Ep-PAINE-nym

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Charles Bonnet Syndrome

Other Known Aliases – visual release hallucinations

Definition – symptoms of visual hallucinations that occur in patients with visual loss

Clinical Significance – these release hallucinations can be simple, non-formed images (such as lines, flashes, shapes, etc.) or the can be formed images (such as people, animals, scenes, etc.). These patients can often be missed diagnosed as psychosis or early dementia. Diagnosis is made in the absence of other psychiatric illness or other causes of hallucinations.

History – Named after Charles Bonnet (1720-1793), who was a Genevan naturalist who was a lawyer by trade, but fascinated by the natural sciences. He spent the majority of career observing and studying insects, germ theory, and philosophy. He described the eponym that bears his name in 1760 in his book “Essai analytique sur les facultés de l’âme“, where he described the hallucinations of his 87yo grandfather who was nearly blind from cataracts

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Bonnet Charles (1760) Essai Analytique sur les facultés de l’âme. Copenhagen: Philibert, pp 426–428

PAINE #PANCE Pearl – Psychiatry

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Question

A 20yo man, with no significant past medical history, is brought in by his parents for evaluation of concerning behaviors. They state he often feels he “needs” to arrange the items in his room in a certain way and becomes very agitated if they are moved. He also must make sure that there is no dirt on his shoes before he walks in his room and is meticulous in his cleaning endeavors every day. His parents are worried about his level of functioning and ability to move out and maintain his own apartment. He denies any thoughts of self-harm, homicidal ideations, or audio-visual hallucinations. On physical examination, he seems composed, non-distracted, and answers all questions appropriately. When asked about these behaviors, he recognizes that they are a problem, but states he can’t relax and has severe anxiety unless these are taken care of.

  1. What is the most likely diagnosis based on this presentation?
  2. What criteria must be met per the DSM-V for diagnosis?

Ep-PAINE-nym

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Wernicke’s Aphasia

Other Known Aliases – receptive aphasia

Definition – difficulty in understanding written or spoken language, but demonstrate fluent speech that lacks meaning

Clinical Significance – this condition manifests due to damage to Wernicke’s area of the brain in Brodmann area 22. This region is located in the posterior section of the superior temporal gyrus of the dominant hemisphere.

History – Named after Karl Wernicke (1848-1905), who was a German physician, anatomist, and neuropathologist and received his medical doctorate from the University of Breslau in 1870. He went on to study under Ostrid Foerster and Theodor Maynert after serving as an army surgeon during the Franco-Prussian War and had a modest career in both private and academic practice, culminating as head of the University Hospital’s Department of Neurology and Psychiatry at Breslau. A proponent of the same cerebral localization theory as Broca, he described his theory of “sensory aphasia” being different from Broca’s “motor phasia” in his book Der Aphasische Symptomencomplex in 1874.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Wernicke C. Der Aphasische Symptomencomplex. 1874.

PAINE #PANCE Pearl – Neurologic

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Question

A 47yo man is being evaluated for a headaches that he describes as “someone jabbing my brain through my eye”. He reports these headaches occur several times a day for the past several weeks, lasting only for a minute, and only affecting his right side of this head. While speaking with him, he has another episode and you notice his eye becomes red and injected with significant tearing and nasal drainage present. On closer examination, he also notice his pupil on the affected side is constricted and he has a mild lid lag.

  1. What is the treatment protocol of choice for this patient?

Answer

This patient is suffering from a classic cluster headache due to hypothalmic activation of the trigeminal-autonomic reflex. Abortive treatment for this type of headache includes:

  • 100% oxygen via non-rebreather
  • Sumatriptan 6mg SQ
  • 4-10% Lidocaine 1mL IN
  • Dihydroergotamine 1mg IV

Verapamil 240mg daily with a prednisone 60-100mg daily bridge for 5 days can be used for prevention.

Ep-PAINE-nym

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Broca’s Aphasia

Other Known Aliases – expressive aphasia

Definition – partial or full inability to produce language/communication in any form, with full preservation of language/communication comprehension

Clinical Significance – this condition manifests due to damage to Broca’s area of the brain. This region is bounded by the pars opercularis and pars triangularis of the inferior frontal gyrus of the dominant hemisphere.

History – Named after Pierre Paul Broca (1824-1880), who was a French physician and anatomist who received his medical doctorate from the University of Paris in 1844 at the age of 20. He went on to study under and assist Peirre Gerdy before becoming the youngest prosector for his alma mater in 1848. He went on to practice in various surgical and pathologic specialties culminating as Chair of Clinical Surgery in 1868 at the University of Paris. In 1861, in an effort to support the cerebral localization theory for speech, he dissected the brain of a patient with a 21-year progressive loss speech, after succumbing to a gangrenous infection of his paretic limb, where he found a frontal lobe lesion. He would go on to find similar localized lesions on 13 additional patients with expressive aphasia and called this region the “circonvolution du language”. He would later be given the posthumous eponym by David Ferrier who termed this area “Broca’s convolution”.

Other notable accomplishments include describing muscular dystrophy before Duchenne, rickets as a nutritional disease before Virchow, and the venous spread of cancer before von Rokitansky.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Broca, P.P. (1861) Loss of Speech, Chronic Softening, and Partial Destruction of the Anterior Left Lobe of the Brain. Bulletin de la Société Anthropologique, 2, 235-238.

#59 – Headaches

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Classifications and Subtypes

  • 3rd Edition of the International Classification of Headache Disorders (ICHD-3)
    • Primary Headaches
    • Secondary Headaches
    • Neuropathies, Facial Pains, and Other Headaches
  • 90% of headaches fall into 3 primary headache categories

Migraines

Tension-Type

Trigeminal Autonomic Cephalgias

Approach to Evaluation

  • Malignancy of myeloid precursor cells
    • Multipotential hematopoietic stem cell –> common myeloid progenitor –> myeloblast

Signs and Symptoms

  • Environment
    • Turn off the lights
    • Speak quiet
    • Let the patient talk uninterrupted about what is going on
  • History
    • Age of onset
    • Past medical and family history
    • Medication history
    • Presence of absence of aura
    • Characteristics
      • Frequency
      • Intensity
      • Duration
      • Onset
      • Quality
      • Location
      • Radiation
    • Number of headaches per month
    • Associated symptoms
      • Fever, nausea, vomiting, visual disturbances, dizziness, syncope
    • Precipitating, exacerbating or relieving factors
      • Positional changes, exertional
      • Photophobia, phonophobia
      • Relationship to food or alcohol
    • Women
      • Contraception
      • Associated with menstrual cycle
  • Physical Examination
    • Review of vital signs
    • Auscultate for bruits (evaluation for AVM)
      • Neck, eyes, head
    • Palpate head, neck, and shoulder regions
    • Palpate neck and head arteries
    • Palpate neck muscles for spasms or tightness
    • Neurologic examination
      • Mental status
      • Cranial nerve evaluation
      • Fundoscopy
      • Motor and sensory examination
      • Cerebellar exam, including gait, Romberg

Concerning History and Physical Examination Findings

  • SNNOOP10 Red Flag List
    • Systemic symptoms
      • Fever
    • Neoplasm history
    • Neurologic deficits
      • Focal or general
    • Onset
      • Sudden or abrupt
    • Older age
      • Age > 50 years
    • Pattern change or recent new headache
    • Positional
    • Precipitation
      • Sneezing, coughing, exercise, exertional
    • Papilledema
    • Progressive headache and atypical presentations
    • Pregnancy or postpartum
    • Painful eye with autonomic features
    • Post-traumatic
    • Pathology of the immune system
    • Painkiller overuse
  • Presence of ANY of the SNNOOP10 require further investigation
  • Low-Risk Documentation Pearls
    • Age < 50 years
    • Features typical of primary headache
    • History of similar headache
    • No abnormal neurological findings
    • No concerning change in usual headache pattern
    • No high-risk comorbid conditions
    • No new or concerning findings on physical examination

Serious and/or Life-Threatening Headaches

  • “Thunderclap”
    • sudden onset, maximal intensity
  • Neck pain with Horner’s Syndrome and/or neurologic deficit
    • Cervical artery dissection
  • Fever, AMS, and/or nuchal rigidity
    • Meningitis, encephalitis
  • Neurologic deficit and/or papilledema
    • Increased intracranial pressure
      • Pseudotumor cerebri, mass effect lesion
  • Orbital or periorbital symptoms
    • Acute angle closure glaucoma, cavernous sinus thrombosis/fistula

Imaging Recommendations

  • Criteria for imaging in Headaches
    • Any of the SNNOOP10 findings
  • Emergency Setting
    • CT is generally the study of choice because:
      • Widely available
      • Most life-threatening conditions are seen on CT
      • Safer for unstable patients
    • MRI is an option if:
      • New headache with optic disc edema
      • Chronic headache with new features
      • Known or suspected cancer
      • Patient is pregnant
  • Outpatient Setting
    • American Academy of Neurology recommend imaging for:
      • Patients with unexplained abnormal finding on neurologic examination
      • Patients with atypical headache features or headaches that don’t fulfill strict definition of other primary headache disorder
    • Choosing Wisely Campaign – MRI is recommended over CT
    • Consult radiology for recommendations of type of study
      • Imaging vessels, facial structures, orbits

Indications for Lumbar Puncture

  • Suspicion of SAH with a negative CT
  • Suspicion of infectious or inflammatory pathology
  • Suspicion of pseudotumor cerebri

Tension-Type Headache

Epidemiology

  • Most common headache subtype
  • 2nd most prevalent disorder in the world
  • Slightly more prevalent in women
  • Least distinct of the primary subtypes
  • Least studied

Classifications

  • Episodic
    • Infrequent – < 1 episode per month
    • Frequent – 1-14 episodes per month
  • Chronic – 15 or more episodes per month

Pathophysiology

  • Peripheral activation or sensitization of the myofascial nociceptors leading to heightened sensitivity of the pain pathways in the central nervous system
    • Central factors
      • Increased pain sensitivity
      • Altered brainstem and limbic-controlled descending pain systems
    • Peripheral factors
      • Muscular abnormalities
        • Trigger points, postural, mobility

Clinical Features

  • History
    • Quality
      • Dull, pressure, fullness, band-like, weight on shoulders
    • Increased stress and mental tension
    • Pericranial muscular tenderness
      • Masseter, temporalis, sternocleidomastoid, trapezius

Diagnostic Criteria

  • Two of the following:
    • Bilateral location
    • Pressing/tightening, non-pulsatile quality
    • Mild/moderate intensity
    • Not aggravated by routine physical activity
  • Both of the following
    • No more than one of photophobia or phonophobia
    • No moderate/severe nausea or vomiting
  • Episodic
    • At least 10 episodes lasting 30 minutes to 7 days
  • Chronic
    • At least 15 episodes per month for at least 3 months lasting for hours to days

Treatment

  • Acute/Abortive
    • NSAID Analgesia
      1. Ibuprofen, acetaminophen, aspirin
      1. Can be combined with caffeine
    • Triptans can be used if NSAIDs fail
  • Preventative
    • Antidepressants
      • Tricyclic antidepressants
        • Amitriptyline has the best evidence
          • Start 10mg and increased 10mg every 2-3 weeks until:
            • Improvement of headaches
            • Max dose of 125mg/day
      • Mirtazapine and venlafazine has some limited data
    • Anticonvulsants
      • Topiramate and gabapentin can also be helpful
    • Trigger point injections
    • Botulinum toxin injections
    • Behavioral treatments
      • Cognitive-behavioral therapy
      • Relaxation techniques
      • Biofeedback
    • Acupuncture and physical therapy has limited evidence of success

Migraines

Epidemiology

  • Affects up to 12% of the population
  • More frequent in women
  • Most common age range is 30-40 years
Up-to-Date. 2020

Pathophysiology

  • Cortical spreading depression
    • Self-propagating wave of neuronal and glial depolarization that spreads across the cerebral cortex
    • This then causes:
      • Aura
      • Activation of the trigeminovascular system
        • Causes inflammatory changes in the pain-sensitive meninges
        • Increase pain sensitization
      • Alters blood-brain barrier permeability

Clinical Features

  • Cascade of four events over a course of hours to days:
    • Prodrome
      • 24-48 before headache
      • Yawning, euphoria, depression, irritability, food cravings
    • Aura
      • 25% of patient experience focal neurologic symptom
        • Visual
          • Positive
            • Lines, shapes, objects
          • Negative
            • Scintillating scotomas, vision loss
        • Sensory
          • Positive
            • Burning, paresthesias
          • Negative
            • numbness
        • Auditory
          • Positive
            • Tinnitus, noises
          • Negative
            • Hearing loss
    • Headache
      • Unilateral
      • Throbbing, pulsatile quality
      • Nausea or vomiting common
      • Photophobia and phonophobia common
    • Prodrome
      • Feeling of exhaustion, elation, euphoria
Scintillating Scotoma

Precipitating Factors or Triggers

Common Migraine Triggers

Diagnostic Criteria

  • Without an Aura
    • ≥ 5 attacks with the following:
      • Lasting 4-72 hours
      • Headache as 2 of the following:
      • Unilateral
      • Pulsating quality
      • Moderate/severe
      • Aggravation by exertion
    • ≥ 1 of the following:
      • Nausea or vomiting
      • Photophobia or phonophobia
  • With an Aura
    • ≥ 2 attacks with the following:
      • ≥ 1 of the following reversible aura symptoms:
        • Visual
        • Sensory
        • Speech
        • Motor
        • Brainstem
        • Retinal
    • ≥ 2 of the following:
      • Aura spreads and/or 2 or more occur in succession
      • Each aura lasts 5-60 min
      • At least 1 aura is unilateral
      • Aura is accompanied or followed by headache within 60 min

Treatment

  • Acute/Abortive Therapy
    • Without nausea or vomiting
      • NSAIDs
    • With nausea or vomiting
      • Triptans
        • Sumatriptan
          1. SQ 6mg
          1. IN 20mg
      • Antiemetics
        • Metoclopramide 10mg
        • Prochlorperazine 10mg
      • Dihydroergotamine 1mg IM/SQ
        • Generally combined with metoclopromide
      • Dexamethasone 10mg IM
        • More for prevention of migraine recurrence
  • Preventative Therapy
    • Think about compelling indications and concomitant diseases
    • Antihypertensives
      • Beta Blockers
        1. Metoprolol, propranolol
      • Calcium Channel Blockers
        1. Verapamil, flunarizine
      • ACE/ARB
        1. Lisinopril, candesartan
    • Antidepressants
      • Amitriptyline, venlafaxine
    • Anticonvulsants
      • Topiramate, valproate, gabapentin
    • Calcitonin Gene-Related Peptide (CGRP) Antagonist
      • Erenumab, fremanezumab, galcanezumab
    • Acupuncture, nerve stimulation

Cluster

Epidemiology

  • <1% of headaches
  • Men > women

Pathophysiology

  • Complex and incompletely understood
    • Most widely accepted theory
      • Hypothalamic activation with secondary activation of the trigeminal-autonomic reflex

Clinical Features

  • Unilateral attacks of severe orbital, supraorbital, or temporal pain
    • Autonomic phenomena
      • Ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion
        • Only occur during the episode
        • Ipsilateral to the pain site
    • Circadian periodicity
      • Occur daily for several weeks and then remit for up to a year

Diagnostic Criteria

  • At least five attacks characterized by severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes with at least one of the following:
    • Conjunctival injections and/or lacrimation
    • Nasal congestion and/or rhinorrhea
    • Eyelid edema
    • Forehead and facial sweating
    • Miosis and/or ptosis
    • Sense of restlessness or agitation
  • Classification
    • Episodic
      • Occur in circardian periodicity in clusters
        • At least two cluster periods lasting 7 days to one year separated by a pain-free remission of at least 3 months
    • Chronic
      • Attacks occur without a remission period or remission lasting less than 3 months
  • Imaging
    • Initial event warrants an MRI to rule-out intracranial pathology that also can cause autonomic dysfunction

Treatment

  • Acute/Abortive Therapy
    • 100% oxygen via non-rebreather
    • SQ sumatriptan 6mg
    • IN lidocaine 4-10% 1mL
    • Ergot-derivitives
    • Octreotide 100mcg SQ
  • Preventative Therapy
    • Verapamil 240mg daily
      • Bridge with prednisone 60-100mg daily for 5 days, with a 10mg/day taper
    • Galcanezumab can be used for chronic
    • Lithium has limited data
    • Topiramate can be used as add-on therapy
Up-to-Date. 2020
Up-to-Date. 2020

The Cottage Physician (1893)

References

  1. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia : an international journal of headache. 2018; 38(1):1-211. [pubmed]
  2. Goadsby PJ. Migraine and Other Primary Headache Disorders. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.ezproxy.uthsc.edu/content.aspx?bookid=2129&sectionid=192532155 . Accessed May 03, 2020.
  3. Koyfman A, Long B. Headache. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.ezproxy.uthsc.edu/content.aspx?bookid=2353&sectionid=189593946 . Accessed May 03, 2020.
  4. Hainer BL, Matheson EM. Approach to acute headache in adults. American family physician. 2013; 87(10):682-7. [pubmed]
  5. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019; 92(3):134-144. [pubmed]
  6. Lyrer PA, Brandt T, Metso TM, et al. Clinical import of Horner syndrome in internal carotid and vertebral artery dissection. Neurology. 2014; 82(18):1653-9. [pubmed]
  7. Loder E, Weizenbaum E, Frishberg B, Silberstein S, . Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. ; 53(10):1651-9. [pubmed]
  8. Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache. 2018; 58(2):339-345. [pubmed]
  9. Martelletti P, Birbeck GL, Katsarava Z, Jensen RH, Stovner LJ, Steiner TJ. The Global Burden of Disease survey 2010, Lifting The Burden and thinking outside-the-box on headache disorders. The journal of headache and pain. 2013; 14:13. [pubmed]
  10. Bendtsen L. Central sensitization in tension-type headache–possible pathophysiological mechanisms. Cephalalgia : an international journal of headache. 2000; 20(5):486-508. [pubmed]
  11. Moore RA, Derry S, Wiffen PJ, Straube S, Bendtsen L. Evidence for efficacy of acute treatment of episodic tension-type headache: methodological critique of randomised trials for oral treatments. Pain. 2014; 155(11):2220-8. [pubmed]
  12. Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007; 68(5):343-9. [pubmed]
  13. Laurell K, Artto V, Bendtsen L, et al. Premonitory symptoms in migraine: A cross-sectional study in 2714 persons. Cephalalgia : an international journal of headache. 2016; 36(10):951-9. [pubmed]
  14. Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia : an international journal of headache. 2007; 27(5):394-402. [pubmed]
  15. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015; 55(1):3-20. [pubmed]
  16. Nesbitt AD, Goadsby PJ. Cluster headache. BMJ (Clinical research ed.). 2012; 344:e2407. [pubmed]
  17. May A, Schwedt TJ, Magis D, Pozo-Rosich P, Evers S, Wang SJ. Cluster headache. Nature reviews. Disease primers. 2018; 4:18006. [pubmed]
  18. Obermann M, Holle D, Naegel S, Burmeister J, Diener HC. Pharmacotherapy options for cluster headache. Expert opinion on pharmacotherapy. 2015; 16(8):1177-84. [pubmed]
  19. Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology. 2010; 75(5):463-73. [pubmed]

PAINE #PANCE Pearl – Neurologic

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Question

A 47yo man is being evaluated for a headaches that he describes as “someone jabbing my brain through my eye”. He reports these headaches occur several times a day for the past several weeks, lasting only for a minute, and only affecting his right side of this head. While speaking with him, he has another episode and you notice his eye becomes red and injected with significant tearing and nasal drainage present. On closer examination, he also notice his pupil on the affected side is constricted and he has a mild lid lag.

  1. What is the treatment protocol of choice for this patient?

PAINE #PANCE Pearl – Pediatrics

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Question

A 3yo girl is brought to your office by her parents for concern of asthma. They state that when she plays with her siblings, she often gets short of breath and needs to stop to rest for a few minutes. She is otherwise healthy and was born at 38 weeks gestation via cesarean section. She has had an uncomplicated past medical history and is up to date on all immunizations.

Physical examination reveals a well-nourished, well-developed girl, who is at 67% for height and 46% for weight for her age. Vital signs are BP-110/68, HR-87, RR-13, O2-100%, and temperature-98.7o. There is no evidence of cyanosis and auscultation findings are below.

  1. Describe what you hear.
  2. What condition is this most suggestive of?
  3. What is the management of this condition?

Answer

  1. Continuous, holosystolic, blowing mumur with a faint split S2

2. This type of murmur and the above clinical features are most likely due to a patent ductus arteriosus.

3. After a Doppler echocardiogram has been performed, surgery would be the next step to close this defect. Pharmacologic therapy does not work as well in older infants and children. Transcatheter closure would be the preferred option given the patient’s age.

#58 – Acyanotic Congenital Heart Defects

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***LISTEN TO THE PODCAST HERE***

Click Here for Episode #11 – Review of Cyanotic Congenital Heart Defects

Review of In-Utero and Neonatal Cardiovascular Physiology

  • Ductus arteriosus
    • Connects the pulmonary artery to the descending aorta
    • Prostaglandin E2 are produced by the placenta and keep this open, along with low arterial oxygen concentration
    • Begins to close 10-15 hours after delivery and should be completed by 2-3 weeks of age
  • Foramen ovale
    • Communication between right and left atrium
    • Once the infant begins spontaneously breathing, increases in pulmonary blood flow and left atrial pressures mechanically seals the foramen ovale

Review of Initial Approach to Screening for Congenital Heart Diseases

  • The main approach to initial cardiac evaluation for infants with suspected heart disease is to determine:
    • Innocent vs Congenital Heart Disease
      • Cyanotic vs Acyanotic
      • Indications for emergent referral
  • Historical Clues
    • Symptomatic
      • Cyanosis, respiratory, poor growth, poor feeding, syncopal episodes
    • Family History
      • Parent or sibling with congenital heart disease
        • 1st degree relative with any CHD – RR 3.21
    • Genetic syndromes
    • Prenatal Evaluation
      • Abnormalities on prenatal ultrasound
      • Maternal factors that increase risk
        • Multifetal pregnancy, prematurity, preeclampsia, DM, HTN, Age > 40, alcohol/substance use, smoking,
    • Age of child
  • Physical Examination
    • Murmurs
      • Innocent murmur
        • ≤ Grade 2
        • Short systolic phase
        • Minimal radiation
        • Soft intensity
    • Extra Heart Sounds
      • Abnormal S2
      • S3 or S4
      • Systolic click
      • Thrills and heaves
    • Other Findings
      • Abnormal vital signs
        • BP differences between right arm, left arm, and legs
        • Weak or bounding pulses
      • Hepatomegaly
  • Diagnostic Studies
    • Pulse oximetry screening
      • Measure in right hand (pre-ductal) and either foot (post-ductal)
    • Chest radiograph
      • Cardiomegaly, increased pulmonary vascular markings, pulmonary edema
    • EKG
      • LVH, RVH, abnormal axis, dysrhythmias, prolonged QT
    • Echocardiogram
Up-to-Date. 2020

Ventricular Septal Defect

Epidemiology

  • 30% of all CHD (most common)

Normal Development

  • Three main components
    • AV canal septum (1)
    • Muscular septum (2)
    • Parietal band or distal conal septum (3)
  • Closure of the interventricular foramen is dependent on:
    • Right-sided endocardial cushions  projecting into the AV canal
    • Connective tissue growth on the crest of the muscular septum
    • Downward growth of ridges dividing the conus
Up-to-Date. 2020

Types

  • Membranous Defects
    • Most common clinically significant VSD
    • Under aortic valve and behind septal leaflet of the tricuspid valve
      • May extend into muscular septum
    • Can be associated with LVOTO and coarctation
  • Muscular Defects
    • Located along right ventricular free wall-septal junction, in the central muscular septum, or in the apical septum
    • Often close spontaneously
  • Malalignment Defects
    • Result from anterior/posterior malalignment of the conal septum
    • Associated with Tetralogy of Fallot
  • Subpulmonic Defects (outlet)
    • Superior and anterior conal septum defects
  • AV Canal Defects (inlet)
    • Posterior and superior to annulus of tricuspid valve
    • Associated with ASDs
Up-to-Date. 2020

Pathophysiology

  • Cause no problems in-utero
  • Causes a left-to-right shunt ex-utero
    • Higher left ventricular pressures
  • Categorization is based on:
    • Size
      • Small – < 4mm
      • Moderate – 4-6mm
      • Large – > 6mm
    • Shunt (Pulmonary:Systemic flow)
      • Small – Qp:Qs < 1.5
      • Moderate – Qp:Q 1.5-2.3
      • Large – Qp:Qs > 2.3
  • Effects on Circulation
    • Pulmonary
      • Increased and causes tachypnea and increased respiratory effort
    • Systemic
      • LV output must increase to maintain systemic flow
      • As systemic flow decreases (large VSDs):
        • Increased alpha-adrenergic stimulation
        • Increased catecholamine release
        • Increased angiotensin release
      • Increases risk of heart failure

Natural History

  • Small
    • 75% close spontaneously within 2 years of life
    • Those that persist in adulthood are benign
  • Moderate
    • Spontaneous closure depends on pulmonary arterial pressure and size/location of defect
    • Can respond to medical management
  • Large
    • Rarely spontaneously close
    • Surgery must be performed within 1st year to avoid permanent pulmonary vascular resistance

Clinical Presentation

  • Prenatal
    • Moderate to large VSD can be diagnosed during 20week ultrasound
  • Postnatal
    • Small VSD
      • Can be asymptomatic and present with only a murmur
    • Moderate to Large VSD
      • Present 3-4 weeks from birth with signs and symptoms of heart failure
        • Tachypnea
        • Poor feeding or poor weight gain
        • Tachycardia
        • Hepatomegaly
        • Rales, retractions
      • Cardiac Examination
        • Murmur
          • Harsh or blowing holosystolic
          • Heard best at 3rd-4th intercostal space
          • May have a diastolic rumble
            • Increased flow across mitral valve
          • Loud, splitting of S2
            • Due to increased pulmonary arterial pressure
        • Palpable thrill may be present

Diagnostic Studies

  • EKG
    • LVH, RVH, RAE
  • Chest Radiograph
    • Increased pulmonary vascular markings
  • Echocardiography
    • Two-dimensional Doppler confirms diagnosis
Radiopaedia

Management

  • Expectant
    • Most small VSD close spontaneously
    • Follow-up every 6 months with cardiologist until murmur resolves or yearly if murmur persists but still asymptomatic
  • Medical
    • Heart failure management
      • Diuretics are first line
    • Nutritional support
    • Pulmonary hypertension management
      • May need cardiac catheterization for accurate measurements and determination for surgical management
  • Surgical
    • Indications
      • Persistent symptoms with maximal medical therapy
      • Moderate/large defects with pulmonary hypertension
      • Persistent left-to-right shunt with LV dilation
      • Associated aortic valve prolapse or aortic regurgitation
      • Double-chambered right ventricle
    • Direct patch closure is procedure of choice in most children
    • Transcatheter closure is technically challenging and not offered routinely due to higher incidence of AV block and valve injury

Atrial Septal Defect

Epidemiology

  • 10-15% of all CHD
  • 1-2 per 1000 live births

Normal Development

  • Begins at 5th week and is made up of 3 structures
    • Septum primum and AV canal septum (endocardial cushions)
      • Arises from superior portion of common atrium
      • Grows caudally towards AV canal septum
        • These two fuse close ostium primum between right and left atria
    • Septum secundum
      • Covers the ostium secundum on the right atrial side of the septum primum
        • Forms the fossa ovalis
      • Leaves a small opening in-utero
        • Foramen ovale
          • Held open due to pressure gradients between the higher right atria and lower left atria
            • Allows for right to left flow
Up-to-Date. 2020

Types

  • Primum Defect
    • 15-20% of ASDs
    • Occurs when primum septum does not fuse with endocardial cushions
  • Secundum Defect
    • 70% of ASDs
    • 2x more common in females
    • Located within the fossa ovalis
  • Sinus Venosus Defect
    • 5-10% of ASDs
    • Malposition of the insertion of the superior or inferior vena cava on the atrial septum
  • Patent Foramen Ovale
    • Identified on 30% of adult autopsies
    • NOT considered an ASD because no septal tissue is missing
Up-to-Date. 2020

Natural History

  • Most close spontaneously
    • >80% of small (<5mm)
    • 30-60% of moderate (6-10mm)
    • Large (>10mm) do not close spontaneously
  • Persistent ASDs can cause pulmonary hypertension and heart failure in adulthood

Clinical Presentation

  • Most are asymptomatic and diagnosed only by identification of murmur
  • Murmur
    • Midsystolic pulmonary flow or ejection murmur
      • Heard best left 2nd intercostal space
    • Wide, fixed split S2
      • ASD equalizes the respiratory effect on both right and left ventricular output
      • If pulmonary hypertension is present, there may be an accentuated pulmonic component of S2
    • May have associated mitral regurgitation murmur

Diagnostic Studies

  • EKG
    • May show rSr’ or rsR’ pattern in V1
      • Incomplete RBBB
  • Echocardiogram
    • Transthoracic may see, but a transesophageal is better

Management

  • Often watch until child is 2yo as most will spontaneous
    • Even persistent defects are not recommended to close
  • Closure Indications
    • Right heart enlargement
    • Pulmonary overcirculation
    • Substantial left-to-right shunt
  • Types of Closures
    • Percutaneous
      • Criteria
        • < 30mm is diameter
        • ≥ 5mm or rim tissue around defect sufficient for effective closure without obstructing surrounding structures
      • Avoids bypass and major surgical incisions
      • Complications
        • Device embolization, malposition, dysrhythmias, cardiac perforation
    • Surgery
      • Indications
        • Sinus venosus defects
        • Coronary sinus defects
        • Primum ASDs
        • Large ASDs with heart failure
      • Closed with pericardial or Dacron patch

Atrioventricular Septal Defect

Epidemiology

  • 4-5% of CHD
  • 0.3-0.4 per 1000 live births
  • Up to a 50% risk of trisomy 21

Normal Development

  • Primitive AV canal connects the atria with the ventricles
  • At 4-5 weeks gestation, the superior and inferior endocardial cushions fuse and form the AV canal
    • This contributes to the AV valves and septum

Types and Classifications

  • Classified based on the degree of the defect
    • Complete
      • Complete failure of fusion between the superior and inferior endocardial cushions
        • Combined primum ASD and posterior VSD with a single, common AV valve
      • Can be balanced (both ventricles get same flow) or unbalanced (one gets more than the other)
        • Unbalanced can lead to hypoplasia
    • Partial
      • Incomplete fusion of superior and inferior endocardial cushions
        • Primum ASD, single AV valve annulus with 2 valve orifices
    • Transitional
      • Large primum defect, cleft mitral valve, and inlet VSD
Up-to-Date. 2020
  • Rastelli Classification
    • Type A
      • Most common form and most common ASVD with Down syndrome
    • Type B
      • Least common
    • Type C
      • Frequently found with other conditions
        • Tetralogy of Fallot, Transposition of Great Vessels
Up-to-Date. 2020

Pathophysiology

  • Complete AV Canal Defect
    • Increased pulmonary blood flow due to left-to-right shunting
      • Leads to heart failure and pulmonary hypertension
  • Partial AV Canal Defect
    • Volume overload of right atrium and right ventricle with pulmonary overcirculation due to left-to-right shunting
      • No pulmonary hypertension
    • Mitral regurgitation can be severe
  • Transitional AV Canal Defect
    • Shunting often mild due to small VSD

Clinical Presentation

  • In-Utero
    • Can be diagnosed early during pregnancy
    • Rarely cause any fetal distress or growth disturbances
  • Complete
    • Heart failure develops early in infancy
      • Tachypnea, poor feeding, poor growth, sweating, and pallor by 2 month
      • Severity of symptoms depends on size and degree of AV valve regurgitation
    • Physical examination
      • Hyperactive precordium with inferior/laterally displaced PMI
      • Increased S2
      • Systolic ejection murmur heard best at left upper sternal border
  • Partial and Transitional
    • Asymptomatic during childhood and only diagnosed on routine examination
    • Physical examination
      • Wide and fixed S2 during respiration
      • Systolic ejection murmur heard best at left upper sternal border
        • Diastolic rumble may be heard
        • Holosytolic murmur of MR

Diagnostic Studies

  • Echocardiography
    • Transthoracic is adequate
    • Apical four chamber or subcostal view is best to see defect

Management

  • In general, surgical correction is recommended because of significant morbidity and mortality of the pulmonary circulation effects
  • Complete
    • Correction by 6 months of age to prevent permanent pulmonary hypertension
    • Close the ASD and VSD and create to separate, competent AV valves
      • Single-patch or double-patch
Up-to-Date. 2020
  • Partial and Transitional
    • Primum ASD does not close spontaneously and leaves the patient at risk for atrial fibrillation and heart failure later in life
    • Surgical goal is to close intraatrial communication and restore/preserve AV valve competence
      • Patch closure of ostium primum defect and mitral valvuloplasty
    • Timing is usually between 18 months and 3 years

Patent Ductus Arteriosus

Epidemiology

  • 3-8 per 10,000 live births
  • 2:1 female predominance

Normal Development

  • Derived from the embryonic left sixth arch
  • Actually has different tissue than the aorta or pulmonary artery
    • Intima is thicker
    • Media contains more smooth muscle
  • In utero, allows from RV flow to placenta to get oxygenated
  • Keep open by low arterial oxygen and prostaglandin E2 from placenta
  • At birth, increased levels of arterial oxygen and the lack of prostaglandin E2 begins the process of spontaneous closure

Clinical Presentation

  • Symptoms depend on the degree of left-to-right shunting
    • Dependent on size and length of PDA, as well as the difference between the pulmonary and systemic vascular resistances
  • Classic murmur
    • Continuous, holosystolic murmur
      • Machinery murmur
    • Heard best over left upper sternal border
  • Small (Qp:Qs < 1.5 to 1)
    • Asymptomatic and detected on routine physical examination
  • Moderate (Qp:Qs 1.5-2.2 to 1)
    • May present with exercise intolerance and heart failure
      • Left-to-right shunt increasing left atrial and ventricular volume
        • Progress to left ventricular dilation and dysfunction
    • Displaced PMI
    • Widened pulse pressure
  • Large (Qp:Qs > 2.2 to 1)
    • Due to increased left sided pressures, can lead to increased pulmonary pressures
      • May be irreversible if not corrected
      • Can lead to right-to-left shunt if pressure is high enough
        • Eisenmenger syndrome (cyanosis)
      • Split S2 with prominent pulmonary component
      • Murmur may disappear as pulmonary pressure increases
    • Heart failure, poor feeding, failure to thrive, respiratory distress
    • Dynamic PMI with a thrill
    • Wide pulse pressures and bounding pulses

Diagnostic Studies

  • Transthoracic, doppler color flow echocardiography
    • The ductus is best viewed on the parasternal short-axis and suprasternal view

Management

  • Decisions are made on whether to actively close the PDA or monitor cardiac status
    • Term vs pre-term
      • Pre-term respond well to prostaglandin inhibitors
    • Size of the PDA
      • Moderate to large warrant closure
      • Small, audible PDA also benefit from closure to lower long term complications
        • Especially bacterial endocarditis
    • Degree of left-to-right shunt
    • Degree of left sided volume overload
    • Evidence of pulmonary hypertension
      • Closure not recommended in severe PAH
  • Closure Options
    • Medical/Pharmacologic Therapy
      • Prostaglandin inhibitors
        • Indomethacin, ibuprofen
          • Ibuprofen > indomethacin in term infants and older patients
    • Surgery
      • Posterolateral thoracotomy with direct PDA ligation
      • Video-Assisted Thoracoscopic Surgery (VATS) is less invasive option
        • Not indicated if PDA size > 9mm
      • Percutaneous closure using coils or commercial occlusion devices

Coarctation of the Aorta

Definition

  • Narrowing of the descending aorta at the insertion of the ductus arteriosus distal to the left subclavian artery

Epidemiology

  • 4-6% of all CHD
  • 4 cases per 10,000 live births
  • More common in males

Pathogenesis

  • Unknown, but two theories prevail:
    • Decreased intrauterine blood flow leading to under development of the fetal aortic arch
    • Migration/extension of ductal tissue into the wall of thoracic aorta
  • Genetic associations and increased familial risk
  • Usually accompanied with other CHD

Pathophysiology

  • As PDA and FO begin to close after birth, increased pressure over the narrowed aorta
    • Leads to left ventricular outflow tract obstruction
    • Increased collateral blood flow across the intercostals, internal mammary, and scapular vessels

Clinical Manifestations

  • Classic findings
    • Absent/delayed femoral pulses
    • Difference in upper extremity and lower extremity blood pressures
  • Neonates
    • Asymptomatic as long as there is a patent ductus
    • Murmurs of other CHD
  • Infants and Older Children
    • Complain of lower extremity claudication symptoms with exertion
    • Hypertension may be prominent
  • Adults
    • Hypertension is may sign
      • If severe, may lead to heart failure, aortic pathologies
    • Claudication can also be present

Diagnostic Studies

  • Chest radiography
    • Infants
      • Cardiomegaly with increased pulmonary vascular markings
    • Older children and adults
      • Rib notching from large collateral development
      • “3” sign from indentation of aortic wall at coarctation site
The red arrows point to rib notching caused by the dilated intercostal arteries. The yellow arrow points to the aortic knob, the blue arrow to the actual coarctation and the green arrow to the post-stenotic dilation of the descending aorta. Learning Radiology. 2020
  • Echocardiography
    • Transthoracic, doppler flow can visualize coarctation and evaluate for other defects
    • Ideal view is high parasternal long axis or suprasternal view
  • Cardiovascular MRI/CT
    • Recommended for adolescent and adult patients
  • Cardiac catheterization
    • Generally performed in conjunction with therapeutic interventions, or in adults with associated coronary disease

Management

  • Indications for inventions
    • Neonates with critical coarctation
      • Emergent medical therapy
        • Continuous infusion of prostaglandin E1
        • Inotropic support
        • Support care to correct metabolic derangements
    • Gradient > 20 mmHg
    • Radiologic evidence of clinically significant collateral flow
    • Hypertension or heart failure attributed to the defect
  • Types of Interventions
    • Balloon angioplasty (only)
      • Infants > 4 months and young children < 25kg
      • Preferred therapy for isolated coarctation
    • Stent Placement (after angioplasty)
      • Children > 25kg and adults
    • Surgical repair
      • Falling out of favor with increasing advancement and safety of transcatheter techniques

References

  1. Liu S, Joseph KS, Lisonkova S, et al. Association between maternal chronic conditions and congenital heart defects: a population-based cohort study. Circulation. 2013; 128(6):583-9. [pubmed]
  2. Jenkins KJ, Correa A, Feinstein JA, et al. Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics. Circulation. 2007; 115(23):2995-3014. [pubmed]
  3. Øyen N, Poulsen G, Boyd HA, Wohlfahrt J, Jensen PK, Melbye M. Recurrence of congenital heart defects in families. Circulation. 2009; 120(4):295-301. [pubmed]
  4. Frank JE, Jacobe KM. Evaluation and management of heart murmurs in children. American family physician. 2011; 84(7):793-800. [pubmed]
  5. Kang G, Xiao J, Wang Y, et al. Prevalence and clinical significance of cardiac murmurs in schoolchildren. Archives of disease in childhood. 2015; 100(11):1028-31. [pubmed]
  6. McCrindle BW, Shaffer KM, Kan JS, Zahka KG, Rowe SA, Kidd L. Cardinal clinical signs in the differentiation of heart murmurs in children. Archives of pediatrics & adolescent medicine. 1996; 150(2):169-74. [pubmed]
  7. van der Linde D, Konings EE, Slager MA, et al. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. Journal of the American College of Cardiology. 2011; 58(21):2241-7. [pubmed]
  8. Hoffman JI, Kaplan S. The incidence of congenital heart disease. Journal of the American College of Cardiology. 2002; 39(12):1890-900. [pubmed]
  9. Zhao QM, Niu C, Liu F, Wu L, Ma XJ, Huang GY. Spontaneous Closure Rates of Ventricular Septal Defects (6,750 Consecutive Neonates). The American journal of cardiology. 2019; 124(4):613-617. [pubmed]
  10. Zhang J, Ko JM, Guileyardo JM, Roberts WC. A review of spontaneous closure of ventricular septal defect. Proceedings (Baylor University. Medical Center). 2015; 28(4):516-20. [pubmed]
  11. Bol-Raap G, Weerheim J, Kappetein AP, Witsenburg M, Bogers AJ. Follow-up after surgical closure of congenital ventricular septal defect. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2003; 24(4):511-5. [pubmed]
  12. Butera G, Carminati M, Chessa M, et al. Transcatheter closure of perimembranous ventricular septal defects: early and long-term results. Journal of the American College of Cardiology. 2007; 50(12):1189-95. [pubmed]
  13. Hanslik A, Pospisil U, Salzer-Muhar U, Greber-Platzer S, Male C. Predictors of spontaneous closure of isolated secundum atrial septal defect in children: a longitudinal study. Pediatrics. 2006; 118(4):1560-5. [pubmed]
  14. Muta H, Akagi T, Egami K, et al. Incidence and clinical features of asymptomatic atrial septal defect in school children diagnosed by heart disease screening. Circulation journal : official journal of the Japanese Circulation Society. 2003; 67(2):112-5. [pubmed]
  15. Korenberg JR, Bradley C, Disteche CM. Down syndrome: molecular mapping of the congenital heart disease and duodenal stenosis. American journal of human genetics. 1992; 50(2):294-302. [pubmed]
  16. Cetta F, Minich LL, Edwards WD, et al. Atrioventricular septal defects. In: Moss and Adams’ Heart Disease in Infants, Children, and Adolescents Including the Fetus and Young Adult, 7th ed, Allen HD, Shaddy RE, Driscoll DJ, Feltes TF (Eds), Lippincott Williams & Wilkins, Philadelphia 2007.
  17. Rastelli G, Kirklin JW, Titus JL. Anatomic observations on complete form of persistent common atrioventricular canal with special reference to atrioventricular valves. Mayo Clinic proceedings. 1966; 41(5):296-308. [pubmed]
  18. Backer CL, Stewart RD, Mavroudis C. What is the best technique for repair of complete atrioventricular canal? Seminars in thoracic and cardiovascular surgery. 2007; 19(3):249-57. [pubmed]
  19. Minich LL, Atz AM, Colan SD, et al. Partial and transitional atrioventricular septal defect outcomes. The Annals of thoracic surgery. 2010; 89(2):530-6. [pubmed]
  20. Hoffman JI, Kaplan S. The incidence of congenital heart disease. Journal of the American College of Cardiology. 2002; 39(12):1890-900. [pubmed]
  21. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008; 118(23):e714-833. [pubmed]
  22. Giroud JM, Jacobs JP. Evolution of strategies for management of the patent arterial duct. Cardiology in the young. 2007; 17 Suppl 2:68-74. [pubmed]
  23. Keane JF, Flyer DC. Coarctation of the aorta. In: Nadas’ Pediatric Cardiology, 2nd ed, Keane JF, Lock JE, Fyler DC (Eds), Saunders Elsevier, Philadelphia 2006.
  24. Beekman RH III. Coarctation of the Aorta. In: Moss and Adams’ Heart Disease in Infants, Children, and Adolescents, 6th ed, Allen HD, Driscoll DJ, Shaddy RE, Feltes TF (Eds), WK Lippincott Willams and Wilkins, Philadelphia 2008. Vol 2
  25. Silversides CK, Kiess M, Beauchesne L, et al. Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: outflow tract obstruction, coarctation of the aorta, tetralogy of Fallot, Ebstein anomaly and Marfan’s syndrome. The Canadian journal of cardiology. 2010; 26(3):e80-97. [pubmed]
  26. Baumgartner H, Bonhoeffer P, De Groot NM, et al. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). European heart journal. 2010; 31(23):2915-57. [pubmed]

PAINE #PANCE Pearl – Pediatrics

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Question

A 3yo girl is brought to your office by her parents for concern of asthma. They state that when she plays with her siblings, she often gets short of breath and needs to stop to rest for a few minutes. She is otherwise healthy and was born at 38 weeks gestation via cesarean section. She has had an uncomplicated past medical history and is up to date on all immunizations.

Physical examination reveals a well-nourished, well-developed girl, who is at 67% for height and 46% for weight for her age. Vital signs are BP-110/68, HR-87, RR-13, O2-100%, and temperature-98.7o. There is no evidence of cyanosis and auscultation findings are below.

  1. Describe what you hear.
  2. What condition is this most suggestive of?
  3. What is the management of this condition?