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1. Extern ทุกคน โปรดมานั่งข้างหน้าให้เต็มครับ><

2. Extern Conference27/12/2007

3. History • A 13-year-old Thai boy • CC : Chronic progressive headachefor 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.

4. History PI : The parentbrought 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.

5. History 1 monthago, 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.

6. History 1 wk PTA the patient got progressive headache with awakening pain without nausea and vomiting, then he came to the hospital again.

7. History No history of • Aura, Photophobia, Phonophobia • Weakness, Numbness, Ataxia • Sinusitis • Fever • Myopia, Eye pain

8. History Past history • 5-month-old, He fallen down from the swinging bed 1 m. tall. • 7-year-old : Dengue fever

9. History Personal history • Study in grade VII with the 1St rank • Left handed

10. History Family history No family history of migraine

11. Question

12. What is the most common cause of headache in children ? Tension type headache Migraine Refractive error ปวดหัวช่วงใกล้สอบ

13. PHYSICAL EXAM

14. Which part of physical exam should be focused in the children with progressive headache ? Blood pressure Visual acuity Fundoscopy Bowel sound

15. Physical Exam • V/S T 37.3, BP 102/68 mmHg, P98/min,RR 20/min • GA13 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

16. 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

17. NEURO EXAM

18. Neuro Exam • Good consciousness, good orientation • Cranial nerves CN II : VA20/25,20/25,novisual 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

19. 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

20. 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

21. Eyeground

22. Eye ground back Papilledema both eyes

23. Loss of spontaneous venous pulsations Early • Disc elevated • Disc margins obscured • Engorgement of veins • Disc hyperemia • Multiple flame hemorrhages and cotton wool spots Full developed

24. Chronic : Pale disc • Central cup obliterated • Hemorrhage &Exudate resolve

25. Cerebellar Sign

26. 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 Cerebellar sign

27. Finger-to-nose test +Rt

28. Co-ordination

29. Approach to Headache

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

31. History Associated symptoms • Fever • Visual disturbance, Photophobia • Nausea, Vomiting • Focal neuro deficit such as weakness, numbness ,ataxia • Prodromal symptom (eg. Aura)

32. Red flags : Headache • Progressive headache • Awakening the patient from sleep • Increase with valsava maneuver • Accompany with vomiting “ ICP ”

33. History Past medical history • Infection • Coagulopathy • Cyanotic heart disease • Family history : Migraine Current medication

34. Physical examination • Vital signs : Fever, Elevated blood pressure, Bradycardia. • HEENT : Evidence of trauma • Skin : Rash or Cutaneous lesions (eg, Petechiae, purpura, Ash leaf spots, Cafe-au-lait spots) • CVS : Murmur ?

35. 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

36. Indication: Imaging • Presence of neurological sign • Sign of increased intracranial pressure : papilledema, loss of visual acuity, visual field defect, vomiting

37. Adapted from

38. Problem list

39. 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

40. Discussion

41. Discussion Functional or Organic cause ? Red flags Progressive headache  Awakening pain  Aggravating by valsava manuver + Papilledema “ ICP ”

42. 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

43. Sign & Symptom of increased ICP • In older children and adult - Change in personality - Declining school performance - Cushing response in late stage

44. 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

45. Discussion • Where is the lesion History – Bioccipital headache , deny other focal neuro deficit eg. ataxia PE- Cerebellar sign positive Rt “RIGHT CEREBELLAR HEMISPHERE”

46. What is the lesion • Clinical time course • Sign & Symptoms of Increased ICP • Cerebellar sign Positive Cerebellar tumor

47.     From

48. Cerebellar tumor DDx • Juvenile pilocystic astrocytoma • Medulloblastoma

49. 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

50. 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