1. Extern ทุกคน โปรดมานั่ง ข้างหน้า ให้เต็มครับ ><

2. Extern Conference 27/12/2007

3. History A 13-year-old Thai boy CC : Chronic progressive headache for 6 mo. PI : 6 mo. PTA He had headache at the vertex and bioccipital area. The character of the pain was unspecified, and pain duration was about 5 min. He developed headache 4-5 times/day that mostly occurred on day time and got worse when he strained. He had no nausea or vomiting.

4. History PI : The parent brought him to see a local physician. He was diagnosed as tension- typed headache and the painkiller-Ibuprofen was prescribed but the pain did not get better.

5. History 1 month ago, He came to see a doctor at Siriraj hospital. After complete neurological examination including eyeground, he was diagnosed as migraine headache, Propanolol was given. But the pain still persist.

6. History 1 wk PTA the patient got progressive headache with awakening pain without nausea and vomiting, then he came to the hospital again.

7. History No history of Aura, Photophobia, Phonophobia Weakness, Numbness, Ataxia Sinusitis Fever Myopia, Eye pain

8. History Past history 5-month-old, He fallen down from the swinging bed 1 m. tall. 7-year-old : Dengue fever

9. History Personal history Study in grade VII with the 1 St rank Left handed

10. History Family history No family history of migraine

11. Question

12. Tension type headache Migraine Refractive error ปวดหัวช่วงใกล้สอบ What is the most common cause of headache in children ?

13. PHYSICAL EXAM

14. Which part of physical exam should be focused in the children with progressive headache ? Blood pressure Visual acuity Fundoscopy Bowel sound

15. Physical Exam V/S T 37.3, BP 102/68 mmHg, P98/min,RR 20/min GA 13 year-old boy, alert, not pale, no jaundice, no edema, no dyspnea HEENT Pharynx not injected, Tonsil not enlarged, Ear : TM are intact, no discharge, Sinus : Not tender on percussion, TMJ : Not tender No cervical lymphadenopathy

16. Physical Exam CVSNormal S1&S2, no murmur RS Normal equal breath sound both lungs ABD Soft, not tender, liver&spleen not palpable, normal bowel sounds Skin No petechiae, no ecchymoses

17. NEURO EXAM

18. Neuro Exam Good consciousness, good orientation Cranial nerves CN II: VA 20/25,20/25,no visual field defect, Pupil 4 mm BRTL CN III,IV,VI : Full EOM CN V: Normal facial sensation, no weakness of masseter & temporalis m. normal corneal reflex

19. Neuro Exam CN VII : No facial palsy CN IX,X : Uvula in midline, Gag reflex : Positive CN XI : No weakness of Sternocleidomastoid & Trapezius m. CN XII : No tongue deviation

20. Neuro Exam Motor: Normal muscle tone, Muscle Power gr. V all extremities No Pronator drift Sensation: Within normal limit DTR: 2+ all extremities, Clonus : Neg Babinski’s sign : Negative No stiff neck, Kernig’s sign: Neg

21. Eyeground

22. back Papilledema both eyes

23. Loss of spontaneous venous pulsations Disc elevated Disc margins obscured Engorgement of veins Disc hyperemia Multiple flame hemorrhages and cotton wool spots Early Full developed

24. Chronic : Pale disc Central cup obliterated Hemorrhage & Exudate resolve

25. Cerebellar Sign

26. Cerebellar sign Speech Normal Balance No wide-based gait, No truncal ataxia Tandem walk : Neg Nystagmus No nystagmus Coordination Finger-to-Nose test : Rt. Dysmetria Heel-to-Knee test : Neg Dysdiadokokinesia : Neg

27. Finger-to-nose test +Rt

28. Co-ordination

29. Approach to Headache

30. History Headache characteristic Onset Duration and progression Character Location Severity and diurnal variation Aggravating, Alleviating factors History of previous headaches

31. History Associated symptoms Fever Visual disturbance, Photophobia Nausea, Vomiting Focal neuro deficit such as weakness, numbness,ataxia Prodromal symptom (eg. Aura)

32. Red flags : Headache Progressive headache Awakening the patient from sleep Increase with valsava maneuver Accompany with vomiting “ ICP ”

33. Past medical history Infection Coagulopathy Cyanotic heart disease Family history : Migraine Current medication History

34. Physical examination Vital signs : Fever, Elevated blood pressure, Bradycardia. HEENT : Evidence of trauma Skin : R ash or Cutaneous lesions (eg, Petechiae, purpura, Ash leaf spots, Cafe- au-lait spots) CVS : Murmur ?

35. Physical examination Complete neurogical exam : level of consciousness, cranial nerve dysfunction, hypertonia, hyperreflexia, emiparesis, or hemiplegia Nuchal rigidity Fundoscopic examination : papilledema, pale disc, loss of retinal venous pulsatile

36. Indication: Imaging Presence of neurological sign Sign of increased intracranial pressure : papilledema, loss of visual acuity, visual field defect, vomiting

37. Adapted from

40. Problem list

41. Problem List Chronic progressive bioccipital headache aggravating by valsava maneuver for 6 months Focal neurological deficit : cerebellar sign positive Sign of increased intracranial pressure : papilledema of both eyes

42. Discussion

43. Functional or Organic cause ? Red flags Progressive headache Awakening pain Aggravating by valsava manuver + Papilledema “ ICP ” Discussion

44. In older children and adult - Chronic progressive headache or sudden headache - Vomiting - Diplopia (6 th nerve palsy) - Papilledema or loss of retinal venous pulsation Sign & Symptom of increased ICP

45. In older children and adult - Change in personality - Declining school performance - Cushing response in late stage Sign & Symptom of increased ICP

46. In infant - Irritable, anorexia - Cranial enlargement - Developmental regression - Bulging of anterior fontanelle, prominent of scalp vein - Separation of cranial suture

47. Discussion Where is the lesion History – Bioccipital headache, deny other focal neuro deficit eg. ataxia PE- Cerebellar sign positive Rt “RIGHT CEREBELLAR HEMISPHERE”

48. What is the lesion Clinical time course Sign & Symptoms of Increased ICP Cerebellar sign Positive Cerebellar tumor

49.    From 

50. Cerebellar tumor 1.Juvenile pilocystic astrocytoma 2.Medulloblastoma DDx

51. Juvenile pilocytic astrocytoma (JPA) Benign tumor Grossly cystic character Occur predominantly in patients less than 25 years of age. Most frequently arise in the cerebellar hemispheres and around the third ventricle

52. Medulloblastoma Malignant tumor Predominately in males Age of 5–7 yr The majority of tumors occur in the midline cerebellar vermis Patients present with S&S of increased ICP and cerebellar dysfunction

53. Provisional diagnosis Right Cerebellar Tumor

54. Investigation Emergency CT

65. CBC Hb 12.2, Hct 37.1%, WBC 9,110/mm3 (N 72.9%, L 18.8%), Plt 343,000/mm3 Blood Chemistry : BUN 16.0, Cr 0.4, Na 136, K 3.7, Cl 101, HCO3 25, Alb/Glb : 4.0/3.2, TB/DB : 0.2/0.0, AST 18, ALT 9, ALP 218, GGT 9, LDH 316

66. Most likely Diagnosis Juvenile pilocystic astrocytoma with Obstructive hydrocephalus

67. Management

68. Patient Goal Referral to medical center without morbidity Morbidity Increasing of ICP And complication Medical Center

69. ICP treatment Head elevation Maintain euvolemic state Avoid valsalva Correct brain edema Vasogenic Steroid

70. ICP treatment If Comatose Intubation Hyperventilation O2 Supplementation Correct brain edema Beware of brain herniation Make a connection and have an emergency referral

71. What type of herniation is most likely to occur in this patient ? Tonsilar herniation Uncal herniation Central herniation Inguinal hernia

73. So, What should we closely monitor in this patient ? Pupillary reflexes Respiration Urine output Deep tendon reflexes

74. ICP treatment If Comatose Intubation Hyperventilation O2 Supplementation Correct brain edema Beware of brain herniation Make a connection and have an emergency referral

75. Fortunately, this patient walks into medical school ! Emergency CT Admit

76. Progression S : Patient is well, less headache (Pain score = 2/10) No nausea and vomiting, Can do normal activity, Sleep well O : BT 37.2 c, BP 105/70, Pulse 95 /min,RR 22/min NS : Good consciousness, Good orientation Cerebellar function is same, Pupil 4 mm BRTL, Papilledema both. A : Cerebellar tumor with increased intracranial pressure P : 1)Set OR for Craniotomy with tumor removal 2)Dexamethasone administration if clinical worsening

77. Progression Intraoperative finding Soft greyish cystic tumor with mural nodule occupies the entire vermis of cerebellum No brainstem invasion

78. Progression Post Operative @ ICU E4VTM6 Feeling moderate wound pain No respiratory complication He was extubated the day after operation

79. Take home message Do not underestimate headache in children, Complete Neuroexam including Fundus should be performed to avoid underdiagnosis.

80. Thank You