PEDS L18 - Neurology

Primary vs secondary HA

Primary - migraine or tension type HA

Secondary - minor illness or serious condition

Clin pres of migraine HA

Frontal, bitemporal or UL

Mod-severe

Pounding or throbbing pain

Lasts 1-72 hours

A/w: N/V, photophobia, phonophobia, and intense desire to seek a quiet, dark room for resk

What is the MC type of recurrent primary HA in children and teens

Tension type HA

Typically mild and NO associated sxs

What can tension type HA be a/w

Environmental stressors or a sx of underlying illness like anxiety or depression

Clin pres of tension type HA

Squeezing or pressure

Lasts hours to days

NO N/V, photophobia, or phonophobia

Secondary HA commonly caused by

Head trauma

Viral illness

Sinusitis

Serious cause of secondary HA

INC ICP -> mass or intrinsic inc in pressure

- HA and vomiting are WORSE with laying down or on first awakening and wake them up from sleep

- Worse with cough, valsalva, or bending over

- Papilledema

- Focal neuro deficits

Workup for HA - when to obtain imaging (MRI with and without contrast)

Abn neuro exam

Sxs of inc ICP

Unusual features (atypical aura)

HA progressively worsening

If sudden and severe onset of HA - what imaging

Emergent CT

If negative -> LP

Migraine HA tx

Lifestyle modifications -> regulate sleep, cut out aggravating factors such as caffeine, foods, stress, missed meals, dehydration), stress management and biofeedback

Meds: analgesics (tylenol, NSAIDs) and rest in a dark quiet room

- Incl abortive and adjunct therapy if needed

Abortive meds for migraine HA

Triptans

Adjunctive therapy for migraine HA

Hydration and antiemetics (Ondansetron, Promethazine)

If migraine HA occurs weekly or more often, what tx

daily preventative tx

- Tricyclics

- Anticonvulsants

- Antihistamines

- BB

- CCBs

Tension HA tx

Manage stress

Analgesics (Tylenol, NSAIDs)

Muscle relaxers (Cyclobenzaprine)

What to use if analgesics for tension HA do not work

Tricyclics (amitriptyline), some use SSRI

Common causes of seizures

Fever

Encephalopathy

Meningitis

Hemorrhage

Hypoglycemia

Head trauma (incidental, abuse)

familial

Can be cryptogenic - no underlying cause found

most useful neurodiagnostic test

EEG

- Helps to dx and classify seizures a focal or generalized

Brain imaging is not necessary in pts with

primary generalized epilepsy (absence)

children who have an obvious cause for their seizures identified on the history and physical examination, such as febrile seizures.

Labs for new onset seizures

CBC

CMP

Blood or urine tox screen

Look for infection -> urine cx, stool cx, PCR (HSV, CMV, enterovirus)

If concern for meningitis -> LP

Generally, children can be weaned off medication for seizures after ____ seizure free

2 years

____ if seizure is > 5 min

Rectal Diazepam

Safety concerns for seizures

No swimming or bathing unless under adult supervision

Appropriate safety gear (helmets, etc)

NO scuba diving, hang gliding, or free climbing

Driving laws vary

Focal seizure with retained awareness arise from

an anatomical focus - can spread to surrounding brain regions

Focal seizure with retained awareness clin pres

Depends on the location and extent of spread

- Motor - tonic, clonic, myoclonic

- Sensory

- Psychic or autonomic abn (deja vu, fear)

- Consciousness presurved

Focal seizure with altered awareness (complex partial seizure) clin pres

ALTERED

- May not be completely unresponsive

- Slowing or alteration of mental status

- Automatisms - automatic semipurposeful movements of the mouth like chewing, lip smacking or extremities, like rubbing fingers, shuffling feet

When a focal seizure spreads to B/L hemispheres, what is this called

BL convulsive seizure

Tx of focal seizures

appropriate seizure med is chosen based on type, ADE, patient age, use of other meds and medical comorbidities

describe biphasic tonic clonic aspect of generalized seizure

Loss of consciousness and control of posture

tonic stiffening and upward deviation of eyes

- Drooling, pupil dilation, diaphoresis and HTN

Followed by clonic jerks

Post ictal phase - irritable, HA

- May be hypotonic

Generalized seizure usually begins

abruptly - occasionally preceded by myoclonic jerks

Primary clinical feature of absence seizures is

staring

A type of generalized seizure

CLin pres of absence seizure

< 15 sec episode of loss of awareness

- Accompanied by eyelid fluttering or automatisms (finger movements, lip smacking)

Often provoked by hyperventilation

EEG finding of absence seizure

Generalized 3 Hz spike and wave activity

1st line tx for absence seizure

Ethosuximide

Clin pres status epilepticus

Ongoing seizure activity that lasts more than 5 minutes

OR

Repetitive seizures w/o recovery of consciousness > 30 minutes

Status epilepticus management

ABCs

Cardiac monitoring

O2 and pulse ox

intravenous access

immediate lab tests

- Glucose

- Basic metabolic panel - sodium, calcium, magnesium

- Anticonvulsant drug levels

- Toxicology studies as appropriate

- Complete blood counts, platelets, differential

Initial pharm mgnt for status ep

Benzodiazepine if sz > 5min

- Lorazepam, Diazepam, or Midazolam

- IV preferred

If status epilepticus not resolved after 2 doses of benzos

Newborns/infants- Phenobarbital

Older children - IV fosphenytoin, valproic acid, levetiracetam

Clin pres of simple febrile seizures

Seizure that occurs in the presence of a fever in a neurologically and developmentally normal child

- Generalized at onset

- Lasts less than 15 minutes

- Occur only once in a 24 hour period

Seizure is NOT a febrile seizure if

Focal features, >15 min, recurs within 24 hours or child with preexisting neurological problems -> Complex febrile seizure

Is there preventative tx for simple febrile seizures

no

If a simple febrile seizure is prolonged (>5 min) what do you do

rectal or IV diazepam

What is a psudoseizure

psychogenic nonepileptic seizure

Clin pres of psychogenic nonepileptic seizure

Eyes CLOSED

Movements or tremulous/thrashing rather than tonic or clinic

NO urinary or fecal incontinence

No injury

Often initiated/terminated by suggestion

If EEG obtained for psychogenic nonepileptic seizures,

no epileptiform patterns

what to consider with psychogenic nonepileptic seizure

physical or sexual abuse

Simple vs complex motor tics

Simple - blinking, nose twitching, extremity jerking

Complex - head shaking, gesturing, jumping

Phonic tics - simple vs complex

Simple - grunting, throat clearing

Complex - words or phrases

Tics can be unmasked or worsened by

stimulants

tics are often triggered by an identifiable stressor such as

fatigue, anxiety, excitement

What are tics present for less than 1 year known as

Provisional tic disorder

tx needed for provisional tic d/o

no

What is the clinical hallmark of tourrette syndrome

tics - motor or phonic lasting >12 months

Clin pres of tourette syndrome - motor or phonic

Motor

- Simple-> single muscle or muscle group: Blinking, facial grimacing, shoulder shrugging, and head jerking

- Complex -> sequential, coordinated movements: Bizarre gait, kicking, jumping, body gyrations, or obscene gestures

Phonic

- Simple noises to more complex utterances (coprolalia, echolalia, palilalia)

onset of tourettes for dx before what age

21

Tx for tourette syndrome

Not always needed

Psychological support- habit reversal training

Medications -> depending on type of tic and level of impairment

What causes spina bifida

Folate deficiency

- likely in combo with genetic or other environmental RFs

What is spina bifida

Defective closure of the neural tube at the end of week 4 of gestation

- Results in anomalies of the lumbar and sacral vertebrae or spinal cord

Spina bifida occulta

Skin of back is intact, but defects of the underlying bone or spinal cord present

Meningocele

Herniation of the meningies

Myelomeningocele

spinal cord uncovered by skin or bone on the infant's back

Clin pres of spina bifida - Spina bifida occulta or meningocele

- Dimple or tuft of hair

- Associated with lipoma, dermoid cyst or

tethering of the cord

- Weakness or numbness in feet

- Bowel/bladder control issues

Clin pres myelomeningocele

Flaccid paralysis and loss of sensation in LE

Bowel/bladder incontinence, neurological deficit

Dx imaging for spina bifida

Imaging- US or MRI

Neonatal:

- AFP

- Amniocentesis

- Neonatal US

Prevention of spina bifida

400 mcg folic acid

- Universal preconception and first trimester folate supplementation

Cerebral palsy - most cases are diagnosed within the first __ months

18

Fail to reach major motor milestones or show abn (asymmetric gross motor function, hypertonia, hypotonia

MC type of CP

spastic