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Neurological Diseases

Neurological Diseases. Manifestations Cerebrovascular Diseases Inflammatory Diseases Degenerative Diseases Nerve and Muscle disease Infections of Nervous System Intracranial Mass lesions and Raised ICP. Cerebrovascular diseases.

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Neurological Diseases

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  1. Neurological Diseases Manifestations Cerebrovascular Diseases Inflammatory Diseases Degenerative Diseases Nerve and Muscle disease Infections of Nervous System Intracranial Mass lesions and Raised ICP

  2. Cerebrovascular diseases • A 56 year old woman is bought to emergency department by her daughter, complaining of SUDDEN ONSETof Right upper extremity weakness, that began while she was watching TV this morning. The daughter became concerned when her mother was unable to talk in response to her question. Neurologic examination shows Rt Upper extremity weakness with pronator drift with right facial palsy. When questioned, the patient seems to understand what is being said but cannot clearly respond.

  3. Definition Of Stroke/CVA • Sudden onset on focal neurological deficit • “A clinical syndrome consisting of rapidly developing clinical signs of focal(or global in case of Coma) disturbance of cerebral function lasting for more than 24 hrs or leading to death with no apparent cause other than a vascular origin” WHO • TIA (Transient Ischemic Attack) recovery is complete within 24 hours. 10% of patients will go on to have a complete stroke.

  4. Risk factors Modifiable • HTN • Smoking • Cardiac • A. fib • InfEndocarditis • Recent MI • OCP • Carotid stenosis • Obesity • TIA • Sickle cell diseases Potentially modifiable • DM • Hyperhomocystinuria Non modifiable • Age- doubles the risk for each decade after 55 • Familial

  5. Sub-types Of Stroke • Ischaemic – obstruction to one of major cerebral arteries, brainstem strokes are less common. • Haemorrhage – 9% are caused by haemorrhage to the deep parts of the brain. Patients are usually hypertensive.

  6. Stroke Classification • TACI (Total Anterior Circulation Infarct) • PACI (Partial Anterior Circulation Infarct) • LACI (Lacunar Infarct) • POCI (Posterior Circulation Infarct)

  7. Classification • Infarction (85%) • Atherosclerosis (60%) • Non Atherosclerotic (40%) • Emboli (50%) • Others (50%) • Hemorrhagic (15%) • ICH(85%) • HTN (70%) • AVM+Others (30%) • SAH(15%) • Ruptured aneurysms (85%) • Idiopathic (15%)

  8. Clinical presentations • Acute onset of focal neurological deficit • MCA occlusion: • Contralateral hemiplegia • Hemisensory loss • Homonymous hemianopia, eyes deviated TOWARDS cortical lesion • Aphasia- Dominant hemisphere involvement • Preserved speech- nondominant hemisphere involvement but comprehension with confusion, apraxia with spatial and constructional deficits

  9. Clinical presentations • ACA occlusion • Contralateral weakness + sensory loss in lower limbs>upper limbs • Urinary incontinence • Confusion • Behavioral disturbances

  10. Clinical presentations PCA • Contralateral homonymous hemianopia • Visual hallucinations • Agnosias • If penetrating branches of PCA are occluded • CNIII palsy with contralateral hemiplegia (Weber Syndrome) Or Contralateral ataxia or athetosis (Benedict syndrome)

  11. Investigations • CT head • Noncontrast hemorrhagic and no hemorrhagic stroke • Diffusion-weighted MRI • Other diagnostic workup ECHO, Duplex, 24 hr Holter monitor, Blood glucose, ECG, Markers of cardiac ischemia, PT/INR, APTT, Oxygen saturation • For selected patients- LFT, Toxicology scan,Blood alcohol levels, ABG, CXR, LP (SAH), EEG(Seizures)

  12. Management 5 mainstays • Treatment of general condition that needs to be stabilized • Specific therapy directed against particular aspect of stroke pathogenesis • Prophylaxis and treatment of complications- neurological/ medical • Early 2⁰ prevention • Early rehabilitation

  13. Treatment • TPA-If pt presents within 3 hrs • Aspirin- 1st line for 2⁰ prevention • Dipyridamole/ Clopidegrol is added with antiplatelets if • Failed aspirin therapy/ Aspirin allergy • Heparin (↓no of recurrent strokes-Afib/basilar artery thrombosis/stroke in evolution) • ↓ rate of recurrent CVA/ Afib/2nd incidence • Carotid endarterectomy- When occlusion exceeds 70% of arterial lumen

  14. Contraindications for using TPA • Stroke/serious head trauma within three months • Hemorrhage(GI/ Genitourinary) within 21 days • Surgery within 14 days • H/O intracranial Hge • BP>185/110 mm of Hg • Recent use of anticoagulants • Platelets<100,000/mm³ • Glucose>400mg/dl or <50mg/dl • Coagulopathy(PT>15 seconds)

  15. !!Avoid • Dextrose containing fluids in non-hypoglycemic patients • Excessive reduction of BP • Excessive IVF

  16. Cranial NerveMajor Functions • I Olfactory smell • II Optic vision  • III Oculomotor eyelid and eyeball movement • IV Trochlear innervates superior oblique turns eye downward and laterally  • V Trigeminal chewing  face & mouth touch & pain • VI Abducens turns eye laterally  • VII Facial controls most facial expressions  secretion of tears & saliva taste . VIII Vestibulocochlear(auditory)  hearing  equillibrium sensation  • IX Glossopharyngeal taste  senses carotid blood pressure  • X Vagus senses aortic blood pressure  slows heart rate  stimulates digestive organs taste  • XI Spinal Accessory controls trapezius & sternocleidomastoidcontrols swallowing movements • XII Hypoglossal controls tongue movements

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