Febrile Seizures Amy Kao, MD 2005-2006 Division of Pediatric Neurology Oregon Health & Science University Stirred, Not Sha...
Learning Objectives <ul><li>Review basic definitions and classification of seizures </li></ul><ul><li>Discuss the specific...
The Basics <ul><li>Definition of a  Seizure </li></ul><ul><ul><li>sudden event caused by abrupt, uncontrolled, hypersynchr...
More Definitions <ul><li>Epilepsy </li></ul><ul><ul><li>condition characterized by the tendency for  recurrent  seizures t...
Seizures—Differential Dx <ul><li>Loss of tone or consciousness </li></ul><ul><ul><li>Abnormal heart rhythm </li></ul></ul>...
Seizures—Differential Dx (2) <ul><li>Unusual” movements </li></ul><ul><ul><li>Benign sleep myoclonus </li></ul></ul><ul><u...
Seizures—Etiology <ul><li>V (ascular): AVM, stroke, hemorrhage, HTN </li></ul><ul><li>I (nfectious): meningitis, encephali...
Classification of Seizures  By Onset <ul><li>Generalized </li></ul><ul><ul><li>Begins simultaneously in both hemispheres <...
Classification by Onset, continued <ul><li>Partial  (=Focal) </li></ul><ul><ul><li>Onset in a focal region of the brain </...
 
Classification of Seizures  By Cause <ul><li>Acute Symptomatic </li></ul><ul><ul><li>Shortly after an acute insult </li></...
Classification by Etiology, continued <ul><li>Remote Symptomatic </li></ul><ul><ul><li>Pre-existing brain abnormality or i...
Classification by Etiology, continued <ul><li>Idiopathic </li></ul><ul><ul><li>No history of preceding insult </li></ul></...
Classification by Syndromes <ul><li>Definition of a  syndrome </li></ul><ul><ul><li>Cluster of symptoms, signs, and lab fi...
Febrile Seizures <ul><li>Definition </li></ul><ul><ul><li>“ a seizure in association with a febrile illness in the absence...
Febrile Seizures <ul><li>Epidemiology </li></ul><ul><ul><li>2 to 5 % of children in the US </li></ul></ul><ul><ul><li>Most...
Simple Febrile Seizures <ul><li>< 15 minutes </li></ul><ul><li>Generalized-tonic-clonic </li></ul><ul><li>Fever > 100.4 re...
Risk Factors for 1 st  Feb Sz <ul><li>Febrile seizure in 1 st /2 nd  degree relative </li></ul><ul><li>Day care </li></ul>...
Risk Factors for Recurrent FS <ul><li>1/3 will have a recurrence </li></ul><ul><li>10% will have 3 or more </li></ul><ul><...
Risk Factors for Epilepsy <ul><li>2 to 10% will go on to have epilepsy </li></ul><ul><li>Developmental delay </li></ul><ul...
Evaluation in Febrile Seizures <ul><li>Exclude acute etiologies </li></ul><ul><ul><li>HCT, lytes/cbc  if  history/PE sugge...
Evaluation in FS (2) <ul><li>EEG </li></ul><ul><ul><li>Does NOT predict recurrence or epilepsy </li></ul></ul><ul><ul><li>...
Febrile Seizures—Treatment <ul><li>May reduce short-term recurrence </li></ul><ul><li>But NO effect on occurrence of epile...
FS—Treatment (2) <ul><li>Antipyretics </li></ul><ul><ul><li>No data that this reduces risk </li></ul></ul><ul><ul><li>FS a...
FS—Treatment (3) <ul><li>Daily medications NOT recommended </li></ul><ul><ul><li>Phenobarbital </li></ul></ul><ul><ul><ul>...
Seizures—Exam <ul><li>Temp, BP, HC </li></ul><ul><li>Skin (rash, neurocutaneous lesions), Neck </li></ul><ul><li>Evidence ...
Seizures—Exam (2) <ul><li>Evidence of focal deficits </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><ul><li>Intracr...
Seizures—Evaluation <ul><li>Lumbar puncture </li></ul><ul><ul><li>“ Strongly consider” in patient <12 mo with first febril...
Seizures—Evaluation (2) <ul><li>Neuroimaging </li></ul><ul><ul><li>“ Emergent” HCT </li></ul></ul><ul><ul><ul><li>Concern ...
Location, Location, Location
Overview of the Neuro Exam <ul><li>Mental Status </li></ul><ul><li>Cranial Nerves </li></ul><ul><li>Motor </li></ul><ul><l...
General <ul><li>Growth parameters (HC) </li></ul><ul><li>Vital signs (temp, BP) </li></ul><ul><li>Anterior fontanelle </li...
Mental Status <ul><li>Change in mental status =  brain  is not working correctly </li></ul><ul><li>Level of consciousness ...
Cranial Nerves <ul><li>=  Brain stem or nerve </li></ul><ul><li>CN2 = optic nerve </li></ul><ul><ul><li>Funduscopic exam <...
Cranial Nerves (2) <ul><li>CN5 = trigeminal </li></ul><ul><ul><li>Sensation </li></ul></ul><ul><ul><li>Masseter function <...
Cranial Nerves (3) <ul><li>CN8 = vestibulocochlear nerve </li></ul><ul><ul><li>Finger rub </li></ul></ul><ul><ul><li>Weber...
Motor <ul><li>Hypotonia = LMN or UMN, cerebellum </li></ul><ul><li>Hypertonia = UMN lesion, basal ganglia </li></ul><ul><l...
Gait <ul><li>Motor cortex, corticospinal tracts, basal ganglia, cerebellum, vestibular system, nerves, muscles, vision, pr...
Coordination <ul><li>Limb ataxia = cerebellar hemispheres </li></ul><ul><li>Gait ataxia = midline cerebellum </li></ul><ul...
Reflexes <ul><li>Hyperreflexia = UMN lesion </li></ul><ul><li>Hyporeflexia = LMN lesion </li></ul><ul><li>0 to 5+ grading ...
Sensation <ul><li>Stocking-glove = nerve </li></ul><ul><li>Vibration/proprioception = dorsal columns </li></ul><ul><li>Pai...
Questions re:Neuro Exam? http://medstat.med.utah.edu/pedineurologicexam/home_exam.html
Bibliography <ul><li>Baumann RJ and Duffner PK. Treatment of children with simple febrile seizures: The AAP practice param...
Bibliography <ul><li>Provisional committee on quality improvement, subcommittee on febrile seizures. Practice parameter: t...
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  • No acute CNS insult or systemic insult such as fever, meningitis or encephalitis, hypoglycemia or syncope.
  • When it comes to the scenario of possible seizure, the first question is always, “Was it a seizure?” Because, particularly in children, there are many conditions which can mimic seizures by history and actually sometimes by the clinical presentation. Before we get into the specific scenarios, there is one point that I think is important to make in discussing the approach to neurologic complaints. What helps guide us in our differential diagnosis and our evaluation of a problem, is the course of that problem, meaning whether it is acute, subacute, or chronic. And you’ll see that many of the entities I’ll be listing under the differential diagnoses of these various symptoms and signs can be ruled in or out just based upon the course.
  • Now, if you’re sure that a seizure occurred, the differential dx as far as etiology obviously is vast….One approach in determining what etiologies might be likely, is to start by classifying the seizure into whether it was generalized or focal in onset. For instance, a focal lesion such as an AVM or acute stroke or developmental malformation will give you a focal-onset sz, as opposed to electrolyte imbalance or febrile seizures which affect the brain diffusely, and thus would be more likely to lead to generalized-onset seizures.
  • Rhythmic or semi-rhythmic jerks….sudden brief muscle contractions akin to a lightning bolt or a start….contraction of extensor muscles
  • A seizure certainly could be generalized but have started in a distinct region of the brain and then secondarily generalized. So any clue to that, such as eye deviation to one side, or onset of shaking in one arm, or aura with lipsmacking and motor automatisms, will help to give you a clue to the area of the brain of concern.
  • By ILAE
  • May be at the start of illness and thus be the first sign of illness, though in one large epidemiological study, only 21% of the kids had seizures either prior to or within 1 hour of onset of fever, 57% had sz after 1 to 24 hrs and 22% had sz more than 24 hr after onset of fever….though studies have used 1 or 3 months as youngest age of occurrence, and onset above age 7 years is rare but does occur….though febrile seizures can occur in kids with abnormal development, the concern is that this is not a febrile seizure which implies a benign course, but a “seizure with fever,” which implies that the child has an underlying predisposition to having seizures and the fever merely lowered the seizure threshold significantly enough to bring that out.
  • 2 of these RFs led to a 28% chance of having at least one FS.
  • The longer they have to have more seizures. The higher the peak temperature, the lower the chance of recurrence. The shorter the duration of recognized fever, the higher the chance of recurrence. The more of these RFs the higher the chance of recurrence. Interestingly, factors that don’t seem to predict recurrence of feb szs is neurodevelopmental abnormality or complex FS.
  • Not substantially different than the risk in the general population (&gt;1% by age 20; 3% by elderly)
  • Caution anxiety and guilt of the parents.
  • Could this be what we call seizure with fever, as opposed to febrile seizure, implying that the child is at risk for seizures anyways, and the fever merely lowered his seizure threshold. May be hard to differentiate the post-ictal state from depressed consciousness that is caused by an ongoing etiology, but overall if it’s just the seizure causing the change in behavior, we should see evidence that the child is headed in the right direction in terms of getting back to baseline. Of course, depressed level of consciousness signifies a more immediate need for more aggressive evaluation, which is likely the reason why patients get blood drawn, a head CT, and LP in the ER probably more often than is truly needed.
  • Some of the reports in the literature suggest that Todd’s paresis occurs in 7 to 16% of patients with seizures.
  • About 15% of kids with meningitis present with seizure, but there’s usually something more than just the seizure alone.
  • Emergent HCT if will influence mgmt/Rx, if there is concern of acute focal lesion (as opposed to a chronic), I.e. if the presumed Todd’s paresis is not resolving quickly. Although there have been reports of Todd’s paresis lasting up to 2 to 3 days, particularly after very severe or long seizures, most usually resolve within 6 hours, and really should not be longer than 24 hours.
  • If based on your history and neurologic exam, you can localize where a lesion must be, that will narrow your differential diagnosis as far as etiology tremendously. These diagrams are to remind you about what constitutes the upper motor neuron and the lower motor neuron, because we use these terms frequently, to describe relatively broad localizations. Remember that the UMN most often refers to the cortical neuron which sends its axons via tracts in the white matter to synapse on a neuron in the spinal cord. Now this schematic depicts the entire reflex arc, so you don’t need to worry about this part of it, but the LMN refers to that neuron in the spinal cord, in the anterior horn of the cord, that sends its axon via the peripheral nerve, to synapse in the NMJ to the muscle. So roughly speaking, the UMN suggests central nervous system, the LMN correlates with peripheral nervous system.
  • These are the components of the neuro exam. The neuro exam is not actually that hard to do. So much of the neuro exam in infants and young children is based upon observation anyways, so you probably are eliciting much of the exam without even knowing it. So really, remembering what you’re looking for, so that you register the findings, is half the battle. It’s a matter of being systematic, like when you look at a chest X-ray, so that you don’t miss something. Remember that when you present the neuro exam, you want to start with the mental status, because that sets the stage for the listener in terms of what to expect out of the exam, for instance if it is a comatose patient versus an awake and active patient.
  • Being encephalopathic suggests an upper motor neuron lesion, essentially that the brain is not working correctly, which is sort of a silly comment to make, but actually is an important clue for localization purposes. For instance, the differential diagnosis for an infant who is floppy but looking around and alert is very different from that for the infant who is floppy and lethargic. In one scenario, you’re going to be looking for signs of botulism or spinal muscular atrophy; in the other scenario you might need to rule out an intracranial infection perhaps.
  • Now roughly-speaking because cranial nerves anatomically come out of the brain stem, a cranial nerve abnormality points to either the brain stem which usually falls into the upper motor neuron category of lesion, or to the actual cranial nerve, which would be a lower motor neuron lesion. Overall, because the brainstem is a relatively small area, and it’s organized in sort of clumps of nuclei from which the nerves come out, it’s usually pretty hard to have a brain stem lesion that is manifested by signs of only a single cranial nerve.
  • The contralateral forehead is spared because it has bilateral upper motor neuron innervation, whereas the lower face does not.
  • Atrophy and fasciculations suggest lower motor neuron. Motor development (? Early hand preference) 1 is flicker, 3 is only to gravity, 5 is full resistance
  • Spastic (scissoring, up on toes), ataxic, waddling, “hysterical” (astasia/abasia, crumpling)
  • Generally-speaking…However, one thing to keep in mind is the other confounding factor in our population, with the little ones we see, is whether we’re seeing true ataxia, or whether a wide-based gait or dysmetria is actually due to weakness.
  • Generally speaking….as a result of release from normal descending inhibition. 2+ is normal, 3+ is increased (may spread to adjacent muscles), 4+ few beats of clonus, 5+ is sustained clonus
  • Abnormal sensation can have a wide range of causes and localization, because sensation goes from our receptors on the skin, thru the peripheral nerve, to our spinal cord, up the spinal tracts to our cortex where the sensation is registered. But the pattern of findings will help to differentiate. If the sensory abnormalities occur in a stocking-glove distribution, so that distal sensation is worse than peripheral, that suggests nerve. If there is a spinal level, meaning that there is a distinct cut off at which the patient does not feel and than does feel the sensation, that suggests a spinal cord lesion. And if there is a particular pattern of sensory modalities affected, that may suggest a certain part of the cord. One sign is extinction, by giving double simultaneous stimulation, so touching both legs at the same time, or giving visual stimulation bilaterally by moving both hands at the same time. If the patient does not perceive one of the stimuli only when given both at the same time, that suggests a neglect and would suggest a cortical abnormality.
  • Stirred, Not Shaken Getting Comfortable with Neurology Febrile ...

    1. 1. Febrile Seizures Amy Kao, MD 2005-2006 Division of Pediatric Neurology Oregon Health & Science University Stirred, Not Shaken Getting Comfortable with Neurology
    2. 2. Learning Objectives <ul><li>Review basic definitions and classification of seizures </li></ul><ul><li>Discuss the specific epilepsy syndrome of febrile seizures </li></ul><ul><li>Review the neurologic exam in the context of the concept of anatomical localization of neurologic symptoms and deficits </li></ul>
    3. 3. The Basics <ul><li>Definition of a Seizure </li></ul><ul><ul><li>sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons </li></ul></ul>
    4. 4. More Definitions <ul><li>Epilepsy </li></ul><ul><ul><li>condition characterized by the tendency for recurrent seizures that are unprovoked by an immediate cause </li></ul></ul><ul><li>Status epilepticus </li></ul><ul><ul><li>> 30 minutes long OR </li></ul></ul><ul><ul><li>Back-to-back without return to baseline </li></ul></ul>
    5. 5. Seizures—Differential Dx <ul><li>Loss of tone or consciousness </li></ul><ul><ul><li>Abnormal heart rhythm </li></ul></ul><ul><ul><li>Vasovagal syncope (classic fainting) </li></ul></ul><ul><ul><li>Attention deficit disorder </li></ul></ul><ul><li>Disorders of breathing </li></ul><ul><ul><li>Breathholding spells </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><li>Other medical disorders </li></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Gastroesophageal reflux </li></ul></ul>
    6. 6. Seizures—Differential Dx (2) <ul><li>Unusual” movements </li></ul><ul><ul><li>Benign sleep myoclonus </li></ul></ul><ul><ul><li>Shuddering attacks </li></ul></ul><ul><ul><li>Migraine (torticollis, ataxia, confusional) </li></ul></ul><ul><ul><li>Tics </li></ul></ul><ul><ul><li>“ Pseudoseizures” </li></ul></ul><ul><li>Behavioral or Self-stimulation </li></ul><ul><ul><li>Night terrors </li></ul></ul><ul><ul><li>Sleep walking </li></ul></ul><ul><ul><li>Rocking </li></ul></ul><ul><ul><li>Head banging </li></ul></ul><ul><ul><li>Infantile masturbation </li></ul></ul>
    7. 7. Seizures—Etiology <ul><li>V (ascular): AVM, stroke, hemorrhage, HTN </li></ul><ul><li>I (nfectious): meningitis, encephalitis </li></ul><ul><li>T (raumatic) </li></ul><ul><li>A (utoimmune): SLE, vasculitis, ADEM </li></ul><ul><li>M (etabolic/toxic): electrolyte imbalance, tox </li></ul><ul><li>I (diopathic): “idiopathic epilepsy” </li></ul><ul><li>N (eoplastic) </li></ul><ul><li>S (tructural): cortical malformation, prior stroke, “other causes of CP” </li></ul><ul><li>S (yndrome): genetic disorder </li></ul>
    8. 8. Classification of Seizures By Onset <ul><li>Generalized </li></ul><ul><ul><li>Begins simultaneously in both hemispheres </li></ul></ul><ul><ul><li>Generalized-tonic-clonic = “grand-mal” </li></ul></ul><ul><ul><li>Absence = “petit-mal” </li></ul></ul><ul><ul><li>Myoclonic </li></ul></ul><ul><ul><li>Tonic </li></ul></ul><ul><ul><li>Atonic </li></ul></ul>
    9. 9. Classification by Onset, continued <ul><li>Partial (=Focal) </li></ul><ul><ul><li>Onset in a focal region of the brain </li></ul></ul><ul><ul><li>Simple partial </li></ul></ul><ul><ul><li>Complex partial </li></ul></ul><ul><ul><li>Secondarily generalized </li></ul></ul>
    10. 11. Classification of Seizures By Cause <ul><li>Acute Symptomatic </li></ul><ul><ul><li>Shortly after an acute insult </li></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Hypoglycemia, low sodium, low calcium </li></ul></ul></ul><ul><ul><ul><li>Head trauma </li></ul></ul></ul><ul><ul><ul><li>Toxic ingestion </li></ul></ul></ul>
    11. 12. Classification by Etiology, continued <ul><li>Remote Symptomatic </li></ul><ul><ul><li>Pre-existing brain abnormality or insult </li></ul></ul><ul><ul><ul><li>Brain injury (head trauma, low oxygen) </li></ul></ul></ul><ul><ul><ul><li>Meningitis </li></ul></ul></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><li>Tumor </li></ul></ul></ul><ul><ul><ul><li>Developmental brain abnormality </li></ul></ul></ul>
    12. 13. Classification by Etiology, continued <ul><li>Idiopathic </li></ul><ul><ul><li>No history of preceding insult </li></ul></ul><ul><ul><li>Likely “genetic” component </li></ul></ul>
    13. 14. Classification by Syndromes <ul><li>Definition of a syndrome </li></ul><ul><ul><li>Cluster of symptoms, signs, and lab findings (EEG) </li></ul></ul><ul><ul><li>Consistent </li></ul></ul><ul><ul><li>Implies diagnosis, treatment, or prognosis </li></ul></ul><ul><li>There are syndromes specific to children </li></ul>
    14. 15. Febrile Seizures <ul><li>Definition </li></ul><ul><ul><li>“ a seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures” </li></ul></ul>
    15. 16. Febrile Seizures <ul><li>Epidemiology </li></ul><ul><ul><li>2 to 5 % of children in the US </li></ul></ul><ul><ul><li>Most common form of childhood seizures </li></ul></ul><ul><ul><li>Peak at 18 months </li></ul></ul><ul><ul><li>Simple = isolated, brief, generalized </li></ul></ul><ul><ul><li>Complex = focal, multiple, or prolonged </li></ul></ul>
    16. 17. Simple Febrile Seizures <ul><li>< 15 minutes </li></ul><ul><li>Generalized-tonic-clonic </li></ul><ul><li>Fever > 100.4 rectal to 101 F (38 to 38.4 C) </li></ul><ul><li>No recurrence in 24 hours </li></ul><ul><li>No post-ictal neuro abnormalities (e.g. Todd’s paresis) </li></ul><ul><li>Most common 6 months to 5 years </li></ul><ul><li>Normal development </li></ul><ul><li>No CNS infection or prior afebrile seizures </li></ul>
    17. 18. Risk Factors for 1 st Feb Sz <ul><li>Febrile seizure in 1 st /2 nd degree relative </li></ul><ul><li>Day care </li></ul><ul><li>Neonatal nursery stay of >30 days </li></ul><ul><li>Developmental delay </li></ul><ul><li>Height of temperature </li></ul>
    18. 19. Risk Factors for Recurrent FS <ul><li>1/3 will have a recurrence </li></ul><ul><li>10% will have 3 or more </li></ul><ul><li>FH of febrile seizures </li></ul><ul><li>Age <18 months </li></ul><ul><li>Height of temperature </li></ul><ul><li>Duration of fever </li></ul>
    19. 20. Risk Factors for Epilepsy <ul><li>2 to 10% will go on to have epilepsy </li></ul><ul><li>Developmental delay </li></ul><ul><li>Complex FS (possibly > 1 complex feature) </li></ul><ul><ul><li>5% > 30 mins => ¼ of all childhood status </li></ul></ul><ul><li>FH of epilepsy </li></ul><ul><li>Duration of fever </li></ul>
    20. 21. Evaluation in Febrile Seizures <ul><li>Exclude acute etiologies </li></ul><ul><ul><li>HCT, lytes/cbc if history/PE suggests </li></ul></ul><ul><ul><li>Strongly consider LP </li></ul></ul><ul><ul><ul><li>< 12 months old </li></ul></ul></ul><ul><ul><ul><li>Prior antibiotic therapy </li></ul></ul></ul><ul><ul><ul><li>Suspicious findings on history/PE </li></ul></ul></ul><ul><ul><ul><li>Not absolutely necessary in > 18 mos </li></ul></ul></ul>
    21. 22. Evaluation in FS (2) <ul><li>EEG </li></ul><ul><ul><li>Does NOT predict recurrence or epilepsy </li></ul></ul><ul><ul><li>More likely to be abnormal in: </li></ul></ul><ul><ul><ul><li>Older children </li></ul></ul></ul><ul><ul><ul><li>Neurodevelopmental abnormalities </li></ul></ul></ul><ul><ul><ul><li>Family history of febrile seizures </li></ul></ul></ul><ul><ul><ul><li>Complex febrile seizure </li></ul></ul></ul>
    22. 23. Febrile Seizures—Treatment <ul><li>May reduce short-term recurrence </li></ul><ul><li>But NO effect on occurrence of epilepsy </li></ul><ul><li>AND the side effects ! </li></ul><ul><li>The approach is based on epidemiological data that FS are benign, so </li></ul><ul><li>Prevent status epilepticus </li></ul>
    23. 24. FS—Treatment (2) <ul><li>Antipyretics </li></ul><ul><ul><li>No data that this reduces risk </li></ul></ul><ul><ul><li>FS at onset of fever => highest recurrence </li></ul></ul><ul><li>Benzodiazepines </li></ul><ul><ul><li>Rectal diazepam (Valium) </li></ul></ul><ul><ul><ul><li>2-5 y/o 0.5 mg/kg </li></ul></ul></ul><ul><ul><ul><li>6-11 y/o 0.3 mg/kg (round up to 2.5, 5, 10 mg) </li></ul></ul></ul><ul><ul><li>Oral diazepam </li></ul></ul><ul><ul><ul><li>0.33 mg/kg q8 hrs x 48 hrs during illness </li></ul></ul></ul>
    24. 25. FS—Treatment (3) <ul><li>Daily medications NOT recommended </li></ul><ul><ul><li>Phenobarbital </li></ul></ul><ul><ul><ul><li>Drowsiness, sleep problems, hyperactivity, IQ </li></ul></ul></ul><ul><ul><li>Valproic acid </li></ul></ul><ul><ul><ul><li>Hepatotoxicity </li></ul></ul></ul><ul><ul><li>Phenytoin and carbamazepine </li></ul></ul><ul><ul><ul><li>Not effective </li></ul></ul></ul>
    25. 26. Seizures—Exam <ul><li>Temp, BP, HC </li></ul><ul><li>Skin (rash, neurocutaneous lesions), Neck </li></ul><ul><li>Evidence of dysmorphisms, developmental delay </li></ul><ul><li>Evidence of increased intracranial pressure </li></ul><ul><ul><li>Bulging anterior fontanelle </li></ul></ul><ul><ul><li>Depressed level of consciousness </li></ul></ul><ul><ul><li>Pupillary asymmetries </li></ul></ul><ul><ul><li>Downgaze/sunsetting eyes </li></ul></ul><ul><ul><li>Abducens palsy </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul>
    26. 27. Seizures—Exam (2) <ul><li>Evidence of focal deficits </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><ul><li>Intracranial lesion versus Todd paresis </li></ul></ul></ul><ul><ul><li>Tone or reflex asymmetry </li></ul></ul><ul><ul><ul><li>? Chronic versus acute </li></ul></ul></ul>
    27. 28. Seizures—Evaluation <ul><li>Lumbar puncture </li></ul><ul><ul><li>“ Strongly consider” in patient <12 mo with first febrile seizure </li></ul></ul><ul><ul><ul><li>Kernig’s, Brudzinski’s, nuchal rigidity low sensitivity (Thomas 2002) </li></ul></ul></ul><ul><ul><li>But usually more than isolated seizure </li></ul></ul><ul><ul><ul><li>History of irritability/lethargy </li></ul></ul></ul><ul><ul><ul><li>Complex febrile seizure </li></ul></ul></ul><ul><ul><ul><li>Slow postictal clearing of mentation </li></ul></ul></ul>
    28. 29. Seizures—Evaluation (2) <ul><li>Neuroimaging </li></ul><ul><ul><li>“ Emergent” HCT </li></ul></ul><ul><ul><ul><li>Concern of acute focal lesion, mass effect </li></ul></ul></ul><ul><ul><ul><li>I.e. persistent paresis or change in MS </li></ul></ul></ul><ul><ul><li>MRI (nonurgent) </li></ul></ul><ul><ul><ul><li>Focal sz </li></ul></ul></ul><ul><ul><ul><li>Cognitive/motor impairment </li></ul></ul></ul><ul><ul><ul><li>Focal EEG findings </li></ul></ul></ul><ul><li>EEG </li></ul><ul><ul><li>Not if simple febrile seizure </li></ul></ul>
    29. 30. Location, Location, Location
    30. 31. Overview of the Neuro Exam <ul><li>Mental Status </li></ul><ul><li>Cranial Nerves </li></ul><ul><li>Motor </li></ul><ul><li>Gait </li></ul><ul><li>Coordination </li></ul><ul><li>Reflexes </li></ul><ul><li>Sensory </li></ul><ul><li>“General” </li></ul>
    31. 32. General <ul><li>Growth parameters (HC) </li></ul><ul><li>Vital signs (temp, BP) </li></ul><ul><li>Anterior fontanelle </li></ul><ul><li>Flattening of the occiput </li></ul><ul><li>Dysmorphic features </li></ul><ul><li>Cardiac abnormalities </li></ul><ul><li>Hepatosplenomegaly </li></ul><ul><li>Cutaneous lesions </li></ul>
    32. 33. Mental Status <ul><li>Change in mental status = brain is not working correctly </li></ul><ul><li>Level of consciousness </li></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Stupor </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><li>Attentive/interactive </li></ul><ul><li>Language (receptive, expressive) </li></ul>
    33. 34. Cranial Nerves <ul><li>= Brain stem or nerve </li></ul><ul><li>CN2 = optic nerve </li></ul><ul><ul><li>Funduscopic exam </li></ul></ul><ul><ul><li>Visual fields/blink to threat </li></ul></ul><ul><ul><li>Visual acuity/color vision </li></ul></ul><ul><li>CN3, 4, 6 = oculomotor, trochlear, abducens </li></ul><ul><ul><li>Eyelids </li></ul></ul><ul><ul><li>Pupils </li></ul></ul><ul><ul><li>Extraocular movements </li></ul></ul>
    34. 35. Cranial Nerves (2) <ul><li>CN5 = trigeminal </li></ul><ul><ul><li>Sensation </li></ul></ul><ul><ul><li>Masseter function </li></ul></ul><ul><ul><li>Corneal reflex (comatose or focal brain stem) </li></ul></ul><ul><li>CN7 = facial </li></ul><ul><ul><li>Wide palpebral fissure and flat nasolabial fold </li></ul></ul><ul><ul><li>Both upper and lower face = LMN </li></ul></ul><ul><ul><li>Only lower face weak = UMN </li></ul></ul>
    35. 36. Cranial Nerves (3) <ul><li>CN8 = vestibulocochlear nerve </li></ul><ul><ul><li>Finger rub </li></ul></ul><ul><ul><li>Weber’s—louder ear = conduction deafness </li></ul></ul><ul><ul><li>Rinne—confirms above ear (air < bone) </li></ul></ul><ul><li>CN9, 10 = glossopharyngeal and vagus </li></ul><ul><ul><li>Palate elevation, gag </li></ul></ul><ul><li>CN11 = spinal accessory </li></ul><ul><ul><li>L SCM turns head to R, ear to ipsi clavicle </li></ul></ul><ul><li>CN12 = hypoglossal </li></ul><ul><ul><li>Tongue in cheek </li></ul></ul>
    36. 37. Motor <ul><li>Hypotonia = LMN or UMN, cerebellum </li></ul><ul><li>Hypertonia = UMN lesion, basal ganglia </li></ul><ul><li>Bulk/Fasciculations </li></ul><ul><li>Tone </li></ul><ul><ul><li>Resistance to passive ROM </li></ul></ul><ul><ul><li>Traction response, horizontal/vertical suspension </li></ul></ul><ul><li>Power </li></ul><ul><ul><li>0 to 5 grading scale </li></ul></ul><ul><ul><li>Techniques to bring out asymmetry </li></ul></ul><ul><ul><ul><li>Pronator drift, finger tapping, gait </li></ul></ul></ul>
    37. 38. Gait <ul><li>Motor cortex, corticospinal tracts, basal ganglia, cerebellum, vestibular system, nerves, muscles, vision, proprioception </li></ul><ul><li>Good screening test </li></ul><ul><li>Natural gait </li></ul><ul><li>Toe walk, heel walk, tandem walk </li></ul><ul><li>Romberg (proprioception, vestibular) </li></ul><ul><li>Sit to stand </li></ul>
    38. 39. Coordination <ul><li>Limb ataxia = cerebellar hemispheres </li></ul><ul><li>Gait ataxia = midline cerebellum </li></ul><ul><li>Finger-to-nose testing/reaching for toys </li></ul><ul><li>Rapid rhythmic alternating movements </li></ul><ul><li>Titubation (truncal ataxia) </li></ul>
    39. 40. Reflexes <ul><li>Hyperreflexia = UMN lesion </li></ul><ul><li>Hyporeflexia = LMN lesion </li></ul><ul><li>0 to 5+ grading scale </li></ul><ul><li>Babinski’s sign = UMN lesion </li></ul><ul><li>Correspond to spinal roots </li></ul><ul><li>Primitive reflexes </li></ul>
    40. 41. Sensation <ul><li>Stocking-glove = nerve </li></ul><ul><li>Vibration/proprioception = dorsal columns </li></ul><ul><li>Pain/temp = spinothalamic tracts </li></ul><ul><li>Extinction = cortex </li></ul><ul><li>Localization of stim </li></ul><ul><li>Purposeful withdrawal to painful stim </li></ul><ul><li>Spinal level </li></ul>
    41. 42. Questions re:Neuro Exam? http://medstat.med.utah.edu/pedineurologicexam/home_exam.html
    42. 43. Bibliography <ul><li>Baumann RJ and Duffner PK. Treatment of children with simple febrile seizures: The AAP practice parameter. Pediatr Neurol 2000;23:11-17. </li></ul><ul><li>Hirtz D et al. Practice parameter:evaluating a first nonfebrile seizure in children. Neurology 2000;55:616. </li></ul><ul><li>Knudsen FU. Febrile seizures: Treatment and prognosis. Epilepsia 2000;41:2-9. </li></ul><ul><li>Prensky AL. An approach to the child with paroxysmal phenomena with emphasis on nonepileptic disorders. In: Pellock JM, ed. Pediatric epilepsy diagnosis and therapy . New York: Demos Medical Publishing, 2001:97. </li></ul>
    43. 44. Bibliography <ul><li>Provisional committee on quality improvement, subcommittee on febrile seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996;97:769. </li></ul><ul><li>Shinnar S and Glauser TA. Febrile seizures. J Child Neurol 2002;17:S44-52. </li></ul><ul><li>Thomas KE et al. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Inf Dis 2002;35:46. </li></ul><ul><li>Warden CR et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 2003;41:215. </li></ul>

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