Pediatric Neurosurgery : General Principles Flashcards
Development of which one of the following domains has the best predictive value of future intelligence?
a. Gross motor
b. Adaptive
c. Visuomotor
d. Language
e. Social
d. Language
Which one of the following combinations of birthweight, height, and head circumference most likely represent normality?
a. Weight 3500 g, height 50 cm, head circumference 35 cm
b. Weight 3000 g, height 40 cm, head circumference 30 cm
c. Weight 2500 g, height 50 cm, head circumference 40 cm
d. Weight 2000 g, height 50 cm, head circumference 25 cm
e. Weight 1500 g, height 30 cm, head circumference 20 cm
a. Weight 3500 g, height 50 cm, head circumference 35 cm
For the average term newborn:
* Weight is 3500 g (low birthweight is
<2500 g, very low birthweight <1500 g
and extremely low <1000 g). Neonates
with birthweight below the 10th percentile
are termed small for gestational age, and
may be genetic or due to intrauterine
growth restriction.
* Height is 50 cm
* Occipitofrontal head circumference (OFC)
is 32.5-38 cm (mean 35 cm).
Head circumference increases approximately
* By 2 cm in first month
* By 6 cm in the first 4 months
* Approximately 1 cm/month during the first
year of life
* Brain weight doubles by 4-6 months of age
and triples by 1 year of age
* The majority of head growth is complete by
4 years of age
The measuring tape should encircle the head and
include an area 1-2 cm above the glabella anteriorly and the most prominent portion of the occiput posteriorly. Measurement of OFC in the
newborn may be unreliable until the 3rd or 4th
day of life since it may be affected by caput
succedaneum, cephalohematoma, or molding.
It may be inappropriate to use a single head
circumference standard for children in all countries or ethnic groups. The standard growth
curves are not appropriate for monitoring the
head size of children with certain medical conditions associated with macrocephaly (e.g. achondroplasia, neurofibromatosis) and other curves are available for these specific conditions.
A neonate born at term has a weight of 3400 g, a length of 50 cm and a head circumference of 30 cm. There are no abnormal neurological findings or syndromic features. Which one of the following statements regarding the child’s apparent microcephaly is true?
a. He has a secondary microcephaly
b. Microcephaly is due to the fact they are small for gestational age
c. Cranial ultrasound should be performed as first choice for microcephaly
d. Microcephaly is due to postnatal cause
**
e. Isolated microcephaly
Microcephaly is generally defined as an occipitofrontal circumference more than 2 standard deviations (SD) below the mean for a given age, sex,
and gestation (i.e. <3rd percentile); using this
definition approximately 2% of the general population would be considered microcephalic even
though many of these individuals are simply at
the low end of the population distribution.
Because head growth is driven by brain growth,
microcephaly usually implies microencephaly
(small brain size) except in cases of generalized craniosynostosis in which skull growth is restricted,
but microencephaly may be present in children
with normal OFC. In general, microencephaly
can result either from abnormal brain development or insult to a previous normal brain.Multiple
classifications: primary microcephaly is present at
birth, while secondary develops postnatally;
others include genetic vs. environments, isolated
vs. syndromic, symmetric vs. asymmetric. The
causes of microcephaly are summarized below:
A 1-year-old infant has a head circumference in the 98th centile for age, he is at 75th centile for weight and height. At birth, his head circumference was just above the 95th centile.
His father and mother have large heads. The child has achieved appropriate developmental milestones for age, and normal examination.
Which one of the following is most accurate?
a. He needs cranial ultrasound to rule out hydrocephalus
b. Heislikely to have subtle cerebral anomalies
c. He is at risk for learning disabilities later in life
d. He probably has familial macrocephaly and needs no further workup
e. He is at risk for craniosynostosis
d. He probably has familial macrocephaly and needs no further workup
Head growth is affected by growth and alterations in the contents of the cranium and the
timing of these changes in relation to closure
of the fontanelles and sutures. Changes in
the volume of any component before the closure of the fontanelles and sutures may alter
the OFC. Evaluation for macrocephaly should
be initiated when a single OFC measurement
is abnormal, when serial measurements reveal
progressive enlargement (i.e. crossing of one or
more major percentile lines [e.g. 10th, 25th,
50th, 75th, 90th] between health supervision
visits), or when there is an increase in OFC of
>2 cm/month (for infants aged 0-6 months).
Macrocephaly is defined as an OFC greater
than two standard deviations (SD) above the
mean for a given age, sex, and gestation
(i.e. 97th percentile). The most common type
of anatomic megalencephaly is benign familial
megalencephaly where children are born with
large heads and normal body size, and during
infancy OFC increases to greater than the
90th percentile, typically 2-4 cm above, but parallel to, the 98th percentile; head growth velocity slows to a normal rate by approximately
6 months of age. In children with a normal
neurologic examination, normal development,
no clinical features suggestive of a specific
syndrome, and no family history of abnormal
neurologic or developmental problems, familial
megalencephaly can be confirmed by measuring
the patient’s parents’ head circumferences and
by using Weaver curves. If the child’s OFC falls
within the normal ranges as estimated using the
Weaver curves, radiologic evaluation is not
necessary. Other causes of macrocephaly are
summarized below:
You are involved in a trauma call for a 2-yearold child fallen from a climbing frame and sustained a head injury. Hypotensive, and you are asked to prescribe a fluid bolus for him (he weighs 30 kg). What volume of fluid would you prescribe as per ATLS protocol?
a. 600 ml
b. 150 ml
c. 300 ml
d. 450 ml
e. 900 ml
a. 600 ml
Current ATLS protocol for fluid boluses in
pediatric trauma is 20 ml/kg (0.9% saline or ringer’s
lactate). If hypotensive after two boluses of fluid,
packed red cells should be administered (10 ml/kg).
You are asked to prescribe maintenance fluids for an infant weighing 10 kg. Which one of the following volumes of maintenance fluid should they receive over 24 h?
a. 1000 ml
b. 100 ml
c. 500 ml
d. 240 ml
e. 750 ml
a. 1000 ml
In general, maintenance fluid requirement for
children (excluding losses from drains, etc.) can
be calculated as:
* 100 ml/kg/24 h for the first 10 kg of weight
* 50 ml/kg/24 h for the next 10 kg of weight
* 20 ml/kg/24 h for each kg over 20 kg
For example, in 24 h maintenance fluid requirement for a child weighing 25 kg would be:
(10 kg100 ml/kg) + (10 kg50 ml/kg)
+ (5 kg20 ml/kg)¼1000 ml + 500 ml
+100 ml¼1600 ml (i.e. run at 1600/24¼66.7 ml/h)
What is the normal heart rate and respiratory rate for a child under 1 year?
a. HR<100 and RR<40
b. HR<120 and RR<30
c. HR< 160 and RR < 60
d. HR<140 and RR<50
e. HR<150 and RR<30
c. HR< 160 and RR < 60
Which one of the following presentations most accurately suggests moderate blood volume loss (30-45%) in pediatric patients?
a. A 6-year-old child with increased HR, weak thready peripheral pulses, normal SBP, normal pulse pressure, confused, mottled skin, and capillary refill 3 s. Urine output is 0.5 ml/kg/h.
b. An 8-year-old child with markedly increased HR, weak thready central pulses, low normal SBP, normal pulse pressure, confused, prolonged CRT, and urine output 0.2 ml/kg/h.
c. A 5-year-old child with bradycardia, weak central pulses, hypotension, widened pulse, unresponsive to painful stimuli, cold, and anuric.
d. An 8-month-old child with increased HR, weak thready peripheral pulses, normal SBP, normal pulse pressure, irritable, mottled skin, and capillary refill 3 s. Urine output is 2 ml/kg/h.
e. An 8-year-old child with markedly
increased HR, weak thready central
pulses, low normal SBP, narrowed pulse
pressure, dulled response to pain, markedly prolonged CRT, and urine output 0.2 ml/kg/h
b. An 8-year-old child with markedly increased HR, weak thready central pulses, low normal SBP, normal pulse pressure, confused, prolonged CRT, and urine output 0.2 ml/kg/h.
Which one of the following is NOT a feature of Down’s syndrome?
a. Atrial septal defect
b. Occipital (and nasal) flattening
c. Brushfield spots
d. Epicanthic folds
e. Simian crease
f. Duodenal atresia
g. Clinodactyly
h. Butterfly erythema
h. Butterfly erythema
Which one of the following statements about brain death in children is most accurate?
a. A single examination and confirmatory ancillary test are sufficient to make a diagnosis of brain death in most children
b. The diagnosis of brain death cannot be made in preterm infants less than 37 weeks of gestational age
c. MRI head is a commonly used ancillary test
d. Apnea testing must have been performed for a diagnosis of brain death
e. An observation period of 12 h is recommended between clinical examinations determining brain death
b. The diagnosis of brain death cannot be made in preterm infants less than 37 weeks of gestational age
The most common causes of brain death in children are trauma, anoxic encephalopathy, infections, and cerebral neoplasms. In the UK, in
children >2 months the criteria used to establish
death should be the same as those in adults; it is
also appreciated that between 37 weeks of gestation and 2 months of age, it is rarely possible
confidently to diagnose death as a result of cessation of brainstem reflexes, and below 37 weeks
of gestation the criteria to establish this cannot
be applied. Although the definition of brain
death and the declaration process in children is
very similar to adult patients, there are several
specific recommendations made by the American Academy of Pediatrics in 2011 (below).
These guidelines are based in large part on consensus opinion as evidence is limited and committees in several countries decided to declare
brain death only in children >2 months of age,
while others requiring serial examinations in
younger infants.
Scratching the skin of the infant’s back from the shoulder downward, 2-3 cm lateral to the spinous processes results in incurvation of the trunk, with the concavity on the stimulated side.
Primitive reflexes:
a. Asymmetric tonic neck
b. Babinski
c. Crossed extensor
d. Galant
e. Heel
f. Moro
g. Palmar grip
h. Plantar grip
i. Rossolimo
j. Suprapubic extensor
d. Galant
Primitive reflexes are brainstem-mediated, complex, automatic movement patterns that commence as early as the 25th week of gestation,
are fully present at birth in term infants, and disappear with central nervous system maturation
(when voluntary motor activity and thus cortical
inhibition emerges). Infants with cerebral palsy
have been known to demonstrate persistence of primitive reflexes or a delay in their disappearance. Persistence of obligatory primitive reflexes
beyond 12 months of age is an indicator of a poor
prognosis regarding ambulation. The major
primitive motor reflexes or patterns that have
been described include Moro, palmar and plantar grasp, rooting, sucking, placing, Moro,
Galant (or truncal incurvation), asymmetric
tonic neck reflex, crossed extensor, tonic labyrinthine reflex, and others. Special emphasis
should be placed on the plantar response: different types of responses have been elicited in
infants, varying from flexor to extensor according to the intensity of the stimulus used but it
is generally accepted and that extensor plantar
response matures to flexor by the end of the first
year in most normal infants. The Babinski sign
refers to the extensor toe response observed in
corticospinal tract pathology but there is ongoing debate as to whether a true Babinski sign
(dorsiflexion of the great toe and fanning of
the remaining toes) is present as a primitive
reflex in infants where it is part of flexion withdrawal of the leg.
Passive total flexion of one lower extremity results in extension of the other lower limb, with adduction and internal rotation into
talipes equinus.
Primitive reflexes:
a. Asymmetric tonic neck
b. Babinski
c. Crossed extensor
d. Galant
e. Heel
f. Moro
g. Palmar grip
h. Plantar grip
i. Rossolimo
j. Suprapubic extensor
c. Crossed extensor
Sudden head extension produced by a light drop of the head results in abduction followed by adduction and flexion of upper extremities.
Primitive reflexes:
a. Asymmetric tonic neck
b. Babinski
c. Crossed extensor
d. Galant
e. Heel
f. Moro
g. Palmar grip
h. Plantar grip
i. Rossolimo
j. Suprapubic extensor
f. Moro
The child’s parents report that she can ride a bicycle, write her own name, identifies written letters and numbers, knows right from left and knows all the color names.
Developmental milestones:
a. 1 month
b. 2 months
c. 4 months
d. 6 months
e. 9 months
f. 12 months
g. 15 months
h. 18 months
i. 2 years
j. 3 years
k. 4 years
l. 5 years
m. 6 years
m. 6 years
The child’s parents report that she can run, walks upstairs with her hand held, stoops and recovers, builds a three block tower, can use a spoon and scribbles spontaneously. Additionally, she uses up to 25 words, points to body parts when asked, uses words to communicate wants and needs, and plays near other children.
Developmental milestones:
a. 1 month
b. 2 months
c. 4 months
d. 6 months
e. 9 months
f. 12 months
g. 15 months
h. 18 months
i. 2 years
j. 3 years
k. 4 years
l. 5 years
m. 6 years
h. 18 months
The child’s parents report that she can sit but may need support, rolls in both directions, reaches with one hand, transfers object between hands, babbles and seems to recognize an object or person as unfamiliar.
Developmental milestones:
a. 1 month
b. 2 months
c. 4 months
d. 6 months
e. 9 months
f. 12 months
g. 15 months
h. 18 months
i. 2 years
j. 3 years
k. 4 years
l. 5 years
m. 6 years
d. 6 months
The child’s parents report that she raises her head slightly in the prone position, follows with her eyes to the midline only, her hands are tightly fisted, startles to sound and fixes on people’s faces.
Developmental milestones:
a. 1 month
b. 2 months
c. 4 months
d. 6 months
e. 9 months
f. 12 months
g. 15 months
h. 18 months
i. 2 years
j. 3 years
k. 4 years
l. 5 years
m. 6 years
a. 1 month
The child’s parents report that she sits without support, crawls, pulls to stand, uses a pincer grasp, finger feeds, imitates speech sounds (nonspecific mama, dada), understands the meaning of “no,” plays gesture games (pat-a-cake) and understands her own name. They have also noticed that she now knows hidden objects still remain there and is anxious around people she doesn’t know.
Developmental milestones:
a. 1 month
b. 2 months
c. 4 months
d. 6 months
e. 9 months
f. 12 months
g. 15 months
h. 18 months
i. 2 years
j. 3 years
k. 4 years
l. 5 years
m. 6 years
e. 9 months
