The brain of the blue baby… NEUROLOGY MODULE Pediatrics II

Salient Points A 5-year-old girl with TOF May 2004  Headache and on-and-off fever June 2004  Fever, vomiting, severe bifrontal headache Pertinent Physical Examination Findings: Wt=12 kg HR=102 beats/min RR=40/min Temp = 37.6 HC = 48.5 cm (P10) Liver edge palpable below the right subcostal margin Full pulses

Salient Points Neurological Examination Findings: Awake, irritable, uncooperative Fundi: hazy disc margins Shallow left nasolabial fold Moves right extremities more than the left (LEFT HEMIPARESIS) Left lower extremity externally rotated DTRs brisk (+) sustained ankle clonus, left; few beats, right (+) Babinski, left (PYRAMIDAL TRACT SIGNS)

Question #1: Is there a neurologic problem? The abnormal neurologic findings point to a problem in the nervous system.

Question #2: Where is the lesion? Levelize The left hemiparesis, pyramidal tract signs and increased ICP suggest a cerebral lesion. Lateralize The left hemiparesis will point to a right cerebral lesion. Localize The motor (frontal) area is likely to be affected.

Question #2: Where is the lesion? The left hemiparesis and pyramidal signs suggest an upper motor lesion specifically a focal lesion over the right cerebral hemisphere. There are no brain stem, spinal cord nor lower motor signs. The patient presented with signs of increased intracranial pressure.

Increased intracranial pressure In children should not exceed 180 mm water in a relaxed position. Neonates have lower values.

Clinical features of increased ICP differ with age: In Infants In Children Bulging fontanel Diplopia Failure to thrive Headache Setting-sun sign Mental changes Enlarging head Nausea / vomiting Shrill cry Papilledema Behavioral changes

What are the diagnostic possibilities? Causes of Increased Intracranial pressure: 1.Infectious Bacterial meningitis TB meningitis Fungal meningitis Viral meningitis/encephalitis Brain abscess

2. Non-infectious Neoplasms / Tumors Porencephalic cysts Hematomas AV malformation Metabolic and toxic encephalopathies 3. Idiopathic Pseudotumor cerebri What are the diagnostic possibilities?

Diagnostic Tests 1. Neuroimaging – CT / MRI (for neoplasms, hematoma, vascular malformation) 2. Lumbar puncture and CSF analysis Indications: should be done if CNS infection is considered or cannot be ruled out Neuroimaging should be done before LP if space-occupying lesions are suspected or if focal manifestations are seen. 3. Intracranial pressure determination/monitoring

Diagnostic Tests Cranial CT Scan showing a right frontal lobe abscess

Brain Abscess Manifestations are similar to any space occupying lesion in the brain Clinical Manifestations: 1. Signs of increased intracranial pressure 2. Neurological deficit depending on the area of the brain involved 3. Seizures 4. Signs of infection may be subtle or absent

Brain Abscess: Causes History of Sepsis Otitis Media / Mastoiditis Trauma Cyanotic Congenital Heart Disease

Brain Abscess: Management 1.Specific measures for the abscess Massive antibiotics before and after surgery depending on the organism involved. Common agents are: S. aureus Streptococcus Pneumococci Gram-negative rods Surgical drainage

2. Manage the increased intracranial pressure Medical Mannitol Dexamethasone Others – acetazolamide, furosemide Nonmedical Position – may be of help Surgical Ventriculostomy / VP shunting Aspiration or excision Brain Abscess: Management

Brain Abscess: Sequelae Progressive increase in pressure  Herniation Shock and death

Thank you!