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8/14/2019 Balamurugan Neuro Diagnostic
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Neuro-diagnostic
procedure
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Uses :As an adjunct to a complete clinical
examination. To evaluate the effectiveness of
various treatment modalities.
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1.History /physical examination2.Radiographic studies
skull radiography• Spine radiography• Computed tomography• Magnetic resonance imaging• Cerebral angiography• Myelography
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3.Cerebro spinal fluid evaluation4.Biophysical studies•
Carotid Doppler imaging• Transcranial Doppler imaging5.Electrophysiologic studies• Electro encephalography
• Electromyography• Evoked potential studies
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6.Nuclear medicine testingPositron emission tomography
7.Special sense testingCaloric testingAudiometric studiesVisual field testing
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HistoryPhysical examination
Cerebral function testCranial nerve testMotor function test
Sensory function test
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Now a days very rare
because of CT .Findings Presence of fracture Displacement of
pineal body
Sinuses Hematomas
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Radiography of specific region of spine areusually ordered in traumatised patients
Usually AP,oblique,and lateral views are ordered
FindingsVertebral fracture Traumatic dislocationSublaxationCollapsed vertebra,scoliosis,spondylosis
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Patient preparationHelp to reduce anxiety
Neck stabilization with cervical collarin case of suspected injury
Patient mouth open for C1 andC2Downward traction of arms for C6
andC7Flexion and extension views
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Post procedure care Immobilization
Patient neurologic status should bereassessed
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It uses a narrow X-ray beams to scan thehead in successive layer
The images provide cross sectional views
of brain with distinguishing difference intissue density of skull, cortex, sub corticalstructure and ventricles.
The patient lies on a table and moved in
and out of a dougnut like device calledgantry The image is photographed and stored
digitally
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Can be done with contrast or plain CT IndicationDetect brain infection like abscessDetect ventricular enlargementDetermine any tumourDetermine multiple sclerosis
Determine the size and location of lesioncausing a stroke
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Differentiate among hematomaContra indication
Patient allergic to shell fish oriodinated dyePatients who are claustrophobicPatients who are pregnantPatient with dehydration
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Pre procedure Inform and consentObtain history of allergiesRecord the date of last menstrual period
Obtain list of medication in useExplain about duration 30-60 minutes
explain about insertion of IV line Inform about experience of nausea
,feeling of warmth, a salty metallic tasteor transient headache
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Instruct the patient to remove jewellery,dentures etc
Intra testEnsure that the patient has compiled
with pretesting preparationHave emergency equipment readily
available administer orderedprophylactic steroids or anti histaminebefore procedure
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Instruct the patient to cooperate and remainstill throughout the procedure
Establish an IV line
Administer anti anxiety drug when necessary If contrast medium is used contrast medium
is injected and a rapid series of images aretaken during and after filling of the vessel
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Post testMonitor for complication
Remove needle and apply pressureRenal function should be evaluatedMonitor vital signs and neurologic
function Instruct patient to increase fluid
intake
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Magnetic resonance imaging uses amagnet and radio waves to produce
a energy fields that can be displayedon an imageUse of magnetic fields with the aid of
radiofrequency energy produces
images primarily based on watercontent of tissue
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MRI produces cross sectional imagesof pathologic lesion of the brain in
multiple planes without the use of ionising radiationMRI can be done with contrast or
without a contrast agent
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IndicationLocate brain tumour
Detect cause of CVAEvaluate cerebral changesassociated with dementia
Evaluate demylenating disorderEvaluate intracranial infection
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Evaluate optic and auditory nerve evaluate the potential cause of
headache ,vomiting, visual lossEvaluate the vascularity of the brain
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Contra indicationPatient with metal prosthesis
, valves, aneurysm clips, ortho pedichard ware and other metallic objectsPatients with pace maker, cochlear
implantsPatients with IUD patients who are claustrophobic
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Preprocedure Inform and consent
Obtain history of allergic agentsObtain history of any implants Inform about duration of procedure
usually 30-60 minutes
Inform patient that he will be placedin supine position on a flat table in alarge cylindrical scanner
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Tell patient to expect to hear loudbanging from the scanner and flickeringlight in the visual field
Explain that an IV line may be inserted instruct the patient to remove
dentures, jewellery including watches,
hairpins, credit card and other metallicobjects
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Intra testEnsure that the patient has removed all
metallic objects prior to procedureHave emergency equipment readily availableAdminister prophylactic steroids or
antihistamine before the procedurePatient are given a gown and instructed to
void before the procedure Instruct the patient to remain still during the
procedure
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Supply ear plugs to patient to block out theloud , banging sound that occur during thetest
The patient can communicate with thetechnologist with he microphone attached
establish IV lineAdminister anti anxiety drugs
Contrast medium are injected and series of images are taken
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Post testObserve for delayed allergic reaction
Instruct the patient to reportimmediately symptoms like fastheart rate, difficulty breathing, skinrash, decreased urine output
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It is an X-ray study of cerebralcirculation with a contrast agentinjected into selected artery
IndicationVascular aneurysmArteriovenous malformation
Before craniotomyVascular blockage or other disruption
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Contra indicationPatients with allergic to shell fish or
iodinated dyePatient with bleeding disorder patient who are pregnant dehydrated patients renal failure
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Pre procedure Inform and consentObtain history of allergic agentsRecord the date of menstrual periodsObtain list of medication patient is
taking to affect bleeding
Review the procedure with he patientExplain about symptoms experienced
during contrast agent
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Intra testEnsure the patient is compiled with all
necessary restrictionHave emergency equipment availableEstablish IV line The location of appropriate peripheral
pulses are done Instruct patient to remain still during
procedure
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Encourage to increase fluid intake ice packs to be applied to reduce
edema Immobilise extremity for 6-8 hoursObserve for delayed reaction of dye
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Lumbar puncture is a procedure thatinvolves the introduction of a hallow
needle and stylet between twovertebrae into sub arachnoid space of the lumbar part of of the spinal canal
below the level of spinal cordPurposeDiagnostic Therapeutic
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IndicationCSF measurementWith drawl of CSF to reduce Increased
ICPEvaluation of canal for the presence of
of CSF blockage or tumour
Evaluation of signs of haemorrhageLab analysis of CSF for infection Therapeutic administration of drugFor spinal anaesthesia
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Pre procedure Inform and consent
review the procedure with thepatientNo dietary restriction is requiredBase line neurologic examination Inform patient about the position Inform to void
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position on one side of edge of bed wth backfacing towards physician ,thighs ang legs flexedas much as possible
Pillow is placed under patient head to maintainthe spine in horizontal position The nurse must assist in maintaining position The area of L4-L5 is prepared with iodine or
alcohol and covered with sterile drapes
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a imaginary line is drawn from tip of illiac crest to help locate site
Aesthetic agent is injected ,afterwhich a spinal needle with obturatoris inserted below fourth lumbarvertebrae
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Once the physician feels that the needle is insubarachnoid space the obturator is removed
Collect CSF in 3 vials separately
If pressure is to be measured a sterilemanometer is attached to spinal needle
Queckenstedt’ s testPost test
Apply pressure to the area for severalminutes and put a a sterile covering
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Some physician prefer patient onprone with a pillow in abdomen
Encourage intake of fluid and keeptheir head flat foe several hoursMonitor for vital signsActivity restricted for 6-8 hours
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Electroencephalography It is a non invasive study that
measures the brain activity andrecords that activity on a graph
Electrodes placed at 8-20 sites onthe patient scalp transmit different
frequency and amplitude of the brainelectrical activity to the EEG
machine
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IndicationDetect seizure activity and focusConfirm brain deathDetect cerebral ischemia during
endartectomyDetect intracranial cerebrovascular
lesionDetermine the presence of tumour evaluate sleep apnoea
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Inform and reassureObtain medication histroyExplain about the duration30-60
minutes and even days in VEEG Inform patient that he or she may be
asked to alter breathing, follow simple
commands like opening , closing,blinking or swallowing, stimulated withbright light or given drug to inducesleep
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Instuct patient to clean the hair and torefrain from using any hair spray
under medical supervision the patient
should avoid sedative,anticonvulsant,anxiolytics alcohol, andstimulants such as caffeine and nicotine
for 24 to 48 hours before the test Instruct patient to limit sleep to 5 hours
for adult and 7 hours for child the nightbefore the study
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Intra testEnsure pre procedure instruction are
followed
Ensure that the patient is able to relaxplace patient in supine position or in semi
recumbent position on a recliner in a specialroom protected from any noise or electrical
interference that could affect tracing
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Remind patient to relax and not to moveany muscle or parts of the face or head.
The eletrode are applied to scalp over
frontal,temporal,parietal and occipital lobeRecordings are made with the patientrest,drowsy,and sleep period based onpatient clinical condition
Procedures eg. Light stimulation,hyperventilation and sleep induction aredone
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Observation of seizure activity are carriedout during the study and description andtime of activity is noted by the technician
Post testClean the hairsAllow patient to recover from sleep, bed side
rails are put in the raised position for safety
Resume medication as ordered
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It measures the skeletal muscle activityduring rest, voluntary contraction andelectrical stimulation
Per cutaneous extracellular needleelectrode containing fine wires areinserted into selected muscle group to
detect neuromuscular abnormality andmeasure nerve and electricalconduction property of skeletal muscle
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Comparison and analysis of theamplitude ,duration, number andconfiguration of the muscle activityprovide diagnostic information aboutextent of nerve or muscleinvolvement in the detection of
primary muscle disease, includinglower motor neuron, anterior horncell, or neuro muscular junction
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Detect muscle disorder caused bydisease of lower motor neuroninvolving the nerve root such asgullian barre syndrome
Detect neuromuscular disorder likeperipheral neuropathy etc
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ContraindicationExtensive skin infectionPatients with anti coagulant therapy
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Intra test ensure that the patient has refrained from
smoking and drinking caffeine containing
beverages for 3 hours before the procedure have patient remove clothing, patients are givena gown to wear and instructed to void beforeprocedure
Ask patient to remain still and relaxed and to
cooperate with instruction
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Administer mild analgesic asordered to promote a restful statebefore the procedure
Cleanse skin with alcohol, thenectrode are applied to the skin
During the test muscle activity is
tested while the patient is at est andduring varying degree of musclecontraction
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Post testRemove electrodeMonitor electrode site fir bleeding
hematomaMild analgesic and warm compress
are applied
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It is a physiological studies performed tomeasure the brain electrical response tovarious visual, auditory and somato
sensory stimuli. EP studies help diagnoselesion of the nervous system by evaluatingthe integrity of visual, sensory and auditorynerve path ways
Three responses are measured visual evoked
response, auditory brainstem response,and somato sensory evoked response
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IndicationVERDetect retro bulbar neuritis detect lesion of optic nerve evaluate optic pathway lesion and
visual cortex defectsABRDetect abnormality in brain stem or
auditory nerve areas
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detect acoustic neuromaSERDetect multiple sclerosis and
gullianbarre syndromeDetect sensorimotor neuropathy and
cervical pathologies
Evaluate spinal cord and brain injuryand function
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Pre-test informReview the procedure with the
patientExplain the duration of procedure
30-2 hours instruct the patient to
clean the hairs and refrain fromusing any spray
No food restriction
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Intra testEnsure the patient is able to relax In VERpatient in comfortable position
about 1 meter from the stimulationsource attach electrode to theoccipital area. A light emitting
stimulation is provided
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In AER electrode are placed in scalp atvertex lobe area on each ear lobe. Earphone are placed in patients ears and a
clicking noise stimulus is delivered In SER electrodes are placed at nerve
sites of wrist,knee, and ankle
Post testRemove electrode and clean skin
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Positron emission tomography It combines the biochemical properties
of nuclear medicine with the accuracy
of computed tomographyPET uses specific nucleotide to produce
functional images of bodyAfter the radio nucleotide becomes
concentrated in brain, PET images of blood flow or metabolic process atcellular level can be obtained
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Commonly used radio nucleotide areflourine-18 in the form of flurodeoxyglucose, it is a glucose
analogue IndicationDetect parkinsons disease, huntingtons
diseaseDetermine the biochemical activity of the brain
Evaluate Alzheimer's disease
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Identify focal seizureContraindicationPregnancyPreprocedure InformObtain history of allergic agent
Review the procedure and explainabout the duration of the procedureusually 60-120 mt
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The patient should restrict food for 4hours; restrict alcohol, nicotine andcaffeine containing foods
Intratest Ensure the patient is compiled with
dietary regimen
Patient are given gown , foot coveringand instructed to void before theprocedure
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Instruct he patient to cooperate andremain still during the procedure
After radio nucleotide is injectedimages are taken after 30 minutes
The patient may be asked to performdifferent cognitive activities like
reading to measure changes in brainactivity
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The patient may be blindfolded orasked to use earplug to decreaseauditory and visual stimuli
Wear glove during injection and patientexcretaMonitor for any complicationPost test
Advise patient to report symptoms likefast heart rate, difficult breathing, skinrash, decreased urine output
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Instruct the patient to take increasedamount of water to increase theelimination of radio nucleotide
Instruct all care giver to wear glovefor 24 hour
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Carotid Doppler imaging It provides a non-invasive means for
monitoring intracranial
hemodynamic at bedsideDoppler imaging uses ultrasonic
technology to provide information
about patency of the carotid arteryUsed to assess the location and
extent of plaque and flow velocity
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Trans cranial Doppler It uses the same non-invasive
technique as carotid flow studiesexcept that it records the blood flowvelocities of intracranial vessel
Flow velocities of basal artery can be
measured through thin areas of temporal and occipital bones of theskull
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indication TIAs related to arteriostenosis or
with atherosclerosisCerebro vascular diseaseVasospasm secondary to
subarachnoid haemorrhage ,
following aneurysm clippingNursing implication Inform and educate
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Caloric testing for vestibular function It is used to evaluate the vestibular part of
eighth cranial nerve by irrigating auditory
canal with warm or cold water.Normal finding include rotatary nystagmus
away from the side being irrigated withcold water. Hot water conversely induces
nystagmus toward the side being irrigated
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In abnormal test result no nystagmus is produced.
Contra indicated in perforated ear drumPreprocedure Inform and explainNPO before 6-8 hours before the procedurePost procedure The patient should lie down until untoward
effects such as nausea, vertigo, resume diet.
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Audiometric studies Individual with injury to auditory branch of
eighth cranial nerve or hearing loss may be
reffered for a routine battery of audiologicstudies. The test include voice, tuning fork, a ticking
watch and a electronic audiometer to assess
the hearing loss.
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Visual field testing It is used to evaluate peripheral vision.Gross visual field testing may be performed
by means of confrontationFor more precise testing visual field are
evaluated by perimeter It is used to detect lesion of the retina or
optic nerve and hemianopia caused bycompression of optic tract
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UsesVarious classificationRadiographic studies
Cerebrospinal fluid analysisNuclear medicine testingBiophysical methodsElectrophysiological methodsspecial sense testing