Neurological Disorders Cerebral hemispheres Brainstem ...
Transcript of Neurological Disorders Cerebral hemispheres Brainstem ...
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Neurological Disorders
Neurological Disorders
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Cerebral hemispheresBrainstem & Cerebellum
Spinal CordSpinal and Cranial
Structural Organization
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Nervous System Function
Brain: Central Processing Unit
Sensory Inputsafferent
efferent
Secretion Movement
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Sensory Tracts
dorsalanterolateral
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Dorsal column ipsilateral until
medulla, then crosses
sensation is well localized
touch, vibration, pressure,
Major Sensory Tracts
Anterolateral (Spinothalamic) crosses
immediately in the cord
sensation is poorly localized
itch, pain, temp
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Medial Tracts some tracts
cross at medulla, some don’t
innervates axial muscles
balance, gross motor
Major Motor Tracts
Lateral Corticospinal crosses at medulla innervates distal
muscles fine motor control
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How Do Neurons Communicate?
dendrite
axon
axonterminal
synapse
postsynapticneuron
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Acetylcholine
Amines (DA, NE, E, 5HT, histamine)
Amino acids (glutamate, GABA, glycine)
Purines (adenosine)
Gases (nitric oxide)
Neuropeptides (Sub P, endorphins, AII, oxytocin, many others)
Neurotransmitter Classes
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Head Trauma / Bleeds
Focal: localized
Polar: acceleration-deceleration
Diffuse: widespread disruption
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Determinants of Intracranial Pressure
Three space occupying components Brain CSF Blood
Compensation for Increased ICP CSF shunt to spinal cord Hyperventilation leading to vasoconstriction
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Causes of Increased ICP
Brain infection
Rupture of blood vessels
Hydrocephalus
F & E imbalances
Head Injury – most common
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Types of Injury
Primary injury
Secondary injury
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Ischemia
ATP deficiencyRelease ofglutamate
“excitotoxin”
Na+, Ca++ in cell
Activation ofphospholipases
mitochondriadysfunction
free radicalsprostaglandinsthromboxanes
cell damagevasospasmplatelet plug
Pathophysiology of Secondary Injury
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Compensation for Increased ICP
Brain Swelling
CSF shunted to spinal cord
CSF in brain ventricles
ICP
ICPHyperventilation
PaCO2
Cerebral vasoconstriction
Blood in brain
ICP
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Progression of S/S of Increasing ICP
Mild to moderate
Moderate to severe
Severe
Headache, LOC, projectile vomiting, localized pain, decorticate posturing
Pupil changes, hyperventilation, decerebrate posturing, seizures
Loss of respiratory control, apnea
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Progression of S/S of Increasing ICP
Severe
Severe
Respiratory arrestFlaccidityIschemic response
Brain deathNo spontaneous respirations/3 minutesFixed pupilsFlat EEG
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Ischemic Response “Cushing’s Reflex”
Increased blood pressure
Wide pulse pressure
Decreased heart rate
Loss of respirations
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Assessment of Brain Function
Level of Consciousness: ABCs
Manifestations of increased ICP headache, vomiting, pupil reactivity
Glasgow Coma Scale Eye Opening Best Motor Response Verbal Response
CT scan
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General Therapy for Increased ICP
Elevate HOB
Diuretics
Sedation
Hyperventilation
Decompression
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Classification of Head Injury
Concussion
Contusion
Brainstem Contusion
Hemorrhage
* Epidural * Subdural
- acute - subacute/chronic
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Intracranial Bleeds
skull
dura
arachnoid
epiduralbleed
subduralbleed
subarachnoidbleed
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CVA: Stroke
Thrombotic atherosclerosis, assess carotids > age 50
Embolic atrial fibrillation, valvular disease, hyper-
coagulable states
Hemorrhagic structural anomalies hypertension
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Stages of Thrombotic Stroke
Transient ischemic attacks (TIAs)
Stroke in evolution
Completed stroke
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Manifestations of Stroke
Acute focal neurological signs may rapidly change (evolve) depends greatly on area of brain damage
Transient Ischemic Attack (TIA) signs and symptoms resolve quickly no permanent loss of function
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Stroke: Ischemic vs Hemorrhagic?
TIA: give ASA refer for carotid assessment
Stroke: Get CT scan immediately
Ischemic: evaluate for tPA (within 3 hours) embolic and thrombotic
Hemorrhagic: Neurosurgical consult
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Chronic Manifestations of Stroke
Contralateral hemiplegia
Ptosis
Homonymous hemianopsia
Neglect
Aphasia
Loss of bowel and bladder control
Emotional Instability
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area of strokedamage
right visualfield
left visualfield
left visual field blindness
Homonymous Hemianopsia
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General Therapy for CVA
Get to a Brain Trauma Center
Prevention
Manage high blood pressure
Anticoagulation
Rehabilitation
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Alzheimer Disease
Dementia (deterioration of mentation) about 70% Alzheimer type others are multi-infarct type (vascular)
Manifestations (JAMICO) judgment -confusion affect -orientation Memory Intellect
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Pathology of Alzheimer Disease
Genetics VS Environment Apo-E gene toxins, viruses, aluminum
Pathological Findings (at autopsy) amyloid plaques neurofibrillary tangles cerebral atrophy and large ventricles
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Alzheimer Disease
Diagnosis of Exclusion rule out other, potentially treatable causes
MRI brain atrophy, enlarged ventricles
Poor mental function Mini Mental State Exam
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Seizures
Partial
Simple (no LOC)
Complex ( LOC) Secondarily generalized
Generalized
Absence (Petit Mal)
Tonic-Clonic (Grand Mal)
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Upper vs Lower Motorneuron
UMN
Reflexes Increased Decreased
Atrophy No Yes
Muscle tone Spastic Flaccid
Fasciculations No Yes
LMN
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Upper Motor Neuron Disorders
Stroke/Head Injury
Cerebral Palsy
Huntington’s Chorea
Parkinson’s Disease
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Localization of Motor Dysfunction
Reflexes Deep tendon reflexes (cord reflexes) Babinski (corticospinal tract)
Strength focal vs general ipsilateral vs contralateral spasticity vs flaccidity
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Parkinson Disease
Etiology unknown, possibly neurotoxin
– some suspect pesticide exposure
– MPTP cases of Parkinson-like syndrome
Pathogenesis Low dopamine level in basal ganglia Excessive action of acetylcholine Disease process is progressive
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Manifestations of Parkinson Disease
Classic Triad (unilateral --> bilateral) Akinesia Rigidity Resting tremor
Associated Manifestations Propulsive gait - Poor speech quality Masklike face - 30-50% have dementia Drooling
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Features of Parkinson disease
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Management of Parkinson Disease
Drug Therapy is controversial
Restore Dopamine / Ach balance MAOI (selegiline) Amantadine (Symmetrel) Levodopa, carbidopa (Sinemet) anticholinergics (Cogentin, Artane)
Surgical Techniques adrenal medulla tissue transplants
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Brainstem and Spinal Cord Disorders
Multiple Sclerosis
Poliomyelitis
Spinal Cord Injury
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Multiple Sclerosis
Etiology Autoimmune attack on CNS myelin
Pathogenesis Immune injury to myelinated neurons Sclerotic plaques noted on MRI Demyelination disturbs neuron conduction Extremely variable course and presentation
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Presentation of MS
Usually relapsing remitting pattern paresthesias gait disturbance leg weakness vision loss (optic neuritis) double vision arm weakness vertigo
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Diagnosis and Treatment
Suspect with episodic neurologic deficits in 20-40 age group especially Northern European
MRI lesion is diagnostic
Treatment: symptoms Beta interferon may decrease frequency of
attacks Immune suppression
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Transection of Spinal Cord
Spinal Shock (lasts 2-8 weeks) loss of spinal cord reflexes below injury
– flaccidity
– decreased vascular tone - hypotension
– atony of bowel and bladder
Autonomic Dysreflexia reflex activation of sympathetic neurons
below level of injury
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Autonomic Dysreflexia
stimulus(full bladder)
Reflex vasoconstrictionbelow level of injury
Increased bloodpressure
Baroreceptor Response
bradycardiavasodilate above SCI
xCan’t get signal to vesselsbelow injury
hypertension
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transection of lateral cord
Contralateralmotor?sensory?
Ipsilateralmotor?sensory?
Q: What Pattern of Sensory-Motor Impairment Would Occur?
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Lower Motor Neuron Disorders
Bell’s Palsy
Guillian Barre’ Syndrome
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Guillain Barre’ Syndrome
Most common cause of acute flaccid paralysis
Presentation: Back leg pain progressing to weakness decreased DTRs Hx viral infection esp. mono preceding decreased nerve conduction velocity
Hospitalize, plasmapheresis, IgG
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YYY
Disorder of Neuromuscular Junction
Myasthenia Gravis 80%-90% have anti-receptor antibodies 75% have abnormal thymus
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Myasthenia Gravis
Presentation: NM fatigue which worsens with activity: eye droop, diplopia, head droop, jaw dropping
No loss of reflexes, no change in sensation
Respond to edrophonium (fast acting anticholinesterase)
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Muscle Disorders
Muscular Dystrophy
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Disorders of Hearing
Conductive hearing loss otosclerosis otitis media
Sensorineural hearing loss Presbycusis Menière Disease
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Disorders of Vision
Errors of Refraction myopia, hyperopia, presbyopia
Cataract
Retinal detachment
Glaucoma increased intra-ocular pressure
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Open Angle Glaucoma
fluid
clogged canal of Schlemm
IncreasedanteriorchamberIOP
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Closed Angle Glaucoma
fluid
plugged canal of Schlemm when pupil dilates (acute)
IncreasedanteriorchamberIOP
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Open and Closed Angle Glaucoma
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Sensory dermatomes
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Pain Transmission
Gate Theory
Uses the analogy of a gate to describe how impulses from damaged tissues are sensed in the brain.
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Pain Transmission, con’t.
Tissue injury stimulates the release of:
* Bradykinin * Histamine * Potassium * Prostaglandins * Serotonin
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Pain Transmission, con’t.
“A” Fibers
* myelin sheath* large fiber size* conduction is fast* inhibits pain transmission* Sharp & well- localized
“C” Fibers
* no myelin sheath* small fiber size* conduction is slow* facilitates pain transmission* dull & non-localized
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Pain Transmission, con’t.
Types of pain are related to the proportion of
“A” to “C” fibers
in the damaged tissue.
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Pain Transmission, con’t.
These two pain fibers enter the spinal cord at the dorsal horn and travel up to the brain.
This is the location of the GATE
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Pain Transmission, con’t.
The gates regulate the flow of sensory impulses to the brain!
If the gate is closed – no impulses get through. Therefore no impulses are transmitted to the higher centers in the brain so there is no perception of PAIN!
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Pain Transmission, con’t.
It’s the large, activated “A” fibers that
closes the gate
and this will inhibit transmission to the brain and limits perception of
PAIN!
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Pain Transmission, con’t.
It’s the small, activated “C” fibers that
opens the gate
and this will allows transmission to the brain and causes perception of
PAIN!
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Pain Transmission, con’t.
Nerve fibers from the brain innervate the GATE and allow the brain some control over the GATE….in that the brain can:
* evaluate the pain * identify the type of pain * localize the pain
This also allows the brain to control the GATE before the gate is open.
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Pain Transmission, con’t.
Along with the “A” and “C” fibers, there arespecialized cells that control the GATE – these are the “T” cells, which have a threshold…meaning that impulses must overcome the threshold in order to be sent to the brain.
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Pain Transmission, con’t.
Body produces endogenous neurotransmitters:
* Enkephalins & Endorphins
They are produced by the body to: (1) fight pain (2) bind to opioid receptors (3) inhibit transmission of pain impulses by closing the GATE.
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Measures to Close the GATE
Rubbing the painful area(this inhibits the large “A” sensory fibers
Give the opiates to close the GATE(this will reduce recognition of pain)
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Hang in there – just one more week!!