This chapter is designed to help the pediatrician feel comfortable and confident with the assessment of neurologic disease. More detailed discussions of individual diseases are given in other chapters.
When tackling any case, accurate diagnosis and management start with the history. The information found in the history, starting with the chief complaint, allows the practitioner to then focus on certain elements of the neurologic examination. At the end of the encounter, the combination of information found in the history and neurologic examination will direct the practitioner to determine if specialized neurologic care is needed and, if so, whether that care can be provided in an outpatient setting or if inpatient/emergent care is needed.
The following sections will be divided into a variety of neurologic chief complaints a pediatrician could encounter. Also presented are additional elements of the history and physical examination that need to be elicited to ensure proper localization of the disease process. Once a neurologic lesion has been confidently localized, appropriate management can begin.
To understand the magnitude of potential etiologies for weakness, one must have an understanding of the intricate nature of the neurologic axis. At the time of first encounter for weakness, one should attempt to localize the lesion to the brain (cortex, white matter, basal ganglia, thalamus, brain stem), the spinal cord, the anterior horn cell, the nerve root, the nerve (axon or myelin or both), the neuromuscular junction, the muscle, or multiple components of the aforementioned.
The acuity of onset and whether the weakness is static or progressive are extremely important factors in determining the plan of care. Weakness that is long-standing (ie, months to years) is rarely going to represent a disease process that requires emergent care, and outpatient neurology follow-up should be sufficient. However, weakness that is acute to subacute in onset (minutes, hours, or days to weeks) may represent a neurologic condition requiring emergent care.
CEREBRAL LESIONS REQUIRING EMERGENT EVALUATION
Altered mental status, or encephalopathy, can occur when there is a bilateral hemispheric disturbance involving the cerebral cortex. Language dysfunction and impaired fluency or comprehension can occur if the cortices of the frontal or temporal lobes are affected, respectively. Finally, since seizures frequently originate from the cerebral cortex, lesions affecting the cortex can give rise to seizures. Neurologic disease giving rise to weakness in the setting of any of the aforementioned symptoms would suggest a disease process affecting the cerebral cortex. The differential of such a case includes intracranial hemorrhage, cerebral infarct (stroke), infectious/inflammatory encephalitis, demyelinating processes such as acute disseminating encephalomyelitis, and neoplastic processes. To evaluate for these processes, emergent imaging in the form of computed tomography (CT) scans or magnetic resonance imaging (MRI) of the brain should be pursued. Alteration of mental status will be discussed in more detail later in the chapter.