Neurologic Disorders Chapters 14 PDF

Chapter 14 Neurologic Disorders 0 of 82  The Nervous System (1/3)  A complex regulatory network Neurons (nerve cells) Nerves Brain Spinal cord  Divisions Central nervous system Peripheral nervous system...

Chapter 14 Neurologic Disorders 0 of 82  The Nervous System (1/3)  A complex regulatory network Neurons (nerve cells) Nerves Brain Spinal cord  Divisions Central nervous system Peripheral nervous system Somatic → voluntary Autonomic → involuntary  Sympathetic  Parasympathetic 1 of 82  The Nervous System (2/3)  Causes of dysfunction Vascular compromise Trauma Infection Inherited defects Congenital defects Degenerative disorders Tumors 2 of 82  The Nervous System (3/3)  Assessment Evaluating neurologic status & cognitive function Medical history  Including any medications Mental functions  Speech, language, and writing skills  Alert and oriented by person, place and time → “A&Ox3” Cranial nerve function  Sense of smell, vision, taste hearing, swallowing, etc. Motor function  Muscle strength and tone Coordination and balance Sensory function  Diminished or abnormal sensation MRS  Muscle - reflexes - sensation 3 of 82 Vascular Disorders 4 of 82 Cerebrovascular Accident (CVA/Stroke) (1/3)  Sudden blood flow disruption Blockage or bleeding  Result Brain damage  Causes Atherosclerosis plaque Blood clot (cerebral thrombosis) Cerebral embolism Cerebral hemorrhage Aneurysm rupture Hypertension 5 of 82 Cerebrovascular Accident (CVA/Stroke) (2/3)  Symptoms Severe HA Aphasia Partial/total loss of ability to produce/comprehend language Hemiparesis → unilateral weakness Numbness Hemiplegia → unilateral paralysis Confusion, impaired consciousness Loss or blurred vision Diplopia → double vision Dizziness → loss of balance or coordination 6 of 82 Cerebrovascular Accident (CVA/Stroke) (3/3)  Treatment Intervention within three hours may limit damage Oral aspirin (chew and swallow quickly) Anticoagulants - warfarin (Coumadin) Surgery to improve circulation and remove clots  Prevention Risk factors Smoking Excesses trans fat, high blood cholesterol Excess alcohol High blood pressure Diabetes 7 of 82  Transient Ischemic Attack (TIA)  Temporary impairment of neurologic function Inadequate blood flow Thrombosis, embolism, narrowing  Symptoms Sudden hemiparesis Dizziness, dysphagia, confusion  Diagnosis History, PE, MRI, CT, EEG  Treatment Aspirin, anticoagulants Possible surgery to increase blood flow  40% of TIA’s lead to stroke 8 of 82 Traumatic Disorders 9 of 82 Epidural and Subdural Hematomas (1/2)  Epidural hematoma Blood accumulates between skull and dura mater  Subdural hematoma Blood accumulates below the dura mater  Cause Trauma 10 of 82 Epidural and Subdural Hematomas (2/2)  Symptoms appear within a few hours Sudden headache Dilated pupils Nausea and vomiting Drowsiness Possible hemiparesis – weakness of ½ body  Treatment, if: Unconsciousness Burr hole craniotomy  Hole drilled in skull to relieve pressure Conscious Immediate medical attention for monitoring 11 of 82  Cerebral Concussion (1/2)  Aka: Mild traumatic brain injury Short duration loss of brain function Resolves spontaneously Normal function/activities may be interrupted No structural damage to brain  Result: Diffuse Axonal Injury Axonal shearing  Cause Blunt force trauma Hyperextension/hyperflexion 12 of 82  Cerebral Concussion (2/2)  Symptoms HA, dizziness, nausea/vomiting, slurred speech Blurred vision, photophobia, irritability Poor concentration, emotional changes or instability Difficulty answering questions or following directions Personality changes If loss of consciousness Possible period of amnesia Shallow respiration, slower pulse, flaccid muscle tone  Diagnosis Complete neurological examination, CT  Treatment Bed rest, observation for behavioral changes 13 of 82  Cerebral Contusion  Bruising of brain tissue Coup injury → initial impact site Contrecoup injury → opposite impact Severe Diffuse Axonal Injury  Symptoms Vary → site, extent of injury Conscious → temporary unconsciousness → coma When conscious Severe HA, hemiparesis, drowsiness, lethargy, combative  Diagnosis Complete neurological examination, CT  Treatment Hospitalization to monitor vital signs 14 of 82  Depressed Skull Fracture  Fractured bones are depressed Below normal skull level  Cause Trauma  Symptoms 25% → conscious 25% → unconscious < 1 hour 50% → unconscious > 1 hour Varies based upon site of fracture Similar to cerebral contusion  Treatment Relieve any intracranial pressure Craniotomy to raise depressed bone 15 of 82  Spinal Cord Injuries: Paraplegia and Quadriplegia (1/3)  Paraplegia Loss of neural function Below waist S/S Loss of motor & sensory control Loss of bladder, bowel, sexual function  Quadriplegia Loss of neural function Below the cervical region S/S Loss of motor and sensory control below neck Low blood pressure (hypotension) High body temperature (hyperthermia) Slow heart rate (bradycardia) Respiratory dysfunction 16 of 82  Spinal Cord Injuries: Paraplegia and Quadriplegia (2/3)  Causes Compression of vertebrae T1 and below  Paraplegia Hyperflexion of neck C5 or above  Quadriplegia Hyperextension of spine Above C3  Usually fatal 17 of 82  Spinal Cord Injuries: Paraplegia and Quadriplegia (3/3)  Diagnosis Neurological assessment Spinal radiographs MRI CT  Treatment Surgery Restore normal alignment and stability of spine Decompress spinal cord, nerves, and vertebrae Rehabilitation Medication Treat signs and symptoms 18 of 82 Degenerative Disorders 19 of 82 Degenerative Disc Disease (DDD) (1/2)  Degeneration of intervertebral discs  Cause Long term wear Spinal misalignment  Symptoms Myelopathy vs Radiculopathy Pain, numbness Burning along nerve path Possible weakness Possible motor function loss  Diagnosis X-ray, MRI, CT 20 of 82 Degenerative Disc Disease (DDD) (2/2)  Treatment Acute cases Rest, bracing Analgesics NSAID’s Aspirin, ibuprofen (Motrin, Advil) Celebrex, naproxen (Aleve, Anaprox) HMP, cryotherapy, EMS, U/S Spinal manipulation/mobilization Acupuncture, massage therapy Surgery Laminectomy, laminotomy, spinal fusion  Continuous flow of morphine for “Failed Back Syndrome” 21 of 82  Herniated and Bulging Disc (1/2)  Herniated disc Annulus fibrosus disruption Nucleus pulposus migration  Bulging disc Weak annulus fibrosus Nucleus pulposus/annulus bulge  Causes Sudden trauma Improper lifting biomechanics Poor posture Age (DDD) Spinal misalignment 22 of 82  Herniated and Bulging Disc (2/2)  Symptoms Myelopathy vs Radiculopathy Mild to severe back pain Pain radiates to buttocks, thigh, leg, foot Possible motor disability  Treatment Conservative Bed rest, heat and cryotherapy Muscle relaxants, analgesics, bracing Spinal manipulation/mobilization Advanced Surgery  Discectomy, laminectomy, laminotomy, spinal fusion  Continuous flow of morphine for “Failed Back Syndrome”23 of 82 Sciatic Nerve Injury: Spinal Stenosis (1/2)  Pressure on sciatic nerve Sciatica  Cause Canal narrowing Trauma Degeneration HNP at L4 - S1 levels  Symptoms Sharp, radiating pain LB down leg to foot Numbness, pain LB, buttocks, thighs, calves Difficulty sitting or standing 24 of 82 Sciatic Nerve Injury: Spinal Stenosis (2/2)  Treatment Bed rest, HMP, cryotherapy EMS, U/S Back bracing Spinal manipulation, acupuncture, massage therapy Physical therapy Analgesics, muscle relaxants, anti-inflammatories Strengthening core muscles Surgery Discectomy Laminectomy Laminotomy Spinal fusion 25 of 82 Functional Disorders 26 of 82  Headache (1/2)  Pain in head Not confined to specific nerve region  Types Tension headache → muscle strain Vascular headache → blood vessel pressure  Symptoms Pain Dull to severe pain; constant or intermittent; throbbing, pressure May signal underlying disorder Hypertension, stroke, brain tumor, or encephalitis  Treatment Analgesics, muscle relaxants, tranquilizers Massage, cervical spinal manipulation, dietary changes 27 of 82  Botox Prophylactic therapy Mechanism unclear Headache (2/2) Possible analgesic effect on peripheral nerves and muscles  Migraine Periodic, severe, incapacitating headaches Symptoms Bilateral throbbing pain, nausea/vomiting, photosensitive, auras Cause Possible decrease in serotonin  Causes trigeminal nerve to release inflammatory chemicals  Result in meningeal blood vessel dilation and inflammation Triggers Hormones, food, stress, sensory stimuli, sleep irregularities Physical activity, environmental changes, drugs Treatment Bed rest, relaxation therapy, biofeedback, analgesics Antiemetics, vasoconstrictors, abortive/preventive meds. 28 of 82  Epilepsy (1/2)  Sudden, abnormal, intense, electrical activity in brain Chronic disorder  Causes Scar tissue on cerebral cortex → infection or trauma Tumor, cerebral edema Stroke Birth trauma (cerebral palsy) Drug toxicity (alcoholism) Idiopathic  Seizures classification Partial Generalized 29 of 82  Epilepsy (2/2)  Symptoms Partial seizure Involve motor activity  Twitching, lip smacking, picking at clothing Sensory auras, amnesia of attack Generalized seizures Absence attacks (petit mal)  Frequent, transient lapse of consciousness (rarely have spasms) Tonic-clonic attacks (grand mal)  Spasms and loss of consciousness  Treatment Anticonvulsive medications Surgery (rare) remove brain lesion 30 of 82  Tremors (1/6)  Involuntary, rhythmic muscle contraction Shaking in one or more parts of the body Often affects hands, arms, head, vocal cords, torso and legs Intermittent or constant May occur on its own or as a result of another disorder  Common - 40+ yrs., may occur at any age  Affects men and women equally  Not life threatening  Can be embarrassing  Can be disabling Impacting ADL’s and work 31 of 82  Tremors (2/6)  Classification by type (2 types) 1. Resting tremor - occurs when the muscle is relaxed 2. Action tremor (majority) - occurs with movement Postural - while maintaining a position against gravity Kinetic - any voluntary movement Intention - with purposeful movement toward a target Task-specific - only when performing highly-skilled tasks Isometric - voluntary muscle contraction not accompanied by any movement 32 of 82  Tremors (3/6)  Classification by etiology (8 types) 1. Essential tremor (aka - benign or familial) Most common movement disorder Exact cause unknown: 50% possibly genetic Bilateral but more in dominant hand Both active and resting 2. Dystonic tremor Individuals with dystonia  Movement disorder with abnormal brain activity causing overactive muscles 3. Cerebellar tremor Damage to the cerebellum  Stroke, tumor, MS, inherited ataxia (lose of arm & leg control)  Chronic damage to cerebellum due to alcoholism 33 of 82  Tremors (4/6) 4. Psychogenic tremor (aka functional tremor) Can appear as any form of tremor Increases with stress and decreases when distracted Underlying psychiatric disorder (depression or PTSD) 5. Physiologic tremor Occurs in all healthy individuals Rarely visible Typically fine shaking of both hands and the fingers Not a disease - normal human phenomenon Result from heart beat and other muscle activity 6. Enhanced physiological tremor More noticeable case of physiologic tremor - easily seen Not caused by a neurological disease Due to certain drugs, alcohol withdrawal, or medical 34 of 82 condition  Tremors (5/6) 7. Parkinsonian tremor Seen with approximately 65% of Parkinson’s patients In one or both hands at rest, lips, face, and legs Initially in one limb or on one side – often spreads to both 8. Orthostatic tremor Rare - cause unknown Rapid muscle contractions in legs that occur when standing  May not visible Causes unsteadiness or imbalance (wanting to sit or walk)  Diagnosis Physical and neurological examination, medical history Electromyogram Diagnose muscle vs. nerve problems Measures involuntary muscle response to nerve stimulation 35 of 82  Tremors (6/6)  Treatment Medication Anti-seizure, tranquilizers, Botulinum toxin, Parkinson’s meds. Surgery Deep brain stimulation  Surgically implanted electrodes send signals to thalamus – Motor nuclei Thalamotomy  Precise, permanent destruction of tiny area in thalamus – Motor nuclei Radiofrequency ablation  When deep brain surgery is contraindicated Focused ultrasound MRI guided US beam to damage problem area of thalamus Lifestyle changes 36 of 82  Parkinson Disease (1/2)  Neurodegenerative disorder  Affects movement  Slow and progressive  ~78% develop dementia  Symptoms Resting tremor Weakness of resting muscles Shuffling gait  Cause Substantia nigra cells (midbrain) Decreased dopamine secretion Reason is unclear Genetic anomaly or environmental toxins 37 of 82  Parkinson Disease (2/2)  Symptoms Body flexed forward, prone to falling Shuffling (quickening) gait (festinating gait) Pill-rolling (tremor of thumb and forefinger) Expressionless (mask-like), muffled speech, dysphagia Sleep issues Tremor  Treatment Insomnia Nightmares Excessive daytime sleepiness No cure (manage symptoms) Sleep attacks Physical therapy Sudden, involuntary episodes of sleep REM sleep disorder Drug therapy Acting out dreams during sleep Periodic leg movement disorder (PLMD) Restless legs syndrome (RLS)  Levodopa and Carbidopa Sleep apnea  Antidepressants Nocturia (frequent nighttime urination)  Anticholinergics (for tremor and rigidity) Shorter life expectancy due to complications Pneumonia most common cause of death 38 of 82  Huntington’s Disease (Chorea)  Progressive atrophy of cerebral cortex & basal ganglia Basal ganglia regulates motor function and cognition  Cause Autosomal dominant disorder  Symptoms Early → mild loss of muscle control → fidgeting to lip smacking Later → involuntary writhing → chorea Speech difficulties Mental state Personality changes, moody, loss of memory, paranoia, dementia  Treatment No cure → avg. LE from DX at 20 yrs. → 10 to 30 yrs. Treatment → symptoms Medication → erratic movement and agitation Eventually residential care 39 of 82 Amyotrophic Lateral Sclerosis (1/2)  Progressive atrophy of CNS motor neurons Lou Gehrig’s Disease Stephen Hawking (Diagnosed at 21 yrs. → Given 2 yrs. to live) Survived 55 years → Death at age 76 (March 14, 2018)  Cause Inherited (10%) Free radicals Autoimmune High glutamate levels Common neurotransmitter Should be absorbed once used Continues stimulating nerves Nerves become overexcited and die 40 of 82 Amyotrophic Lateral Sclerosis (2/2)  Symptoms Early → small, involuntary contractions (fasciculations) Usually forearms and hands Late → muscle atrophy Difficulties → Speech, Swallowing, Chewing, Breathing  Treatment No cure (avg. LE – 2 to 5 yrs. from diagnosis) Medication → symptoms Drug therapy Maintaining pulmonary function Death Respiratory failure Malnutrition and dehydration → inability to swallow 41 of 82  Multiple Sclerosis (MS) (1/5)  Progressive demyelination of neurons In brain, spinal cord, and cranial nerves  Loss of myelin May affect motor, sensory, and autonomic fibers Occurs in diffuse patches in the nervous system  Early lesions Inflammatory response Loss of myelin in white matter of brain or spinal cord  Late lesions Plaques Larger, variable size areas of inflammation/demyelination Often beside the lateral ventricles, brainstem, optic nerve 42 of 82  Multiple Sclerosis (MS) (2/5)  Onset usually occurs between ages 20 and 40  Cause unknown Possibly autoimmune disease Possibly nutritional deficit Possibly change in blood flow to neurons Possibly → Genetic, immunologic, environmental Family members at increased risk 43 of 82  Multiple Sclerosis (MS) (3/5)  Types of MS Variation in effects, severity, and progression Relapsing remitting (RRMS)  Onset → remission → relapse → remission → relapse → etc. – Unpredictable with months to years of remission Secondary progressive (SPMS)  Onset → remission → progression – No additional remission – Usually develops from RRMS Primary progressive (PPMS)  Onset → progression – No remission from onset Progressive relapsing (PRMS)  Onset → progresses slowly → occasional (exacerbations) – No remission from onset 44 of 82  Multiple Sclerosis (MS) (4/5)  Possible signs and symptoms Determined by areas of demyelination Blurred vision Weakness in legs Diplopia (double vision) Scotoma (spot in visual field) Dysarthria Paresthesia - areas of numbness, burning, tingling Progressive weakness and paralysis extending to upper limbs Loss of coordination Bladder dysfunction Bowel dysfunction Sexual dysfunction Chronic fatigue 45 of 82  Multiple Sclerosis (MS) (5/5)  Diagnostic tests No definite test MRI for diagnosis and monitoring Lumbar puncture Elevated: IgG’s, oligoclonal bands proteins, myelin products Evoke potential testing – nerve stimuli response time  Treatment No definitive treatment Corticosteroids (natural & synthetic) - anti-inflammatory Reduce inflammation Beta interferon - natural anti-inflammatory Physical therapy Occupational therapy 46 of 82  Progressive Multifocal Leukoencephalopathy (PML) (1/2)  Cause Polyomavirus JC (John Cunningham) JC virus Carried by 70 – 90% and harmless Except immunocompromised Targets oligodendrocytes – myelin – brain white matter  Risk Chronic steroid or immunosuppressive therapy Organ transplant, leukemia, lymphoma, HIV/AIDS Autoimmune disease – MS, RA, SLE  Signs/symptoms Weeks to months Clumsiness; weakness; visual, speech, personality changes Progression leads to life-threatening disability and death 47 of 82  Progressive Multifocal Leukoencephalopathy (PML) (2/2)  Diagnosis Brain biopsy Observations consistent with MRI & JVC IN spinal fluid  Treatment No effective drugs Reversal of immune-deficient state Plasma exchange to removal drugs putting patients at risk HIV-associated PML - immediately anti-retroviral therapy Hexadecyloxypropyl-Cidofovir (CMX001)  Currently being studied - suppress JVC viral DNA replication  Prognosis 30-50 percent in first months following diagnosis Survivors often have severe neurological disabilities https://www.ninds.nih.gov/Disorders/All-Disorders/Progressive-Multifocal- 48 of 82 Leukoencephalopathy-Information-Page#disorders-r1  Transient Global Amnesia  Temporary amnesia; short duration (few hours)  Cause → unclear Stress or emotional events Previous migraines Swimming or immersion in cold water  Symptoms Sudden, permanent memory loss of past few hours to days Does not affect self-identity Cannot form new memories while impaired No recall while impaired Confusion, repetitive questioning Prognosis good; recurrence unlikely 49 of 82 Peripheral Nerve Disorders 50 of 82  Peripheral Neuritis (1/2)  Nerve degeneration in extremities Muscle weakness Sensory loss  Causes Chronic alcohol use Nutritional deficiency B vitamins , vitamin E Infectious diseases (mumps, pneumonia, diphtheria) Toxicity (arsenic, lead, mercury, etc.) Metabolic disease Metabolic syndrome Diabetes Inflammatory diseases Rheumatoid arthritis, gout, lupus 51 of 82  Peripheral Neuritis (2/2)  Symptoms Loss of sensation in hands and feet → clumsiness Loss of muscle tone → foot drop Glossy or red appearance to skin (trophic changes) Due to interruption in innervation Decreased sweating  Treatment Eliminate toxin exposure Correct nutritional deficiencies Control underlying diseases Stop chronic alcohol use Physical therapy Analgesics 52 of 82 Complex Regional Pain Syndromes (CRPS) (1/2)  Variable, chronic progressive pain conditions Vascular changes, sweating, swelling in pain area Usually arm/leg → difficult to move → may migrates May be self-limiting  Types CRPS I - Reflex Sympathetic Dystrophy (RSD) Non-Nerve injury → skin, bone, joints, soft tissue injury CRPS II - Causalgia Nerve injury → minor or major injury Cause Not clear Seen post-surgically Some CRPS cases involved the sympathetic nervous system 53 of 82 Complex Regional Pain Syndromes (CRPS) (2/2)  Sympathetically-Maintained Pain (SMP) Sympathetic Nervous System (SNS) maintains pain Diagnosis with sympathetic nerve block Pain stops → sympathetic pain  Sympathetically Independent Pain (SIP) CRPS pain not caused by sympathetic nerves (SNS) On SNS brain may perpetuate pain 54 of 82 Trigeminal Neuralgia (Tic Douloureux) (1/2)  Cranial Nerve 5 pain Trigeminal nerve Sensory (Motor for mastication)  Cause Usually none identified Possibly Tumor Nerve compression MS Shingles  Varicella-zoster virus – Causes chickenpox 55 of 82 Trigeminal Neuralgia (Tic Douloureux) (2/2)  Symptoms Sudden excruciating pain Ophthalmic branch → eye and forehead Maxillary branch → nose, upper lip, and cheek Mandibular branch → lower jaw, tongue, cheek near ear  Treatment Analgesics Nerve block injections Surgery to dissect nerve roots 56 of 82  Bell’s Palsy (1/2)  Cranial Nerve 7 paresis/paralysis Facial nerve Motor (Sensory for taste: anterior 2/3 of tongue)  Cause Nerve inflammation Usually viral  Herpes simplex (cold sores, genital herpes)  Herpes zoster (chickenpox, shingles)  Epstein-Barr (mononucleosis) Compression of facial nerve 57 of 82  Bell’s Palsy (2/2)  Symptoms (usually unilateral) Pain behind ear Paralysis Inability to open/close eye Drooping of mouth Drooling Distorted facial expression  Treatment Warm, moist heat Massage Facial exercises Prednisone Analgesics Electrotherapy 58 of 82 Infectious Disorders 59 of 82 Parasitic Meningitis Parasite Naegleria fowleri Primary amebic meningoencephalitis (PAM) Usually fatal within 5 days 133 known infected in U.S. since 1962 Only three survived Meningitis (1/2)  Inflammation of meninges  Cause Bacterial meningitis Most sever and most communicable Neisseria meningitidis (meningococcus) Vaccines for some forms Haemophilus influenzae (haemophilus) Streptococcus pneumoniae (pneumococcus) Viral meningitis – less severe Vaccinate against Entero-viruses (Most common - 90% in US) measles, mumps, Best prognosis with complete recovery rubella, chicken pox. Fungal meningitis Uncommon → Cryptococcal meningitis Non-infectious causes Drug allergies, some cancers, inflammatory diseases (lupus) 60 of 82  Meningitis (2/2)  Symptoms Vomiting, HA, nuchal rigidity Drowsiness, irritability Photophobia, phonophobia  Diagnosis Brudzinski’s sign Spinal tap CSF  Increased – WBC’s, protein, and glucose  Treatment Bacterial → antibiotics Viral → supportive, recovery in 7 – 10 days Fungal → IV antifungals Anticonvulsives, analgesic → HA 61 of 82  Encephalitis (1/2)  Inflammation of brain  Cause Herpes virus HSV, EBV, varicella-zoster Arbo-virus Insect (usually mosquito) Rabies virus Other viruses Chickenpox, measles, mumps Lyme disease Bacterial  Primary → infection begins in CNS  Secondary → infection spreads to CNS 62 of 82  Encephalitis (2/2)  Symptoms Headache, fever, visual dysfunction Neck/back stiffness, muscle weakness, restlessness Lethargy, mental confusion, disorientation, coma  Diagnosis Blood tests, spinal tap, EEG, CT, biopsy  Treatment Antiviral agents (work best for HSV, varicella-zoster) Antibiotics if bacterial infection Analgesics Anti-inflammatory drugs (corticosteroids) Anticonvulsive 63 of 82  Guillain-Barré Syndrome (1/2)  Inflammatory polyneuropathy disorder – Rare 1.5 per 100,000