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Pediatric Neurologic Emergencies

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Pediatric Neurologic Emergencies

  1. 1. pediatric neurologic emergencies may 2002 core rounds
  2. 2. contents <ul><li>seizures </li></ul><ul><ul><li>approaches to </li></ul></ul><ul><ul><ul><li>febrile seizure </li></ul></ul></ul><ul><ul><ul><li>new onset non-febrile seizure </li></ul></ul></ul><ul><ul><ul><li>established seizure disorder with recurrence </li></ul></ul></ul><ul><ul><ul><li>neonatal seizures </li></ul></ul></ul><ul><ul><ul><li>status epilepticus </li></ul></ul></ul><ul><ul><li>investigation, treatment, disposition </li></ul></ul><ul><li>headache </li></ul><ul><ul><li>discussion (as little evidence to support) </li></ul></ul><ul><ul><ul><li>migraine treatment </li></ul></ul></ul><ul><ul><ul><li>imaging indications </li></ul></ul></ul>
  3. 3. case 1 <ul><li>2 year old </li></ul><ul><li>parents “shaking episode” lasting “10 mins” </li></ul><ul><li>EMS called - child no longer shaking </li></ul><ul><li>V/S - BP 105/60 HR 100 RR 18 Sat N T39 </li></ul><ul><li>approach? </li></ul><ul><ul><li>well looking child </li></ul></ul><ul><ul><ul><li>first event </li></ul></ul></ul><ul><ul><ul><li>multiple events </li></ul></ul></ul><ul><ul><li>sick looking child </li></ul></ul>
  4. 4. case 2 <ul><li>8 year old </li></ul><ul><li>parents describe good history for tonic-clonic activity lasting 2 mins </li></ul><ul><li>1st event </li></ul><ul><li>post event confusion - improving </li></ul><ul><li>in ED - V/S N, N sensorium, N neuro exam </li></ul><ul><li>otherwise healthy, no meds, no allergies </li></ul><ul><li>approach? </li></ul>
  5. 5. case 3 <ul><li>16 year old </li></ul><ul><li>known seizure disorder, on phenytoin </li></ul><ul><li>typical seizure presenting complaint </li></ul><ul><li>V/S N, neuro N, otherwise looks well </li></ul><ul><li>approach? </li></ul>
  6. 6. case 4 <ul><li>2 week old </li></ul><ul><li>parents - “doesn’t look right”, “mouth opening and closing” </li></ul><ul><li>one episode lasting 1 minute </li></ul><ul><li>child not interested in feeding, sleepy </li></ul><ul><li>V/S - BP 90/50 HR 130 RR 38 sat N T 37.8 </li></ul><ul><li>otherwise normal exam </li></ul><ul><li>approach? </li></ul>
  7. 7. definitions <ul><li>febrile seizure – NIH defn - event of infancy/childhood, typically between age 3mo and 5yrs, with no evidence intracranial infection or defined cause </li></ul><ul><li>epilepsy - two or more seizures not provoked by a specific event such as fever, trauma, infection, or chemical change </li></ul>
  8. 8. definitions <ul><li>neonatal seizure – in first 28 days of life (typically first few days) </li></ul><ul><li>status epilepticus </li></ul><ul><ul><li>seizure lasting >30 mins </li></ul></ul><ul><ul><ul><li>NB rosen 5-10 mins </li></ul></ul></ul><ul><ul><li>sequential seizures without regain LOC >30min </li></ul></ul>
  9. 9. classification <ul><li>generalized </li></ul><ul><ul><li>LOC </li></ul></ul><ul><ul><li>tonic, clonic, tonic-clonic, myoclonic, atonic, absence </li></ul></ul><ul><li>partial – focal onset </li></ul><ul><ul><li>simple partial – no LOC </li></ul></ul><ul><ul><li>complex partial – LOC </li></ul></ul><ul><ul><li>partial secondarily generalized </li></ul></ul><ul><li>unclassified </li></ul>
  10. 10. etiology <ul><li>infectious </li></ul><ul><li>metabolic </li></ul><ul><li>traumatic </li></ul><ul><li>toxic </li></ul><ul><li>neoplastic </li></ul><ul><li>epileptic </li></ul><ul><li>other </li></ul>
  11. 11. differential diagnosis <ul><li>syncope </li></ul><ul><li>breath holding </li></ul><ul><li>sleep disorders (eg. narcolepsy) </li></ul><ul><li>paroxysmal movement disorder </li></ul><ul><ul><li>tics,tremors </li></ul></ul><ul><li>migraines </li></ul><ul><li>psychogenic seizures </li></ul>
  12. 12. approach to febrile seizures the numbers <ul><li>epidemiology </li></ul><ul><ul><li>age 3mo – 5yrs </li></ul></ul><ul><ul><li>peak age 9-20 mo </li></ul></ul><ul><ul><li>2-5% children will have before age 5 </li></ul></ul><ul><ul><li>25-40% will have family history </li></ul></ul><ul><ul><li>80 – 97% simple </li></ul></ul><ul><ul><li>3 - 20% complex </li></ul></ul>
  13. 13. simple febrile seizure <ul><li>< 15 mins </li></ul><ul><li>no focal features </li></ul><ul><li>no greater than 1 episode in 24h </li></ul><ul><li>neurologically and developmentally normal </li></ul>
  14. 14. complex febrile seizure <ul><li>>15 min </li></ul><ul><ul><li>febrile epilepticus >30min or recurrent without regaining consciousness > 30min </li></ul></ul><ul><li>focal </li></ul><ul><li>recurrence within 24h </li></ul>
  15. 15. what do parents want to know? <ul><li>recurrence </li></ul><ul><ul><li>risk recurrence 25-50% </li></ul></ul><ul><ul><li>risk recurrence after 2 nd – 50% </li></ul></ul><ul><ul><li>most recurrences within 6-12 mo </li></ul></ul><ul><ul><ul><li>(20% within same febrile illness) </li></ul></ul></ul><ul><li>risk of epilepsy </li></ul><ul><ul><li>2-3% (baseline 1%) </li></ul></ul><ul><ul><li>increased in </li></ul></ul><ul><ul><ul><li>family history of epilepsy </li></ul></ul></ul><ul><ul><ul><li>abnormal developmental status </li></ul></ul></ul><ul><ul><ul><li>complex febrile seizure </li></ul></ul></ul>
  16. 16. neonatal seizure <ul><li>brief and subtle </li></ul><ul><ul><li>eye blinking </li></ul></ul><ul><ul><li>mouth/tongue movements </li></ul></ul><ul><ul><li>“ bicycling” motion to limbs </li></ul></ul><ul><li>typically sz’s can’t be provoked/consoled </li></ul><ul><li>autonomic changes </li></ul><ul><li>EEG less predictable </li></ul>
  17. 17. neonatal seizure <ul><li>etiology </li></ul><ul><ul><li>hypoxic-ischemic encephalopathy </li></ul></ul><ul><ul><ul><li>Presents within first day </li></ul></ul></ul><ul><ul><li>congenital CNS anomalies </li></ul></ul><ul><ul><li>intracranial hemorrhage </li></ul></ul><ul><ul><li>electrolyte abnormalities – hypoglycemia and hypocalcemia </li></ul></ul><ul><ul><li>infections </li></ul></ul><ul><ul><li>drug withdrawal </li></ul></ul><ul><ul><li>pyrodoxine deficiency </li></ul></ul>
  18. 18. status epilepticus <ul><li>definition </li></ul><ul><ul><li>deizure lasting >30 mins </li></ul></ul><ul><ul><ul><li>NB Rosen 5-10 mins </li></ul></ul></ul><ul><ul><li>sequential seizures without regain LOC >30min </li></ul></ul><ul><li>mortality in pediatric status epilepticus 4% </li></ul><ul><li>morbidity may be as high as 30% </li></ul>
  19. 19. SE treatment considerations <ul><li>ABC’s </li></ul><ul><li>brief directed Hx and Px </li></ul><ul><li>glucose </li></ul><ul><li>antibiotics/antivirals </li></ul><ul><ul><li>if meningitis/encephalitis considered </li></ul></ul>
  20. 20. SE treatment <ul><li>1 st line anticonvulsants </li></ul><ul><ul><li>IV </li></ul></ul><ul><ul><ul><li>lorazepam 0.1mg/kg </li></ul></ul></ul><ul><ul><ul><li>diazepam 0.2 mg/kg </li></ul></ul></ul><ul><ul><ul><li>midazolam 0.2 mg/kg </li></ul></ul></ul><ul><ul><li>rectal diazepam </li></ul></ul><ul><ul><ul><li>2-5 yrs – 0.5 mg/kg </li></ul></ul></ul><ul><ul><ul><li>6-11 yrs – 0.3 mg/kg </li></ul></ul></ul><ul><ul><ul><li>>12 yrs – 0.2 mg/kg </li></ul></ul></ul><ul><ul><li>IM, intranasal, buccal midazolam </li></ul></ul>
  21. 21. SE treatment <ul><li>2 nd line agents </li></ul><ul><ul><li>phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min) </li></ul></ul><ul><ul><li>fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150 mg/min) </li></ul></ul><ul><li>3 rd line agents </li></ul><ul><ul><li>phenobarbital 20mg/kg @ 100mg/min </li></ul></ul><ul><ul><li>repeat prn 5-10mg/kg </li></ul></ul><ul><ul><li>maximum 40 mg/kg or 1 gram </li></ul></ul>
  22. 22. refractory SE treatment <ul><li>consider midazolam </li></ul><ul><ul><li>0.2 mg/kg bolus </li></ul></ul><ul><ul><li>then 1-10 mcg/kg/min infusion </li></ul></ul><ul><li>induce barbiturate coma </li></ul><ul><ul><li>pentobarbital 5-15 mg/kg @ 25 mg/min </li></ul></ul><ul><ul><li>then 1-5 mg/kg/hour </li></ul></ul><ul><li>others </li></ul><ul><ul><li>valproic acid </li></ul></ul><ul><ul><li>paraldehyde, chloral hydrate </li></ul></ul><ul><ul><li>propofol, inhalational anesthesia, paralysis </li></ul></ul><ul><ul><li>lidocaine </li></ul></ul>
  23. 23. approach – stable post sz <ul><li>history </li></ul><ul><ul><li>pre-seizure </li></ul></ul><ul><ul><ul><li>what was child doing when attack occurred </li></ul></ul></ul><ul><ul><ul><li>precipitants – fever, trauma, poisoning, drug/med use </li></ul></ul></ul><ul><ul><ul><li>aura </li></ul></ul></ul><ul><ul><li>deizure </li></ul></ul><ul><ul><ul><li>what movements – incl. eyes </li></ul></ul></ul><ul><ul><ul><li>how long </li></ul></ul></ul><ul><ul><ul><li>LOC? </li></ul></ul></ul><ul><ul><ul><li>consequences – resp distress, incontinence, injury </li></ul></ul></ul><ul><ul><li>post seizure </li></ul></ul><ul><ul><ul><li>Post-ictal </li></ul></ul></ul>
  24. 24. approach to stable patient <ul><li>physical directed towards </li></ul><ul><ul><li>systemic disease </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><ul><li>toxic exposure </li></ul></ul><ul><ul><li>focal neuro signs </li></ul></ul>
  25. 25. laboratory <ul><li>blood glucose? </li></ul><ul><li>electrolytes? </li></ul><ul><li>magnesium, calcium? </li></ul><ul><li>anything at all? </li></ul><ul><li>what about first time seizures? recurrent? </li></ul>
  26. 26. laboratory <ul><li>yes if… </li></ul><ul><ul><li>neonatal </li></ul></ul><ul><ul><li>abnormal mental status persistent </li></ul></ul><ul><ul><li>diabetics, renal disease </li></ul></ul><ul><ul><li>diuretic use </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><ul><li>malnourishment </li></ul></ul>
  27. 27. laboratory <ul><li>septic work-up (CBC, BC, urine C+S, CXR, LP) </li></ul><ul><ul><li>as indicated </li></ul></ul><ul><ul><ul><li>sick child </li></ul></ul></ul><ul><ul><ul><li>< 12 - 18 mo </li></ul></ul></ul><ul><li>therapeutic drug levels </li></ul><ul><li>other </li></ul><ul><ul><li>ABG </li></ul></ul><ul><ul><li>toxicologic screen </li></ul></ul><ul><ul><li>TORCH, ammonia, amino acids in neonate </li></ul></ul><ul><ul><li>CPK, lactate, prolactin – ?confirm seizure? </li></ul></ul>
  28. 28. lumbar puncture <ul><li>patients at greatest risk for meningitis </li></ul><ul><ul><li>under 18 months of age </li></ul></ul><ul><ul><li>seizure in the ED </li></ul></ul><ul><ul><li>focal or prolonged seizure </li></ul></ul><ul><ul><li>seen a physician within the past 48 hours </li></ul></ul><ul><li>other indications </li></ul><ul><ul><li>concern about follow-up </li></ul></ul><ul><ul><li>prior treatment with antibiotics </li></ul></ul><ul><li>The American Academy of Pediatrics </li></ul><ul><ul><ul><li>“ strongly consider” in infants under 12 months of age with a first febrile seizure </li></ul></ul></ul>
  29. 29. neuroimaging <ul><li>WHO? which patients? </li></ul><ul><li>WHAT? CT vs. MRI </li></ul><ul><ul><li>ultrasound in neonates </li></ul></ul><ul><li>WHEN? emergent vs. elective </li></ul>
  30. 30. ACEP guidelines - >6 yo <ul><li>consensus indication for non-contrast CT </li></ul><ul><li>first time seizure patients </li></ul><ul><ul><li>if suspect structural lesion </li></ul></ul><ul><ul><li>partial onset seizure </li></ul></ul><ul><ul><li>age > 40 </li></ul></ul><ul><ul><li>no other identified cause </li></ul></ul><ul><li>recurrent seizure patients </li></ul><ul><ul><li>change in pattern </li></ul></ul><ul><ul><li>prolonged post-ictal period </li></ul></ul><ul><ul><li>worsening mental status </li></ul></ul>
  31. 31. neuroimaging <ul><li>predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures </li></ul><ul><li>Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23 </li></ul><ul><ul><li>retrospective case series </li></ul></ul><ul><ul><li>predicts CT scan results normal if </li></ul></ul><ul><ul><ul><li>no underlying high-risk condition </li></ul></ul></ul><ul><ul><ul><ul><li>malignancy, NCT, recent CHI, or recent CSF shunt revision </li></ul></ul></ul></ul><ul><ul><ul><li>older than 6 months </li></ul></ul></ul><ul><ul><ul><li>sustained a seizure of 15 minutes or less </li></ul></ul></ul><ul><ul><ul><li>no new-onset focal neurologic deficit </li></ul></ul></ul><ul><ul><li>not prospectively validated </li></ul></ul>
  32. 32. emergent EEG? <ul><li>not generally available on emergent basis </li></ul><ul><li>but consider in.. </li></ul><ul><ul><li>persistent altered mental status (?non convulsive status epilepticus) </li></ul></ul><ul><ul><li>paralyzed patients </li></ul></ul><ul><ul><li>pharmacologic coma </li></ul></ul>
  33. 33. disposition <ul><li>can be discharged home if </li></ul><ul><ul><li>single seizure </li></ul></ul><ul><ul><li>stable, returning to baseline neuro status </li></ul></ul><ul><ul><li>no underlying condition/cause requiring treatment in hospital </li></ul></ul><ul><ul><li>arranged follow-up </li></ul></ul>
  34. 34. EEG – 1 st non-febrile seizure <ul><li>follow-up EEG </li></ul><ul><ul><li>within 24h </li></ul></ul><ul><ul><ul><li>Lancet 1998;352:1007-11 </li></ul></ul></ul><ul><ul><ul><li>improved pick-up 51% vs 34% </li></ul></ul></ul><ul><ul><ul><li>? how soon do we get ours ? </li></ul></ul></ul><ul><ul><li>inter-ictal EEG’s often normal </li></ul></ul><ul><ul><ul><li>neuro may do sleep deprivation study (provocation) </li></ul></ul></ul><ul><ul><li>absence epilepsy and infantile spasms are invariably associated with an abnormal EEG </li></ul></ul><ul><ul><li>spike and wave 3HZ </li></ul></ul>
  35. 35. idiopathic seizure <ul><li>recurrence risk stratification </li></ul><ul><ul><li>normal EEG – 25% </li></ul></ul><ul><ul><li>abN EEG – 60% </li></ul></ul><ul><ul><li>2 nd seizure – 75% </li></ul></ul>
  36. 36. neuroimaging <ul><li>MRI superior </li></ul><ul><li>not emergently available </li></ul><ul><li>?defer imaging until follow-up MRI available in low risk patients? </li></ul>
  37. 37. treatment <ul><li>correct underlying pathology, if any </li></ul><ul><li>antipyretics ineffective in febrile seizure </li></ul><ul><li>anti-epileptic choice often trial and error </li></ul><ul><ul><ul><li>no anti-epileptic 100% effective </li></ul></ul></ul><ul><ul><ul><li>febrile seizure – diazepam, phenobarbital, valproic acid </li></ul></ul></ul><ul><ul><ul><ul><li>Currently AAP does not recommend </li></ul></ul></ul></ul><ul><ul><ul><li>neonatal - phenobarbital </li></ul></ul></ul><ul><ul><ul><li>generalized TC – phenytoin, phenobarbital, carbamazepine, valproic acid, primidone </li></ul></ul></ul><ul><ul><ul><li>absence – ethosuximide, valproic acid </li></ul></ul></ul><ul><ul><ul><li>new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate, tiagabine, vigabatrine </li></ul></ul></ul><ul><li>in consultation with neurologist </li></ul>
  38. 38. pediatric headache
  39. 39. case 5 <ul><li>14 year old </li></ul><ul><li>mother’s chief complaint - “having headaches all the time, getting worse, this is not normal!!” etc. etc…….. </li></ul><ul><li>V/S N </li></ul><ul><li>looks in discomfort but otherwise well </li></ul><ul><li>approach? </li></ul><ul><ul><li>treatment </li></ul></ul><ul><ul><li>imaging? </li></ul></ul>
  40. 40. classification <ul><li>classify based on temporal pattern </li></ul><ul><li>acute headaches </li></ul><ul><ul><li>any febrile illness, sinus/dental infection, intracranial infection/bleed (AVM,SAH,trauma) </li></ul></ul><ul><li>acute recurrent </li></ul><ul><li>chronic progressive </li></ul><ul><li>chronic non-progressive </li></ul><ul><ul><li>tension, psychogenic, post-traumatic, ocular refractive error </li></ul></ul>
  41. 41. acute recurrent headache <ul><li>migraine </li></ul><ul><li>other </li></ul><ul><ul><li>cluster headache – typically >10 yo </li></ul></ul><ul><ul><li>sinusitis </li></ul></ul><ul><ul><li>vascular malformation </li></ul></ul>
  42. 42. migraine - terminology <ul><li>classic migraine </li></ul><ul><ul><li>biphasic </li></ul></ul><ul><ul><ul><li>neuro aura </li></ul></ul></ul><ul><ul><ul><li>headache, N/V, anorexia, photophobia </li></ul></ul></ul><ul><ul><li>either unilateral (older) / bilateral(younger) or both </li></ul></ul><ul><li>common migraine </li></ul><ul><ul><li>malaise, dizziness, N/V, feels and looks sick </li></ul></ul><ul><ul><li>unilateral/bilateral </li></ul></ul><ul><li>migraine equivalent/”complicated migraine” </li></ul><ul><ul><li>transient neuro deficits </li></ul></ul><ul><ul><li>+/- headache </li></ul></ul><ul><li>migraine variants </li></ul><ul><ul><li>Cyclic N/V, abdo pain </li></ul></ul><ul><ul><li>BPV </li></ul></ul>
  43. 43. migraine treatment <ul><li>very little supporting evidence for pharmacologic treatment in children compared to adults </li></ul><ul><li>classes of medication </li></ul><ul><ul><li>acetaminophen </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>phenothiazines (dopamine antagonists) </li></ul></ul><ul><ul><li>dihydroergotamine </li></ul></ul><ul><ul><li>triptans </li></ul></ul>
  44. 44. the simple stuff <ul><li>acetaminophen 15 mg/kg PO 30mg/kg PR </li></ul><ul><li>ibuprofen 10 mg/kg PO </li></ul><ul><li>Hamalainen ML Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled, crossover study </li></ul><ul><li>Neurology 48:103-107, 1997 </li></ul><ul><ul><li>N = 88 age 4-16 </li></ul></ul><ul><ul><li>relief at 2 hours </li></ul></ul><ul><ul><ul><li>acetaminophen 54% </li></ul></ul></ul><ul><ul><ul><li>ibuprofen 68% </li></ul></ul></ul>
  45. 45. other NSAIDS <ul><li>naproxen 5-7 mg/kg PO </li></ul><ul><ul><li>no pediatric evidence </li></ul></ul><ul><li>ketorolac IV 0.5 mg/kg (max 30mg dose) </li></ul><ul><ul><li>not studied in pediatric migraine </li></ul></ul><ul><ul><li>not approved <16 yo </li></ul></ul><ul><ul><li>Houck CS – Safety of intravenous ketorolac in children and cost savings with a unit dosing system . J Pediatr - 01-Aug-1996; 129(2): 292-6 </li></ul></ul><ul><ul><ul><li>1747 children </li></ul></ul></ul><ul><ul><ul><li>0.2% hypersensitivity </li></ul></ul></ul><ul><ul><ul><li>0.1% renal complications (in patients with renal disease) </li></ul></ul></ul><ul><ul><ul><li>0.05% gi bleed </li></ul></ul></ul>
  46. 46. dihydroergotamine <ul><li>not approved </li></ul><ul><li>?dose – 0.1 – 0.5 mg IV </li></ul><ul><li>not studied in emergency population </li></ul><ul><li>Linder SL – Treatment of childhood migraine with dihydroergotamine mesylate Headache - 1994 Nov-Dec; 34(10): 578-80 </li></ul><ul><ul><li>N = 30 </li></ul></ul><ul><ul><li>inpatient protocol </li></ul></ul><ul><ul><li>IV DHE and PO metoclopramide – average 5 doses! </li></ul></ul><ul><ul><li>80% response </li></ul></ul>
  47. 47. phenothiazines <ul><li>again no studies </li></ul><ul><li>metoclopramide 1-2 mg/kg IV (max 10mg) </li></ul><ul><li>prochloperazine 0.1 – 0.15 mg/kg IV/IM/PO/PR (max 10mg) </li></ul><ul><li>children may be more susceptible to EPS </li></ul><ul><ul><li>? pre-treat with benadryl </li></ul></ul>
  48. 48. triptans <ul><li>mostly studied in adolescent groups </li></ul><ul><li>sumitriptan subcutaneous 0.06mg/kg </li></ul><ul><ul><li>Linder S: Subcutaneous sumatriptan in the clinical setting: The first 50 consecutive patients with acute migraine in a pediatric neurology office practice. Headache 36:419–422, 1996 </li></ul></ul><ul><ul><li>N = 50 age 6-18 </li></ul></ul><ul><ul><li>78% effective at 2 hours </li></ul></ul><ul><ul><li>6% recurrence </li></ul></ul><ul><li>sumitriptan intranasal </li></ul><ul><ul><li>long term treatment studies done </li></ul></ul><ul><ul><li>no emergent studies </li></ul></ul><ul><li>triptans PO </li></ul><ul><ul><li>studies plagued by high placebo response </li></ul></ul>
  49. 49. chronic progressive headache <ul><li>least common presentation </li></ul><ul><li>most worrisome for increased ICP </li></ul><ul><ul><li>pseudotumor cerebri </li></ul></ul><ul><ul><li>space occupying lesion </li></ul></ul>
  50. 50. imaging indications? discuss <ul><li>lack of evidence to help </li></ul><ul><ul><li>small studies lack power to guide decision making </li></ul></ul><ul><li>MRI preferred in non-urgent indication </li></ul>
  51. 51. imaging indications? discuss <ul><li>classically based on historical and physical </li></ul><ul><ul><li>sudden severe headache </li></ul></ul><ul><ul><li>rapid increase over days - weeks </li></ul></ul><ul><ul><li>chronic progressive </li></ul></ul><ul><ul><li>suggestive of increased ICP </li></ul></ul><ul><ul><ul><li>severe nocturnal headache (wakes or upon waking), changes in pain with position, coughing </li></ul></ul></ul><ul><ul><li>following head trauma </li></ul></ul><ul><ul><li>persistent neuro findings </li></ul></ul><ul><ul><ul><li>? include migraine equivalents ? </li></ul></ul></ul><ul><ul><li>growth abnormality </li></ul></ul><ul><ul><li>age (? <3 ?) </li></ul></ul>

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