1. Neurological conditions and
diseases
Post Basic Paediatrics
18 April 2012

2. Neurological conditions and
diseases
Part I
– At birth (Congenital, acquired)
Macrocephaly
Microcephaly
Spine defect
Other developmental defect
Birth trauma/HIE
Part II
– During development (Congenital, acquired)
Meningitis
Seizure
Headache
Stroke/Vascular
Neoplasm/Tumour
Trauma
Coma

3. Neurological conditions and
diseases
Part II
During development
(Congenital, acquired)

4. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

5. Meningitis
Inflammation of the meninges
Most common infection of the CNS
Most cases (70%) occur in children <5 years old
May be secondary to other localized or systemic infections
(e.g., otitis media).
Two primary classifications
– Viral
– Bacterial
– Others: fungi and (rarely) parasites
Morbidity is also high.
About 30% of survivors have some sequelae of their
disease
However, these complications can be reduced if meningitis
is treated early.

6. Assessment
Viral meningitis
– Infants and toddlers
Irritability, lethargy, vomiting
Change in appetite
– Older children
Usually preceded by a nonspecific febrile
illness
Headache, malaise, muscle aches, nausea/
vomiting, photophobia, nuchal/spinal rigidity

7. Assessment
Bacterial meningitis
– Infants and toddlers
Poor feeding/suck, vomiting, high-pitched
cry, bulging fontanel, fever or hypothermia,
poor muscle tone
– Children and adolescents
Abrupt onset
Fever, chills, headache, nuchal rigidity,
vomiting, changes in LOC, photophobia,
extreme irritability

8. Assessment
In children <1 month old:
– group B Streptococcus, Escherichia coli
In children 4-12 weeks old:
– E. coli, Hemophilus influenzae type B,
Streptococcus pneumoniae, group B
Streptococcus, Neisseria meningitidis
(meningococcal)
In children 3 months to 18 years old:
– Streptococcus pneumoniae (most common
cause), N. meningitidis, H. influenza type B
(rare)
– Mycobacterium tuberculosis

9. Assessment
PHYSICAL EXAM
- Temperature- elevated
- Tachycardia or bradycardia with increased intracranial
pressure
- Blood pressure normal (low if septic shock has occurred)
- Child in moderate-to-acute distress
- Flushed
- Level of consciousness variable
- Possible enlargement of the cervical nodes
- Focal neurologic signs:
- photophobia
- nuchal rigidity (in children >12 months old)
- positive Brudzinski's sign ( in children >12 months)
- positive Kernig's sign (in children >12 months )

10. Differential Diagnosis
Bacteremia
Sepsis
Septic shock
Brain abscess

11. Complication
Seizures
Coma
Blindness
Deafness
Death
Palsies of cranial nerves III, VI, VII,
VIII

12. Lumbar puncture
Patients at greatest risk for meningitis
– under 18 months of age
– seizure in the ED
– focal or prolonged seizure
– seen a physician within the past 48 hours
Other indications
– concern about follow-up
– prior treatment with antibiotics
The American Academy of Pediatrics
“strongly consider” in infants under 12
months of age with a first febrile seizure

13. Management: Nursing Interventions
Place child in isolation until 24 hours of antibiotic
therapy has completed
Administer antibiotics (7-14 days)
Fever control
Monitor for signs of ICP
Monitor for fluid overload
Viral meningitis is treated symptomatically

14. Prevention and Control
Meningitis Caused by Hemophilus influenzae
– A vaccine is now routinely given to infants as
part of the usual childhood immunizations.

15. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

16. Seizure
Febrile seizure
Epilepsy - two or more seizures not
provoked by a specific event such as fever,
trauma, infection, or chemical change
Neonatal seizures
Status epilepticus

17. Febrile seizure
Definition: Convulsions occurring in association
with fever in children between 3 months and 6
years of age, in whom there is no evidence of
intracranial pathology or metabolic derangement.
- No signs or history of underlying seizure disorder
- Often familial
- Uncomplicated and benign if seizure is of short
duration (<15 minutes), only 1 in 24 hours, and
normal CNS exam after seizure
- Involves tonic-clonic movements, bilaterally
- Associated with temperature >38°C

18. Epidemiology
Age 3mo – 5yrs
Peak age 9-20 months
2-5% children will have before age 5
25-40% will have family history
80 – 97% simple
3 - 20% complex

19. Management
Control fever
– take off clothing and tepid sponging.
– antipyretic e.g. syrup or rectal Paracetamol 15
mg/kg 6 hourly.
– antipyretic is indicated for parent’s comfort,
but has not been shown to reduce the
recurrence rate of febrile convulsion.

20. Epilepsy
Definition: a neurological condition
characterised by recurrent unprovoked
epileptic seizures
ILAE Classification of seizure types:
– generalized
LOC
tonic, clonic, tonic-clonic, myoclonic, atonic, absence
– partial – focal onset
simple partial – no LOC
complex partial – LOC
partial secondarily generalized
– unclassified

21. Epilepsy: Etiology
infectious
metabolic
traumatic
toxic
neoplastic

22. Epilepsy: Differential diagnosis

23. Neonatal seizure
brief and subtle
– eye blinking
– mouth/tongue movements
– “bicycling” motion to limbs
typically seizure’s can’t be provoked/ consoled
autonomic changes
EEG less predictable

24. Neonatal seizure
Etiology
– hypoxic-ischemic encephalopathy
Presents within first day
– congenital CNS anomalies
– intracranial hemorrhage
– electrolyte abnormalities – hypoglycemia and
hypocalcemia
– infections
– drug withdrawal
– pyrodoxine deficiency

25. Status Epilepticus
Definition
– Seizure lasting >30 mins
– sequential seizures without regain LOC >30min
Mortality in pediatric status epilepticus 4%
Morbidity may be as high as 30%

26. Treatment
Correct underlying pathology, if any
Antipyretics ineffective in febrile seizure
Anti-epileptic choice often trial and error
no anti-epileptic 100% effective
febrile seizure – diazepam, phenobarbital, valproic acid
– Currently AAP does not recommend
neonatal - phenobarbital
generalized TC – phenytoin, phenobarbital, carbamazepine,
valproic acid, primidone
absence – ethosuximide, valproic acid
new anti-epileptics – felbamate, gabapentin, lamotrigine,
topiramate, tiagabine, vigabatrine
in consultation with neurologist

27. Neuroimaging
Neuroimaging (preferably MRI) is indicated for
any child with
– epilepsy occurring in the first year of life,
except febrile seizures
– partial epilepsy except benign rolandic epilepsy
– developmental delay or regression

28. EEG
EEG is important to support the:
– clinical diagnosis of epileptic seizures,
– Classify the epileptic syndrome,
– selection of anti-epileptic drug and prognosis
– helps in localization of seizure foci in
intractable epilepsy
Consider in:
– persistent altered mental status (?non
convulsive status epilepticus)
– paralyzed patients
– pharmacologic coma

29. Disposition
can be discharged home if
– single seizure
– stable, returning to baseline neuro
status
– no underlying condition/cause requiring
treatment in hospital
– arranged follow-up

30. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

31. Headaches
Occurs in 20% of school-age children. Onset may
occur at any age
The most common causes of headache in
children:
- benign vascular headaches (leading to
migraine)
- muscle contraction (leading to tension
headaches)

32. Headaches: classification
Classify based on temporal pattern
– acute headaches
any febrile illness, sinus/dental infection,
intracranial infection/bleed
(AVM,SAH,trauma)
– acute recurrent
– chronic progressive
– chronic non-progressive
tension, psychogenic, post-traumatic, ocular
refractive error

33. Headaches: Etiologies
Vascular / Organic Causes
- Arteriovenous malformation
- Berry aneurysm
- Cererbral infarction
- Intracranial hemorrhage
Other causes
– Infection
– Trauma
– Toxic Effects
– Psychogenic
– Organic -Traction
– Food allergy or sensitivity
– Refractive error
– Ocular muscle imbalance
– Temporomandibular joint (TMJ) dysfunction
– Hypertension

34. Acute Recurrent Headache
migraine
other
– cluster headache – typically >10 yo
– sinusitis
– vascular malformation

35. Organic –Traction
Result of an abnormality in the brain or skull
- Headaches increase rapidly in frequency and
severity
- Headache is worst upon awakening in the
morning, diminishes during the day
- Headache wakens child from sleep
- Aggravated by coughing or valsalva maneuver
- May be relieved by vomiting
- Associated symptoms: focal neurological findings;
altered gait; changes in behavior, personality,
cognition or learning ability

36. Migraine
- Headache -pulsatile (throbbing)
- Headaches are periodic, separated by symptom-
free intervals
- Associated with at least three of the following
symptoms: abdominal pain and nausea or
vomiting, aura (motor, sensory, visual), family
history of migraine
- Unilateral or bilateral
- Headache relieved by sleep

37. Tension Headache
- Band-like tightness or pressure in the
bifrontal, occipital or posterior cervical
regions
- Seen at any age
- Lasting for days or weeks but not
disrupting regular activities
- Not associated with a prodrome
- Associated symptoms: tight neck muscles,
sore scalp, nausea, vomiting and aura are
uncommon

38. Refractive Error
- Persistent frontal headache, which is worse while
reading or doing schoolwork

39. TMJ Dysfunction
- Temporal headache
- Associated symptoms: local jaw discomfort,
malocclusion (crossbite), decreased range of
motion of mouth, click with jaw movement,
bruxism (grinding of teeth)

40. Chronic Sinusitis
- Frontal headache
- Tenderness to percussion over the frontal,
maxillary or nasal sinuses
- Associated symptoms: prolonged rhinorrhea and
congestion, chronic cough and postnasal drip,
anorexia, low-grade fever, malaise
- It is unusual for children <10 years old to have
recurrent headaches secondary to chronic
sinusitis

41. Chronic Progressive Headache
least common presentation
classically based on historical and physical
– sudden severe headache
– rapid increase over days - weeks
– suggestive of increased ICP
severe nocturnal headache (wakes or upon
waking), changes in pain with position,
coughing
– pseudotumor cerebri
– space occupying lesion
– following head trauma
Imaging
– CT
– MRI preferred in non-urgent indication

42. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

43. Stroke/Vascular
Arteriovenous malformation
Cerebrovascular accident, or stroke

44. Arteriovenous malformations
Cerebral arteriovenous
malformations occur in about 1 in
100, 000 of the population
They are the most common
cerebrovascular lesions in children.
AVMs are congenital lesions which
occur as a result of a malfunction
in the normal separation of arteries
and veins during embryonic
development.
AVMs in the CNS are more common
above the tentorium, particularly
around the middle cerebral artery.

45. Arteriovenous malformations
The majority of AVMs are asymptomatic.
Often these malformations are only discovered
incidentally, usually during treatment for an
unrelated disorder.
AVMs that are symptomatic usually present in
young adulthood; the average age of
presentation in children is about 10 years of age.

46. Arteriovenous malformations
Generalized symptoms include seizures and
headaches, additionally, children with an AVMs
may present with a range of specific focal
neurological signs depending on the location of
the lesion, such as
– muscle weakness or hemiplegia,
– loss of coordination,
– visual disturbances,
– abnormal sensations or
– alterations in cognitive functioning.
Approximately 50 to 80 per cent of AVMs present
with signs and symptoms of raised intracranial
pressure as a result of intracranial haemorrhage

47. Arteriovenous malformations
Treatment options:
– Microsurgery
– Endovascular embolization
– Radiotherapy

48. Cerebrovascular Accident (stroke)
Defined as a clinical syndrome characterized by focal
neurological deficits caused by a sudden disruption of the
blood supply to the brain, lasting more than 24 hours
Stroke is much less common in children than in adults.
The estimated incidence of stroke in children is
approximately 3 in every 100,000 children
Stroke in children is more likely to occur in the presence of
underlying diseases, such as metabolic disorders,
haematological disorders (particularly sickle cell anaemia),
congenital cardiac disease and moyamoya disease

49. Cerebrovascular Accident (stroke)
General care of a child who has had a stroke includes
maintaining normal temperature, ensuring adequate
oxygenation and consideration of aspirin in ischaemic
stroke
In the case of moyamoya disease improvements to cerebral
blood flow, as a result of intracranial internal carotid
occlusion, can be made by performing vasoreconstructive
surgery (bypass surgery).
The outcome following stroke in children is variable but
survival is thought to be better than in adults
The survival rate following stroke in children has been
estimated to be about 85 per cent

50. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

51. Childhood Malignancies
Cancer is the most common cause of disease
related deaths in children 1-19 years
Incidence has increased slowly, but mortality
rates have declined significantly

52. Brain Tumours
Primarily infratentorial involving cerebellum,
midbrain, brainstem
Glial( cerebellar astrocytomas most common)
Presentation
- Poor feeding, Vomiting , FTT( failure to thrive)
- Arrest or regression of developmental
milestones
- Morning headache, increased head
circumference
( hydrocephalus)
- Diplopia, nystagmus, papilloedema
- Focal neuro deficits (+Cranial nerves),
seizures, ataxia

53. Brain Tumours: Diagnosis and Mx
Comprehensive history and complete PE
Careful CNS exam
Rule out other causes -
infection/trauma/metabolic
CT head and/or MRI
Referral to neurosurgery

54. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

55. Head Injuries
HISTORY-Ascertain the following:
- Mechanism of injury
- Time of injury
- Loss of consciousness (a brief seizure at the time of
injury) may not be clinically significant
- Loss of memory , amnesia
- Irritability
- Visual disturbance
- Disorientation
- Abnormal gait
- Lethargy, pallor or agitation may indicate severe injury
- Vomiting
- Symptoms of increased intracranial pressure (vomiting,
headache, irritability)

56. Head Injuries
Physical Examination
- Vital Signs
- Tachypnea:
- Bradycardia (with hypertension - Cushing
response):
- Hypertension
- Hypotension

57. Head Injuries
Signs of Skull Fracture
- Hemotympanum
- Periorbital or post-auricular ecchymosis
- Cerebrospinal fluid otorrhea or rhinorrhea
- Depressed fracture or penetrating injury
- Palpate scalp for hematomas and contusions,
underlying depressions, which may signify
depressed skull fracture

58. Head Injuries
Neurologic Examination
- Pediatric Glasgow coma scale
- Papilloedema
- Pupillary light reflexes
- Cranial nerve examination
- Movement of extremities
- Abnormal posture (decorticate or decerebrate)
- Muscle flaccidity, spasticity
- Plantar responses

59. Head Injuries
Mild GCS >12
Moderate GCS 9-12
Severe GCS <9

60. Management Mild Injury
Children with mild intracranial injury may be
discharged home
An instruction sheet should be given to the
parents or caregiver concerning observation and
precautions

61. Table 15-3: Instructions to Parents or Caregivers for
Observation at Home of Children with Head Trauma
Bring child back to clinic immediately if any of the
following signs and symptoms appear within the first
72 hours after discharge:
Any unusual behavior
Disorientation as to name and place
Inability to wake child from sleep
Increasing headache
Seizures
Unsteadiness on feet
Unusual drowsiness and sleepiness
Vomiting more than two or three times

62. Moderate To Severe Injury
- ABC’s first priority
- C-spine control
- Suture scalp lacerations, as major blood loss can
occur
- Start IV therapy with normal saline to keep vein
open (unless the child is in shock from other
injuries)
- Restrict fluids to 60% of normal intake (except in
cases of shock)
- Oxygen
- Elevate head of bed by 30° to 45°
- Place head and neck in midline position

63. Moderate To Severe Injury
- Minimize stimuli (e.g., suctioning and movement)
- To control increased intracranial pressure: above
measures
plus establish controlled hyperventilation
- CT scan of head
- C-spine x-ray
- Diuretics if intracranial pressure is increased (and
there is documented deterioration) despite
measures outlined above:mannitol, 0.5-1 g/kg IV
- Monitor ABCs, vital signs, pulse oximetry, level of
consciousness (with serial pediatric Glasgow
coma scores), intake and output

64. Pediatric Glasgow Coma Scale

65. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

66. Pediatric Coma
Most common pattern in children is diffuse
impairment of cerebral hemispheres
Less commonly results from brainstem
dysfunction
Differential Dx of causes:
– Trauma
– Insulin/hypoglycemia/inborn errors of
metabolism/intususception
– Psychiatric
– Seizures, stroke, shock, shunt malfunction
– Alcohol abuse
– Electrolytes, encephalopathy, endocrinopathy
– Infection
– Overdose/ingestion
– Uremia

67. Pediatric Coma-Initial
Approach
Primary Survey
- ABC;s - C-spine precautions
- Pediatric Glasgow Coma Scale
- Vital signs including rectal temperature
- Check for signs of obvious trauma
- Check for S&S of raided ICP
- Hypoglycemia- give glucose 0.5 g/kg( D50W, 1-2
ml/kg IV empirically - chemstrip sugar low
- Narcan empirically 0.1 mg/kg if pupils
small/pinpoint

68. Pediatric Coma-Initial
Approach
Secondary survey
- History - known underlying cause, acute fever,
trauma, ingestion, PMH, Medications, allergies,
last meal
- General CPX including CNS exam
- Look for evidence of infection, intoxication,
traumatic and metabolic causes
- Fontanelle, neck stiffness, neck bruits,
fundi( retinal hemorrhages), oculomotor
movements
- Breathing patterns
- Motor responses ( focalizing/lateralizing signs)

69. Pediatric Coma-Initial
Approach
Investigations - depends on potential etiology
and clinical condition
– Blood work may include:
- CBC, cultures, glucose, electrolytes, BUN, creatinine,
Calcium, magnesium, LFT’s, ammonium, blood clotting
screen, ABG
– Diagnostic Imaging
- CT of head essential if focal causes suspected e.g trauma
not if diffuse cause e.g infection
- CRX, C-spine XR, Flat plate of Abdomen, limb XR
- Urinalysis, C&S, latex agglutination
- LP- CSF analysis
- ECG
- EEG
Further management directed at underlying cause
Serial Glasgow coma scale assessments
Maintain homeostasis with Oxygen, IV fluids, electrolytes,
nutrition

70. During development (Congenital,
acquired)
– Meningitis
– Seizure
– Headache
– Stroke/Vascular
– Neoplasm/Tumour
– Trauma
– Coma

71. Thank You