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Neurology

Neurology. Study of disorders of the nervous system. What is the nervous system?. Central Nervous system (CNS) Brain Spinal Cord Peripheral Nervous system Nerves to and from body parts to the CNS. Autonomic Nervous System. Breathing Digestion Heart rate Blood Pressure Sweating etc.

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Neurology

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  1. Neurology Study of disorders of the nervous system

  2. What is the nervous system? • Central Nervous system (CNS) • Brain • Spinal Cord • Peripheral Nervous system • Nerves to and from body parts to the • CNS

  3. Autonomic Nervous System • Breathing • Digestion • Heart rate • Blood Pressure • Sweating etc.

  4. Disciplines frequently interacting with Neurology • NeuroSURGERY • Physical Medicine & Rehabilitation (PM&R) • Psychiatry • Family Practice • Medicine • Pediatrics

  5. Common Reasons Why Referrals are made to Neurology • Diagnosis and treatment • Headaches • Weakness or paralysis • Seizures • Mental Delay or deterioration • Memory Loss • Change in Personality

  6. What Happens in the Neurology Clinic of Consult? • History • Neurological Exam • Confirmatory Tests

  7. History • THE MOST IMPORTANT PART !! • Why are you here? • NO GOOD - my doctor sent me, or for a neurological check !! • The questions asked during the history ar based upon the concern for being there!

  8. Neurological Exam • Consists of several parts, HOWEVER IS ALSO FOCUSED BY THE PRESENTING CONCERN !! • Mental Status (Language, memory, affect) • Cranial Nerves • Motor (strength, muscle mass, tone) • Deep Tendon Reflexes (DTR’s – WHY??) • Sensory (Perception of touch, pain) • Coordination & Balance (walking, manual dexterity)

  9. Confirmatory Tests • CT Brain or Spinal Cord Scan • MRI Brain or Spinal Cord Scan • Angiography • Electroencephalogram (EEG) • Electromyogram (EMG) • Ultrasound • Blood and Genetic Tests

  10. Computerized Tomography (CT SCAN) • Relatively inexpensive • Quick • Very good for acute bleeding • Good for fractures & bones • BUT significant X-Ray exposure

  11. Magnetic Resonance Imaging (MRI) • Can be more informative • No x-ray exposure BUT • Much more expensive • Takes longer, may need sedation • Can induce claustrophobia

  12. Electroencephalogram (EEG) • In some ways similar to an EKG (ECG) of the heart • Records the tiny electrical currents emitted by the brain • About thirty wires are pasted to the scalp for about 30-60 minutes • Harmless • Especially valuable in seizure disorders and epilepsy

  13. EEG

  14. Electromyogram (EMG) • Electrical recording of the peripheral nerves and muscles • Invaluable for neuropathiesand muscle disease • Needle exam, also delivery of small electric shock to see they travel • Harmless, BUT not too comfortable

  15. EMG exam

  16. Problems Evaluated and Treated by a Pediatric Neurologist

  17. Delayed (Slow) Intellectual and / or Motor Development • Why not sitting, Walking? • No or Abnormal talking • Is it both or just one or these • Commonly a combination or the two

  18. Intellectual impairment (mental retardation) • A result of ANYTHING which harms the brain • Genetic • Brain malformations • Lack of oxygen • Infection • Trauma • Environment, lack of stimulation • Toxin (ALCOHOL, drug, Pb, Hg)

  19. Management of Intellectual Impairment • Early referral to therapy • Correct cause where possible • Genetic counseling

  20. Abnormal Motor Development • When profoundly weak, muscle disease, muscular dystrophy • Stiff, poor coordination, Cerebral Palsy

  21. Cerebral palsy (CP) • Cerebral = head or brain • Palsy = abnormal muscle function, weakness, coordination, tremor

  22. Cerebral Palsy • A RESULT OF ANYTHING which harms the brain • Genetic • Brain malformations • Lack of oxygen • Infection • Trauma (Birth or post natal) • Environment, lack of stimulation

  23. Cerebral Palsy What Does it Look Like? • Abnormal motor development - delay • Weakness • Stiff (or limp) • Abnormal posture & movement

  24. Part of body affected

  25. Spasticity and Dystonia = stiffness • Often the predominant feature of CP • Can contribute to orthopedic deformity • Interferes with function & care • Can be painful

  26. Management of Spasticity • Drugs - valium, baclofen, dantrium • Indwelling pump for intrathecalbaclofen • Surgery - selective dorsal rhizotomy (SDR)

  27. Surgical implantation

  28. Additional Management of CP • Feeding issues • Surgery to correct secondary orthopedic deformities, especially painful hip dislocation • Adaptive equipment, standers, wheelchairs, powered wheelchairs • Communication devices

  29. Abnormally Large Head • Can be the result of: • Blood clot (extradural hematoma) • Thick skull • Hydrocephalus **

  30. What is Hydrocephalus? • Excessive fluid (CSF) INSIDE of the brain. • Caused by: • Birth deformity (Meningomyelocoel) • Genetic • Infection or bleed • Drugs (seizure meds)

  31. Management of Hydrocephalus • Observation • Medication - Diamox • Surgery - Ventriculo-peritoneal (VP) shunting

  32. Problems with CP Shunts • Infection (about 3%) • Obstruction (resulting in headaches, vomiting, enlarging head, death) • Outgrowing the length of the peritoneal catheter

  33. Duchenne Muscular Dystrophy • X-linked recessive, decr dystrophin • 1 / 3-8,000 males, onset 3-6 yrs • WEAKNESS, difficulty climbing stairs • Abnl tests: CPK, EMG, dystrophin • Stop walking abut 12 years • May live to 3rd decade

  34. Problems Seen by both Pediatric and Adult Neurologists

  35. EpilepsyCharacterized primarily by having seizures • More than one, unprovoked seizure • Seizure – transient, usually sudden disruption of cerebral function • i.e., shaking, paralysis, abnormal speech, staring

  36. Epilepsy • A RESULT OF ANYTHING which harms the brain • Genetic • Brain malformations • Lack of oxygen • Infection • Trauma (Birth or post natal) • Environment, lack of stimulation • Brain tumor **

  37. Seizures • Usually confirmed by EEG • Often completely controlled with medication (AEDs) about 50% • Another 25% much improved with drugs (one or more) • Some benefitted by seizure surgery and / or vagal nerve stimulator

  38. Management of Seizures • Requires follow-up, seizure diary, AE of meds, drug levels. Usually several times per year, usually for years. • Focused history at each clinic visit • Special issues if pregnant

  39. Headaches • Occur in both Children & Adults • Great Majority are NOT due to tumors! • Most are Migraine, Tension, or Cluster • When the histories are typical and the examination is normal, Ct or MRI brain scans usually are not necessary. • At least 10% of children & adults have HA • Frequently there is a positive family history

  40. Management of Headaches • Prophylaxis: • diet, biofeedback,propranolol,Depakene, antidepresant, topiramate, • Acute Attack: • ergotamine, triptan (5-HT agonist-sumatriptan)

  41. Brain Tumors • Occur both in children & adults, however the types vary by age • Although most headaches are NOT due to tumors, many brain tumors present with headaches. • Other symptoms: vomiting, failure to thrive & weight loss, visual impairment, ataxia, neurologic deficits, seizures,

  42. Brain Tumors • Tumor types differ by age (more primaries in kids, metastatic in adults) • Symptoms similar- headache, visual changes, seizures, neurol deficits

  43. Work-up of Brain Tumors • Neurological and Eye exam • Imaging – MRI or CT scans, angiography

  44. Management of Brain Tumors • Stabilize and decrease intracranial pressure with steroids, shunting • Surgical excision or tumor reduction • Radiation and/or chemotherapy • Immunologic reduction (gliomas, melanoma)

  45. Stroke • More common in adults, but also in kids • Syndrome with rapid onset of symptoms & signs(seconds or minutes) loss of CNS function • Transient Ischemic Attacks (reverse < 24 hours = “TIA”) & Reversible Ischemic Neurological deficits

  46. Problems Which Could Look Like a Stroke • Diabetic Coma and hypoglycemia • Seizure • Head Injury • Complicated Migraine • Transient Global Amnesia

  47. Causes of Stroke • Thrombosis & occlusion of vessels • Emboli – something traveling in vascular supply (usually clot) to occlude • Hemorrhage – berry aneurism, hypertension, abnl blood vessel (AVM) • (Risk factors SMOKING, obesity, diet, hypertension, family history)

  48. Stroke

  49. Stroke Types

  50. Work-up of Stroke • CT / MRI brain scan • CT angiogram • MRI angiogram • Traditional angiogram

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