Children With Acute Neurological Emergency - An Overview

Introduction:

Children with acute neurological emergencies usually are admitted to the intensive care unit. Children often present with physical signs of trauma, fever, nausea, vomiting, altered mental status, headache, and focal neurological symptoms such as loss of muscle tone, tremors (involuntary and repetitive movements of a part of the body), paralysis (loss of muscle function), and weakness. Neuroimaging plays an essential role in diagnosing since gathering patient information is difficult. A radiologist should suggest the type of imaging modality to be carried out, such as CT (computed tomography) or an MRI (magnetic resonance imaging). CT scanning is the first choice since it can produce detailed images of a pediatric brain, but MRI does not use any radiation and can help in evaluating the posterior fossa.

What Are the Acute Neurological Emergencies Seen in Children?

Acute neurological emergencies seen in children are:

1. Status Epilepticus: A continuous seizure (sudden abnormal electrical activity of the brain that causes abnormal movements, behavior, and mood) that lasts for more than five minutes without gaining normal mental status. It can occur due to head trauma, brain infection, drug intoxication, or metabolic disturbances.

• Symptoms: The seizures can be convulsions (jerking of the body), focal seizures (involvement of a specific part of the body), generalized tonic-clonic seizures, or non-convulsive seizures (changes in mental status). Other features include unusual movements, urine incontinence, changes in breathing, changes in heart rate, vomiting, clenched teeth, confusion, and irregular breathing.

• Diagnosis: Electroencephalogram (EEG) test should be done, which measures the electrical activity of the brain. A CT scan is carried out to detect any structural brain abnormality. Cerebrospinal fluid should be analyzed for any infections, such as meningitis (inflammation of protective membranes that surround the brain and spinal cord). Other than these, blood tests should be done to assess blood levels, glucose levels, kidney function, and metabolic abnormalities.

• Management: Early treatment should be carried out because antiepileptic drugs are effective in the early stages. ABCDE (airway, breathing circulation, disability, and exposure) approach and IV (intravenous) fluid administration should be carried out. In case of a known history of seizures, prescribed rescue medications should be administered, which include buccal Midazolam or rectal Diazepam. In case of an active seizure (before five minutes), Lorazepam 0.0453 mg/lb, with a maximum dose of 4 mg, is given through IV, or Diazepam 0.0907 to 0.136mg/lb (milligram per pounds) with a maximum dose of 10 mg is given intravenously, intramuscularly or rectally. If seizures persist, second-line antiepileptic medications are given, which are Phenytoin, Fosphenytoin, or Levetiracetam.

2. Stroke: A pediatric stroke occurs when there is brain damage due to disruption in the blood supply. It is a rare type of condition. Two types of strokes can occur, which are ischemic or hemorrhagic. Ischemic occurs when there is decreased blood supply due to a tear or clot in a blood vessel. Hemorrhagic occurs when there are blood vessel ruptures.

• Symptoms: Paralysis of the face, leg, or arm mostly affects one side of the body, severe headache, dizziness, trouble speaking, unable to concentrate, problems in vision, loss of balance, seizures, altered consciousness, and behavioral changes.

• Diagnosis: Complete clinical history and neurologic examination should be assessed, which include the child's motor function, reflexes, and coordination. Imaging modalities such as magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and computed tomography (CT) scans should be conducted to evaluate the location of the ischemic stroke.

• Management: Supportive care, such as ensuring vital signs, hydration, and oxygenation, should be maintained. Thrombolysis which involves the administration of clot-dissolving medication, or thrombectomy, in which the clot is removed mechanically, is considered. Underlying risk factors should be evaluated, which includes evaluation of the child's cardiac function, vascular abnormalities, and genetic testing. Rehabilitation programs should be started, which include speech therapy, physical therapy, and occupational therapy.

3. Autoimmune CNS Diseases: These can include Acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS). Acute disseminated encephalomyelitis (ADEM) is a type of autoimmune disorder that causes inflammation of the spinal cord and brain. This occurs after an upper respiratory tract infection. Multiple sclerosis is a type of autoimmune disorder that damages the central nervous system.

• Symptoms: In the case of ADEM, symptoms are headaches, vomiting, seizures, behavioral disturbances, focal neurological lesions, fever, and coma. In the case of MS, the patient presents with severe pain, vision impairment, and inability to maintain balance.

• Diagnosis: MRI in case of ADEM shows poorly demarcated, hyperintense lesions (brighter areas) which affect both gray and white matter and can be present bilaterally. The spinal cord also shows ill-defined hyperintense lesions. MRI in the case of MS shows lesions on the spinal cord, optic nerve, and brain.

• Management: This includes continuous monitoring and supportive care, such as ensuring hydration and nutrition and managing symptoms such as pain and fever. Anti-inflammatory treatment includes intravenous Methylprednisolone or oral Prednisolone. This is followed by rehabilitation therapy.

4. Metabolic Imbalances: Metabolic imbalances such as diabetic ketoacidosis, a serious condition that can cause neurological complications, occurs when the blood glucose levels are more than 11 mmol/L (millimoles per liter), bicarbonate levels below 15 millimoles per liter, pH (potential of hydrogen) below 7.3, and high concentration of ketones in the body.

• Symptoms: Abdominal pain, confusion, shortness of breath, increased frequency of urination, thirst, weight loss, and dehydration. Some patients may undergo hemorrhagic or ischemic stroke, and newborns can undergo severe brain damage.

• Diagnosis: Neuroimaging with CT or MRI usually shows brain edema (swelling). There can be findings of brain herniation and brain infarction (less blood flow).

• Management: Fluid replacement, intravenous (IV) infusion of insulin, administration of potassium in fluids if serum plasma levels are below 5 mEq/L (milliequivalents per liter). In the case of cerebral edema (accumulation of excess fluid in the brain), osmotherapy, diuretics, and surgical decompression are indicated.

5. Hydrocephalus: Hydrocephalus is a condition where there is increased CSF (cerebrospinal fluid) accumulation in the brain. This increases the pressure inside the brain, causing its malfunction. This condition can occur due to ventricular obstruction, brain tumors, cysts, or infection. It can also be due to a birth defect called spina bifida, where the spinal cord is not formed correctly.

• Symptoms: Increased headache, vomiting, nausea, problem in coordination, balance, and memory, blurred vision, rapidly increasing head size, and bulging of the fontanelle. Shunt malformation is a common complication that can cause altered mental status, vomiting, and headache.

• Diagnosis: MRI is used in evaluating hydrocephalus. In infants, cranial ultrasound can be done. The diagnostic criteria for hydrocephalus are the temporal horn size is more than two millimeters.

• Management: A mechanical shunting device is placed on the head, which drains the fluid, and the tubing is connected to the abdomen or lung, where it can be absorbed. The most common type of stunt is the ventriculoperitoneal (VP) shunt, where the CSF fluid is drained from the ventricles to the lining of the abdomen (peritoneum).

Conclusion:

Children with acute neurological emergencies such as stroke, hemorrhages, drowning, seizures, or hydrocephalus which is discussed in detail above, should undergo emergency treatment. If left untreated, they can undergo long-term disabilities. Imaging modalities such as CT and MRI can help in diagnosing acute emergencies which can aid in faster treatment.