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:

• 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

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!