Neuropathology

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  • Afferent pathways – move sensory impulses towards CNS Efferent pathways – innervate effector organs such as skeleltal muscle, cardiac and smooth muscle as wel as glands – transmits impulses away from CNS Somatic NS – motor and sensory pathways regulating voluntary motor control of skeletal muscle Autonomic NS – motor and sensory components and regulates body’s internal environment through involuntary control of organ systems
  • Neurons – vary in size, shape and processes; contain cell body (AKA soma – in groups called ganglia or plexuses), dendrites (extensions carrying nerve impulses toward cell body) and axons (projections that carry impules away from cell body) Typical neurons have one axon covered in myelin (insulating substance) Schwann cells forms and maintains the myelin – myelin acts as an insulator allowing ions to flow between segments thereby increasing velocity Neuroglia are classifications of cell supporting the neurons of the CNS Nerve injury leads to swelling, hypertrophy of the neurofilaments, myelin shealth shrinks and disintigrates and axon degenerates and disappears Nerve regeneration depneds on location of the injury, type of injury, iflammatory response and scarring; the closer to the cell body, the greater the chance the nerve cell will die; a crushing injury allows recovery than a cutting injury Synapses – region between adjacent neurons – impulses are carried across by chemical and electrical conduction Chemical conduction uses neurotransmitters More than 30 neurotransmitters – norepinephrine, acetylcholine, dopamine, serotonin, histamine and various amino acids Neurotransmitters are responsible for regulation of sleep, mood, dreams, maintenance of arousal, perception and integration of pain, emotional experiences
  • Cranium
  • Acute – alerts a person to a condition or experience that is immediately harmful; acute pain is sudden in onset and is relieved when chemical mediators which produced the pain are gone; mobilizes the person to take action Chronic – cause is unknown and if known, the pain does not response to usual treatment; develops slowly, insidiously; individuals adapt and try to modify the pain; leads to hopelessness and depression, disability and unemployment
  • Neuralgias – result from infection or disease which damages a peripheral nerve – diabetic neuropathy Hyperesthesias – increased sensitivity and decreased pain threshold to touch and painful stimuli Phantom limb pain – pain felt in an amputated limb after the stump is completely healed; occurs if the neuronal pathway from the amputated limb is stimulated at any point along the pathway Cancer pain – pain attributed to the advance of the disease, associated with the treatment of the disease, pain attributed to comorbidities
  • Level of consciousness – confusion, disorientation, lethargic, obtunded, stuporous, coma – light (purposeful movement with stimulation), coma (nonpurposeful movement with stimulation only), deep (unresponsiveness to stimuli) Pattern of breathing – Cheyne-Stokes respirations – smooth increase (crescendo) in rate and depth of breathing which peaks and is followed by a gradual smooth decrease (decrescendo) in the rate and depth of breathing to the point of apnea Pupillary changes  used to guide to eval the presence and level of brain stem dysfunction b/c brain stem areas control pupils also control level of arousal; must consider drugs pt is taking in evaluation See figure 15-1 page 442 Oculomotor responses  resting, spontaneous and reflexive eye movements under changes with different levels of brain dysfunction – see table 15-5 page 443 – figure 15-3 pages 443 and 444 Motor responses  help evaluate level of brain dysfunction as well as determine the side of brain that is maximally damaged. Purposeful – defensive or withdrawal movement of limbs to noxious stimuli  requires an intact corticospinal systems. Inappropriate or not purposeful  generalized motor movement, posturing, grimacing or groaning. Not present  unresponsive  severe dysfunction of corticospinal system
  • Aura – partial seizure experienced as a peculiar sensation preceding onset of generalized seizure – gustatory, visual or auditory experience, dizziness, numbness Prodroma – early clinical manifestations such as headache, malaise, depression occurring hours to days before the seizure Tonic – muscle contraction with excessive muscle tone Clonic – alterhnating contraction and relaxation of muscles Postictal state – period immediately following seizure activity – in generalized seizures people are confused, disoriented, complaining of headache, muscle aches and fatigue; may need to sleep after seizure, no memory of the seizure
  • Generalized seizures Account for 30% of seizures Involve neurons bilaterally Not always with a focal onset Originate from a subcortical or deeper brain focus Consciousness is impaired or lost Partial seizures Unilateral neuron involvement Have a focal onset and originate from cortical brain tissue Consciousness is maintain if kept to one hemisphere May become generalized  loss of consciousness (secondary generalization) Status epilepticus subsequent seizures before a person has time to regain consciousness Lasts more than 30 minutes Occurs from abrupt discontinuation of anti-seizure medications or inadequate treatment of seizure disorder Medical emergency due to cerebral hypoxia
  • Classification is based upon etiology – trauma, tumors, vascular disorders, infections Degeneration of nerve tissue from genetics, inflammation, biochemical alterations; atherosclerosis  multiple infarcts; trauma, lesions in the frontal and temporal regions of brain; compression or increased intracranial pressures
  • Neurofib tangle – protein on the neurons becomes distorted and twisted Senile plaques – groups of nerve cells degenerate and coalesce around an amyloid core; plaques disrupt nerve transmission Dx of AD is made from a CT scan, history and physical exam Disease develops over 5 years Treatment – use of Aricept in early AD; pts are taught compensation techniques to help memory, maintain cognitive functions which are not impaired, maintain general health and nutrition
  • Extra dural hematomas – epidural is another name for them. Occur in all age groups and account for 1-2% of all major head injuries. Most common in persons 20-40 yrs old. Injuries to menigeal vein or dural sinus leads to bleed. Sx include loss of consciousness at time of injury; become lucid for a few hours to a few days; as blood accumulates  headache, vomiting, drowsiness, confusion, seizure and hemiparesis with subsequent loss of consciousness; dx with MRI or CT scan; tx is surgical evacuation and ligation of bleeding vessel Subdural hematoma – found in 10-20% of persons with TBI; acute form develops rapidly usually w/in 48 hrs; subacute subdural hematomas develop over a few days after initial injury; chronic subdural hematomas most commonly in elderly and chronic alcoholics and occur over days to wks to months; tearing of the bridging veins in acute, torn cortical veins or venous sinuses also the source; the accumulation of blood acts as an expanding mass and increase intracranial pressure; sx of acute SDH include headache, drowsiness, restlessness, agitation, slowed cognition and confusion; as bleed progresses may develop visual changes, loss of consciousness and pupillary dilation; sx of Chronic SDH include chronic headache and tenderness over the hematoma. Tx is surgical evacuation of clot; chronic SDH may require a craniotomy to evacuate the blood and cut away the meninges around the clot.
  • Thrombi formed in vessels supply the brain; most commonly due to atherosclerosis and inflammatory disease process that damage the vessel walls. TIA sx – depend on vessel affected; transient loss of vision, visual changes, speech/cognition changes, transient weakness, hemiparesis, facial drooping; treatment is life long anticoagulation with either anti-platelet medication, ASA or warfarin Sx of stroke
  • Migraine triggers – stress, hunger, weather changes, seasonal changes, sunlight, noise, jet lag, foods such as red wine and aged cheeses, chocolate, hormonal changes, oral contraceptives Migraine auras – smells, lights, visual changes Migraine w/o aura - Lasts 4-72 hours Unilateral throbbing pain – moderate to severe and aggravated by activity Nausea, vomiting, photophobia, diarrhea
  • Bacterial – secondary to infection in bloodstream or extension of infected area to subarachnoid space; mortality is 25%; children and adolescents are primarily affected – highly contagious Aseptic or viral – inflammation limited to meninges; seasonal with summer and autumn most common times of year;
  • Primary – loss of neurons in substantia nigra Secondary – anything other than primary cause – virus, trauma, infection, drugs, toxins “designer drugs” - “Ecstasy”
  • Degeneration of normal myelin sheaths
  • Relapsing-remitting – acute exacerbations with recovery and lasting disabilty; between attacks there is no disease progression Primary progressive – steady progression of disease; only occasional minor recoveries (Plateaus); this course is fairly uncommon Secondary progressive – pattern of clear cut relapses and recoveries; becomes steadily progressive over time with continued worsening of disease Progressive-relapsing – rare type that is a steady progressive form but with acute exacerbations
  • Neuropathology

    1. 1. Neurological Disorders Paul Kelner, M.D.
    2. 3. Neurological Disorders <ul><li>Overview and Organization of the Nervous System </li></ul><ul><ul><li>Central Nervous System – brain and spinal cord </li></ul></ul><ul><ul><li>Peripheral nervous system – cranial nerves and spinal nerves </li></ul></ul>
    3. 4. Divisions of the Nervous System
    4. 5. Neurological Disorders: Organization of the Nervous System <ul><li>The Central Nervous System </li></ul><ul><ul><li>The Brain </li></ul></ul><ul><ul><li>The Spinal Cord </li></ul></ul><ul><ul><li>Motor pathways (in spinal cord) - efferent </li></ul></ul><ul><ul><li>Sensory pathways (in spinal cord) - afferent </li></ul></ul>
    5. 6. Central Nervous System
    6. 7. Afferent and Efferent Pathways
    7. 8. Neurological Disorders: Organization of the Nervous System <ul><li>Peripheral Nervous System </li></ul><ul><ul><li>Cranial nerves </li></ul></ul><ul><ul><li>Spinal nerves </li></ul></ul><ul><ul><li>Somatic nerves </li></ul></ul><ul><ul><li>Autonomic nervous system </li></ul></ul><ul><ul><ul><li>Sympathetic </li></ul></ul></ul><ul><ul><ul><li>Parasympathetic </li></ul></ul></ul>
    8. 9. Neurological disorders Cranial Nerves
    9. 10. Cranial Nerves
    10. 12. Cranial Nerves Reviewed
    11. 13. Autonomic Nervous System
    12. 14. Neurological disorders <ul><li>Cells of the Nervous System </li></ul><ul><ul><li>The Neuron </li></ul></ul><ul><ul><li>Neuroglia and Schwann cells </li></ul></ul><ul><li>The Nerve Impulse </li></ul><ul><ul><li>Synapses </li></ul></ul><ul><ul><li>Neurotransmitters </li></ul></ul><ul><li>Myelin Formation: </li></ul><ul><ul><li>Peripheral NS – Schwann cells </li></ul></ul><ul><ul><li>Central NS – Oligodendrocytes </li></ul></ul>
    13. 15. Neuron
    14. 16. Neuroglia
    15. 17. Saltatory Conduction
    16. 18. http://s3.amazonaws.com/ppt-download/nerve-impulse-28770.ppt#256,1,NERVE IMPULSE/ACTION POTENTIAL Web Site with AP transmission animation
    17. 19. The Synapse
    18. 21. The Brain
    19. 22. The Brain (Functional Areas)
    20. 23. Neurological disorders <ul><ul><li>Protective structures </li></ul></ul><ul><ul><ul><li>Cranium </li></ul></ul></ul><ul><ul><ul><li>Meninges </li></ul></ul></ul><ul><ul><ul><li>Cerebrospinal fluid and the ventricular system </li></ul></ul></ul><ul><ul><ul><li>Vertebral column </li></ul></ul></ul><ul><ul><ul><li>Blood supply </li></ul></ul></ul>
    21. 24. Neurological disorders
    22. 25. The Meninges
    23. 26. Cerebral Ventricular System
    24. 27. MRI of Spinal Cord within Vertebrae
    25. 28. Cerebral Blood Supply
    26. 29. Circle of Willis
    27. 30. Pain A Summary of Important Concepts Part II
    28. 31. Pain
    29. 32. Pain (definitions) <ul><li>Pain Threshold – point at which a stimulus is perceived as pain </li></ul><ul><li>Pain Tolerance – amount of pain a person will tolerate before outwardly responding to it </li></ul><ul><li>Nociceptive pain – pain resulting from direct tissue injury </li></ul><ul><li>Non-nociceptive pain – neuropathic pain </li></ul>
    30. 33. Neuropathic (non-nociceptive pain)
    31. 34. Neurological disorders <ul><li>Pain (continued) </li></ul><ul><ul><li>Acute versus chronic pain </li></ul></ul><ul><ul><ul><li>Acute pain is a protective mechanism </li></ul></ul></ul><ul><ul><ul><li>Chronic pain is persistent, lasting > 6 months </li></ul></ul></ul>
    32. 35. Neurological disorders <ul><ul><li>Clinical manifestations of pain </li></ul></ul><ul><ul><ul><li>Acute pain </li></ul></ul></ul><ul><ul><ul><ul><li>Somatic pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Visceral pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Referred pain </li></ul></ul></ul></ul><ul><ul><ul><li>Chronic pain </li></ul></ul></ul><ul><ul><ul><ul><li>Neuropathic pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperesthesias </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Phantom limb pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cancer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Reflex sympathetic dystrophy(RSD) </li></ul></ul></ul></ul>
    33. 36. Referred Pain
    34. 37. Alterations in Neurological Function Part III
    35. 38. Neurological Disorders <ul><li>Alterations in Cognitive Systems </li></ul><ul><ul><li>Alterations in arousal – Coma </li></ul></ul><ul><ul><ul><li>Structural vs. metabolic vs. psychogenic causes </li></ul></ul></ul><ul><ul><ul><li>Grouped according pathologic process </li></ul></ul></ul><ul><ul><ul><ul><li>Infectious </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vascular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Neoplastic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Traumatic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Congenital </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Degenerative </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Polygenic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Metabolic </li></ul></ul></ul></ul>
    36. 39. Coma <ul><li>By definition, coma (decreased arousal) is produced by: </li></ul><ul><ul><li>Bilateral hemispheric damage </li></ul></ul><ul><ul><li>Suppression by hypoxia,hypoglycemia, drugs or toxins </li></ul></ul><ul><ul><li>Brain stem lesion or metabolic derangement that suppresses Reticular Activating System (RAS) </li></ul></ul>
    37. 40. Neurological disorders <ul><li>Coma </li></ul><ul><ul><li>Clinical manifestations </li></ul></ul><ul><ul><ul><li>Level of consciousness </li></ul></ul></ul><ul><ul><ul><li>Pattern of breathing (cheyne-stokes) </li></ul></ul></ul><ul><ul><ul><li>Pupillary changes </li></ul></ul></ul><ul><ul><ul><li>Oculomotor responses (ie. Doll’s eyes) </li></ul></ul></ul><ul><ul><ul><li>Motor responses </li></ul></ul></ul>
    38. 41. Posturing <ul><li>Decorticate </li></ul><ul><ul><li>Flexion of arms, wrists, fingers </li></ul></ul><ul><ul><li>Adduction of upper extremities </li></ul></ul><ul><ul><li>Extension of lower extremities </li></ul></ul><ul><li>Decerebrate </li></ul><ul><ul><li>Extremities in extension </li></ul></ul><ul><ul><li>Pronation of forearms and plantar extension of feet </li></ul></ul>
    39. 42. Decorticate -> <- Decerebrate
    40. 43. Glasgow Coma Scale (GCS)
    41. 44. Neurological disorders <ul><ul><li>Outcomes </li></ul></ul><ul><ul><ul><li>Mortality </li></ul></ul></ul><ul><ul><ul><ul><li>Brain death – brain stem death – no potential for recovery –no control of homeostasis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cerebral death – death of cerebral hemispheres not including the brain stem – vegetative state </li></ul></ul></ul></ul><ul><ul><ul><li>Morbidity </li></ul></ul></ul><ul><ul><ul><ul><li>Recovery of consciousness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Residual cognitive dysfunction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Psychosocial domain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vocational domain </li></ul></ul></ul></ul>
    42. 45. Neurological disorders <ul><ul><li>Seizures – a sudden, explosive disorderly discharge of cerebral neurons </li></ul></ul><ul><ul><ul><li>Characterized by sudden, transient alterations in brain function </li></ul></ul></ul><ul><ul><ul><li>Clinical manifestations – Motor, Sensory, Autonomic, Psychic, Level of arousal </li></ul></ul></ul><ul><ul><ul><li>Epilepsy – term applied to seizures in which no underlying cause is found </li></ul></ul></ul><ul><ul><ul><ul><li>General term for primary condition causing seizures </li></ul></ul></ul></ul>
    43. 46. Neurological disorders <ul><ul><li>Conditions associated with seizure disorders </li></ul></ul><ul><ul><ul><li>Any disorder that alters neuronal environment </li></ul></ul></ul><ul><ul><ul><ul><li>Metabolic defects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Congenital conditions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Genetic predisposition </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Peri- or post-natal injury </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Infections </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tumors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Drugs or alcohol </li></ul></ul></ul></ul>
    44. 47. Neurological disorders <ul><li>Terminology </li></ul><ul><ul><li>Aura </li></ul></ul><ul><ul><li>Prodroma </li></ul></ul><ul><ul><li>Tonic phase </li></ul></ul><ul><ul><li>Clonic phase </li></ul></ul><ul><ul><li>Postictal state </li></ul></ul>
    45. 48. Generalized Seizures <ul><li>Generalized Seizures </li></ul><ul><li>(Produced by the entire brain) Symptoms </li></ul><ul><li>1. &quot;Grand Mal&quot; or Generalized tonic-clonic Unconsciousness, convulsions, muscle rigidity </li></ul><ul><li>2. Absence Brief loss of consciousness </li></ul><ul><li>3. Myoclonic Sporadic (isolated), jerking movements </li></ul><ul><li>4. Clonic Repetitive, jerking movements </li></ul><ul><li>5. Tonic Muscle stiffness, rigidity </li></ul><ul><li>6. Atonic Loss of muscle tone </li></ul>
    46. 49. Partial Seizures <ul><li>Partial Seizures </li></ul><ul><li>(Produced by a small area of the brain) Symptoms </li></ul><ul><li>1. Simple (awareness is retained) </li></ul><ul><li>a. Simple Motor </li></ul><ul><li>b. Simple Sensory </li></ul><ul><li>c. Simple Psychological a. Jerking , muscle rigidity, spasms, head-turning </li></ul><ul><li>b. Unusual sensations affecting either the vision, hearing, smell taste or touch </li></ul><ul><li>c. Memory or emotional disturbances </li></ul><ul><li>2. Complex </li></ul><ul><li>(Impairment of awareness) Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements </li></ul><ul><li>3. Partial seizure with secondary generalization Symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions. </li></ul>
    47. 50. Neurological disorders <ul><li>Types of seizure disorders </li></ul><ul><ul><li>Generalized seizures </li></ul></ul><ul><ul><li>Partial seizures </li></ul></ul><ul><ul><li>Status epilepticus </li></ul></ul><ul><ul><li>Absence </li></ul></ul><ul><ul><li>Pseudo-seizures </li></ul></ul><ul><li>Treatment of seizure disorders </li></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Patient education </li></ul></ul><ul><ul><li>surgery </li></ul></ul>
    48. 51. Neurological Disorders <ul><ul><li>Data processing defects </li></ul></ul><ul><ul><ul><li>Agnosia – failure to recognize form and nature of objects </li></ul></ul></ul><ul><ul><ul><li>Dysphasia – impairment in understanding or production of language </li></ul></ul></ul><ul><ul><ul><ul><li>Expressive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Echolalia </li></ul></ul></ul></ul><ul><ul><ul><li>Aphasia – loss of ability to understand or produce language </li></ul></ul></ul>
    49. 52. Neurological disorders <ul><ul><li>Dementia </li></ul></ul><ul><ul><ul><li>Progressive failure of multiple cerebral functions </li></ul></ul></ul><ul><ul><ul><li>Syndrome with many causes </li></ul></ul></ul><ul><ul><ul><li>Loss of intellect with impaired mental abilities </li></ul></ul></ul><ul><ul><ul><ul><li>Disoriented </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Memory problems (recent and remote) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Language problems </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Attentional focus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Alterations in behaviors </li></ul></ul></ul></ul>
    50. 53. Neurological Disorders <ul><ul><ul><li>Evaluation of cause </li></ul></ul></ul><ul><ul><ul><ul><li>Neuropsychological testing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Laboratory and diagnostic testing </li></ul></ul></ul></ul><ul><ul><ul><li>Treat underlying cause </li></ul></ul></ul><ul><ul><ul><ul><li>Infections </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nutritional issues </li></ul></ul></ul></ul><ul><ul><ul><li>Progressive dementias </li></ul></ul></ul><ul><ul><ul><ul><li>Goal is to maintain current function and prevent continued deterioration </li></ul></ul></ul></ul>
    51. 54. Neurological disorders <ul><ul><li>Alzheimer disease (AD) </li></ul></ul><ul><ul><ul><li>Most common cause of severe cognitive dysfunction in older persons </li></ul></ul></ul><ul><ul><ul><ul><li>Familial, early-onset – occurs in persons before age 65 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Familial, late-onset – known as FAD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Non-hereditary, late-onset AD – occurs in 70% of cases </li></ul></ul></ul></ul><ul><ul><ul><li>Exact cause is not known – several theories </li></ul></ul></ul><ul><ul><ul><ul><li>Loss of neurotransmitter stimulation by choline acetyltransferase </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mutations in genes that code amyloid proteins </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Alterations in apolipoprotein E (binds beta amyloid) </li></ul></ul></ul></ul><ul><ul><ul><li>Neurofibrillary tangle </li></ul></ul></ul><ul><ul><ul><li>Senile plaques – diagnostic of Alzheimer’s Disease </li></ul></ul></ul><ul><ul><ul><li>Diagnosis </li></ul></ul></ul><ul><ul><ul><li>Treatment </li></ul></ul></ul>
    52. 55. Alzheimer’s Atrophy
    53. 56. Pet Scan and AD
    54. 57. Alzheimer’s Disease Microscopic Pathology
    55. 58. Neurological disorders: Trauma and Bleeds <ul><li>Hematomas </li></ul><ul><ul><li>Extradural hematomas </li></ul></ul><ul><ul><li>Subdural hematomas </li></ul></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><ul><li>Intracerebral hemorrhage </li></ul></ul>
    56. 59. Epidural Hematoma
    57. 60. Subdural Hematoma
    58. 61. Subarachnoid Hemorrhage
    59. 62. Intracerebral Hemorrhage
    60. 63. Neurological disorders <ul><li>Cerebrovascular accidents (Stroke) </li></ul><ul><ul><li>Occurs in 600,000 persons per year </li></ul></ul><ul><ul><li>Third leading cause of death in US </li></ul></ul><ul><ul><li>Most common in persons > 65 years </li></ul></ul><ul><ul><li>More common in women </li></ul></ul><ul><ul><li>More common in African-Americans and Asians </li></ul></ul><ul><ul><li>Heredity component </li></ul></ul>
    61. 64. CVA on CT
    62. 65. Neurological disorders <ul><li>Risk factors for CVA </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Insulin resistance </li></ul></ul><ul><ul><li>Polycythemia and thrombocythemia </li></ul></ul><ul><ul><li>Elevated lipoprotein-a </li></ul></ul><ul><ul><li>Impaired cardiac function </li></ul></ul><ul><ul><li>Hyperhomocysteinemia </li></ul></ul><ul><ul><li>Atrial fibrillation </li></ul></ul><ul><ul><li>Estrogen deficiency </li></ul></ul>
    63. 66. Carotid Artery Disease
    64. 67. Carotid Artery Disease
    65. 68. Neurological disorder <ul><ul><li>Thrombotic strokes </li></ul></ul><ul><ul><ul><li>Due to arterial occlusion caused by thrombi </li></ul></ul></ul><ul><ul><ul><li>Classified secondary to clinical manifestations </li></ul></ul></ul><ul><ul><ul><ul><li>Transient ischemic attacks (TIA) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Caused by thromboembolic particles </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Abrupt onset of symptoms </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Strokes-in-evolution (Sometimes called RIND –reversible ischemic neurologic deficit) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Intermittent progression of neuro deficits over hours to days </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Completed strokes </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Maximum amount of destruction has occurred </li></ul></ul></ul></ul></ul>
    66. 69. Neurological disorders <ul><li>Embolic strokes </li></ul><ul><ul><li>Fragment of clot breaks off from thrombi outside of brain </li></ul></ul><ul><ul><li>Most common from heart, aorta, carotid artery or thorax </li></ul></ul><ul><ul><li>Risk factors  atrial fibrillation, MI, endocarditis, valve replacements </li></ul></ul><ul><ul><li>Tumors, fat and air can also cause strokes </li></ul></ul><ul><li>Hemorrhagic strokes </li></ul><ul><ul><li>Third most common cause of CVA </li></ul></ul><ul><ul><li>Risk factors </li></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Aneurysms </li></ul></ul></ul><ul><ul><ul><li>Bleeding disorders </li></ul></ul></ul><ul><ul><ul><li>Tumors </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Drug use </li></ul></ul></ul>
    67. 70. Neurological disorders <ul><li>Symptoms of CVA </li></ul><ul><ul><li>Depend upon which artery is obstructed </li></ul></ul><ul><ul><ul><li>Weakness </li></ul></ul></ul><ul><ul><ul><li>Facial drooping </li></ul></ul></ul><ul><ul><ul><li>Loss of or trouble with speech </li></ul></ul></ul><ul><ul><ul><li>Loss of function of limbs – hemiparesis </li></ul></ul></ul><ul><ul><ul><li>Loss of or changes in vision </li></ul></ul></ul><ul><ul><ul><li>Headache </li></ul></ul></ul><ul><ul><ul><li>Inability to recognize objects or persons </li></ul></ul></ul><ul><ul><ul><li>Changes in level of consciousness </li></ul></ul></ul>
    68. 71. Neurological disorders <ul><li>Treatment of CVA </li></ul><ul><ul><li>“ Time is Brain”  treatment within 6 hours of onset of symptoms </li></ul></ul><ul><ul><li>Interventional and drug therapy </li></ul></ul><ul><ul><ul><li>Clot busters – thrombolytics – TPA </li></ul></ul></ul><ul><ul><ul><li>Improve blood flow - vasodilators </li></ul></ul></ul><ul><ul><ul><li>Stenting of vessels </li></ul></ul></ul><ul><ul><ul><li>Prevention of thrombus – anti-platelet drugs </li></ul></ul></ul><ul><ul><li>Physical, emotional and mental rehabilitation </li></ul></ul><ul><ul><li>Education of patient and family </li></ul></ul>
    69. 72. Aneurysms <ul><li>Many etiologies (can be inherited) </li></ul><ul><li>Dilation or outpouching of vessels </li></ul><ul><li>Usually go undiagnosed until they bleed </li></ul><ul><li>Treated surgically </li></ul>
    70. 73. Aneurysm
    71. 74. Aneurysm Clip
    72. 75. Neurological disorders <ul><li>Headaches – Most common neurological disorder </li></ul><ul><ul><li>Can be a symptom of serious illness </li></ul></ul><ul><ul><li>Can be a symptom of being a nursing student </li></ul></ul><ul><li>Migraines - Benign recurring headache provoked by a trigger </li></ul><ul><ul><li>Affects 11 million person in the U.S. </li></ul></ul><ul><ul><li>Prevalent in women ages 15-55 years and can occur in children </li></ul></ul><ul><ul><li>Auras can occur </li></ul></ul><ul><ul><li>Most common is migraine without aura </li></ul></ul>
    73. 76. Tension Vs. Migraine Headaches <ul><li>Symptom A </li></ul><ul><li>Tension B </li></ul><ul><li>Migraine </li></ul><ul><li>Intensity, Duration and Quality of Pain </li></ul><ul><li>Mild or moderate pain intensity √ √ </li></ul><ul><li>Severe √ </li></ul><ul><li>Duration of headache </li></ul><ul><li>30 min – 7 days </li></ul><ul><li>4-72 hours √ </li></ul><ul><li>√ </li></ul><ul><li>Intense pounding, throbbing and/or debilitating √ </li></ul>
    74. 77. Symptom A Tension B Migraine Intensity, Duration and Quality of Pain Mild or moderate pain intensity √ √ Severe   √ Duration of headache             30 min – 7 days             4-72 hours √   √ Intense pounding, throbbing and/or debilitating   √ Distracting but not debilitating √   Steady ache √   Location of Pain One side of head   √ Both sides of head √ √ Associated Symptoms Nausea/vomiting   √ Sensitivity to light and/or sounds   √ Aura before onset of headache such as visual symptoms   √
    75. 78. Neurological disorders <ul><li>Basis of migraines is multifactorial </li></ul><ul><ul><li>Serotonin </li></ul></ul><ul><ul><li>Vasoactive substances </li></ul></ul><ul><ul><li>Inflammatory processes </li></ul></ul><ul><li>Treatment of migraine </li></ul><ul><ul><li>Avoidance of triggers </li></ul></ul><ul><ul><li>Rest or sleep in a dark, quiet room </li></ul></ul><ul><ul><li>Compresses, cold or warm </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><ul><li>Serotonin antagonists (Imitrex) </li></ul></ul></ul><ul><ul><ul><li>Beta or calcium channel blockers </li></ul></ul></ul><ul><ul><ul><li>Aspirin, caffeine, NSAIDS </li></ul></ul></ul><ul><ul><ul><li>Magnesium supplements </li></ul></ul></ul>
    76. 79. Migraine On MRI
    77. 80. Neurological disorders <ul><li>Meningitis – infection & inflammation of meninges </li></ul><ul><ul><li>Caused by bacteria, viruses, fungi, parasites or toxins </li></ul></ul><ul><ul><li>Acute, subacute or chronic </li></ul></ul><ul><ul><ul><li>Bacterial vs. aseptic meningitis </li></ul></ul></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Fever, chills, petechial rash </li></ul></ul></ul><ul><ul><ul><li>Headache, photophobia, otophobia, neck stiffness </li></ul></ul></ul><ul><ul><ul><li>Nuchal rigidity, decrease consciousness, seizures, hemiparesis, hemiplegia </li></ul></ul></ul>
    78. 81. Meningitis
    79. 82. Neurological disorders <ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Supportive measures - Quiet, dark room </li></ul></ul></ul><ul><ul><ul><li>Antibiotics or anti-viral medications </li></ul></ul></ul><ul><ul><ul><li>Vaccinations are available for bacterial form </li></ul></ul></ul><ul><ul><ul><li>Chemoprophylaxis for exposed persons </li></ul></ul></ul>
    80. 83. Neurological disorders <ul><li>Parkinson’s disease </li></ul><ul><ul><li>Common degenerative disease of basal ganglia involving the dopamine-secreting cells </li></ul></ul><ul><ul><li>Onset after age 40, most common in men </li></ul></ul><ul><ul><li>Primary vs. secondary </li></ul></ul>
    81. 84. Degeneration of the Substantia Nigra NORMAL Parkinson’s Disease
    82. 85. Neurological disorders <ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Resting tremor </li></ul></ul></ul><ul><ul><ul><li>Rigidity </li></ul></ul></ul><ul><ul><ul><li>Akinesia – hypokinesia and bradykinesia </li></ul></ul></ul><ul><ul><ul><li>Stooped posture </li></ul></ul></ul><ul><ul><ul><li>Shuffling gait, equilibrium disorders </li></ul></ul></ul><ul><ul><ul><li>Orthostatic hypotension, gastric/urinary retention and constipation </li></ul></ul></ul><ul><ul><ul><li>Depression </li></ul></ul></ul>
    83. 86. Neurological disorders <ul><li>Treatment </li></ul><ul><ul><li>Administration of dopaminergic drugs -> L-Dopa </li></ul></ul><ul><ul><li>Antihistamines, amantadine reduce akinesia </li></ul></ul><ul><ul><li>Drugs lose effects over time </li></ul></ul><ul><ul><li>Stem cell research </li></ul></ul><ul><li>Slow, progressive disease </li></ul><ul><ul><li>Total loss of function </li></ul></ul><ul><ul><li>Death is commonly due to pneumonia </li></ul></ul>
    84. 87. Neurological disorders <ul><li>Multiple sclerosis (MS) </li></ul><ul><ul><li>Common immune disorder involving CNS </li></ul></ul><ul><ul><li>Demyelinating disorder </li></ul></ul><ul><ul><ul><li>Onset between 20 and 50 years </li></ul></ul></ul><ul><ul><ul><li>Females affected twice as often as males </li></ul></ul></ul><ul><ul><ul><li>Most prevalent in northern countries </li></ul></ul></ul><ul><ul><ul><li>Genetic susceptibility </li></ul></ul></ul><ul><ul><li>Previous viral insult in a genetically susceptible person  T cells reactive to myelin </li></ul></ul><ul><ul><ul><li>Destruction of myelin leads to slowing and eventual blockage of conduction </li></ul></ul></ul>
    85. 88. MS on MRI
    86. 89. Neurological disorders <ul><li>MS (continued) </li></ul><ul><ul><li>Different types of MS </li></ul></ul><ul><ul><ul><li>Mixed, spinal, cerebellar, amaurotic forms </li></ul></ul></ul><ul><ul><ul><li>Different clinical courses </li></ul></ul></ul><ul><ul><ul><ul><li>Relapsing-remitting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Primary progressive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Secondary progressive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Progressive relapsing </li></ul></ul></ul></ul>
    87. 90. Neurological disorders <ul><li>MS (continued) </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Optic neuritis </li></ul></ul></ul><ul><ul><ul><li>Visual changes </li></ul></ul></ul><ul><ul><ul><li>Dizziness </li></ul></ul></ul><ul><ul><ul><li>Nystagmus </li></ul></ul></ul><ul><ul><ul><li>Weakness </li></ul></ul></ul><ul><ul><ul><li>Numbness, tingling </li></ul></ul></ul><ul><ul><ul><li>Ataxia, tremor </li></ul></ul></ul><ul><ul><ul><li>Bladder and bowel changes </li></ul></ul></ul>
    88. 91. Neurological disorder <ul><li>MS (continued) </li></ul><ul><ul><li>Diagnosis with CT scan or MRI </li></ul></ul><ul><ul><li>CSF exam </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Acute management of exacerbations </li></ul></ul></ul><ul><ul><ul><li>Reducing frequency of relapses or disease progression </li></ul></ul></ul><ul><ul><ul><ul><li>Steroids </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Interferon </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Immunosuppressive agents </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Symptom management </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physical and occupational therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Patient education </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Support of patient and family </li></ul></ul></ul></ul>
    89. 92. Intracranial Neoplasms <ul><li>50 – 60% of all adult intracranial neoplasms are malignant gliomas and/or astrocytomas </li></ul><ul><li>Approximately 25% of patients with primary tumors outside of the CNS will develop intracranial metastases. Most of these develop secondary to lung cancer. </li></ul>
    90. 93. Glioblastoma on MRI
    91. 94. Glioblastoma on MRI GLIOBLASTOMA
    92. 95. Cerebral Edema
    93. 96. Elevated Intracranial Pressure (ICP) <ul><li>Medical Emergency </li></ul><ul><li>Symptoms include headache, vomiting and changes in LOC </li></ul><ul><li>Medically treated with mannitol and other agents </li></ul><ul><li>Definitive treatment involves correction of underlying pathology </li></ul><ul><li>Complications include herniation </li></ul>

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