Flashcards in Neurology Deck (70):
Describe a focused pediatric neuro exam
1. Coordination/ gait
2. Pupillary response, extra-ocular movements
4. Fundoscopic-- ICP (unreliable in kids)
7. Balancing, hopping, heel-to-toe gait
8. Deep tendon reflexes
*listed in descending order of where you are more likely to find the neurological deficit in the event that a brain lesion exists, with changes in gait and coordination occurring in 42-78% of patients with brain tumors, followed by deficits in CN 2, 3, 4, and 6.
Fortunately, children with brain tumors will develop a focal neurological deficit within ___ of the onset of their ___ symptoms
*Seizures may or may not occur, depending on the specific lesion
Describe where brain lesions are most likely to exist
changes in gait and coordination occurring in 42-78% of patients with brain tumors, followed by deficits in CN 2, 3, 4, and 6.
While most children ____ y/o can cooperate with the instructions for the fundoscopic exam, if you are really entertaining the possibility of ICP, they should have a dilated fundoscopic exam by an ophthalmologist.
4y/o and older
Hx questions for pediatric seizures
1. Alteration in awareness/consciousness*
3. Witnessed movements/video
4. Length of episode
5. Association with fever, illness, trauma-- provoked?
7. Post-ictal state
8. Previous episodes
9. FHx of seizures
10. Adolescent- EtOH, drugs, sleep deprivation
__ and __ are very suggestive of a true seizure
incontinence and post-ictal state
In adolescents it is important to ask about __, __ and ___, as all of these are implicated both in breakthrough seizures in those patients who have a true seizure disorder, but __ and ___ can also cause a provoked seizure in a non-epileptic patient.
alcohol, drugs and sleep deprivation
alcohol and drugs
Describe the presentation of infantile spasms
1. peak age 4-7 months
2. exaggerated moro-like movements
Describe the presentation of febrile seizures
1. 6 mo-5 years
2. General tonic-clonic movement
3. Complex febrile seizure
Describe the presentation of absence seizure
1. 3-15 years
2. 3-10s lapses in awareness, often many per day
3. No post-ictal state
4. Classic EEG of 3Hz spike/wave pattern
Describe the presentation of simple or complex partial seizures
1. Any age
2. Complex: Focal start, progressing to generalized seizure
3. Simple: consciousness not altered initially
Describe the presentation of Benign Rolandic epilepsy
1. 5-15 years, remits in puberty
2. Focal motor seizure involving face, hand
3. Usually during sleep or upon awakening
4. Classic EEG pattern of central temporal spikes, no imaging or treatment usually needed
describe the prognosis for infantile spasms
Infantile spasms do not have a particular favorable prognosis, so they are important not to miss, delaying treatment.
complex febrile seizure is defined as
more than 1 febrile seizure occurring within 24 hours, febrile seizures lasting longer than 15 minutes or that have focal features.
The difference between simple and complex partial seizures is
the intact awareness in patients with simple partial seizures.
This type of seizure is particularly concerning for the possibility of a brain lesion as the focality of motor activity indicates a specific area of the brain is emitting the aberrant electrical activity.
complex febrile seizure
What does the EEG pattern look like for Benign Rolandic Epilepsy
-central temporal spikes,
*no imaging or treatment usually needed
What does the EEG pattern look like for absence seizures
3Hz spike/wave pattern
Describe acute management for febrile seizures
1. safety measures to ensure that they do not hurt themselves
3. Occasionally, if a child is still seizing after 5 minutes, it may be necessary to contact 911.
4. If the office has supplies, it is possible to use rectal diazepam and attempt IV access.
-The patient who require 911 will likely continue their evaluation in the ED.
-For the patients who are able to remain in your office because their seizure stopped spontaneously after a few minutes, which is 99% of them, you will need to proceed through the evaluation for fever.
Keep in mind that children < 1 y/o or unimmunized should have a ___ if they have had a seizure.
For children <6m, you should consider ____, and these children should probably be evaluated in the ED.
an electrolyte panel
The only additional consideration in a child >12m is a ____, if anything about the history suggests access to pain medications, sleeping pills, or their post-ictal phase seems prolonged.
urine toxicology screen
Therefore, most children ___ are evaluated for their seizure and fever in the ED.
Returning then to the PCP role of follow-up after a febrile seizure, the role is really ___
patient education-- helping parents understand febrile seizures and prevent these kids from getting frequent ambulance rides to the ED
The risk of recurrent febrile seizure is ___
Risk factors for recurrent febrile seizure
1. FHx of febrile sz
2. age <18 months
3. febrile seizure threshold
4. duration of fever prior to sz
How do febrile sz effect brain fxn
Febrile sz do not cause brain damage
___ won’t prevent a febrile seizure
For children who have recurrent febrile seizures, it is possible to prescribe ___ so that parents feel they have some way to stop a febrile seizure
What patient education should you give about management of febrile seizures
1. place their seizing child in a place where they cannot injure themselves,
2. do not try to restrain them,
3. time the seizure and if it reaches 5 minutes, call 911.
4. Otherwise, when the seizure ends, take and document the fever, give an anti-pyretic and have the child evaluated with a few hours at the clinic or ED for the cause of the fever.
Risk factors for later epilepsy w/ febrile sz
1. FH- epilepsy,
2. neurodevelopmental abnormality,
3. complex febrile sz,
4. duration of fever prior to sz
Describe the ED management of 1st non-febrile seizures
focuses on ruling out a provoked seizure*
1. labs: CBC, electrolyte panel,
2. possibly an LP or
3. a CT scan of the head (looking for ICP, head trauma, lesions or bleeds)
4. f/u w/ PCP for w/u of possible epilepsy
Non-febrile or unprovoked seizures will likely require __-
an MRI to look for intracranial pathology.
*CT’s are not a good modality for looking for small tumors, which is why an MRI is superior.
PCP w/u of non-febrile seizure
1. careful history and neuro exam
2. MRI for intracranial pathology
3. order EEG w/in 2 weeks-- ask the protocol of the EEG lab that you clinic utilizes. Sometimes, they require that you provide the patient with a prescription for sedatives that the parent fills before the appointment and they will administer when the child arrives
**No anti-epileptics-- leave for neurologist
4. A referral to the neurologist should occur if the EEG or MRI are abnormal, the neuro exam is abnormal, or if the history is concerning
For children <4y, who will later be determined to have epilepsy, __% of their initial EEG’s are negative.
*Further seizures will then send them back for another EEG, increasing the likelihood of seeing pathology on the EEG
1. no swimming w/o a buddy
2. no scuba diving
3. no activities involving heights where a fall could result in serious injury.
4. Laws about driving differ by state, but generally, patients need to be seizure-free for 6 months with or w/o meds in order to be able to drive (CO does not have this law nor a mandatory reporting protocol for patients with seizures)
Concerning sz hx
2. past hx of cranial radiation,
3. focal seizures,
4. recurrent seizures, or
5. the child has a baseline neurologic impairment, such as a child with cerebral palsy where it may be difficult to determine if they may have a new focal deficit in their neurologic exam.
*refer these kids to neurology
When do you refer a kid to neurology for a sz?
1. abnormal EEG
2. abnormal MRI
3. abnormal neuro exam
4. concerning hx
1. Infantile shuddering
2. Benign nocturnal myoclonus
3. Sandifer's syndrome
4. Breath-holding spells
6. Psychogenic seizure
Presentation of Infantile shuddering
1. has a rhythmicity to the extremity movement, which can look somewhat seizure like.
2. Occurs with eating, excitement
3. Appears to shiver with decrease in awareness, occurs in clusters
4. No post-ictal state
What instructions should you give for infantile shuddering
Instruct the parents to apply gentle pressure to the extremity the next time they note it. If pressure causes the movement to stop, the diagnosis of shuddering is confirmed. Pressure also stops myoclonic jerks in infants.
Presentation of Sandifer's syndrome
1. can look oddly like a focal seizure, and because it is usually in very young infants, it is difficult to ascertain their level of awareness.
2. It is caused by the pain of gastroesophageal reflux
3. unusual head, neck, trunk movement
4. no change in awareness
Describe the presentation of breath-holding spells
1. 6months- 3y/o
2. always precipitated by fright or trauma
3. followed by a syncopal episode, with eyes rolling back in their head and some jerking motions.
4. They will not have a post-ictal state
6. tonic-clonic movement,
Causes of syncope in kids
3. cardiac-- prolonged QT (requires stress EKG)
Presentation of syncope
1. More common in adolescents and females
2. Syncopal episode with possibly some clonic movements
3. Usually preceded by pallor,
4. no post-ictal state
Presentation of psychogenic seizures
1. psychiatric hx
3. clonic movement may be non-rhythmic or thrashing movement
4. adolescents and adults
5. rarely incontinent or post-ictal
Psychogenic sz often end up with __, __ and __ to r/o true epilepsy
3. neuro referral
Hx for pediatric headache
1. Age (<5)
2. Length of H/A episodes
3. Duration of H/A history
4. Location of pain
5. Timing of H/A
6. Character of pain
7. Recent changes in frequency, severity
8. Associated symptoms (Vomiting, phonophobia/photophobia, Viral symptoms)
9. Neurologic symptoms
10. FH- Migraine H/A
11. Hx of motion sickness
Red flags for pediatric HA
1. age <5y/o
2. Recent changes in frequency and/or severity are concerning for increased ICP or pathology
3. HA relieved by vomiting (ICP)
4. HA which awaken child at night
HA in < 5y is concerning for__, as this age group gets headaches infrequently unless it accompanies a viral illness.
, intracranial pathology is usually obvious by focal neurologic findings by ___ after the onset of h/a’s so these patients, if they have a normal neurologic exam, are reassuring
MC types of HA in children
1. Tension: bandlike pattern
2. Migraines: throbbing (not as unilateral as in adults and may have phonophobia and photobobia)
PE of pediatric HA
See neuro exam card, add skin exam for cafe au lait spots or axillary freckling
Skin Manifestations of Neurofibromatosis
1. Cafe Au Lait Spots (a few)
2. Axillary freckling
Neurofibromatosis patients have a risk for development of ___
optic gliomas, a usually benign brain tumor, which may manifest with h/a’s.
Indications for head CT for HA
1. new/acute vomiting
2. signs of ICP
*CT’s would almost exclusively be used in the ED
Indications for head MRI for HA
1. H/A’s younger than 5 y/o
2. New onset and Progressive H/A’s
3. Focal neurologic deficit
4. Nighttime or postural H/A
5. Neurofibromatosis lesions
6. Hemiplegic migraine (also include head and neck MRA)
*You might want to consider talking with the neurologist that your practice refers to, to discuss the case with them before ordering an MRI.
Occasionally, a patient with ___ will present with a.m. h/a’s from sleep and oxygen deprivation
General HA management
1. No opioids or excedrin (caffeine)
2. Sleep hygiene
3. Hydration- no caffeine
4. Diet with 3x/d protein
6. Stress Management (lie in a dark room, quiet for 20-30 min after school to destress)
7. Tech Control-- Encourage the parents to not have the TV, smart phone, I-Pod, computer available to them during rest time.
Tx of Tension HA
1. NSAID max 800mq q 8hrs
3. warm/cold pack
Tx of Migraine HA
3. Triptans, 12y/o+ and no more than 2-3x/week
DDX for chronic migraine HA
2. school avoidance
Chronic migraine management can be used if HA are occuring how often
what meds can be used for chronic migraine mangement
1. Cyproheptadine (Periactin)**
2. Topiramate (Topamax)
3. Amitryptaline (Elavil)
4. wean NSAIDs
How do you use Cyproheptadine (Periactin) for chronic migraines
1. <12y/o, not overweight
2. start 2mg QHS plan 6 month therapy
How do you use Topiramate (Topamax) for chronic migraines
1. Any age , higher BMI ok
2. Start 2.5mg QHS, increase q 2week to 25mg BID
How do you use Amitryptaline (Elavil) for chronic migraines
1. >12 y/o
2. No FH of sudden cardiac death
3. Start 10mg QHS, increase q 3 week to 1mg/kg QHS
Describe the basic approach of chronic migraine management
1. The basic approach is to titrate up until they are not having h/a’s and can discontinue their use of abortive NSAIDs.
2. They then continue on prophylaxis for 6 months and then taper off, to see if the h/a’s have resolved or decreased enough to return to abortive medications.
When do you refer to neurology for chronic migraines
1. Abnormal neurologic exam
2. All hemiplegic migraines (w/ transient gait abnormality)
3. Diagnostic uncertainty
4. Not responding to treatment as expected.