Neurology

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Neurology
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NEUROLOGY

• CHAPTER 24

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Symptoms Headache (HA)

• Acute
• Age gt 50 years.
• Rapid onset and severe intensity.
• Fever.
• Trauma.
• Vision changes.
• Past medical history of hypertension or HIV
  infection.
• Hypertension.
• Neurologic findings (mental status changes, motor
  or sensory deficits).

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Headches

• Chronic
• Migraine (pulsating or throbbing),
• Tension (tightness or pressure ), or
• Depression
• Tumor, head injury, cervical spondylosis, dental
  or ocular disease, TM joint dysfunction,
  sinusitis, hypertension

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Headaches

• Sharp and lancinating neuralgic
• Ocular/periorbital-icepick like pain-
  migraine/cluster headaches
• Dull and steady- tumor
• Cough aggravated in brain tumors
• Severe headache in a previously well patient
  rule out- sub arachnoid hemorrhage/ meningitis

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Headaches

• Cranial MRI or CT scan required if
• New onset in middle or later life
• Progressive
• Disturb the sleep/related to exertion
• Associated with neurological deficit

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Tension Headaches

• Poor concentration
• Vague non specific symptoms
• Vise-like, worse on emotional stress/noise/ glare
  and occurs almost daily
• Intense around back of the neck head
• May respond to Tylenol/ or migraine medicine
• Relaxation therapy/Massage/Hot baths/
  Biofeedback/?Botox

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Depression HA

• Worse on waking up
• Associated depressive symptoms
• Antidepressants/Psychiatric help

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Migraine HA

• Headache, usually pulsatile/dull/throbbing.
• Nausea, vomiting, photophobia, and phonophobia
  are common
• Transient neurologic symptoms (commonly visual)
  preceding headache of classic migraine.
• No preceding aura is common.

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Migraine

• Related to serotonin (5-HT)
• Trigeminal trigger
• Episodic lateralized throbbing headache
• Late teen/early adult onset
• Anorexia/Nausea/Vomiting
• Visual/Auditory disturbances- gradual build up,
  last several hours
• External Carotid artery system dilation/pulsation
• Focal neurological signs/symptoms due to initial
  constriction of ICA

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Migraine

• Visual common-
• field defects
• luminous visual hallucinations such as stars,
  sparks, unformed light flashes, geometric
  patterns, or zigzags of light
• Aphasia/numbness/tingling/clumsiness

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Migraine

• FH
• Factors- emotional stress, lack/excess sleep,
  missed meals, specific food items (chocolate,
  alcohol), menses, pill
• Basilar artery migraine- blindness/visual field
  defects initially and later- tinnitus/perioral
  tingling and transient loss of consciousness/
  confusion followed by throbbing occipital HA,
  nausea/vomiting

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Migraine Treatment

• AVOID! Factors
• Prophylactic treatment aspirin/brufen/allieve
• Ergot caffeine (vasoconstrictor)
• Serotonin blocker- Sumatriptan/Zolimtriptan

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Cluster Headache (Migrainous Neuralgia)

• Predominantly middle-aged men
• ?Vascular/?serotonin
• No FH
• Unilateral periorbital pain with-
• ipsilateral nasal congestion,
• rhinorrhea,
• lacrimation,
• redness of the eye, and
• Horner's syndrome

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Horner syndrome

• Results from an interruption of the sympathetic
  nerve supply to the eye, and is characterized by
  the classic triad
• 1 Miosis (ie, constricted pupil)
• 2 Partial ptosis and
• 3 Loss of hemifacial sweating (ie, anhidrosis)

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Cluster Headache (Migrainous Neuralgia)

• AT night (wakeup)
• Lasts lt2hrs
• Spontaneous remission
• ?alcohol trigger/ glare/food

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THERAPY

• Oxygen (acute attack)
• Oxygen (8 L/min for 10 min or 100 by mask) may
  abort the headache if used early.
• Mechanism of action is unknown.
• Sumatriptan
• Most studied of the triptans in cluster headache.
  
• Subcutaneous injections can be effective, in
  large part, due to the rapidity of onset.
• No evidence suggests that they are effective
  orally.
• Dihydroergotamine
• Can be abortive agent
• IV/IM self-injections

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Posttraumatic Headache

• Closed head injury
• Worsen over the ensuing weeks, and then gradually
  subsides
• Disequilibrium, enhanced by postural change or
  head movement
• Impaired memory, poor concentration, emotional
  instability, and increased irritability
• Tests not helpful, Treatment difficult

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?
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TRIGEMINAL NERVE
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Trigeminal Neuralgia

• Brief episodes of stabbing facial pain.
• Pain is in the territory of the second and third
  division of the trigeminal nerve.
• Pain exacerbated by touch
• Middle and later life (FgtM)

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Trigeminal Neuralgia

• Sudden lancinating facial pain occur
• commonly arise near one side of the mouth and
  shoot toward the ear, eye, or nostril on that
  side
• Trigger-touch, movement, drafts, and eating
• Pain become more frequent, remissions become
  shorter and less common, and a dull ache may
  persist between the episodes of stabbing pain
• Confined to the distribution of the trigeminal
  nerve (usually the second or third division

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Trigeminal Neuralgia

• Young patient presenting with trigeminal
  neuralgia, multiple sclerosis
• Tests-evoked potential testing and examination of
  cerebrospinal fluid may be corroborative
• Treatment- carbamazepine (Tegretol)/ Baclofen/
  Gabapentin
• Nerve ablation
• Structural cause for the neuralgia (despite
  normal findings on CT scans, MRI, or
  arteriograms) -surgery

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TCM Diagnoses and Acupuncture Treatments

• Etiology Pathology
• Exterior WIND-COLD Invasion
• Interior LV/ST FIRE
• Interior YIN DEFICIENCY w/empty fire rising
• Differentiation
• Wind-Cold Invasion
• Signs Symptoms
• Acute onset, severe pain for a few seconds to a
  few minutes several times/day
• Exterior signs, runny nose, tearing
• Tongue Thin white coat
• Pulse Tight, floating

• LV/ST Fire
• Signs Symptoms
• Severe pain w/irritability
• Internal heat signs, thirst, constipation
• TongueYellow, dry coat
• Pulse Wiry
• Yin Deficiency w/empty heat rising
• Signs Symptoms
• Pain is more insidious, gradual, comes and goes,
  malar flush, soreness in lumbar area
• Tongue Red w/no coat
• Pulse Thin, fast

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Treatment Points

• For pain in the supraorbital region
• Local Taiyang
• GB14/ UB2
• Distal TH5 / LI4
• For pain in the maxillary region
• Local ST2 / SI 18 / LI 20
• Distal LI4
• For pain in the mandibular region
• Local ST6 / ST 7
• Extra point 1 cun lateral to CV24
• Distal LI4
• Wind-Cold Add GB 20
• LV/ST Fire Add LV3, possibly LV2, ST44
• Yin Deficiency Add KD6, SP6

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Glossopharyngeal Neuralgia

• Occurs in the throat, about the tonsillar fossa,
  and sometimes deep in the ear and at the back of
  the tongue
• Precipitated by swallowing, chewing, talking, or
  yawning

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Postherpetic Neuralgia

• 15 of patients who develop shingles
• suffer from postherpetic neuralgia
• High risk elderly and involvement of
  Ophthalmic (I) division
• Incidence of postherpetic neuralgia may be
  reduced by the treatment of shingles with oral
  acyclovir or famciclovir (?)
• Corticosteroids do not help (?)
• Zoster vaccine for elderly (?)
• ZOSTAVAX Zoster Vaccine Live (Oka/Merck)
• Carbamazepine/TCA/Lidocaine (local)

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Epilepsy

• Recurrent seizures.
• Characteristic electroencephalographic changes
  accompany seizures.
• Mental status abnormalities or focal neurologic
  symptoms may persist for hours postictally
• Seizure is a transient disturbance of cerebral
  function

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Epilepsy

• Usually begin between 5 and 20
• Congenital abnormalities and perinatal injuries
• Alcohol withdrawal/hypo or hyper glycemia
• Trauma (within 2 years following the injury)
• Tumors-especially important cause of seizures in
  middle and later life , must be excluded by
  appropriate imaging studies in all patients with
  onset of seizures after 30 years of age

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RED FLAGS!Epilepsy

• Epilepsy-Old age
• Vascular diseases
• Alzheimer's disease
• Infectious disease-
• AIDS

?bacterial meningitis or herpes encephalitis
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Tests

• Imaging?-
• new onset of seizures after the age of 20 years,
• A chest radiograph should also be obtained in
  such patients, since the lungs are a common site
  for primary or secondary neoplasms.

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Tests

• EEG
• CBC
• Blood glucose
• BUN, Creatinine

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DD

• TIAs
• Rage attacks
• Panic attacks
• Syncope
• Cardiac arrhythmias

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Treatment

• goal of preventing further attacks and is usually
  continued until there have been no seizures for
  at least 3 years
• report to the state department of public health
  any patients with seizures or other episodic
  disturbances of consciousness

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Generalized tonic-clonic (grand mal) or partial
(focal) seizures

• Phenytoin -Dilantin,
• Carbamazepine-Tegretol
• Valproic Acid, Depakene
• Gabapentin Neurontin
• Topiramate Topamax
• Ethosuximide Zarontin
• Clonazepam Klonopin

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• Monitoring serum drug levels has led to major
  advances in the management of seizure disorders
• Surgical treatment
• Vagal nerve stimulation
• Status epilepticus is a medical emergency

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Sensory Disturbances

• Peripheral Nerve
• Nerve roots
• One limb
• One half of the body
• Distal
• glove stocking

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Weakness Paralysis 1Upper/Lower motor
neuron2Spinal roots3Plexus4Peripheral nerves
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UMN LMN

• Muscle groups involved
• Spasticity
• Brisk DTRs
• Babinskis Sign present

• Muscle wasting
• Falccid weak muscle
• Loss of DTRs
• Babinskis sign absent
• Fasciculations present

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Transient Ischemic Attacks TIAs

• Focal neurologic deficit of acute onset.
• Clinical deficit resolves completely within 24
  hours.
• Risk factors for vascular disease often present.
• Increased in patients with hypertension or
  diabetes
• Risk of stroke is highest in the month after a
  transient ischemic attack

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TIA Causes

• Emboli- from Carotids
• Cardiac- atrial fibrillation, post infarction
• Cervical spondylitis
• Subclavian steal syndrome bruit in the
  supraclavicular fossa, unequal radial pulses, and
  a difference of 20 mm Hg or more between the
  systolic blood pressures in the arms

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TIA symptoms

• Abrupt onset within minutes
• Rapid recovery
• Carotid territory - Weakness and heaviness of the
  contralateral arm, leg, or face, singly or in any
  combination.
• Slowness of movement, dysphasia, or monocular
  visual loss in the eye contralateral to affected
  limbs.

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Vertebrobasilar ischemic attacks

• Vertigo, ataxia, diplopia, dysarthria, dimness or
  blurring of vision, perioral numbness and
  paresthesias, and weakness or sensory complaints
  on one, both, or alternating sides of the body

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TIA risks

• Carotid ischemic attacks are more liable than
  vertebrobasilar ischemic attacks to be followed
  by stroke
• Stroke risk is greater in patients older than 60
  years, in diabetics, or after transient ischemic
  attacks that last longer than 10 minutes and with
  symptoms or signs of weakness, speech impairment,
  or gait disturbance.

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Imaging Tests

• CT scans
• Carotid duplex US
• Aretirography
• MRI angio less sensitive than conventional

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Lab Tests

• Assessment for hypertension, heart disease,
  hematologic disorders, diabetes mellitus,
  hyperlipidemia, and peripheral vascular disease
• CBC/ Lipids, Cholesterol, Homocysteine/ ECG/ CXR/
  Echo/ Holter

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Treatment

• Carotid artery surgery
• Preventive- Stop smoking/ treat underlying
  disease/
• If embolic- anticoagulants
• ?antiplatelet drugs- aspirin 325 mg/ or Plavix
  75 mg (clopidogrel)

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Strokes

• Sudden onset of characteristic neurologic
  deficit.
• Patient often has history of hypertension,
  diabetes mellitus, valvular heart disease, or
  atherosclerosis.
• Distinctive neurologic signs reflect the region
  of the brain involved.

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Four Main Types of Strokes

• Ischemic
• 1 Cerebral thrombosis (61 of all strokes,
  excluding transient ischemic strokes), a blood
  clot (thrombus) forms in an artery that supplies
  blood to the brain
• 2 Cerebral embolism (24 of all strokes), a clot
  (embolus) develops in a blood vessel and is
  carried through the bloodstream and becomes
  lodged in a brain artery
• Thrombosis and embolism account for about 85 of
  strokes. These strokes are ischemic, or caused by
  blood clots, which result in insufficient blood
  circulation.
• Hemorrhagic
• 3 Subarachnoid hemorrhage (3 of all strokes), a
  blood vessel on the surface of the brain
  ruptures, causing bleeding into the space between
  the brain and skull
• 4 Cerebral hemorrhage (9 of all strokes), an
  artery in the brain ruptures, causing bleeding
  into the surrounding brain tissue

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Strokes

• Third leading cause of death
• Risk factors
• hypertension
• diabetes
• hyperlipidemia
• cigarette smoking
• cardiac disease
• AIDS
• recreational drug abuse
• heavy alcohol consumption
• family history of stroke

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Stroke Classification

• Infarcts- 85
• Thrombotic
• Embolic
• Hemorrhagic 12

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Lacunar Infarcts

• Small (lt5mm) basal ganglia/ pons/
  cerebellum/anterior limb of internal capsule
• Common in poorly controlled HTN or diabetics
• Recovery good takes 4-6 weeks
• Contralateral pure motor or pure sensory deficit
• Ipsilateral ataxia with crural paresis and
• Dysarthria with clumsiness of the hand

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Stroke Assessment
Abrupt onset ?bruit present 1. Anterior 2.
Middle 3. Posterior 4. Vertebro-basilar

• Anterior cerebral artery
• Anterior communicating artery
• Internal carotid artery
• Posterior communicating artery
• Middle cerebral artery
• Posterior cerebral artery
• Superior cerebellar artery
• Basilar artery
• Anterior inferior cerebellar artery

• Internal carotid artery
• Vertebral artery
• Cavernous sinus
• Carotid canal
• Anterior cerebral artery
• Posterior cerebral artery

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Anterior cerebral artery

• Weakness and
• sensory loss in contralateral leg
• Mild arm weakness
• Grasp reflex

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Middle cerebral artery

• Contralateral hemiplegia
• Hemisensory loss, and
• Homonymous hemianopia (i.e., bilaterally
  symmetric loss of vision in half of the visual
  fields), with the eyes deviated to the side of
  the lesion
• Global aphasia if dominant hemisphere involved

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Posterior cerebral artery

• Receptive (Wernicke's)
• aphasia and
• A homonymous visual field defect
• Confusional state
• Dressing apraxia and
• Constructional and spatial deficits

The inability to execute a voluntary motor
movement despite being able to demonstrate normal
muscle function. Apraxia is not related to a lack
of understanding or to any kind of physical
paralysis but is caused by a problem in the
cortex of the brain.
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Vertebrobasilar artery

• Involuntary movements and
• Alexia

Loss of the ability to read or understand the
written word
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Posterior inferior cerebellar artery

• Ipsilateral spinothalamic sensory loss involving
• The face, ninth and tenth cranial nerve lesions
• Limb ataxia and numbness, and
• Horner's syndrome

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Superior cerebellar artery

• The contralateral
• spinothalamic loss also involves the face
• And ipsilateral-
• the face, ninth and tenth cranial nerve lesions
• limb ataxia and numbness, and
• Horner's syndrome

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Anterior inferior cerebellar artery

• ipsilateral spinothalamic sensory loss involving
  the face, usually in conjunction with ipsilateral
  facial weakness and deafness

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THROMBOSIS OF ICA
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Therapy for thrombotic strokes

• T-pa initiation within 3 hours after stroke
  onset, and the prognosis therefore depends on the
  time that elapses before arrival at the hospital
• CLOT BUSTERS

Tissue-plasminogen activator Retiplase RETAVASE
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Intracerebral Hemorrhage

• Usually due to hypertension
• Most frequently in the basal ganglia and less
  commonly in the pons, thalamus, cerebellum, and
  cerebral white matter
• Common in- advancing age and male sex
• Consciousness is initially lost or impaired in
  about one-half of patients
• Vomiting

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Tests/ Treatment

• CT scanning (superior to MRI) for this
• Management generally conservative and
  supportive,

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Subarachnoid Hemorrhage

• Sudden severe headache.
• Signs of meningeal irritation usually present.
• Obtundation is common.
• Focal deficits frequently absent

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SUBARACHNOID HEMORRHAGE

• 5 and 10 of strokes are due to subarachnoid
  hemorrhage
• sudden headache of a severity never experienced
  previously by the patient
• May lead to coma and death

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Brain Tumors

• Frontal lobe intellectual decline, slowing of
  mental activity, personality changes, and
  contralateral grasp reflexes.
• Expressive aphasia.
• Anosmia may also occur as a consequence of
  pressure on the olfactory nerve.

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Temporal lobe

• olfactory or gustatory hallucinations
• licking or smacking of the lips, and some
  impairment of external awareness
• depersonalization, emotional changes, behavioral
  disturbances, sensations of déjà vu or jamais vu,
  micropsia or macropsia
• dysnomia and receptive aphasia (L)
• musical notes and melodies (R)

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Parietal lobe

• Sensory loss- postural / tactile discrimination
• appreciation of shape, size, weight, and texture
  is impaired
• Objects placed in the hand may not be recognized
  (astereognosis)

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Parietal lobe

• Gerstmann's syndrome
• (a combination of-
• Alexia
• Agraphia
• Acalculia
• Agnosia (right-left confusion, and finger)

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Occipital lobe

• Field defect
• Visual agnosia both for objects and for colors
• Color perception, prosopagnosia (inability to
  identify a familiar face)

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Brainstem and cerebellar

• Cranial nerve palsies, ataxia, incoordination,
  nystagmus, and pyramidal and sensory deficits in
  the limbs on one or both sides.

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Tests for Tumors

• CT scans
• MRI scans
• EEG
• Treatment ? Surgery/ anticonvulsants

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Neurofibromatosis

• Multiple hyperpigmented macules (café au lait
  spots ) (chromosome 17 )
• Eighth nerve tumors
• (chromosome 22 )
• Mobile nodules

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PARKISNOSNS PATHOLOGY
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Parkinsonism

• Tremor, rigidity, bradykinesia, progressive
  postural instability.
• Seborrhea of skin quite common.
• Mild intellectual deterioration may occur
• Begins most often between 45 and 65 years of age.
  

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Parkinsonism

• Familial
• Toxins-manganese, carbon disulfide, carbon
  monoxide poisoning
• Degeneration of the dopaminergic nigrostriatal
  system
• Imbalance of dopamine and acetylcholine

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Parkinsonism

• Tremor- most conspicuous at rest, less severe
  during voluntary activity
• Rigidity,
• Bradykinesia, and
• Postural instability
• Immobile face with widened palpebral fissures,
  infrequent blinking, and a certain fixity of
  facial expression.
• Seborrhea of the scalp and face is common

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Parkinsonism

• Sustained blink response (Myerson's sign)
• Saliva drooling from the mouth
• Gait itself is characterized by small shuffling
  steps and a loss of the normal automatic arm
  swing

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Drugs for Parkinsonism

• Amantadine
• Cogentin
• Artane
• Levodopa /Sinimet
• Selegeline

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Huntington's Disease

• Gradual onset and progression of chorea and
  dementia or behavioral change.
• Family history of the disorder.
• Responsible gene identified on chromosome 4 (AD)
• chorea and dementia
• 5 per 100,000

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Huntingtons

• Onset is usually between 30 and 50 years
• Fatal outcome within 1520 years
• Abnormal movements or intellectual changes, but
  ultimately both occur
• CT scanning usually demonstrates cerebral atrophy
  and atrophy of the caudate nucleus in established
  cases (reduced glucose utilization )

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Huntington's Disease

• No cure for Huntington's
• Relative under activity of neurons containing
  gamma-aminobutyric acid (GABA) and acetylcholine
  or a relative overactivity of dopaminergic
  neurons.

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Restless Leg Syndrome RLS

• RLS affects about 10-15 of the general
  population
• MF
• Often unrecognized or misdiagnosed.
• Many patients are not diagnosed until 10-20 years
  after symptom onset.
• It may begin at any age, even as early as infancy
• Middle-aged or older are affected severely .
• Symptoms progress over time in about two thirds
  of patients and may be severe enough to be
  disabling.
• "pins and needles," an "internal itch," or "a
  creeping or crawling sensation.

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RLS DIAGNOSTIC CRITERIA

• A compelling urge to move the limbs, usually
  associated with paresthesias/dysesthesias
• Motor restlessness, as seen in activities such as
  floor pacing, tossing and turning in bed, and
  rubbing the legs
• Symptoms worse or exclusively present at rest
  (ie, lying, sitting) with variable and temporary
  relief on activity
• Circadian variation of symptoms, which are
  present in the evening and at night. Often,
  symptoms are relieved after 500 am. In more
  severe cases, symptoms can be present throughout
  the day without circadian variation.

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DD for RLS

• Iron deficiency and peripheral neuropathy
• Folate or magnesium deficiency
• Polyneuropathy (either idiopathic or caused by
  alcohol abuse)
• Amyloidosis
• Diabetes mellitus
• Lumbosacral radiculopathy
• Lyme disease
• Rheumatoid arthritis, Sjögren syndrome
• Uremia or
• Vitamin B-12 deficiency
• Affects 25-40 of pregnant women

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Restless Legs Syndrome

• Idiopathic disorder or in relation to pregnancy,
  iron-deficiency anemia, peripheral neuropathy, or
  periodic leg movements of sleep
• ? hereditary
• Irresistible urge to move the limbs, especially
  during periods of relaxation. Disturbed nocturnal
  sleep and excessive daytime somnolences may
  result.
• clonazepam. Levodopa

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Gilles de la Tourette's Syndrome

• Multiple motor (80) and phonic tics. (20)
• Symptoms begin before age 21 years.
• Tics occur frequently for at least 1 year.
• Tics vary in number, frequency, and nature over
  time.
• Onset ages of 2 and 15.
• Motor tics face, head, and shoulders (e.g.,
  sniffing, blinking, frowning, shoulder shrugging,
  head thrusting,
• Phonic tics grunts, barks, hisses,
  throat-clearing, coughs, obscene speech
• Obsessive-compulsive behaviors