peds - neurology

gross motor and fine motor expectations

social skills and language expectations

symptoms of neurological issues in children

vomiting

headache

bowel/bladder dysfunctions

failure to meet developmental milestones

important family history to assess in children with suspected neurological issue

epilepsy

migraines

CVA

metabolic or degenerative disorders

anterior fontanelle should close by

12 to 18 months

posterior fontanelle should close by

2 months

craniotabes

softening of the cranial bones

- seen in prematurity

when auscultating during a neurological examination of a child, cranial bruits may be present over

anterior fontanelle

soft cranial bruits may be normal in

children less than 4 years old

children with loud cranial bruits should be suspected of having

AV malformation

increased ICP

severe anemia

horner's syndrome triad

ptosis, miosis, anhydriasis

horner's syndrome

damage to sympathetic trunk resulting in ipsilateral ptosis (sympathetics innervate superior tarsal muscle), anhydriasis of the ipsilateral face (sweating is sympathetic and muscarinic - M3) and ipsilateral miosis (sympathetics innervate radial fibers providing mydriasis)

papilledema

swelling of the optic disc, sign of increased cranial pressure

fundoscopic exam findings of increased cranial pressure

papilledema

constricted arterioles, dilated veins

retinal hemorrhages

macular star

innervations of the EOM

(LR6SO4)3

- lateral rectus = CN6 (abducens)

- superior oblique = CN4 (trochlear)

- all others = CN3 (oculomotor)

examination of the EOMs assesses what cranial nerves

3, 4, 6

clinical presentation of oculomotor paralysis

eye is displaced "down and out" with ptosis and mydriasis

- abduction and elevation

clinical presentation of trochlear paralysis

Up and out

(head slight turned away from lesion, eyeball displace up and out

diplopia when looking down and toward the nose

SO: depression and abduction, intorsion)

clinical presentation of abducens paralysis

medial deviation of the eye

- lateral rectus abducts the eye

nystagmus

involuntary, jerking movements of the eyes

horizontal nystagmus may be due to

labyrinth or vestibular injury

vertical nystagmus may be due to

brain stem injury

mydriasis may be seen in

sympathetic overactivity (hyperthyroidism, anxiety, etc)

miosis may be seen in

morphine poisoning (pinpoint pupils), neurosyphilis

pinpoint pupils

opioid overdose

unequal pupils may be seen in

oculomotor lesions, iritis

irregularly shaped pupils may be seen in

iritis

Argyll Robertson pupil

Neurosyphilis (tabes dorsalis)

- irregularly shaped pupils with absent pupillary light reflex and INTACT accommodation (called light-near dissociation)

light near dissociation occurs in

neurosyphilis

parinaud's syndrome (compression of pretectal nuclei in dorsal midbrain)

diabetes

pupils are fixed and dilated in

brain death

ways to assess trigeminal nerve function

jaw jerk

masster/pterygoid/temporalis strength

corneal blink reflex

corneal blink reflex

CN V feels the pain

CN VII closes the eyelid

facial nerve innervates

the superficial muscles of facial expression

nasolabial folds

anterior 2/3 of tongue to supply taste

taste to anterior 2/3 of tongue

facial nerve

isolated loss of CNVII seen in

bell's palsy

paralysis of the lower face on one side only suggests lesion to

contralateral facial nerve in corticobulbar tract (upper motor neuron lesion)

- muscles for the upper face have bilateral representation in the motor cortex

- lesion to an upper motor neuron for the facial nerve on one side would not damage UMN projections from the contralateral side

pt can wrinkle their forehead or furrow their brow, but unable to puff their cheeks or make facial expressions

paralysis of the upper and lower face on on side only suggests lesion of

ipsilateral facial nerve projections from the facial nucleus (LMN lesion)

bell's palsy

LMN CN VII palsy

ramsay hunt syndrome

occurs when VZV site of latency is the facial nerve near the ear

reactivation of latent infection results in herpes zoster of the ear (herpetic pinna) and bell's palsy

ocular complication of bell's palsy/ramsay hunt syndrome

exposure keratopathy (corneal ulcerations from being unable to close the eye fully)

ways to examine CN8

assess hearing function

assess vestibular function

how to assess vestibular function

caloric test

dolls head in comatose patient

caloric test

cold: simulates turning of the head in the opposite direction of the ear in which cold water was injected = ipsilateral slow phase with contralateral fast phase

- cold water in the left ear results in right beating nystagmus

warm: simulates turning of the head in the same direction of the ear in which warm water was injected = contralateral slow phase with ipsilateral fast phase

- warm water in the left ear results in left beating nystagmus

mnemonic: COWS (cold = opposite, warm = same)

hearing loss in children is associated with

prematurity

ototoxic drugs

hyperbilirubinemia

bacterial meningitis

TORCH infections

taste to posterior 1/3 of tongue

Glossopharyngeal (IX)

assessment of CNIX

taste to posterior 1/3 of tongue

gag reflex (provides sensory information to soft palate)

gag reflex assesses the function of

CNIX (in on 9) and CNX (out on 10)

- sensory fibers of CN9 innervate the soft palate and synapse in the nucleus ambiguus to trigger CNX LMN fibers to contract the levator palatini

- palate should elevate bilaterally, uvula should elevate on midline

palate deviation suggests

lesion to contralateral circuit (CNX innervates levator palatini)

CNX lesion could present with

palate deviation, vocal cord paralysis (recurrent laryngeal nerves are branches of vagus nerve)

how to assess CNXI function

SCM and trapezius

CNXI innervates

SCM and trapezius

how to assess CNXII function

tongue protrusion

- deviation suggests lesion on contralateral side (tongue deviates toward intact innervation)

gower's sign

when asked to get up from sitting on floor, child will move hands on legs as though crawling up to the thighs and then assume a standing position

gower's sign suggests

pelvic girdle/lumbar/proximal LE muscle weakness which may be due to DMD

clasp knife rigidity

in response to sudden passive stretch of a muscle, the antagonists will fire and contract to resist the stretch until stretch reaches a certain point at which the antagonist will no longer contract and the muscle will be suddenly stretch to full length, like opening or closing a clasp knife

abnormal response seen in UMN lesions

cogwheel rigidity

muscle tension that intermittently halts movement as an examiner attempts to manipulate a limb

seen in lesions of the basal ganglia (parkinson's)

scarf sign

exam for gestational maturity, resistance to attempt to bring one elbow farther than the midline of the chest

assesses the passive tone of the shoulder girdle flexors in a newborn

- in preterm infants, elbow may be able to cross midline before resistance is met

- in term infants with normal tone, the elbow should not be able to cross midline

opisthotonus

tightness in the entire body with the head back and an arched neck

- seen in tetanus, meningitis, hyperbilirubinemia

frog leg posture in infant

indicates hypotonia of the hip girdle muscles

Truncal ataxia, dysarthria. Where is the lesion?

cerebellar vermis (spinocerebellar system)

cerebellar signs

ataxia

- gait

- truncal

disdiadochokinesia

dysarthria

nystagmus

romberg's

romberg's sign

SENSORY ataxia

falling to one side while standing with eyes closed

- cerebellar sign

chorea

sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face

seen in huntington's (most common hereditary cause) and post-stroke in caudate/putamen strokes

spastic gait

a stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction; seen with cerebral palsy

also called scissor gait or tin solider gait

gait seen in hemiparesis

circumduction gait/waddling gait

where is LP performed

L4/L5

protein content of CSF in neonate

up 120 mg/dL

normal protein content of CSF

10-40mg/dL

normal glucose of CSF

60% of serum glucose

CSF characteristics of bacterial meningitis

- very high WBC

- Low to very low glucose

- Very high protein

- High opening pressure

normal RBC content of CSF

NONE (in an ideal draw)

in neonates, in addition to LP sampling, CSF may be drawn from

ventricles via the anterior fontanelle

- usually in treatment of hydrocephalus

normal lymphocyte content of CSF

0 to 5 lymphocytes per mm^3

NORMAL lymphocyte count in CSF in neonates may be as high as

15 lymphocytes per mm^3

myelography use

analyze spinal cord in suspected SC lesion

definition of seizure

paroxysmal, involuntary disturbance of brain function involving altered consciousness and motor activity

epilepsy

recurrent seizures unrelated to fever or brain insult

types of seizures

partial and generalized

types of partial seizures

simple and complex

which type of seizure is consciousness maintained

simple partial ONLY

partial seizures

focal, involve one lobe or one part of a lobe

simple partial seizure

Focal seizure in which consciousness is NOT impaired

- may be motor, sensory, autonomic

complex partial seizure

Focal seizure (at onset) in which consciousness IS impaired, either at onset or following a simple partial seizure

- MAY spread to become generalized (partial seizure with secondary generalization)

generalized seizures

diffuse/bilateral involvement with impaired consciousness

types of generalized seizures

absence, myoclonic, tonic-clonic, tonic, clonic, atonic, infantile spasms

absence seizures

May be seen in children who are accused of inattention in class and confused with ADHD

- child "turns off"

- generalized seizure involving loss of consciousness

up to 40% of childhood seizures are what type

partial

EEG of complex partial seizures

abnormal even in interictal phase

signs of complex partial seizure

preictal aura seen in 30% of patients

automatism seen in 50-70% of patients (lip smacking, chewing, rubbing, pulling, jerking, etc)

EEG in simple partial seizures

spikes and or waves

complex partial seizures often involve

temporal lobe

children with complex partial seizures should suspect of lesion to

temporal lobe

absence seizures in children may be mistaken for

ADHD (teacher may think child is unable to pay attention and dozes off)

unique findings of absence seizures

NO aura and NO postictal phase

- almost like child just reboots randomly

absence seizures are unusual in children under

5 years old

in a child with history of absence seizures, these seizures may be induced with

hyperventillation

EEG of absence seizures

3 Hz spike and wave (3 per second) - important

generalized tonic clonic seizure

preictal aura, tonic-clonic activity, postictal phase

tonic seizure

Muscle stiffness, rigidity, usually bilateral extension = arching of back

clonic seizure

repetitive jerking movements