Neurology

• Neuron: nerve, logos: knowledge• Neurology: deals with the prevention, therapy and

rehabilitation of organic disease of NS and musculatureCharacteristisc:• 1. Psychiatric alterations are not typical • 2. Morphological or functional abnormalities• 3. Psychogenic mechanisms only modify Internal Medicine: functional diagnosisneurology: localisation, importance of neuroanatomy

The most frequent neurological disorders

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- What Provokes discomfort? –Q- What is the Quality of the discomfort? –R- Where is the Region of the discomfort? –S- What is the Severity of the discomfort? –T- What is the Time sequence?

Neurol. examination

Signs of meningeal irritationCranial nervesReflexesSensory Motor Vegetative functionOrientation, cognition, perception

II. optic nerve

• Papilla-edema: increased intracran.

pressure• Optic atrophy: chronic disease; • Vascular diseases: HT, diabetes

Corneal reflex (V and VII)

Afferent (V) efferent (VII),

Babinski reflexBabinski reflex

Brisky:physiological

pathological:brisky +pyramidal sign

CT

• Ischemia, bleeding, tumor abscess, degeneration, trauma.

62 yrs stroke at admission

One day later

2 days later

Hemorrhagic transformation11th Dec dysart+mild hemipar 21st December worsening

27th of December

Cerebral hemorrhages

Angiography

DSA angiography• DSA (digital subtraction angiography, mask-image) excellent resolution DSA, MR, CT and PET integration intervention neuroradiology:embolisation of

malformations, 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 focuswhole 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

F-DG-PETF-DG-PET

Left MCA infarctLeft MCA infarct

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 , CMVPot. complications: headache, hematoma, CSF fistel, infection, herniation

EEG0,6-0,8 % 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 atrophy could be differentiated

psychogenic and organic paresisclinically silent paresisreinnervation 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 amplitude

decrease

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 of consciousness

Either brain stem or Diffuse cortical damage or both

• Somnolent• Stupor • coma

Glasgow coma scaleGlasgow coma scale

Eye openingEye opening1-41-4

Motor responseMotor response1-61-6

Verbal responseVerbal response1-51-5

1. Brainstem

Hyperglychypercapniauremia/vesehyperammon./májhyperosmol.Hypernatr.Hypercalc.hyperthermia

Hypoxiahypoglyc.Hyponatr.Hypocalc.hypothermia endocrin

5.Extracorporal factors bact. viral inf. drugs, poisons

•Ischemia•bleeding

2.Trauma?Subcutan hem.Fract linear impres.epidural h. Subdural h.SSAH Commotion Contusion (SAH)

4. Large focal lesion

with sec. edema

•tumor

•Ischemia

•bleedinh

3. Dysequilibrium of homeostasis/metab.

Supratentorial

Infratentorial

Causes of disturbances ofCauses of disturbances ofunconsciousnessunconsciousness

Hunt and Hess Classification(*1) of Subarachnoid Hemorrhage Grade Description Periop. mortality (%) *2 Prob of survival (%) *30 Unruptured aneurysm 1 Assympto-matic, or mild headacheor nuchal rigidity 0-5 902 CN palsy, moderate or severe headache or nuchal rigidity 2-10 753 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 of conscioussness

• Locked in: corticospinal and corticobulbar pathways intact vertical

• Apallic synd.: intact brain stem, cortex damage, opened eyes

• Akinetic mutism: frontal lobe/ efferent pathways. Lack of motivation

• Delir • Amentiform syndr.: desorientation + halluc.

Brain death

• Complete and irreversible lack of brain functions rostal from 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)

Brain death 1.

• Complete, irreversible

• clinical investigations and course

• ancillary instr.

Exclusion

– intox., drug, neuromusc;– shock;– metabolic or endocrine? – hypothermia (below 35 ºC);– brain stem encephalitis, cranial polyneuritis)

Criteria

• coma (no spont. motor., seizure, extrapyramidal.) • no rigor, spasm, decortic. or decerebr. posture). • Spinal automatism?

No breath

– apnoe-test: • a-pCO2 38-42 mmHg • 10 min 100% oxygen • 6 liter/min O2• art. pCO2 higher than • 60 mmHg!!

Diagnosis in stroke

From blood•BSR, counts•glucose, ions•hemostasis•lipids, •Immunological(in youngs)

Heart

Functional•BP monitoring•ECG•Holter ECG

Morphological•TTE•X-ray•TEE

TEE

Carotid, vertebral•Ultrasound•CTA•MRA•DSA

Brain imaging•CT•MRI

•Diff. WI•Perf. WI

•TCD•Angiogr.(DSA, MRA)•SPECT, PET