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Flashcards in Paediatric Neurology Deck (33):
1

How should we approach the neurological history in childhood? 

  • History taking: interactive
  • Hear what was said, not what you thought was said
  • Avoid quasi-medical language
  • Time course of symptoms crucial
  • Distinguishing static from slowly progressive symptoms can be challenging

2

How does one carry out the neurological examination in childhood? 

  • Opportunistic approach and observation skills
  • Appearance
  • Gait
  • Head size
  • Skin findings
  • Real world examination (depends on age)

3

List some common paeds neurology and their epidemiology:

  • Migraine 7.7% of children 10-17
  • Traumatic Brain Injury: 180-300/ 100,000 children
  • Tourette syndrome: 1% of all children with high frequency in ADHD and OCD
  • Epilepsy: 0.7% of all children, 1/3 will have intractable epilepsy
  • Brain tumours: second most common cancer in children

4

What are different types of headache patterns in paeds?

Which ones are more concerning 

  • Isolated acute
  • Recurrent acute
  • Chronic progressive
  • Chronic non-progressive

5

What headache questions do we need to ascertain? 

  • Any warning?
  • Location?
  • Severity?
  • Duration?
  • Frequency?

6

What are elements of headaches examination? 

  • Growth parameters, OFC, BP
  • Sinuses, teeth, visual acuity
  • Fundoscopy
  • Visual fields (craniopharyngioma)
  • Cranial bruit
  • Focal neurological signs
  • Cognitive and emotional status

7

Childhood migraine: SSx? 

  • Associated abdominal pain, nausea, vomiting
  • Focal symptoms/ signs before, during, after attack: Visual disturbance, paresthesia, weakness
  • ‘Pallor’
  • Aggravated by bright light/ noise
  • Relation to fatigue/ stress
  • Helped by sleep/ rest/ dark, quiet room
  • Family history often positive

8

Tension headache: SSx? 

  • Diffuse, symmetrical
  • Band-like distribution
  • Present most of the time (but there may be symptom free periods)
  • “Constant ache"

9

List the main differences between tension and migraine: 

write down and use previous to slides to compare

10

What would suggest raised ICP? 

  • Aggravated by activities that raise ICP eg. Coughing, straining at stool, bending
  • Woken from sleep with headache

11

What would suggest analgesic overuse headache? 

  • Headache is back before allowed to use another dose
  • Paracetamol/ NSAIDs
  • Particular problem with compound analgesics eg. Cocodamol

12

What are some indications for neuroimaging? 

  • Features of cerebellar dysfunction
  • Features of raised intracranial pressure
  • New focal neurological deficit eg. new squint
  • Seizures, esp focal
  • Personality change
  • Unexplained deterioration of school work

13

Rx for migraine? 

  • Acute attack: effective pian relief, triptans
  • Preventative (at least 1/week):
    • Pizotifen, Propranolol, Amitryptyline, Topiramate, Valproate

14

Rx for tension type headache (TTH)? 

  • Aim at reassurance: no sinister cause
  • Multidisciplinary management
  • Attention to underlying chronic physical, psychological or emotional problems
  • Acute attacks: simple analgesia
  • Prevention: Amitryptiline
  • Discourage analgesics in chronic TTH

15

What comes under bracket of paroxysmal disorders? 

Fits, Faints and Funny-turns

16

What is a convulsion? 

Seizure where there is prominent motor activity

17

What is epilepsy

A tendency to recurrent, unprovoked (spontaneous) epileptic seizures

18

What is an epileptic seizure

An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons

19

How can we Dx epilepsy

clinically, with recourse to EEG only for supportive evidence

20

DDx for non-epileptic seizures and other mimics in children? 

  • Acute symptomatic seizures: due to acute insults eg. Hypoxia-ischaemia, hypoglycemia, infection, trauma
  • Reflex anoxic seizure: common in toddlers
  • Syncope
  • Parasomnias eg. night terrors
  • Behavioural stereotypies
  • Psychogenic seizures (NEAD)

21

What is febrile convulsion?? 

  • Event occurring in infancy/ childhood, usually between 3 months and 5 years of age, associated with fever but without evidence of intracranial infection or defined cause for the seizure
  • Commonest cause of ‘acute symptomatic seizure’ in childhood

22

What are the 4 different seizure types?

  • Jerk/ shake: clonic, myoclonic, spasms
  • Stiff: usually a tonic seizure
  • Fall: Atonic/ tonic/ myoclonic
  • Vacant attack: absence, complex partial seizure

23

Pathophysiology of epileptic fit? 

  • Chemical stimulation produces an electrical current
  • Summation of a multitude of electrical potentials results in depolarization of many neurons which can lead to seizures

24

What is an epileptic seizure that only affects a small area of brain vs one that affects whole brain? 

25

What are the differences between childhood and adult onset epilepsies? 

  • Majority are idiopathic in origin (both Focal & Generalised)
  • Majority of epilepsies are generalised
  • Seizures can be subtle (absences, myoclonus, drop attacks)

26

What questions should we ask ourselves to diagnose epilepsy? 

  • Is the paroxysmal event epileptic in nature?
  • Is it epilepsy?
  • What seizure types are occurring?
  • What is the epilepsy syndrome?
  • What is the etiology?
  • What are the social and educational effects on the child?

27

What is the role of the EEG? 

  • An interictal EEG has limited value in deciding when the individual has epilepsy
  • Useful in identifying seizure types, seizure syndrome and etiology

28

Dx procedure for epilepsy?

  • History
  • Video recording of event
  • ECG in convulsive seizures
  • Interictal/ ictal EEG
  • MRI Brain: to determine etiology eg. Brain malformations/ brain damage
  • Genetics: idiopathic epilepsies are mostly familial; also single gene disorders eg. Tuberous sclerosis
  • Metabolic tests: esp if associated with developmental delay/ regression

29

When do we start Mx for epilepsy? 

  • Only be considered if diagnosis is clear even if this means delaying treatment
  • Role of drugs is to control seizures not stop epilepsy 

30

What is Rx for epilepsy

  • Sodium Valproate: first line for generalised epilepsies (not in girls- recent MHRA advice)
  • Carbamazepine: first line for focal epilepsies

31

When would we suspect NM disorder? 

  • Baby ‘floppy’ from birth
  • Slips from hands
  • Paucity of limb movements
  • Alert, but less motor activity
  • Delayed motor milestones
  • Able to walk but frequent falls

32

Anatomical approach:

If affecting muscle: DDx?

If affecting neuromuscular junction: DDx?

If affecting nerve: DDx?

If affecting anterior horn cells: DDx? 

  • Muscle: muscular dystrophies, myopathies- congenital and inflammatory, myotonic syndromes
  • Neuromuscular junction: myasthenic syndromes
  • Nerve: Hereditary or acquired neuropathies
  • Anterior Horn Cell: Spinal muscular atrophy

33

What is Duchenne muscular dystrophy?

  • Xp21, dystrophin gene, 1/3500 male infants
  • Delayed gross motor skills
  • Symmetrical proximal weakness
    •  Waddling gait, calf hypertrophy
    •  Gower’s sign positive
  • Elevated Creatinine Kinase levels
    •  >1000 in DMD
  • Cardiomyopathy
  • Respiratory involvement in teens