CNS disorders in pediatrics

Why is the CNS function so
important?
• What does it do?
• What happens with impairment?
• What affects the degree of disability?

Changes to be noted in pediatric
neurological disorders
• Reflexes: may be hypo/hyper
• LOC: may have altered mental status
• Cranial nerves:
• I, III
• II, IV, VI
• III, VIII
• V,VII
• IX, X

Neuro assessment, cont.
• Vital signs:changes in BP, HR
• Eyes: changes in pupils,focus,gaze
• Behavior: subtle
• Respiratory status: assess 1st
• Motor function: movement? Spontaneous?
• Skin: dry vs. diaphoretic

Central nervous system disease
Definition
• Diseases of any component of the brain or the
spinal cord.
http://www.hon.ch/HONselect/Selection/C10.228.html

CNS disease: pathology
• Trauma
• Infections
• Degeneration
• Structural defects
• Tumors
• Blood flow disruption
• Autoimmune disorders
http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_syst
em_disorders/overview_of_nervous_system_disorders_85,P00799/

Common CNS disease
• Meningitis
• Acute bacterial meningitis
• Acute viral meningitis
• Tuberous meningitis
• Encephalitis
• Herpe simplex
• OTHERS
• Brain abscess
• Hydrocephalus
• Spina Bifida
• Cerebral palsy
• Seizure disorder
• ADHD

Meningitis
• Acute meningitis
• Acute bacterial meningitis
• Acute viral meningitis
• Subacute meningitis
• Tuberous meningitis
• Fungal meningitis

Meningitis
• Suspicion of bacterial and viral meningitis
• acute onset of fever,
• headache,
• neck stiffness
• photophobia,
• confusion.
• Bacteria significant morbidity (neurologic sequelae,
particularly sensorineural hearing loss) and mortality
• immediate antibiotic therapy.
• only supportive care with analgesics is necessary for
viral meningitis.
Pathophysiology of Disease: An Introduction to Clinical Medicine, 7e

Pathophysiology

Bacterial meningitis
Pathology
• Acute purulent infection within the sub-
arachnoid space.
• CNS inflammatory reaction
• decreased consciousness, seizures, raised
intracranial pressure (ICP), and stroke.
• meninges, the subarachnoid space, and the
brain parenchyma are all frequently involved
(meningoencephalitis).
Harrison's Principles of Internal Medicine, 18e

Common causes of bacterial meningitis vary by age group:
Age Group Causes
Newborns
Group B Streptococcus, Escherichia
coli, Listeria monocytogenes
Infants and Children
Streptococcus pneumoniae,
Neisseria meningitidis,
Haemophilus influenzae type b
Adolescents and Young Adults
Neisseria meningitidis,
Streptococcus pneumoniae
Older Adults
Streptococcus pneumoniae,
Neisseria meningitidis, Listeria
monocytogenes
http://www.cdc.gov/meningitis/bacterial.html

Viral meningitis
Common symptoms in
children
• Fever
• Headache
• Stiff neck
• Sensitivity to bright light
• Sleepiness or trouble
waking up from sleep
• Nausea
• Vomiting
• Lack of appetite
• Lethargy (a lack of energy)
Common symptoms in
infants
• Fever
• Irritability
• Poor eating
• Sleepiness or trouble
waking up from sleep
• Lethargy (a lack of energy)
Most people with viral meningitis usually get
better on their own within 7 to 10 days.

Viral meningitis
Virus
Season or
Geography
Vector Features
Meningitis
Enterovirus Echo, coxsackie Summer, fall Human Rash, gastroenteritis, carditis
Herpesvirus
Herpes simplex type 2
(HSV2)
— Human Neonates
Varicella-zoster virus
(VZV)
— Human Immunosuppression; rash
Epstein-Barr virus
(EBV)
— Human
Teenagers; infectious
mononucleosis syndrome
Other
Human
immunodeficiency virus
(HIV)
— Human Immunosuppression
Mumps Winter, spring Human
Especially boys; parotitis,
orchitis, oophoritis, pancreatitis
Lymphocytic
choriomeningitis
Fall, winter Mouse
Pharyngitis, pneumonia; marked
CSF pleocytosis, low CSF
glucose; transmissible by organ
transplantation

Diagnosis clinical & lab
• Physical examination
• naso-oropharyngeal swabs
• rectal swabs, stool
• cerebrospinal fluid
• Hemoculture
• Urine culture
• CT-brain
• Electrolyte
• Urinalysis

Meningitis sign
http://www.physio-pedia.com/Meningitis

Lumbar puncture
indications:
• Suspicion of meningitis
• Suspicion of subarachnoid hemorrhage (SAH)
• Suspicion of central nervous system (CNS)
diseases such as Guillain-Barré syndrome and
carcinomatous meningitis
• Therapeutic relief of pseudotumor cerebri
http://emedicine.medscape.com/article/80773-overview#aw2aab6b2b3

Lumbar puncture: contraindication
Absolute: puncture on CT of the brain:
• Midline shift
• Loss of suprachiasmatic and basilar cisterns
• Posterior fossa mass
• Loss of the superior cerebellar cistern
• Loss of the quadrigeminal plate cistern
Relative
• Increased intracranial pressure (ICP)
• Coagulopathy
• Brain abscess
http://emedicine.medscape.com/article/80773-overview#aw2aab6b2b3

CSF analysis
Etiology
Pressure (mm
H2O)
Cells (μL)
Proteins
(mg/100 cc)
Glucose
(CSF/blood)
Normal <200
0–5 Lymphs, 0
Polys
<45 >0.6
Acute bacterial Increased
200–5000;
mostly (>90%)
Polys
>100 <0.6
Acute viral Slight increase
100–700
Lymphs
Slight increase Normal
Subacute/chro
nic (TB,
fungus)
Increased
25–500
Lymphs
>100 <0.6
Review of Medical Microbiology and Immunology, 13e

Treatment: Bacterial meningitis
Patient Population Empiric Treatment
Neonate
Ampicillin plus cefotaxime or an
aminoglycoside
Healthy children and adults with
community-acquired disease
3rd - or 4th -generation cephalosporin +
vancomycin [+metronidazole if otitis,
mastoiditis, sinusitis are predisposing
conditions]
≥ 55 year or with chronic illness or
immunosuppressed patients
3rd - or 4th -generation cephalosporin +
vancomycin + ampicillin
Postneurosurgical Vancomycin + meropenem
Principles and Practice of Hospital Medicine > Chapter 199. Meningitis and Encephalitis

Treatment acute viral meningitis
• Viral meningitis is treated symptomatically
• antipyretics, antiemetics, and analgesics.
• Amytriptyline and NSAIDs are often required for months
to treat headache from viral meningitis.
• Patients with HSV-2 meningitis can be treated with
• acyclovir 800 mg 5 times daily, or
• famciclovir 500 mg 3 times daily, or
• Valacyclovir 1000 mg 3 times daily for 7 to 14 days.

Treatment Subacute meningitis
Tuberculous meningitis:
• Empirical therapy of tuberculous meningitis is often
initiated on the basis of a high index of suspicion without
adequate laboratory support.
• Initial therapy is a combination
• isoniazid (300 mg/d)
• rifampin (10 mg/kg per day)
• pyrazinamide (30 mg/kg per day)
• ethambutol (15–25 mg/kg per day)
• pyridoxine (50 mg/d) for 8 weeks
• isoniazid and rifampin continued alone for 9–12 months.
• Dexamethasone therapy is recommended for HIV-
negative patients with tuberculous meningitis. The dose
is 12–16 mg per day for 3 weeks, then tapered over 3
weeks.

C. neoformans
• intravenous amphotericin B (0.7–1.0 mg/kg/d) or
amBisome 4 mg/kg/day or abelcet 5 mg/kg/day
plus
• oral flucytosine (25 mg/kg four times a day). This
combination is typically used for two weeks or until
the CSF culture is sterile.
then
• followed by fluconazole 400 to 800 mg/day, which
is continued for 8 to 10 weeks.

H. capsulatum
• Amphotericin B (0.7–1.0 mg/kg per day) for 4–
12 weeks. A total dose of 30 mg/kg is
recommended. Therapy with Amphotericin B is
not discontinued until fungal cultures are
sterile.
then
• itraconazole 200 mg twice daily is initiated and
continued for at least 6 months to a year

Meningococcal prophylaxis
Rifampicin
• Adults: 600 mg twice daily for two days
• Children: 10 mg/kg twice daily for two days
• Neonates: 5 mg/kg twice daily for two days
Ceftriaxone (pregnant women or contraindication to rifampicin)
• < 12yo: 125mg IM once only
• > 12yo: 250 mg IM once only
• Reconstitute 1 g vial with 3.2 ml lignocaine 1% (250
mg/ml)
The Royal Children's Hospital Melbourne. Meningococcal Prophylaxis. 2012.

Encephalitis
Definition
• Encephalitis is an infection of the brain parenchyma
predominantly caused by viruses.
• Sometimes both the brain and the meninges are
involved, a condition called meningoencephalitis
Review of Medical Microbiology and Immunology, 13e

Viruses Commonly Causing Encephalitis with Various Predisposing Factors
Predisposing Factor Common Viruses Comment
Neonate HSV-2 Acquired at time of birth
Child over age of 1 year and
adult
HSV-1
Primarily affects temporal
lobe. Probably reach the brain
by traveling down sensory
neuron following activation of
latent infection in trigeminal
ganglion
Animal bite (e.g., dog, cat,
bat, skunk, raccoon)
Rabies
In United States, dogs and
cats are uncommon
reservoirs. Bats are the most
common reservoir; raccoons
are common reservoirs east of
the Mississippi
Mosquito bite
West Nile virus, Eastern and
Western equine encephalitis
viruses, St. Louis encephalitis
virus, jE
West Nile virus is the most
common arboviral infection in
the United States
Review of Medical Microbiology and Immunology, 13e > Central Nervous System Infections

Herpes simplex encephalitis
• HSV-1:
• children > 3 months and in adults
• localized to the temporal and frontal lobes
• HSV-2:
• neonates
• brain involvement is generalized, and the usual
cause is acquired at the time of delivery
• Incidence is 2 cases per million population per
year. HSE may occur year-round. HSV-1 is
ubiquitous, and HSV-2 is also common.
International incidence is similar to that in the
United States
http://emedicine.medscape.com/article/1165183-overview#a0156

• Viral infections can affect the CNS in three ways
• hematogenous dissemination of a systemic viral
infection (eg, arthropod-borne viruses),
• neuronal spread of the virus by axonal transport (eg,
herpes simplex, rabies),
• autoimmune postinfectious demyelination (eg, varicella,
influenza).
Clinical Neurology, 8e

Symptom
• Alteration of consciousness (97%)
• Fever (92%)
• Dysphasia (76%)
• Ataxia (40%)
• Seizures (38%): Focal (28%); generalized (10%)
• Hemiparesis (38%)
• Cranial nerve defects (32%)
• Visual field loss (14%)
• Papilledema (14%)

Diagnosis
• cerebrospinal fluid (CSF)
• computed tomography (CT)
• confirmed only by
• polymerase chain reaction (PCR)
• brain biopsy.

Management
• Initial Management
• supportive management: airway, breathing, and
circulation (ABCs)
• General nutritional and fluid support
• Monitor for ICP and seizures.
• Antiviral
• Adults should receive a dose of 10 mg/kg of
acyclovir intravenously every 8 h (30 mg/kg per day
total dose) for 14–21 days.
• neonates with HSV encephalitis receive 20 mg/kg of
acyclovir every 8 h (60 mg/kg per day total dose)
for a minimum of 21 days

Brain abscess
Definition
• A brain abscess is a focal, suppurative infection
within the brain parenchyma, typically
surrounded by a vascularized capsule.
• The term cerebritis is often employed to
describe a nonencapsulated brain abscess.

Brain abscess
• direct spread: paranasal sinusitis, otitis media,
mastoiditis, or dental infection;
• head trauma or a neurosurgical procedure
• hematogenous spread from a remote site of
infection

Brain abscess
The most common pathogenic
• Aerobic, Anaerobic, and Microaerophilic
streptococci, and gram-negative anaerobes
such as bacteroides, Fusobacterium, and
Prevotella. Staphylococcus aureus, Proteus,
• and other gram-negative bacilli are less
common.
• Actinomyces, Nocardia, and Candida are also
found. Multiple organisms are present in the
majority of abscesses.

Brain abscess
Fever 58%
Headache 55%
Disturbed
consciousness
48%
Hemiparesis 48%
Nausea, vomiting 32%
Nuchal rigidity 29%
Dysarthria 20%
Seizures 19%
Sepsis 17%
Visual disturbances 15%

Brain abscess
Diagnosis
• Lumbar puncture:
• Brain CT scan

Brouwer MC et al. N Engl J Med 2014;371:447-456.

Indication for medical treatment
• Size < 3 cm
• Symptom < 2 wks
• Improve within 1 wks
จีรนันท์ วีรกุล. ปัญหาโรคทางระบบประสาทที่พบบ่อย. คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร

Hydrocephalus
Hydro= Water
Cephaly= of the head/brain

An excess of CSF in the
ventricles or in the
subarachnoid space
•Imbalance in the
production and
absorption of CSF in the
ventricular system
•Causes passive dilation of
ventricles

Etiology and Pathophysiology:
• Congenital anomalies
• Trauma
• Unknown causes

Classification
1. Obstructive/ intraventricular
• caused by a block in the passage of fluid.
2. Communicating/ extraventricular
• fluid passes between the ventricles and spinal cord

Assessment/Clinical feature
1. Widened fontanelles
2. Separates suture lines in
the skull -Mc Evan
sign/Crack pot sign
3. Enlarged head diameter
4. Shiny scalp
5. Prominent scalp veins
6. “Bossing” of forehead
7. Shrill cry
8. Sunset eyes
9. s/sx of increased ICP
10.Hyperactive reflexes
11.Strabismus
12.Optic atrophy
13.Irritable
14.Lethargic

Diagnostics
• Sonogram
• CT scan
• MRI
• Skull X-ray
• Transillumination

Therapeutic Management
• Ventricular endoscopy
• Ventriculoperitoneal Shunt

Complications of Shunts
• Infections
• Blocked shunts
• Seizures

Most common developmental defect of the CNS
Occurs when incomplete closure of the embryonic
neural tube results in an incompletely formed
spinal cord.

Clinical Manifestations:
• Visualization of the defect
• Motor sensory, reflex and sphincter abnormalities
• Flaccid paralysis of legs- absent sensation and
reflexes, or spasticity
• Malformation
• Abnormalities in bladder and bowel function

Pathophysiology/types
• Failure of the neural
tube to close
• Degree of neurological
dysfunction is directly
related to the
anatomic level of the
defect and the nerves
involved

Types
Spina bifida occulta
• Occulta is Latin for "hidden."
• no opening of the back, but the outer part of some
of the vertebrae are not completely closed
• The skin at the site of the lesion may be normal, or
it may have some hair growing from it; there may
be a dimple in the skin, or a birthmark

Meningocele
• least common form
• Meninges covering the spinal cord herniate through the
unformed vertebrae
• Protrusion may be covered with a layer or skin just the
clear dura

Spina bifida cystica (myelomeningocele)
• most serious and common form
• the unfused portion of the spinal column allows the spinal cord to protrude
through an opening in the overlying vertebrae
• meningeal membranes that cover the spinal cord may or may not form a sac
enclosing the spinal elements

Encephalocele
Cranial meningocele or
myelomeningocele.
Most often occur in the
occipital area

Diagnostic Tests:
Prenatal detection
• Ultrasound
• Alpha-fetoprotein
Following Birth:
• NB assessment
• X-ray of spine
• X-ray of skull

Surgical Intervention
• Immediate surgical closure
• Prior to closure keep sac moist & sterile
• Maintain NB in prone position with legs in
abduction

Nursing Interventions:
Pre-OP:
• Place in prone position
• Sterile moist dressing with normal saline or
antibiotic solution
• Maintain proper abduction of legs and alignment of
hips
• Meticulous skin care
• Protect from feces or urine
• Keep in isolette

Cerebral Palsy
• Chronic, nonprogressive disorder of posture and
movement (motor system)

Etiology & Manifestations
Most common permanent physical disability of
childhood
• Prenatal, perinatal, or postnatal damage to
motor system
• Incidence: 2 in 1000 live births
• Abnormal posturing, perceptual problems,
language deficits, intellectual impairment

Physiologic/Swedish
classification
Spastic type
Dyskinetic type:
Choreo-athetoid type
Dystonic type
Ataxic type
Hypotonic type
Mixed type

Pathophysiology
• Cerebral assault:
loss of voluntary
muscular control
• Neuromuscular
disability:
determined by area
of brain damage

Diagnostic Evaluation
• Neuro exam & history
• Test: R/O other
pathology
• Primitive reflexes
continue
• Physical signs include
poor head control after 3
months of age, feeding
difficulties and floppy or
limp body posture

• Early recognition and
intervention to attain
optimum development,
maximum abilities
• Multidisciplinary
approach
• Establish locomotion,
communication and self
help
• Provide educational
opportunities
• Promote socialization

Seizure Disorders
Brief paroxysmal behavior due to malfunctions of the
brain’s electric system (excessive discharge of
neurons)
Most common observed neurologic dysfunction in
children
• 3% - 5% children under 18 mos
• 3% - 4% children 6 mos – 3 yrs (febrile)
• Neonatal seizures: 20% of preterm infants
• Epilepsy: seizure onset before 18 yrs: 60%

Epilepsy:
A chronic seizure disorder with
recurrent and unprovoked
seizures.
Seizures are characteristic of
epilepsy: not every seizure is
epileptic

Jitteriness –vs- Seizure
•Jittery
• Responsive
• Gaze Okay
•Seizure
• Not responsive to
stimuli
• Abnormal gaze

Etiology
• Symptomatic of altered neuronal activity in CNS
• Primary: no underlying brain structure
abnormality
• Secondary: structural or metabolic abnormality
• 50% idiopathic (cause unknown)
• Most common in the first 2 years of life

Classification
• Generalized
• Tonic-Clonic
• Atonic
• Myoclonic
• Absence
• Partial

• Health history & family history
• Behavior prior, during, & after seizure
• Video recording and EEG
• Complete physical and neurological exam
• Lab tests (metabolic causes)
• CT & MRI (trauma, tumor, congenital)
• Neonates: TORCH titers

• Discover cause and effect
• Live normal life
• Medication
• Oral care
• Don’t stop medication abruptly! Reduce medication
dose gradually.

Nursing Care Management
• Assessment
• Protect from harm during seizure
• Reorient to environment
• Determine trigger factors
• Medication
• Family support

Status Epilepticus
Continual or recurrent seizures lasting 30 minutes
or more with no return to normal consciousness
• Support and maintenance of vital functions
• IV administration of diazepam (Valium) or
lorazepam (Ativan)
• IV phenobarbital (2nd round)
• Monitor closely
• Safety

Febrile Seizures (not epilepsy)
• 2-4 % of children age ~ 6 months – 6 years
• Provoked by a sudden spike in temp usually with URI, Acute OM,
AGE (genetic predisposition)
• “Simple”
• Generalized convulsion (whole body shaking)
• Brief (< 15-20 minutes)
• Only one in the course of an illness
• Future risk of epilepsy 1% like other children
• “Complex”
• focal seizure (one side of body shaking, staring)
• prolonged (> 15-20 minutes)
• multiple in 24 hours
• Complex febrile seizures hint at an increased risk of future
epilepsy

Treatment of Febrile Seizures (not epilepsy)
• Rectal Diazipam stat (valium gel) may be used to:
• abort prolonged complex febrile seizure
• prevent complex febrile seizure clusters (if child known to
cluster)
• prevent febrile seizure recurrence during a febrile illness
• Anti-pyretics have NOT been proven to decrease the risk of
recurrent febrile seizures

ADHD:
(Attention-Deficit Hyperactivity Disorder)
Most common chronic behavioral disorder of children
• Developmentally inappropriate degrees of inattention
and concentration, impulsiveness, and hyperactivity
• Incidence: 1% - 20%; 4% - 12% > consensus
• 3:1 males to females
• Onset: 3-4 years

• Battery of tests
• Hand eye coordination
• Auditory and visual perception
• Comprehension, memory, IQ
• Symptoms present 6 months or more, before age
7, present in 2 settings (e.g., home, school,
recreation, church)

• Environmental manipulation
• Classroom education
• Support to family
• Parenting classes
• Medication: methylphenidate Ritalin, Dexedrine,
Adderall

Neurological Disorders
in the Pediatric Patient

CNS disorders in pediatrics

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to CNS disorders in pediatrics

Similar to CNS disorders in pediatrics (20)

More from Virendra Hindustani

More from Virendra Hindustani (20)

Recently uploaded

Recently uploaded (20)

CNS disorders in pediatrics