Neurological Diseases1. Manifestations2. Cerebrovascular Diseases3. Inflammatory Diseases4. Degenerative Diseases5. Nerve and Muscle disease6. Infections of Nervous System7. Intracranial Mass lesions and Raised ICP

Cerebrovascular diseases• A 56 year old woman is bought to emergency

department by her daughter, complaining of SUDDEN ONSET of Right upper extremity weakness, that began while she was watching TV this morning. The daughter became concerned when her mother was unable to talk in response to her question. Neurologic examination shows Rt Upper extremity weakness with pronator drift with right facial palsy. When questioned, the patient seems to understand what is being said but cannot clearly respond.

Definition Of Stroke/CVA

• Sudden onset on focal neurological deficit• “A clinical syndrome consisting of rapidly

developing clinical signs of focal(or global in case of Coma) disturbance of cerebral function lasting for more than 24 hrs or leading to death with no apparent cause other than a vascular origin”

WHO• TIA (Transient Ischemic Attack) recovery is

complete within 24 hours. 10% of patients will go on to have a complete stroke.

Risk factorsModifiable• HTN• Smoking• Cardiac

– A. fib– Inf Endocarditis– Recent MI

• OCP• Carotid stenosis• Obesity • TIA • Sickle cell diseases

Potentially modifiable• DM• Hyperhomocystinuria

Non modifiable• Age- doubles the risk for

each decade after 55• Familial

Sub-types Of Stroke

• Ischaemic – obstruction to one of major cerebral arteries, brainstem strokes are less common.

• Haemorrhage – 9% are caused by haemorrhage to the deep parts of the brain. Patients are usually hypertensive.

Stroke Classification

• TACI (Total Anterior Circulation Infarct)• PACI (Partial Anterior Circulation Infarct)• LACI (Lacunar Infarct)• POCI (Posterior Circulation Infarct)

Classification• Infarction (85%)– Atherosclerosis (60%)– Non Atherosclerotic (40%)

• Emboli (50%)• Others (50%)

• Hemorrhagic (15%)– ICH(85%)

• HTN (70%)• AVM+Others (30%)

– SAH(15%)• Ruptured aneurysms (85%)• Idiopathic (15%)

Clinical presentations• Acute onset of focal neurological deficit• MCA occlusion:• Contralateral hemiplegia• Hemisensory loss• Homonymous hemianopia, eyes deviated

TOWARDS cortical lesion• Aphasia- Dominant hemisphere involvement• Preserved speech- nondominant hemisphere

involvement but comprehension with confusion, apraxia with spatial and constructional deficits

Clinical presentations

• ACA occlusion• Contralateral weakness + sensory loss in lower

limbs>upper limbs• Urinary incontinence• Confusion• Behavioral disturbances

Clinical presentations

PCA• Contralateral homonymous hemianopia• Visual hallucinations• Agnosias• If penetrating branches of PCA are occluded• CNIII palsy with contralateral hemiplegia (Weber

Syndrome) Or Contralateral ataxia or athetosis (Benedict

syndrome)

Investigations

• CT head– Noncontrast hemorrhagic and no hemorrhagic

stroke• Diffusion-weighted MRI• Other diagnostic workup ECHO, Duplex, 24 hr

Holter monitor, Blood glucose, ECG, Markers of cardiac ischemia, PT/INR, APTT, Oxygen saturation

• For selected patients- LFT, Toxicology scan, Blood alcohol levels, ABG, CXR, LP (SAH), EEG(Seizures)

Management

5 mainstays1. Treatment of general condition that needs to be

stabilized2. Specific therapy directed against particular

aspect of stroke pathogenesis3. Prophylaxis and treatment of complications-

neurological/ medical4. Early 2⁰ prevention5. Early rehabilitation

Treatment• TPA-If pt presents within 3 hrs• Aspirin- 1st line for 2⁰ prevention• Dipyridamole/ Clopidegrol is added with

antiplatelets if– Failed aspirin therapy/ Aspirin allergy

• Heparin (↓no of recurrent strokes-Afib/basilar artery thrombosis/stroke in evolution)

• ↓ rate of recurrent CVA/ Afib/2nd incidence• Carotid endarterectomy- When occlusion

exceeds 70% of arterial lumen

Contraindications for using TPA• Stroke/serious head trauma within three months• Hemorrhage(GI/ Genitourinary) within 21 days• Surgery within 14 days• H/O intracranial Hge• BP>185/110 mm of Hg• Recent use of anticoagulants• Platelets<100,000/mm³• Glucose>400mg/dl or <50mg/dl• Coagulopathy(PT>15 seconds)

!!Avoid

• Dextrose containing fluids in non-hypoglycemic patients

• Excessive reduction of BP• Excessive IVF

Cranial Nerve Major Functions

• I Olfactory smell• II Optic vision • III Oculomotor eyelid and eyeball

movement• IV Trochlear innervates superior

oblique turns eye downward and laterally

• V Trigeminal chewing face & mouth touch & pain

• VI Abducens turns eye laterally • VII Facial controls most facial

expressions secretion of tears & saliva taste

. VIII Vestibulocochlear (auditory) hearing equillibrium sensation

• IX Glossopharyngeal taste senses carotid blood pressure

• X Vagus senses aortic blood pressure slows heart rate stimulates digestive organs taste

• XI Spinal Accessory controls trapezius & sternocleidomastoid controls swallowing movements

• XII Hypoglossal controls tongue movements