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신경외과 환자의 신경학적 검사
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신경외과 환자의 신경학적 검사

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신경외과 환자의 신경학적 검사 Presentation Transcript

  • 1. Overview of Neurosurgicalpatient management
  • 2. Brain 대뇌 (Cerebrum) 소뇌 (Cerebellum) 뇌간 (Brain Stem) 변연계 (Limbic System)
  • 3. Brain cortex
  • 4. 전두엽 일차운동영역
  • 5. 전두엽 일차운동영역
  • 6. 전두엽 일차운동영역의 분포
  • 7. 전두엽 전운동영역
  • 8. 전두엽 전운동안구영역
  • 9. 두정엽 일차 체성감각영역체감각연합영역삼차연합영역
  • 10. 후두엽일차 시각영역시각연합영역
  • 11. 측두엽 청각수용영역Wernicke 영역
  • 12. Diagnostic approach ofdysphasia Content Fluency Comprehension Expression Repetition
  • 13. Dysphasia Broca’s aphasia Wernicke’s aphasia Global aphasia Conductive aphasia
  • 14. Skull
  • 15. Cranial N. Cbr: 1,2 Midbrain:3,4 Pons:5,6,7,8 Medulla oblongata:9,10,11,12
  • 16. Intracranial artery
  • 17. Diagnostic Tool Indications of use of CT `Hounsfield number(Bone>>> lipid>air) `fisrt line in evaluation of a change in mental status `Test of choice for those with implantable devices `shows acute and sub acute blood(ICH/SAH,SDH) `Bony abnormalities,i.e Trauma or Fracture `Edema/mass effect `Abnormalities in size and shape of structures (brain atrophy,gyri effacement with swelling) `Hydrocephalus `Ischemic stroke
  • 18. Diagnostic Tool Indications of use of MRI `Use with caution with people with claustrophobia,implantable devices or programmable shunts `Provide better soft tissue differentiation than CT `Tumor `Abscess `Edema/mass effect `Stroke `Hydrocephalus `Stereotactic surgical planning
  • 19. Plane
  • 20. Plane
  • 21. Plane
  • 22. Plane
  • 23. How things appear on a CT Acute blood/Calcifications -White Chronic blood collection -Low density black to gray as increasing density CSF/Air-Black White matter- Less dense than gray matter Ischemia-lower density and therefore will be darker and may not appear for 12hours
  • 24. Types of MRI Gadilinium enhancement(tumor/infection) T1/T2 Diffusion- can assess an acute infarct within the last 2 weeks MRV-Assess patency,stenosis or occlusion of the venous system MRA Flair/Echo gradient-Similar studies(Echo gradient may see a smaller bleed clearer Functional MRI-Asked to do sensory,motor and cognitive tasks. Shows increasing signals with cerebral activity
  • 25. MRI overview (T1/T2) T1 CSF appears black White matter brighter than gray matter T2 CSF apperars white
  • 26. Tumor??
  • 27. Pneumocephalus
  • 28. Meningioma
  • 29. Meningioma
  • 30. Hydrocephalus
  • 31. Basal ganglia ICHThalamic ICH
  • 32. Lt.F infarction(Broca area)
  • 33. Rt.Cbll infarction
  • 34. Pontine ICH
  • 35. Lt.MCA infarctionSAH(Subarachnoid hemorrhage)
  • 36. CT angiography
  • 37. Trauma
  • 38. Chronic SDH
  • 39. EDH c skull Fx.
  • 40. T12 bursting Fx.
  • 41. Brain death(Reversal sign)
  • 42. Orbital wall Fx.
  • 43. Spine
  • 44. Cord
  • 45. Dermatome
  • 46. Compression Fx.(L1)
  • 47. HNP
  • 48. Spinal stenosis
  • 49. Spondylolysis
  • 50. Spineinjury
  • 51. Spinal cord injury Methylprednisolone(Within 8hrs) 1.concentration:62.5mg/ml 2.bolus:30mg/kg initial bolus over 15minutes 3.followed by a 45 minutes pause 4.maintenance:then 5.4 mg/kg/hr if<3hrs:23hrs, >3~8hrs:47hrs
  • 52. Spinal cord injury(Frankel Scale)Grade Description1(A) complete motor and sensory paralysis below lesion2(B) Complete motor paralysis,but some residual sensory perception below lesion3(C) Residual motor function,but of no practical use4(D) Useful but subnormal motor function below lesion5(E) normal
  • 53. Glasgow coma scale(≥4yrs)Points Eye opening verbal motor 6 - - obeys 5 - oriented Localizes pain 4 Spontaneou Confused Withdrawals to pain s 3 To speech Inappropriate Flexion 2 To pain Incomprehesible Extenson 1 None None none
  • 54. Glasgow coma scale(≤4yrs) Points Eye opening verbal motor 6 - - obeys 5 - Smile,interact Localizes pain s 4 Spontaneous Consolable , Withdrawals to inappropriate pain 3 To speech moaning Flexion 2 To pain Inconsolable, Extenson restless 1 None None none
  • 55. Alteration in consciousness Alert Confusion Obtundation Drowsy(Lethargy) Stupor Coma
  • 56. Vegetative state Preservation of autonomic function and primitive reflex. No meaingful interaction for external stimuli.
  • 57. Locked in syndrome A state quadriplegia with preservation of cognition Consciousness,vertical eye movements,eyelid blinking Destructive lesions in the ventral pons or ventral midbrain Reemergence of horizontal movement (within 4weeks):Predictive of improved recovery
  • 58.  Convulsion(Involuntary jerky movement) Seizure(with epileptic discharge, episodic event,LOC,EBD,drooling etc.drug,Uremia, encephalopathy) Epilepsy(recurrent,chronic)
  • 59. Muscle strengthGrade Strength0 No contraction1 Flickering2 Movement with gravity eliminated3 Movement against gravity4 Against resistance(4-,4 ,4+)5 normal
  • 60. Muscle tone Hypotonia Flaccidity Spasticity( 강직 ):clasp-knife Rigidity( 경직 ):Cogwheel ridigity,lead pipe rigidity
  • 61. CSF pathway
  • 62. CSF dynamics 1500 cc intracranial space -140cc(ventricle:23cc,spinal:30cc, cistern:87cc)V(CSF)+V(blood)+V(brain)=constant ;Monro-kellie doctrine Pressure 60~180 mmH2O(lateral) 200~350 mmH2O(sitting)
  • 63. Cushing’s response Hypertension Bradycardia Irregular respiration
  • 64. Theapeutic modalities for thereduction of ICP CSF vol. -Acetazolamide,steroid,EVD Blood vol. -Hyperventilation,head elevation, Brain vol. -Osmotic agents,diuretics, Surgical decompression
  • 65. Lumbar tapping Contra Ix. -skin infection -IICP -Degenerative spondylosis -bleeding tendency
  • 66. IICP precipitating factor Hypercapnia(Paco2>45mmHg) Hypoxemia(PaO2<50mmHg) Respirtory procedure(Suction,PEEP,ambu bagging) Position(angulation) Valsalva maneuver Anxiety,coughing,
  • 67. Cranial N.I. Olfactory 냄새II. Optic 시력 , 시야 , 동공대광반사III. Oculomotor 안구운동 , 동공대광반사IV. Trochlear 안구운동 ( 하외전 )V. Trigeminal 안면감각 , 각막반사 , 저작운동VI. Abducens 안구운동 ( 측방 )VII. Facial 안면근육운동VIII. Vestibularcochlear 듣기 , 균형IX. Glossopharyngeal 구토반사 , 소리내기X. Vagus 연구개운동 ,XI. Accessory 머리돌리기 , 어깨움추리기XII. Hypoglossal 혀내밀기
  • 68. Bell’s palsy
  • 69. Facial weakness H-B(House-Brackmann grade)Grade Description1 Normal function in all areas2 Slight weakness on close inspection3 Obvious but not disfiguring4 Obvious weakness and/or disfiguring asymmetry5 Barely perceptible motion6 No movement
  • 70. Bell’s palsy
  • 71. Ocular movement
  • 72. Disorder of gaze
  • 73. Ischemic CVD TIA(transient ischemic attack):24 시간이내에 full recovery.30% 환자에서 한달이내에 뇌경색 RIND(Reversible ischemic neurologic deficit):3 주이 내 회복 Progressive stroke:ischemic cerebral edema Completed stroke
  • 74. Ischemic CVD Atherothrombotic infarction Embolic infarction(Atrial fibrillation) Lacunar infarction Hemodynamic infarction
  • 75. Acute medical management ofischemic stroke Effective therapy for stroke -Reduce degree of ischemic change -Minimize effect of reperfusion injury*penumbra:Target ofneuroprotective therapy
  • 76. Thrombolytic agents Plasminogen to plasmin Degradation of fibrin Canal recanalization * t-PA:only drug approved by FDA
  • 77. t- PA administration Inclusion -18yr older -Signs of measurable neurological deficit -Onset≤3hrs
  • 78. t- PA administration Exclusion -Hemorrhage ICH,SAH,active internal bleeding Platelet count<100,000/mm 3 Heparin within48hrs,PT>15sec Recent lumbar or arterial puncture GI bleeding within 21 days
  • 79. t- PA administration Exclusion -Minor or rapidly improving symptoms -Uncontrolled HTN (SBP>180,DBP<110) -abnormal blood glucose(<50 or >400) -Post myocardial infarction -Seizure at time stroke onset
  • 80. t- PA administration Monitor BP every 15min for 2hrs Recommneded goal of BP -less than 185/100 Aggressive blood pressure reduction might precipitate further ischemic injury
  • 81. Pain-sensitive structure Venous sinuses Cortical veins Artery Dura mater Scalp vessels and muscle
  • 82. Classfication(Headache) Sinusits Migrane Cluster headache Post traumatic Drug-induced HA Menigitis Hydrocephalus Tension HA Cervicalgia Hemorrhage
  • 83. History taking Character,site,mode of onset Frequently duration Timing Associated symptoms Precipitating factors
  • 84. Meningeal irritation sign Photophobia Neck and back pain Brudzinski’s sign