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Neurology Study of disorders of the nervous system.

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Presentation on theme: "Neurology Study of disorders of the nervous system."— Presentation transcript:

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 minutes Harmless Especially valuable in seizure disorders and epilepsy

13 EEG

14 Electromyogram (EMG) Electrical recording of the peripheral nerves and muscles Invaluable for neuropathies and 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 intrathecal baclofen 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 3 rd decade

34 Problems Seen by both Pediatric and Adult Neurologists

35 Epilepsy Characterized 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 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 ** Epilepsy

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

51 Treatment of Stroke Thrombolysis (< 5-6 hours) Rarely Surgery (aneurism, large hemorrhage) Rehabilitation (TIAs should be worked up – migh prevent future stroke)

52 Parkinson’s Disease Akinesia, rigidity, tremor, stooped gait & posture Atrphy of substantia nigra, decreased dopamine Increases with age (1-2% > 60 years) Rarely genetic or environmental

53 Treatment of Parkinson’s Disease Drugs: L-DOPA, Carbidopa, bromocriptine, amantadine, selegiline Surgery: Stereotactic thalamotomy for tremor Cell transplantation Deep brain stimulation - tremor


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