Neurology - PowerPoint PPT Presentation


Title: Neurology


1
Neurology
2
NEUROLOGY
  • CHAPTER 24

3
Symptoms Headache (HA)
  • Acute
  • Age gt 50 years.
  • Rapid onset and severe intensity.
  • Fever.
  • Trauma.
  • Vision changes.
  • Past medical history of hypertension or HIV
    infection.
  • Hypertension.
  • Neurologic findings (mental status changes, motor
    or sensory deficits).

4
Headches
  • Chronic
  • Migraine (pulsating or throbbing),
  • Tension (tightness or pressure ), or
  • Depression
  • Tumor, head injury, cervical spondylosis, dental
    or ocular disease, TM joint dysfunction,
    sinusitis, hypertension

5
Headaches
  • Sharp and lancinating neuralgic
  • Ocular/periorbital-icepick like pain-
    migraine/cluster headaches
  • Dull and steady- tumor
  • Cough aggravated in brain tumors
  • Severe headache in a previously well patient
    rule out- sub arachnoid hemorrhage/ meningitis

6
Headaches
  • Cranial MRI or CT scan required if
  • New onset in middle or later life
  • Progressive
  • Disturb the sleep/related to exertion
  • Associated with neurological deficit

7
Tension Headaches
  • Poor concentration
  • Vague non specific symptoms
  • Vise-like, worse on emotional stress/noise/ glare
    and occurs almost daily
  • Intense around back of the neck head
  • May respond to Tylenol/ or migraine medicine
  • Relaxation therapy/Massage/Hot baths/
    Biofeedback/?Botox

8
Depression HA
  • Worse on waking up
  • Associated depressive symptoms
  • Antidepressants/Psychiatric help

9
Migraine HA
  • Headache, usually pulsatile/dull/throbbing.
  • Nausea, vomiting, photophobia, and phonophobia
    are common
  • Transient neurologic symptoms (commonly visual)
    preceding headache of classic migraine.
  • No preceding aura is common.

10
Migraine
  • Related to serotonin (5-HT)
  • Trigeminal trigger
  • Episodic lateralized throbbing headache
  • Late teen/early adult onset
  • Anorexia/Nausea/Vomiting
  • Visual/Auditory disturbances- gradual build up,
    last several hours
  • External Carotid artery system dilation/pulsation
  • Focal neurological signs/symptoms due to initial
    constriction of ICA

11
Migraine
  • Visual common-
  • field defects
  • luminous visual hallucinations such as stars,
    sparks, unformed light flashes, geometric
    patterns, or zigzags of light
  • Aphasia/numbness/tingling/clumsiness

12
Migraine
  • FH
  • Factors- emotional stress, lack/excess sleep,
    missed meals, specific food items (chocolate,
    alcohol), menses, pill
  • Basilar artery migraine- blindness/visual field
    defects initially and later- tinnitus/perioral
    tingling and transient loss of consciousness/
    confusion followed by throbbing occipital HA,
    nausea/vomiting

13
Migraine Treatment
  • AVOID! Factors
  • Prophylactic treatment aspirin/brufen/allieve
  • Ergot caffeine (vasoconstrictor)
  • Serotonin blocker- Sumatriptan/Zolimtriptan

14
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15
Cluster Headache (Migrainous Neuralgia)
  • Predominantly middle-aged men
  • ?Vascular/?serotonin
  • No FH
  • Unilateral periorbital pain with-
  • ipsilateral nasal congestion,
  • rhinorrhea,
  • lacrimation,
  • redness of the eye, and
  • Horner's syndrome

16
Horner syndrome
  • Results from an interruption of the sympathetic
    nerve supply to the eye, and is characterized by
    the classic triad
  • 1 Miosis (ie, constricted pupil)
  • 2 Partial ptosis and
  • 3 Loss of hemifacial sweating (ie, anhidrosis)

17
Cluster Headache (Migrainous Neuralgia)
  • AT night (wakeup)
  • Lasts lt2hrs
  • Spontaneous remission
  • ?alcohol trigger/ glare/food

18
THERAPY
  • Oxygen (acute attack)
  • Oxygen (8 L/min for 10 min or 100 by mask) may
    abort the headache if used early.
  • Mechanism of action is unknown.
  • Sumatriptan
  • Most studied of the triptans in cluster headache.
  • Subcutaneous injections can be effective, in
    large part, due to the rapidity of onset.
  • No evidence suggests that they are effective
    orally.
  • Dihydroergotamine
  • Can be abortive agent
  • IV/IM self-injections

19
Posttraumatic Headache
  • Closed head injury
  • Worsen over the ensuing weeks, and then gradually
    subsides
  • Disequilibrium, enhanced by postural change or
    head movement
  • Impaired memory, poor concentration, emotional
    instability, and increased irritability
  • Tests not helpful, Treatment difficult

20
?
21
TRIGEMINAL NERVE
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Trigeminal Neuralgia
  • Brief episodes of stabbing facial pain.
  • Pain is in the territory of the second and third
    division of the trigeminal nerve.
  • Pain exacerbated by touch
  • Middle and later life (FgtM)

24
Trigeminal Neuralgia
  • Sudden lancinating facial pain occur
  • commonly arise near one side of the mouth and
    shoot toward the ear, eye, or nostril on that
    side
  • Trigger-touch, movement, drafts, and eating
  • Pain become more frequent, remissions become
    shorter and less common, and a dull ache may
    persist between the episodes of stabbing pain
  • Confined to the distribution of the trigeminal
    nerve (usually the second or third division

25
Trigeminal Neuralgia
  • Young patient presenting with trigeminal
    neuralgia, multiple sclerosis
  • Tests-evoked potential testing and examination of
    cerebrospinal fluid may be corroborative
  • Treatment- carbamazepine (Tegretol)/ Baclofen/
    Gabapentin
  • Nerve ablation
  • Structural cause for the neuralgia (despite
    normal findings on CT scans, MRI, or
    arteriograms) -surgery

26
TCM Diagnoses and Acupuncture Treatments
  • Etiology Pathology
  • Exterior WIND-COLD Invasion
  • Interior LV/ST FIRE
  • Interior YIN DEFICIENCY w/empty fire rising
  • Differentiation
  • Wind-Cold Invasion
  • Signs Symptoms
  • Acute onset, severe pain for a few seconds to a
    few minutes several times/day
  • Exterior signs, runny nose, tearing
  • Tongue Thin white coat
  • Pulse Tight, floating
  • LV/ST Fire
  • Signs Symptoms
  • Severe pain w/irritability
  • Internal heat signs, thirst, constipation
  • TongueYellow, dry coat
  • Pulse Wiry
  • Yin Deficiency w/empty heat rising
  • Signs Symptoms
  • Pain is more insidious, gradual, comes and goes,
    malar flush, soreness in lumbar area
  • Tongue Red w/no coat
  • Pulse Thin, fast

27
Treatment Points
  • For pain in the supraorbital region
  • Local Taiyang
  • GB14/ UB2
  • Distal TH5 / LI4
  • For pain in the maxillary region
  • Local ST2 / SI 18 / LI 20
  • Distal LI4
  • For pain in the mandibular region
  • Local ST6 / ST 7
  • Extra point 1 cun lateral to CV24
  • Distal LI4
  • Wind-Cold Add GB 20
  • LV/ST Fire Add LV3, possibly LV2, ST44
  • Yin Deficiency Add KD6, SP6

28
Glossopharyngeal Neuralgia
  • Occurs in the throat, about the tonsillar fossa,
    and sometimes deep in the ear and at the back of
    the tongue
  • Precipitated by swallowing, chewing, talking, or
    yawning

29
Postherpetic Neuralgia
  • 15 of patients who develop shingles
  • suffer from postherpetic neuralgia
  • High risk elderly and involvement of
    Ophthalmic (I) division
  • Incidence of postherpetic neuralgia may be
    reduced by the treatment of shingles with oral
    acyclovir or famciclovir (?)
  • Corticosteroids do not help (?)
  • Zoster vaccine for elderly (?)
  • ZOSTAVAX Zoster Vaccine Live (Oka/Merck)
  • Carbamazepine/TCA/Lidocaine (local)

30
Epilepsy
  • Recurrent seizures.
  • Characteristic electroencephalographic changes
    accompany seizures.
  • Mental status abnormalities or focal neurologic
    symptoms may persist for hours postictally
  • Seizure is a transient disturbance of cerebral
    function

31
Epilepsy
  • Usually begin between 5 and 20
  • Congenital abnormalities and perinatal injuries
  • Alcohol withdrawal/hypo or hyper glycemia
  • Trauma (within 2 years following the injury)
  • Tumors-especially important cause of seizures in
    middle and later life , must be excluded by
    appropriate imaging studies in all patients with
    onset of seizures after 30 years of age

32
RED FLAGS!Epilepsy
  • Epilepsy-Old age
  • Vascular diseases
  • Alzheimer's disease
  • Infectious disease-
  • AIDS

?bacterial meningitis or herpes encephalitis
33
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34
Tests
  • Imaging?-
  • new onset of seizures after the age of 20 years,
  • A chest radiograph should also be obtained in
    such patients, since the lungs are a common site
    for primary or secondary neoplasms.

35
Tests
  • EEG
  • CBC
  • Blood glucose
  • BUN, Creatinine

36
DD
  • TIAs
  • Rage attacks
  • Panic attacks
  • Syncope
  • Cardiac arrhythmias

37
Treatment
  • goal of preventing further attacks and is usually
    continued until there have been no seizures for
    at least 3 years
  • report to the state department of public health
    any patients with seizures or other episodic
    disturbances of consciousness

38
Generalized tonic-clonic (grand mal) or partial
(focal) seizures
  • Phenytoin -Dilantin,
  • Carbamazepine-Tegretol
  • Valproic Acid, Depakene
  • Gabapentin Neurontin
  • Topiramate Topamax
  • Ethosuximide Zarontin
  • Clonazepam Klonopin

39
  • Monitoring serum drug levels has led to major
    advances in the management of seizure disorders
  • Surgical treatment
  • Vagal nerve stimulation
  • Status epilepticus is a medical emergency

40
Sensory Disturbances
  • Peripheral Nerve
  • Nerve roots
  • One limb
  • One half of the body
  • Distal
  • glove stocking

41
Weakness Paralysis 1Upper/Lower motor
neuron2Spinal roots3Plexus4Peripheral nerves
42
UMN LMN
  • Muscle groups involved
  • Spasticity
  • Brisk DTRs
  • Babinskis Sign present
  • Muscle wasting
  • Falccid weak muscle
  • Loss of DTRs
  • Babinskis sign absent
  • Fasciculations present

43
Transient Ischemic Attacks TIAs
  • Focal neurologic deficit of acute onset.
  • Clinical deficit resolves completely within 24
    hours.
  • Risk factors for vascular disease often present.
  • Increased in patients with hypertension or
    diabetes
  • Risk of stroke is highest in the month after a
    transient ischemic attack

44
TIA Causes
  • Emboli- from Carotids
  • Cardiac- atrial fibrillation, post infarction
  • Cervical spondylitis
  • Subclavian steal syndrome bruit in the
    supraclavicular fossa, unequal radial pulses, and
    a difference of 20 mm Hg or more between the
    systolic blood pressures in the arms

45
TIA symptoms
  • Abrupt onset within minutes
  • Rapid recovery
  • Carotid territory - Weakness and heaviness of the
    contralateral arm, leg, or face, singly or in any
    combination.
  • Slowness of movement, dysphasia, or monocular
    visual loss in the eye contralateral to affected
    limbs.

46
Vertebrobasilar ischemic attacks
  • Vertigo, ataxia, diplopia, dysarthria, dimness or
    blurring of vision, perioral numbness and
    paresthesias, and weakness or sensory complaints
    on one, both, or alternating sides of the body

47
TIA risks
  • Carotid ischemic attacks are more liable than
    vertebrobasilar ischemic attacks to be followed
    by stroke
  • Stroke risk is greater in patients older than 60
    years, in diabetics, or after transient ischemic
    attacks that last longer than 10 minutes and with
    symptoms or signs of weakness, speech impairment,
    or gait disturbance.

48
Imaging Tests
  • CT scans
  • Carotid duplex US
  • Aretirography
  • MRI angio less sensitive than conventional

49
Lab Tests
  • Assessment for hypertension, heart disease,
    hematologic disorders, diabetes mellitus,
    hyperlipidemia, and peripheral vascular disease
  • CBC/ Lipids, Cholesterol, Homocysteine/ ECG/ CXR/
    Echo/ Holter

50
Treatment
  • Carotid artery surgery
  • Preventive- Stop smoking/ treat underlying
    disease/
  • If embolic- anticoagulants
  • ?antiplatelet drugs- aspirin 325 mg/ or Plavix
    75 mg (clopidogrel)

51
Strokes
  • Sudden onset of characteristic neurologic
    deficit.
  • Patient often has history of hypertension,
    diabetes mellitus, valvular heart disease, or
    atherosclerosis.
  • Distinctive neurologic signs reflect the region
    of the brain involved.

52
Four Main Types of Strokes
  • Ischemic
  • 1 Cerebral thrombosis (61 of all strokes,
    excluding transient ischemic strokes), a blood
    clot (thrombus) forms in an artery that supplies
    blood to the brain
  • 2 Cerebral embolism (24 of all strokes), a clot
    (embolus) develops in a blood vessel and is
    carried through the bloodstream and becomes
    lodged in a brain artery
  • Thrombosis and embolism account for about 85 of
    strokes. These strokes are ischemic, or caused by
    blood clots, which result in insufficient blood
    circulation.
  • Hemorrhagic
  • 3 Subarachnoid hemorrhage (3 of all strokes), a
    blood vessel on the surface of the brain
    ruptures, causing bleeding into the space between
    the brain and skull
  • 4 Cerebral hemorrhage (9 of all strokes), an
    artery in the brain ruptures, causing bleeding
    into the surrounding brain tissue

53
Strokes
  • Third leading cause of death
  • Risk factors
  • hypertension
  • diabetes
  • hyperlipidemia
  • cigarette smoking
  • cardiac disease
  • AIDS
  • recreational drug abuse
  • heavy alcohol consumption
  • family history of stroke

54
Stroke Classification
  • Infarcts- 85
  • Thrombotic
  • Embolic
  • Hemorrhagic 12

55
Lacunar Infarcts
  • Small (lt5mm) basal ganglia/ pons/
    cerebellum/anterior limb of internal capsule
  • Common in poorly controlled HTN or diabetics
  • Recovery good takes 4-6 weeks
  • Contralateral pure motor or pure sensory deficit
  • Ipsilateral ataxia with crural paresis and
  • Dysarthria with clumsiness of the hand

56
Stroke Assessment
Abrupt onset ?bruit present 1. Anterior 2.
Middle 3. Posterior 4. Vertebro-basilar
  • Anterior cerebral artery
  • Anterior communicating artery
  • Internal carotid artery
  • Posterior communicating artery
  • Middle cerebral artery
  • Posterior cerebral artery
  • Superior cerebellar artery
  • Basilar artery
  • Anterior inferior cerebellar artery
  • Internal carotid artery
  • Vertebral artery
  • Cavernous sinus
  • Carotid canal
  • Anterior cerebral artery
  • Posterior cerebral artery

57
Anterior cerebral artery
  • Weakness and
  • sensory loss in contralateral leg
  • Mild arm weakness
  • Grasp reflex

58
Middle cerebral artery
  • Contralateral hemiplegia
  • Hemisensory loss, and
  • Homonymous hemianopia (i.e., bilaterally
    symmetric loss of vision in half of the visual
    fields), with the eyes deviated to the side of
    the lesion
  • Global aphasia if dominant hemisphere involved

59
Posterior cerebral artery
  • Receptive (Wernicke's)
  • aphasia and
  • A homonymous visual field defect
  • Confusional state
  • Dressing apraxia and
  • Constructional and spatial deficits

The inability to execute a voluntary motor
movement despite being able to demonstrate normal
muscle function. Apraxia is not related to a lack
of understanding or to any kind of physical
paralysis but is caused by a problem in the
cortex of the brain.
60
Vertebrobasilar artery
  • Involuntary movements and
  • Alexia

Loss of the ability to read or understand the
written word
61
Posterior inferior cerebellar artery
  • Ipsilateral spinothalamic sensory loss involving
  • The face, ninth and tenth cranial nerve lesions
  • Limb ataxia and numbness, and
  • Horner's syndrome

62
Superior cerebellar artery
  • The contralateral
  • spinothalamic loss also involves the face
  • And ipsilateral-
  • the face, ninth and tenth cranial nerve lesions
  • limb ataxia and numbness, and
  • Horner's syndrome

63
Anterior inferior cerebellar artery
  • ipsilateral spinothalamic sensory loss involving
    the face, usually in conjunction with ipsilateral
    facial weakness and deafness

64
THROMBOSIS OF ICA
65
Therapy for thrombotic strokes
  • T-pa initiation within 3 hours after stroke
    onset, and the prognosis therefore depends on the
    time that elapses before arrival at the hospital
  • CLOT BUSTERS

Tissue-plasminogen activator Retiplase RETAVASE
66
Intracerebral Hemorrhage
  • Usually due to hypertension
  • Most frequently in the basal ganglia and less
    commonly in the pons, thalamus, cerebellum, and
    cerebral white matter
  • Common in- advancing age and male sex
  • Consciousness is initially lost or impaired in
    about one-half of patients
  • Vomiting

67
Tests/ Treatment
  • CT scanning (superior to MRI) for this
  • Management generally conservative and
    supportive,

68
Subarachnoid Hemorrhage
  • Sudden severe headache.
  • Signs of meningeal irritation usually present.
  • Obtundation is common.
  • Focal deficits frequently absent

69
SUBARACHNOID HEMORRHAGE
  • 5 and 10 of strokes are due to subarachnoid
    hemorrhage
  • sudden headache of a severity never experienced
    previously by the patient
  • May lead to coma and death

70
Brain Tumors
  • Frontal lobe intellectual decline, slowing of
    mental activity, personality changes, and
    contralateral grasp reflexes.
  • Expressive aphasia.
  • Anosmia may also occur as a consequence of
    pressure on the olfactory nerve.

71
Temporal lobe
  • olfactory or gustatory hallucinations
  • licking or smacking of the lips, and some
    impairment of external awareness
  • depersonalization, emotional changes, behavioral
    disturbances, sensations of déjà vu or jamais vu,
    micropsia or macropsia
  • dysnomia and receptive aphasia (L)
  • musical notes and melodies (R)

72
Parietal lobe
  • Sensory loss- postural / tactile discrimination
  • appreciation of shape, size, weight, and texture
    is impaired
  • Objects placed in the hand may not be recognized
    (astereognosis)

73
Parietal lobe
  • Gerstmann's syndrome
  • (a combination of-
  • Alexia
  • Agraphia
  • Acalculia
  • Agnosia (right-left confusion, and finger)

74
Occipital lobe
  • Field defect
  • Visual agnosia both for objects and for colors
  • Color perception, prosopagnosia (inability to
    identify a familiar face)

75
Brainstem and cerebellar
  • Cranial nerve palsies, ataxia, incoordination,
    nystagmus, and pyramidal and sensory deficits in
    the limbs on one or both sides.

76
Tests for Tumors
  • CT scans
  • MRI scans
  • EEG
  • Treatment ? Surgery/ anticonvulsants

77
Neurofibromatosis
  • Multiple hyperpigmented macules (café au lait
    spots ) (chromosome 17 )
  • Eighth nerve tumors
  • (chromosome 22 )
  • Mobile nodules

78
PARKISNOSNS PATHOLOGY
79
Parkinsonism
  • Tremor, rigidity, bradykinesia, progressive
    postural instability.
  • Seborrhea of skin quite common.
  • Mild intellectual deterioration may occur
  • Begins most often between 45 and 65 years of age.

80
Parkinsonism
  • Familial
  • Toxins-manganese, carbon disulfide, carbon
    monoxide poisoning
  • Degeneration of the dopaminergic nigrostriatal
    system
  • Imbalance of dopamine and acetylcholine

81
Parkinsonism
  • Tremor- most conspicuous at rest, less severe
    during voluntary activity
  • Rigidity,
  • Bradykinesia, and
  • Postural instability
  • Immobile face with widened palpebral fissures,
    infrequent blinking, and a certain fixity of
    facial expression.
  • Seborrhea of the scalp and face is common

82
Parkinsonism
  • Sustained blink response (Myerson's sign)
  • Saliva drooling from the mouth
  • Gait itself is characterized by small shuffling
    steps and a loss of the normal automatic arm
    swing

83
Drugs for Parkinsonism
  • Amantadine
  • Cogentin
  • Artane
  • Levodopa /Sinimet
  • Selegeline

84
Huntington's Disease
  • Gradual onset and progression of chorea and
    dementia or behavioral change.
  • Family history of the disorder.
  • Responsible gene identified on chromosome 4 (AD)
  • chorea and dementia
  • 5 per 100,000

85
Huntingtons
  • Onset is usually between 30 and 50 years
  • Fatal outcome within 1520 years
  • Abnormal movements or intellectual changes, but
    ultimately both occur
  • CT scanning usually demonstrates cerebral atrophy
    and atrophy of the caudate nucleus in established
    cases (reduced glucose utilization )

86
Huntington's Disease
  • No cure for Huntington's
  • Relative under activity of neurons containing
    gamma-aminobutyric acid (GABA) and acetylcholine
    or a relative overactivity of dopaminergic
    neurons.

87
Restless Leg Syndrome RLS
  • RLS affects about 10-15 of the general
    population
  • MF
  • Often unrecognized or misdiagnosed.
  • Many patients are not diagnosed until 10-20 years
    after symptom onset.
  • It may begin at any age, even as early as infancy
  • Middle-aged or older are affected severely .
  • Symptoms progress over time in about two thirds
    of patients and may be severe enough to be
    disabling.
  • "pins and needles," an "internal itch," or "a
    creeping or crawling sensation.

88
RLS DIAGNOSTIC CRITERIA
  • A compelling urge to move the limbs, usually
    associated with paresthesias/dysesthesias
  • Motor restlessness, as seen in activities such as
    floor pacing, tossing and turning in bed, and
    rubbing the legs
  • Symptoms worse or exclusively present at rest
    (ie, lying, sitting) with variable and temporary
    relief on activity
  • Circadian variation of symptoms, which are
    present in the evening and at night. Often,
    symptoms are relieved after 500 am. In more
    severe cases, symptoms can be present throughout
    the day without circadian variation.

89
DD for RLS
  • Iron deficiency and peripheral neuropathy
  • Folate or magnesium deficiency
  • Polyneuropathy (either idiopathic or caused by
    alcohol abuse)
  • Amyloidosis
  • Diabetes mellitus
  • Lumbosacral radiculopathy
  • Lyme disease
  • Rheumatoid arthritis, Sjögren syndrome
  • Uremia or
  • Vitamin B-12 deficiency
  • Affects 25-40 of pregnant women

90
Restless Legs Syndrome
  • Idiopathic disorder or in relation to pregnancy,
    iron-deficiency anemia, peripheral neuropathy, or
    periodic leg movements of sleep
  • ? hereditary
  • Irresistible urge to move the limbs, especially
    during periods of relaxation. Disturbed nocturnal
    sleep and excessive daytime somnolences may
    result.
  • clonazepam. Levodopa

91
Gilles de la Tourette's Syndrome
  • Multiple motor (80) and phonic tics. (20)
  • Symptoms begin before age 21 years.
  • Tics occur frequently for at least 1 year.
  • Tics vary in number, frequency, and nature over
    time.
  • Onset ages of 2 and 15.
  • Motor tics face, head, and shoulders (e.g.,
    sniffing, blinking, frowning, shoulder shrugging,
    head thrusting,
  • Phonic tics grunts, barks, hisses,
    throat-clearing, coughs, obscene speech
  • Obsessive-compulsive behaviors
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Title: Neurology


1
Neurology
2
NEUROLOGY
  • CHAPTER 24

3
Symptoms Headache (HA)
  • Acute
  • Age gt 50 years.
  • Rapid onset and severe intensity.
  • Fever.
  • Trauma.
  • Vision changes.
  • Past medical history of hypertension or HIV
    infection.
  • Hypertension.
  • Neurologic findings (mental status changes, motor
    or sensory deficits).

4
Headches
  • Chronic
  • Migraine (pulsating or throbbing),
  • Tension (tightness or pressure ), or
  • Depression
  • Tumor, head injury, cervical spondylosis, dental
    or ocular disease, TM joint dysfunction,
    sinusitis, hypertension

5
Headaches
  • Sharp and lancinating neuralgic
  • Ocular/periorbital-icepick like pain-
    migraine/cluster headaches
  • Dull and steady- tumor
  • Cough aggravated in brain tumors
  • Severe headache in a previously well patient
    rule out- sub arachnoid hemorrhage/ meningitis

6
Headaches
  • Cranial MRI or CT scan required if
  • New onset in middle or later life
  • Progressive
  • Disturb the sleep/related to exertion
  • Associated with neurological deficit

7
Tension Headaches
  • Poor concentration
  • Vague non specific symptoms
  • Vise-like, worse on emotional stress/noise/ glare
    and occurs almost daily
  • Intense around back of the neck head
  • May respond to Tylenol/ or migraine medicine
  • Relaxation therapy/Massage/Hot baths/
    Biofeedback/?Botox

8
Depression HA
  • Worse on waking up
  • Associated depressive symptoms
  • Antidepressants/Psychiatric help

9
Migraine HA
  • Headache, usually pulsatile/dull/throbbing.
  • Nausea, vomiting, photophobia, and phonophobia
    are common
  • Transient neurologic symptoms (commonly visual)
    preceding headache of classic migraine.
  • No preceding aura is common.

10
Migraine
  • Related to serotonin (5-HT)
  • Trigeminal trigger
  • Episodic lateralized throbbing headache
  • Late teen/early adult onset
  • Anorexia/Nausea/Vomiting
  • Visual/Auditory disturbances- gradual build up,
    last several hours
  • External Carotid artery system dilation/pulsation
  • Focal neurological signs/symptoms due to initial
    constriction of ICA

11
Migraine
  • Visual common-
  • field defects
  • luminous visual hallucinations such as stars,
    sparks, unformed light flashes, geometric
    patterns, or zigzags of light
  • Aphasia/numbness/tingling/clumsiness

12
Migraine
  • FH
  • Factors- emotional stress, lack/excess sleep,
    missed meals, specific food items (chocolate,
    alcohol), menses, pill
  • Basilar artery migraine- blindness/visual field
    defects initially and later- tinnitus/perioral
    tingling and transient loss of consciousness/
    confusion followed by throbbing occipital HA,
    nausea/vomiting

13
Migraine Treatment
  • AVOID! Factors
  • Prophylactic treatment aspirin/brufen/allieve
  • Ergot caffeine (vasoconstrictor)
  • Serotonin blocker- Sumatriptan/Zolimtriptan

14
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15
Cluster Headache (Migrainous Neuralgia)
  • Predominantly middle-aged men
  • ?Vascular/?serotonin
  • No FH
  • Unilateral periorbital pain with-
  • ipsilateral nasal congestion,
  • rhinorrhea,
  • lacrimation,
  • redness of the eye, and
  • Horner's syndrome

16
Horner syndrome
  • Results from an interruption of the sympathetic
    nerve supply to the eye, and is characterized by
    the classic triad
  • 1 Miosis (ie, constricted pupil)
  • 2 Partial ptosis and
  • 3 Loss of hemifacial sweating (ie, anhidrosis)

17
Cluster Headache (Migrainous Neuralgia)
  • AT night (wakeup)
  • Lasts lt2hrs
  • Spontaneous remission
  • ?alcohol trigger/ glare/food

18
THERAPY
  • Oxygen (acute attack)
  • Oxygen (8 L/min for 10 min or 100 by mask) may
    abort the headache if used early.
  • Mechanism of action is unknown.
  • Sumatriptan
  • Most studied of the triptans in cluster headache.
  • Subcutaneous injections can be effective, in
    large part, due to the rapidity of onset.
  • No evidence suggests that they are effective
    orally.
  • Dihydroergotamine
  • Can be abortive agent
  • IV/IM self-injections

19
Posttraumatic Headache
  • Closed head injury
  • Worsen over the ensuing weeks, and then gradually
    subsides
  • Disequilibrium, enhanced by postural change or
    head movement
  • Impaired memory, poor concentration, emotional
    instability, and increased irritability
  • Tests not helpful, Treatment difficult

20
?
21
TRIGEMINAL NERVE
22
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23
Trigeminal Neuralgia
  • Brief episodes of stabbing facial pain.
  • Pain is in the territory of the second and third
    division of the trigeminal nerve.
  • Pain exacerbated by touch
  • Middle and later life (FgtM)

24
Trigeminal Neuralgia
  • Sudden lancinating facial pain occur
  • commonly arise near one side of the mouth and
    shoot toward the ear, eye, or nostril on that
    side
  • Trigger-touch, movement, drafts, and eating
  • Pain become more frequent, remissions become
    shorter and less common, and a dull ache may
    persist between the episodes of stabbing pain
  • Confined to the distribution of the trigeminal
    nerve (usually the second or third division

25
Trigeminal Neuralgia
  • Young patient presenting with trigeminal
    neuralgia, multiple sclerosis
  • Tests-evoked potential testing and examination of
    cerebrospinal fluid may be corroborative
  • Treatment- carbamazepine (Tegretol)/ Baclofen/
    Gabapentin
  • Nerve ablation
  • Structural cause for the neuralgia (despite
    normal findings on CT scans, MRI, or
    arteriograms) -surgery

26
TCM Diagnoses and Acupuncture Treatments
  • Etiology Pathology
  • Exterior WIND-COLD Invasion
  • Interior LV/ST FIRE
  • Interior YIN DEFICIENCY w/empty fire rising
  • Differentiation
  • Wind-Cold Invasion
  • Signs Symptoms
  • Acute onset, severe pain for a few seconds to a
    few minutes several times/day
  • Exterior signs, runny nose, tearing
  • Tongue Thin white coat
  • Pulse Tight, floating
  • LV/ST Fire
  • Signs Symptoms
  • Severe pain w/irritability
  • Internal heat signs, thirst, constipation
  • TongueYellow, dry coat
  • Pulse Wiry
  • Yin Deficiency w/empty heat rising
  • Signs Symptoms
  • Pain is more insidious, gradual, comes and goes,
    malar flush, soreness in lumbar area
  • Tongue Red w/no coat
  • Pulse Thin, fast

27
Treatment Points
  • For pain in the supraorbital region
  • Local Taiyang
  • GB14/ UB2
  • Distal TH5 / LI4
  • For pain in the maxillary region
  • Local ST2 / SI 18 / LI 20
  • Distal LI4
  • For pain in the mandibular region
  • Local ST6 / ST 7
  • Extra point 1 cun lateral to CV24
  • Distal LI4
  • Wind-Cold Add GB 20
  • LV/ST Fire Add LV3, possibly LV2, ST44
  • Yin Deficiency Add KD6, SP6

28
Glossopharyngeal Neuralgia
  • Occurs in the throat, about the tonsillar fossa,
    and sometimes deep in the ear and at the back of
    the tongue
  • Precipitated by swallowing, chewing, talking, or
    yawning

29
Postherpetic Neuralgia
  • 15 of patients who develop shingles
  • suffer from postherpetic neuralgia
  • High risk elderly and involvement of
    Ophthalmic (I) division
  • Incidence of postherpetic neuralgia may be
    reduced by the treatment of shingles with oral
    acyclovir or famciclovir (?)
  • Corticosteroids do not help (?)
  • Zoster vaccine for elderly (?)
  • ZOSTAVAX Zoster Vaccine Live (Oka/Merck)
  • Carbamazepine/TCA/Lidocaine (local)

30
Epilepsy
  • Recurrent seizures.
  • Characteristic electroencephalographic changes
    accompany seizures.
  • Mental status abnormalities or focal neurologic
    symptoms may persist for hours postictally
  • Seizure is a transient disturbance of cerebral
    function

31
Epilepsy
  • Usually begin between 5 and 20
  • Congenital abnormalities and perinatal injuries
  • Alcohol withdrawal/hypo or hyper glycemia
  • Trauma (within 2 years following the injury)
  • Tumors-especially important cause of seizures in
    middle and later life , must be excluded by
    appropriate imaging studies in all patients with
    onset of seizures after 30 years of age

32
RED FLAGS!Epilepsy
  • Epilepsy-Old age
  • Vascular diseases
  • Alzheimer's disease
  • Infectious disease-
  • AIDS

?bacterial meningitis or herpes encephalitis
33
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34
Tests
  • Imaging?-
  • new onset of seizures after the age of 20 years,
  • A chest radiograph should also be obtained in
    such patients, since the lungs are a common site
    for primary or secondary neoplasms.

35
Tests
  • EEG
  • CBC
  • Blood glucose
  • BUN, Creatinine

36
DD
  • TIAs
  • Rage attacks
  • Panic attacks
  • Syncope
  • Cardiac arrhythmias

37
Treatment
  • goal of preventing further attacks and is usually
    continued until there have been no seizures for
    at least 3 years
  • report to the state department of public health
    any patients with seizures or other episodic
    disturbances of consciousness

38
Generalized tonic-clonic (grand mal) or partial
(focal) seizures
  • Phenytoin -Dilantin,
  • Carbamazepine-Tegretol
  • Valproic Acid, Depakene
  • Gabapentin Neurontin
  • Topiramate Topamax
  • Ethosuximide Zarontin
  • Clonazepam Klonopin

39
  • Monitoring serum drug levels has led to major
    advances in the management of seizure disorders
  • Surgical treatment
  • Vagal nerve stimulation
  • Status epilepticus is a medical emergency

40
Sensory Disturbances
  • Peripheral Nerve
  • Nerve roots
  • One limb
  • One half of the body
  • Distal
  • glove stocking

41
Weakness Paralysis 1Upper/Lower motor
neuron2Spinal roots3Plexus4Peripheral nerves
42
UMN LMN
  • Muscle groups involved
  • Spasticity
  • Brisk DTRs
  • Babinskis Sign present
  • Muscle wasting
  • Falccid weak muscle
  • Loss of DTRs
  • Babinskis sign absent
  • Fasciculations present

43
Transient Ischemic Attacks TIAs
  • Focal neurologic deficit of acute onset.
  • Clinical deficit resolves completely within 24
    hours.
  • Risk factors for vascular disease often present.
  • Increased in patients with hypertension or
    diabetes
  • Risk of stroke is highest in the month after a
    transient ischemic attack

44
TIA Causes
  • Emboli- from Carotids
  • Cardiac- atrial fibrillation, post infarction
  • Cervical spondylitis
  • Subclavian steal syndrome bruit in the
    supraclavicular fossa, unequal radial pulses, and
    a difference of 20 mm Hg or more between the
    systolic blood pressures in the arms

45
TIA symptoms
  • Abrupt onset within minutes
  • Rapid recovery
  • Carotid territory - Weakness and heaviness of the
    contralateral arm, leg, or face, singly or in any
    combination.
  • Slowness of movement, dysphasia, or monocular
    visual loss in the eye contralateral to affected
    limbs.

46
Vertebrobasilar ischemic attacks
  • Vertigo, ataxia, diplopia, dysarthria, dimness or
    blurring of vision, perioral numbness and
    paresthesias, and weakness or sensory complaints
    on one, both, or alternating sides of the body

47
TIA risks
  • Carotid ischemic attacks are more liable than
    vertebrobasilar ischemic attacks to be followed
    by stroke
  • Stroke risk is greater in patients older than 60
    years, in diabetics, or after transient ischemic
    attacks that last longer than 10 minutes and with
    symptoms or signs of weakness, speech impairment,
    or gait disturbance.

48
Imaging Tests
  • CT scans
  • Carotid duplex US
  • Aretirography
  • MRI angio less sensitive than conventional

49
Lab Tests
  • Assessment for hypertension, heart disease,
    hematologic disorders, diabetes mellitus,
    hyperlipidemia, and peripheral vascular disease
  • CBC/ Lipids, Cholesterol, Homocysteine/ ECG/ CXR/
    Echo/ Holter

50
Treatment
  • Carotid artery surgery
  • Preventive- Stop smoking/ treat underlying
    disease/
  • If embolic- anticoagulants
  • ?antiplatelet drugs- aspirin 325 mg/ or Plavix
    75 mg (clopidogrel)

51
Strokes
  • Sudden onset of characteristic neurologic
    deficit.
  • Patient often has history of hypertension,
    diabetes mellitus, valvular heart disease, or
    atherosclerosis.
  • Distinctive neurologic signs reflect the region
    of the brain involved.

52
Four Main Types of Strokes
  • Ischemic
  • 1 Cerebral thrombosis (61 of all strokes,
    excluding transient ischemic strokes), a blood
    clot (thrombus) forms in an artery that supplies
    blood to the brain
  • 2 Cerebral embolism (24 of all strokes), a clot
    (embolus) develops in a blood vessel and is
    carried through the bloodstream and becomes
    lodged in a brain artery
  • Thrombosis and embolism account for about 85 of
    strokes. These strokes are ischemic, or caused by
    blood clots, which result in insufficient blood
    circulation.
  • Hemorrhagic
  • 3 Subarachnoid hemorrhage (3 of all strokes), a
    blood vessel on the surface of the brain
    ruptures, causing bleeding into the space between
    the brain and skull
  • 4 Cerebral hemorrhage (9 of all strokes), an
    artery in the brain ruptures, causing bleeding
    into the surrounding brain tissue

53
Strokes
  • Third leading cause of death
  • Risk factors
  • hypertension
  • diabetes
  • hyperlipidemia
  • cigarette smoking
  • cardiac disease
  • AIDS
  • recreational drug abuse
  • heavy alcohol consumption
  • family history of stroke

54
Stroke Classification
  • Infarcts- 85
  • Thrombotic
  • Embolic
  • Hemorrhagic 12

55
Lacunar Infarcts
  • Small (lt5mm) basal ganglia/ pons/
    cerebellum/anterior limb of internal capsule
  • Common in poorly controlled HTN or diabetics
  • Recovery good takes 4-6 weeks
  • Contralateral pure motor or pure sensory deficit
  • Ipsilateral ataxia with crural paresis and
  • Dysarthria with clumsiness of the hand

56
Stroke Assessment
Abrupt onset ?bruit present 1. Anterior 2.
Middle 3. Posterior 4. Vertebro-basilar
  • Anterior cerebral artery
  • Anterior communicating artery
  • Internal carotid artery
  • Posterior communicating artery
  • Middle cerebral artery
  • Posterior cerebral artery
  • Superior cerebellar artery
  • Basilar artery
  • Anterior inferior cerebellar artery
  • Internal carotid artery
  • Vertebral artery
  • Cavernous sinus
  • Carotid canal
  • Anterior cerebral artery
  • Posterior cerebral artery

57
Anterior cerebral artery
  • Weakness and
  • sensory loss in contralateral leg
  • Mild arm weakness
  • Grasp reflex

58
Middle cerebral artery
  • Contralateral hemiplegia
  • Hemisensory loss, and
  • Homonymous hemianopia (i.e., bilaterally
    symmetric loss of vision in half of the visual
    fields), with the eyes deviated to the side of
    the lesion
  • Global aphasia if dominant hemisphere involved

59
Posterior cerebral artery
  • Receptive (Wernicke's)
  • aphasia and
  • A homonymous visual field defect
  • Confusional state
  • Dressing apraxia and
  • Constructional and spatial deficits

The inability to execute a voluntary motor
movement despite being able to demonstrate normal
muscle function. Apraxia is not related to a lack
of understanding or to any kind of physical
paralysis but is caused by a problem in the
cortex of the brain.
60
Vertebrobasilar artery
  • Involuntary movements and
  • Alexia

Loss of the ability to read or understand the
written word
61
Posterior inferior cerebellar artery
  • Ipsilateral spinothalamic sensory loss involving
  • The face, ninth and tenth cranial nerve lesions
  • Limb ataxia and numbness, and
  • Horner's syndrome

62
Superior cerebellar artery
  • The contralateral
  • spinothalamic loss also involves the face
  • And ipsilateral-
  • the face, ninth and tenth cranial nerve lesions
  • limb ataxia and numbness, and
  • Horner's syndrome

63
Anterior inferior cerebellar artery
  • ipsilateral spinothalamic sensory loss involving
    the face, usually in conjunction with ipsilateral
    facial weakness and deafness

64
THROMBOSIS OF ICA
65
Therapy for thrombotic strokes
  • T-pa initiation within 3 hours after stroke
    onset, and the prognosis therefore depends on the
    time that elapses before arrival at the hospital
  • CLOT BUSTERS

Tissue-plasminogen activator Retiplase RETAVASE
66
Intracerebral Hemorrhage
  • Usually due to hypertension
  • Most frequently in the basal ganglia and less
    commonly in the pons, thalamus, cerebellum, and
    cerebral white matter
  • Common in- advancing age and male sex
  • Consciousness is initially lost or impaired in
    about one-half of patients
  • Vomiting

67
Tests/ Treatment
  • CT scanning (superior to MRI) for this
  • Management generally conservative and
    supportive,

68
Subarachnoid Hemorrhage
  • Sudden severe headache.
  • Signs of meningeal irritation usually present.
  • Obtundation is common.
  • Focal deficits frequently absent

69
SUBARACHNOID HEMORRHAGE
  • 5 and 10 of strokes are due to subarachnoid
    hemorrhage
  • sudden headache of a severity never experienced
    previously by the patient
  • May lead to coma and death

70
Brain Tumors
  • Frontal lobe intellectual decline, slowing of
    mental activity, personality changes, and
    contralateral grasp reflexes.
  • Expressive aphasia.
  • Anosmia may also occur as a consequence of
    pressure on the olfactory nerve.

71
Temporal lobe
  • olfactory or gustatory hallucinations
  • licking or smacking of the lips, and some
    impairment of external awareness
  • depersonalization, emotional changes, behavioral
    disturbances, sensations of déjà vu or jamais vu,
    micropsia or macropsia
  • dysnomia and receptive aphasia (L)
  • musical notes and melodies (R)

72
Parietal lobe
  • Sensory loss- postural / tactile discrimination
  • appreciation of shape, size, weight, and texture
    is impaired
  • Objects placed in the hand may not be recognized
    (astereognosis)

73
Parietal lobe
  • Gerstmann's syndrome
  • (a combination of-
  • Alexia
  • Agraphia
  • Acalculia
  • Agnosia (right-left confusion, and finger)

74
Occipital lobe
  • Field defect
  • Visual agnosia both for objects and for colors
  • Color perception, prosopagnosia (inability to
    identify a familiar face)

75
Brainstem and cerebellar
  • Cranial nerve palsies, ataxia, incoordination,
    nystagmus, and pyramidal and sensory deficits in
    the limbs on one or both sides.

76
Tests for Tumors
  • CT scans
  • MRI scans
  • EEG
  • Treatment ? Surgery/ anticonvulsants

77
Neurofibromatosis
  • Multiple hyperpigmented macules (café au lait
    spots ) (chromosome 17 )
  • Eighth nerve tumors
  • (chromosome 22 )
  • Mobile nodules

78
PARKISNOSNS PATHOLOGY
79
Parkinsonism
  • Tremor, rigidity, bradykinesia, progressive
    postural instability.
  • Seborrhea of skin quite common.
  • Mild intellectual deterioration may occur
  • Begins most often between 45 and 65 years of age.

80
Parkinsonism
  • Familial
  • Toxins-manganese, carbon disulfide, carbon
    monoxide poisoning
  • Degeneration of the dopaminergic nigrostriatal
    system
  • Imbalance of dopamine and acetylcholine

81
Parkinsonism
  • Tremor- most conspicuous at rest, less severe
    during voluntary activity
  • Rigidity,
  • Bradykinesia, and
  • Postural instability
  • Immobile face with widened palpebral fissures,
    infrequent blinking, and a certain fixity of
    facial expression.
  • Seborrhea of the scalp and face is common

82
Parkinsonism
  • Sustained blink response (Myerson's sign)
  • Saliva drooling from the mouth
  • Gait itself is characterized by small shuffling
    steps and a loss of the normal automatic arm
    swing

83
Drugs for Parkinsonism
  • Amantadine
  • Cogentin
  • Artane
  • Levodopa /Sinimet
  • Selegeline

84
Huntington's Disease
  • Gradual onset and progression of chorea and
    dementia or behavioral change.
  • Family history of the disorder.
  • Responsible gene identified on chromosome 4 (AD)
  • chorea and dementia
  • 5 per 100,000

85
Huntingtons
  • Onset is usually between 30 and 50 years
  • Fatal outcome within 1520 years
  • Abnormal movements or intellectual changes, but
    ultimately both occur
  • CT scanning usually demonstrates cerebral atrophy
    and atrophy of the caudate nucleus in established
    cases (reduced glucose utilization )

86
Huntington's Disease
  • No cure for Huntington's
  • Relative under activity of neurons containing
    gamma-aminobutyric acid (GABA) and acetylcholine
    or a relative overactivity of dopaminergic
    neurons.

87
Restless Leg Syndrome RLS
  • RLS affects about 10-15 of the general
    population
  • MF
  • Often unrecognized or misdiagnosed.
  • Many patients are not diagnosed until 10-20 years
    after symptom onset.
  • It may begin at any age, even as early as infancy
  • Middle-aged or older are affected severely .
  • Symptoms progress over time in about two thirds
    of patients and may be severe enough to be
    disabling.
  • "pins and needles," an "internal itch," or "a
    creeping or crawling sensation.

88
RLS DIAGNOSTIC CRITERIA
  • A compelling urge to move the limbs, usually
    associated with paresthesias/dysesthesias
  • Motor restlessness, as seen in activities such as
    floor pacing, tossing and turning in bed, and
    rubbing the legs
  • Symptoms worse or exclusively present at rest
    (ie, lying, sitting) with variable and temporary
    relief on activity
  • Circadian variation of symptoms, which are
    present in the evening and at night. Often,
    symptoms are relieved after 500 am. In more
    severe cases, symptoms can be present throughout
    the day without circadian variation.

89
DD for RLS
  • Iron deficiency and peripheral neuropathy
  • Folate or magnesium deficiency
  • Polyneuropathy (either idiopathic or caused by
    alcohol abuse)
  • Amyloidosis
  • Diabetes mellitus
  • Lumbosacral radiculopathy
  • Lyme disease
  • Rheumatoid arthritis, Sjögren syndrome
  • Uremia or
  • Vitamin B-12 deficiency
  • Affects 25-40 of pregnant women

90
Restless Legs Syndrome
  • Idiopathic disorder or in relation to pregnancy,
    iron-deficiency anemia, peripheral neuropathy, or
    periodic leg movements of sleep
  • ? hereditary
  • Irresistible urge to move the limbs, especially
    during periods of relaxation. Disturbed nocturnal
    sleep and excessive daytime somnolences may
    result.
  • clonazepam. Levodopa

91
Gilles de la Tourette's Syndrome
  • Multiple motor (80) and phonic tics. (20)
  • Symptoms begin before age 21 years.
  • Tics occur frequently for at least 1 year.
  • Tics vary in number, frequency, and nature over
    time.
  • Onset ages of 2 and 15.
  • Motor tics face, head, and shoulders (e.g.,
    sniffing, blinking, frowning, shoulder shrugging,
    head thrusting,
  • Phonic tics grunts, barks, hisses,
    throat-clearing, coughs, obscene speech
  • Obsessive-compulsive behaviors
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