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Peds. Neurolgic Disorders Salih Alhetela. Content ABM ABM Seizures Seizures Headache Headache Breath-holding spells Breath-holding spells.

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Presentation on theme: "Peds. Neurolgic Disorders Salih Alhetela. Content ABM ABM Seizures Seizures Headache Headache Breath-holding spells Breath-holding spells."— Presentation transcript:

1 Peds. Neurolgic Disorders Salih Alhetela

2 Content ABM ABM Seizures Seizures Headache Headache Breath-holding spells Breath-holding spells

3 ABM Acute Bacterial Meningitis

4 ABM Mortality of treated cases Mortality of treated cases 20%-40% neonate 20%-40% neonate 5%-10% infant/child 5%-10% infant/child Morbidity 25%-50% of survivors Morbidity 25%-50% of survivors Incidence Incidence Highest in the neonate, then Highest in the neonate, then 3-8 months 3-8 months < 2 years < 2 years > 90% of cases occur before 5 years > 90% of cases occur before 5 years

5 Q: What the causative organisms of ABM?

6 ABM Organisms Neonate GB strep >50% GB strep >50% E.coli & other coliform 25% E.coli & other coliform 25% S. epid., S. aureus S. epid., S. aureus S. pneumoniae S. pneumoniae N. meningitidis N. meningitidis GDS GDS HIB HIB INF. +CHILD HIB ? Less after vaccin 90 % caused by S. pneumoniae N. meningitidis Unusual organisms Salmonella Campylobacter Francisella

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

8 ABM Principle of disease Mechanical disturbances Surgical procedure Surgical procedure Skull fracture Skull fracture Cong. CNS abnormality Cong. CNS abnormality Intracranial cyst Intracranial cyst Epidermoid /dermoid tumors Epidermoid /dermoid tumors neurenteric fistula neurenteric fistula

9 ABM Principle of disease Subarachnoid space entrance Subarachnoid space entrance Haematogenous spread > 90% Haematogenous spread > 90% direct extension direct extension In the SA space In the SA space Endotoxin  inflammatory response  vascular and parenchymal changes Vasculitis, microthrombi, venous sinuses occlusion Vasculitis, microthrombi, venous sinuses occlusion Reduced blood flow, cerebral edema, hemorrhage Reduced blood flow, cerebral edema, hemorrhage

10 ABM clinical features Presentation 75% with nonspecific subacute presentation 2-5 days 75% with nonspecific subacute presentation 2-5 days 25% with acute illnesses <24 hrs 25% with acute illnesses <24 hrs Easier to diagnose Easier to diagnose Higher risk for death &complication Higher risk for death &complicationAge The younger the infant, the more nonspecific S/S The younger the infant, the more nonspecific S/S

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

12 Q: What is livedo reticularis sign? Generalized pallor accompanied by indistinctly outlined truncal patches of blue discoloration

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

14 Q: Describe kernig & burdzinski signs.

15 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

16 What is the indication for LP? s/s of meningitis s/s of meningitis Suspected neonatal sepsis Suspected neonatal sepsis Suspected ABM Suspected ABM Febrile infant 4-8 wks ? Febrile infant 4-8 wks ? Toxic appearance Toxic appearance Documented bacteremia Documented bacteremia Febrile illness after intimate contact Febrile seizures Fever and petechiae sepsis suspected in an abnormal host Penetration of dura Acute hearing loss

17 What is the normal and abnormal value of CSF glucose and protein ? Glucose Glucose Normal CSF serum glucose ratio 0.6 Normal CSF serum glucose ratio 0.6 < 0.4 is found in ABM +TB < 0.4 is found in ABM +TB Protein Protein Normal range is 40-170 mg/dl in neonate Normal range is 40-170 mg/dl in neonate Normal range is 15-45 mg/dl in children Normal range is 15-45 mg/dl in children Modestly elevated in viral M. Modestly elevated in viral M. Higher level in ABM +traumatic LP Higher level in ABM +traumatic LP

18 What is the normal range of CSF WBC in deferent age group? What is your threshold of abnormal? Preterm 0-44 >9 Preterm 0-44 >9 Newborn 0-32 >22 Newborn 0-32 >22 Neonate 0-50 >35 Neonate 0-50 >35 4-8 wks 0-50 >10 4-8 wks 0-50 >10 >8 wks 0-8 > 6 >8 wks 0-8 > 6 Classically WBC in ABM ranges from 1000-20000 Classically WBC in ABM ranges from 1000-20000 * wbc/mm3

19 How about PMN? <4 wks 60 % of WBC is PMN <4 wks 60 % of WBC is PMN >4wks not more than 3pmn/mm3 >4wks not more than 3pmn/mm3

20 How accurate is gram stain? Depend on number of bacterial organism present. Depend on number of bacterial organism present. 25% positive with 10 3 CFU/ml 25% positive with 10 3 CFU/ml 60% positive with 10 3 -10 5 CFU/ml 60% positive with 10 3 -10 5 CFU/ml 97% positive with 10 6 CFU/ml 97% positive with 10 6 CFU/ml

21 What is the DDX of ABM? Infectious : Infectious : Septicemia, subdural empyema, epidural abscess, (viral, fungal and TB meningitis ) Traumatic Traumatic Closed head injury, shaken impact syndrome Metabolic Metabolic Hypoglycemia, DKA, hypo/hypernatremia, uremia Others Others Toxin, seizure, brain tumer, ruptured dermoid cyst

22 Outline your management priority for ABM ? Airway protection and oxygenation Airway protection and oxygenation Volume resuscitation +/- pressor Volume resuscitation +/- pressor Prevention of hypoglycemia Prevention of hypoglycemia Control of seizures Control of seizures Maintain CBF/ and ICP control measures Maintain CBF/ and ICP control measures Antibiotic therapy Antibiotic therapy

23 When will you give the antibiotic for suspected ABM ?considering patient stability and risk Classically 1-2 hrs of presentation for all suspected ABM Classically 1-2 hrs of presentation for all suspected ABM Offered clinical scenario by Rosen Offered clinical scenario by Rosen Non toxic, low risk ---  blood  LP  wait Non toxic, low risk ---  blood  LP  wait Non toxic, high risk --  blood  LP  Non toxic, high risk --  blood  LP  Critical, stable  blood  ABx  LP Critical, stable  blood  ABx  LP Critical, unstable stabilize  blood  ABx +/- LP Critical, unstable stabilize  blood  ABx +/- LP

24 What is the initial empiric antibiotic regiment ? 0-4 wks 0-4 wks ampicillin plus genta or cefotaxim ampicillin plus genta or cefotaxim 1-3 months 1-3 months ampicillin plus cefotaxim or ceftriaxon or chloram >3months >3months cefotaxim or ceftriaxon +/- vanco

25 Is there any role for steroid in ABM ? Dexamethason may improve some neurologic sequelae, particularly hearing loss with ABM caused by h. inf 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 Risk of GI bleed, false sense of improvement and reduced penetration of vanco AAP limit the use for h. inf. Meningitis AAP limit the use for h. inf. Meningitis

26 Seizures

27 What is the difference between seizures and epilepsy ? A seizure is a paroxysmal event characterized by a change in behavior of the patient 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 results when a large population of neurons in the brain discharges synchronously Epilepsy is the occurrence of two or more unprovoked seizures Epilepsy is the occurrence of two or more unprovoked seizures

28 Seizures and brain damage Children with seizures at a significant risk for cognitive impairment and behavioral abnormality 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 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 There is a growing evidence pointing to the lasting effect of repetitive, brief seizures in early childhood

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

30 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 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 Either may spread and become secondary generalized An aura may occur at the beginning of either type ( noxious smell or taste ) An aura may occur at the beginning of either type ( noxious smell or taste )

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

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

33 what the chance of developing epilepsy in febrile seizures ? 2-3% while in normal population 1% 2-3% while in normal population 1% Higher in Higher in Presence of family history of epilepsy Presence of family history of epilepsy Abnormal developmental status Abnormal developmental status Complex febrile seizures Complex febrile seizures

34 What the common precipitants of status epilepticus ? Febrile illness ( the most common ) Febrile illness ( the most common ) Medication change Medication change Idiopathic Idiopathic Metabolic derangement Metabolic derangement Congenital abnormality Congenital abnormality

35 What the common complications of status epilepticus ? Hyper/hypotension Hyper/hypotension Dysrhythmia Dysrhythmia CHF CHF Apnea Apnea Aspiration Aspiration Non cardiogenic pulmonary edema Non cardiogenic pulmonary edema Rhabdomyolysis Rhabdomyolysis Hypo/hyperglycemia Hypo/hyperglycemia

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

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

38 How about imaging and EEG after a first seizure? Imaging indicated in Imaging indicated in Partial seizures Partial seizures Abnormal neurological exam Abnormal neurological exam EEG EEG Rarely needed in the acute setting Rarely needed in the acute setting 10-40% don’t show epileptiform abnormalities in EEG 10-40% don’t show epileptiform abnormalities in EEG

39 Approach in actively convulsing child? ABC ABC Stop seizure Stop seizure Benzo, phenytoin, Phenobarb then Benzo, phenytoin, Phenobarb then IV drip ( midazolam, propofol or pentobarbital ) IV drip ( midazolam, propofol or pentobarbital ) Prevent seizure recurrent Prevent seizure recurrent Identify precipitant or cause and treat Identify precipitant or cause and treat

40 Approach if the child presents after the event? Determine if truly seizure Determine if truly seizure Determine seizure type Determine seizure type Identify precipitant or cause and treat Identify precipitant or cause and treat Determine if further work up needed Determine if further work up needed Determine if anticonvulsant therapy is appropriate Determine if anticonvulsant therapy is appropriate

41 Riske factor of recurrence of a seizure ? Todd’s paralysis Todd’s paralysis Abnormal EEG Abnormal EEG Family history of epilepsy Family history of epilepsy Remote symptomatic seizure Remote symptomatic seizure Seizure while asleep Seizure while asleep

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

43 Types of headache in pediatric Acute headache Acute headache Chronic progressive headache Chronic progressive headache Migraine headache Migraine headache Chronic non progressive headache Chronic non progressive headache tension headache tension headache Cluster headache Cluster headache

44 Causes of acute headache ? Infection (CNS infection, viral illnesses, sinusitis) Infection (CNS infection, viral illnesses, sinusitis) Hypertension Hypertension Vascular ( hemorrhages ) Vascular ( hemorrhages ) Trauma Trauma Toxin Toxin Dental disorder Dental disorder Opthalmologic problem Opthalmologic problem

45 Causes of chronic progressive headache ? Increased ICP Increased ICP Brain tumors Brain tumors Pseudo tumor cerbri Pseudo tumor cerbri Hydrocephalus Hydrocephalus Brain abscess Brain abscess Subdural heamatoma Subdural heamatoma

46 Classification of migraine headache 1. Migraine with aura Classic Classic Complicated ( hemiplegic, opthalmoplegic, basilar artery migraine) Complicated ( hemiplegic, opthalmoplegic, basilar artery migraine) 2. Migraine without aura ( common migraine) 3. Migraine variants Abdominal migraine Abdominal migraine Benign paroxysmal vertigo Benign paroxysmal vertigo Paroxysmal torticollis Paroxysmal torticollis

47 Criteria for pediatric migraine without aura ≥ 5 attacks each last 1-48 hrs ≥ 5 attacks each last 1-48 hrs Headache with 2 of Headache with 2 of Bilateral or unilateral Bilateral or unilateral Pulsating quality Pulsating quality Moderate to severe Moderate to severe Aggravated by routine physical activity Aggravated by routine physical activity Associated symptoms 1 of Associated symptoms 1 of Nausea or vomiting Nausea or vomiting Photophobia or photophobia Photophobia or photophobia

48 Criteria for pediatric migraine with aura At least 2 episodes with the following criteria At least 2 episodes with the following criteria 1. Reversible symptoms arising from focal cerebral or brainstem dysfunction 2. Gradual development of the headache 3. Aura with a duration of less than 60 min 4. Headache either before or within 60 min of aura

49 Treatment of migraine in peds? Acetaminophen Acetaminophen NSAIDs NSAIDs Narcotic (codeine or oxycodon) Narcotic (codeine or oxycodon) Antiemetic Antiemetic Metoclopromide Metoclopromide Promethazine Promethazine Ergotamine Ergotamine Sumatriptan Sumatriptan


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