Paediatric Neurology - Head Injury, Migraines and Cerebral Palsy Flashcards
How can primary head injuries be split?
Focal
Diffuse
What are the causes for focal head injuries?
Haematoma
Contusion
What are the causes for diffuse head injury?
Diffuse axonal injury
Concussion
Describe the pathophysiology of a contusion
Microhaemorrhages and small vessel leaks lead to cerebral oedema
What happens in diffuse axonal injury?
Shearing of grey/white matter interfaces damages the axons leading to cerebral oedema
What happens in a concussion?
Axon injury means there is impaired neurotransmission, ion regulation and cerebral blood flow
This causes temporary brain dysfunction
When would you request an immediate CT head?
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
Why is a CT of the cervical spine not ideal in children?
Ionising radiation damage the thyroid gland
Children at lower risk of C spine injuries
When do you CT the cervical spine in children?
GCS < 13
Intubation needed
Focal peripheral neurological signs
Limb paraesthesia
What investigation would you request for neck pain and tenderness?
3 view cervical spine X-Ray
Where can children get intracranial haemorrhages?
Subdural Extradural Intraventricular Subarachnoid Lobar intracerebral Deep intracerebral
What is the mechanism of a subdural haematoma?
Shearing force on cortical bridging veins
How quickly do subdural haematoma’s present?
Slow onset of symptoms
Chronic subdural haematoma seen in infants due to fragile bridging veins
How do extradural haematoma’s happen?
Acceleration-deceleration
Blow to side of head
What causes an extradural haematoma?
Middle meningeal artery bleed (normally)
Over what timeframe do extradural haematoma’s present?
Lucid interval first
Rapid deterioration follows
Who gets intraventricular haemorrhages?
Children with premature periventricular vasculature
Neonates
How do intraventricular haemorrhages appear on CT?
Hyperdense ventricles on CT
When and why do neonates get intraventricular haemorrhages?
Occur within 72 hours of birth
Combination of:
Delicate neonatal structures
Birth trauma
Cerebral hypoxia
What complications are associated with head injuries?
RICP
Seizures
Infection
What is a migraine?
Recurrent headache +- aura lasting 30 minutes to 48 hours
How many migraine attacks does a child need to have before diagnosis?
5
What are the types of migraines?
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)
How do migraines present?
Pre-monitory symptoms of mood and appetite change
Photophobia and phonophobia common
Tiredness and depression following attack
What are the types visual aura?
Fortification spectra - see picture
Micropsia - things appear smaller than they are
Macropsia - things appear larger than they are
What other types of aura can you get?
Sensory Motor Speech Confusion Brainstem dysfunction - LOC and vertigo
Visual most common
What investigations do you do for migraines?
Fundoscopy
Head circumference
Neurological exam
Describe the headache felt in migraines
Frontotemporal
Bilateral
Doesn’t always throb
Who is more likely to get migraines?
Boys until menarche, then more common in girls
How do very young children with migraines appear?
Look very ill
Abdominal pain and vomiting + being tired and wanting to sleep
How are migraines managed?
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
What medication is used prophylactically for migraines?
Propranolol
Topiramate
Prescribed by specialist in severe cases
What medication is used to treat migraines?
NSAID’s, Aspirin and anti-emetic
Sumatriptan - specialist prescribed only
What is cerebral palsy?
Non-progressive, permanent disorder of movement and/or posture due to damage to developing brain
What causes cerebral palsy?
Damage to brain at any point upto post natal period
Hypoxic Vascular Teratogenic Infection Toxins Trauma Genetic
How does cerebral palsy present?
Low APGAR score Floppy Unusual fidgety movements Feeding difficulty Delayed gross motor milestones Speech and language delay Toe walking Persistent primitive reflexes
What is the APGAR score?
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
How is a diagnosis of cerebral palsy made?
Clinical diagnosis based on observation
More than one abnormality in: Tone Power Reflexes Movements Posture
When should you consider other diagnoses instead of cerebral palsy?
No risk factors
FH of progressive motor disease - SMA
Loss of acquired skill
Focal neurological sign
How can cerebral palsy be classified?
Spastic - 70%
Ataxic - 10%
Dyskinetic - 10%
What is affected in spastic Cerebral Palsy?
Corticospinal tract
How does spastic Cerebral Palsy present?
Increased tone Pathological reflexes Stiff, jerky movements Slow slurred speech Flexed UL Club foot Tiptoe gait
Hypotonia may precede spasticity
How can you describe which limbs are affected?
Monoplegia
Hemiplegia - one side of body
Diplegia - either both arms or both legs
Quadriplegia
What eventually happens in spastic Cerebral Palsy?
Contractors develop
Bone deformities
What is affected in ataxic Cerebral Palsy?
Cerebellum
What are the features of ataxic Cerebral Palsy?
Uncoordinated muscles - movements have abnormal force and inaccuracy Intention tremor Poor balance Wide gait Delayed motor development Early hypotonia
What is affected in dyskinetic Cerebral Palsy?
Basal ganglia or Extrapyramidal pathways
What are the features of dyskinetic Cerebral Palsy?
Involuntary movements Fluctuation in tone Chorea - irregular unpredictable movement Dystonia - twisting repetitive movement Athetosis - slow writhing movement
How is Cerebral Palsy managed?
MDT approach - SALT, psych, oath
Affected joints splinted
Oral diazepam and baclofen - spasticity
Botulinum injections
What conditions are associated with Cerebral Palsy?
Learning disability Emotional and behavioural - ADHD, ASD, depression Sensory disorder Visual and hearing problems Chronic constipation Epilepsy Incontinence
