Neurology :Neurology Neuron: nerve, logos: knowledge Neurology: deals with the prevention, therapy and rehabilitation of organic disease of NS and musculature Characteristisc: 1. Psychiatric alterations are not typical 2. Morphological or functional abnormalities 3. Psychogenic mechanisms only modify Internal Medicine: functional diagnosis neurology: localisation, importance of neuroanatomy


The most frequent neurological disorders :The most frequent neurological disorders Headache (tension type: pop. 40-60%, migraine: femails:9-12%, males:4-6%) Low back pain Stroke: prev.:2000/ 100 000 Epilepsy: 60-80 0 / 100 000 Parkinsonism: 20 –40 0 / 100 000 Polyneuropathy:30 0 / 100 000 Multiplex Sclerose 6-80 / 100 000


Slide 3:P- What Provokes discomfort? Q- What is the Quality of the discomfort? R- Where is the Region of the discomfort? S- What is the Severity of the discomfort? T- What is the Time sequence?


Neurol. examination :Neurol. examination Signs of meningeal irritation Cranial nerves Reflexes Sensory Motor Vegetative function Orientation, cognition, perception


II. optic nerve :II. optic nerve Papilla-edema: increased intracran. pressure Optic atrophy: chronic disease; Vascular diseases: HT, diabetes


Corneal reflex (V and VII) :Corneal reflex (V and VII) Afferent (V) efferent (VII),


Slide 7:Babinski reflex


Slide 8:Brisky:physiological pathological:brisky +pyramidal sign


CT :CT Ischemia, bleeding, tumor abscess, degeneration, trauma.


Slide 10:62 yrs stroke at admission One day later 2 days later


Hemorrhagic transformation11th Dec dysart+mild hemipar 21st December worsening :Hemorrhagic transformation11th Dec dysart+mild hemipar 21st December worsening 27th of December


Slide 12:Cerebral hemorrhages


Angiography :Angiography


DSA angiography :DSA angiography DSA (digital subtraction angiography, mask-image) excellent resolution DSA, MR, CT and PET integration intervention neuroradiology:embolisation of malformations, fistels, aneurysm Problems:(bleeding, dissection, embolisation, vasospasm, contrast-allergy)


Angiography 2. :Angiography 2. Diagnosis Stenosis, vascular malformation, aneurysm, vasculitis, sinus thrombosis Therapy local lysis, preop. embolisation, tumor chemotherapy


MR-angiography :MR-angiography "angiogramm" dark (flow void) or slow flow :bright (flow related enhancement). Stenosis could be misdiagnosed:occlusion aneurysm Non-invasive


US :US B-mode:high resolution, plaque const., Intima-Media thickness Carotid Duplex:flow+morphology stroke prevention:carotid stenosis+OP embolus-detection Transcranial Doppler TTE, TEE


SPECT (Single Photon Emission Computer Tomography) :SPECT (Single Photon Emission Computer Tomography) 99mTc-HMPAO or 133 I-amphetamin (IMP), 133Xe CBF, CBV and receptors epileptic focus Alzheimer (temporoparietal decrease) before and after carotid reconstruction


PET (Positron Emission Computer Tomography) :PET (Positron Emission Computer Tomography) (18F:120 min, 150:2 min, 11C:20 min) pH, CBF, CBV, O2, Glu met Receptor imaging dopaminergic, cholinergic, histaminergic, opioid. systems dementia pharmacotherapy


PET 2. :PET 2. 18F-deoxyglucose epileptic focus whole body PET:tumor(methionin or oxigen) Radionecrosis or recidive? New tracers, important for pharma research


Slide 21:Stroke in the left MCA area MRI TCD CBF HMPAO-SPECT F-DG-PET Left MCA infarct


Lumbal punction :Lumbal punction Infection? SAH, infiltration of meninx by tumor? Before Lp funduscopy! Between L-III-IV. vertebra Sample for culture but immediate AB therapy Normal CSF:clear, water-like cell:2-3


CSF :CSF protein (0.2-0.4 g/l) glucose 2/3 of the blood, staining Ziehl-Nielsen, Gram serology viral titers oligoclonal band ELISA (Enzyme-linked-immunadsorbent assay) Tumormarkers (carcinoembryonal antigen, Beta2-mikroglobulin Neuronspecific enolase PCR: TBC, Herpes, Borrelia , CMV Pot. complications: headache, hematoma, CSF fistel, infection, herniation


EEG :EEG 0,6-0,8 % of population:epilepsy Brain death, prion-diseases New techniques:frequency analysis, EEG-mapping. video,long-term EEG,holter EEG. cortical electrodes before epilepsy-surgery!!


EEG 2. methods :EEG 2. methods Hyperventilation Fotostimulation Sleep deprivation Pathol. EEG important, but not diagnostic for epilepsy Normal EEG does not exclude epilepsy!!!


EEG 3. :EEG 3. Alpha (8-13 c/s): at rest: rhytm.occipital max. Beta (14-30 c/s): frontal-central: attention, anxiety, intox. theta (4-7 c/s): Delta (0.5-3 c/s)


EEG 4. :EEG 4. Focal disease:circumscribed slow activity General abnormality:intox. trauma, metab. diseases Spikes:important but only with clinical findings epilepsy:1/3 with normal EEG!!! Useful:Encephalitis metabolic diseases (uremic, hepatic coma etc.) Coma No typical findings:in tumor or vascular diseases


Transcranial Magnetic Stimulation :Transcranial Magnetic Stimulation Centr. and peripheral. motor system conduction time fields:MS, ALS, lesion of motor pathway


VEP :VEP light or checkerboard, occipital registration 100 ms latency is an important parameter averaging (64-128) important:Multiple sclerosis


SEP :SEP excitation, vertebras, parietal cortex Comparison:with controls and contralateral values MS, spinal cord diseases, intraop. monitoring


BAEP :BAEP Sound, vertex, mastoid, averaging of 1-2000 impulse, I-V. waves, latency, distance between III.-V. waves brain stem tumor, vascular, brain death


EMG :EMG neurogenic and myogenic atrophy could be differentiated psychogenic and organic paresis clinically silent paresis reinnervation tremor types


ENG :ENG ENG:motor and sensory conduction velocity motor: orthodrom, sensory fibers:orthodrom and antidrom sensory action pot. less than motor ones:averaging is important Myelin lesion:slow vel. Axon lesion:no or small changes, but amplitude decrease


MEG :MEG Spontanous or after stim. Magnetic dipol changes with magnetic field Isolation is important good spatial resolution (? 3mm) 1 ms epilepsy, stroke metabolic disorders


Other methods 1. :Other methods 1. Muscle biopsy Light- and -electronmicr, immunohistology Neurogenic atrophy:atrophy in groups Myositis:inflamm.cells, immuncomplex, IgG deposition Non inflamm::necrosis, fibers, connect. tissue Nerve biopsy lateral sural n. (sensory) sometimes n. musculocut. Gammopathy, inflammation, PAN, leukodystr., amyloidosis


Others 2. :Others 2. Brain biopsy CT, MR-orient., tumor, lymphoma Rectal, skin Amyloidosis Lactate-test metab. myopathia, anaerob glycogenolysis, glycolysis before and after effort (3-4 x), aldolase, kreatinkinase, myoglobin


Others 3. :Others 3. Hormones GH, FSH, LH Neuronspecific enolase If 30 ng/ml poor prognosis Antineural AB Paraneoplasia Tumormarkers Ach-Receptor AB Myasthenia


Hypnoid type of disturbance of consciousness :Hypnoid type of disturbance of consciousness Either brain stem or Diffuse cortical damage or both


Slide 39:Somnolent Stupor coma


Slide 40:Glasgow coma scale Eye opening 1-4 Motor response 1-6 Verbal response 1-5


Slide 41:1. Brainstem Hyperglyc hypercapnia uremia/vese hyperammon./máj hyperosmol. Hypernatr. Hypercalc. hyperthermia Hypoxia hypoglyc. Hyponatr. Hypocalc. hypothermia endocrin 5.Extracorporal factors bact. viral inf. drugs, poisons Ischemia bleeding 2.Trauma? Subcutan hem. Fract linear impres. epidural h. Subdural h.S SAH Commotion Contusion (SAH) 4. Large focal lesion with sec. edema tumor Ischemia bleedinh 3. Dysequilibrium of homeostasis/metab. Supratentorial Infratentorial Causes of disturbances of unconsciousness


Slide 42:Hunt and Hess Classification(*1) of Subarachnoid Hemorrhage Grade Description Periop. mortality (%) *2 Prob of survival (%) *3 0 Unruptured aneurysm 1 Assympto-matic, or mild headacheor nuchal rigidity 0-5 90 2 CN palsy, moderate or severe headache or nuchal rigidity 2-10 75 3 Mild focal deficit, lethargy, or confusion 10-15 65 4 Stupor, moderate or severe hemiparesis, early decerebrate posturing 60-70 45 5 Coma, decerebrate posturing, moribund 70-100 5


Non-hypnoid types of disturbance of conscioussness :Non-hypnoid types of disturbance of conscioussness Locked in: corticospinal and corticobulbar pathways intact vertical Apallic synd.: intact brain stem, cortex damage, opened eyes Akinetic mutism: frontal lobe/ efferent pathways. Lack of motivation Delir Amentiform syndr.: desorientation + halluc.


Brain death :Brain death Complete and irreversible lack of brain functions rostal from foramen magnum Diagnosis: coma lack of motor functions (no seizure, no spasticity or rigor) general muscle hypotony lack of pupil, corneal, vestibular, pharyngeal, palatal refl., no response to caloric stimul. Doll’s head phenomen. Diabetes insip. Missing rhytm. of body temperature lack of heart and vasomotor regulation (apnoe test)


Brain death 1. :Brain death 1. Complete, irreversible clinical investigations and course ancillary instr.


Exclusion :Exclusion intox., drug, neuromusc; shock; metabolic or endocrine? hypothermia (below 35 ºC); brain stem encephalitis, cranial polyneuritis)


Criteria :Criteria coma (no spont. motor., seizure, extrapyramidal.) no rigor, spasm, decortic. or decerebr. posture). Spinal automatism?


No breath :No breath apnoe-test: a-pCO2 38-42 mmHg 10 min 100% oxygen 6 liter/min O2 art. pCO2 higher than 60 mmHg!!


Slide 49:Diagnosis in stroke From blood BSR, counts glucose, ions hemostasis lipids, Immunological (in youngs) Heart Functional BP monitoring ECG Holter ECG Morphological TTE X-ray TEE TEE Carotid, vertebral Ultrasound CTA MRA DSA Brain imaging CT MRI Diff. WI Perf. WI TCD Angiogr.(DSA, MRA) SPECT, PET