A child with epilepsy / first fit Flashcards
what headaches are seen in children? what are the features associated with each?
- Usually seen in older children
- Primary headache (primary malfunction of neurones; NICE)
- Migraine
- Tension type headache
- Symmetrical, gradual onset
- Described as a tightness, band or pressure • No other symptoms
- Cluster headaches
- Severe headache to one side of head
- May be seen around the eye
- There may be eye watering or nasal congestion
- Cough and exertional headaches
List causes of secondary headaches in children
- Secondary headaches:
- Symptomatic of underlying pathology – SOL, Raised ICP
- Head and neck trauma
- Vascular disorders
- Non vascular disorders
- Medication / drug overuse
- Infection – meningitis /encephalitis • Disorders of homeostasis
- Hypercapnia; Hypertension • Acute sinusitis
- Trigeminal / cranial neuralgias
Headache Red flag signs & symptoms in children
- Symptoms
- Acute headache with fever (consider meningitis)
- Headache – worse on lying down
- Headaches – wakes up child
- Associated early morning nausea/vomiting, confusion • Change in personality or behaviour
- Signs
- Growth failure
- Visual field defects/ squint/ papilloedema • Cranial nerve abnormalities
- Torticollis
- Ataxia
Management of headaches in children
- Thorough history and clinical examination
- Detailed explanation
- Advice
- Lifestyle changes • analgesics
- Imaging unnecessary if no ‘red flag signs’
Describe the symptoms of Migraine in children
- Migraine without aura (90%)
- Unilateral or bilateral headache
- Pulsatile over temporal or frontal area • Unpleasant GI symptoms
- Aggravated by physical activity
- Migraine with aura (10%)
- Headache preceded by aura (visual, sensory or motor) • Visual –negative phenomena hemianopia or scotoma
- Positive – fortification spectra – zig zag lines
- Last a few hours, prefer quiet dark place • Sleep relieves the bout
- Genetic predisposition
- Triggering factors
Management of migrane in children
• Migraine
• Acute management
Management
• Early analgesic use, NSAID/paracetamol
• Oral triptan (nasal preparations available for >12 yr of age)
• Transcutaneous electrical/magnetic stimulation (specialist advice)
• Prophylactic treatment
• Avoidance of triggers/ lifestyle changes – hydration, sleep
• Topiramate (fetal malformations, consider contraception for girls) • Propranolol
• Amitriptyline
• Acupuncture
Motor disorders in children
• Corticospinal tract disorders symptoms and signs
- Weakness with adduction at shoulder
- Flexion at elbow, pronation of forearm
- Adduction and internal rotation at hips, with flexion at hip and knee
- Plantar flexion at ankle
- hyper-reflexia, extensor plantars
Motor disorders in children
• Basal ganglia disorders symptoms and signs
• Fluctuating tone, dystonia, dyskinesia
Motor disorders in children
• Cerebellar disorders symptoms and signs
• posture difficulty, coordination, nystagmus, dysarthria
Motor disorders
• Peripheral symptoms and signs
- Key feature is weakness (progressive or static) • Delayed development
- Floppiness
- Muscle weakness or cramps
- Sites affected
- Anterior horn cells – Spinal Muscular Dystrophy, Polio
- Peripheral nerve – hereditary motor sensory neuropathies, post- infectious polyneuropathy (Guillain-Barre), Bell’s palsy
- Neuromuscular transmission – Myasthenia Gravis
- Muscle – muscular dystrophy (Duchenne’s), inflammatory myopathies, myotonic dystrophy
Neural tube defects pathophysiology
- Failure of normal fusion of the neural plate to form the neural tube in fetus
- Prevalence dramatically fallen • Improved maternal nutrition • Folic acid supplementation
what is the difference between Anencephaly and Encephalocele
Anencephaly – failure of development of most of cranium & brain. Stillborn or die shortly after birth
• Encephalocele – extrusion of brain & meninges through a midline skull defect
what is Spina bifida occulta
- Incidental finding on Xray
* Tuft of hair, dermal sinus in lumbar region
what is the difference between Meningocele and Myelomeningocele. what is the Treatment ?
Meningocele – cystic lesion with meningeal extension covered by skin
• Good prognosis
• Myelomeningocele – open sac that contains dysplastic spinal
cord and nervous tissue
• Associated muscle, bladder, bowel problems • Scoliosis
• Treatment – MDT, Symptomatic and supportive management
Pathophysiology of Hydrocephalus
• Obstruction to the flow of CSF, leading to dilatation of ventricular system proximal to site of obstruction
• Non-communicating (obstructive – within the ventricular system)
• Congenital
• Aqueduct stenosis
• Chiari malformation (cerebellar herniation through foramen magnum)
• Communicating (arachnoid villi – site of CSF absorption) • Intracranial haemorrhage
• Meningitis
Remember the HEAD CIRCUMFERENCE in a child whose fontanelle has not closed
Hydrocephalus - clinical features
- In infants
- Head circumference grows disproportionately • Sutures separate
- Anterior fontanelle bulges
- Scalp veins distended
- Advanced sign - ‘sun setting of the eyes’
- Older children
- Raised intracranial pressure
Hydrocephalus - Investigations
- Antenatal ultrasound screening
- Routine scans in preterm babies
- Head circumference monitoring
- CT or MRI
Hydrocephalus - Treatment
- Symptomatic relief of raised ICP and minimise neurological damage
- Ventriculo-peritoneal shunt • Endoscopic ventriculostomy
Neurofibromatosis - signs
- Neurofibromatosis – Autosomal dominant
- Café-au-lait patches (size matters!) , Neurofibroma
- Axillary freckling, Optic glioma
- Lisch nodule (hamartoma of iris)/Bony lesions/First degree family history
Tuberous sclerosis - signs
Autosomal dominant
• Ash-leaf patches
• Development delay, epilepsy
• Calcified lesions on CT scan
Sturge – Weber syndrome - signs
• Haemangiomatous lesion (Port-wine stain) in trigeminal nerve distribution associated with intracranial lesion ipsilaterally
Neurodegenerative disorders key features
- Deterioration in motor and intellectual function • Development stops and then regresses
- Abnormal neurological features
- Seizures
- Involuntary movements
- abnormal head circumference • Loss of vision and hearing
Non-epileptic events that are differential for seizures
- Breath holding attacks
- Reflex Anoxic seizure
- Syncope
- Staring related to inattention (day dreaming)
- Migraine
- Benign paroxysmal vertigo
- Others
- Cardiac arrhythmia
- Pseudo-seizures
- Fabricated illness
- Induced illness (non accidental injury)
- Tics, night terrors
Febrile seizures - will they reoccur?
30-40% will have further episodes after first
