Pediatric Neurology

Barbara Kolk-Seda MS PA-C

Neurological
Neurological Evaluation
Evaluation
Pediatricians & Pediatric Practitioners may be the first to discover
abnormal neurological findings
Newborns Adolescents on routine PE
Consults for behavior problems or poor school performance
Sick visits due to C/O
Headaches
Dizziness
Head Injuries
Visual Disturbances

Work up should begin with a detailed history

Physical Exam
Pertinent Labs
Referrals when appropriate

Screening
Screening Tools
Tools

Denver Developmental Screen

ASQ
Pediatric Symptom Check List
Modified Checklist for Autism in Toddlers

Goals of Screening tools

To give the practitioner an idea of any specific problems
Point the practitioner in the direction of further questioning and examination
THESE SCREENING TOOLS ARE NOT A SUPPLEMENT
FOR CAREFUL CLINICAL EVALUATION

Other types of evaluations available

EEG
Evoked Potentials
Lumbar Puncture
CT/MRI PET Scan
Ultra Sound
Cerebral Angiography
Myelography/ EMG

Seizure
Seizure Disorders
Disorders

Seizure Classification
Partial vs Generalized

Epilepsy Syndromes are defined by

Nature of the seizure
Age of Onset
EEG Findings

Epilepsy Classification
Symptomatic
Cryptogenic
Idiopathic

Neonatal
Neonatal Seizures
Seizures

Onset
Birth to 2 weeks
Cause
Hypoxia
Ischemia
Intracranial Hemorrhage
Metabolic disturbances
Infections
Clinical Findings
Sudden limpness/ tonic posturing/ twitching/ clonic movements
Brief apnea
Cyanosis
Odd cry/ lip smacking
Eyes rolling
EEG
Focal Spikes
Slow Rhythms
Multifocal Discharges
Electrical Dissociation

Neonatal
Neonatal Seizures
Seizures
Labs / Diagnostic Studies
LP for CSF PCR
Metabolic Panel, calcium, Phosphorus, Magnesium, ammonia,
TORCH IgM
Ultra Sound CT / MRI
Treatment
Correct underlying abnormalities
Phenobarbital IV or IM
Phenytoin IV
Diazepam
Stop protein feedings

Infantile
Infantile Spasms
Spasms
Onset
3-18 months
Cause
CNS Injury
Biochemical
Infections
Pyridoxine Dependency
Inherited Metabolic Disorder
Tuberous Sclerosis
TORCH Infections
Genetic
Clinical Findings
Sudden, symmetrical adduction or flexion
of limbs with flexion of head and trunk
Occur in clusters
Typically upon awakening
Associated irritability
Developmental Regression

Infantile
Infantile Spasm
Spasm
EEG

Hypsarrhythmia

Labs & Diagnostic Tests

Fundiscopic and skin exam
Trial of Pyridoxine
Amino acid & Organic acid screen
Chromosome Analysis
TORCH Screen
CT/MRI
Treatment
ACTH gel (40 IU/d 150 IU/m/d) IM QD
Vigabatrin
Topiramate
Zonisamide
Valproic Acid
Lamotrigine
Trial of B/ Ketogenic Diet

Febrile Seizure
Seizure
Onset
3mo 5 years
Cause

How quickly a fever rises or falls

Family History
Day Care
Slow Development
Prolonged Neonatal Hospitalization

Clinical Findings
Generalized Seizures (<15 min)
30% risk of second seizure

Febrile
Febrile Seizures
Seizures
EEG
Normal
Labs & Diagnostic Studies
Consider LP if suspicion of meningitis

Treatment
Fever Stability
Diazepam (0.3-0.5 mg/kg, PO divided TID during illness)
Diastat (Prolonged Seizures)
Prophylaxis
Phenobarbital
Valproic Acid

Childhood
Childhood Absence Seizures
Onset
3 12 years
Causes
Unknown
Suspected
Genetic
Abnormal Thalmocortical circuitry
Clinical Findings
Lapses of Consciousness
Vacant Stares (3 10 sec)
Automatisms
No Aura
No Postictal Confusion
EEG
3/s bilaterally synchronous,
symmetrical, high voltage spikes

Childhood
Childhood Absence Seizures
Labs & Diagnostic Testing
Rarely of value
Treatment
Ethosuximide
Valproic Acid
Lamictal
Zonisamide
Topiramate
Levetiracetam
Acetazolamide
Ketogenic Diet

Juvenile
Juvenile Absence
Absence Seizures
Seizures
Onset
10 15 years
Cause
Unknown
Clinical Findings
Similar to Childhood onset but higher risk of convulsive seizures
EEG

3-Hz spike wave

Atypical Generalized Discharges

Labs & Other Diagnostic Tests

Rarely of Value
Treatment
Same as Childhood onset

Simple
Simple Partial
Partial Seizures
Seizures
AKA- Focal Seizures
Affects All Age Groups
Cause
Often unknown
Birth trauma
Inflammatory process
Vascular accident
Meningo-encephalitis
Structural lesions
Clinical Findings
May involve any part of the body
May spread in fixed pattern (Jacksonian March)
becoming generalized

Simple
Simple Partial
Partial Seizures
Seizures
EEG

Normal
Focal spikes
Slow waves in cortical region
Rolandic Spikes= centrotemporal spikes

Other Diagnostic Studies

MRI
Treatment
Carbamazepine
Oxycarbamazepine
Phenytoin
Lamotrigine
Gabapentin
Topiramate
Levetiractam
Zonisamide
Valproic Acid (adjunct)

Generalized
Generalized Tonic-Clonic
Tonic-Clonic Seizures
Seizures
AKA Grand Mal Seizures
Any Age Group
Cause
Majority unknown
Genetic
Metabolic disturbances
Trauma
Infection
Intoxication
Brain tumors
Clinical Findings
LOC
Tonic Clonic Movements
Vague Aura or Cry
Incontinence 15%
Postictal phase
Can be mixed with or masking other
seizure patterns

Generalized
Generalized Tonic-Clonic
Tonic-Clonic Seizures
Seizures
EEG

Bilateral, synchronous, symmetrical high-voltage spikes

Younger than 4 years often normal
Focal spikes may become Secondarily Generalized

Other Diagnostic Tests

Most likely not needed
consider CT or MRI, electrolytes
Treatment
Phenobarbital (infants)
Carbamazepine
Valproic Acid
Phenytoin
Topiramate
Lamotrigine