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  • 1. APPROACH TO A PATIENT WITH CNS DISORDER DR M SHOAIB SHAFI
  • 2. MAIN PRESENTING COMPLAINTS OF CNS       Headache, backache or neck pain Facial pain Fits ,faints or funny turns Dizziness or vertigo Disturbance of vision, hearing or smell Disturbance of memory, sphincter control, sleep, speech, language or gait
  • 3. CONTD….      Disorders of movement weakness abnormal involuntary movements Acute confusional state Coma and brain death Problem with brainstem function Sensory disturbances
  • 4. HOW TO APPROACH
  • 5. APPROACH TO DIAGNOSIS It involves two questions:  Where is the lesion?  What is its etiology?
  • 6. Where is the lesion? 1) Is the lesion :  Single,multiple or is it a diffuse process  Restricted to CNS or part of systemic illness 2) Do the findings combine to form a recognizable clinical syndrome eg parkinsonism
  • 7.           What is the etiology? VITAMINS-D Vascular eg CVA, venous sinus thrombosis Infectious eg meningitis, cerebral abscess Inflammatory eg acute transverse myelitis, MS, ADEM Traumatic eg Extradural hematoma or SDH Autoimmune eg myesthenia gravis, GBS Metabolic & toxic eg hypoglycemia, hyponatremia, alcohol intoxication, uremia Iatrogenic eg antipsychotic induced parkinsonism Neoplastic eg primary or secondary brain tumours Seizures & psychiatric disorders Degenerative lesions eg alzheimers dementia
  • 8. HISTORY          Onset of illness & its course Comorbation of history by attendants Premorbid condition Family history Medical history Drug use, abuse & toxin exposure Formulating an impression of the patient Precipitating factors Associated symptoms
  • 9. PHYSICAL EXAMINATION GPE:          BP PULSE TEMPERATURE PURPURIC SPOTS RASH HANDS ( CLUBBING,SPLINTER HGES) FACE (FEATURES OF C.T DISORDER,EYE,SINUSES) EAR NECK (CAROTID,JVP,THYROID)
  • 10. SYSTEMIC EXAMINATION  CENTRAL NERVOUS SYSTEM  CARDIOVACULAR EXAMINATION HEART MURMUR GASTROINTESTINAL EXAMINATION KIDNEYS, SPLEEN RESPIRATORY SYSTEM   PULMONARY INFECTION PULMONARY EDEMA
  • 11. CENTRAL NERVOUS SYSTEM  GCS  PUPILS HIGHER MENTAL FUCTION       E4V5M6 Time- knows month or year Place- has general knowledge of where they are Person- knows own name, able to name relatives or friend Memory- capability for early and recent recall CRANIAL NERVES
  • 12. SENSORY SYSTEM  Primary sensation  Touch Pain Temperature Sense of position and vibration     cortical sensation  Localization Two point discrimination Stereognosis Graphesthesia Perceptual rivalry    
  • 13. MOTOR SYSTEM BOTH UPPER & LOWER LIMBS        Bulk of muscles Tone of muscle Power of muscles Reflexes Gait Coordination of movement Spine
  • 14. CEREBELLAR SIGNS           Nystagmus Scanning speech Finger nose test Dysdiadochokinesia Rebound phenomenon Pendular knee jerk Hypotonia Heel knee shin test Romberg sign Drunken gait
  • 15. SPEECH  Dysphasia  Dysarthria
  • 16. SIGNS OF MENINGEAL IRRITATION    Neck stiffness Kernigs sign Brudinzkis sign
  • 17. INVESTIGATIONS Finger stick glucose CBC(wbc,plt) LFTs PT, APTT& INR Creatinine Electrolytes (Na,Ca,Mg,K) Blood culture ECG Echocardiogram Lumbar puncture NCS/ EMG EEG CT head Cerebral angiography Carotid Doppler Testing MRI/ MRA Evoked potentials
  • 18.       LIPID PROFILE HYPERCOUGUBALE STATE HOMOCYSTEINURIA ANTICARDIOLIPIN ANTIBODIES SLE VASCULITIS
  • 19. Tin-pot dictators have ravaged Asia, Latin America & Africa. They are the worst tyrants of post-colonial period. They have destroyed time-honored institutions & treated their people like animals. They have caused internal divisions &external confusion. The dictator is one animal who needs to be caged. He betrays his profession & his constitution. Not a single one of them has made a moments contribution to history.
  • 20. HOW TO LOCATE THE LESION IN CNS
  • 21. IMPORTANT STRUCTURES         Cerebral cortex Corona radiata Internal capsule Brainstem (midbrain, pons, medulla oblongata, cerebellum) Thalamus Hypothalamus Extrapyramidal system
  • 22.         Case scenario A 45yrs old lady is brought to ER with c/o sudden weakness of right half of body. O/E Patient drowsy BP = 180/110 mmHg Pulse = 68/min CNS: GCS 7/15 Power decreased on right Tone increased on right Right plantar upgoing Right facial nerve palsy (UMN type) Explain the nature of lesion.
  • 23. CASE SCENARIO   A 56yrs old gentleman with h/o uncontrolled hypertension presents in ER with sudden onset of weakness of left arm. Where is the lesion in brain?
  • 24. CEREBRAL DOMINANCE    Two cerebral hemispheres All the right handed persons and most of left handed persons have left hemisphere as the dominant one. Dominant hemisphere controls the speech.
  • 25. Frontal Lobe • Initiation • Problem solving • Judgment • Inhibition of behavior • Planning/anticipation • Self-monitoring • Motor planning • Personality/emotions • Awareness of abilities/limitations • Organization • Attention/concentration • Mental flexibility • Speaking (expressive language) Parietal Lobe • Sense of touch • Differentiation: size, shape, color • Spatial perception • Visual perception Parietal Lobe Frontal Lobe Occipital Lobe Occipital Lobe • Memory • Hearing • Understanding language (receptive language) • Organization and sequencing Cerebellum • Balance • Coordination • Skilled motor activity Temporal Lobe Temporal Lobe • Vision Cerebellum Brain Stem Brain Stem • Breathing • Heart rate • Arousal/consciousness • Sleep/wake functions • Attention/concentration
  • 26. MEDIAL VIEW
  • 27. HOMENCULUS
  • 28. HOMENCULI
  • 29.     Spinal cord begins at the end of medulla oblongata and extends upto lumbar vertebra 2 or 3 in adults. Lower tapering part is called conus medularis and the lowermost bundle of nerve fibres is called cauda equina. It contains all the ascending and descending fibres. Lesion here can cause hemiplegia, paraplegia or quadriplegia.
  • 30. Cross section of cord
  • 31. Main arteries are:  Internal carotid arteries  Basilar arteries  Vertebral arteries  Anterior cerebral arteries  Middle cerebral arteries  Posterior cerebral arteries These form a circle called CIRCLE OF WILLIS 
  • 32. Areas of supply    MCA supplies lateral surface of frontal, parietal & temporal lobe ie most of the motor & sensory cortex except which lies on medial side and controls legs. ACA supplies medial side of brain. PCA supplies the occipital lobe.
  • 33.    It includes: Corticospinal tracts Extrapyramidal system Cerebellum (for coordination)
  • 34. CORTICOSPINAL PATHWAY        Neurons in precentral gyrus Corona radiata Posterior limb of internal capsule Cerebral peduncle in pons Midbrain Medulla oblongata Decussation of fibres occur in pyramids of MO and then descend as lateral corticospinal tracts.
  • 35. 5 PATTERNS OF MOTOR WEAKNESS      UMN weakness LMN weakness Muscle disease Neuromuscular junction Functional weakness
  • 36. APPROACH TO WEAKNESS       First determine whether its: Generalised weakness Weakness of all 4 limbs Hemiplegia Paraplegia Monoplegia Patchy weakness
  • 37. Weakness all 4 limbs yes Upper motor Neuron pattern Cervical spinal cord Or bilateral brainstem Or hemisphere no no proximal>distal no Neuropathy Distal sensory loss yes Myopathy No sensory loss no Weakness in both legs no yes Upper motor neuron pattern Yes Spinal cord, thoracic spine or above
  • 38. Unilateral arm And leg yes Lesion in brainstem Or hemisphere no Single limb Single root no yes Radiculopathy no no Patchy weakness Single named nerve yes yes Multiple named nerves yes Mononeuropathy Mononeuritis multiplex no Variable weakness yes Fatigues yes Myesthenia gravis
  • 39. Case scenario   A 50yrs old male suddenly develops weakness of left half of body. O/E there is weak left arm & leg with increased tone & upgoing plantar. There is sensory loss also.3 days later patient starts complaining of agonizing pain down the left leg. Patient says that he feels like as his flesh is being torn away from bones. What is the lesion and where is the lesion?
  • 40. Case scenario   A 46yrs old male is brought to OPD with c/o sudden inability to walk & to hold the objects. O/E pt is having right nystagmus. There is dysarthria & past pointing on right. When asked to walk, patient sways to right. Where is the lesion in CNS?
  • 41. 1:Generalised weakness    Nerve lesion polyradiculopathy Neuromuscular junction myasthenia gravis Muscle disease myopathy
  • 42. 2:All four limbs---quadriplegia     UMN type LMN type Mixed upper & lower motor neuron type myopathy
  • 43. 3:hemiplegia    Cerebral lesion Brainstem lesion Hemisection of cord
  • 44. 4:paraplegia   UMN TYPE LMN TYPE spinal cord lesion cauda equina lesion
  • 45. 5:Patchy weakness   UMN LMN multiple sclerosis polyradiculopathy mononeuritis multiplex
  • 46. Sensory Pathways Main sensory pathways are:  Dorsal column  Lateral Spinothalamic tract
  • 47. Dorsal Column     It is concerned with joint position sense, vibration and touch Axons proceed in the posterior column to dorsal column nuclei in medulla Second order neurons decussate and ascend in medial lemniscus to thalamus From thalamus fibres relay in parietal sensory cortex
  • 48. Lateral spinothalamic tract    It is concerned with pain and temperature Fibres synapse in posterior horns and decussate in the center of cord Later they pass in lateral column as spinothalamic tract and join medial leminiscus to reach thalamus
  • 49. Symptoms of Sensory disturbances       Complaints like: Being unable to feel feet on the floor Unable to judge temperature of bath water Pins and needle sensations Sensory ataxia Paraesthesias and pain in nerve root region of supply
  • 50. Patterns of Sensory loss Single nerve lesion e.g., median n. lesion  Root lesion as in cervical or lumbar disc protrusion  Peripheral nerve lesion e.g., neuralgias, glove and stocking sensory loss  Brain stem lesions: loss of pain and temperature on ipsilateral half of face and opposite half of body (e.g. lateral medullary syndrome) 
  • 51. Patterns of Sensory loss (continued-----) Thalamic lesion: hemisensory loss of all modalities and severe deep seated burning pain (Dejerine roussy syndrome )  Cortical lesion (parietal lobe ) Hemisensory loss of all modalities  Spinal cord lesions 
  • 52. SPINAL CORD LESIONS
  • 53. CASE SCENARIOS  Gulzar bibi, 65 yr old lady presented via opd with c/o gradual weakness of both the legs for last 2months associated with urinary and fecal incontinence. There is also a c/o tingling and burning sensation in the legs.
  • 54. O/E An old lady lying in bed, conscious.  No abnormality on inspection  Power 0/5 in both the legs  Tone decreased in both the legs  Reflexes diminished  Plantars bilaterally upgoing  Spine normal  Sensory level at T6 what is the investigation of choice?
  • 55. MRI spine showed degenerative spondylitis at mid and lower thoracic spine,most evident at T8 & T9 causing cord compression.
  • 56. Case 2 Mr Fazal kareem, an 80yr old gentleman presented in ER with c/o weakness of legs, constipation & urinary retention. Patient referred to surgical unit as a case of intestinal obstruction and urinary retention. Later no surgical abnormality detected. Medical consultation taken.
  • 57. O/E       BULK equal bilaterally TONE increased in both the legs POWER 2/5 in both legs REFLEXES diminished PLANTARS upgoing SENSORY LEVEL T4 Clinical diagnosis?
  • 58. CASE 3 Miss maryam, 16 yr old presented in OPD with c/o progressively increasing difficulty in walking. O/E  POWER 3/5 in both legs  TONE increased  REFLEXES hyperreflexia  Plantars upgoing  Ankle & knee clonus positive  Sensory level T6
  • 59. Patient had pulmonary TB 3yrs back, took ATT for 2months. MRI spine showed two soft tissue density masses in thoracic spine causing cord compression. Histopathology of the mass showed features consistent with the diagnosis of -------?
  • 60. CASE 4        A 30 yrs man is brought to ER after an RTA causing injury to spine. O/E: Vitals stable Power 0/5 in the legs Reflexes absent Tone decreased in both legs Plantars non-specific Complete absence of all sensations below the umbilicus
  • 61. What is the lesion? Where is the lesion?
  • 62. CASE 5        A 40 yrs old male, victim of earthquake with spinal injury is admitted in the ward. Examination of legs shows: Power 0/5 in left leg Tone increased in left leg Left plantar upgoing Reflexes brisk on left side Absent joint position & vibration sense on left Absent pain & temperature sensation on right What is the pathology?
  • 63. CASE 6   A 57 yrs old man is brought to ER with c/o sudden inability to walk. O/E power reduced in both legs with upgoing plantars. There is loss of pain & temperature sensation in both legs but joint position sense is intact. What is your diagnosis?
  • 64. CASE 7   A 48 yrs old male is brought to ER with c/o weakness of all the four limbs over a period of 1year. However there is no incontinence. Thre is also dysphagia. Examination reveals UMN quadriplegia with visible fasciculations over the tongue. Uvula deviates to left when 10th nerve is examined. Where is the lesion & what is the pathology?
  • 65. CASE 8    A 42 yrs old lady comes in OPD with c/o numbness of both the hands and difficulty in holding the objects. O/E there is absent pain & temperature sensation over the hands and forearms. Sensory loss is dissociated. Sense of vibration and joint position sense is intact. There is weakness of small muscles of hands. What is your impression?
  • 66. CASE 9 A 65 yrs old gentleman is brought to OPD with c/o progressively increasing generalised weakness, anorexia, SOB & easy bruisability. There is previous h/o partial gastrectomy due to unknown reason. O/E: An elderly gentleman with marked pallor, bilateral pitttting edema feet & bruises over the arms and legs. Vitals stable GIT: no abnormality
  • 67. LABS Hb = 5.7 g/dl  MCV = 116 Fl  Serum albumin = 2.7 g/dl  PT = 22sec/ 14 sec What is your diagnosis & management plan? 
  • 68. CNS:     POWER 3/5 in legs REFLEXES : absent ankle reflex on both sides PLANTARS: upgoing Absent sensations upto knees
  • 69. COMPLETE SECTION Bilateral loss of all modalities below the level of lesion
  • 70. Hemisection   Contralateral loss of pain and temperature Ipsilateral loss of touch and pressure Below the level of lesion Brown sequard syndrome
  • 71. Contralateral loss of pain and Temp with preservation of Dorsal column (e.g.syringomyelia)
  • 72. Spinal cord lesions Posterior column loss  Anterior spinal artery syndrome: Involvement of lateral spinothalamic tract with preservation of dorsal column 
  • 73. Cerebral Cortex     Contralateral hemiplegia with hemisensory loss Left hemisphere; dominant: Aphasia Cortical sensory loss Right hemisphere Inattention, denial, constructional apraxia, dressing apraxia, spatial disorientation
  • 74. Corona radiata   Contralateral weakness mostly monoplegia Sensory loss according to area involved
  • 75. Internal capsule   Dense contralateral hemiplegia and sensory loss Face, arm and leg equally affected
  • 76. Midbrain Involvement of:  Third and fourth cranial nerves  Descending corticospinal and corticobulbar tracts  Reticular formation  Red nucleus
  • 77. Clinical syndromes associated with lesion Weber´s syndrome: Contralateral hemiplegia and ipsilateral third nerve lesion  Benedikt´s syndrome: third nerve palsy with involuntary movements of opposite limbs (red nucleus involvement)  Akinetic mutism: Involvement of reticular formation; patient makes no voluntary movements except that of eyes 
  • 78. Weber syndrome
  • 79. Lesions in pons     It contains 5th, 6th,7th & 8th cranial nerve nuclei. Lateralized lesion in pons causes ipsilateral CN involvement with crossed paralysis or sensory loss as in Millard Gubler syndrome. (6th and 7th nerve palsy) Central pontine lesion may cause coma, hyperthermia & pinpoint pupils. Locked in syndrome: only eye movement is possible. Pt is able to communicate via eye signals.
  • 80. Lesions in medulla  Medial medullary syndrome: Weakness and loss of postural sense in limbs on side oposite to lesion with ipsilateral paralysis of tongue.
  • 81. Lateral medullary/pica/wallenberg syndrome          Dysphagia Dysarthria Dizziness Hiccups and vomiting Ipsilateral horners syndrome Ipsilateral cerebellar lesion Ipsilateral sensory loss in face Contralateral loss of pain and temperature in limbs Ninth and tenth cranial nerve palsies Pyramidal tract is not involved
  • 82. Lateral medullary syndrome
  • 83. Unilateral Cranial nerve abnormalities Contralateral Hemiplegia or tetraplegia Multiple Cranial nerve abnormalities No yes IIIrd nerve palsy yes No VI and/ or VII No XII ± IX and XI yes Combined V VII and VIII yes No Cerebellopontine lesion Midbrain lesion Combined III, VIth yes And V No Cavernous sinus Pontine lesion lesion Combined IX, X and XI Medullary lesion Jugular foramen syndrome
  • 84. Middle cerebral artery      It constitutes 2/3 of all cerebral infarcts Contralateral hemiparesis and sensory loss, arm and face most affected Expressive aphasia(dominant hemisphere) Anosogonosia and spatial disorientation (nondominant) Contralateral inferior quadrantanopia
  • 85. Anterior cerebral artery     It constitutes two percent of all infarcts Contralateral hemiparesis and sensory loss, worse in leg Incontinence of urine Loss of verbal fluency but preserved ability to repeat
  • 86. Posterior cerebral artery  As it supplies occipital lobe, so lesion causes visual field defects, contralateral homonymous hemianopia
  • 87. Frontal lobe      Intellectual impairement Personality changes Urinary incontinence Mono or hemiplegia Motor aphasia
  • 88. Parietal lobe      Loss of cortical sensations Apraxia Contralateral homonymous lower quadrantanopia Dominant lobe involvement causes acalculia, agraphia, finger agnosia, right left disorientation----Gerstmann syndrome Non-dominant lobe involvement causes sensory and visual inattention, spatial neglect, apraxia, anosogonosia and autopagnosia
  • 89. Temporal lobe     Auditory or olfactory hallucinations Auditory or visual illusions Contralateral homonymous quadrantanopia déjà vu phenomenon
  • 90. Occipital lobe     Visual inattention Visual loss Visual agnosia Homonymous hemianopia with macular sparing