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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.
PI :
History
The parent brought him to see a local
physician. He was diagnosed as tensiontyped headache and the painkiller-Ibuprofen
was prescribed but the pain did not get
better.
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.
History
1 wk PTA the patient got progressive
headache with awakening pain without
nausea and vomiting, then he came to the
hospital again.
History
No history of
• Aura, Photophobia, Phonophobia
• Weakness, Numbness, Ataxia
• Sinusitis
• Fever
• Myopia, Eye pain
History
Past history
• 5-month-old, He fallen down from
the swinging bed 1 m. tall.
• 7-year-old : Dengue fever
History
Personal history
• Study in grade VII with the 1St rank
• Left handed
History
Family history
No family history of migraine
Question
What is the most common cause of
headache in children ?
Tension type headache
Migraine
Refractive error
ปวดหัวช่วงใกล้สอบ
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 tender
No cervical lymphadenopathy
Physical Exam
• CVS
• RS
• ABD
• Skin
Normal S1&S2, no murmur
Normal equal breath sound
both lungs
Soft, not tender, liver&spleen not
palpable, normal bowel sounds
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 BRTL
CN III,IV,VI : Full EOM
CN V : Normal facial sensation,
no weakness of masseter
& temporalis m.
normal corneal reflex
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
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
Papilledema both eyes
back
Early
Full
developed
•Loss of spontaneous
venous pulsations
•Disc elevated
•Disc margins obscured
•Engorgement of veins
•Disc hyperemia
•Multiple flame
hemorrhages and cotton
wool spots
Chronic : Pale disc
•Central cup
obliterated
•Hemorrhage &
Exudate resolve
Cerebellar
Sign
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
Finger-to-nose test +Rt
Co-ordination
Approach to
Headache
History
Headache characteristic
• Onset
• Duration and progression
• Character
• Location
• Severity and diurnal variation
• Aggravating, Alleviating factors
• History of previous headaches
History
Associated 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 ”
History
Past medical history
• Infection
• Coagulopathy
• Cyanotic heart disease
• Family history : Migraine
Current medication
Physical examination
• Vital signs : Fever, Elevated blood
pressure, Bradycardia.
• HEENT : Evidence of trauma
• Skin : Rash or Cutaneous lesions (eg,
Petechiae, purpura, Ash leaf spots, Cafeau-lait spots)
• CVS : Murmur ?
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
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
Discussion
Functional or Organic cause ?
Red flags
 Progressive headache
 Awakening pain
 Aggravating by valsava
manuver
+ Papilledema
“ ICP ”
Sign & Symptom of
increased ICP
• 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
• 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.
ataxia
PE- 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
DDx
1.Juvenile pilocystic
astrocytoma
2.Medulloblastoma
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
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
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
Goal
Referral 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 treatment
If 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 herniation
Uncal herniation
Central herniation
Inguinal hernia
So, What should we closely
monitor in this patient ?
Pupillary reflexes
Respiration
Urine output
Deep tendon reflexes
ICP treatment
If 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
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
Progression
Intraoperative finding
Soft greyish cystic tumor with
mural nodule occupies the entire
vermis of cerebellum
No brainstem invasion
Progression
Post Operative @ ICU
E4VTM6
Feeling moderate wound pain
No 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