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260 Cards in this Set
- Front
- Back
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When working with the head, why is CT sometimes less radiation?
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Because usually several views are required anyway
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What can a plain radiograph of the skull show?
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Linear fracture or craniosynostosis
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What does cranial U/S in infants and neonates show?
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Examines size of ventricles, subdural effusions, used to monitor IVH in nursery and will r/o enlarged ventricles as the source of macrocephaly
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What does a U/S of the sacral spine assess?
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Spinal anomalies, vertebral defects and cord motion
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When does a U/S of the sacral spine need to be done?
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Before 3 months because otherwise ossification has begun and you can’t see tethering
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If you suspect a brain tumor, should you do a MRI or a CT?
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MRI because CT doesn’t image the brainstem
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Why do a CT?
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Trauma, craniofacial, temporal bone disease, size of ventricle, bony changes in histiocytosis, neuroblastoma and to assess intracranial bleed or stroke
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Who is a most risk for radiation?
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Children
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What are the 2 most common radiation imaging studies done on children?
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CT of head and abdomen
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T or F: kids don’t need sedation with MRI?
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False, they do
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What can MRI detect?
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Intrinsic changes in water concentration, soft tissue changes, can give high resolution image on multiple planes with 3D images and can image the posterior fossa and brainstem
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What is a fMRI used for?
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To measure minute changes in cerebral blood flow during visual, motor and verbal tasks, mapping cortical speech and motor area prior to brain tumor resection
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What is MRS helpful in?
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Evaluating brain chemistry, determining the degree of malignancy and metabolic abnormalities
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What is a MRA used for?
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Imaging blood flow in the large arteries and veins, evaluate vessel patency, flow magnitude, flow direction, aneurysms, vascular malformations, arterial trauma and occlusive vascular disease
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What should you think about with a motor delay?
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Muscular Dystrophy
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Picking up MD early can start ______ and prolong __________.
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Steroids, walking
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What are key history points for a motor delay?
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Loss of skills, difficulty keeping up with peers, falling, clumsiness, difficulty feeding. Loss of previous skills is big one
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What are the key exam components with motor delay?
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History, developmental milestones, weight, height, HC, dysmorphic features, signs of respiratory distress, organomegaly, strength testing by observation, fasiculations, primitive and deep tendon reflexes and muscle tone
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__________ indicates metabolic disease.
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Organomegaly
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_______ ________ is not necessarily indicative of MD.
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Speech delay
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What should you ALWAYS send with a motor delay?
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Creatinine Kinase
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If the serum CK is high this points to ______ ________.
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Muscle disorder
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What are myopathies?
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Spectrum of disorders characterized by weakness
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When is CK the highest?
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Early in muscle disease
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If the disease progresses, CK will ________ _______ _______.
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Return to normal
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AST may have _______ elevation in MD.
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Mild
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Why should a ECG be done in patients with MD?
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Conduction defects or arrhythmias may occur later in disease
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Why is a muscle biopsy rarely done in the dx of MD?
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Because have genetic testing
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What will a CXR show in patients with MD?
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Large cardiac silhouette if there is cardiomyopathy
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MD is an ____ linked disorder.
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X
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What’s the difference between Beckers and Duchenne’s?
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Duchenne’s is a complete absence of dystrophin whereas Beckers is a partial absence of dystrophin
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What are the common signs and symptoms of MD?
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Mild delay in motor and languge, proximal muscle weakness, Gowers, calf pseudohypertrophy and trendelenburg gait
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What’s the tx for MD?
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Steroids prolong walking, scoliosis repair can preserve pulmonary function, assisted ventilation and cardiac regimen
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How long do patients with MD live?
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Into 30’s
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What’s the mean IQ of people with MD?
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80
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What emotional problem becomes more common as patients with MD age?
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Anxiety
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T or F: Learning disabilities are more common in patients with MD?
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True, ADHD, OCD and ASD more common
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A TSH must be done in order to r/o thyroid disease before _____ ______ dx.
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Muscular Dystrophy
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What do you need to ask about with weakness?
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Start, progression, change in motor skills, vision changes, pain, is weakness localized, proximal or distal, periodic, relieving factors, tenderness, rash, weight loss, fatigue or pain, family history of neuromuscular disease, change in bowel or bladder habits, toxin exposure, systemic symptoms, is weakness intermittent, cramping upon exertion, eyelid droop, reflexes, weakness symmetrical, symmetry of reflexes, does weakness follow anatomical pattern and excessive lumbar lordosis
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What should you look for on PE with weakness?
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Is it generalized or only in legs, signs of hypotonia, hand grasps present and equally strong, gait, pseudohypertrophy of calf muscles, Gowers maneuver, anal reflex, cremasteric reflex and high foot arch
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Hypotonia is ______ in origin whereas weakness may be ___________.
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Central, peripheral
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With CP, patients have ______ at birth and then develop hypertonia.
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Hypotonia
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High foot arch is a sign of?
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Peripheral disease
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What are the neurological differentials for weakness?
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Spinal cord tumor, spinal dysraphism and MS
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What are the myopathic differentials for weakness?
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Duchenne/Becker MD, SMA
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What are the infectious/postinfectious differentials for weakness?
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Botulism, Guillan Barre Syndrome and tick paralysis
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What is Guillan Barre?
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Ascending neuropathy
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What’s the major problem with Guillan Barre?
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Respiratory failure
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How will an infant with Botulism present?
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Constipated with a weak cry
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How does tick paralysis go away?
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With tick removal
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SMA 1 is a ________ disease and a ______ motor neuron disease.
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Muscle, motor
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SMA 1 is an autosomal _______ defect in the _______ ______ _______ gene.
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Recessive, survivor motor neuron
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What’s type 1 SMA?
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Cannot sit independently
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What’s type 2 SMA?
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Can sit but can’t walk
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What’s type 3 SMA?
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Can walk (for a time)
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What’s the treatment for SMA?
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Supportive – respiratory, nutrition, palliative
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T or F: patients with SMA have low IQ?
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False, have normal IQ
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T or F: Hypotonia = hypermobility
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False
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What should be evaluated in DTR’s with hyper/hypotonia?
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Look for spread
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What do spreading DTR’s indicate?
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Increased tone
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How do you check for proximal strength in kids?
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Have them spread open their hand and not let you close
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With central hypotonia, the DTR’s may be _________ but with peripheral hypotonia, the DTR’s are likely ________.
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Normal, depressed
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What are the genetic syndromes associated with hypotonia?
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Trisomy 21, Ehlers Danlos syndrome, Prader Willi, Fragile X and Laurence Moon Biedle syndrome
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What are the endocrine differentials for hypotonia?
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Congenital hypothyroidism and disorders of the parathyroid
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Static encephalopathies due to what can cause hypotonia?
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Congenital malformation, perinatal or postnatal acquired encephalopathy
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What are the congenital brain anomalies that are differentials for hypotonia?
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Dandy walker cyst, Arnold Chiari malformation and hydrocephalus
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What are the symptoms of Angelman Syndrome?
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Hypotonia, significant development delay and fascination with water
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What chromosomal disorders cause hypotonia?
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Trisomy 21, Klinefelters, deletions and duplications and deletion 22q11 syndrome
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What are the common genetic disorders that have hypotonia?
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Fragile X, Duchenne MD, Mitochondrial myopathies, neurofibromatosis, myotonia muscular dystrophy, Prader Willi and spinal muscle atrophy
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What are the red flags for motor disease?
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Elevated Ck (3x normal values), fasiculations, facial dysmorphism, organomegaly, signs and symptoms of heart failure, early joint contractures, abnormalities on brain MRI, respiratory insufficiency, loss of motor milestones
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What does elevated CK indicate?
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Muscle destruction, MD
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What do fasiculations indicate?
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Lower motor neuron disorder (SMA)
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What do facial dysmorphism, organomegaly, heart failure and contracture indicate?
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Glycogen storage disease
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What do brain abnormalities indicate?
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Neurosurgical consult
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What does respiratory insufficiency indicate?
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Neuromuscular disease with risk of respiratory failure
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What does loss of motor milestones indicate?
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Neurodegenerative disorder
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What is classic of upper motor neuron disease?
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No atrophy, no fasiculations, spastic tone, hyperreflexive DTR’s and up Babinski
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What is class of lower motor neuron disease?
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Severe atrophy, fasiculations are common, decreased tone, absent or diminished DTR’s and down Babinski
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What is classic of muscular disease?
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No atrophy, no fasiculations, normal of decreased tone, normal or hypoactive DTR’s and down Babinski
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How should you assess macrocephaly?
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Transilluminate the head, listen for canal bruits, signs of increased ICP, signs of neurocutaneous disease, extraocular movement esp upward gaze and bony abnormalities
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What are the signs of neurocutaneous disease?
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Café au laite spots, multiple epidermal nevi and hypopigmented macules
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What are the anatomic causes of macrocephaly?
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Due to an increase in brain substance as a result of an increase in size and number of brain cells
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What are the genetics of macrocephaly?
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Parental HC is large and child’s development is normal and neuro exam is normal
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What syndromes are associated with macrocephaly?
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Neurocutaneous syndromes, achondroplasia, cerebral gigantism and Fragile X
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What are the metabolic causes of macrocephaly?
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Due to a deposit of metabolic products without an increase in cells
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What is external hydrocephalus?
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Benign enlargement of the subarachnoid space in the frontal or frontoparietal region
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How does external hydrocephaly present?
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Macrocephaly with a full but pulsatile anterior fontanel with normal ventricles, head size increases rapidly but then parallels the growth curve
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What should you do with external hydrocephalus?
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Refer to neuro but its benign
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What is microcephaly?
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HC that is 2 standard deviations below the mean for age and gender
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In a normal small head the brain should…?
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Appear normal in suical pattern and have no destruction lesions
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If the head is 3 standard deviations below the mean…?
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There is a higher incidence of developmental delay with cognitive impairment
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What is primary microcephaly?
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Lack of brain development
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There is a autosomal _______ form of familial microcephaly that is _______.
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Dominant, mild
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Autosomal ________ familial microcephaly occurs when parents have normal sized head and is associated with ______ ________ ________.
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Recessive, severe mental retardation
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When the fontanel closes early, there is a ______ in brain development.
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Decrease
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What is secondary microcephaly?
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Result of insult occurring to a normal brain during the last part of the third trimester, during delivery, neonatal period or in early infancy
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What causes microcephaly during the perinatal period?
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Vascular damage to the developing brain from neonatal stroke, thrombosis of the vessel, hypoxic-ischemic injury, intracranial hemorrhage and congenital infection
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What’s the most common form of brain injury?
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Hypoxic-ischemic injury
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What’s the most common injury in term infant?
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Neuronal injury
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What’s the most common injury in preterm infant?
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Oligodendroglial or white matter injury
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Always refer patient with microcephaly to what 3 places?
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Neuro, audiology and ophthalmology
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What is CP?
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A group of permanent disorders of the development of movement and posture that cause activity limitations that are attributed nonprogressive disturbances that occurred in the developing fetal or infant brain
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What is CP often accompanied by?
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Disturbances of sensation, perception, cognition, communication and behavior
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T or F: CP is a static disease?
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True
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What is the spasticity of CP like?
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Velocity dependent resistance to movement caused by a hyperexcitable stretch reflex
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Spasticity in CP is usually accompanied by?
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Hyperreflexia and clonus
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You see a persistence in ________ reflexes especially _______ _______ in CP?
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Neonatal, tonic neck
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What is the spasticity in CP caused by?
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Abnormal processing of afferent activity that generates excessive force to the motor unit
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What happens at 6 months in CP?
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Scissoring and can’t pull a cloth of themselves
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If you see hypotonic CP what should you think about?
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Metabolic disease
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Children with CP are often hypotonic during the ______ _____ of life.
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First year
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What if hypotonia persists beyond first year of life in CP?
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CP may not be dx
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What work up should be done with hypotonic CP?
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MRI, CT, genetics, EMG, muscle biopsy if needed
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T or F: Neuroimaging is recommended in CP?
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True
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In children with quad CP diagnostic testing for what should be done?
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Coagulation disorders
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T or F: Metabolic and genetic studies should be regularly obtained in the evaluation of a child with CP?
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False
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When should metabolic/genetic testing be considered in CP?
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If the history and findings do not determine a structural abnormality or if there are atypical features in the history or clinical exam
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Detection of a _______ ________ in a child with CP warrants consideration of an underlying genetic or metabolic disease
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Brain malformation
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T or F: Kernicturus is a common cause of CP?
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False
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Who complains of headaches the most?
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Adolescents
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Before puberty _______ are affected more by migraines but in adulthood ______ are more affected.
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Males, females
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How do you assess headaches?
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Begin, frequency, change in frequency, how did it start, when during the day do they happen, how long, where located, what makes better or worse, warning signs, associated symptoms, associated with food, what meds, medical/psych history, personality changes, drug/alcohol use
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Migrains are not _________ but TTH can occur _______ or several times per week.
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Daily, daily
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What are cluster headaches?
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Occur in clusters of 2-3 per week over a few weeks and then disappear for some time
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Headache associated is what?
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An ominous sign
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Headaches that are predominantly notcural or early morning and associated with vomiting deserve what?
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Neuroimaging
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TTH can last how long?
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Entire day
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How long do migraines last?
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1-72 hours
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Bitemporal headache is associated with what?
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Migraines
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TTH occurs where?
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Around the head
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Occipital headaches are what?
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Ominous sign
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What type of auras should get neuroimaging?
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Unilateral
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Lightheadedness suggests what?
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Cerebral hypotension or orthostasis
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Unsteadiness or vertigo suggests what?
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Balance disorder suggesting the need for neuroimaging to R/O vestibular or cerebellar pathology
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T or F: Migraines can have a trigger?
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True
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Benign headaches shouldn’t have what?
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Change in school performance, behavior or personality
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Pallor with headache = what?
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Migraine
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If a female adolescent presents with headache what else should you ask about?
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OC
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Headache with purulent nasal discharge is what?
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Sinusitis
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Children with migraines will have increased _______ disturbances.
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Sleep
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Seizures + headaches get what?
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Neuroimaging
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What are the red flags for headaches?
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Sudden onset, occipital, worsening pattern, with systemic illness, focal neurologic signs other than aura, papilledema, triggered by valsalva, cough or exertion and during pregnancy/postpartum
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What are the worrisome symptoms with headache?
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Early morning headache, progressive headache, persistent vomiting, changes in language skills, changes in motor skills, worse with coughing, sneezing or straining, diplopia, visual field defects and impaired school performance
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What are the worrisome signs with headaches?
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Ataxia, macrocephaly, neurocutaneous syndrome, problems with upward gaze, changes in mental status, growth abnormalities, precocious puberty, nuchal rigity, hemiparesis and seizures
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What are the most common headaches?
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Tension, migrain and psychogenic
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What are the somewhat common headaches?
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Ass. w/viral illness, tooth pain and sinuses
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What is the least common type of headache?
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Brain tumor
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What are the differentials for acute headache?
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Fever, sinusitis, viral illness, migraine, acute bleed, increased ICP and pseudotumor cerebri
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In children it may be difficult to distinguish between migraine and TTH due to what?
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Developmental level of child
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Secondary headaches are due to what?
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Variety of injuries, illnesses and disorders
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What is TTH?
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Tightening feeling with or without associated photophobia but without N/V or exacerbation with activity
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In the absence of other symptoms, recurrent headaches of more than 3 months duration are ______ due to an organic cause?
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Rarely
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What type of headache feels like a band around the head?
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TTH
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What’s the patho of TTH?
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Neurobiologic basis
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Central pain mechanisms play a role in __________ TTH and peripheral pain mechanisms play a role in __________ TTH.
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Frequent, infrequent
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What’s the tx for TTH?
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NSAIDS, nonpharmacologic measures and avoiding triggers
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Migraines are usually _________ and ______ in children.
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Frontotemportal and bilateral
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What are the signs and symptoms of migraines?
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Recurrent headache with symptom free intervals with at least 3 of the following: visual, sensory or motor aura, abdominal pain, N/V, throbbing headache, unilateral location, relief after sleeping and positive family hx
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T or F: NSAIDS can lead to chronic daily headache.
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True
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What’s the common migraine?
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No aura, positive family history, abdominal pain, N/V, throbbing headache, unilateral location
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What’s the classic migraine?
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With aura, may have vertigo, lightheadedness, perioral parethesia, numb hands and feet
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What’s childhood periodic syndrome?
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Benign paroxysmal torticollis, cyclic vomiting, abdominal migraine and benign paroxysmal vertigo
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T or F: cluster headaches are common in children?
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False, rare
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What are complicated migraines?
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Neurologic signs occur during the headache persist, suggests underlying structural lesion
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What does benign paroxysmal vertigo?
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Migraine variance, gets dizzy, sits down, goes away, walks normal
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Who gets benign paroxysmal torticollis?
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2-8 month olds
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What’s the main symptom of BPT?
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Torticollis
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What are symptoms associated with BPT?
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Pallor, vomiting and changes in behavior
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T or F: Benign Paroxsymal Torticollis can become vertigo?
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True
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Who gets cyclic vomiting?
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4-10 year olds
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What’s the main symptom of cyclic vomiting?
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Vomiting with nausea associated with migraine
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What symptoms are associated with cyclic vomiting?
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May be triggered by something and associated with pallor
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How long does cyclic vomiting last?
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Occurs frequently and regularly and can last for several hours
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Who gets abdominal migraines?
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School age children
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What’s the main symptom of abdominal migraines?
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Abdominal pain which is crampy and located in the periumbilical or epigastric area
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What symptoms are associated with abdominal migraines?
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Vague headache and motion sickness
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What migraines get referrals?
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Complicated, hemiplegia, ophthalmologic and basilar
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What are complicated migraines?
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Headaches that are accompanied or manifested by transient neurologic symptoms that may occur immediately before, during or after the headache
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T or F: Hemiplegic migraines are common
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False, unusual
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What is a hemiplegic migraine?
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Characterized by abrupt onset of hemiparesis which is usually followed by a headache
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What is a ophthalmoplegic migraine?
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May occur at any age and is usually associated with orbital or periorbital pain and involvement of cranial nerve 3,4 or 6
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Basilar artery migraines are more common in who?
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Females
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What are basilar artery migraines characterized by?
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Dizziness, weakness, ataxia and severe occipital headache with vomiting
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What foods are associated with migraines?
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Cheese, chocolate, citrus, hot dogs, ham, cured meat, dairy, fatty and fried foods, Asians, frozen snack food, coffee, tea, cola, food dyes, additives, wine, beer, fasting and artificial sweeteners
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What are the chemical triggers for migraines?
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Tyramine, phenylethylamine, nitrates, nitric oxide, allergenic proteins, caffeine (withdrawal), histamine, aspartame, sulfites
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What are common migraine triggers?
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Menses, stress, anxiety, OC, physical exertion, fatigue, lack of sleep, glare and hunger
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What are less common migraine triggers?
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Reading, refractive error, cold food, high altitude and drugs
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Guidelines show ___ value in routine LP or EEG in migraines.
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No
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EEG is recommended if there are _____ or ______ components to the migraine.
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Motor, sensory
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Neuroimaging is recommended for migraines with what hx?
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Worsening headache, changes in type of headache, changes in neurological function, changes in school performance, onset of severe headache and occipital headache
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When must you tx a migrain?
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At onset of attack
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What are 1st line meds for migraines?
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NSAIDS
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What are 2nd line meds for migraines?
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Amytriptaline
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NSAID with what work amazing for migraines?
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Coke
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T of F: Codeine works well with migraines?
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False
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What’s nonmedical therapy for migraines?
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Stress reduction, biofeedback, avoid triggers, good sleep, exercise, avoiding rebound agents, adequate hydration, massage
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What are primary causes for organic headaches?
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Mass lesion, hydrocephalus, intracranial hypotension and pseudotumor cerebri
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What’s the most common cause of chronic progressive headache?
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Brain tumor
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T or F: AVM will have no warning signs
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True
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Mass lesions will have what kind of headache?
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Steady with deep aching pressure that increases with exertion, position changes, cough and defecation
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What are the signs of brain tumor?
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Vomiting without nausea, neurologic abnormality, 6th nerve palsy, decreased visual acuity, seizures with headache, less than 6, deceleration of growth and focal neurological symptoms
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What are the psychological/behavioral signs of brain tumor?
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Drowsiness, irritability, change in eating habits, temper tantrums, anxiety, mood swings, poor concentration and recent school failure
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What does diencephalic syndrome look like?
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Posterior fossa tumor, FTT and wasting
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The brain is divided into an upper and lower section by the what?
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Tentorium
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What are the supratentorial tumors?
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Cerebrum, pituitary gland, hypothalamus, basal ganglia and pineal region
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What are the infratentorial tumors?
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Cerebellum, brain stem and fourth ventricular region
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What are the most common types of brain tumor?
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Glial cell (most common), ependymomas, astrocytomas, oligodendroglioma, embryonal or primitive neuroectodermal tumor
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Which genetic diseases have higher incidence of brain tumors?
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Neurofibromatosis, tuberous sclerosis, multiple endocrine neoplastia and retinoblastoma
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Where do ependymomas come from?
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Arise from the cells that line the ventricles, mostly the 4th ventricle affecting the cerebellum and pons
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Ependymomas _____ rather than ________ brain tissue.
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Displace, invade
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What are the signs of an ependymoma?
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Headache, vomiting, head tilt, torticollis, clumsy movement, dysmetria and dysphonia
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What are the most common types of PNET?
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Medulloblastoma
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How does PNET present?
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Unsteady gait, vomiting and signs of increased ICP
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A tumor below the tentorium will have what?
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Ataxia
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What is a concussion?
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Clinical syndrome of biomechanically induced alteration of brain function typically affecting memory and orientation which may involve LOC
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What’s worse concussion or mTBI?
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MTBI
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Reinjury with a concussion can ______ problems.
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Worsen
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What’s second impact syndrome?
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2 or more head injuries in a 2 week period, associated with subdural hematoma and malignant cerebral edema
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Why do people die with second impact syndrome?
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Because of the cerebral edema
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T or F: kids will make up what they can’t remember with concussions?
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True
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What are the 2 worst sports for head trauma?
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Football and hockey
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Which gender doesn’t do so well with concussions?
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Females
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Does the age of the patient matter with concussions?
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Apparently no
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Who’s at the highest risk for concussions?
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Females who play soccer basketball
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Which sports have the highest incidence of concussions?
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Football and Australian rugby
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What kind of headgear should kids use?
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Cover entire head
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Which football positions are the worst?
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Linebacker, offensive linemen and defensive back
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BMI greater than what increases concussion risk?
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27
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What 2 concussion scales does the American Academy of Neurology recommend?
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Post concussion symptom scale and graded symptom checklist
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What is the standardized assessment of concussion?
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A 6 minute administration looking at 4 neurocognitive domains, orientation, immediate memory, concentraion and delayed recall
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T or F: In some states, players can’t return to sports after head injury until cleared by provider?
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True
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Who’s in higher danger of having ongoing concussive symptoms?
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Younger, higher level play, peewee hockey because body checking
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What are the risk factors for prolonged RTP?
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Dizziness, quarterbacks and only wearing half a face shield and playing on artificial turf, early posttraumatic headache, fatigue, fogginess, early amnesia and alteration in mental status
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What are the physical symptoms of concussion problems?
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Headache, nausea, vomiting, fatigue, dazed, stunned, dizziness and balance problems
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What are the cognitive symptoms of concussion problems?
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Feeling foggy, feeling slowed down, answers questions slowly, difficulty concentrating, forgetful of recent events, repeats questions and drop in academic performance
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What are the emotional symptoms of concussion problems?
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Irritability, sadness, depression, personality change, anxiety, panic, more or less emotional
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What are the symptoms associated with sleep in concussion problems?
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Drowsy, sleeping more, sleeping less, difficulty falling or staying asleep
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What happens immediately with concussions?
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LOC, amnesia and confusion
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What happens during the intermediate time with concussions?
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Temperature dysregulation, water imbalance and sleep disturbances
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What are long term complications of consussions?
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Cognitive, memory and balance
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What are the concussion diagnostic tools?
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Concussion symptoms score, pocket SCAT2, on smart phone
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How do you approach a concussion?
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1. Reach out (educate family), 2. Recognize, 3. Response, 4. Refer (if you think more than a concussion), 5. Rest, 6. Return to play (graduated), 7. Release (if OK in 2 weeks)
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What should you do you concussion symptoms don’t go away in 2 weeks?
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Refer
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What meds do you give concussions?
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Tyelenol, Advil (only after 48 hours), Amitriptyline and Triptan (concern about reduction in cerebral blood flow)
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What helps with sleep in concussions?
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Malatonin, Amitriptyline and Benzo
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Where are linear skull fractures most common?
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On parietal bone
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Why do infants get skull more often?
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Because they have thinner skull
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What diagnostic tool is a good choice to assess depressed fracture?
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CT
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Intracranial bleeding can be seen on what?
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CT
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_______ ________ can follow fracture as a long term complication.
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Leptomeningeal cyst
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Linear skull fractures almost always heal without _____.
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Complications
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What should you monitor for with a linear skull fracture?
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If it grows over months, observe skull defect or swelling, neurological changes
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What’s a basilar skull fracture?
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When you get punched in the nose
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Depressed skull fractures can present with _____ _______ of the skull.
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Bony abnormalities
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A depressed fracture may?
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Lacerate the dura, compress the underlying brain parenchyma or intraparenchyma bone fragments, produce an obvious cosmetic deformity
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Basilar fractures that occur through the temporal bone may what?
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Disrupt the mastoid air cells or paranasal sinuses
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A dural tear can occur following a fracture causing what?
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CSF leak with resultatant CSF otorrhea or rhinorrhea
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Hearing loss and cranial nerve 6,7,8 impairment can follow what?
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A basilar skull fracture
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When an obese patient presents with a headache what should you always look at and why?
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The optic disk because pseudotumor cerebri
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What are the risk factors for pseudotumor cerebri?
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Venous thrombosis, otitis media, obesity, meds, Addisons, mild head injuries, SLE, IDA, steroid withdrawal, hypoparathyroidism, pregnancy and cystic fibrosis
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