Management of Clients with problems of the nervous system

1. Management of Clients with problems of the nervous system

2. Stroke is acute disorders of cerebral circulation, rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other then that of vascular origin

3. Hemorrhagic stroke • Intracerebral (when the hemorrhage is into the substance or parenchyma of the brain ) • Membrane • subarachnoid (when the bleeding originates in the subarachnoid spaces surrounding the brain) • epidural and subdural • Combined • subarachnoid – parenchymatose • parenchymatose– subarachnoid • parenchymatose–ventricular • ventricular

4. The most common causes of hemorrhage are: • Hypertension • Symptomatic arterial hypertension (at kidney diseases, systemic vessel processes) • Inborn arterial and arterio – venous malformations • Blood diseases (leucosis, polycythemia) • Cerebral atherosclerosis • Intoxications, such as uremia, sepsis

5. Aneurysm

6. Aneurysm

7. According to the localization there are :Lateral hemorrhage (they are located laterally compared with the internal capsule)

8. Medial hemorrhage (they are located medially compared with the internal capsule) Medial hemorrhage(they are located medially compared with the internal capsule)

9. Combined hemorrhages(they take the whole region of basal nuclei: subcortical nuclei, thalamus, internal capsule)

10. Brain stem hemorrhages • Cerebellar hemorrhages

11. In hemisphere

12. In ventricules

14. Per rexis Per diapedesis Pathomorphology

15. The main periods of stroke • Acute (up to 3 – 4 months) • Renewal (up to 1 year) • Residual

16. Stages of acute period • Precursors • Apoplectic stroke • Focal signs

17. General cerebral symptoms • severe headache • nausea • vomiting • seizures • consciousness disorders • sopor • stupor • semicoma • coma

18. is characterized by deep consciousness disorder, disturbance of breathing and heart activity. The patient doesn’t respond to stimuli. Coma

19. C o m a • response to stimuli is absent • eyes are closed, mouth is opened • face is red, lips are cyanotic, skin is cold, • neck vessels are pulsing • there is breathing disturbance • pulse is strained and slow • blood pressure is increased • temperature increases in 24 hours • patient is lying on his back • all muscles are relaxed • pupils are changed (there can be anizokoria, cross – eyes, sometimes gaze paresis can be observed) • mouth angle is a little bit lower

20. On the opposite side hemiplegia is often observed: • the arm is falling down like bine • there is hypotonia of muscles • reflexes are low • Babinski sign is often observed too

21. Large hemisphere hemorrhage • meningeal signs • vomiting and dysphagia • retention of urine or involuntary urination • in case of cortex irritation epileptic attacks

22. Sign of paralysis in right side

23. Sign of central paralysis

26. Secondary brain stem syndrome • progressive breathing disorders • disturbance of heart activity • consciousness disorders • disturbance of eye movements • changes of muscle tonus (hormetonia) • autonomic disorders (sweating, tachycardia, hyperthermia)

27. Brain stem hemorrhage • tetraparesis • alternating syndromes • eye movements disorders • Nystagmus • gorge disorders • cerebellar syndromes.

28. Pons hemorrhage • ptosis • gaze paresis • increased muscular tone (hormetonia)

29. Cerebellar hemorrhage • Dizziness • Severe headache in occipital lobe • Vomiting • Eye movements disorders • Ptosis • Gervig – Mazhandi syndrome, Parino syndrome • Cerebellar symptoms - nystagmus, dysartria, hypotonia, ataxia • Paresis of extremities is not common

30. Complication of intracerebral hemorrhage • is rupture into the ventricle system. This is usually associated with: • worsening of patient’s state • Hyperthermia • breathing disorders • hormetonia manifests as changes of muscle tone in extremities, when hypotonia is changed into hypertonia in a few seconds or minutes.

31. Diagnostics • In blood usually leucocytosis, related lymphopenia, hyperglycemia (up to 8 – 10 mmole per liter) • In liquor high pressure during lubar puncture a great number of erythrocytes are found • On eye fundus – retinal hemorrhages, hypertonic angioretinopathy and Salus symptoms are observed • At echoencephaloscopy there is dislocation of middle structures on 6 –7 sm to the healthy side • At angiography - aneurysm, dislocation of blood vessels, to find out zone “without vessels“ • CT and MRI find out hyperdensive focuses.

32. 1. normal 2. subarachnoid hemorrhage 3. intracerebral hemorrhage 4. xantochromia In liquorhigh pressure during lubar puncture a great number of erythrocytes are found

33. 1-2 embolism of retinal vessels 3 – hypertensive encephalopathy 4 – subarachnoid hemorrhage On eye fundus – retinal hemorrhages, hypertonic angioretinopathy and Salus symptoms are observed

34. there is dislocation of middle structures on 6 –7 sm to the healthy side At echoencephaloscopy

35. Differential diagnosis • Infarction of brain (thrombembolic) • Epistatus • Uremic coma • Diabetic coma • Traumatic hemorrhage • Brain tumor with inside hemorrhage

36. Subdural haematoma

37. Subdural haematoma

38. MRI. Intracerebralhemorrhig

39. Subarachnoid hemorrhage Aetiologic factors: • Aneurysmatic ( 50 – 62 % ) – aneurysm rupture. • Hypertensive ( at hypertension ) • Atherosclerotic ( 15 % ) • Traumatic ( 5 – 6 % ) • Infectious – toxic ( 8.5 % ) • Blastomatose ( at tumors ) • Pathohemic ( at blood diseases ) • Cryptogenic ( 4 – 4.8 % )

40. Clinical features • Severe headache or feeling of hot liquid flowing in the brain (pain is local in the region of occipital lobe). Later pains in neck, back appear, sometimes they irradiate in legs. • Simultaneously with headache vomiting and nausea occur. • there are other general cerebral symptoms: short loss of consciousness, psychomotor excitement, seizures.

41. Subarachnoid hemorrhig

42. Subarachnoid hemorrhig

46. Clinical features Meningeal syndrome • rigidity of occipital muscles • symptoms of Kernig, Brudzinsky • general hyperesthesia. Significant focal neurologic symptoms are not common. Only in case of basal hemorrhage CNs suffer (that is the reason of ptosis, cross – eye, dyplopia, paresis of mimic muscles). That’s why lesion of CNs is typical for basal aneurysm rupture.

48. Kernig’s sign

49. Complications • Brain edema • Recurrent SH • Occlusive hydrocephalia • Brain infarction

50. Diagnosis • Stroke – like development with general cerebral and meningeal symptoms and absence of significant focal neurologic deficit • The presence of blood in liquor (bleeding liquor during first day and yellow liquor on 3rd – 5th day) • Retinal hemorrhages are on eye fundus