Download upper motor lesion

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
Bulging fontanel
Failure to thrive
Setting-sun sign
Enlarging head
Shrill cry
Behavioral changes
In Children
Diplopia
Headache
Mental changes
Nausea / vomiting
Papilledema
What are the diagnostic
possibilities?
Causes of Increased Intracranial pressure:
1. Infectious
Bacterial meningitis
TB meningitis
Fungal meningitis
Viral meningitis/encephalitis
Brain abscess
What are the diagnostic
possibilities?
2. Non-infectious
Neoplasms / Tumors
Porencephalic cysts
Hematomas
AV malformation
Metabolic and toxic encephalopathies
3. Idiopathic
Pseudotumor cerebri
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
Brain Abscess: Management
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: Sequelae
Progressive increase in pressure  Herniation
Shock and death
Thank you!