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)

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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