Upload
lykhuong
View
216
Download
0
Embed Size (px)
Citation preview
Neurology
• Neuron: nerve, logos: knowledge
• Neurology: deals with the prevention, therapy andrehabilitation of organic disease of NS and musculature
Characteristisc:• 1. Psychiatric alterations are not typical• 2. Morphological or functional abnormalities• 3. Psychogenic mechanisms only modifyInternal Medicine : functional diagnosisneurology: localisation, importance of neuroanatomy
The most frequent neurologicaldisorders
• Headache (tension type: pop. 40-60%, migraine: femails:9-12%, males:4-6%)
• Low back pain• Stroke: prev.:2000/ 100 000• Epilepsy: 60-80 0 / 100 000• Parkinsonism: 20 –40 0 / 100 000• Polyneuropathy:30 0 / 100 000• Multiplex Sclerose 6-80 / 100 000
–P- WhatProvokes discomfort?
–Q- What is theQuality of the discomfort?
–R- Where is theRegion of thediscomfort?
–S- What is theSeverity of the discomfort?
–T- What is theTime sequence?
Neurol. examination
•Signs of meningeal irritation•Cranial nerves•Reflexes•Sensory•Motor •Vegetative function•Orientation, cognition, perception
DiagnosisDiagnosis
InstrumentalInstrumental
NeurolNeurol. . examexam
ObservationObservation,,generalgeneralexaminationexamination
AutoanamnesisAutoanamnesis
HeteroanamnesisHeteroanamnesis, , environmentenvironment
12.09.200712.09.2007
1.Case history
Airways?
Temperature?
Consc? (alert-somnolent-stupor-coma?)
Aphasia?
• Coniug eyes?• Anisocoria?
• paresis:• upper?• Lower?
2. Examination
Auscult?
at least 3 parameters
• head
• Trauma sign• Nuchal rigidity,
• holes:ear(bleeding?), eyes(anisoc.) mouth
cont.
• chest
• fever• BP
• Pulse
cont
• abdomen
• Defense?• Kidney area
• bladder
cont.
• extremities
• Pathol. position• Movement asymmetry
• Reflexes
Neurol. exam:
•Signs of meningeal irritation•Cranial nerves•Reflexes•Sensation•Motorium
• Vegetative function• Orientation, cognition, perception
NuchalNuchalrigidityrigidityMENINGITISMENINGITISspondylosisspondylosisexsiccosisexsiccosisSAHSAH
II. Opticus: fundi
• papillaedema increased intracran. pressure
• Optic atrophy chronic disease;
• Vascular diseases: HT, diabetes
III.-IV.-VI.
• Anisocoria?
• Dissociated eyes?
• Parasympathic (III) or sympathicdysfunction.
Disturbances of coniugate eyemovements
• Symmetric, parallel movements butrestricted in some directions, (eg. Left, rightup or down). Brodman 8
• Frontal eye movement center moves botheyes to contralateral direction
Nystagmus
• Rhytmic, biphasic repetitive eyemovement
Nystagmus• Dysfunction of periph. vestibular
system (VIII.): horizontal or rotatoricnystagmus
• Vertical nystagmus: CNS damage.
Corneal reflex (V and VII)
•Afferent (V)
•efferent (VII),
VII (Facial)UMN
• asymmetry only by mouth
LMN all impaired:
• forehead
• eye
• mouth
XII (Hypoglossus)
• atrophy, fasciculation deviation?
Reflexes
–Tendon reflexes (proprioceptive, muscle)
–nociceptive reflexes
–Pathological reflexes
Brisky :physiological
Increased:brisky +pyramidal sign
Reflexes;
TENDON REFLEXES:
• If the reflex arch is impaired:
•LMN
•Motor radix
•Sensory radix
•Peripheral nerve
TENDON REFLEXES:
• UMN (pyramidal tract)
Nociceptive reflexes
• If UMN is impaired
Nociceptive reflexesreceptor
effector in different organs
• Corneal• pharyngeal• abdominal• cremaster• anal• bulbocavernosus
Muscle tone
–UMN spasticity,
–LMN: flaccid
–Extrapyramidal:rigidity
Muscle strength
0 no movement
1 visible, but no movement at joint
2 movement at joint, but no elevation
3 Elevation but not against resistance
4 against resistance, but not with normal strength
5 Normal strength
Disturbance of sensation
• Subjective– paraesthesia
– spontaneous pain
• Objective– tactile
– thermal stimulus
– pain
Eddig 2008Eddig 2008--0909--1717
BabinskiBabinskireflexreflex
CT
• Ischemia, bleeding, tumor abscess, degeneration, trauma.
62 yrs stroke at admission
One day later
2 days later
Cerebral hemorrhages
Angiography
DSA angiography
• DSA (digital subtraction angiography, mask-image)
• excellent resolution• DSA, MR, CT and PET integration
• intervention neuroradiology:embolisation ofmalformations, fistels, aneurysm
• Problems:(bleeding, dissection, embolisation, vasospasm, contrast-allergy)
Angiography 2.
• Diagnosis• Stenosis, vascular malformation, aneurysm,
vasculitis, sinus thrombosis
• Therapy• local lysis, preop. embolisation, tumor
chemotherapy
MR-angiography
• "angiogramm" dark (flow void)
• or slow flow :bright (flow related enhancement). • Stenosis could be misdiagnosed:occlusion
aneurysm• Non-invasive
US
• B-mode:high resolution, plaque const., Intima-Media thickness
• Carotid Duplex:flow+morphology
• stroke prevention:carotid stenosis+OP• embolus-detection• Transcranial Doppler
• TTE, TEE
SPECT (Single Photon Emission Computer Tomography)
• 99mTc-HMPAO or 133 I-amphetamin (IMP), 133Xe
• CBF, CBV and receptors
• epileptic focus• Alzheimer (temporoparietal decrease) • before and after carotid reconstruction
PET (Positron Emission Computer Tomography)
• (18F:120 min, 150:2 min, 11C:20 min)
• pH, CBF, CBV, O2, Glu met• Receptor imaging
• dopaminergic, cholinergic, histaminergic, opioid. systems
• dementia• pharmacotherapy
PET 2.
•18F-deoxyglucose epileptic focus•whole body PET:tumor(methionin or
oxigen) •Radionecrosis or recidive?•New tracers, important for pharma
research
Stroke in the left MCA areaMRI
TCD CBF HMPAO-SPECT
FF--DGDG--PETPET
LeftLeft MCA MCA infarctinfarct
Lumbal punction
• Infection? SAH, infiltration of meninx by tumor?
• Before Lp funduscopy! • Between L-III-IV. vertebra
• Sample for culture but immediate AB therapy• Normal CSF:clear, water-like
• cell:2-3
CSF• protein (0.2-0.4 g/l) glucose 2/3 of the blood,
• staining Ziehl-Nielsen, Gram
• serology• viral titers• oligoclonal band
• ELISA (Enzyme-linked-immunadsorbent assay)• Tumormarkers (carcinoembryonal antigen, Beta2-
mikroglobulin• Neuronspecific enolase• PCR: TBC, Herpes, Borrelia , CMV
Pot. complications: headache, hematoma, CSF fistel, infection, herniation
EEG
0,6-0,8 % of population:epilepsy
•Brain death, prion-diseases•New techniques:frequency analysis,
EEG-mapping. •video,long-term EEG,holter EEG. •cortical electrodes•before epilepsy-surgery!!
EEG 2. methods
• Hyperventilation• Fotostimulation• Sleep deprivation• Pathol. EEG important, but not diagnostic for
epilepsy
• Normal EEG does not exclude epilepsy!!!
EEG 3.
• Alpha (8-13 c/s): at rest: rhytm.occipital max.
• Beta (14-30 c/s): frontal-central: attention, anxiety, intox.
• theta (4-7 c/s):
• Delta (0.5-3 c/s)
EEG 4.
• Focal disease:circumscribed slow activity
• General abnormality:intox. trauma, metab. diseases
• Spikes:important but only with clinical findings
• epilepsy:1/3 with normal EEG!!!
• Useful:Encephalitis– metabolic diseases (uremic, hepatic coma etc.)
– Coma
• No typical findings:in tumor or vascular diseases
Transcranial Magnetic Stimulation
• Centr. and peripheral. motor system
• conduction time
• fields:MS, ALS, lesion of motor pathway
VEP
• light or checkerboard, occipital registration
• 100 ms latency is an important parameter
• averaging (64-128)
• important:Multiple sclerosis
SEP
• excitation, vertebras, parietal cortex
• Comparison:with controls and contralateral values
• MS, spinal cord diseases, intraop. monitoring
BAEP
• Sound, vertex, mastoid, averaging of 1-2000 impulse, I-V. waves,
• latency, distance between III.-V. waves
• brain stem
• tumor, vascular, brain death
EMG
•neurogenic and myogenic atrophycould be differentiated
•psychogenic and organic paresis•clinically silent paresis•reinnervation• tremor types
ENG
• ENG:motor and sensory conduction velocity
• motor: orthodrom, • sensory fibers:orthodrom and antidrom
• sensory action pot. less than motor ones:averaging is important
• Myelin lesion:slow vel.
• Axon lesion:no or small changes, but amplitudedecrease
MEG
• Spontanous or after stim.
• Magnetic dipol changes with magnetic field
• Isolation is important
• good spatial resolution (± 3mm) 1 ms
• epilepsy, stroke
• metabolic disorders
Other methods 1.
• Muscle biopsy• Light- and -electronmicr, immunohistology
• Neurogenic atrophy:atrophy in groups
• Myositis:inflamm.cells, immuncomplex, IgG deposition
• Non inflamm::necrosis, fibers, connect. tissue
• Nerve biopsy• lateral sural n. (sensory)
• sometimes n. musculocut.– Gammopathy, inflammation, PAN, leukodystr., amyloidosis
Others 2.
Brain biopsy• CT, MR-orient., tumor, lymphoma
Rectal, skin• Amyloidosis
Lactate-test• metab. myopathia, anaerob glycogenolysis, glycolysis
• before and after effort (3-4 x), – aldolase, kreatinkinase, myoglobin
Others 3.
• Hormones• GH, FSH, LH
• Neuronspecific enolase• If 30 ng/ml poor prognosis
• Antineural AB• Paraneoplasia
• Tumormarkers• Ach-Receptor AB
– Myasthenia
Hypnoid type of disturbance ofconsciousness
Either brain stem or Diffusecorticaldamage or both
Grades
• Somnolent
• Stupor
• coma
Glasgow Glasgow comacomascalescale(3(3--15)15)
EyeEyeopeningopening11--44
Motor Motor responseresponse11--66
VerbalVerbal responseresponse11--55
5. Brainstem
HyperglychypercapniaUremiaHyperammonhyperosmol.Hypernatr.Hypercalc.hyperthermia
Hypoxiahypoglyc.Hyponatr.Hypocalc.hypothermiaendocrin
2.Extracorporal non-traumaticfactors
bact. viral inf.drugs, toxins
•Basilar artery occlusion
1.Trauma?)
4. Large focallesion only if(!) space occupyingeffect
•tumor
•Ischemia
•bleeding
3. Dysequilibrium ofhomeostasis/metab.
Supratentorial
Infratentorial
CausesCausesofof disturbancesdisturbancesofofhypnoidhypnoid typetype ifif consciousnessconsciousness
Hunt and Hess Classification(*1) of Subarachnoid Hemorrhage
Grade Description Periop. mortality (%) *2Prob of survival (%) *30 Unruptured aneurysm1 Assympto-matic, or mild headacheor nuchal rigidity 0-5 902 CN palsy, moderate or severe headache or nuchal rigidity2-10 753 Mild focal deficit, lethargy, or confusion 10-15 654 Stupor, moderate or severe hemiparesis, early decerebrate posturing 60-70 455 Coma, decerebrate posturing, moribund 70-100 5
Non-hypnoid types of disturbance ofconscioussness
• Locked in: corticospinal and corticobulbar pathwaysintact vertical
• Apallic synd.: intact brain stem, cortex damage, openedeyes
• Akinetic mutism : frontal lobe/ efferent pathways. Lackof motivation
• Delir
• Amentiform syndr.: desorientation + halluc.
Brain death
• Complete and irreversible lack of brain functions rostalfrom foramen magnum
• Diagnosis:• coma
• lack of motor functions (no seizure, no spasticity or rigor)
• general muscle hypotony
• lack of pupil, corneal, vestibular, pharyngeal, palatal refl.,
• no response to caloric stimul.
• Doll’s head phenomen. Diabetes insip.
• Missing rhytm. of body temperature
• lack of heart and vasomotor regulation (apnoe test)
Low back pain
• Low back pain– No irradiation– No Lasegue sign– No reflex abnorm. Paresis or sensory abnorm.
• Sciatic pain or lumboischialgic pain– Lasegue positive– Irradiating painBut no reflex abnorm. and no dermatomal sens. deficit
• Disc herniation– Clinically:
• reflex abnormality• Dermatomal sensory abnorm• Paresis
– Imaging:CT or MRI
Diagnosis in stroke
From blood•BSR, counts•glucose, ions•hemostasis•lipids, •Immunological(in youngs)
Heart
Functional•BP monitoring•ECG•Holter ECG•TTE, TEE
Morphological•TTE•X-ray•TEE
TEE
Carotid, vertebral•Ultrasound•CTA•MRA•DSA
Brain imaging•CT-CTAg•MRI
•Diff. WI•Perf. WI
•TCD•Angiogr.(DSA, MRA)•SPECT, PET
Primérvasc. prev. !
•age•obesity•HT•diabetes•Lipid•AF•CEA
MI
PAD
stroke
Risk estimation Clin Second prevevent
Vascular Risk Factors• Conditions and lifestyle characteristics identified as a
risk factors for strokeHigh blood pressure High Cholesterol
Atrial fibrillation Diabetes mellitusSmoking
Carotid artery disease Heavy alcohol use
Myocardial infarction Physical inactivity
Obesity
TIA
• transient
• minutes
• Max. 24
Emergency!!!
High probability
• ischemia:– Risk factors,
– carotid bruitj,
– morning, intact consiousness ,
– RR slightly elevated. Breath OK
• bleeding– HT
– Dailly activity
– Severe sypmt, plethora
– sleepy
• embolia• sudden
• L-r hemisph.
• heart
80%hemiparesis
-upper?-lower?
-Hemihypaesth-visual field-deviating tongus- fold-outward rot.-aphasia?
20%-vertigo-gait dist.-dysarthria-diplopia-swallowing-paresis
iv.Time window for 0.9 mg/kg t-PA lysis3 h (recently 4.5 h)
(Lancet 2004; 363: 768-74)
percek
Sik
er v
alós
zin
sége
2,0
2,5
3,0
3,5
4,0
1,5
1,0
0,5
060 90 120 150 180 210 240 270 300 330 360
4 9 21 45
Number needed to treat
(2 in 60‘)
60’ 2!!
Optimal lysis candidates
• Intact consciousness
• Medium severity sympt.
• No accomp. Disease
• Within 3 h recently 4.5 h (but ASAP)
General Stroke Treatment
� Intermittent monitoring of neurological status, pulse, blood pressure, temperature and oxygen saturation is recommended for 72 hours in patients with significant persisting neurological deficits
� Oxygen should be administered if sPO2 falls below 95%
� Regular monitoring of fluid balance and electrolytes is recommended in patients with severe stroke or swallowing problems
General Stroke TreatmentRecommendations (2/4)
� Normal saline (0.9%) is recommended for fluid replacement during the first 24 hours after stroke
� Routine blood pressure lowering is not recommended following acute stroke
� Cautious blood pressure lowering is recommended in patients with any of the following; extremely high blood pressures (>220/120 mmHg) on repeated measurements, or severe cardiac failure, aortic dissection, or hyper-tensiveencephalopathy
General Stroke TreatmentRecommendations (3/4)
� Abrupt blood pressure lowering should be avoided
� Low blood pressure secondary to hypovolaemia or associated with neurological deterioration in acute stroke should be treated with volume expanders
� Monitoring serum glucose levels is recommended
� Treatment of serum glucose levels >180mg/dl (>10mmol/l) with insulin titration is recommended
General Stroke TreatmentRecommendations (4/4)
� Severe hypoglycaemia (<50 mg/dl [<2.8 mmol/l]) should be treated with intravenous dextrose or infusion of 10–20% glucose
� The presence of pyrexia (temperature >37.5°C) should prompt a search for concurrent infection
� Treatment of pyrexia (>37.5°C) with paracetamol and fanning is recommended
� Antibiotic prophylaxis is not recommended in immunocompetent patients
Secondary stroke prevention
1. AP • asp+DP> Aspirin, clopidogrel
2. HT • ACE inhib with or without
diureticum• E.g.Perindopril+indapamide
3. statin4. AF:anticoagulation INR 2-35. Carotid stenosis
70-99% TIA és minor stroke
6. CEA preferred