migraines appear?

Answer 30

Look very ill | Abdominal pain and vomiting + being tired and wanting to sleep

Question 31

How are migraines managed?

Answer 31

Explain and reassure - parents often concerned about lack of investigations Keep trigger diary Avoid - lack of sleep, stress, skipped meals, video games Sleep and food diary Medication

Question 32

What medication is used prophylactically for migraines?

Answer 32

Propranolol Topiramate Prescribed by specialist in severe cases

Question 33

What medication is used to treat migraines?

Answer 33

NSAID's, Aspirin and anti-emetic | Sumatriptan - specialist prescribed only

Question 34

What is cerebral palsy?

Answer 34

Non-progressive, permanent disorder of movement and/or posture due to damage to developing brain

Question 35

What causes cerebral palsy?

Answer 35

Damage to brain at any point upto post natal period ``` Hypoxic Vascular Teratogenic Infection Toxins Trauma Genetic ```

Question 36

How does cerebral palsy present?

Answer 36

``` Low APGAR score Floppy Unusual fidgety movements Feeding difficulty Delayed gross motor milestones Speech and language delay Toe walking Persistent primitive reflexes ```

Question 37

What is the APGAR score?

Answer 37

``` Appearance (skin color) Pulse (heart rate) Grimace response (reflexes) Activity (muscle tone) Respiration (breathing rate and effort) ``` Each scored out of 2 7+ = good health

Question 38

How is a diagnosis of cerebral palsy made?

Answer 38

Clinical diagnosis based on observation ``` More than one abnormality in: Tone Power Reflexes Movements Posture ```

Question 39

When should you consider other diagnoses instead of cerebral palsy?

Answer 39

No risk factors FH of progressive motor disease - SMA Loss of acquired skill Focal neurological sign

Question 40

How can cerebral palsy be classified?

Answer 40

Spastic - 70% Ataxic - 10% Dyskinetic - 10%

Question 41

What is affected in spastic Cerebral Palsy?

Answer 41

Corticospinal tract

Question 42

How does spastic Cerebral Palsy present?

Answer 42

``` Increased tone Pathological reflexes Stiff, jerky movements Slow slurred speech Flexed UL Club foot Tiptoe gait ``` Hypotonia may precede spasticity

Question 43

How can you describe which limbs are affected?

Answer 43

Monoplegia Hemiplegia - one side of body Diplegia - either both arms or both legs Quadriplegia

Question 44

What eventually happens in spastic Cerebral Palsy?

Answer 44

Contractors develop | Bone deformities

Question 45

What is affected in ataxic Cerebral Palsy?

Answer 45

Cerebellum

Question 46

What are the features of ataxic Cerebral Palsy?

Answer 46

``` Uncoordinated muscles - movements have abnormal force and inaccuracy Intention tremor Poor balance Wide gait Delayed motor development Early hypotonia ```

Question 47

What is affected in dyskinetic Cerebral Palsy?

Answer 47

Basal ganglia or Extrapyramidal pathways

Question 48

What are the features of dyskinetic Cerebral Palsy?

Answer 48

``` Involuntary movements Fluctuation in tone Chorea - irregular unpredictable movement Dystonia - twisting repetitive movement Athetosis - slow writhing movement ```

Question 49

How is Cerebral Palsy managed?

Answer 49

MDT approach - SALT, psych, oath Affected joints splinted Oral diazepam and baclofen - spasticity Botulinum injections

Question 50

What conditions are associated with Cerebral Palsy?

Answer 50

``` Learning disability Emotional and behavioural - ADHD, ASD, depression Sensory disorder Visual and hearing problems Chronic constipation Epilepsy Incontinence ```