Peds. Neurolgic Disorders

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Peds. Neurolgic Disorders

• Salih Alhetela

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Content

• ABM
• Seizures
• Headache
• Breath-holding spells

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ABM

• Acute Bacterial Meningitis

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ABM

• Mortality of treated cases
• 20-40 neonate
• 5-10 infant/child
• Morbidity 25-50 of survivors
• Incidence
• Highest in the neonate, then
• 3-8 months
• lt 2 years
• gt 90 of cases occur before 5 years

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Q What the causative organisms of ABM?
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ABMOrganisms

• Neonate
• GB strep gt50
• E.coli other coliform 25
• S. epid., S. aureus
• S. pneumoniae
• N. meningitidis
• GDS
• HIB

• INF. CHILD
• HIB ? Less after vaccin
• 90 caused by
• S. pneumoniae
• N. meningitidis
• Unusual organisms
• Salmonella
• Campylobacter
• Francisella

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ABMPrinciple of disease

• Host factors
• Premature neonate
• Male
• African Americans
• Day care attendants
• Immunodeficiency
• SCA, AIDS , asplenia, renal disease
• Liver dis., DM, dysgammaglobulinemia
• Immunosupp. Therapy

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ABMPrinciple of disease

• Mechanical disturbances
• Surgical procedure
• Skull fracture
• Cong. CNS abnormality
• Intracranial cyst
• Epidermoid /dermoid tumors
• neurenteric fistula

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ABMPrinciple of disease

• Subarachnoid space entrance
• Haematogenous spread gt 90
• direct extension
• In the SA space
• Endotoxin ? inflammatory response ?vascular and
  parenchymal changes
• Vasculitis , microthrombi, venous sinuses
  occlusion
• Reduced blood flow, cerebral edema, hemorrhage

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ABMclinical features

• Presentation
• 75 with nonspecific subacute presentation 2-5
  days
• 25 with acute illnesses lt24 hrs
• Easier to diagnose
• Higher risk for death complication
• Age
• The younger the infant, the more nonspecific S/S

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ABMclinical features

• Newborn
• General Hypo/hyperthermia- apnea-tachypnea-
  brady/tachcardia
• Behavioral Restless -irritability lethargy
• Neuro high Pitched cry- seizure- nystagmus-
• bulging fontanelle
• Derm Cyanosis- petechiae- purpura- livedo
  reticularis
• GI Altered feeding- diarrhea- vomiting-jaundice

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Q What is livedo reticularis sign?

• Generalized pallor accompanied by indistinctly
  outlined truncal patches of blue discoloration

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ABMclinical features

• Infant/child
• General Fever-chills-myalgia neck back pain-
  tachy
• Behavioral irritability - lethargy
• Neuro Altered mentation- focal neurologic signs-
  seizure- hearing deficit- photophobia- nuchal
  rigidity- kernig burdzinski
• Derm Cyanosis- petechiae- purpura-
• GI Anorexia- nausea- vomiting

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Q Describe kernig burdzinski signs .
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What the complication of the LP? How can you
prevent each?

1. Lumbar pain use of anesthetic agent
2. Post-LP cephalgia smaller needle, reinserting
   the stylet and smaller amount of CSF
3. Infection proper aseptic technique
4. Herniation rarely occurs / check S/S of ICP-CT

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What is the indication for LP?

• s/s of meningitis
• Suspected neonatal sepsis
• Suspected ABM
• Febrile infant 4-8 wks ?
• Toxic appearance
• Documented bacteremia

• Febrile illness after intimate contact
• Febrile seizures
• Fever and petechiae
• sepsis suspected in an abnormal host
• Penetration of dura
• Acute hearing loss

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What is the normal and abnormal value of CSF
glucose and protein ?

• Glucose
• Normal CSF serum glucose ratio 0.6
• lt 0.4 is found in ABM TB
• Protein
• Normal range is 40-170 mg/dl in neonate
• Normal range is 15-45 mg/dl in children
• Modestly elevated in viral M.
• Higher level in ABM traumatic LP

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What is the normal range of CSF WBC in deferent
age group? What is your threshold of abnormal?

• Preterm 0-44 gt9
• Newborn 0-32 gt22
• Neonate 0-50 gt35
• 4-8 wks 0-50 gt10
• gt8 wks 0-8 gt 6
• Classically WBC in ABM ranges from 1000-20000
• wbc/mm3

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How about PMN?

• lt4 wks 60 of WBC is PMN
• gt4wks not more than 3pmn/mm3

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How accurate is gram stain?

• Depend on number of bacterial organism present.
• 25 positive with 103 CFU/ml
• 60 positive with 103 -105 CFU/ml
• 97 positive with 106 CFU/ml

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What is the DDX of ABM?

• Infectious
• Septicemia, subdural empyema, epidural abscess,
  (viral, fungal and TB meningitis )
• Traumatic
• Closed head injury, shaken impact syndrome
• Metabolic
• Hypoglycemia, DKA, hypo/hypernatremia, uremia
• Others
• Toxin, seizure, brain tumer, ruptured dermoid cyst

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Outline your management priority for ABM ?

• Airway protection and oxygenation
• Volume resuscitation /- pressor
• Prevention of hypoglycemia
• Control of seizures
• Maintain CBF/ and ICP control measures
• Antibiotic therapy

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When will you give the antibiotic for suspected
ABM ?considering patient stability and risk

• Classically 1-2 hrs of presentation for all
  suspected ABM
• Offered clinical scenario by Rosen
• Non toxic, low risk ---?blood ? LP ? wait
• Non toxic, high risk --?blood ? LP ?
• Critical, stable ?blood ? ABx ? LP
• Critical, unstable stabilize ? blood ? ABx /-
  LP

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What is the initial empiric antibiotic regiment ?

• 0-4 wks
• ampicillin plus genta or cefotaxim
• 1-3 months
• ampicillin plus cefotaxim or ceftriaxon or
  chloram
• gt3months
• cefotaxim or ceftriaxon /- vanco

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Is there any role for steroid in ABM ?

• Dexamethason may improve some neurologic
  sequelae, particularly hearing loss with ABM
  caused by h. inf
• Risk of GI bleed , false sense of improvement and
  reduced penetration of vanco
• AAP limit the use for h. inf. Meningitis

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Seizures
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What is the difference between seizures and
epilepsy ?

• A seizure is a paroxysmal event characterized by
  a change in behavior of the patient
• results when a large population of neurons in the
  brain discharges synchronously
• Epilepsy is the occurrence of two or more
  unprovoked seizures

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Seizures and brain damage

• Children with seizures at a significant risk for
  cognitive impairment and behavioral abnormality
• It is difficult to distinguish the effect of
  seizures from the underlying pathology and the
  effect of anticonvulsants
• There is a growing evidence pointing to the
  lasting effect of repetitive , brief seizures in
  early childhood

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What the difference between partial and
generalized seizures?

• Partial seizures involve only part of the brain
  at onset , clinically distinguished from GS by a
  lack of complete loss of conscious

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Partial seizures are further subdivided into
simple and complex partial seizures, What the
difference between them ?

• Simple partial seizures do not impaired
  consciousness, complex partial seizures do and
  the patient usually amnestic for the ictal event
• Either may spread and become secondary
  generalized
• An aura may occur at the beginning of either type
  ( noxious smell or taste )

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Generalized seizures are further subdivided into
convulsive and nonconvulsive seizures, What the
difference between them ?

• Convulsive seizures include tonic-clonic, tonic
  and clonic seizures , with post ictal confusion
• Nonconvulsive include absence , myoclonic and
  atonic seizuers
• No post ictal drowsiness in absence seizures

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What the criteria for febrile seizures?

• Febrile seizures are defined as seizures in the
  presence of fever without CNS infection or other
  causes
• Generalized
• last less than 15 min
• In child 6 months -5 years
• Neurologically and developmentally normal

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what the chance of developing epilepsy in febrile
seizures ?

• 2-3 while in normal population 1
• Higher in
• Presence of family history of epilepsy
• Abnormal developmental status
• Complex febrile seizures

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What the common precipitants of status
epilepticus ?

• Febrile illness ( the most common )
• Medication change
• Idiopathic
• Metabolic derangement
• Congenital abnormality

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What the common complications of status
epilepticus ?

• Hyper/hypotension
• Dysrhythmia
• CHF
• Apnea
• Aspiration
• Non cardiogenic pulmonary edema
• Rhabdomyolysis
• Hypo/hyperglycemia

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What are the etiology of seizures?

• Febrile seizures
• CNS infection
• Trauma ( contusion, hematoma and impact )
• Toxins ( intoxication or withdrawal)
• CNS tumor ( primary or mets)
• Metabolic ( hypoglycemia, electrolyte, inborn
  errors, renal and liver disorders)
• Vascular ( hemorrhage, A-V malformation, cerebral
  vein thrombosis
• Other ( hypoxia, post immunization, V-P shunt
  malf.)

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Diagnostic strategies

• History is the cornerstone
• To differentiate actual and pseudo seizures
• Type of seizure
• The cause or precipitant
• Exam
• Mainly looking for the cause
• No abnormality referred to the seizures

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How about imaging and EEG after a first seizure?

• Imaging indicated in
• Partial seizures
• Abnormal neurological exam
• EEG
• Rarely needed in the acute setting
• 10-40 dont show epileptiform abnormalities in
  EEG

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Approach in actively convulsing child?

• ABC
• Stop seizure
• Benzo, phenytoin , Phenobarb then
• IV drip ( midazolam, propofol or pentobarbital )
• Prevent seizure recurrent
• Identify precipitant or cause and treat

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Approach if the child presents after the event?

• Determine if truly seizure
• Determine seizure type
• Identify precipitant or cause and treat
• Determine if further work up needed
• Determine if anticonvulsant therapy is
  appropriate

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Riske factor of recurrence of a seizure ?

• Todds paralysis
• Abnormal EEG
• Family history of epilepsy
• Remote symptomatic seizure
• Seizure while asleep

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Headache

• History
• Headache data base
• Neurological symptoms
• Past medical/ medication history
• EXAM
• Vital sign
• Growth parameter (wt, head circumference, height)
• G. exam including the skin
• Full neurological exam appropriate to age

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Types of headache in pediatric

• Acute headache
• Chronic progressive headache
• Migraine headache
• Chronic non progressive headache
• tension headache
• Cluster headache

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Causes of acute headache ?

• Infection (CNS infection, viral illnesses,
  sinusitis)
• Hypertension
• Vascular ( hemorrhages )
• Trauma
• Toxin
• Dental disorder
• Opthalmologic problem

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Causes of chronic progressive headache ?

• Increased ICP
• Brain tumors
• Pseudo tumor cerbri
• Hydrocephalus
• Brain abscess
• Subdural heamatoma

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Classification of migraine headache

• Migraine with aura
• Classic
• Complicated ( hemiplegic, opthalmoplegic, basilar
  artery migraine)
• Migraine without aura ( common migraine)
• Migraine variants
• Abdominal migraine
• Benign paroxysmal vertigo
• Paroxysmal torticollis

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Criteria for pediatric migraine without aura

• 5 attacks each last 1-48 hrs
• Headache with 2 of
• Bilateral or unilateral
• Pulsating quality
• Moderate to severe
• Aggravated by routine physical activity
• Associated symptoms 1 of
• Nausea or vomiting
• Photophobia or photophobia

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Criteria for pediatric migraine with aura

• At least 2 episodes with the following criteria
• Reversible symptoms arising from focal cerebral
  or brainstem dysfunction
• Gradual development of the headache
• Aura with a duration of less than 60 min
• Headache either before or within 60 min of aura

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Treatment of migraine in peds?

• Acetaminophen
• NSAIDs
• Narcotic (codeine or oxycodon)
• Antiemetic
• Metoclopromide
• Promethazine
• Ergotamine
• Sumatriptan