Tuesday, November 28, 2017

Diagnosing functional acute neurological disorders in children

A thorough neurological exam may be more effective in diagnosing functional acute neurological disorders in children than ordering diagnostic tests, according to a retrospective examination of medical charts at Children's Hospital of Michigan affiliated with the Wayne State University School of Medicine. The findings were presented here at the Child Neurology Society annual meeting in October.

Rajkumar Agarwal, MD, assistant professor of neurology and pediatrics, and his colleagues reviewed the medical charts of 222 patients (156 females and 66 males) with a mean age of 13.9 years who presented to the emergency room with neurologic symptoms that pushed clinicians to consider seizure disorders or stroke. The presenting symptoms included seizure-like symptoms in 143 children, stroke-like symptoms in 51 children, acute vision problems in 11 children, gait problems in nine, and a combination of these symptoms in eight children.

About 82 children diagnosed with a functional neurological disorder also had scans done: magnetic resonance imaging (MRI) of the brain (37) and the spine (eight); 37 had computed tomography of the head; and 56 had electroencephalography. Fifteen children also had lumbar puncture. All tests came back negative.

Dr. Agarwal said that those more likely to have further diagnostic testing were non-African-Americans (54 percent versus 40 percent of African-Americans), patients who present with new symptoms (compared to recurring symptoms), as well as those who were admitted to the hospital and were evaluated by either a neurologist (75 percent) or a psychiatrist (60 percent); 145 children were hospitalized, and the average length of stay was 63.8 hours. The others were sent home from the emergency room with a diagnosis of functional acute neurological disorder.

“There is often clinical suspicion of conversion disorder,” said Dr. Agarwal. He explained that there are well-described signs for functional syndromes: A child whose whole body shakes, but he or she can focus and track the examiner or if the eyes are forcefully closed, is more likely to have a functional seizure. If a child has a stroke-like presentation — he can't move his arm — a good way to assess whether it is a functional disorder is to put the arm over the child's face and drop it. If it is a true weakness, the arm will fall on the child's face. If the arm moves around to avoid the face, you should expect a conversion disorder, Dr. Agarwal said.

“Despite clinical suspicion of conversion disorder, often children are subjected to a variety of tests, sometimes even invasive and potentially harmful. The need for these tests should be considered judiciously on a case-by-case basis.”

Many of the children did not report any serious acute stressors that could have sparked a conversion disorder. “The stressors were commonplace,” said Dr. Agarwal. “It tells us that a catastrophic stressor is not required to trigger a conversion disorder.”

Also, 67 percent did not have a prior psychiatric diagnosis, suggesting that these are often otherwise “healthy” children who may have an underlying unresolved psychological conflict. Neurological exams were also normal in more than 90 percent of the children…

He said that the lessons learned are that in a child presenting to the emergency room with a suspected functional symptom and a normal clinical exam, further testing should be considered on an outpatient basis.

“We found that 46 percent who went on to have further testing in the hospital were all normal,” Dr. Agarwal added. “Inpatient admission and testing increases health care costs and resource utilization should be optimized.”

[Joseph Jankovic, MD] “The diagnosis of functional movement disorders should be based not only on exclusion of organic causes but also on positive criteria, such as sudden onset, distractibility, and phenomenology that is incongruous with organic movement disorder. One organic disorder that is commonly misdiagnosed initially as ‘psychogenic’ is anti-NDMA encephalopathy.”

[Barbara Ann Dworetzky, MD] “Functional disorders are common and it is important for patients to feel that their doctors believe they have a real disorder, that they are not making their symptoms up. It is the brain's automatic response (‘like a reflex’) to an accumulation of stressors that occur over time.”


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