Ch.27: The Child With Cerebral Dysfunction (Clinical Manifestation)

Clinical manifestation of increased intracranial pressure in infant

• tense bulging fontanel

• separated cranial sutures

• Macewen (crack-pot) sign

• irritability and restlessness

• drowsiness

• increased sleeping

• high-pitched cry

• increased frontoocciptal circumference

• distended scalp veins

• poor feeding

• cyring when disturbed

• setting-sun sign

Clinical manifestation of increased intracranial pressure in children

• headache

• nausea

• forceful vomiting

• diplopia, blurred vision

• seizures

• indifference, drowsiness

• decline in school performance

• diminished physical activity and motor performance

• increased sleeping

• inability to follow simple commands

• lethargy

Clinical manifestation of increased intracranial pressure in infant and children late signs

• bradycardia

• decreased motor response to command

• decreased sensory response to painful stimuli

• alteration in pupil size and reactivity

• extension or flexion posturing cheyne-stokes respiration

• papilledema

• decreased consciousness

• coma

full consciousness

awake and alert, orientated to time, place, and person; behavior appropriate for age

confusion

impaired decision-making

disorientation

confusion regarding time, place, and/or person; decreased level of consciousness

lethargy

limited spontaneous movement; sluggish speech, drowsiness

obtundation

arousable with stimulation

stupor

remaining in a deep sleep, responsive only to vigorous and repeated stimulation

coma

no motor or verbal response to noxious (pain) stimuli

persistent vegetative state (PVS)

permanently lost function of the cerebral cortex

lumbar puncture (LP)

spinal needle is inserted between L3 and L4 or L4 and L5 vertebral spaces into subarachnoid space

• measures spinal fluid pressure

• obtains CSG for laboratory analysis

• injection of medication

subdural tap

needle is inserted into anterior fontanel or coronal suture (midline to pupil)

• help rule out subdural effusions

• removes CSF to relieve pressure

ventricular puncture

needle is inserted into lateral ventricular via coronal suture (midline to pupil)

• remove CSG to relieve pressure

electroencephalography (EEG)

records changes in electrical potential of the brain

• detects spikes, or bursts of electrical activity, that indicate the potential for seizures

• used to determine brain death

nuclear brain scan

radioisotope is injected intravenously, then counted and recorded after fixed time intervals and accumulates in areas where blood-brain barrier is defective

• identifies focal brain lesions (tumors, abscesses)

• positive uptake of material with encephalitis and subdural hematoma

• visualized CSF

Endocephalography

pulses of ultrasonic waves are beamed through head; echoes form reflecting surfaces are recored graphically

• identifies shifts in midline structures from their mormal positions as a result of intracranial lesions

• may show ventricular dilation

real-time ultrasonography (RTUS)

RTUS is similar to CT but uses ultrasound instead of ionizing radiation

• allows high-resolution anatomic visualization in variety of imaging planes

radiography

skull films are taken from different views (lateral, posterolateral, axial [submentoventricular], and half-axis )

• shows fracture, dislocations, spreading suture lines, craniostenosis

• shows degenerative changes, bone erosion, calcification

CT

pinpointt x-ray beam is directed on horiztonal or vertical plae to provide series of image that are fed into computer and assembled in image displayed on video screen

• visualized horizontal and vertical cross-section of brain in three planes (axial, coronal, sagittal)

• distinguishes density of various intracranial abnormalities, hemorrhage, tumors, demyelinating and inflammatory processes, calcification

MRI

produces radiofrequency emission from elements (e.g. hydrogen, phosphorus) which are converted to visual images by computer

• permits visualization of morphologic features of target structures

• permits tissue discrimination unavailable with many techniques

Positron emission tomogrpahy (PET)

involves IV injection of positron-emitting radinucleotide; local concentrations of detected and transformed into visual display by computer

• dtects and measures blood volume and floe in brain, metabolic activity, biochemical changes within tissue

digital subtraction angiography (DSA)

contrast dye is injected intravenously; computer “subtract” all tissues without contrast medium; leaving clear image of contrast medium in vessels studied

• visualizes vasculature of target tissues

• visualized finite vascular abnormalities

single-photon emission computed tomography (SPECT)

involves IV injection of photon-emitting radionuclide; radionuclides are absorbed by healthy tissue at different rate than diseased or necrotic tissue; data are transfered to computer that converts image to film

• provides information regarding blood floe to tissues; analyzing blood flow to organ may help determine how well it is functioning

clinical manifestation of acute head injury: minor

• may or may not lose consciousness

• transient period of confusion

• somnolence listlessness

• irritability

• pallor

• vomiting (one or more episodes)

clinical manifestation of acute head injury: signs of progession

• altered mental status (e.g., difficulty arousing child)

• mounting agitation

• development of focal lateral neurologic signs

• marked changes in vital signs

clinical manifestation of acute head injury: severe injury

• signs of increased intracranial pressure

• bulging fontanel (infant)

• retinal hemorrhage

• extraocular palsies (especially cranial nerve III)

• hemiparesis

• quadriplegia

• elevated temperature

• unsteady gait (older child)

• Papilledema (older child)

• retinal hemorrhage

clinical manifestation of acute head injury: associated signs

• scalp trauma

• other injuries (e.g., to extremities)

clinical manifestation of bacterial meningitis in children and adolescent

• usually abrupt onset

• fever, chills, headache, vomiting

• alterations in sensorium

• seizures (often the initial sign)

• irritability

• agitation

• may develop:

  • photophobia

  • delirium

  • aggressive behavior

  • drowsiness

  • stupor

  • coma

• nuchal rigidity; may progress opisthotonos

• postive kernig and Brudiznski signs

• hyperactivity but variable reflex reponses

• signs and symptoms peculiar to individual organism:

  • petechial or purpuric rahse (meningococcal) epsically when associated with shock-like state

  • joint involvement (meningococcal or H. influenzae infection)

  • Chronically draining ear (pneumonococcal meningitis)

clinical manifestation of bacterial meningitis in infant and young children

• fever

• poor feeding

• marked irritability

• frequent seizures often accompanied by a high-pitched cry

• bulging fontanel

• nuchal rigidity possible

• difficult to elicit and evaluate in this age-group

• subdural empyema (H. Influezae)

clinical manifestation of bacterial meningitis in neonatal

• child well at birth but a few days begins to look and behave poorly

• refuses feeding

• poor sucking ability

• vomiting and diarrhea

• poor tone

• lack of movement

• weak cry

• full, tense, and bulging fontanel may appear late in course of illness

• neck usually supple

clinical manifestation of bacterial meningitis nonspecific sign that may be present

• hypothermia or fever

• jaundice

• irritability

• drowsiness

• seizures

• respiratory irregularities or apnea

• weight loss

clinical manifestation oof encephalitis: onset

• malaise

• fever

• headache

• apathy

• lethargy

• dizziness

• ataxia

• nuchal rigidity

• tremors

• hyperactivity

• speech difficulties

• altered mental status

clinical manifestation of encephalitis: severe cases

• high fever

• stupor

• seizures

• disorientation

• spasticity

• coma

• ocular palsies

• paralysis

Etiology of seizures in children: acute

• febrile episodes

• intracranial infection

• intracranial hemorrhage

• space-occupying lesions (cyst, tumor)

• acute cerebral edema

• anoxia

• toxins

• drugs

• tetanus

• lead encephalopathy

• shigeella and salmonella organisms

• metabolic alterations

  • Hypocalcemia

  • hyponatremia

  • hypomagnesemia

  • alkalosis

  • disorders of amino acid metabolism

  • deficiency states

  • hyperbilirubinemia

Etiology of seizures in children: chronic

• idiopathic epilepsy

• epilepsy secondary to

  • trauma

  • hemorrhage

  • anoxia

  • infections

  • toxins

  • degenerative phenomena

  • congenital defects

  • parasitic brain disease

  • hypoglycemia injury

• epilepsy-sensory stimulus

• epilepsy'-stimulating states

  • nacrolepsy and catalepsy

  • tetany from hypocalcemia, alkalosis

• hypoglycemia states:

  • hyperinsulinism

  • hypopituitarism

  • adrenocortical insufficiency

  • hepatic disorders

• uremia

• allergy

• cardiovascular dysfunctions or syncopal episodes

• migraine

simple partial seizures with motor signs

• characterized by:

  • localized motor symptoms

  • somatosensory, psychic, autonomic symptoms

  • abnormal discharge remaining unilateral

• manifestation:

  • aversive seizure—eye or eyes and head turn away from the side of the focus; awareness of movement or loss of consciousness

  • Rolandic (Sylvan) seizure— tonic-clonic movements involving the face, salivation, arrested speech; most common during sleep

• Jacksonian march—orderly, sequential progression or clonic movements beginning in a foot, hard, or faces and moving, or “marching” to adjacent body part

simple partial seizures with sensory signs

• characterized by:

  • numbness, tingling, prickling, paresthesia, or pain originating in one area

  • visual sensations or formed images

  • motor phenomena such as posturing or hypertonia

focal seizures with impaired awareness

• characterized by : (in children 3 yrs through adolescent)

  • period of altered behavior

  • amnesia for even (no recollection of behavior)

  • impaired consciousness during event

  • drowsiness or sleep usually following seizure

  • confusion and amnesia possibly prolonged

  • complex sensory phenomena (aura)

• patterns of motor behavior:

  • stereotypic

  • similar with each subsequent seizure

  • may suddenly cease by activity; appear dazed, stare into space, become confused and pathetic, and become limp or stiff or display some form of posturing

  • may be confused

  • may perform purposeless, complicated activities in a repetitive manner (automatisms), such as walking, running, kicking, laughing, or speaking, etc.

tonic-clonic seizures (Grand Mal)

• occur without warning

• tonic phase lasts approximately 10-20 seconds

• mainfestation:

  • eyes roll upward

  • immediate loss of consciousness

  • if stading, falls to floor or ground

  • stiffens in generalized, symmetric tonic contraction of entire body musculature

  • arms usually flexed

  • legs, head, and neck extended

  • may utter a peculiar piercing cry

  • apneic, may become cyanotic

  • increased salivation and loss of swallowing reflex

• clonic phase: lasts about 30 seconds but can bary from only a few seconds to a half-hour or longer

• manifestation:

  • violent jerking movements as the trunk and extremities undergo rhythmic contraction and relaxation

  • may foam at the mouth

  • may be incontinent of urine and feces

status epileptics

series of seizures at intervals too brief to allow the child to regain consciousness between the time one event ends and the next begins

• requires emergency interventions

• can lead to exhaustion, respiratory failure, and death

postictal state

• appears to relax

• may remain semiconscious and difficult to arouse

• may awaken in a few minutes

• remains confused for several hours

• poor coordination

• mild impairment of fine motor movements

• may have visual and speech difficulties

• may vomit or complain of severe headache

• when left alone, usually sleeps for several hours

• on awakening is fully conscious

• usually feels tired and complains of sore muscles and headaches

• no recollection of entire event

absence seizures (Petit mal)

• characterized by:

  • onset usually between 4 to 12 years of age

  • more common in girls than in boys

  • usually cease at puberty

  • brief loss of consciousness

  • minimum or no alteration in muscle tone

  • may go unrecognized because of little change in child’s behavior

  • abrupt onset; suddenly develops 20 or more attack daily

  • event often mistaken for inattentiveness or daydreaming

  • event possibly precipitated by hyperventilation, hypoglycemia, stresses (emotional and physiologic), fatigue, or sleeplessness

• manifestation:

  • brief loss of consciouness

  • appwar without warning or aura

  • usually last abut 5 to 10 seconds

  • slight loss of muscle tone may cause child to drop objects

  • ability to maintain postural control; seldom falls

  • minor movements such as lip smacking, twitching of eyelids or face, or slight hand movements

  • not accompanied by incontinence

  • amnesia for episode

  • may need to reorient self to previous activity

atonic and akinetic seizures (drop attack)

• characterized by:

  • onset usually between 2 to 5 years of age

  • sudden, momentary loss of muscle tone and postural control

  • events recurring frequently during the day, particularly in the morning hours and shortly after awakening

• manifestation:

  • loss of tone causing child to fall to the floor violenting; unable to break fall by putting out hand; may incur a serious injury to the face, head, or shoulder

  • loss of consciousness only momentary

myoclonic seizures

• may be isolated as begnign essential myoclonus

• characterized by:

  • sudden, brief contractures of a muscle or group of muscles

  • occur singly or repetitively

  • no postictal stae

  • may or may not be symmetric

  • may or may not include loss of consciousness