MCH Neurology – Flashcards
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How can you distinguish hemorrhagic CSF caused by a traumatic lumbar puncture from a true subarachnoid hemorrhage?
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If the LP fluid clears significantly as the sequence of tubes are collected= traumatic LP
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When do you recommend using an LP on a peds patient?
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-suspected CNS infection -subarachnoid hemorrhage
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When is LPs contraindicated?
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evidence of increased ICP -papilledema -depression of consciousness -focal neurologic deficits *could cause cerebral herniation
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What is included in a CSF analysis?
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-cell count -protein -glucose
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What is an electroencephalography (EEG), 3 key features
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records electrical activity generated by cerebral cortex 1. background patterns 2. behavioral state modulation 3. presence or absence of epileptiform patterns
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What does normal EEG look like?
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-general symmetry/ synchrony b/t background of the 2 hemispheres w/o localized area o high amplitude or slower frequencies
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What do delta rhythms on an EEG suggest?
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underlying structural abnormality -brain tumor -abscess -stroke
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What do spikes, polyspikes and spike and wave abnormalities indicated on an EEG?
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seizure
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what are electromyography and nerve conduction studies?
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-assess for abnormalities of the neuromuscular apparatus -spontaneous discharge of motor fibers (fibrillations) or groups of muscle fibers (fasciculation)- indicates *denervation*
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what do abnormal muscle responses indicate on electromyography/nerve conduction studies?
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neuromuscular junction disorders -myasthenia gravis -botulism
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What are NCVs?
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Nerve conduction velocities -asses AP transmission along peripheral nerves *slowed in demyelinating neuropathies ie. Guillain-Barre*
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When do you use a CT scan in peds?
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emergency purposes -quick, accessible *study of choice for head injury or sudden headache*
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When do you use a MRI scan in peds?
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-provides fine detail, detects posterior fossa lesions, cerebral abnormalities, vascular abnormalities, tumors, ischemic changes -spinal cord views *study of choice for new onset complex partial seizures*
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When do you use a cranial US in peds?
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-visualize brain, ventricles of infants -young children with open fontanelles *noninvasive bedside procedure
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Primary vs secondary headache
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primary- migraines, tension secondary- viral URI, sinusitis OR symptom of serious condition (meningitis, brain tumors)
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4 temporal patterns of childhood headache
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1. *Acute*- single episode of pain w/o history 2. *Acute recurrent*- pattern of attacks of pain separated by symptom free intervals 3. *Chronic progressive*- gradually increasing frequency and severity of headache; most ominous 4. *Chronic non progressive or chronic daily*- constant headache
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S/S of tension-type headache
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-mild, lack associated symptoms -not disruptive of life -*global pain and sneezing or pressing* -lasts hours to days -related to stresses, depression, anxiety
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Clinical manifestation of migraines
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-begin in childhood -frontal, bitemporal or unilateral -*pounding, throbbing pain aggravated by activity* -N/V, pallor, photophobia, phonophoba, want to be in dark
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What is the most common recurrent patten of primary headaches?
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tension-type
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How can you tell if a toddler is having a migraine? aka they cant tell you so what do they show you
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-irritability -sleepiness -pallor -vomiting
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Signs of increased ICP in headache
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-associated vomiting worse when lying down or on first awakening -awakens child from sleep -remits on arising -exacerbated by cough, valsalva, bending over
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Is head trauma a primary or secondary headache?
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secondary
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When do you get imaging for headache/migraine complaint in peds?
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-neuro exam is abnormal -unusual neurologic features during headache -s/s of increased ICP
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What is the diagnostic study of choice for headache/migraine in peds (if indicated)?
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MRI
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Mainstay treatment of headache/migraine in peds?
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-intermittent symptomatic or abortive analgesics -acetaminophen or NSAIDS -hydration, antiemetics -psych support, counseling, stress management
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What meds do you give for kido experiencing one disabling headache per week?
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daily preventative agents including -tricyclic antidepressants -anticonvulsants -antihistamines -BB, CCB *must work with lifestyle modification before initiation daily meds*
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Should you consider triptans in kids with migraines?
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yes if symptomatic or abortive analgesics do not work
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Describe neonatal seizures caused by hypoxic-echemic encephalopathy (postasphyxial seizures)
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-occur 12-24 hrs after birth asphyxia, refractory to anticonvulsants -also caused by metabolic disorders
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seizures caused by intraventricular hemorrhage (IVH) in a neonate?
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-common in premature infants -bulging fontanelle, hemorrhage spinal fluid, anemia, lethargy, coma
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delivery room seizures in neonates?
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caused by direct injection of local anesthetic agents, severe anoxia, congenital brain malformation
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seizures after 5 days of life
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result of infection or drug withdrawl
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what do subtle seizures in neonate look like
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-apnea -eye deviation -tongue thrusting -eye blinking -fluctuation of vital signs -starring
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What is the immediate diagnostic test after neonate seizure?
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cap blood glucose level
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treatment for neonate seizures
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-correction of hypoglycemia, hypocalcemia, hypomagnesemia, hyponatremia, or vitamin B6 deficiency or dependency *if there is no identifiable cause of the seizure= anticonvulsant agent*
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symptoms of a simple focal (or partial) seizure
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-motor (tonic, clonic, myoclonic) -sensory -psychic or autonomic abnormalities -consciousness preserved
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what is the difference b/t simple focal or complex partial seizures
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-complex partial seizures go in and out of consciousness (alternation of consciousness) aka *dyscognitive features* -starring, automatisms
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what are automatisms?
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automatic semi purposeful movements of mouth (lip smacking, chewing) or extremities (rubbing of fingers, shuffling of feet)
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what is the Jacksonian march?
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when focal seizures spread to whole brain, producing generalized seizures (*secondarily generalized*)
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clinical hallmark of absence seizures
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brief (less than 15 seconds) loss of environmental awareness accompanied by eye fluttering or simple automatisms -4-6 year olds -eeg shows generalized 3-Gz spike and wave activity
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how do you clinically provoke absence seizures
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hyperventilation or strobe light
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atypical absence seizure
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episodes of impaired consciousness w/automatisms, autonomic phenomena, motor manifestations (eye opening, eye deviation, body stiffening)
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myoclonus seizure
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sudden jerk of all or part of body *not all epileptic in nature*
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atonic seizures
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typically brief (1-2 sec) but disabling b/c of loss of postural tone= *falls, injuries*
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febrile seizures
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unrecongnized epilepsy caused by fever -6 months-6 years -generalized onset, less than 15 min, only once in 24 hours
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do you treat febrile seizures?
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Nope -antipyretics don't help -can use rectal diazepam during seizure to abort prolonged event
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psychogenic nonepileptic seizure (PNES)
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manifestation of *conversion disorders or malingering* -often have closed eyes, thrashing movement, tremulousness -verbalization, pelvic thrusting often initiated or terminated by suggestion get these kidos some mental health care- no meds damnit
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most common causes of seizures
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perinatal conditions- ischemic encephalopathy, hemorrhage infections- encephalitis, meningitis metabolic conditions- hypoglycemia poisoning neurocutaneous syndromes systemic disorders accidental trauma, febrile illness, familial
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benign childhood epilepsy with centrotemporal spikes aka benign rolandic epilepsy
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-begins 5-10 -occurs during sleep, on awakening -no imaging -anticonvulsants -resolves after puberty most common epilepsy sydrome
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childhood absence epilepsy
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begins early school years, resolves by adolescence -treatment= ethosuximide
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juvenile myoclonic epilepsy
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myoclonic jerks exacerbated in the morning, drops objects, tonic- clonic resolve with anticonvulsant meds (*valproic acid*)
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do you treat juvenile myoclonic epilepsy for life?
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yup anticonvulsants
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infantile spasms
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-brief contractions of neck, trunk, arm muscles followed by phase of sustained muscle contraction *high risk for long-term neurodevelopmental difficulties*
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how do you treat infantile spasms?
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adrenocorticotropic hormone, high dose coricosteroid, vigabatrin
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west syndrome
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triad of infantile spasms, developmental regression, dramatically abnormal eeg pattern
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hypsarrrhythmia
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chaotic high voltage slow waves, spikes, polyspikes -peak age of onset- 3-8 months
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What is Lennox-Gastaut syndrome?
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frequent, multiple seizure types due to *brain injury/malformation* -respond poorly to treatment -significant intellectual disability
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acquired epileptic aphasia (Landau-Fleffner syndrome)
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-abrupt loss of previous acquired language in young children -pts with autistic regression
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causes of status epilepticus
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VITAMINS *V*ascular *I*nfection *T*rauma *M*etabolic *I*ngestion/W*I*thdrawal *N*eoplasm P*s*ych or epilepsy
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management of status epilepticus
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ABCs O2 IV Labs- glu, BMP, anticonvulsant drug levels, toxicology studies, CBC/diff -*BENZOS*- lorazepam, diazepam, midazolam -fosphenytoin -phenobarbital -valproic acid
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common causes of coma in peds
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infection- meningitis, abscess, encephalitis trauma- hemorrhages toxins (intoxication or withdrawal)- etoh, narcotics etc hypoxia-ischemia- near drowning, carbon minoxide epilepsy- postictal states, status epilepticus stroke, increased ICP migraine systemic disorders metabolic derangements
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diagnostic approach to coma
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labs- glu, CMP, blood gases, ammonia, urinalysis CSF analysis neuroimaging- head CT, MRI EEG
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DDX for transient, recurrent depression of consciousness
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-episodic alteration or depression of consciousness with full recovery due to seizure, migraine, syncope, metabolic abnormality -basilar artery or confusional migraines -syncope -metabolic derangements ie. hyperammonemia
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what are the most common solid tumors in children
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CNS tumors -sxs caused by impingement on normal tissue or increase in ICP
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sxs for CNS tumors
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increased ICP- lethargy, headache, vomiting slow growing tumors- irritability, anorexia, poor school performance, loss of developmental milestones
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immediate treatment used to reduce tumor-associated edema
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-high dose dexamethasone
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most common location of CNS tumors in children
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infratentorial (posterior fossa)
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sxs of neuroblastoma
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abdominal pain or mass, mass palpated in flank, hard smooth, nontener -secretory diarrhea, profuse sweating, opsomyoclonus (dancing eyes/feet)
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lab test for neuroblastoma
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CBC + urine (looking for catecolamines)
