Clinical categorization of 312 children with chronic headache

Three hundred and twelve children referred to an outpatient pediatric neurology clinic, with headache that lasted more than 3 months, were retrospectively reviewed. On average, the age of pain onset was 8.4 years. Migraine was diagnosed in 54% of these children and tension-type headache was found in 22% of those with chronic headache. Most children (85%) had common migraine, while classic and complicated migraine was found in only 8.8% and 5.3%, respectively. Brief headaches, lasting from seconds to a few minutes, were found in 5.1% of the children evaluated. In this subgroup, a high rate of epileptic EEG activity was found. Out of 110 children who had undergone computerized tomography, only one was pathological (posterior arachnoid cyst). Our results indicate that chronic and recurrent headache without accompanying neurological symptoms are usually benign and therefore in most cases neuroimaging is not indicated.     

Head up tilt test in the diagnosis of neurocardiogenic syncope in childhood and adolescence

BACKGROUND: Neurocardiogenic syncope (NCS) is a common paroxysmal disorder that is often misdiagnosed as a seizure disorder. Head up tilt test (HUTT) has been used to confirm this diagnosis. There is no data available of its use in children / adolescents from India. AIM: To study the usefulness of the HUTT in children and adolescents with suspected NCS. SETTINGS AND DESIGN: This was a part retrospective and later prospective study set in a tertiary child neurology outpatient department (OPD). MATERIAL AND METHODS: Patients with a strong clinical suspicion of syncope were recruited for the study. Clinical and treatment details were either retrieved from the chart or prospectively recorded in later patients. The HUTT was then carried out at baseline and after provocation and the results correlated with the clinical diagnosis. Results: Eighteen children with a mean age of 10.8 years were studied. Eight had precipitating factors. Thirteen had premonitory symptoms. Pallor, temperature change, diaphoresis, headache, tonic / clonic movements, post-ictal confusion and peri-ictal headache were symptoms noticed. Sixteen had a positive HUTT. Seven were on long-term anti-epileptic drugs (AEDs). Two had epileptiform abnormalities on their electroencephalogram (EEG). CONCLUSION: The diagnosis of syncope is often confused with epilepsy. Head up tilt test has a high sensitivity in the diagnosis of NCS in children / adolescents. It is fairly safe and easy to perform.     

Cardiogenic syncope. Seizure versus syncope

Our recommendations for the evaluation of the patient with suspected cardiogenic syncope are as follows: An initial thorough history and physical examination of the patient will suggest the diagnosis of cardiogenic syncope in at least 50 per cent of patients. A sudden occurrence of syncope, or "drop attack", is most suggestive of an arrhythmic cause for syncope. If there is no evidence of neurologic, metabolic, or obvious cardiac (for example, aortic stenosis) cause for syncope, a 24-hour ambulatory ECG should be performed. If the patient has had repeated syncopal episodes or if the patient has had seizures that are difficult to control with anticonvulsant therapy, ambulatory ECG monitoring may reveal an arrhythmia in these preselected patients. If the initial 24-hour ambulatory ECG is negative and if the patient has had multiple episodes of syncope, multiple days of recording will be necessary before typical symptoms occur that correlate with arrhythmias. Seventy-two hours of ambulatory ECG monitoring should be sufficient in most instances to establish an arrhythmic cause for syncope. Echocardiography and exercise stress testing are not routinely indicated in the evaluation of syncope unless the clinical history and examination suggest valvular or coronary disease. Rarely, an atrial myxoma will be visualized by echocardiography that is not apparent clinically. Those patients who still have unexplained recurrent syncopal episodes, despite all noninvasive studies, can benefit from invasive electrophysiologic studies, although the expected yield from electrophysiologic testing is low.     

Clinical predictors of intractable childhood epilepsy

OBJECTIVE: This study aimed to determine the clinical, electroencephalographic, and radiological factors associated with medically intractable seizures in children in the Al Ain Medical District in the United Arab Emirates. METHODS: This work used a prospective case-control study of children referred to pediatric neurology and neurodevelopmental clinics at Tawam and Al Ain University Hospitals. RESULTS: There were 55 children with intractable epilepsy; their data were compared with 50 children who responded well to antiepileptic drugs and who were seizure-free for at least 2 years. Onset <1 year of age, a high seizure frequency at onset, positive history of neonatal seizures, developmental delay and status epilepticus, neurological deficits, and abnormal brain imaging results were found to be significantly more common in the study group. Symptomatic localization-related epilepsy was more common in children in this group than in the control group. CONCLUSION: Our study suggests that children who present with idiopathic localization-related and generalized epilepsy syndromes with few seizures at onset and with no neurological deficits tend to have a relatively good prognosis.     

Distinguishing benign syncope from life-threatening cardiac causes of syncope

Syncope is a common clinical event. An organized, detailed approach to diagnosis, with particularly close attention paid to the details of the history, is most likely to result in a time-cost effective evaluation. To optimally define treatment, restrictions, and prognosis, patient-specific diagnosis is important. Although NCS is the most common cause of pediatric syncope, potentially life-threatening etiologies should not be overlooked.     

Pathophysiology of syncope

Clinical Autonomic Research - Syncope or near-syncope is a not uncommon effect of gravitational or other stresses and it occurs when cerebral blood flow falls to below about half the normal value....     

Swallow syncope

Swallow syncope is an often misdiagnosed rare disorder due to enhanced vagal tone during eating in patients with underlying esophageal and/or cardiac abnormalities. We present three cases of this disorder, one related to digitalis toxicity and the other two with diffuse esophageal spasm. The investigation, differential diagnosis, prognosis and management of swallow syncope are discussed.     

Comparison of the active standing test and head-up tilt test for diagnosis of syncope in childhood and adolescence

Abstract We examined 51 children and adolescents with orthostatic symptoms using two orthostatic tests, the active standing test (the AS test) and head-up tilt test (HUT), and compared circulatory responses, autonomic function in addition to the induction rate of syncope during short-time orthostasis. Syncope was induced in eight patients with both tests, in only six patients with the AS test and in only one patient with HUT. The induction rate was significantly higher with the AS test (p<0.0001). In addition, the AS test is common and daily postural motion and does not require a tilt table. We calculated percent changes in systolic blood pressure at the initial drop (ID-SBP), in systolic blood pressure (SBP), in diastolic blood pressure (DBP), in heart rate (HR), component coefficient variation LF/HF (LF/HF) from supine to upright. HR were significantly larger in fainters than in non-fainters with both tests, although there was no difference in SBP and in DBP. In six fainters only with the AS test, HR was significantly larger with the AS test than with HUT. With the AS test ID-SBP were correlative with LF/HF, and LF/HF were correlative with HR, whereas these relations were not clear in HUT. These results indicated the AS test caused cardiac sympathetic activation associated with an initial pressure drop, and was more prone to induce syncope with a greater HR increase in some patients. We conclude the AS test is as potential as HUT as a diagnostic test for syncope.     

Ondine's curse with convulsive syncope. Clinical and Doppler ultrasound observations]

In a 31 years old woman with primary alveolar hypoventilation (Ondine's curse) and noctural seizures the arterial blood gases, EEG and blood flow velocity in the middle cerebral artery were measured before, during and after a phase of apnea terminated by a convulsive syncope. The blood flow velocity abruptly increased to the 2.5 fold of the initial value with the beginning of the convulsions, which is interpreted as a break down of the cerebral autoregulation.     

Clinical features of childhood onset essential tremor

Childhood onset essential tremor (ET) is uncommon. It is not clear as to whether ethnicity-specific differences may influence the phenotypic features. To determine the frequency and clinical characteristics of childhood ET in a tertiary referral center. In a prospective evaluation of 120 consecutive ET patients in a movement disorders clinic, we found a 15.5% (19) frequency of childhood onset ET patients. The mean age of onset and mean age was 10.8 ± 4.1 (6–16) years and 25.7 ± 15.0 (16–73) years consisting of 73.6% (14/19) men and 26.4% (5/19) women. A positive family history of ET was present in 11 of 19 (52.6%). Presence of a head tremor was observed in 2/19 (10.5%). We highlighted a relatively high frequency (15,5%) of childhood ET in our Asian cohort. In addition, we drew attention to the male preponderance and the low frequency of head tremor in childhood ET corroborating study findings in white ET patients. These observations appear to transcend ethnic and cultural differences and lend further support that gender difference may play a role in the pathogenesis and expression of ET.     

Clinical manifestations of cerebrovascular hypoplasias in childhood

The aim of the study was to analyze cerebrovascular hypoplasia in childhood and its clinical manifestations in a clinical population of 205 children aged 3 to 14 years. Cerebrovascular hypoplasias were diagnosed using angiography (n=63), magnetic resonance angiography, and transcranial Doppler ultrasonography. Hypoplasias were localized in the internal carotid artery in 41.9% of patients, in the middle cerebral artery in 54.1%, the anterior cerebral artery in 1.0%, and in the vertebro-basilar system in 3.0%. Clinical manifestations included transient ischemic attacks (21% of patients), cerebral infarcts (17%), progressive unilateral cerebral hemisphere atrophy (1.0%), focal and secondary generalized epileptic seizures (56.1%), and migraine-like headache (4.9%). Hypoplasias of the internal carotid artery and middle cerebral artery manifested as focal and secondary generalized epileptic seizures, transient ischemic attacks, cerebral infarcts, migraine-like headache, and progressive unilateral cerebral hemisphere atrophy, in descending order of frequency. Hypoplasias in the anterior cerebral artery or the basilar artery caused cerebral infarcts, and hypoplasias in the vertebral arteries caused transient ischemic attacks. This article discusses the pathophysiology of ischemia in the territory of the hypoplastic cerebral artery in childhood, as well as possibilities for noninvasive neuroimaging for diagnosis of cerebrovascular hypoplasias.     

Clinical characteristics of unexplained syncope and their relationship to tilt table test outcomes

Summary Aims To describe the clinical characteristics of patients presenting to a tertiary referral centre undergoing tilt table testing (HUT), comparing those who have vasovagal syncope (VVS) confirmed as a cause of symptoms and those with unexplained syncope after HUT. Design Prospective study of consecutive patients presenting to a regional tertiary referral centre, with more than two episodes of unexplained syncope in the past year. Detailed semi-structured questionnaires were completed regarding presenting symptoms, prodromal features and precipitating factors. Results Eighty-seven patients were studied, 31 had positive passive head up tilt (HUT), 31 positive provocative HUT (either sublingual glyceryl trinitrate or intravenous isoprenaline) and in 25 patients, syncope remained unexplained at the end of tilt testing. Characteristics of patients with positive passive HUT did not differ significantly from those requiring pharmacological provocation, although passive HUT patients were more likely to have classical prodrome and precipitants. The clinical characteristics of those whose syncope remained unexplained differed from those who had VVS confirmed by tilt table testing, in particular symptoms after syncope were less common and clustering of episodes was unlikely. Prodrome was absent in over 80 % of the “unexplained” group. Conclusions Clinical characteristics of patients with unexplained syncope and negative tilt tests differ from those with positive tilt studies. Further cardiovascular testing should be undertaken in this group to determine other causes of syncope. Received: 26 January 2001, Accepted: 25 July 2001     

The investigation of syncope

Patients with syncope are usually referred to either neurology or cardiology clinics, yet the facilities for detailed syncope investigation are mostly in cardiac units. The diagnosis rests principally upon the history, but investigations may be required to support the clinical diagnosis. Close collaboration between the epilepsy clinician and a cardiologist is essential for effective investigation and safe management of syncope. It is frequently misdiagnosed and often erroneously treated as epilepsy. Furthermore, it is potentially a marker of sudden death when associated with certain cardiac disorders. Here we review the main syncope types and explore diagnostic approaches.     

Epidemiology of reflex syncope

Clinical Autonomic Research - Cost-effective diagnostic approaches to reflex syncope require knowledge of its frequency and causes in different age groups. For this purpose we reviewed the...