Nervous System Flashcards by Seldon House

What is cerebral palsy?

A group of disorders in which there is developmental delay and disorder of posture and movement resulting from a non-progressive, permanent, fixed cerebral lesion in developing/immature brain

May or may not also present with other neurological symptoms eg learning difficulties / epilepsy

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How common is cerebral palsy?

Most common motor impairment in children

1/500

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What proportion of cerebral palsy are caused by damage to the immature brain antenatally, perinatally and postnatally?

Antenatal = 80%
Perinatal = 10%
Postnatal = 10%

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What are some antenatal causes of cerebral palsy?

1) Maternal infection = TORCH
2) Radiation exposure
3) Intraventricular haemorrhage (IVH)
4) Chorioamnionitis
5) Multiple births eg twins
6) Maternal resp or genitourinary infection

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What is TORCH?

Toxoplasmosis
Other infections eg syphilis, VZV, parvovirus B19, Listerosis and Coxsackie virus
Rubella
CMV
Herpes simplex

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What are some perinatal causes of cerebral palsy?

1) Hypoxic-ischaemic encephalopathy (HIE)

2) Intrapartum trauma

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What are some postnatal causes of cerebral palsy in the neonate?

IVH
Hyperbilirubinaemia - Kernicterus
Hypoglycaemia
Cerebral infarct
Meconium aspiration
Meningitis
Encephalitis

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What are some postnatal causes of cerebral palsy in the infant?

Hydrocephalus
Hypoglycaemia
CNS infection

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What are some postnatal causes of cerebral palsy in the child?

Hypoxic event eg drowning
Head trauma
Lead poisoning
CNS infection

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What is the disease progress of cerebral palsy?

Lesion is fixed and non-progressive but the symptoms become worse over time

= “circle on an inflating balloon” as child’s brain grows

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What are the four classification of cerebral palsy based on type of movement disorder?

1) Spastic (80%)
2) Dyskinetic
3) Ataxic

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Describe the spastic movement of cerebral palsy

It is caused by damage to what?

Intermittently increased tone and pathological reflexes = stiff and tight muscles

Damage of UMN

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What are the varying degrees of spastic movement disorder in cerebral palsy?

Hemiplegia
Diplegia
Quadriplegia

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Describe hemiplegic spastic movement in cerebral palsy

Hemiplegia:

Unilateral arm and leg affected (arm>leg)
Arm = flexed and pronated
Leg = cricumducted gate, tiptoe walking, delayed walking
Moderate developmental delay and seizure risk

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Describe diplegic spastic movement in cerebral palsy

Diplegia:

Mostly lower limbs affected (less arms)
Commando crawl = dragging legs scissored
Often normal intellectual development and minimal seizure risk

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Describe quadriplegic spastic movement in cerebral palsy

Quadriplegia:

All four limbs affected
Increased tone
Swallowing difficulties
Significant intellectual delay

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Describe the two types of dyskinetic movement of cerebral palsy

It is caused by damage to what?

1) Athetoid = writhing movement
- Often normal intellectual development

2) Dytonic = involuntary movements
- Worse on movement
- Unusual posture

Damage to basal ganglia

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Describe the ataxic movement of cerebral palsy

It is caused by damage to what?

Shaky movements, poor balance and sense of positioning

Ataxic gait = wide base, unsteady trunk, jerky movements

Damage to cerebellum

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MOVE CARD

When can the lesion occur in cerebral palsy?

At any point from conception - 3yrs

After 3 yrs = acquired brain injury

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How may cerebral palsy present?

1) Delayed milestones
2) Abnormalities of tone eg hypotonia, spaces or dystonia
3) Abnormal motor development eg late head control, rolling, crawling
4) Feeding difficulties

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What are the most common delayed milestones in children with cerebral palsy?

1) Not sitting by 8 months
2) Not walking by 18 months
3) Early hand preference before 1 year (should be ambidextrous until 18 months)

Correct for gestational age

What are complications of CP?

Physical

Muscle spasms and contractions
Feeding difficulties and nutritional problems
incontinence

Social

Problems dressing, ADLs
Developmental delay
Hearing / language impairment

MSK

Scoliosis
Hip dislocation
Inc risk of low bone mineral density = inc risk of osteomalacia / osteoporosis

Neuro
- Epilepsy

Other body systems

Recurrent respiratory infections
GORD
Constipation
UTI

NB many children with CP have preserved cognitive function

What investigations are done for CP?

Diagnosis made clinically

Exclude other causes eg:

Thyroid studies
Chromosomal analysis
CSF etc

What may be given to improve movement in CP?

Mobility aids eg orthotic devices, wheelchairs

Splinting improve ROM eg ankle joints

What may be given to help manage spacisity in CP?

Oral diazepam = useful if rapid effect needed eg pain crisis Baclofen = sustained long term effect eg continuous discomfort Baclofen can be given via continuous pump-administered intrathecal Baclofen

What may be given to help manage dystonia eg problems with posture, function or pain?

Trihexyphenidyl Levodopa Baclofen

When may botulinum toxin type A be given in CP?

Focal spasticity eg impeding fine motor function / disturbing sleep Rapid onset spacisity Pneol and they alcohol can be given if this fails

What professionals involved in MDT approach of CP?

``` Paeds OT SALT Nutrition Education ```

What are febrile seizures?

aka febrile fit/convulsion = Seizures occurring in children aged 6 months - 5 years, associated with fever, without an underlying cause such as a CNS infection or electrolyte imbalance

What two features must be present in order for a classification of a febrile convulsion?

1) Axillary temperature above 37.8 degrees c | 2) Clinical hx / examination indicative of febrile seizures

What is the emergency treatment of febrile seizures?

If child is still convulsing or not fully altert: - Recovery position + ABCDE - Check blood glucose - If still seizing >5min = rectal diazepam OR single dose buccal midazolam OR IV lorazepam Meningococcal disease suspected: - benpen or cefotaxime

What is a simple febrile seizure?

Generalised tonic-clonic seizures Last <15mins Do not recur within 24hrs or within the same febrile illness = most febrile seizures

What is a complex febrile seizure?

Must have one/more of: 1) Focal features at onset or during seizure 2) Duration >15mins 3) Recurrence within the same febrile illness = 20% febrile convulsions

What is a febrile status epileptics?

Febrile seizure lasting more than 30 minutes = 5% febrile convulsions

What are other types of seizures related to acute illness in children?

1) Febrile myoclonic seizures 2) Afebrile convulsions in young children with mild gastroenteritis - clusters of seizures with/without fever over several days in those with gastroenteritis = good prognosis

How common are febrile convulsions?

Common - 2-5% children

What are the most common causes of fever in febrile convulsions? (5)

Most: 1) Viral infections eg URTI 2) OM 3) Tonsillitis Others: 4) Gastroenteritis 5) Post-immunisation

What are some serious illnesses which need excluding in a febrile child with a seizure?

1) Meningitis and septicaemia 2) UTI 3) LFTI 4) Cerebral malaria

What features of a seizure are important in a seizure hx?

1) Conscious level prior to seizure 2) Duration 3) Focal or generalised 4) Time taken to recover 5) State of child after

What other features are important to include in a seizure hx?

1) Any symptoms of meningitis or septicaemia 2) Is it a febrile seizure 3) Past or FH of seizure (24% have FH)

What features are important to include on examination of a child with a febrile convulsions?

``` Vital signs Conscious levels Rash - blanching or non-blanching Fontanelle Meningism Focus of infection ```

What investigations are performed for a febrile convulsion?

Investigate febrile illness rather than seizure, eg: Bloods: FBC, ESR, glucose, U&Es, coagulation, culture Urine microscopy/culture LP

Ddx for febrile convulsion?

``` Rigors Syncope Breath-holding spells Reflex anoxic seizures Apneoa Postictal fever Epilepsy Hypoglycaemia Encephalitis Afebrile seizures with gastroenteritis ```

What are reflex anoxic seizures?

A precipitant eg minor bump causes vaguely mediated cardiac asystole lasting many seconds Child may be pale, floppy and lose consciousness, followed my tonic and clonic movements

What makes a posticltal fever more likely?

Temp >38 | Seizure lasts >10min

What is the management of a febrile convulsion?

Monitor for a few hours Send home if child looks well, parents understand how to treat febrile illness and further seizures and can access medical services easily Arrange review

What advice should be given to a parent of a child with febrile convulsions?

Give leaflet Explain what febrile seizures are How to treat fever at home - remove excess clothing, give fluids, give antipyretics if child uncomfortable Tepid sponging or cooling not recommended Check for non-blanching rash, change of alertness, dehydration, fever >5 min - seek medical assistance Stay with child at night First aid if child has a fit - position child and do not put anything in their mouth Call 999 if seizure lasts more than 5 minutes

What is the prognosis of febrile convulsions?

Good By definition do not recur beyond 5 yrs (30% do) Intellect not affected, nor is there an inc risk of death

What are some risk factors of recurrence of febrile convulsions? (4)

1) FH 2) Onset <18 months 3) Lower temperatures 4) Shorter duration of fever at onset

What % of children with febrile seizures go on to develop epilepsy?

2-7% Higher with complicated febrile convulsions