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Neurology

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  1. Neurology Study of disorders of the nervous system

  2. What is the nervous system? • Central Nervous system (CNS) • Brain • Spinal Cord • Peripheral Nervous system • Nerves to and from body parts to the • CNS

  3. Autonomic Nervous System • Breathing • Digestion • Heart rate • Blood Pressure • Sweating etc.

  4. Disciplines frequently interacting with Neurology • NeuroSURGERY • Physical Medicine & Rehabilitation (PM&R) • Psychiatry • Family Practice • Medicine • Pediatrics

  5. Common Reasons Why Referrals are made to Neurology • Diagnosis and treatment • Headaches • Weakness or paralysis • Seizures • Mental Delay or deterioration • Memory Loss • Change in Personality

  6. What Happens in the Neurology Clinic of Consult? • History • Neurological Exam • Confirmatory Tests

  7. History • THE MOST IMPORTANT PART !! • Why are you here? • NO GOOD - my doctor sent me, or for a neurological check !! • The questions asked during the history ar based upon the concern for being there!

  8. Neurological Exam • Consists of several parts, HOWEVER IS ALSO FOCUSED BY THE PRESENTING CONCERN !! • Mental Status (Language, memory, affect) • Cranial Nerves • Motor (strength, muscle mass, tone) • Deep Tendon Reflexes (DTR’s – WHY??) • Sensory (Perception of touch, pain) • Coordination & Balance (walking, manual dexterity)

  9. Confirmatory Tests • CT Brain or Spinal Cord Scan • MRI Brain or Spinal Cord Scan • Angiography • Electroencephalogram (EEG) • Electromyogram (EMG) • Ultrasound • Blood and Genetic Tests

  10. Computerized Tomography (CT SCAN) • Relatively inexpensive • Quick • Very good for acute bleeding • Good for fractures & bones • BUT significant X-Ray exposure

  11. Magnetic Resonance Imaging (MRI) • Can be more informative • No x-ray exposure BUT • Much more expensive • Takes longer, may need sedation • Can induce claustrophobia

  12. Electroencephalogram (EEG) • In some ways similar to an EKG (ECG) of the heart • Records the tiny electrical currents emitted by the brain • About thirty wires are pasted to the scalp for about 30-60 minutes • Harmless • Especially valuable in seizure disorders and epilepsy

  13. EEG

  14. Electromyogram (EMG) • Electrical recording of the peripheral nerves and muscles • Invaluable for neuropathiesand muscle disease • Needle exam, also delivery of small electric shock to see they travel • Harmless, BUT not too comfortable

  15. EMG exam

  16. Problems Evaluated and Treated by a Pediatric Neurologist

  17. Delayed (Slow) Intellectual and / or Motor Development • Why not sitting, Walking? • No or Abnormal talking • Is it both or just one or these • Commonly a combination or the two

  18. Intellectual impairment (mental retardation) • A result of ANYTHING which harms the brain • Genetic • Brain malformations • Lack of oxygen • Infection • Trauma • Environment, lack of stimulation • Toxin (ALCOHOL, drug, Pb, Hg)

  19. Management of Intellectual Impairment • Early referral to therapy • Correct cause where possible • Genetic counseling

  20. Abnormal Motor Development • When profoundly weak, muscle disease, muscular dystrophy • Stiff, poor coordination, Cerebral Palsy

  21. Cerebral palsy (CP) • Cerebral = head or brain • Palsy = abnormal muscle function, weakness, coordination, tremor

  22. Cerebral Palsy • A RESULT OF ANYTHING which harms the brain • Genetic • Brain malformations • Lack of oxygen • Infection • Trauma (Birth or post natal) • Environment, lack of stimulation

  23. Cerebral Palsy What Does it Look Like? • Abnormal motor development - delay • Weakness • Stiff (or limp) • Abnormal posture & movement

  24. Part of body affected

  25. Spasticity and Dystonia = stiffness • Often the predominant feature of CP • Can contribute to orthopedic deformity • Interferes with function & care • Can be painful

  26. Management of Spasticity • Drugs - valium, baclofen, dantrium • Indwelling pump for intrathecalbaclofen • Surgery - selective dorsal rhizotomy (SDR)

  27. Surgical implantation

  28. Additional Management of CP • Feeding issues • Surgery to correct secondary orthopedic deformities, especially painful hip dislocation • Adaptive equipment, standers, wheelchairs, powered wheelchairs • Communication devices

  29. Abnormally Large Head • Can be the result of: • Blood clot (extradural hematoma) • Thick skull • Hydrocephalus **

  30. What is Hydrocephalus? • Excessive fluid (CSF) INSIDE of the brain. • Caused by: • Birth deformity (Meningomyelocoel) • Genetic • Infection or bleed • Drugs (seizure meds)

  31. Management of Hydrocephalus • Observation • Medication - Diamox • Surgery - Ventriculo-peritoneal (VP) shunting

  32. Problems with CP Shunts • Infection (about 3%) • Obstruction (resulting in headaches, vomiting, enlarging head, death) • Outgrowing the length of the peritoneal catheter

  33. Duchenne Muscular Dystrophy • X-linked recessive, decr dystrophin • 1 / 3-8,000 males, onset 3-6 yrs • WEAKNESS, difficulty climbing stairs • Abnl tests: CPK, EMG, dystrophin • Stop walking abut 12 years • May live to 3rd decade

  34. Problems Seen by both Pediatric and Adult Neurologists

  35. EpilepsyCharacterized primarily by having seizures • More than one, unprovoked seizure • Seizure – transient, usually sudden disruption of cerebral function • i.e., shaking, paralysis, abnormal speech, staring

  36. Epilepsy • A RESULT OF ANYTHING which harms the brain • Genetic • Brain malformations • Lack of oxygen • Infection • Trauma (Birth or post natal) • Environment, lack of stimulation • Brain tumor **

  37. Seizures • Usually confirmed by EEG • Often completely controlled with medication (AEDs) about 50% • Another 25% much improved with drugs (one or more) • Some benefitted by seizure surgery and / or vagal nerve stimulator

  38. Management of Seizures • Requires follow-up, seizure diary, AE of meds, drug levels. Usually several times per year, usually for years. • Focused history at each clinic visit • Special issues if pregnant

  39. Headaches • Occur in both Children & Adults • Great Majority are NOT due to tumors! • Most are Migraine, Tension, or Cluster • When the histories are typical and the examination is normal, Ct or MRI brain scans usually are not necessary. • At least 10% of children & adults have HA • Frequently there is a positive family history

  40. Management of Headaches • Prophylaxis: • diet, biofeedback,propranolol,Depakene, antidepresant, topiramate, • Acute Attack: • ergotamine, triptan (5-HT agonist-sumatriptan)

  41. Brain Tumors • Occur both in children & adults, however the types vary by age • Although most headaches are NOT due to tumors, many brain tumors present with headaches. • Other symptoms: vomiting, failure to thrive & weight loss, visual impairment, ataxia, neurologic deficits, seizures,

  42. Brain Tumors • Tumor types differ by age (more primaries in kids, metastatic in adults) • Symptoms similar- headache, visual changes, seizures, neurol deficits

  43. Work-up of Brain Tumors • Neurological and Eye exam • Imaging – MRI or CT scans, angiography

  44. Management of Brain Tumors • Stabilize and decrease intracranial pressure with steroids, shunting • Surgical excision or tumor reduction • Radiation and/or chemotherapy • Immunologic reduction (gliomas, melanoma)

  45. Stroke • More common in adults, but also in kids • Syndrome with rapid onset of symptoms & signs(seconds or minutes) loss of CNS function • Transient Ischemic Attacks (reverse < 24 hours = “TIA”) & Reversible Ischemic Neurological deficits

  46. Problems Which Could Look Like a Stroke • Diabetic Coma and hypoglycemia • Seizure • Head Injury • Complicated Migraine • Transient Global Amnesia

  47. Causes of Stroke • Thrombosis & occlusion of vessels • Emboli – something traveling in vascular supply (usually clot) to occlude • Hemorrhage – berry aneurism, hypertension, abnl blood vessel (AVM) • (Risk factors SMOKING, obesity, diet, hypertension, family history)

  48. Stroke

  49. Stroke Types

  50. Work-up of Stroke • CT / MRI brain scan • CT angiogram • MRI angiogram • Traditional angiogram