Neurology Flashcards
What is it important to ask about in history of seizures?
Do the seizures occur when the child is awake or asleep
Could be benign sleep myoclonus - not an epileptic seizure and will disappear with age; no change in colour, saturations, otherwise well
Was the child in distress before the episode?
= breath holding spells, reflex anoxic seizures
What is epilepsy?
Umbrella term - tendency to have seizures - which are transient episodes of abnormal electrical activity in the brain
What are the types of seizures?
Tonic-clonic Focal seizures Absence seizures Atonic seizures Myoclonic seizures Infantile spasms
Febrile convulsions
What is seen in a tonic clonic seizure?
loss of consciousness, tonic muscle tensing, clonic muscle jerking
Associated tongue biting, incontinence, irregular breathing
Drowsy post-octal period
What is seen in a focal seizure?
start in temporal lobe Affect hearing, speech, memory, emotions Hallucinations Memory flashbacks Deja vu Doing strange things on autopilot
What is the management of tonic clonic seizures?
First line - sodium valproate
Second line - lamotrigine or carbamazepine
What is the management of focal seizures?
First line: carbamazepine or lamotrigine
Second line: sodium valproate, levetiracetam
What are absence seizures?
Patient becomes blank
Stares into space then abruptly returns to normal
During episode unaware of surroundings
Lasts 10-20 seconds
What is the management of absence seizures?
First line - sodium valproate or ethosuximide
What are atonic seizures?
Drop attacks
Brief lapses in muscle tone
Usually don’t last more than 3 minutes
May be indicate of Lennox-Gastaut syndrome?
What is lennox-gastaut syndrome?
rare type of severe childhood-onset epilepsy
associated with gene mutations, perinatal injuries, brain tumours, malformations
treatment does not tend to end seizure recurrence
What is the treatment of atonic seizures?
First line sodium valproate
Second line lamotrigine
What are myoclonic seizures?
Sudden brief muscle contractions like a sudden jump
Patient usually awake during
Typically happen as part of juvenile myoclonic epilepsy
What is the management of myoclonic seizures?
First line - sodium valproate
Other options - lamotrigine, levetiracetam, topiramate
What is West syndrome?
Infantile spasms
Clusters of full body spasms
Difficult to treat
First line prednisolone or vigabatrin
What are febrile convulsions?
Seizures in children whilst they have a fever
Not caused by epilepsy or underlying neurological pathology
Occur only in children between the ages of 6 months - 5 years
Slightly increases risk of developing epilepsy in future
What are the investigations for epilepsy?
Good history, type of seizure
EEG
MRI brain - first seizure in under 2, focal seizures, no response to first line drugs
ECG to exclude heart problems
Blood electrolytes
Blood glucose - hypoglycaemia and diabetes
Blood cultures, urine cultures, LP - infection
What general advice is key in those with epilepsy?
Take showers rather than baths
Be cautious with swimming unless seizures well controlled and closely supervised
Cautious with heights
Cautious with traffic
Cautious with heavy, hot or electrical equipment
Likely will avoid driving
What is the effect of sodium valproate?
Increasing GABA
Teratogenic
Liver damage, hepatitis
Hair loss
Tremor
What are some of the side effects of carbamazepine?
Agranulocytosis
Aplastic anaemia
Induces P450 system
What are some of the side effects of phenytoin?
Folate and Vit D deficiency
Megaloblastic anaemia
Osteomalacia - Vit D def
What are some of the side effects of lamotrigine?
Stevens Johnson syndrome
Leukopenia
What is the management of a seizure?
Safe position
Recovery position if possible
Something soft under head
Remove obstacles that could lead to injury
Record start and end time
Call ambulance if lasts more than 5 mins, or first seizure
What is the definition of status epilepticus?
Seizures lasting more than 5 minutes
More than 3 seizures in one hour
What is the management of status epilepticus?
Secure airway High conc oxygen Assess cardiac and respiratory function Check blood glucose levels Gain IV access IV lorazepam repeated after 10 mins if continues
If still persists - infusion of IV phenobarbital or phenytoin
Then intubation, ventilation
What are the medical options in the community for status epilepticus?
Buccal midazolam
Rectal diazepam
What questions need to be asked about episodes - fits, faints or funny turns?
Freq - how many in day, week, month
Timing - certain time of day or behavioural states
Relationship to sleep - on falling asleep, during sleep, waking
Triggers - tired, travel, excitement, exercise
Warnings beforehand
Duration - if clustered how long between episodes
Colour change - pallor, early cyanosis
Alterations in conscious level
Motor phenomena - act it out
Recovery and symptoms after
Family history
What defines epilepsy?
At least two unprovoked seizures occurring more than 24 hours apart
One unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures occurring over next 10 years
Diagnosis of an epilepsy syndrome
What are acute asymptomatic seizures?
Result of acute insults
e.g. hypoglycaemia, hypoxia, electrolyte derangements, infection, trauma
What are the common paediatric epilepsy syndromes?
West Syndrome - infantile spasms Age 4-7 Sudden jerks of neck, trunk Shortly after wakening, or when falling asleep, clustered Cries at end Loss of visual alertness
Benign epilepsy with Centro-temporal spikes
3-12 years, spontaneous remission by adolesence
From sleep, focal onset
Sensory or motor
Tingling, drooling, aphasia
Childhood absence epilepsy 4-8 years, more common in girls Brief arrest of speech, activity Perioral, periocular flickering Unrousable, rapid recovery Can be induced by hyperventilation
Juvenile myoclonic epilepsy
12-18 years
Present with first generalised tonic-clonic seizure
Awareness retained during jerks
What are examples of non-epileptic paroxysmal episodes which can occur during sleep?
Benign neonatal sleep myoclonus
Myoclonic movements not involving the face
Occur in infants few wks old
Parasomnias Sleep paralysis Confusional arousal Sleep walking Night terrors
What are examples of non-epileptic paroxysmal episodes which can occur during feeding?
GORD/Sandifer syndrome
GORD can cause apnoea and dystonic posturing of the head, neck and back
Associated with feeding is Sandifer syndrome
What are examples of non-epileptic paroxysmal episodes which can occur during fevers?
Febrile seizures
Brief, generalised convulsions
6 months to 6 years
Vaso-vagal syncope
In older children
Triggers e.g. intercurrent illness, heat, low food and water intake, prolonged standing
Prodromal pallor, nausea, visual greying, dizziness
What are examples of non-epileptic paroxysmal episodes which can occur due to pain, shock or startles?
Reflex asystolic syncope/reflex anoxic seizure:
Sudden unexpected pain or discomfort e.g. headbanging
Child becomes pale, hypotensive, loses consciousness
May have limb stiffening, clonic jerking, vagally mediated
Cyanotic breath holding
End expiratory apnoea following crying
Hyperekplexia:
Whole body stiffening in response to sudden noises, being touched or handled
Severe neonatal form can result in life threatening apnoea - forcible flexion of the neck can terminate it
What are examples of non-epileptic paroxysmal episodes which can occur due to boredom, tiredness, stress?
Self gratification behaviour: Self comforting Can occur in older children with a neurological disability Adducted, crossed legs Unresponsive to interruption
Tics:
Compulsive movements
Gestures
Occur in isolation, or may have vocal tics or Tourette’s
Daydreaming
What are examples of non-epileptic paroxysmal episodes which can occur due to excitement?
Shuddering spells
Excitement from toy or food - provokes shivering as if chilld
Benign
Cataplexy Strong emotion e.g. laughter provokes sudden loss of tone Temporary Brief sagging of the legs Associated with sleep-wake fragment
What are the types of primary headaches?
Migraine
Tension type headache
Cluster headache and other trigeminal autonomic cephalagias
other primary headaches
What are causes of secondary headaches?
Headaches due to an underlying pathology Head or neck trauma Intracranial haemorrhage Vascular malformation Substance or withdrawal Infection Disorder of homeostasis Psychiatric disorder
What are tension headaches?
Mild ache across forehead
Pain or pressure in band like pattern
Come on and resolve gradually
Children become quiet, stop playing, turn pale, tired
Resolve quicker
Triggers include stress, fear, discomfort Skipping meals dehydration infection
What is the management of tension headaches in children?
Reassurance
Analgesia
Regular meals
Avoid dehydration, stress
What are the types of migraine?
Migraine with aura Migraine without aura Silent migraine - migraine with aura but no headache Hemiplegic migraine Abdominal migraine
What is an abdominal migraine?
May occur in younger children before they develop traditional migraines
Episodes of central abdominal pain lasting more than one hour
Examination normal
May have associated N&V, anorexia, headache, pallor
In child with possible migraines, ask about history of recurrent central abdominal pain as a child
What may be the presentation of migraine?
Unilateral
More severe
Throbbing
Take longer to resolve
Associated with visual aura
Photophobia, phonophobia
Nausea and vomiting
Abdominal pain
What is the management of migraines in children?
Rest, fluids, low stimulus environment Paracetamol Ibuprofen Sumatriptan Antiemetics e.g. domperidone unless contraindicated
What are options for migraine prophylaxis?
Propranolol - but avoid in asthma
Pizotifen - causes drowsiness
Topiramate - girls with child bearing potential need good contraceptive as teratogenic
What are options for migraine prophylaxis?
Propranolol - but avoid in asthma
Pizotifen - causes drowsiness
Topiramate - girls with child bearing potential need good contraceptive as teratogenic
How can infections cause a headache in a child?
Sinusitis causes headaches with inflammation of ethmoidal, maxillary, frontal or sphenoidal sinuses
Viral URTI, otitis media, sinusitis, tonsillitis
How might a headache suggest a space occupying lesion?
Worse when lying down
Morning vomiting
Night time wakening
Change in mood, personality
Visual field defects Cranial nerve abnormalities Abducens often affected - squint with diplopia Abnormal gait Torticollis - tilting of head Growth failure Papilloedema - late feature Cranial bruits
