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Pediatric Neurology Flashcards

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1
Q

Amblyopia

A

Decrease in visual acuity that occurs as a result of a lack of clear image on the retina
- can be unilateral (more common) or bilateral (less common)

Can’t be immediately corrected with glasses of surgery

  • instead they wear a patch over their good eye to force the bad eye to work and get better
  • can also where lens that blur that good eye

Age 6 years -8yrs is the highest likelihood
- 2-4% of North American population

Caused by anything that interferes with formation of a clear retinal image usually during the critical period of development before the cortex has become visually mature

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2
Q

What 3 abnormal visual experiences results in unilateral amblyopia

A

Strabismus
- eyes dont look in the same direction at the same time (crossed eyes)

Anisometropia
- unequal refractive errors

Monocular visual deprivation
- cataracts, corneal opacity, hemangioma, severe ptosis

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3
Q

Secondary results of amblyopia

A

Deviated eye

Unequal need for vision correction

A high refractive error in both eyes

Media opacity on the visual axis

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4
Q

Diagnosis of amblyopia

A

Kinda challenging

For preverbal children
- differences between eyes in fixation and following/preference can be diagnostic (but not 100%)

Automated photo-screeners are now gold standard

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5
Q

What abnormalities can a photo screener detect

A

Myopia

Hyperopia

Astigmatism

Anisometropia

Strabismus

Anisocoria

Amblyopia

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6
Q

Strabismus

A

Eyes are not aligned properly

  • bad eye can look inward/outward/upward/downward
  • eye that is misaligned can change or stay the same.

Leading cause of amblyopia

Can be convergent (esotropia) or divergent (exotropia) if horizontal

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7
Q

Pseudostrabismus

A

At a young age epicanthic folds in the inner eyelids of children can make it appear a child is cross eyed.

  • due to having a wide flat nose
  • pupil light reflex will be normal
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8
Q

Periorbital cellulites

A

Common in patients younger than 5 and have a decent history of upper respiratory tract infections

Possible Complication of sinusitis
- if this is the case, ethmoid and/or maxillary sinuses are affected

Must make sure the cellulitis is confined to the tissues outside the orbit only. (If inside orbit is worse orbital cellulitis)

  • ask if moving the eye under the swollen eyelid is possible and does it hurt if it can be moved
  • no movement or painful movement = orbital cellulitis
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9
Q

Symptoms of periorbital cellulitis

A

Sudden appearance of lid and periorbital swelling
- usually unilateral, indurated and tender to touch

Can show conjunctival injection and discharge

Often shows fever and uncomfortable patient (dont apper toxic or sick though)

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10
Q

Etiologies of periorbital cellulitis

A

50% idiopathic, 50% sinutis or bacteremia predisposed

Can also be caused by trauma to the orbit or via the following infections

  • impetigo
  • pustules
  • chalazions
  • infected dermatitis
  • specific insect bites

Generally in patients older than 5 yrs

  • the two most predominant pathogens associated are S. Aureus and GAS
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11
Q

Diagnosis of periorbital cellulitis

A

Requires a lot of cultures
- can be done via careful needle aspiration but is challenging

Nasopharyngeal and conjunctival drainage can have the affecting organism in 1/2-2/3 of cases

Blood cultures are positive in 1/3 or cases

CT scan is required if you cant tell if it’s periorbital or orbital As well as to show if any sinuses are compromised

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12
Q

Treatment for periorbital cellulitis

A

Broad spectrum empiric IV antimicrobial therapies

*must monitor for signs of complications

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13
Q

Orbital cellulitis

A

Worsened periorbital cellulitis (or develops on its own)
- often presents with subperiosteal abscesses which limits upward eye movement (or painful movement)

Possesses the following triad of symptoms:

  • proptosis (bulging of eyes
  • painful limitation of eye movement
  • decreased visual acuity

Increased chance of occurring in the winter as complicated sinusitis and also often follows respiratory viral infections
- being male also increases risk and mean age is 7yrs old

Requires CT to determine if any sinusitis is present
- most commonly compromised is the paranasla (ethmoid) sinusitis

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14
Q

How does the clinical presentation of orbital cellulitis differ from periorbital cellulitis?

A

Orbital cellulitis patients feel ill and are febrile toxic apperance

Periorbital only shows a fever, but does look toxic

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15
Q

When should you worry about intracranial hematogenous spread of orbital sinusitis?

A

Patient has any of the following symptoms

  • headache
  • vomiting
  • focal neurologic findings
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16
Q

Complications of orbital cellulitis

A

Visual loss Due to increase intraocular pressure

Cavernous sinus thrombosis

Meningitis

Epidural or Subdural empyema

Optic atrophy

Retinal or choroid always ischemia

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17
Q

Treatment of orbital cellulitis

A

CT image is required

Lumbar puncture only if suspect meningitis as secondary complication

Systemic antibiotic therapy with broad spectrum is needed

  • ampicillin/sulbactam
  • IV clindamycin/ceftriaxone
  • cefepime

Give the vancomycin/cefotaxime/metronidazole combo therapy only if you suspect intracranial extension

  • use sinus drainage directly if antibiotics dont work*
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18
Q

Potts puffy tumor

A

Erosion of the frontal bone causes subperiosteal abscesses

Caused usually by untreated frontal sinusitis

Is red, swelling and dough consistency that has serious tenderness

Patients look toxic, febrile and uncomfortable

Must get a CT scan to ensure it has not leaked into the brain and other areas.

Once confirmed by CT, start surgical drainage and IV antimicrobial long-term therapy for the preceding osteomyelitis

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19
Q

What are the 3 most common causes of headaches in children that are not febrile?

A

Migraines

Tension headaches

Cerebellar tumors

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20
Q

Migraines in children

A

Most common cause of acute and recurrent headaches

Multiple triggers can cause it

Usually thought to be a cause of primary neuronal dysfunction (still idiopathic etiology for now)

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21
Q

Red flags for migraines in kids

A

Vomiting
- check for increased intracranial pressure (especially if the vomiting is daily and in the early morning)

Headaches that wake up the child from sleep
- pituitary tumor with increased intracranial pressure needs to be ruled out

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22
Q

Specific red flag for brain tumor in children

A

Vomiting and headache that is frequently present once waking up and goes away with maintenance of upright posture
- increased intracranial pressure is present and almost always caused by brain tumor in this case

  • if the child stands up once awakening and the headache/vomiting gets worse, this is a migraine instead of a tumor
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23
Q

Treatment of migraines

A

NSAIDS (not aspirin) and lifestyle is the gold standard of therapy
- almost always ibuprofen

can’t use triptans/ergots in kids (only in people 13 and above)

  • can use BBs if needed
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24
Q

Brain tumors in pediatric patients

A

Primary CNS tumors are most common type of brain tumor
- 20% of all childhood cancer

2nd most common cancer type in children

  • male and <20 yrs old
  • infratentorial location is most common in children 1-15 yrs

Mortality = 30%

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25
What is most common site and types of brain tumors in children?
Site = infratentorially (50%) - includes brainstem/cerebellum and 4th ventricle Malignant = medulloblastoma Benign = glioma
26
Clinical presentation for brain tumors
Usually doesnt start until Increased intracranial pressure is noted (usually caused by obstruction fo CSF) - most common locations are 4th ventricle/posterior fossa/pineal gland. Symptoms - headaches in the morning (get better once you start moving) - nausea/vomiting/fatigue - 6th cranial nerve palsy - papilledema - tense fontanelle/failure to thrive - developmental delay - paresis of upwards gaze (“sun setting” gaze is this with downward eye deviation)
27
Classic presenting symptoms for astrocytoma in the cerebellum in pediatric populations
Presents with: - ataxia - wide gait w/ falling tendencies - headache and vomiting
28
Classic presenting symptoms for brain glioma in the brainstem in pediatric populations
Presents with - 6th/7th nerve palsy - contralateral limb weakness - headache - nausea/vomiting
29
\What is the classic triad of symptoms for all midline or infratentorial tumors in pediatric patients
Headache (morning always) Nausea Vomiting *papilledema is also very common but isn’t included technically*
30
What classic symptoms are generally associated with infratentorial tumors
Blurred vision Diplopia Nystagmus *also torticollis (static head tilting) ONLY if cerebellar tonsil herniation occurs*
31
Evaluation and management for brain tumors
CT is almost always 1st (95% sensitive) - looks for calcifications in tumors, hydrocephalus and hemorrhages MRI is then next to confirm tumor (100% sensitive) Then refer to a tertiary hospital for neurosurgery and oncology
32
Common pediatric tumors and their general survival rates
Cerebrum Glioma - best rates of survival (60-100%) Medulloblastoma (PNET) - 2nd best rates of survival (33-85%) Ependyomas - 3rd best rates of survival (22-80%) Brain steam glioma - wide range of outcomes - pontine tumors = 9-13 months to live (0% to live) - localized = 80-90% chance of survival Malignant glioma - low survival rates (25%)
33
Do you use radiation in kids?
Usually no unless last resort Causes increased toxicity and neuro cognitive defects as well as stunts growth
34
Supportive care in treatment for brain cancers
Hormonal replacement for neuroendocrine dysfunction Antiepileptic drugs for seizure disorders Physical/occupational/speech therapies
35
What is generally considered the most common type of seizures for kids?
Febrile seizures - occurs 2-5% of kids - is classified only if no intracranial infection/metabolic disturbance/traumatic cause or history of afebrile seizures is present. Risk factors: - high fever >104F (40C) - developmental delay - family history of febrile seizures Treatment: - prognosis is excellent w/ no cognitive impairment - doesnt need work up as long as you can diagnosis a febrile illness as the cause
36
Two types of febrile seizures
Simple - short seizure (<15 min) - returns to baseline mental status within 1 hour - less dangerous Complex - prolonged seizure (>15 min) - either doesn’t return to baseline within 1 hr or has recurrent seizures within 24 hrs of 1st seizure - dangerous
37
Common causes for febrile seizures
Exudative pharyngitis Ottis media Pneumonia Rashes associated with viral syndromes Meningitis
38
Do you do lumbar punctuates on kids for febrile seizures?
Usually not as long as they are immunized * also aggressive use of acetaminophen and ibuprofen does not lower risk of febrile seizures
39
Botulism in children
Common in breast fed infants who have constipation - also most common in children 3weeks- 6 months of age Common sources are: - honey - soil - dust - corn syrup Common states for botulism in children - Hawaii - Utah - California - Pennsylvania Symptoms - NO FEVER - consitpation - poor feeding - weak cry - autonomic dysfunction s - *respiratory arrest is possible (so dangerous)
40
How to diagnosis infant botulism
Isolation of C. Botulinum in stool - gold standard but takes forever Clincial history and physical tests can be enough as well because of the length to confirm for botulism - “rag doll”/“floppy baby” infants is a gold standard sign
41
Treatment of botulism in infants
Call infant botulism treatment program Give baby IV botulism immune globulin (babyBIG) immediately - save money and time in the hospital * dont give Aminoglycosides antibiotics (makes is worse*
42
Shaken baby syndrome | Abusive head trauma
Combination of brain injury and hemorrhages as a result of shaking an infant severely 10% of all cases of child abuse Most common finding is retinal hemorrhages Mortality rate = 25%
43
What physical symptoms are certain evidence for child abuse
Avulsion of the optic nerve or vitreous base Retinal brushes Orbital bone fractures Corneal or sclera lacerations Sub conjunctival hemorrhage (technically not always but like 90%)
44
Tourette disorder diagnosis criteria
1) both multiple moron and one or more multiple vocal tics are present at some time (doesnt have to be concurrent) 2) must last for more than 1 yr from onset 3) onset must be before age 18yr 4) disturbance is not attributable to physiologic effects of a substance or other medical condition
45
Chronic tic diagnostic criteria
1) single or multiple motor OR vocal tics must be present (NOT BOTH) 2) must have persisted > 1 yr from onset - < 1 yr is a provisional tic 3) onset must be before 18 yrs 4) disturbance is not attributable to substances or physiologic effects/medical conditions 5) criteria for Tourette’s has never been met
46
Echopraxia
A type of complex motor tic where a child imitates someone else’s movements without wanting to
47
Copropraxia
A type of complex motor tic where a child makes a sexual or obscene gesture unwantingly
48
Difference between stereotypies and tics
Stereotypies resemble tics but are rhythmic movements and do not demonstrate change in body locations or movement type over time - tics usually changes types over time
49
Pathophysiology of tics
Dysfunction in the corticostriatal-thalamocortical motor pathways Also associated with dopamine, serotonin an NE neurotransmitter systems Is male predominant Onset is 4-6 yrs Peak severity is 10-12 yrs Marked severity in 18-20 yrs Almost never worsens into adulthood
50
Treatment for Tourette’s syndrome and tics
Based on severity - mild tics are not treated usually Need HRT therapy if treating Medications: - haloperidol and primozide - aripiprazole - Clonidine and guanfacine (1st line agents)
51
Partial arousal parasominas (sleepwalking, night terrors and confusional arousals)
More common in school age children - occur during the 1st 3rd of the night (nightmares in the last 3rd) Appears to be a genetic component for sleepwalking and night terrors Scheduled awakenings are the most helpful intervention (wake the child up 15-30 minutes before the normal scheduled event) *if using pharmacotherapy (which is almost never done) use benzos or tricyclic antidepressants*
52
Chorea | Sydenham chorea
“Dance-like” chaotic movements that seem to flow from 1 body part to another - increases exponentially with stress and disappears in sleep Caused by a recent GAS infection (usually acute rheumatic fever) - the cross-reactive antibodies affect cerebellar and basal ganglia functions Risk factors: - family history for chorea or rheumatic fever - being a girl - ages 5-15 - gets GAS/rheumatic fever *clinical hallmarks are chorea with hypotonia and emotional lability
53
Treatment of Sydenham chorea
Diagnosis requires antistreptolysin titers and evaluation for carditis (negative results for both does NOT exclude diagnosis, but can confirm) Treatment = long term antibiotic prophylaxis (penicillin G IM admission every 4 weeks or penicillin V PO admission 2x daily) until the chorea dissolves on its own
54
Guillain-Barré syndrome in pediatrics (GBS)
Post-infections polyneuropathy Usually only affects motor tracts (but can do autonomic nerves also Causes: (usually GI and respiratory infections) - campylobacter jejuni - helicobacter pylori - mycoplasma pneumonia - Zika and haemophilus influenza - CMV - mononucleosis - Lyme disease - listeria Common children specific clincial symptoms: - very irritable - refuses to walk - flaccid tetrapolegia (late stage only) * can affect bulbar muscles which initiates respiratory failure if not treated
55
What vaccines can cause GBS?
Rabies Influenza Meningococcal (especially serogroup C) *note these are ultra rare side effects as long as the patient has a normal immune system
56
What virus can mimic GBS?
West Nile virus
57
Sturge-Weber syndrome (SWS)
Patients that have a facial capillary malformation with buphthalmos (port wine stain) and appear to have epilepsy - generates excessive blood vessel growth Caused by a GNAQ gene mutation Other symptoms: - seizures (opposite side of port wine stain) - TIA-like symptoms - headaches - intellectual disabilities - hemiparesis (opposite side of port wine stain) - glaucoma
58
Diagnosis for SWS
MRI w/ contrast of brain - shows extension of leptomeningeal capillary malformations - shows white matter abnormalities - shows cerebrum atrophy ipsilateral to the port wine stain - choroid plexus is usually enlarged
59
Cerebral palsy (CP)
Group of nervous system disorders that cause abnormal movements, body positions and poor balance Symptoms are often present at both and are born with the condition (not inherited throughout life) Motor defect is ALWAYS present - no loss of function, just doesnt develop Treatment is the symptoms that develop, there is no cure
60
When should genetic and metabolic testing be conducted for cerebral palsy children?
1) evidence of determination or episodes of metabolic decompensation 2) neuro imaging results in no etiology 3) family history of a childhood disorder associated with CP 4) a developmental malformation on neuroimaging is noted (especially if a stroke looks prominent)
61
What is the most common type of CP?
Spastic cerebral palsy Shows mild-severe spastic movement symptoms - can affect legs/arms or the whole body - * symptoms do not get worse
62
Diskinetic CP
A type of CP which causes uncontrolled movements most commonly in the entire body (especially tongue and face)
63
Ataxic CP
Affects balance and coordination of movements (usually in the arm and hand)
64
Common causes of CP
* note this doesn’t include all causes* Reduced blood/oxygen supply at birth or in the womb A brain infection at birth Brain trauma High levels of bilirubin at birth or before 5 yrs Abnormal development of the brain
65
Risk factors for CP
Premature births/ low birth weight Mother has had multiple births Conceived through infertility treatments Mother has a viral or bacterial infection during pregnancy Severe jaundice Complicated births Did not get routine vaccinations

Neurology (65 decks)

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