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PAEDIATRIC NEUROLOGY Agenda 01 02 03 MIGRAINE EPILEPSY FEBRILE CONVULSION 04 05 06 CEREBRAL HEAD INJURY MENINGITIS AND PALSY MENINGICOCCAL SEPTICAEMIAMIGRAINE Definition Neurological Disorder characterised by recurrent, moderate-to- severe headaches, accompanied by additional symptoms [1] Symptoms Aura - Visual, auditory, somatosensory or motor Photophobia Nausea and Vomiting Abdominal pain - Abdominal migraine common in children. [1] Investigations,Treatment andProphylaxis DIAGNOSIS TREATMENT PROPHYLAXIS Migraine without aura Triggers such as stress, COCP and 5 attacks Acute migraine other medicines and other diet 4-72 hours of duration Simple analgesia e.g. paracetamol or factors e.g. cheese and chocloate, 2 of : unilateral, pulsating, moderate to NSAID should be avoided. severe pain, aggravation due to routine Sumitriptan used if this isnt adequate Propanolol hydrochloride and activities 1 or more of N&V or photophobia [1] Prochlorperazine and metoclpramide topiramate can be used for migraine Migraine with Aura hydrochloride for antiemetics [3] prophyalxis 2 attacks Topiramate - Need to discuss One of : visual symptoms, sensory contraception with those of child- symptoms or speech and language symptoms bearing age. Pizotifen - licensed but efficacy 3 of : aura that spreads over 5 minutes, two unkown [3] + aura in succession, aura lasts over 5 minutes, one positive aura symptoms, aura accompanied by a headache [1] EPILEPSY Generalised Tonic Clonic Focal Seizure Absence Seizure Atonic Myoclonic Epilepsy syndromes Febrile convulsionsSeizureinvestigations MRI and EEG EEG is performed after the second simple tonic clonic seizure MRI brain done in those who have their first seizure under the age of two, they have focal seizures or there is no responce to first line medications [3] Additional investigations to do to aid diagnosis ECG Electrolytes Urine cultures Lumbar puncturesGeneralised Absence TonicClonic seizure Features Features Loss of conciousness or awareness Blank, staring into space Tonic - muclse tensing Clonic - muscle jerking Quickly returns to normal Can have tongue biting, incontinence and Lack of awareness - classified irregular breathing [2] as a generalised seizure [2] Treatment Treatment First line - Sodium valporate First line - Ethosuximide Second line - lamotrigine In female children of child bearing age - Second line - Sodium contraception needs to be discussed if they valporate [2] have started their periods. [2]Focal Atonic Myoclonic seizure Seizure Seizure Features Features Features Temporal Lobe seizures Drop attacks Sudden brief muscle Hallucinations Brief lapses in muscle tone contractions Flashbacks Can indicate Lennox-gastut Usually the patient is aware Deja vu syndrome [2] Seen in Juvenile myoclonic Acting in “autopilot” [2] epilepsy [2] Treatment Treatment Treatment First line - Lamotrigine OR First line - Sodium First line - Sodium levetiracetam valporate valporate Second line - Second line - Lamotrigine Second line - Lamotrigine Carbamazepine [2] [2] [2]EpilepsySyndromes Benign Rolandic Epilepsy Typical onset - 3 to 12 years but spontaneous remission in mid-adolescence Seizures typically occur at night They are typically initially focal, followed by secondary generalisation EEG shows centrotemporal spikes Good prognosis [1]EpilepsySyndromes Juvenile Myoclonic Epilepsy Typical onset - 12 to 18 years More common in females May present with myoclonic, generalised tonic-clonic and absence seizures Typical presentation is frequent myoclonic seizures and uncommon generalised seizures GTCs most common in the morning, especially following sleep deprivation Usually present after first GTC, but history of myoclonic seizures - dropping objects during breakfast etc. [1]EpilepsySyndromes West Syndrome Epileptic/ infantile spasms, hypsarrhythmia and an intellectual disability Occur in the first 4 to 8 months of life More common in males Characteristic salaam attacks - flexion of the head, trunk and arms followed by extension of the arms that last 1-2 seconds but occur repeatedly CT can show diffuse or localised brain disease Poor prognosis, vigabatrin is considered first-line therapy [1] FebrileConvulsions EPIDEMIOLOGY AND DEFINITION INVESTIGATIONS PATHOPHYSIOLOGY Internatal League Against Epilepsy Most common neurological condition in Fever over 38C, aged between 6 definition : Paediatrics months to 6 years A seizure associated with a febrile illness Peak incidence between 12-18 months Tonic clonic seizure not caused by infection of the CNS, Thought to be caused by the developing Examine for signs of infection, Check without previous neonatal seizures or a brains responce to fever, increasing fontanelles and signs of meningism previous unprovoked seizure, which neuronal excitability, making the child Neurological examination and urine occurs in children aged 6 months to 6 more suseptable to seizures dipstick years [4] 1/3 of children have another febrile Bloods - FBC, CRP, U&Es , calcium, convulsion after thier first one glucose, magnesium and cultures [4] Mostly caused by viral infections e.g. URTI, LRTI and UTI [4] FebrileConvulsions Management Acute Management A-E 01 Monitoring Hydration. Paracetamol / ibuprofen to control the fever explanation to the parents [4] Prolonged Febrile Convulsions Recurrent seizure without complete resolution between the seizure Seizure longer that 5 minutes 02 Benzodiazepine Rescue treatment [4] Treat as status epilepticus 1.Buccal Midazolam / Rectal diazepam/ IV lorazepam 2.Second dose of these if seizure doesnt stop in 10 minutes 3.IV levetiracetam / Phenytoin / sodium valporate [2] CAUSES OF CEREBRAL PALSY PRESENTATION OF CEREBRAL PALSY Neurological problem resulting from damage Failure to meet mile stones to the brain around the time of birth Increased / decreased muscle tone Antenatal causes include maternal infections Hand preference under 18 months of age and trauma during pregnancy Difficulties in speech, walking and coordinating Perinatal causes include birth asphyxia and pre movements term birth Learning difficulties Postnatal causes include meningitis, severe Really good resource on zero to finals on neonatal jaundice and head injury [2] neuroligcal examination findings [2] TYPES OF CEREBRAL PALSY COMPLICATIONS AND ASSOCIATED CONDITIONS Spastic - hypertonia and reduced functioning Cerebral due to UMN damage Learning Difficulties Dyskinetic - Problems controlling muscle tone Hearing and visual difficulties e.g. squint Palsy Epilepsy - both hypertonia and hypotonia. Athetosis and Kyphoscoliosis oro-motor issues also are caused. Basal ganglia damage Gastro-oesophageal reflux [2] Ataxic - Difficulties in coordinating movements due to cerebellar damage Mixed [2]ManagementofCerebral palsy Spasticity treatment Oral diazepam or Oral baclofen Treats pain, muscle spasms, discomfort and functional disabilities Focal spasticity of the upper / lower limbs which causes significant impact on life can be treated with botulinum toxin type A [3] Other management SALT involvement - swallowing and speach difficulties School and social input for learning difficulties Treatment of constipation Pain management Treat co-morbidities [2] HeadInjury CRITERIA FOR CT HEAD MANAGEMENT CUSHINGS TRIAD Loss of conciousness over 5 Immobilsation of Cervical spine if This triad indicates Raised ICP - minutes the symptoms are the bodies Amnesia for over 5 minutes GCS under 15 Neck pain attempt to improve perfusion Abnormal drowsiness Focal neurological deficit Irregular respirations 3 or more discrete vomiting Paraesthsia in extremities episodes Suspicion of cerevical spine Hypertension Non-accidental injury Bradycardia [5] fracture Suspected skull fracture Anaesthetics input Tense fontanelle Lower blood pressure Bruise, swelling or cut over 5cm in Steroids / diuretics to stop any swelling those under 1 External ventricular drainage - drain Post traumatic seizure blood to reduce ICP increase [3] GCS under 14 / 15 if under 1 year old GCS under 15 , 2 hour after initial presentation Signs of basal skull fracture Focal neurological deficit [3] MENINGITIS MENINGICOCCAL SEPTICAEMIA Meningitisvs Inflammation of the meninges Meningococcal septicaemia Most common causes are Meningicoccal refers to the meningococcus Neisseria meningitidis and Strep bacterial infection in the pneumoniae (bacteria) and HSV Septicaemia and VZV (viral) bloodstream. [1] In neonates it is Group B Strep [1] Meningitis PRESENTATION INVESTIGATIONS MANAGEMENT Fever Management of Bacterial meningitis Neck s tiffness Lumbar puncture in those under 1 month with a fever, under 3 Community - benzylpenicillin Vomiting months with fever and unwell or Cefotaxime with amoxicillin (under 3 Headache under 1with unexplained fever / months) Photophobia Ceftriaxone (over 3 months) serious illness Dexamethasone -4 times daily for 4 Altered conciousness and seizures [1] Blood cultures and general observations. days Kernigs test Viral meningitis treatment is supportive Prophylaxis of close contacts - Brudzinskis test [1] Ciprofloxacin [1] MeningicoccalSepticaemia FEATURES INVESTIGATIONS MANAGEMENT Management is the same as meningitis, along with monitoring Classic non-blanching rash Menningococcal PCR and This rash indicates disseminated blood clutures Hypoglycaemia intravascular coagulopathy Acidosis Stiff neck, generally severely Insuspected meningicoccal Hypokalaemia septicaemia, dont lumbar Hypomagnesaemia unwell and other meningitis Anaemia symptoms present too [1] puncture !! [1] Coagulopathy Dont give high dose steroids in meningicoccal septicaemia (unlike meningitis) [1]A 12-month-old baby is brought to the A&E with a temperature of 38.9 degrees celsius, irritability, and with bulging fontanelle. The baby appears drowsy upon examination, and neck stiffness is observed. Meningococcal bacteria is found upon CSF analysis. What is the most appropriate antibiotic regimen for this child ? 1.IV Amoxicillin 2.IV Ceftriaxone 3.PO Ciprofloxacin 4.IV Cefotaxime and Amoxicillin 5.PO metronidazoleA 12-month-old baby is brought to the A&E with a temperature of 38.9 degrees celsius, irritability, and with bulging fontanelle. The baby appears drowsy upon examination, and neck stiffness is observed. Meningococcal bacteria is found upon CSF analysis. What is the most appropriate antibiotic regimen for this child ? 1.IV Amoxicillin 2.IV Ceftriaxone 3.PO Ciprofloxacin 4.IV Cefotaxime and Amoxicillin 5.PO metronidazole A 4-year-old girl is brought to the paediatric clinic by her mother due to recurrent febrile seizures. The mother reports that her daughter has had six episodes of seizures in the past ten months during febrile illnesses. The seizures lasted around 4 minutes each and were a generalized tonic-clonic seizure What of the following may be prescribed by specialists for the management of recurrent febrile seizures? 1.Rectal lorazepam 2.IV lorazepam 3.Buccal Midazolam 4.Oral Aspirin 5.IV levetiracetam A 3-year-old girl is brought to the paediatric clinic by her mother due to recurrent febrile seizures. The mother reports that her daughter has had six episodes of seizures in the past ten months during febrile illnesses. The seizures lasted around 4 minutes each and were a generalized tonic-clonic seizure. What of the following may be prescribed by specialists for the management of recurrent febrile seizures? 1.IV lorazepam 2.Oral paracetamol 3.Buccal Midazolam 4.Oral Aspirin 5.IV levetiracetamA 10-year-old boy is brought to the emergency department after falling off his bike and hitting his head. He has maintained conscious but has vomited 3 times. The child has no past medical history or any drug allergies . His GCS is 15, he has no difficulties breathing and there are no neurological deficits. There is tenderness and swelling over the right forearm but no other obvious injuries. What is the next step? 1.CT Head within 1 hour 2.CT head within 3 hours 3.Discharge with no follow up 4.Observe for 4 hours 5.Plain x-ray of armA 10-year-old boy is brought to the emergency department after falling off his bike and hitting his head. He has not lost consciousness but has vomited 3 times and he seems extremely drowsy. The child has no past medical history or any drug allergies . His GCS is 15, he has no difficulties breathing and there are no neurological deficits. There is tenderness and swelling over the right forearm but no other obvious injuries. What is the next step? 1.CT Head within 1 hour 2.CT head within 3 hours 3.Discharge with no follow up 4.Observe for 12 hours 5.Plain x-ray of arm A 13 year old girl presents to her gp with a 6 month histroy of severe headaches with nausea and vomiting. These headaches occur every couple of weeks, and the patient reports the feeling of pins and needles on her left side and “weird floaters” in her vision, prior to the onset of the headache. During the headaches she has to lay down in a dark room with no noise, and this typically lasts a whole day, impacting her ability to go to school. Has tried simple analgesia, which has no effect. What initial treatment plan should be started for this patient 1.Ibuprofin 2.Sumatriptan to take during attacks 3.Propanalol 4.Topiramate 5.Sumatriptan and propanalol A 13 year old girl presents to her gp with a 6 month histroy of severe headaches with nausea and vomiting. These headaches occur every couple of weeks, and the patient reports the feeling of pins and needles on her left side and “weird floaters” in her vision, prior to the onset of the headache, which is very severe. During the headaches she has to lay down in a dark room with no noise, and this typically lasts a whole day, impacting her ability to go to school. Has tried simple analgesia, which has no effect. What initial treatment plan should be started for this patient 1.Ibuprofin 2.Sumatriptan to take during attacks 3.Propanalol 4.Topiramate 5.Sumatriptan and propanalol Thank you !! Resources 1.passmedicine.com 2.zerotofinals.com 3.nice.org.uk 4.teachmepaediatrics.com 5.osmosis.org
