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Alterations of Neurologic Function

Alterations of Neurologic Function. Chapter 15. Brain Trauma. Major head trauma A traumatic insult to the brain possibly producing physical, intellectual, emotional, social, and vocational changes Transportation accidents Falls Sports-related event Violence. Brain Trauma.

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Alterations of Neurologic Function

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  1. Alterations of Neurologic Function Chapter 15

  2. Brain Trauma • Major head trauma • A traumatic insult to the brain possibly producing physical, intellectual, emotional, social, and vocational changes • Transportation accidents • Falls • Sports-related event • Violence

  3. Brain Trauma • Closed (blunt, nonmissile) trauma • Head strikes hard surface or a rapidly moving object strikes the head • The dura remains intact and brain tissues are not exposed to the environment • Causes focal (local) or diffuse (general) brain injuries • Open (penetrating, missile) trauma • Injury breaks the dura and exposes the cranial contents to the environment • Causes primarily focal injuries

  4. Brain Trauma • Coup injury- impact against an object(front of skull) • Injury directly below the point of impact • Contrecoup- impact within skull( front and back of skull) • Injury on the pole opposite the site of impact • Compound fractures • Basilar skull fracture

  5. Brain Trauma

  6. Focal Brain Injury • Observable brain lesion • Force of impact typically produces contusions • Contusions can cause: • Extradural (epidural) hemorrhages or hematomas bleed between the dura mater , artery is usually the source of bleed, classically loose consciousness at injury, • Subdural hematomas-common in elderly or alcohol abuse, can be acute usually top of skull or chronic • Intracerebral hematomas – most common frontal and temporal lobes and associated with contusions, + bilateral Babinski reflex, ICP increased

  7. Hematomas

  8. Subdural (Epidural) Hematomas

  9. Diffuse Brain Injury • Categories: • Mild concussion • Classical concussion • Mild, moderate, and severe diffuse axonal injuries (DAI) • Shaking • Acceleration/deceleration • Axonal damage • Severity corresponds to the amount of shearing force applied to the brain and brain stem

  10. Mild Concussion • Temporary axonal disturbance causing attention and memory deficits but no loss of consciousness • I: confusion, disorientation, and momentary amnesia momentary • II: momentary confusion and retrograde amnesia 5-10 min • III: confusion with retrograde and anterogradeamnesia lasting less than 6 hours

  11. Classic Cerebral Concussion • Grade IV • Loss of consciousness (<6 hours) reflexes fail, causing falls symptoms disappear after responsiveness returns. Transient breathing stops, bradycardia occurs and BP falls. Vitals quickly stabilize • Anterograde and retrograde amnesia may last for hours to days • Postconcussivesyndrome- HZ+A< nervousness, anxiety, irritability, insomnia, depression forgetfulness inability to consentrate

  12. Diffuse Axonal Injury • Produces a traumatic coma lasting more than 6 hours because of axonal disruption • Mild –prolong periods of stupor or restlessness • Moderate – unconsciousness for weeks usually permanent memory defect ,Glasgow coma scale 4-8 Posttraumatic antergrade and retrograde amnesia • Severe- ICP appears 4-6 days post injury . Severely Compromised movements, verbal and written communication problems , autonomic dysfunction • Should know DIA consequences p.181 • Must look for secondary problems due to brain injury such as changes in neurotransmitters and electrolytes, breaking of blood brain barrier causing IICP

  13. Spinal Cord Trauma • Most commonly occurs due to vertebral injuries • Simple fracture, compressed fracture, and comminuted fracture and dislocation ,very common in elderly due to degeneration • Traumatic injury of vertebral and neural tissues as a result of compressing, pulling, or shearing forces , swelling temporarily increases dysfunction • Most common locations: cervical (1, 2, 4-7), and T1-L2 lumbar vertebrae • Locations reflect most mobile portions of vertebral column and the locations where the spinal cord occupies most of the vertebral canal injury worse at the level of injury and below

  14. Spinal Cord Trauma

  15. Spinal Cord Trauma

  16. Spinal Cord Trauma

  17. Spinal Cord Trauma

  18. Spinal Cord Trauma • Spinal shock • Normal activity of the spinal cord ceases at and below the level of injury. Sites lack continuous nervous discharges from the brain. • Complete loss of reflex function (skeletal, bladder, bowel, sexual function, thermal control, and autonomic control) below level of lesion( hypothalamus can not control body heat thru vasoconstriction , now have increased metabolism so patient assumes temperature of surrounding air(poikilothermia) • Cervical spinal injury worse due to injury of diaphragm ( phrenic nerve that exit cord at C3-C5

  19. Spinal Cord Trauma • Paraplegia • Quadriplegia • Autonomic hyperreflexia (dysreflexia) PRIORITY QUESTION • Massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system • Stimulation of the sensory receptors below the level of the cord lesion • SS= Increase BP systolic , pounding HA, blurred vision, sweating above level so lesion , skin flushing, nasal congestion, nausea ,poiloerection caused by pilomotor spam and Bradycardia. Often associated with extended bladder and rectum.

  20. Autonomic Hyperreflexia

  21. Degenerative Disorders of the Spine • Degenerative disk disease (DDD) • Spondylolysis- defect in vertebral lamina • Spondylolisthesis- vetabra slides forward on the vertebra below( 4 grades of anterior slipage) • Spinal stenosis-narrowing of spinal canal causing spinal cord pressure • Low back pain-80% of population • Herniated intervertebraldisk most common L4 – S1

  22. Cerebrovascular Disorders • Cerebrovascular accident • Leading cause of disability • Third leading cause of death in United States • Classified • Global hypoperfusion- as in shock • Ischemia (thrombotic, embolic) • Hemorrhagic • Know factors who has increase likelihood of having stroke?

  23. Cerebrovascular Disorders • Cerebrovascular accidents (CVAs) • Thrombotic stroke • Arterial occlusions caused by thrombi formed in arteries supplying the brain or in the intracranial vessels( atherosclerosis) break off and travel upstream. Causes – dehydration, hypotension, prolonged vasoconstriction • Transient ischemic attacks (TIAs)-temporarily decrease brain blood flow. Brief change in brain function-vision, speech, motor function, dizziness of loss of consciences- neurologic defects disappear in 24 hours • Embolic stroke • Fragments that break from a thrombus formed outside the brain

  24. Cerebrovascular Disorders • Embolic stroke • Fragments that break from a thrombus formed outside the brain , heart ,aorta, common carotid. Risk factors MI, aerial fib, endocarditis, Rheumatic Ht. Dz., atria-septal-defect. • Hemorrhagic stroke-hypertension , rupture aneurysms • Lacunar stroke- Smoking, hypertension and DM • Cerebral infarction- brain looses blood supply because of vascular occlusion. Types are ischemic or hemorrhagic • Cerebral hemorrhage- primary cause is hypertension resulting in thickenig of vessels walls

  25. Cerebrovascular Disorders • Clinical manifestations • Excruciating HA . Weakness, transient numbness and tingling transient speech disturbance • Signs- hemiparesis/paralysis, dysphasia, homonymous hemianopsia(Same side of stroke eye blindness)

  26. Cerebrovascular Disorders • Intracranial aneurysm • Congenital • Diffuse arteriosclerotic changes

  27. Intracranial Aneurysm

  28. Cerebrovascular Disorders • Subarachnoid hemorrhage • Blood escapes from defective or injured vasculature into the subarachnoid space • Manifestations • Kernigsign- in sitting position have patient straighten knee , if has pain in neck and back = + • Brudzinskisign- passive neck flexion produces pain and rigidity

  29. Infection and Inflammation of the CNS • Meningitis • Bacterial meningitis • Aseptic (viral, nonpurulent, lymphocytic) meningitis • Fungal meningitis • Tubercular (TB) meningitis

  30. Infection and Inflammation of the CNS • Encephalitis • Acute febrile illness, usually of viral origin with nervous system involvement • Most common forms of encephalitis are caused by arthropod-borne viruses and herpes simplex virus

  31. Neurologic Complications of AIDS • Human immunodeficiency-associated cognitive dysfunction • HIV myelopathy • HIV neuropathy • Aseptic viral meningitis • Opportunistic infections • CNS neoplasms

  32. Demyelinating Disorders • Multiple sclerosis (MS)- autoimmune disorder. Onset 20-50 yrs old • MS is a progressive, inflammatory, demyelinating axon disorder of the CNS- spares peripheral nervous system. Has exacerbations and remissions. Starts on one side of body, loss of strength and grip, diplopia, hyper-reflexiafoot drag and stumbling. Lhermitte sign- shocking and tingling sensations. Heat and increase serum Ca+ bring on symptoms • MRI definitive test • All motor function eventfully lost Amyotrophic lateral sclerosis (ALS)- muscle wasting Dz, • Onset 4—50 ys. Can be familiar. Classic bulbar palsy and muscular atrophy

  33. Peripheral Nervous System Disorders • Amyotrophic lateral sclerosis (ALS) • Classic ALS—“Lou Gehrig disease” • Diffusely affects upper and lower motor neurons of the cerebral cortex, brain stem, and spinal cord (corticospinal tracts and anterior roots) • Disease leads to progressive weakness leading to respiratory failure and death • Patient has normal intellectual and sensory function until death

  34. Peripheral Nervous System Disorders • Neuropathies • Generalized symmetrical polyneuropathies • Distal axonal polyneuropathy • Demyelinating polyneuropathy • Generalized neuropathies • Sensory neuropathies • Focal or multifocal neuropathies

  35. Peripheral Nervous System Disorders • Guillain-Barré syndrome • Acquired inflammatory disease causing demyelinationof the peripheral nerves with relative sparing of axons • Acute onset, ascending motor paralysis • Humoral and cellular immunologic reaction

  36. Peripheral Nervous System Disorders • Myopathies- • Primary muscle disorder • Marked weakness • Symmetrical and proximal Radiculopathies • Radiculitis- sciatica , herpes zoster • Inflammation of the spinal nerve roots • Radicular pain – following dermatome pattern • Plexus injures- cCrvical C1-5. Brachial C6-8, Lumbar T12- S2 • Involves the nerve plexus distal to the spinal roots but proximal to the formation of the peripheral nerves

  37. Neuromuscular Junction Disorders • Myasthenia gravis • Chronic autoimmune disease . Nerve impulse transmission to neuromuscular junction is interrupted • Muscle weakness and fatigue of muscles of the eyes and the throat causing diplopia, difficulty chewing, talking, swallowing

  38. Central Nervous System Tumors • Cranial tumors • Spinal cord tumors

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