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Statement of Intended Use/Disclaimers All informa,on, data, and material contained, presented, or provided in this program / presenta,on (“Informa,on”) is for general informa,on purposes only and solely the opinion of the authors and presenters. The Informa,on should not be construed or intended as providing personalized medical or legal advice. The Informa,on is not necessarily considered mainstream health care. It is leP to the discre,on and judgment and is the sole responsibility of the recipient of the Informa,on to determine if products, procedures, treatments, tests, and therapies described are appropriate for the client. Neither the speakers nor the sponsors of Func,onal Neurology Seminars can be held responsible for the Informa,on, opinions, or any inadvertent errors or omissions in the prepara,on or presenta,on of the Informa,on. The Informa,on should not be construed as a claim regarding any procedure, treatment, therapy, test, or product. It is the sole responsibility of the recipient of this Informa,on to comply with local, state, and federal laws regarding the use of such Informa,on, as it relates to the scope and type of user’s prac,ce. It is the concern of the Department of Health and Human Services that no homeopathic and/or nutri,onal supplement be used to replace established, conven,onal medical approaches, especially in cases of emergencies or serious or life-‐threatening diseases, or condi,ons. Func,onal Neurology Seminars shares in this concern, as replacing conven,onal treatment with homeopathic and/or nutri,onal supplements, especially in serious cases, may deprive the client of necessary treatment thereby causing harm and could also pose a major legal liability for the healthcare professional involved. The Informa,on has not been evaluated by the Food and Drug Administra,on. Any nutri,onal product or procedure reported in this presenta,on is not intended to diagnose, treat, cure, or prevent disease. Various forms of care described in the FNS seminar series should not be used to replace conven,onal neurological care or replace other forms of medically necessary care. Dr. Da,s Kharrazian has the following financial interests. He is a member of Apex Energe,cs, Inc.'s Scien,fic Advisory Board, is a paid consultant to Apex Energe,cs, and receives royal,es on the sale of DVDs and CDs. Dr. Kharrazian is also a member of the editorial board of the Journal of Func,onal Neurology, Rehabilita,on, and Ergonomics. He receives no financial compensa,on for his par,cipa,on on this board. Dr. Kharrazian serves on the Curriculum Advisory Commi\ee of the Ins,tute for Func,onal Medicine. He receives no financial compensa,on for his par,cipa,on on this commi\ee. Dr. Brock has the following financial interests. Dr. Brock is a paid employee of Cerebrum Health Centers and owner and operator or Drbrocklectures.com and does consul,ng work for various clinics. Dr. Brock is a paid instructor for the Academy of Osteopathic Science, unpaid vice president of the Interna,onal Associa,on of Func,onal Neurology and Rehabilita,on, unpaid member of the human council of human func,on and an unpaid board member of the American Associa,on of Integra,ve Medicine. Dr. Brock is a paid lecturer for Apex Energe,cs. Dr. Brock has been engaged as an industry expert by Moleculara Laboratories to assist in the development of educa,onal lectures and to educate healthcare prac,,oners in its technology and the applica,on of its tes,ng. As such, he receives commissions from Moleculara as permi\ed by and in compliance with federal and state laws, codes and regula,ons, including Stark and other an,-‐kickback provisions. He is not an employee of Moleculara and does not own any stock. Dr. Kharrazian has been engaged as an industry expert by Cyrex Laboratories, LLC to assist in the development of clinical assays and to educate healthcare prac,,oners in its technology and the applica,on of its arrays. As such, he receives commissions from Cyrex as permi\ed by and in compliance with federal and state laws, codes and regula,ons, including Stark and other an,-‐kickback provisions. He is not an employee of Cyrex and does not own any stock. All marks and their use are thereby duly governed by the respec,ve owners and any and all rights in connec,on with those marks are en,rely reserved. The presenter receives a speaker’s fee and is reimbursed for his/her travel and related accommoda,ons by the sponsor, Apex Energe,cs, Inc. Dr. Kharrazian nor Dr. Brock have any financial interests in Laboratory Corpora,on of America, Quest Diagnos,cs, Incorporated, Diagnos-‐Techs, Inc., Principal Lab, Inc, Metametrix, Inc., Metabolic Solu,ons Development Company, LLC, Immunosciences Lab, Inc., RealTime Laboratories, Inc., Direct Laboratory Services, Inc., or Genova Diagnos,cs or other labs men,oned in this series other than those listed in this disclaimer.
2
Dr. Da,s Kharrazian DC, DHSc, DACNB, DABCN, FACN, CNS
Dr. Da,s Kharrazian is an Associate Clinical Professor at Loma Linda University School of Medicine. He has contributed significantly to the field of func,onal neurology as an educator, author, and researcher. He is credited with integra,ng the func,onal medicine model with rehabilita,ve neurology to evolve the specialty into a more comprehensive treatment model of brain dysfunc,on. He developed several post-‐graduate programs, protocols, examina,on forms, and ques,onnaire forms in the field of func,onal neurology that are being been used by thousands of health care professionals. His peers at the first Interna,onal Associa,on of Func,onal Neurology and Rehabilita,on (IAFNR) annual mee,ng recognized him with the “Clinical Trailblazer” Award for his contribu,on to evolving the field of func,onal neurology. He has also received numerous accolades for his development of func,onal medicine programs. He is the author of the best-‐selling book, Why Isn’t my Brain Working? This book has received hundreds of posi,ve tes,monials and five star reviews from readers throughout the world and is being translated into several other languages. Many reviewers have called his book the most complete and innova,ve compila,on of work for func,onal neurology nutri,onal concepts. Dr. Kharrazian teaches neuroscience and human brain dissec,on at Bastyr University California and is an Adjunct Professor at Na,onal University of Health Sciences, where he is developing post-‐graduate programs in func,onal neurology. He has developed a 30-‐part Neuroendocrine-‐Immune Series and a Mastering Brain Chemistry course that has been taught to thousands of health care professionals throughout the country and approved by the University of Bridgeport Postgraduate Department. Dr. Kharrazian is also a faculty member of the Ins,tute for Func,onal Medicine (IFM) and supports program development in func,onal medicine, func,onal neurology, neurological physical examina,on, and neurology diagnos,c applica,ons to brain-‐based disorders. The IFM provides medical physicians with con,nuing medical educa,on credits required for physician re-‐licensure and is accredited by the Accredita,on Council for Con,nuing Medical Educa,on. Dr. Kharrazian is a Fellow of the American College of Nutri,on, a Diplomate of the Board of Nutri,on Specialists, A Diplomate of the American Chiroprac,c Neurology Board, and a Diplomate of the American Clinical Board of Nutri,on. He earned a Master of Science degree in Human Nutri,on from the University of Bridgeport, a Doctor of Health Science from Nova Southeastern University, and a Doctor of Chiroprac,c degree from Southern California University of Health Sciences. He is currently comple,ng his Ph.D. degree at Nova Southeastern University with doctoral research in autoimmunity and immunology. Dr. Kharrazian completed a one-‐year post-‐doctorate clinical scholar research program at Harvard Medical School and is an associate alumni member of Harvard University and Harvard Medical School. He has published several scien,fic papers in the fields of nutri,on, autoimmunity, toxicology, and is conduc,ng research in autoimmune molecular mimicry and environmentally induced immune reac,vity. He is on the scien,fic editorial board for the Journal of Func,onal Neurology, Rehabilita,on and Ergonomics and Alterna,ve Medicine Therapies in Health and Medicine. He is also is a requested scien,fic reviewer for several scien,fic journals, including the Bri,sh Journal of Medicine and Medical Research. In addi,on to his contribu,on to func,onal neurology, Dr. Kharrazian has wri\en numerous papers, manuals, and clinical educa,onal material for blood chemistry analysis, hormone and endocrine analysis, complex immunology tes,ng, gastrointes,nal analysis, and func,onal medicine. He has trained more than 20 doctors to teach his model of func,onal medicine throughout the country. Dr. Kharrazian’s approach and clinical model are taught at more than 200 loca,ons each year. Dr. Kharrazian is also the author of the best-‐selling book, Why Do I S,ll Have Thyroid Symptoms When My Lab Tests are Normal? This book led readers to develop of the largest Hashimoto’s community (Hashimoto’s 411) on Facebook, and the development of a non-‐profit pa,ent advocacy group (Hashimoto’s Awareness) to support thyroid pa,ents from around the world. Dr. Kharrazian serves on the Nutri,on Leaders Council. This is an en,ty that directly contributes to the Accredita,on Council for Nutri,on Professional Educa,on, ACNPE (university nutri,on program accredita,on), Board for Nutri,on Specialists, BCNS, (creden,aling Body and Advocacy), and the American Nutri,on Associa,on, ANA (educa,onal and advocacy organiza,on). Dr. Kharrazian is a consultant to the nutri,on industry and has formulated more than 100 products, which are used by health care professionals. He also serves as a consultant to Cyrex Laboratory, where he provides expert clinical opinion on the development of complex immunology profiles. Dr. Kharrazian has a private prac,ce for pa,ents from around the world seeking non-‐pharmaceu,cal alterna,ves to manage chronic condi,ons. He uses diet, nutri,on, neurological rehabilita,ve exercises, and lifestyle applica,ons in his protocols. His prac,ce has a two-‐year wai,ng list and is limited to pa,ents suffering from chronic condi,ons. Most of Dr. Kharrazian’s pa,ents are referred from other health care professionals both na,onally and interna,onally. As an educator, researcher, and clinician, Dr. Kharrazian has blended his scien,fic research with clinical experience to develop effec,ve concepts and applica,ons for complex health disorders, which have been used by thousands of health care professionals and pa,ents around the world.
3
Dr. Joel Brandon Brock MSN, BSN, RN, DC, NP-‐-‐C, DCM, DCN, DAAIM, BCIM, DCBCN, DACNB, FACNB, FICC
Dr. Brandon Brock is a Cer,fied Family Nurse Prac,,oner, Chiropractor and a func,onal neurology diplomate with mul,ple clinical interests, including Func,onal Integra,ve Neurology. In Dallas Texas he serves as a staff clinician at Cerebrum Health Centers and does work at Innova,ve Health and Wellness Group and Founda,on Physicians Group. Along with being a clinician, Dr. Brock has a passion for lecturing and providing learners with didac,c and academic skills in a way that is easy to digest, comprehend and u,lize in a clinical sehng. He has developed thousands of mul,disciplinary hours of curriculum that he or others have presented pertaining to neurology, nutri,on, physical diagnosis, pharmacology, immunology, endocrinology, and this has impacted students of mul,ple educa,onal and clinical backgrounds, including medical doctors, nurse prac,,oners and chiropractors. Offering educa,onal support for Physical and Occupa,onal Therapists, Die,,ans, Naturopaths, Acupuncturists, Oriental Medical Prac,,oners, Health Coaches and lay people that want to learn how to live a healthier life is also part of Dr. Brock's mission. He enjoys teaching for Apex Energe,cs as well as providing educa,on and support to facilitate learning for mul,ple groups and agencies. This includes state associa,on mee,ngs to governmental panels. Dr. Brock is also enjoying the process of developing in part his own func,onal neurology program (Func,onal Neurology Seminars), and short educa,onal lectures that many healthcare and medical providers can learn from over a variety of topics. Dr. Brock is currently a clinical lecturer of Pharmacology at the Ins,tute of Healthcare Professions, clinical neurology lecturer at the Academy of Osteopathic Science and vice president of the Interna,onal Associa,on of Func,onal Neurology and Rehabilita,on (IAFNR) and a board member of the American Academy of Integra,ve Medicine (AAIM). He was recently chosen as a member for the Council of Human Func,on and has been an expert on TAP Integra,ve. Dr. Brock received the most outstanding func,onal neurology teacher of the year from the ACA council of Neurology four years straight and two ,mes from IAFNR (Interna,onal Associa,on of Func,onal Neurology and Rehabilita,on). This year Dr. Brock received the humanitarian award as a result of his research on injured Military Veterans and PTSD and trauma,c brain injury from IAFNR. Dr. Brock is also the honorable recipient of the pres,gious Living Legacy Award from Samford Universi,es Ida Moffe\ School Nursing in 2015 and he was recently named the spotlight student of his doctoral program at Duke University. He holds diplomate status in Neurology, Conven,onal Medicine, Nutri,on, Integra,ve Medicine and a fellowship from the Interna,onal College of Chiropractors as well as the American Chiroprac,c Neurology Board. Currently Dr. Brock is working on a Doctorate of Nursing Prac,ce from Duke University and he is planning on immediately upon comple,on of the program at Duke, star,ng a conjoined PhD program with a major in nursing and a minor in behavioral neuroscience. Dr. Brock’s unique blend of clinical and teaching experience along with a background in medicine, chiroprac,c, neurology and nutri,on has created a very unique clinical background that has helped him treat difficult cases and offers comprehensive and mul,-‐-‐-‐perspec,ve angles on educa,on and clinical presenta,ons. Ul,mately you can typically find him spending ,me with his new wife Tara or his children, Addy, Zoey, Kennedy and Conner. They all love to travel, read, learn and live life. Dr. Brock's wife is a fantas,c English teacher at Sunnyvale High School and Dr. Brock points out that his wife Tara is the best and most grounded thing in his life, along with his kids, co-‐workers and friends.
4
Picture
Cerebral Angiograms
How Can You Use Collateral Vasculature to Support This Region?
How Can You Use Collateral Vasculature to Support This Region?
How Can You Use Collateral Vasculature to Support This Region?
Cerebral Artery Syndromes and
Clinical Presentations
Internal Medicine Journal
2005; 35: 263–266
P
ERSONAL
V
IEWPOINT
– C
LINICAL
T
IPS
The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist
P. GATES
The Geelong Hospital, Barwon Health, Geelong, Victoria, Australia
The rule of 4 is a simple method developed to help‘students of neurology’ to remember the anatomy of thebrainstem and thus the features of the various brainstemvascular syndromes. As medical students, we are taughtdetailed anatomy of the brainstem containing a bewil-dering number of structures with curious names such assuperior colliculi, inferior olives, various cranial nervenuclei and the median longitudinal fasciculus. In realitywhen we do a neurological examination we test for onlya few of these structures. The rule of 4 recognizes thisand only describes the parts of the brainstem that weactually examine when doing a neurological examina-tion. The blood supply of the brainstem is such thatthere are paramedian branches and long circumferentialbranches (the anterior inferior cerebellar artery (AICA),the posterior inferior cerebellar artery (PICA) and thesuperior cerebellar artery (SCA). Occlusion of the para-median branches results in medial (or paramedian)brainstem syndromes and occlusion of the circumferen-tial branches results in lateral brainstem syndromes.Occasionally lateral brainstem syndromes are seen inunilateral vertebral occlusion. This paper describes asimple technique to aid in the understanding of brain-stem vascular syndromes.
Any attempt to over simplify things runs the risk ofupsetting those who like detail and I apologise inadvance to the anatomists among us, but for more than15 years this simple concept has helped numerousstudents and residents understand, often for the firsttime, brainstem anatomy and the associated clinicalsyndromes that result.
In the rule of 4 there are 4 rules:1
There are 4 structures in the ‘midline’ beginning with
M
.
2
There are 4 structures to the side beginning with
S
.
3
There are 4 cranial nerves in the medulla, 4 in thepons and 4 above the pons (2 in the midbrain).
4
The 4 motor nuclei that are in the midline are thosethat divide equally into 12 except for 1 and 2, that is 3,4, 6 and 12 (5, 7, 9 and 11 are in the lateral brainstem).
If you can remember these rules and know how toexamine the nervous system, in particular the cranialnerves, then you will be able to diagnose brainstemvascular syndromes with ease.
Figure 1 shows a cross-section of the brainstem, inthis case at the level of the medulla, but the concept of 4lateral and 4 medial structures also applies to the pons,only the 4 medial structures relate to midbrain vascularsyndromes.
The 4 medial structures and the associateddeficit are:1
The
M
otor pathway (or corticospinal tract): contralateral weakness of the arm and leg.
2
The
M
edial Lemniscus: contra lateral loss of vibrationand proprioception in the arm and leg.
3
The
M
edial longitudinal fasciculus: ipsilateral inter-nuclear ophthalmoplegia (failure of adduction of theipsilateral eye towards the nose and nystagmus in theopposite eye as it looks laterally).
4
The
M
otor nucleus and nerve: ipsilateral loss of thecranial nerve that is affected (3, 4, 6 or 12).
The 4 lateral structures and the associated deficitare:1
The
S
pinocerebellar pathways: ipsilateral ataxia of thearm and leg.
2
The
S
pinothalamic pathway: contra lateral alterationof pain and temperature affecting the arm, leg and rarelythe trunk.
3
The
S
ensory nucleus of the 5th: ipsilateral alterationof pain and temperature on the face in the distributionof the 5th cranial nerve (this nucleus is a long verticalstructure that extends in the lateral aspect of the ponsdown into the medulla).
4
The
S
ympathetic pathway: ipsilateral Horner’s syn-drome, that is partial ptosis and a small pupil (miosis).
Correspondence to: Associate Professor Peter Gates, Director of Neuroscience, The Geelong Hospital, Barwon Health, Geelong, Vic. 3220, Australia. Email: [email protected]
Received 28 November 2003; accepted 24 March 2004.
Funding: None
Potential conflicts of interest: None
Medial Brainstem Syndromes
Lateral Brainstem Syndromes
Plaques and Clots
Types of Strokes
Types of Strokes and TIA
WATCH VIDEO PRESENTATION IN LIVESTREAM OR REPLAYS
Transient Ischemic Attack
WATCH VIDEO PRESENTATION IN LIVESTREAM OR REPLAYS
Hemichorea—Hemiballism after Diabetic Lacunar Stroke
WATCH VIDEO PRESENTATION IN LIVESTREAM OR REPLAYS
Lacunar Stroke
Basilar Migraine
WATCH VIDEO PRESENTATION IN LIVESTREAM OR REPLAYS
Migraine Visual Aura
WATCH VIDEO PRESENTATION IN LIVESTREAM OR REPLAYS
Microvascular Disease
Microvascular Disease
Patient History With Vestibular Migraine
WATCH VIDEO PRESENTATION IN LIVESTREAM OR REPLAYS
Internal Medicine Journal
2005; 35: 263–266
P
ERSONAL
V
IEWPOINT
– C
LINICAL
T
IPS
The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist
P. GATES
The Geelong Hospital, Barwon Health, Geelong, Victoria, Australia
The rule of 4 is a simple method developed to help‘students of neurology’ to remember the anatomy of thebrainstem and thus the features of the various brainstemvascular syndromes. As medical students, we are taughtdetailed anatomy of the brainstem containing a bewil-dering number of structures with curious names such assuperior colliculi, inferior olives, various cranial nervenuclei and the median longitudinal fasciculus. In realitywhen we do a neurological examination we test for onlya few of these structures. The rule of 4 recognizes thisand only describes the parts of the brainstem that weactually examine when doing a neurological examina-tion. The blood supply of the brainstem is such thatthere are paramedian branches and long circumferentialbranches (the anterior inferior cerebellar artery (AICA),the posterior inferior cerebellar artery (PICA) and thesuperior cerebellar artery (SCA). Occlusion of the para-median branches results in medial (or paramedian)brainstem syndromes and occlusion of the circumferen-tial branches results in lateral brainstem syndromes.Occasionally lateral brainstem syndromes are seen inunilateral vertebral occlusion. This paper describes asimple technique to aid in the understanding of brain-stem vascular syndromes.
Any attempt to over simplify things runs the risk ofupsetting those who like detail and I apologise inadvance to the anatomists among us, but for more than15 years this simple concept has helped numerousstudents and residents understand, often for the firsttime, brainstem anatomy and the associated clinicalsyndromes that result.
In the rule of 4 there are 4 rules:1
There are 4 structures in the ‘midline’ beginning with
M
.
2
There are 4 structures to the side beginning with
S
.
3
There are 4 cranial nerves in the medulla, 4 in thepons and 4 above the pons (2 in the midbrain).
4
The 4 motor nuclei that are in the midline are thosethat divide equally into 12 except for 1 and 2, that is 3,4, 6 and 12 (5, 7, 9 and 11 are in the lateral brainstem).
If you can remember these rules and know how toexamine the nervous system, in particular the cranialnerves, then you will be able to diagnose brainstemvascular syndromes with ease.
Figure 1 shows a cross-section of the brainstem, inthis case at the level of the medulla, but the concept of 4lateral and 4 medial structures also applies to the pons,only the 4 medial structures relate to midbrain vascularsyndromes.
The 4 medial structures and the associateddeficit are:1
The
M
otor pathway (or corticospinal tract): contralateral weakness of the arm and leg.
2
The
M
edial Lemniscus: contra lateral loss of vibrationand proprioception in the arm and leg.
3
The
M
edial longitudinal fasciculus: ipsilateral inter-nuclear ophthalmoplegia (failure of adduction of theipsilateral eye towards the nose and nystagmus in theopposite eye as it looks laterally).
4
The
M
otor nucleus and nerve: ipsilateral loss of thecranial nerve that is affected (3, 4, 6 or 12).
The 4 lateral structures and the associated deficitare:1
The
S
pinocerebellar pathways: ipsilateral ataxia of thearm and leg.
2
The
S
pinothalamic pathway: contra lateral alterationof pain and temperature affecting the arm, leg and rarelythe trunk.
3
The
S
ensory nucleus of the 5th: ipsilateral alterationof pain and temperature on the face in the distributionof the 5th cranial nerve (this nucleus is a long verticalstructure that extends in the lateral aspect of the ponsdown into the medulla).
4
The
S
ympathetic pathway: ipsilateral Horner’s syn-drome, that is partial ptosis and a small pupil (miosis).
Correspondence to: Associate Professor Peter Gates, Director of Neuroscience, The Geelong Hospital, Barwon Health, Geelong, Vic. 3220, Australia. Email: [email protected]
Received 28 November 2003; accepted 24 March 2004.
Funding: None
Potential conflicts of interest: None
Lateral Brainstem Syndromes
Lateral Medullary Syndrome
Labyrinthine Artery Syndrome
Vertebrobasilar Insufficiency
Symptoms of Vertebrobasilar Insufficiency
• Ver,go • Loss of vision in one or both eyes • Double vision • Nausea and vomi,ng • Slurred speech • Changes in mental status including confusion • Drop a\acks • Loss of balance and coordina,on • Difficulty swallowing