Cerebral Dysfunction

Cerebral DysfunctionLauren Walker, RN, BSNGeorgetown University

Overview TopicsIncreased Intracranial PressureLevel of ConsciousnessCerebral AbnormalitiesNervous System TumorsInfections

Pediatric Cerebral DysfunctionGeneral InformationChildren under the age of 2 require special evaluation for neurologic functionObservation of fine and motor reflexesPregnancy and delivery history

General AssessmentFamily HistoryHealth HistoryPhysical Evaluation

Children under the age of 2 require special evaluation for neurologic function: -Infants are primarily reflexive- responses are gradually replaced by meaningful movement with development

Info about infants and children are gained by observation: watch spontaneous/elicited reflexes as they develop-A delay or deviation from milestones helps identify high-risk children

-Persistent reappearance of reflexes that normally disappear may indicate a pathologic condition

-Obtain a pregnancy/delivery history: impact of intrauterine influences that affect the CNS (maternal infections, chemicals, trauma)

Fam History: clues for possible genetic disordersHealth History: cause of dysfunction: (injury, febrile illness, encounter with animal/insect, injection of chemical, past illness)Physical Eval of Pt3Abnormal neurologic physical evaluations of infantsSize and shape of headSensory responsesSpontaneous activitySymmetry in extremity movementFrequent movement of extremitiesSkin and hair textureDistinctive facial features

High-pitched, piercing cryAbnormal eye movementsInability to suck or swallowLip smackingAsymmetric facial movementsYawning Muscular activity and coordinationLevel of development

4Increased Intracranial PressureBrain is enclosed in the solid bony craniumCraniums total volume:Brain: 80%Cerebrospinal fluid (CSF): 10%Blood: 10%

Volume must remain approximately the same at all timesBrain is terrible at compensation!Normal ICP 5-10

ICP Video

Brain is well protected but highly vulnerable to pressure that may accumulate inside

Increased ICP- caused by tumors or other space occupying lesions, accumulation of fluid in ventricles, bleeding, edema of brain tissue

Once compensation is exhausted- an increase of volume = rapid increased ICP5Clinical s/s of Increased ICPInfantsTense and/or bulging fontanelSeparated cranial suturesIrritableHigh-pitched cryIncreased occipital circumferenceDistended scalp veinsChanges in feedingCrying when disturbedSetting-sun sign

ChildrenHeadacheNauseaVomitingDiplopia, blurred visionSeizuresBox 28-1, Chapter 28 Wong

setting-sun sign downward deviation of the eyes so that each iris appears to set beneath the lower lid, with white sclera exposed between it and the upper lid; indicative of increased intracranial pressure or irritation of the brain stem.

6Clinical s/s of Increased ICPPersonality and behavioral signsIrritability, restlessnessIndifference, drowsinessDecline in school performanceDiminished physical activity and motor performanceIncreased sleepingMemory lossInability to follow simple commandsLethargy and drowsinessLate signsBradycardiaLowered level of consciousnessDecreased motor response to commandsDecreased sensory response to painful stimuliAlterations in pupil size and reactivity to lightFlexion and extension posturingCheyne-stokes respirationsPapilledemaComa

Box 28-1, Chapter 28 Wong

Level of ConsciousnessEarliest indicator of improvement or deterioration

Determined by observationsPhysical AssessmentMotor activity, reflexes, vital signs

Observations: responses to environment815 points- highest score, unaltered LOC3 points- lowest score, deep coma

http://www.eguidelines.co.uk/eguidelinesmain/gip/media/images/barclay_glasgow_comascore2.gifThree part assessment to interpret the depressed loc (eyes, verbal, motor)

With kids- helpful to have parents interact to initiate a proper response- may not be response to someone unfamiliar

Below 8- typically in coma

http://www.eguidelines.co.uk/eguidelinesmain/gip/media/images/barclay_glasgow_comascore2.gif

9Nursing Management of ICPPositioningAlternating mattressesAvoid causing painCluster careMinimize environmental noiseClosely monitor nutrition and hydration

Positioning: avoid neck vein compression- may further increase ICP by interfering with venous return to heartMattress: prolong pressurePain- may increase ICP, assess frequentlyNutrition: difficult, dont want to fluid overload a pt with increased ICP, may be supplied by iv initially, then feeding tube (examine skin and mucous membranes) 10Nursing Management of Increased ICPIndications for inserting a monitor:GCS of 8 or belowDeteriorationJudgment from clinical appearance and response

Monitors:Intraventricular catheterSubarachnoid boltEpidural sensorAnterior fontanel pressure monitor

Catheters can provide drainage to reduce pressureBolt- connected to a monitorMannitol- administered IV for rapid reduction in ICP11Medications for Altered ICPWhat is the cause?

Corticosteroids: inflammationAntibiotics: infectious processDiuretics: edemaAntiepileptic: seizure activitySedation: combativenessBarbiturates: deep coma

Steroids: decrease inflammationBarbiturates: decreased metabolic rate for oxygen, protects brain (respiratory support, cv monitoring)12Cerebral MalformationsNewborn cranial sutures are separated by membranous seamsSutures:Soft areas:-Sagittal-Anterior fontanel-Coronal-Posterior fontanel-LambdoidalEight weeks: Posterior fontanel closedSix Months: union of suture lines Eighteen Months: Anterior fontanel closedAfter 12 years: sutures unable to be separated by increased ICPCranial bones are highly mobile- allows them to mold and slide to adjust and accommodate to the changing shape and character of the birth canal

Various types of cranial deformities are encountered with early infancyCan occur in prenatal developmentOccur with growth13Hydrocephaluswater on the brainImbalance in the production and absorption of CSF in the ventricular system

Causes:Impaired absorption of CSF fluidObstruction of flow through ventricle

Brain structures become compressedMost cases are from developmental defectsProduction of CSF > than absorption CSF accumulates in the ventricular system- increased pressure- passive dilation of the ventricles

Impaired absorption: nonobstructive or communicative hydrocephalus

Obstruction: obstructive or noncommunicative hydrocephalus- can occur at any point (infections, trauma)

Defects: Arnold-Chiari malformation, aqueduct stenosis) from birth to 2 yrsIntrauterine infections

Older kids- lesions, intracranial infections, hemorrhage

Imbalance of fluid in brain causes an increased accumulation of CSF in the ventricles- become dilated (ventriculomegaly) and compress the brain substance around the bony cranium-before fusion of cranial sutures- enlargement of the skull and dilation of ventricles-younger than 10-12- partially closed suture lines- may become opened14Diagnosing HydrocephalusTime of onset and preexisting lesionsInfants: Head circumferences and neuro signsCTMRI

Infancy: before closure of sutures, they will have an enlarged head- daily head circumferences (abnormal/rapid head growth)

Older infants: neurologic signs through pressure on the adjacent structure 15Clinical Manifestations of Hydrocephalus Infancy (early) Infancy (later) Infancy (general) ChildhoodAbnormal rapid head growthFrontal enlargementIrritableHeadache on awakeningBulging fontanelsDepressed eyesLethargyPapilledemaDilated scalp veinsSun-setting signCries when picked up or rockedstrabismusSeparated suturesPupils sluggishInfantile reflexes persistIrritableMacewen signChange in LOCLethargyThinning of skull bonesLower extremity spasticityConfusion/ incoherenceDifficult suck and feedingvomitingBox 28-13, chapter 28, Wong

Anterior bulging fontanel

Macewen sign- cracked pot sound on perfusion 16Management of HydrocephalusDirect removal of obstruction

Placement of shuntVentriculoperitoneal shunt (VP shunt)Associated with infection and malfunction

High success rate with surgically treatmentVp shunt: drainage of the CSF from the ventricles to an extracranial compartment, ie peritoneum

Catheter is threaded beneath the skinPlaced to relieve csf obstruction- revisions are needed when signs of malfunction appear

-initally very successful, associated with complications that interfere with continued shunt function or threaten a childs life

-infection**, malfunctions (kinking, plugging, separation of tubing) obstruction of tissue thrombosis- growth-s/s of increased ICP, declining neurologic status

Surgical treatment with monitored medical management- 80% survival rateMortality in first yr of treatment have neurologic disabilities17Shunting

Shunting Videohttp://www.youtube.com/watch?v=8tf5VewEfGs

http://www.youtube.com/watch?v=Qmym2iFVNw8&feature=related

18Family SupportCoping is difficult with patentsFeel guilty, anxiousUncertain outcomeContinue to educate familyInclude family in patient carePossibility of long term rehabilitation

Survival of cerebral insult: may have physical or mental limitations- long term rehab process19Nervous System TumorsCNS tumors account for 20% of all childhood cancers

3.3 cases per 100,000 occur in kids under 15 years old

Difficult to treat

No dramatic advancements or improvements seen vs other childhood cancers

Brain TumorsMost common solid tumors in children

Infratentorial (60%)Primairly in brain stem or cerebellumUsually see increased ICP(medulloblastoma, cerebellar astrocytoma, brainstem glioma)

SupratentorialMainly cerebrum(astrocytoma, hypothalamic tumors, optic pathway tumors)

Brain Tumor Diagnosticss/s are related to:LocationSize of tumorChilds age

Most common signs: Headache, vomitings/s are vague and can be overlooked

Detected by:MRICT scanOfficial diagnosis with biopsy from surgery

Infants with open sutures- no early signs will develop

Obstruction Vomiting: increased icp compresses the brainstem- directly stimulates the vomiting center in medulla

MRI: location and extent of tumorCt22Treatment of Brain TumorsTreatment of choice = total removal of tumor without neurologic damageSurgery, radiotherapy, chemotherapy

Prognosis: Depends on size, tumor type, extent of disease

Radiotherapy- shrink tumor before surgeryChemo- rec for kids under 3, recurrent tumors, nonresectable tumors

Prognosis: advances in surgery, radiation,

use of chemo has increased the long-term survival rates in kids23Nursing Management of Brain TumorsEstablish a baseline assessmentVital signsLook for sudden variationsFrequent neurologic assessmentsHeadache? Vomiting? Seizures?Childs behaviorpositioningPostoperatively check muscle strength when awake

Neuro assessment: pupil responses, LOC, sleep patterns, response to stimuli

HA? Vom? Seiz? How long, time of day, aggravating factors

Positioning depends on where the tumor is- check with MD, prevent sudden movements

Facing away from light, non engaging in play24Intracranial InfectionsNervous system is limited in ways to respond to an infection

Inflammatory process in brain affects:Meninges (meningitis)Brain (encephalitis)

Meningitis has many origins

bacteria, virus, or tuberculosis25Bacterial MeningitisDefinition: acute inflammation of the meninges and CSF10-15% of cases are fatal Caused by many bacterial agentsH. Influenzae type b, S. pneumoniae, Neisseria Meningitidis

Vascular dissemination or direct implantation

Infective Process

E. Coli in infancy

Gets from vascular dissemination- organism in nasopharynx invades the underlying blood vessels and enters blood supply

Direct implantation: penetration of wounds, skull fractures- opening in the skin- organism will spread to CSF subarachnoid space

Infective process: inflammation, exudation, WBC accumulation, tissue damage-brain edema, covered in purulent exudate-as infection extends to ventricles, pus, fibrin, or adhesions occlude passages and obstruct CSF flow26Clinical Manifestations of Bacterial MeningitisChildren and Adolescents(Classic picture)Abrupt onset, rashFever, chills, headacheAlteration in sensesSeizures*Irritability/agitationNuchal rigidityPositive Kernig &Brudzinski signs

Infants and Young ChildrenFeverPoor feedingVomitingIrritableFrequent seizuresBulging fontanelDifficult to evaluate in this age groupBox 28-5, Chapter 28 Wong

Kernigs: pt supine, hip flexed 90 degees, knee cant be fully extended

Brudzinski: passive flexion of neck causes flexion of both legs and thighs27Clinical Manifestations of Bacterial MeningitisNeonates: Specific SignsVery hard to diagnoseWell at birth- behaves poorly a few days laterRefuses feedsPoor suckingVomiting/diarrheaPoor toneLack of movementWeak crySupple neckNeonates: Nonspecific SignsHypothermia/feverJaundiceIrritableDrowsinessSeizuresRespiratory irregulationscyanosisBox 28-5, Chapter 28 Wong

28Diagnostic and Therapeutic Management of Bacterial MeningitisLumbar PunctureElevated WBC countDecreased Glucose levelConsidered a medical emergency!Initial management:Isolation, iv antibiotics, fluids, monitored, treatment of complications

LP: Fluid pressure is measured, samples are sent for culture (organism), gram stain, blood cell count, protein and glucose content.

Emergency: early recognition and immediate implementation of therapy to prevent death or residual disabilities

Drugs: initially give steriods to decrease ICP and herniation- not good for long-term useantibiotics29Management of Bacterial MeningitisHydrationQuiet, decreased stimulationSide lying positionCorrect electrolyte imbalanceMeasure for s/s increased ICPMonitor for complications

Prevention:Vaccines for children starting at 2 months

Maintain fluid deficit then restrict to prevent cerebral edema

Electrolytes- assoc with poor neuro outcome laterComplications: DIC, shock, seizures, hearing loss

Vaccines: A, C, Y and W-135 meningococci and H. Influenzae type b.30Nonbacterial (aseptic) MeningitisCaused by many viruses!Abrupt or gradual onsetSymptoms develop 1-2days after onsets/s vague Diagnosis is based on pt assessment and CSF findingsSystematic treatmentNursing care similar to bacterial meningitis

Vague: thought to be associated with a minor illness

Treatment: tylenol for HA and pain, fluids

31EncephalitisDefinition: inflammatory process of the CNS which is caused by a variety of organisms

Virus invades CNS or postinfection after a viral diseaseCause in typically unknown

Bacteria, spirocytes, fungi, protozoa, viruses**

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Clinical Findings of EncephalitisInitial findings are nonspecificEvolve to demonstrate neuro s/sSeizures, abnormal CSFMild s/s for a few days, rapid recovery, to fulminating encephalitis with CNS involvement Onset Severe CasesMalaiseFeverHeadache/DizzinessLethargyNeck StiffnessNausea/VomitingTremorsSpeech DifficultiesAltered Mental StatusHigh FeverStuporSeizuresDisorientationSpasticityComaParalysis

Initially- fever, altered mental status

Sudden or gradual onset34Diagnosis and Management of EncephalitisBased on clinical findings CT in late stagesSome viruses are found in CSF

Hospitalized for observation with supportive treatmentPrognosis depends on age, organism, neurologic damage

CT in late stages can show hemorrhagic areas in the frontotemporal region

Herpes, mumps, measles, enteroviruses found in CSF

Support symptoms: control of cerebral manifestations, adequate nutrition and hydration

Can cause devastating neurologic injury

Kids under 2 years- may have increased disability, learning, seizure disorders35http://www.youtube.com/watch?v=8tf5VewEfGs

http://www.youtube.com/watch?v=Qmym2iFVNw8&feature=related

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