applied neurosciences
TRANSCRIPT
Applied NeurosciencesDone by:
Ahmed Khalafalla MohammedAhmed Abdalla Alamin
Topics
Sensory System.Special senses:
◦Eye.◦Ear.
Motor System.Cranial nerves.Nerve conduction
study.EEG.Neuro-microbiology.
Imaging.Neurology.Neuro-surgery.
Sensory System
Lesion affecting the spinothalamic tract only; Syringomyelia:
Signs: Dissociated sensory loss of the affected segment;◦Loss of pain & temperature.◦Intact touch (fine touch).◦Intact motor function.
Sensory System
Lesion affecting the spinothalamic tract with concomitant motor impairment; Anterior cord syndrome:
Signs of the affected segment;◦Loss of pain & temperature.◦Intact touch (fine touch).◦Loss of motor function.
Sensory System
Lesion affecting the dorsal column tract only;
Seen in posterior cord syndrome, 3ry syphilis (Tabes dorsalis) etc…
Signs of the affected segment; sensory ataxia:◦Loss of vibratory & positional sense. +ve Romberg sign.
◦Intact pain & temperature.◦Intact motor function.
Sensory System
Lesions affecting both tracts; the spinothalamic & the dorsal column tracts: lesions affecting one side of the spine (e.g. Brown-Sequerd syndrome):
Ipsilateral loss of fine (complex) touch, pressure, vibration, position sense & two points discrimination sensations. Impaired motor function.
Contralateral loss of crude (simple) touch, temperature, pain, sexual and itching sensations. Intact motor function.
Sensory System
Lesions affecting both tracts; the spinothalamic & the dorsal column tract: lesions affecting both sides of the spine (e.g. cord transection):
Bilateral loss of all sensations at and below the level of the lesion. Impaired motor function.
Sensory System
Lesions affecting both tracts; the spinothalamic & the dorsal column tracts: lesions affecting the thalamus:
One thalamus: contralateral loss of sensation but the pt still can smell.
Both thalami: impaired sensation sparing the ability to smell.
Sensory System
Lesions affecting the somatosensory cortex:Primary SC (areas 3,1,2): contralateral
impaired sensation but the pt still can feel the pain (by the thalamus) but he can’t localize it.
S association C (areas 5,7): tactile agnosia; difficulty in recognizing, naming & memorizing objects placed on one hand while eyes are closed.
Eye
Light reflex:Direct on the examined eye.Indirect (consensual) on the other one.Abnormalities:
◦Bilaterally: Argyll Robertson pupil; impaired light reflex with intact accommodation. Caused by syphilis.
◦Unilaterally: Holmes-Adie (myotonic) pupil; impaired light reflex with sluggish accommodation.
Eye
Eye
Fundoscopy (Ophthalmoscopy):For examination of the retina (macula,
optic disc and blood vessels).For detection of Papilledema (swelling of
the optic disc) which indicates increased ICP so lumbar puncture will be contraindicated.
Eye
Ophthalmoscopes:
Eye
Ophthalmoscopy:
Eye
Retina:
Eye
Visual Acuity:Snellen’s
charts are used.
Normal ratio is 6/6.
Eye
Color vision:Ishihara charts are used for examination.Color blindness is X-linked so male are
more prone to get it.
Eye
Ishihara charts:
Eye
Visual Field:Using no machines; confrontation method.Using special machines; Perimetry.
Eye
Goldmann kinetic Perimeter
Eye
Automated Perimetry:
Ear
Weber’s test.Rinne’s test.
Tunning Fork
Ear
Weber’s test:Normally; pt hears
equally on both sides.Conductive deafness;
pt hears better on the affected side (due to loss of masking effect of the environment).
Nerve deafness; pt hears better on the normal side.
Ear
Rinne’s test:Normally; air conduction is
better than bone conduction.
Conductive deafness; pt hears bone conduction but not the air conduction.
Nerve deafness; pt does not hear any sound whether it is through bone or air conduction.
Ear
Audiometery:Audiometer is used.It presents tone with
different intensities and frequencies to a pt through earphones.
Audible frequencies are plotted against intensities on a graph paper. It is called audiogram.
Ear
Normal Patient
Ear
Conductive deafness
Ear
Nerve deafness
Ear
Mixed deafness
Motor System
Examination of deep reflexes:Based on the stretch reflex.The “Hammer” is used.Hyper-reflexia in UMNL.Hypo-reflexia in LMNL.
Motor System
Knee reflex; (L1,2,3 ).Biceps reflex; (C5,6).Ankle reflex; (S1).
Motor System
Lesions affecting the pyramidal system:At the cortex → contralateral flaccid weakness that is
limited to a particular area (e.g. monoparesis). At the internal capsule → contralateral paralysis or
weakness (hemiplegia). At the brain stem → contralateral paralysis or
weakness (hemiplegia) + ipsilateral cranial nerve palsy.At the spinal cord:
◦Complete transection → quadriplegia (cervical lesion below C4) or paraplegia (thoracic lesion).
◦Hemisection → ipsilateral hemiplegia (cervical lesion below C4) or ipsilateral monoplegia (thoracic lesion).
Motor System
Lesions affecting the extra-pyramidal system:
At the basal ganglia.At the cerebellum.
Motor System
Disorders of the basal ganglia: Hyperkinetic disorders; Tics, Chorea,
Athetosis, Ballismus and Dystonia. Hypokinetic disorders; Parkinson’s
disease.
Motor System
Tics:Repeated
involuntary movements.
Mostly in the face.
Motor System
Chorea:Dancing movement.Impaired caudate
nucleas.
Motor System
Athetosis:Slow writhing, pronounced in hands, fingers
and may be in the neck.
Motor System
Balismus:Violent movement in
one side of the body (hemi-balismaus).
Motor System
Parkinson’s Disease:
Resting tremor.Slow shuffling gate.Akinesia. Bradykinesia.
Motor System
Lesions affecting the cerebellum:Cerebellar ataxia:•Delay in movement initiation.•Dysmetria: alterations in the rate and force of a movement. •Asynergia: decomposition of movement. •Past Pointing. •Intention Tremor. •Dysarthria. •Dysdiadochokinesis. •hypotonia.
Motor system
Nystagmus is involuntary rhythmic movement of the eyes consisting of slow movement in one direction (due pathology of ocular muscles) and rapid/fast return movement in the other (due to pontine stimulation, this movement determines the direction of nystagmus).
Nystagmus increases when the patient gazes in the direction of the fast component.
Motor System
Motor System
Heel to toe walking :Impaired when
vestibulocerebellum is impaired
Archicerebellar Syndrome
Heel to shin & Fast repetitive movements:
Impaired when cerebrocerebellum is impaired
Neocerebellar Syndrome
Motor System
Romberg test:Ask the pt to stand with close
feet while eyes are open and then he closes his eyes & you note his balance. Also +ve in lesions affecting the dorsal column.
Finger-Nose test:Ask the pt to touch your finger
tip & then he touches the tip of his nose repeatedly while you are moving your hand.
Cranial Nerves
Olfactory Nerve lesion; Anosmia.
Cranial Nerves
Optic nerve:
Right nasal hemianopiaLoss of right eye visionBitemporal heteronymus hemianopia
Left homonymus hemianopiawith macular sparing
(NB: the macula has a duel blood supply.)
Cranial Nerves
Oculomotor nerve:Ptosis.Able to abduct his
eye.According to the
impaired part of the nerve, ocular motor deficit occurs.
Cranial Nerve
Trochlear nerve:Eye is upward and
medially rotated due to un opposed action of the SR muscle.
Impaired abduction.
Paralyzed SO muscle.
Cranial nerves
Trigeminal nerve:Numb face.Atrophied muscles of
mastication.
Cranial Nerves
Abducent nerve:Eye is medially
rotated due to unopposed action of MR.
Impaired abduction of the affected eye.
Cranial Nerves
Facial nerve:Upper part of the face receives duel motor supply
from both cerebral hemispheres.Lower part of the face receives single motor supply
from the contralateral cerebral hemisphere.UMNL; Contralateral paralysis of the lower half of the
face + Contralateral hemiplegia (Nb: hemiplegia is ipsilateral to the paralyzed site of the face & contralateral to the lesion site).
LMNL at the level of pons; Ipsilateral paralysis of half of the face (upper & lower) + Contralateral hemiplegia.
LMNL at the nerve level; Ipsilateral paralysis of half of the face only.
Cranial Nerves
UMNLLMNL (e.g. bell’s palsy)
Cranial Nerves
Vestibulo-cochlear nerve:Vestibular nerve; vertigo (not as fainting).Cochlear nerve; deafness.
Cranial Nerves
Glossopharyngeal and vagus nerves:Gag reflex (for both). Unilateral vagus lesion; deviated uvula to
the opposite site.Bilateral vagus lesion; uvula does not lift.
Cranial Nerves
Accessory nerve:Bilaterally; ask the pt to flex his neck and
resist the movement.Unilaterally; ask the pt to turn his head to
one side and resist him.Ask the to shrug his shoulder.
Cranial Nerve
Hypoglossal nerve:Ask the pt to put out his tongue:
◦UMNL; tongue deviates to the side opposite to the lesion.
◦LMNL; tongue deviates to the same side of the lesion, fasciculation & atrophy.
Cranial Nerves
Test:
Nerve Conduction Studies
They are:1. Sensory studies : nerves are studied by
stimulating them at one point and recording at a distant site along those nerves.
2. Motor studies : nerves are studied by stimulating them at two points (proximal + distal) and recording the muscle action potentials or stimulating them at one point & recording them at two points.
Nerve Conduction Studies
Parameters for nerve studies:1. Amplitude → reduced due axonal neuropathy e.g.
Diabetic axonal neuropathy.2. Velocity (can be calculated from both distance
between the cathodes and latency period between stimulation and wave appearance) → slow in demyelination neuropathy (e.g. Guillian-Barré syndrome).
• These parameters are normal in Myasthenia gravis.• Both parameters are found defective in severe cases
of local nerve entrapment (e.g. Carpel tunnel syndrome).
Nerve Conduction Studies
Sensory studies:1. Amplitude (10 µV)2. Velocity (70-90 m/s)
Nerve Conduction Studies
Recording electrodes
Stimulating electrodes
Nerve Conduction Studies
Motor studies: 1. Amplitude (2-3 mV).2. Velocity (50-70 m/s).
Nerve Conduction Studies
Recording electrodes
Stimulating electrode
EEG
The Electro-Encephalo-Gram:It is a record of the electrical
activity of the brain using electrodes placed on the scalp or directly on the surface of the cortex.
It can be unipolar or bipolar.
EEG
EEG
EpilepsyEpilepsy is a chronic brain disorder
characterized by recurrent synchronous discharges of neuronal groups in the cortex.
The discharges, which are also called seizures, may be localized or generalized.
Seizures have been classified as partial or generalized, depending on the spread, and medication is selected on the basis of the classification.
EEG
Classification of epilepsy:Partial; simple or complex.Generalized;
◦Tonic clonic (grand mal) seizures.◦Absence (petit mal) seizures.◦Other types; myoclonic, febrile & status
epilepticus.
EEG
EEG
In generalized, or non-focal, seizures, there is a massive spread of electrical activity over both hemispheres.
Petit mal (absence) seizures, which begin in childhood, involve a transient loss of consciousness without a loss of muscle tone, so those patients rarely fall down.
In grand mal (tonic-clonic) seizures, the patient suddenly loses consciousness and falls down. Convulsions consist of increased muscle tone (tonic) periods alternating with jerking movements (clonic). After the convulsions, loss of consciousness may persist.
Status epilepticus is a dangerous, uninterrupted series of seizures that requires urgent intravenous administration of drugs.
EEG
Partial (focal) seizures result from localized discharges that spread from the focus to adjacent brain areas. The patient may remain conscious, and the nature of the seizure depends on the area of the brain affected. Discharges in the motor cortex may involve first the seemingly purposeful movement of extremities (fingers), with spread up the arms to the face, and down to the legs as neuronal groups are progressively recruited into the discharge.
Motor seizures are also called jacksonian motor seizures. In simple partial seizures, the patient remains
conscious, but if activity spreads to the other hemisphere, the patient may lose consciousness and the seizure is termed complex or psychomotor, since there may be hallucinatory experiences.
EEG
On EEGA focal seizure produces a characteristic EEG
spike, whereas a generalized seizure produces a series of spikes that are picked up all over the skull simultaneously. The EEG also distinguishes between the tonic and clonic phases of the generalized discharge.
During absence seizures, there are characteristic spike & wave patterns of discharge.
EEG
EEG
EEG
Treatment; anti-epileptics:Partial and grand mal seizures; Na
valproate, phenytoin & carbamazepine.For pregnant ladies; lamotrigineAbsent seizures; ethosuximide.Status epilepticus; emergency tx:
lorazepam, diazepam.
Neuro-Microbiology
Medically important microbial diseases of the Nervous System:
Meningitis.Encephalitis.Brain abscess.Pott’s disease.Botulism.Tetanus.Poliomyelitis.Rabies.AIDS opportunistic infections.Sleeping sickness.Post infection Guillian-Barré syndrome.
Neuro-Microbiology
Meningitis:Inflammation of the meninges which it is
characterized by headache, fever, neck stiffness, photophobia, rash (meningococcal rash), etc..
Forms: ◦Acute meningitis.◦Chronic meningitis.
Neuro-Microbiology
Acute meningitis:Pyogenic (usually bacterial); which is
generally caused by:◦S. pneumoniae, N. menigitidis & H. influenzae
cause meningitis in childern.◦E. coli & S. agalactae cause neonatal meningitis.◦S. pneumoniae, N. menigitidis & L. monocytogenes
cause meningitis in adults.Aseptic (usually viral); caused by
enteroviruses, mumps, HSV-2, varicella-zoster virus, HIV, Epstein-Barr virus, LCMV, etc...
Neuro-Microbiology
Chronic meningitis:Tuberculous meningitis.Meningiovascular syphilis.Lyme disease.Cryptococcus neoformans.
Neuro-Microbiology
Causative agent
WBCs Differential RBCs Protein Glucose
Bacterial >200/µl Polymorphs Few High Low
Viral <200/µl Lymphocytes - Slight high
Normal
Fungal <50/µl Lymphocytes - Not high Low
TB 50-500/µl Lymphocytes - usually Low
Typical changes in the CSF in different types of meningitis
Neuro-Microbiology
Encephalitis:Infection of the brain parenchyma.Characterized by; headache, fever, personality
change, hallucinations, aphasia, signs of meningism.
Caused by:◦Bacterial; bartonella, mycoplasma, listeria.◦Parasitic; malaria, toxoplasma, sleeping sickness,
naegleria.◦Viral (commonest); HSV (most common cause, Mx:
acyclovir), enteroviruses, rabies, paramyxoviruses, arboviruses, CMV.
Neuro-Microbiology
Post infectious encephalitis:Following viral infection:
◦Measles.◦Mumps.◦Rubella.◦VZV.
Diagnosis of encephalitis; PCR for viral genome, MRI.
Neuro-Microbiology
CNS abscesses:Focal pyogenic infection.Exerted effects by:
◦Brain/spine damage.◦Paranchymal compression.◦Raised ICP.◦ Interfering with blood/CSF flow.
Include:◦Brain abscess.◦Subdural empyema.◦Intracranial epidural abscess.◦Spinal epidural abscess.◦Spinal cord abscesses.
Neuro-Microbiology
Brain abscess:Often polymicrobial (strep., enteric, anaerobes);
S. aureus may causes abscess associated with IE.Less common etiologies; nocardia, fungi, T. gondii
& neurocystocercosis.Clinical features; headache, fever, mental status
changes, hemiparesis, papilledema.Diagnosis; neuroimaging, lumbar puncture is
contraindicted.Treatment; surgico-medical, prophlyctic
antiepileptic agents, measures to lower ICP.
Neuro-Microbiology
Ring-shaped enhancement following contrast administration on CT (Abscess):
Neuro-Microbiology
Pott’s disease:Often preceded by pulmonary TB. It attacks
the vertebral bodies of the spinal column making kyphosis.
Charachterized by; signs and symptoms of TB (e.g. night sweating), back pain, weakness.
Diagnosis; imaging of the chest for former TB infection, spinal MRI, PCR, ELISA, culture.
Treatment; TB regimen.
Neuro-Microbiology
Guillian-Barré syndrome:Immuno-mediated acute inflammatory demyelinating
polyneuropathy. Characterized by progressive weakness & areflexia.
Differential diagnosis can be mixed with polio (acute flaccid paralysis) but the incidence of polio is low.
Associated infections:◦ Viral; inflenza, EBV, HSV, CMV, HIV, WestNV.◦ Bacterial; C. jejuni, Mycoplasma.◦ Parasitic; malaria (P. falciparum).◦ Vaccination; inflenza (swine).
Diagnosis; typical clinical features, high CSF protein, recovering from febrile illness, immuno-diagnosis.
Treatment; plasmapharesis, immunoglobulins.
Neuro-Microbiology
AIDS opportunistic infections:Many causative agents but mainly:
◦Toxoplasmosis; cause focal calcified or ring enhancing masses lesions with focal neurological symptoms.
◦CMV; cause encephalitis, myelitis, treated with ganciclovir.
◦Cryptococcal meningitis.◦JC virus; cause progressive multifocal
leucoencephalopathy.
Imaging
Imaging modalities of the CNS:Spiral Computed Tomography scanning (CT)
for brain imaging mainly (it is the primary modality). It can be used in spinal imaging in certain cases & when MRI is contraindicated.
Magnetic Resonance Imaging (MRI) for brain and spinal imaging.
Ultrasonograghy is used for infants by placing the probe on the fontanels before they close.
X rays are used also.
Imaging
CT MRI
Quicker. CT scan is superior in head
trauma.CT measures densities.Bright = Hyperdense.Black = Hypodense.Bone is hyperdense.CSF & water are hypodense.Axial (horizontal) images
only.
Slow.MRI is superior in detecting
strokes.MRI measures signal
intensities.Bright = hyperintenseBlack = hypointense.Bone is hypointense.CSF & water are hyperintense
in T2 & hypointense in T1.Multi-axial images.
Imaging
Type of hemorrhage
Time course Mass effect
Acute ≈ 8 to 72 hrs +++
Early subacute ≈ 3 days to 1 wk +++/++
Late subacute ≈ 1 wk to months ±
Chronic Months to years ــ
Imaging
CT:It is primary modality of brain imaging even
though it is not as sensitive as the MRI in detecting strokes. That is because it very quick & shows blood & other secondary causes of strokes.
With or without contrast.Bone and calcifications are hyperdense.Acute hemorrhage is hyperdense.Early sub-acute hemorrhage is hyperdense. Late sub-acute hemorrhage is isodense to brain.Chronic hemorrhage is hypodense.Infarcts are hypodense.
Imaging
Spiral CT machine
Imaging CT images showing base of the skull
Imaging CT images showing pons & cerebellum
Imaging CT images showing the midbrain
Imaging CT images showing Lateral ventricles
Imaging CT with contrast images showing circle of Willis
Imaging
MRITwo major types of images.
◦T1-wighted images.◦T2-wighted images.
Imaging
T1W images T2W images With or without contrast
(gadolinium) CSF & water are hypointense. Bone and calcifications are
hypointense. Acute hemmorrhage is
iso/hypo-intense. Subacute hemmorrhage is
hyperintense. Chronic hemmorrhage is
hypointense. Infarcts are hypointense in
general.
Without contrast. CSF & water are hyperintense. Bone and calcifications are
hypointense. Acute hemmorrhage is
hypointense. Early subacute hemmorrhage
is hypointense. Late SH is hyperintense + low signal.
Chronic hemmorrhage is hypointense.
Infarcts are hyperintense in general.
Imaging
T2-weighted imageT1-weighted image
Imaging
Neurology
Stroke.Myasthenia Gravis.
Neurology
StrokeTwo types:1. Ischemic. 2. Hemorrhagic.
They are not distinguishable clinically but there are pointers;
◦ Hemorrhage (meningism, severe headache & coma) .◦ Ischemia (carotid bruit, Atrial fibrillation, past TIA,
IHD).
Neurology
Causes of cerebrovascular diseases:Infarction – 71 - 85%Hemorrhage (intracerebral) – 10 - 26%Others (CST, SAH) – 2.9 - 5%
Neurology
Risk factors for Stroke:Hypertension; remains the main modifiable
risk factor for stroke.Diabetes Mellitus.Hypercholesterolemia, IHD.Sickle cell disease.SmokingPhysical inactivity, Obesity & alcohol.TIA.Others.
Neurology
On Examination:Atrial fibrillation (AF) - emboli.Heart valve disease – cardio-embolic
stroke.Carotid bruits are not predictive of
severity of carotid stenosis.Cerebral bruits may suggest arterio-
venous malformation.
Neurology
Transient ischemic attack (TIA or Mini Stroke): TIA is a very small stroke that is caused by a temporary
blocked blood vessel and leaves no permanent brain damage.
A TIA is a warning that there is something seriously wrong with the blood flow to the brain and that the individual is at risk of having a full-blown stroke.
Most symptoms of a TIA disappear within an hour, although they may persist for up to 24 hours.
About one-third of those who have a TIA will have an acute stroke sometime in the future. 5-10 times risk of subsequent stroke.
As many as 20% may sustain a small infarct visible on CT.
Only 15% of strokes are preceded by TIAs.
Neurology
Neurology
ACA territory infarct on CT
Neurology
ACA territory infarct on MRI
Neurology
MCA territory infarct on CT
Neurology MCA territory infarct With occluded MCA on CT
Neurology
MCA territory infarct on MR
Neurology
PCA territory infarct on CT
Neurology
PCA territory infarct on MRI
Neurology Young infarct on MR
Neurology
Intra-cerebral hemorrhage
Note the fluid/fluid level between CSF (up) & blood
(below) by the effect of gravity
Neurology
Subarachnoid hemorrhage: It is spontaneous bleeding into the subarachnoid space. Caused by; rupture of aneurysms, arterio-venous
malformations, etc.. Symptoms & signs:
◦ Sudden acute ‘worst ever’ headache which is often occipital.◦ Neck stiffness due to meningeal irritation that should
differentiated from meningitis.◦ Vomiting, collapse, seizures and coma may follow.
Diagnosis; finding blood stained CSF in lumbar puncture & on CT.
Management; supportive, surgery, etc.. Complications; rebleeding, ischemia, hydrocephalus,
hyponatermia.
Neurology
CT image shows Subarachnoid hemorrhage
NB: The presence of CSF/blood mixture makes CSF hyperdense
Neurology
Myasthenia Gravis:It is a disorder of the neuromuscular
transmission characterized by variable muscle weakness (hypotonic) and fatiguing that is relieved by rest.
Caused by; an organ-specific autoimmune reaction with antibodies directed against acetylcholine receptors (nicotinic receptors).
Neurology
Clinical features:Up to 90% of pts present in early adult life (<40
yrs of age).Women are more affected.Several clinical subdivisions:
◦Grade I; Ocular manifestation. 40% become Gd II.◦Grade IIA; Mild generalized weakness.◦Grade IIB; Moderate generalized weakness.◦Grade III; Acute fulminating.◦Grade IV; severe upon mild or moderate at onset.
Grades IIB, III & IV develop respiratory muscle involvement.
Neurology
Sign and symptoms:Of cranial nerves:
◦Ptosis, ocular muscle paresis.◦Mouth is hanging open.◦Expressionless face.
Of limb and trunk:◦Lolling of the head (neck weakness).◦Proximal limbs are preferentially affected.◦Stress, infection and pregnancy all exacerbate
the weakness.
Neurology
Investigations:Pharmacological; edrophonium test.Serological; anti-acetylcholine receptors
Abs.EMG; reduced amplitude of the compound
muscle action potential.Additional; pt with thymoma may need X-
ray or CT images.
Neurology
Treatment:Symptomatic; cholinesterase inhibitors.Immune; immune suppression, plasma
pharesis and even thymectomy.Supportive; NGT, ventilation, etcDrugs to avoid; that cause or precipitate
myasthenic crisis and repress respiration, beta blockers, Ca channels blockers, amino-glycosides, erythromycin, etc..
Neurology
Other forms of Myasthenias:Neonatal myasthenia:
◦Born to mothers with MG.◦Due to autoimmune Abs (IgG) attacking NMJ.◦Starts within 48 hrs & ends 2-12 wks.
Congenital myasthenia:◦Non-autoimmune.◦Due to structural abnormalities of the receptors
themselves caused by gene mutations.◦Does not respond well to MG treatment.
Neuro-Surgery
Head injury.Raised intracranial pressure.Hydrocephalus.
Neuro-Surgery
Head injury:Brain damage may occur from primary
injury or the secondary effects of that injury.
Neuro-Surgery
Primary brain damage:Cortical contusion and lacerations; occur
under the site of the injury or opposite (contre-coup)it.
Diffuse white matter lesions; as a result of shearing following deceleration and damaging the axons.
Neuro-Surgery
Secondary brain damage:Hemorrhage:
◦Epidural (extradural) hematoma.◦Subdural hemorrhage.
Brain swelling (edema).Brain shift & tentorial/tonsillar herniation.Ischemia.Infection.
Neuro-Surgery
Examination:Lacerations and bruising; indicate the presence of
fractures.Basal skull fracture signs.Conscious level; Glasgow coma scale.Pupil reflex; tests optic & oculomotor nerves but
the latter is important regarding herniations & expanding masses.
Limb weakness; can be contralateral & ipsilateral (due to indentation of the contralateral cerebral peduncle by the edge of the tentorium cerebelli).
Eye movement; prognostic guide.
Neuro-Surgery
Basal skull fracture signs:Anterior fossa fracture:
◦CSF rhinorrhoea (nasal CSF discharge).◦Bilateral periorbital hematoma.◦Subconjuncival hemorrhage.
Petrious fracture:◦Bleeding from external meatus.◦CSF otorrhoea (CSF from external meatus).◦Battle’s sign; bruising over the mastoid.
Neuro-Surgery
Epidural hematoma:It often occurs due to a fractured temporal or parietal
bones lacerating the middle meningeal artery & vein. It can be also due to any tear in dural venous sinus.
Signs and symptoms; due raised ICP causing deteriorating consciousness level, hypertension+bradycardia, focal neurological signs (e.g. hemiparesis).
Diagnosis; lens shaped collection on CT, lumbar puncture is contraindicated.
Management; ‘horse shoe’ craniotomy flap, burr hole, ligation of the bleeding vessel, measures to lower ICP.
Neuro-Surgery
Epidural hematoma on CT
Neuro-Surgery
Epidural hematoma on MRI
Neuro-Surgery
Subdural hematoma:There may be history of trauma or not because it
may be forgotten because it was so minor or so long ago.
The elderly are most susceptible, as brain atrophy makes bridging veins vulnerable.
Signs & symptoms; headache, personality change, physical & intellectual slowing, seizures, neurological symptoms, etc…
Diagnosis; finding crescent-shaped collection over hemisphere on CT.
Management; irrigation/evacuation, via burr twist drill and burr hole craniostomy.
Neuro-Surgery
Subdural hematoma on CT
Neuro-Surgery
Subdural hematoma on MRI
Neuro-Surgery
Raised Intracranial pressure:MONRO KELLIE DOCTRINE (An increase in
one constituent or expanding mass within the skull results in an increase in intracranial pressure).
Causes:◦Expanding mass. ◦Increase in brain water content.◦Increase in cerebral blood volume.◦Increase in CSF.
Neuro-Surgery
Features:◦Headache.◦Vomiting.◦Papilloedema.
Complications; brain shifts:◦ Tentorial herniation.◦ Subfalcine herniation.◦ Tonsilar herniation.
Investigations; CT, MRI, etc...
Neuro-Surgery
Treatment:RestPositionSedationSteroidsHyper-osmotic solutionsHyperventilationSurgery, CSF drainage.
Neuro-Surgery
Hydrocephalus:Classification:
◦Obstructive; CSF flow obstruction within the ventricular system.
◦Communicating; CSF flow obstruction out/with ventricular system (with subarachnoid communication).
Signs & symptoms; mainly due to raised ICP.Investigations; CT, ultrasound, skull X-ray,
isotope cisternography, etc…Management; drainage, shunts.