Learning Child Neurology Through Case
Histories
Vinay Puri MBBS, FAAN
Professor in Neurology and Pediatrics
Director and Founder
Division of Child Neurology
University of Louisville
Neurologist in chief
Kosair children’s hospital
Division of Child Neurology Physicians:
Anna Ehret
Darren Farber
Mike Sowell
Karen Skjei - Epilepsy
Vinay Puri
Martin Brown - Neuromuscular Disorders
Suma D*
Greg Barnes* - Epilepsy & Autism Research
Nurse Practitioners
Paula Hartmann
Angela Bishop
Britt Schloemer
Vanessa Rupee
Staci Crocker
Stephanie Sims
Kristin Schircliff
Nurse Clinicians
Terra Cummins
Lindsey Reed
Email:v0puri01@louisville.edu
Office:601 S Floyd # 500
Louisville – KY
40205
Tel: 502-5898033
Fax: 502-5898233
My Assistant : Miranda Der Ohanian
Miranda.derohanian@ulp.org
Office manager:Heather Ball BS, MS
h0ball01@ulp.org
Our Service Locations:
Louisville- All patients
Commission Clinics:*
Louisville*
Elizabethtown*
Owensboro*
Paducah*
Bowling Green*
Specialty Services:
MDA/Neuromuscular Clinic
Spasticity Clinic
Brain Tumor Clinic- 5025831697
New Onset seizure Clinic
Neurogenetics Clinic
Stroke Clinic
Tuberose Sclerosis & NF Clinic
Ketogenic Diet Clinic
Our Goals
Quality
Timely
Patient centered services
Easy access
Presentation will consist of cases and a collection of
representative videos:
The session will be highly interactive
Listen Carefully to the parent
Help jog memory, be specific in asking questions
No shortcuts
All aspects of history to be leveraged
Vital signs
General examination- head size, dysmorphic, skin exam
Neurological examination- walking !!
Lab testing
Imaging
Assessment
Recommendations
Staring spells in my 9 year old child:
Describe the spells to me
Imitate a spell
Do you have it on video
Examine the child
Maybe EEG
What are the causes of staring spells
Pitfalls
My baby is having jerking of his legs and arms:
Describe the events to me
Do not interrupt the parent when they are describing the spells
Do you have a video of the spells
Awake/asleep or both
May need an EEG or a video EEG
Common Pitfalls
My child is not athletic and is lazy:
What do you mean exactly
How long
Family history
Examine the child what specifically will you look for
Common Pitfalls
My child is developmentally delayed:
Explain it to me
Motor, Language, Cognitive and Social
To what degree and what combination of delay
Specific considerations
Work up: Neuroimaging, Genetic & Metabolic
My child is having abnormal movements
Describe it to me
Detailed history, age of onset, when, effect of
sleep, movement, medications etc
Look at videos if any
Careful examination of child
• For localization of lesion in CNS, history is as important as PE. First step
is to localize the lesion to an anatomical site.
ANATOMICAL DIAGNOSIS
• Is the lesion UMN/LMN
• If it is UMN lesion, is the lesion in the brain/Spinal cord
• If the lesion is in the brain, is it in cortex, subcortex (corona radiata), basal
ganglia, internal capsule, midbrain, pons, medulla or cerebellum.
• If the lesion is in the spinal cord, which level of spinal cord is involved.
• If it is a LMN lesion, which structure is involved, anterior horn cell, radicles,
peripheral nerve, NMJ or muscle.
Etiological diagnosis:
• Acute – stroke, demyelination, infection
• Subacute- infection, inflammation
• Insidious- Tumors, degenerative diseases.
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Progression
Congenital – CP, not progressive
Vascular – maximum deficit at onset(with in
about 72 hours of onset) and then child
gradually recovers.
Demyelinating – GBS(progresses for
sometime and then recovers partially or
completely), MS(waxing and waning or
intermittent progression)
Degenerative- gradual progression.
Neoplastic – gradual progression.
Common Co Morbidities and concerns in Child
Neurology:
Sleep disorders
Mood disorders
ADHD
Learning disabilities
Common questions to consider & teaching points:
Does my child have Cerebral Palsy
Was it a seizure
Missed diagnosis of tics
Is my child weak
MRI or CT
Always sleep deprived EEG
In Conclusion:
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Listen carefully
Keep an open mind
Leverage all information and data
Examination can be quick and thorough
Must examine fundus in headache patients
See the child walk
Have child get up from ground if any concerns
about weakness at all
• A normal test does not always exclude diagnosis
• An abnormal test does not rule in diagnosis
QUESTIONS PLEASE?