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LMCC Review: Pediatric Neurology

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LMCC Review: Pediatric Neurology Asif Doja, MEd, MD, FRCP(C) March 27th, 2012 Outline Seizures Febrile Seizures Status Epilepticus Headache Seizures Question 1 ... – PowerPoint PPT presentation

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Title: LMCC Review: Pediatric Neurology


1
LMCC Review Pediatric Neurology
  • Asif Doja, MEd, MD, FRCP(C)
  • March 27th, 2012

2
Outline
  • Seizures
  • Febrile Seizures
  • Status Epilepticus
  • Headache

3
Seizures
4
Question 1
  • Someone can be diagnosed with epilepsy if they
    have
  • A. More than one febrile seizure
  • B. More than one afebrile seizure
  • C. Seizures in the context of hypoglycemia
  • D. One seizure and a history of brain injury

5
Question 2
  • All of the following seizure types are classified
    as generalized seizures EXCEPT
  • A. Complex partial seizures
  • B. Absence seizures
  • C. Tonic-clonic seizures
  • D. Atonic seizures

6
Question 3
  • All of the following are features of Absence
    seizures EXCEPT
  • A. Lack of an aura or warning
  • B. Impairment in consciousness
  • C. Post-ictal drowsiness/lethargy
  • D. 3 Hz spike and wave on EEG

7
Question 4
  • Which of the following is an appropriate first
    line treatment for an 8 year old child with
    epilepsy?
  • A. Bromide therapy
  • B. Ketogenic Diet
  • C. Carbemazepine
  • D. Phenobarbital

8
Question 5
  • A 9 year old child presents with recurrent
    episodes of waking in the morning with facial
    twitching, dysarthria and normal level of
    consciousness. The most likely diagnosis is
  • A. Transient Ischemic Attacks
  • B. Benign Epilepsy of Childhood with Rolandic
    Spikes
  • C. Juvenile Myoclonic Epilepsy
  • D. Facial tics

9
Definitions
  • Seizure Paroxysmal discharge of neurons
    resulting in behaviour change, motor or sensory
    dysfunction
  • Epilepsy gt 1 unprovoked seizure

10
Was it a Seizure?
  • Differential Diagnosis
  • Syncope
  • Breath Holding
  • Night Terrors
  • Tics
  • GERD
  • etc

11
Syncope vs Seizure
  • Vasovagal reflex
  • Usually happens when standing up
  • Lightheaded feeling
  • Pale, cold, clammy
  • Loss of consciousness and fall
  • Tremble but no tonic-clonic movements
  • No post-ictal lethargy

12
Focal vs. Generalized Seizures
  • Focal
  • Simple Partial
  • Complex Partial
  • Partial Seizure with 2O Generalization
  • Generalized
  • Generalized Tonic-Clonic
  • Tonic
  • Clonic
  • Absence
  • Atonic
  • Myoclonic

13
How to differentiate Staring Spells
  • Complex Partial
  • Aura
  • 30 sec or more
  • Decr LOC
  • Automatisms
  • Post-ictal period
  • EEG focal epileptiform abnormality
  • Hyperventialtion has no effect
  • Absence
  • No aura
  • Lasts few seconds
  • Decr LOC
  • May have automatisms
  • No post-ictal period
  • EEG 3 HZ spike and wave
  • Provoked by hyperventialtion

14
Investigations and Treatment
  • Neuroimaging if focal findings present
  • May do EEG after first seizure
  • Treatment if patient has 2 or more seizures
  • Commonly used Carbemazepine, Valproic Acid,
    Phenobarbital
  • Many other newer anticonvulsants ie Topiramate,
    Levotiracetam
  • (For refractory patients Ketogenic Diet,
    Epilepsy surgery)

15
Epilepsy Syndromes
  • West Syndrome
  • Infantile Spasms
  • Onset in 1st year
  • Symmetrical contractions of trunk/extremities
  • EEG hypsarrythmia
  • Poor prognosis
  • Lennox Gastault
  • Onset age 3-5
  • Multiple seizure types
  • Developmental delay
  • EEG slow spike and wave
  • Many have history of infantile spasms

16
Epilepsy Syndromes
  • Benign Epilepsy of Childhood with Rolandic Spikes
    (BECRS)
  • 5-10 years
  • Simple partial seizures involving face
  • Remits spontaneously, no treatment
  • Juvenile Myoclonic Epilepsy
  • 12-16 years
  • Myoclonus and GTC seizures
  • Good prognosis, but requires lifelong treatment
    with Valproic Acid

17
Question 1
  • Someone can be diagnosed with epilepsy if they
    have
  • A. More than one febrile seizure
  • B. More than one afebrile seizure
  • C. Seizures in the context of hypoglycemia
  • D. One seizure and a history of brain injury

18
Question 2
  • All of the following seizure types are classified
    as generalized seizures EXCEPT
  • A. Complex partial seizures
  • B. Absence seizures
  • C. Tonic-clonic seizures
  • D. Atonic seizures

19
Question 3
  • All of the following are features of Absence
    seizures EXCEPT
  • A. Lack of an aura or warning
  • B. Impairment in consciousness
  • C. Post-ictal drowsiness/lethargy
  • D. 3 Hz spike and wave on EEG

20
Question 4
  • Which of the following is an appropriate first
    line treatment for an 8 year old child with
    epilepsy?
  • A. Bromide therapy
  • B. Ketogenic Diet
  • C. Carbemazepine
  • D. Phenobarbital

21
Question 5
  • A 9 year old child presents with recurrent
    episodes of waking in the morning with facial
    twitching, dysarthria and normal level of
    consciousness. The most likely diagnosis is
  • A. Transient Ischemic Attacks
  • B. Benign Epilepsy of Childhood with Rolandic
    Spikes
  • C. Juvenile Myoclonic Epilepsy
  • D. Facial tics

22
Febrile Seizures
23
Question 1
  • Which of the following is NOT a feature of a
    typical febrile seizure?
  • A. Onset between ages 6 months 6 years
  • B. Duration of lt 15 minutes
  • C. Only one seizure in 24 hour span
  • D. Patients usually have pre-existing
    developmental delay

24
Question 2
  • Which of the following is FALSE regarding
    atypical febrile seizures?
  • A. They may show clonic jerking on only one side
    of the body
  • B. The patient is at no increased risk for
    further febrile seizures.
  • C. The patient can present in status epilepticus
  • D. The patient can show focal abnormalities on
    neurologic exam.

25
Question 3
  • A 8 month old female has one typical febrile
    seizure, then 2 months later has another. With
    respect to anticonvulsants, you would prescribe
  • A. Phenobarbital
  • B. Carbemazepine
  • C. Valproic Acid
  • D. None, as the patient does not require treatment

26
Question 4
  • A 7 month old male has a typical febrile seizure.
    With respect to doing a lumbar puncture, the AAP
    guidelines state that you should
  • Not do an LP
  • Do an LP if the temperature is gt 39 degrees
  • C. Do an LP only if there are meningeal signs
  • D. Do an LP irregardless of the physical exam
    findings

27
Question 5
  • What is the risk of developing epilepsy in a
    child with a typical febrile seizure?
  • A. 1, the same as the general population
  • B. 2-3
  • C. 10-15
  • D. 33

28
Febrile Seizures
  • 3-5 of all children
  • Ages 6 months to 6 years
  • Usually GTC

29
Typical vs Atypical Febrile Seizures
  • Typical
  • Duration lt 15 min
  • No focality
  • Does not recur in 24-hour period
  • No hx of developmental delay
  • Atypical
  • Duration gt 15 min
  • Focal findings during seizure or after exam
  • gt 1 in 24 hours
  • Previous History of Developmental Delay

30
Risk of Recurrence
  • 33 chance of recurrence (75 occur within 1
    year)
  • Risk Factors
  • Family history of feb. con. or epilepsy
  • Short duration of fever prior to seizure
  • Developmental / Neurological problems
  • Atypical febrile seizure

31
Investigations
  • History and Physical determine source of fever
  • EEG and Neuroimaging only needed in atypical
    cases
  • LP
  • If lt 12 months Do LP
  • If 12-18 months Consider LP
  • If gt 18 months Only if meningeal signs present

32
Management
  • Reassurance
  • Risk of developing epilepsy is 2-3 (1 in
    general population)
  • Antipyretics and fluids for comfort (neither
    prevent seizures)
  • No need for anticonvulsants

33
Question 1
  • Which of the following is NOT a feature of a
    typical febrile seizure?
  • A. Onset between ages 6 months 6 years
  • B. Duration of lt 15 minutes
  • C. Only one seizure in 24 hour span
  • D. Patients usually have pre-existing
    developmental delay

34
Question 2
  • Which of the following is FALSE regarding
    atypical febrile seizures?
  • A. They may show clonic jerking on only one side
    of the body
  • B. The patient is at no increased risk for
    further febrile seizures.
  • C. The patient can present in status epilepticus
  • D. The patient can show focal abnormalities on
    neurologic exam.

35
Question 3
  • A 8 month old female has one typical febrile
    seizure, then 2 months later has another. With
    respect to anticonvulsants, you would prescribe
  • A. Phenobarbital
  • B. Carbemazepine
  • C. Valproic Acid
  • D. None, as the patient does not require treatment

36
Question 4
  • A 7 month old male has a typical febrile seizure.
    With respect to doing a lumbar puncture, the AAP
    guidelines state that you should
  • A. Not do an LP
  • B. Do an LP if the temperature is gt 39 degrees
  • C. Do an LP only if there are meningeal signs
  • D. Do an LP irregardless of the physical exam
    findings

37
Question 5
  • What is the risk of developing epilepsy in a
    child with a typical febrile seizure?
  • A. 1, the same as the general population
  • B. 2-3
  • C. 10-15
  • D. 33

38
Status Epilepticus
39
Question 1
  • Status Epilepticus is defined as
  • A. 30 minutes or gt of continuous seizure activity
  • B. Recurrent seizures with no intervening normal
    level of consciousness for gt 30 min
  • C. A and B
  • D. None of the above

40
Question 2
  • A 5 year old boy presents to the ER with a 45
    minute GTC seizure. What is your initial
    management?
  • A. ABCs
  • B. Stat CT head
  • C. Lorazepam 0.1mg IV push
  • D. Tox screen

41
Question 3
  • Which of the following metabolic disturbances is
    MOST likely to cause seizures?
  • A. High Potassium
  • B. High Chloride
  • C. Low urea
  • D. Low glucose

42
Question 4
  • First line anticonvulsant treatment in status
    epilepticus should be
  • A. Lorazepam
  • B. Phenytoin
  • C. Phenobarbital
  • D. Thiopentol coma

43
Status Epilepticus
  • 30 minutes or gt of continuous seizure activity
  • Recurrent seizures with no intervening normal
    level of consciousness for gt 30 min

44
Status Epilepticus
  • ABCs
  • Oxygen / pulse oximetry
  • Bag-valve support or intubation if reqd
  • IV access
  • Check blood sugar -- give dextrose if low (2-4
    ml/kg of 25 solution)

45
Status Epilepticus
  • Anticonvulsants
  • Benzodiazepines ie Lorazepam (0.1 mg/kg IV), can
    repeat X1
  • If fails, Phenytoin 20mg/kg (no faster than 1
    mg/min)
  • If fails, Phenobarbital 20 mg/kg (no faster than
    1 mg/min)
  • If fails, will need to go to ICU for barbituate
    coma (ie thipentol) or midazolam infusion

46
Question 1
  • Status Epilepticus is defined as
  • A. 30 minutes or gt of continuous seizure activity
  • B. Recurrent seizures with no intervening normal
    level of consciousness for gt 30 min
  • C. A and B
  • D. None of the above

47
Question 2
  • A 5 year old boy presents to the ER with a 45
    minute GTC seizure. What is your initial
    management?
  • A. ABCs
  • B. Stat CT head
  • C. Lorazepam 0.1mg IV push
  • D. Tox screen

48
Question 3
  • Which of the following metabolic disturbances is
    MOST likely to cause seizures?
  • A. High Potassium
  • B. High Chloride
  • C. Low urea
  • D. Low glucose

49
Question 4
  • First line anticonvulsant treatment in status
    epilepticus should be
  • A. Lorazepam
  • B. Phenytoin
  • C. phenobarbital
  • D. Thiopentol coma

50
Headache
51
Question 1
  • A 7 year old male presents with headache. Which
    of the following would NOT be a red flag on
    history?
  • A. Early morning vomiting
  • B. Headache worse after certain foods
  • C. Vomiting without nausea
  • D. Focal neurologic symptoms

52
Question 2
  • Which is the following is FALSE regarding
    migraine in children
  • A. The headache can last as little as 1 hour in
    children
  • B. Children do not need to have nausea AND
    vomiting to be diagnosed with migraine
  • C. There is often a family history of migraine
  • D. MRI is often needed to rule ot other serious
    causes of headache.

53
Question 3
  • Which of the following medications has the best
    evidence for aborting migraine in children?
  • A. Acetaminophen
  • B. Demerol
  • C. Sumatripan
  • D. Ibuprofen

54
Question 4
  • Which of the following is NOT a migraine variant
    in childhood?
  • A. Alice in Wonderland syndrome
  • B. Paroxysmal Torticollis
  • C. Cyclic Vomiting Syndrome
  • D. Benign Paroxysmal Vertigo
  • E. All of the above are migraine variants in
    childhood

55
Key Questions to ask on H/A Hx
  • Duration
  • Constant or Intermittent
  • Quality of Pain (ie throbbing, pressure)
  • Scale 1-10
  • Location of pain /- radiation
  • Nausea or vomitting
  • Photo or Phonophobia
  • Aggravating and Alleviating factors

56
Key Questions to ask on H/A Hx
  • Early am waking
  • Weight loss, fever etc
  • Aura / Visual changes
  • Focal neuro symptoms
  • Change with position / Valsalva
  • Family Hx of H/A

57
Key items on Physical
  • Temperature
  • Blood pressure and CVS exam
  • Cranial Bruits
  • Scalp tenderness
  • Fundi
  • Focal neurological signs

58
H/A in increased ICP
  • Nocturnal or early morning H/A in 15
  • Nx and Vx in 50
  • May be precipitated by change in position /
    Valsalva

59
Other features of Brain Tumours/ H/A in increased
ICP
  • Personality change, memory problems, poor
    concentration
  • Seizures in 1/3
  • Vomiting NOT preceded by nausea
  • Focal neuro findings
  • Papilledema formally seen in 60-70
  • Now seen in 10-20
  • Likely due to better neuroimaging techniques

60
Migraine
  • Epidemiology
  • 75 of H/As referred for pediatric neurologic
    consultation
  • prevalence 1.2 11 depending on age
  • ve family hx in 70 90

61
Key Features
  • May have previous history of motion sickness
  • Headache is dull then becomes pulsating/throbbing
    (NOT maximal at onset)
  • Unilateral (2/3) or bilateral (1/3)
  • Can be associated with cutaneous allodynia

62
Key Features
  • Ask re nausea, vomiting, anorexia, relief with
    sleep, Do they look sick?
  • Triggers exercise, anxiety, fatigue, head
    trauma, menses, foods (chocolate, nitrites, MSG)
  • Auras visual changes, dysesthesias of limbs and
    perioral region
  • For auras, ask re sudden onset vs gradual onset

63
Diagnostic Criteria
  • A. At least 5 attacks
  • B.  Headache lasting 30 min to 48 hrs
  • C.  Headache has at least 2 of the following
  • Bilateral (fronto-temporal) or unilateral
    location
  • Pulsating quality
  • Moderate to severe intensity
  • Aggravation by routine physical activity
  • D. During headache, at least 1 of
  • 1. Nausea or vomiting
  • 2 . Photophobia or phonophobia

64
Migraine Treatment Abortive
  • Reference Neurology, 2004
  • Best Evidence (Level A)
  • Ibuprofen (10mg/kg)
  • Level B
  • Acetaminophen (15 mg/kg)
  • (Often need to tell parents correct dose)
  • Intranasal Sumatriptan effective in adolescents
  • (5-20 mg at onset of H/A, can repeat X 1)
  • Insufficient evidence for oral triptans

65
Migraine Variants With Headache
  • Hemiplegic Migraine
  • Confusional Migraine
  • Basilar Migraine
  • Ophthalmoplegic Migraine

66
Migraine Variants No Headache
  • Alice in wonderland syndrome
  • Benign Paroxysmal Vertigo
  • Paroxysmal Torticollis
  • Cyclic Vomitting

67
Question 1
  • A 7 year old male presents with headache. Which
    of the following would NOT be a red flag on
    history?
  • A. Early morning vomiting
  • B. Headache worse after certain foods
  • C. Vomiting without nausea
  • D. Focal neurologic symptoms

68
Question 2
  • Which is the following is FALSE regarding
    migraine in children
  • A. The headache can last as little as 1 hour in
    children
  • B. Children do not need to have nausea AND
    vomiting to be diagnosed with migraine
  • C. There is often a family history of migraine
  • D. MRI is often needed to rule ot other serious
    causes of headache.

69
Question 3
  • Which of the following medications has the best
    evidence for aborting migraine in children?
  • A. Acetaminophen
  • B. Demerol
  • C. Sumatripan
  • D. Ibuprofen

70
Question 4
  • Which of the following is NOT a migraine variant
    in childhood?
  • A. Alice in Wonderland syndrome
  • B. Paroxysmal Torticollis
  • C. Cyclic Vomiting Syndrome
  • D. Benign Paroxysmal Vertigo
  • E. All of the above are migraine variants in
    childhood

71
Questions?
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