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27/12/2007

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.

HistoryPI :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.

History1 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.

History1 wk PTA the patient got

progressive headache with awakening pain without nausea and vomiting, then he came to the hospital again.

HistoryNo history of• Aura, Photophobia,

Phonophobia• Weakness, Numbness, Ataxia• Sinusitis• Fever• Myopia, Eye pain

HistoryPast history

•5-month-old, He fallen down from the swinging bed 1 m. tall.

•7-year-old : Dengue fever

HistoryPersonal history

•Study in grade VII with the 1St rank

•Left handed

HistoryFamily history

No family history of migraine

Question

Tension type headache

MigraineRefractive errorปวดห วช่�วงใกล้�สอบ

What is the most common cause of headache in children ?

PHYSICAL EXAM

Which part of physical exam should be focused in the children with progressive

headache ?Blood pressure

Visual acuity

Fundoscopy

Bowel sound

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 tenderNo cervical lymphadenopathy

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

NEURO EXAM

Neuro Exam• Good consciousness, good orientation• Cranial nerves

CN II : VA 20/25,20/25 ,no visual field defect, Pupil 4 mm BRTLCN III,IV,VI : Full EOMCN V : Normal facial sensation,

no weakness of masseter & temporalis m. normal corneal reflex

Neuro ExamCN VII : No facial palsyCN IX,X : Uvula in midline,

Gag reflex : Positive

CN XI : No weakness of

Sternocleidomastoid & Trapezius m.

CN XII : No tongue deviation

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

Eyeground

Eye ground

backPapilledema both eyes

•L oss of spontaneo us venous pulsation

s

•Disc elevated•D isc margins obscured•E ngorgement of vein s

•D isc hyperemia • Multiple flame hemor

rhages and cotton woo l spots

Early

Full developed

Chronic : Pale disc

•C entral cupobliterated

•Hemorrhage & Exudate r

esolve

CerebellarSign

Cerebellar sign• Speech Normal• Balance No wide-based gait,

No truncal ataxia Tandem walk : Neg

Nystagmus No nystagmus• Coordination

Finger-to-Nose test : Rt. DysmetriaHeel-to-Knee test : Neg

• Dysdiadokokinesia : Neg

Finger-to-nose test +Rt

Co-ordination

Approach to Headache

HistoryHeadache characteristic• Onset • Duration and progression• Character• Location • Severity and diurnal variation• Aggravating, Alleviating factors• History of previous headaches

HistoryAssociated symptoms • Fever • Visual disturbance, Photophobia• Nausea, Vomiting• Focal neuro deficit such as

weakness, numbness ,ataxia• Prodromal symptom (eg. Aura)

Red flags : Headache

•Progressive headache •Awakening the patient from

sleep• Increase with valsava

maneuver•Accompany with vomiting “ ICP ”

Past medical history •Infection •Coagulopathy •Cyanotic heart disease•Family history : Migraine

Current medication

History

Physical examination

•Vital signs : F ever, E levated blood pressure, B radycardia.

•HEENT : Evidence of trauma

•Skin : R ash or C utaneous lesions (eg , P etechiae, purpura, Ash leaf spots, C

- - afe au lait spots)

•CVS : Murmur ?

Physical examination

•Complete neurogical exam : l evel of consciousness, c ranial nerve d

ysfunction, h ypertonia, h yperreflexia, emiparesis, or hemiplegia

• N uchal rigidity

•Fundo scopic examination : papilledema, pale disc, loss of retinal venous pulsatile

Indication: Imaging

• Presence of neurological sign • Sign of increased intracranial

pressure : papilledema, loss of visual acuity, visual field defect, vomiting

Adapted from

Problem list

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

Discussion

Functional or Organic cause ?

Red flags

Progressive headache Awakening pain

Aggravating by valsava manuver

+ Papilledema “ ICP ”

Discussion

• In older children and adult - Chronic progressive headache or sudden headache

- Vomiting- Diplopia (6th nerve palsy) - Papilledema or loss of retinal venous pulsation

Sign & Symptom of increased ICP

• In older children and adult - Change in personality - Declining school performance- Cushing response in late stage

Sign & Symptom of increased ICP

Sign & Symptom of increased ICP

•In infant- Irritable, anorexia - Cranial enlargement

- Developmental regression- Bulging of anterior fontanelle, prominent of scalp vein- Separation of cranial suture

Discussion•Where is the lesion History – Bioccipital headache ,

deny other focal neuro deficit eg. ataxiaPE- Cerebellar sign positive Rt

“RIGHT CEREBELLAR HEMISPHERE”

What is the lesion

•Clinical time course•Sign & Symptoms of Increased ICP

•Cerebellar sign Positive

Cerebellar tumor

From

Cerebellar tumor

1.Juvenile pilocystic astrocytoma

2.Medulloblastoma

DDx

Juvenile pilocytic astrocytoma (JPA)

• Benign tumor • G rossly cystic character• Occur predominantly in patients

less than 25 years of age .• Most frequently arise in the

cerebellar hemispheres and around the third ventricle

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 increas

ed ICP and cerebellar dysfunction

Provisional diagnosis

Right Cerebellar

Tumor

Investigation

Emergency CT

• 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

Most likely Diagnosis

Juvenile pilocystic astrocytoma

with

Obstructive hydrocephalus

Management

Patient

GoalReferral to

medical center without morbidity

Morbidity Increasing of ICP

And complication

Medical Center

ICP treatment•Head elevation •Maintain euvolemic state•Avoid valsalva • Correct brain edema

•Vasogenic Steroid

ICP treatmentIf Comatose• Intubation

• Hyperventilation • O2 Supplementation• Correct brain edema• Beware of brain herniation• Make a connection and have an emergency referral

What type of herniation is most likely to occur in this

patient ?

Tonsilar herniationUncal herniationCentral herniationInguinal hernia

So, What should we closely monitor in this

patient ? Pupillary reflexesRespirationUrine outputDeep tendon reflexes

ICP treatmentIf Comatose• Intubation• Hyperventilation • O2 Supplementation• Correct brain edema• Beware of brain herniation• Make a connection and have an emergency referral

Fortunately, this patient walks into medical

school !

Emergency CT

Admit

ProgressionS : 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 pressureP : 1)Set OR for Craniotomy with tumor removal

2)Dexamethasone administration if clinical worsening

Progression

Intraoperative findingSoft greyish cystic tumor

with mural nodule occupies the entire vermis of cerebellum

No brainstem invasion

Progression

Post Operative @ ICUE4VTM6Feeling moderate wound painNo respiratory complication

He was extubated the day after operation

Take home message

Do not underestimate headache in children,

Complete Neuroexam including Fundus should be performed to avoid underdiagnosis.

Thank

You