Diagnostic methods

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Diagnostic methods

  1. 1. Neurology <ul><li>Neuron: nerve, logos: knowledge </li></ul><ul><li>Neurology: deals with the prevention, therapy and rehabilitation of organic disease of NS and musculature </li></ul><ul><li>Characteristisc: </li></ul><ul><li>1. Psychiatric alterations are not typical </li></ul><ul><li>2. Morphological or functional abnormalities </li></ul><ul><li>3. Psychogenic mechanisms only modify </li></ul><ul><li>Internal Medicine : functional diagnosis </li></ul><ul><li>neurology: localisation, importance of neuroanatomy </li></ul>
  2. 2. The most frequent neurological disorders <ul><ul><ul><li>Headache (tension type: pop. 40-60%, </li></ul></ul></ul><ul><ul><ul><li>migraine: femails:9-12%, males:4-6%) </li></ul></ul></ul><ul><ul><ul><li>Low back pain </li></ul></ul></ul><ul><ul><ul><li>Stroke: prev.:2000/ 100 000 </li></ul></ul></ul><ul><ul><ul><li>Epilepsy: 60-80 0 / 100 000 </li></ul></ul></ul><ul><ul><ul><li>Parkinsonism: 20 –40 0 / 100 000 </li></ul></ul></ul><ul><ul><ul><li>Polyneuropathy:30 0 / 100 000 </li></ul></ul></ul><ul><ul><ul><li>Multiplex Sclerose 6-80 / 100 000 </li></ul></ul></ul>
  3. 3. <ul><ul><li>P- What P rovokes discomfort? </li></ul></ul><ul><ul><li>Q- What is the Q uality of the discomfort? </li></ul></ul><ul><ul><li>R- Where is the R egion of the discomfort? </li></ul></ul><ul><ul><li>S- What is the S everity of the discomfort? </li></ul></ul><ul><ul><li>T- What is the T ime sequence? </li></ul></ul>
  4. 4. Neurol. examination <ul><ul><ul><li>Signs of meningeal irritation </li></ul></ul></ul><ul><ul><ul><li>Cranial nerves </li></ul></ul></ul><ul><ul><ul><li>Reflexes </li></ul></ul></ul><ul><ul><ul><li>Sensory </li></ul></ul></ul><ul><ul><ul><li>Motor </li></ul></ul></ul><ul><ul><ul><li>Vegetative function </li></ul></ul></ul><ul><ul><ul><li>Orientation, cognition, perception </li></ul></ul></ul>
  5. 5. II. optic nerve <ul><li>Papilla-edema: increased intracran. pressure </li></ul><ul><li>Optic atrophy: chronic disease; </li></ul><ul><li>Vascular diseases: HT, diabetes </li></ul>
  6. 6. Corneal reflex (V and VII) <ul><ul><li>Afferent (V) </li></ul></ul><ul><ul><li>efferent (VII), </li></ul></ul>
  7. 7. Babinski reflex
  8. 8. Brisky :physiological pathological :brisky +pyramidal sign
  9. 9. CT <ul><li>Ischemia, bleeding, tumor abscess, degeneration, trauma. </li></ul>
  10. 10. 62 yrs stroke at admission One day later 2 days later
  11. 11. Hemorrhagic transformation 11th Dec dysart+mild hemipar 21st December worsening 27th of December
  12. 12. Cerebral hemorrhages
  13. 13. Angiography
  14. 14. DSA angiography <ul><li>DSA (digital subtraction angiography, mask-image) </li></ul><ul><li>excellent resolution </li></ul><ul><li>DSA, MR, CT and PET integration </li></ul><ul><li>intervention neuroradiology:embolisation of malformations, fistels, aneurysm </li></ul><ul><li>Problems:(bleeding, dissection, embolisation, vasospasm, contrast-allergy) </li></ul>
  15. 15. Angiography 2. <ul><li>Diagnosis </li></ul><ul><li>Stenosis, vascular malformation, aneurysm, vasculitis, sinus thrombosis </li></ul><ul><li>Therapy </li></ul><ul><li>local lysis, preop. embolisation, tumor chemotherapy </li></ul>
  16. 16. MR-angiography <ul><li>&quot;angiogramm&quot; dark (flow void) </li></ul><ul><li>or slow flow :bright (flow related enhancement). </li></ul><ul><li>Stenosis could be misdiagnosed:occlusion aneurysm </li></ul><ul><li>Non-invasive </li></ul>
  17. 17. US <ul><li>B-mode:high resolution, plaque const., Intima-Media thickness </li></ul><ul><li>Carotid Duplex:flow+morphology </li></ul><ul><li>stroke prevention:carotid stenosis+OP </li></ul><ul><li>embolus-detection </li></ul><ul><li>Transcranial Doppler </li></ul><ul><li>TTE, TEE </li></ul>
  18. 18. SPECT (Single Photon Emission Computer Tomography) <ul><ul><ul><li>99m Tc-HMPAO or 133 I-amphetamin (IMP), 133Xe </li></ul></ul></ul><ul><ul><ul><li>CBF, CBV and receptors </li></ul></ul></ul><ul><ul><ul><li>epileptic focus </li></ul></ul></ul><ul><ul><ul><li>Alzheimer (temporoparietal decrease) </li></ul></ul></ul><ul><ul><ul><li>before and after carotid reconstruction </li></ul></ul></ul>
  19. 19. PET (Positron Emission Computer Tomography) <ul><ul><ul><li>( 18 F:120 min, 15 0:2 min, 11 C:20 min) </li></ul></ul></ul><ul><ul><ul><li>pH, CBF, CBV, O2, Glu met </li></ul></ul></ul><ul><ul><ul><li>Receptor imaging </li></ul></ul></ul><ul><ul><ul><li>dopaminergic, cholinergic, histaminergic, opioid. systems </li></ul></ul></ul><ul><ul><ul><ul><li>dementia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pharmacotherapy </li></ul></ul></ul></ul>
  20. 20. PET 2. <ul><ul><ul><li>18 F-deoxyglucose epileptic focus </li></ul></ul></ul><ul><ul><ul><li>whole body PET:tumor(methionin or oxigen) </li></ul></ul></ul><ul><ul><ul><li>Radionecrosis or recidive? </li></ul></ul></ul><ul><ul><ul><li>New tracers, important for pharma research </li></ul></ul></ul>
  21. 21. Stroke in the left MCA area MRI TCD CBF HMPAO-SPECT F-DG-PET Left MCA infarct
  22. 22. Lumbal punction <ul><li>Infection? SAH, infiltration of meninx by tumor? </li></ul><ul><li>Before Lp funduscopy! </li></ul><ul><li>Between L-III-IV. vertebra </li></ul><ul><li>Sample for culture but immediate AB therapy </li></ul><ul><li>Normal CSF:clear, water-like </li></ul><ul><li>cell:2-3 </li></ul>
  23. 23. CSF <ul><li>protein (0.2-0.4 g/l) glucose 2/3 of the blood, </li></ul><ul><li>staining Ziehl-Nielsen, Gram </li></ul><ul><li>serology </li></ul><ul><li>viral titers </li></ul><ul><li>oligoclonal band </li></ul><ul><li>ELISA (Enzyme-linked-immunadsorbent assay) </li></ul><ul><li>Tumormarkers (carcinoembryonal antigen, Beta2-mikroglobulin </li></ul><ul><li>Neuronspecific enolase </li></ul><ul><li>PCR: TBC, Herpes, Borrelia , CMV </li></ul><ul><li>Pot. complications: headache, hematoma, CSF fistel, infection, herniation </li></ul>
  24. 24. EEG <ul><li>0,6-0,8 % of population: epilepsy </li></ul><ul><ul><ul><li>Brain death, prion-diseases </li></ul></ul></ul><ul><ul><ul><li>New techniques:frequency analysis, EEG-mapping. </li></ul></ul></ul><ul><ul><ul><li>video,long-term EEG,holter EEG. </li></ul></ul></ul><ul><ul><ul><li>cortical electrodes </li></ul></ul></ul><ul><ul><ul><li>before epilepsy-surgery!! </li></ul></ul></ul>
  25. 25. EEG 2. methods <ul><li>Hyperventilation </li></ul><ul><li>Fotostimulation </li></ul><ul><li>Sleep deprivation </li></ul><ul><li>Pathol. EEG important, but not diagnostic for epilepsy </li></ul><ul><li>Normal EEG does not exclude epilepsy!!! </li></ul>
  26. 26. EEG 3. <ul><li>Alpha (8-13 c/s): at rest: rhytm.occipital max. </li></ul><ul><li>Beta (14-30 c/s): frontal-central: attention, anxiety, intox. </li></ul><ul><li>theta (4-7 c/s): </li></ul><ul><li>Delta (0.5-3 c/s) </li></ul>
  27. 27. EEG 4. <ul><li>Focal disease: circumscribed slow activity </li></ul><ul><li>General abnormality:i ntox . trauma, metab. diseases </li></ul><ul><li>Spikes:important but only with clinical findings </li></ul><ul><li>epilepsy:1/3 with normal EEG!!! </li></ul><ul><li>Useful:Encephalitis </li></ul><ul><ul><li>metabolic diseases (uremic, hepatic coma etc.) </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><li>No typical findings:in tumor or vascular diseases </li></ul>
  28. 28. Transcranial Magnetic Stimulation <ul><li>Centr. and peripheral. motor system </li></ul><ul><li>conduction time </li></ul><ul><li>fields:MS, ALS, lesion of motor pathway </li></ul>
  29. 29. VEP <ul><li>light or checkerboard, occipital registration </li></ul><ul><li>100 ms latency is an important parameter </li></ul><ul><li>averaging (64-128) </li></ul><ul><li>important:Multiple sclerosis </li></ul>
  30. 30. SEP <ul><li>excitation, vertebras, parietal cortex </li></ul><ul><li>Comparison:with controls and contralateral values </li></ul><ul><li>MS, spinal cord diseases, intraop. monitoring </li></ul>
  31. 31. BAEP <ul><li>Sound, vertex, mastoid, averaging of 1-2000 impulse, I-V. waves, </li></ul><ul><li>latency, distance between III.-V. waves </li></ul><ul><li>brain stem </li></ul><ul><li>tumor, vascular, brain death </li></ul>
  32. 32. EMG <ul><ul><ul><li>neurogenic and myogenic atrophy could be differentiated </li></ul></ul></ul><ul><ul><ul><li>psychogenic and organic paresis </li></ul></ul></ul><ul><ul><ul><li>clinically silent paresis </li></ul></ul></ul><ul><ul><ul><li>reinnervation </li></ul></ul></ul><ul><ul><ul><li>tremor types </li></ul></ul></ul>
  33. 33. ENG <ul><ul><li>ENG: motor and sensory conduction velocity </li></ul></ul><ul><ul><li>motor: orthodrom, </li></ul></ul><ul><ul><li>sensory fibers:orthodrom and antidrom </li></ul></ul><ul><ul><li>sensory action pot. less than motor ones:averaging is important </li></ul></ul><ul><ul><li>Myelin lesion:slow vel. </li></ul></ul><ul><ul><li>Axon lesion:no or small changes, but amplitude decrease </li></ul></ul>
  34. 34. MEG <ul><li>Spontanous or after stim. </li></ul><ul><li>Magnetic dipol changes with magnetic field </li></ul><ul><li>Isolation is important </li></ul><ul><li>good spatial resolution (  3mm) 1 ms </li></ul><ul><li>epilepsy, stroke </li></ul><ul><li>metabolic disorders </li></ul>
  35. 35. Other methods 1. <ul><li>Muscle biopsy </li></ul><ul><li>Light- and -electronmicr, immunohistology </li></ul><ul><li>Neurogenic atrophy:atrophy in groups </li></ul><ul><li>Myositis:inflamm.cells, immuncomplex, IgG deposition </li></ul><ul><li>Non inflamm::necrosis, fibers, connect. tissue </li></ul><ul><li>Nerve biopsy </li></ul><ul><li>lateral sural n. (sensory) </li></ul><ul><li>sometimes n. musculocut. </li></ul><ul><ul><li>Gammopathy, inflammation, PAN, leukodystr., amyloidosis </li></ul></ul>
  36. 36. Others 2. <ul><li>Brain biopsy </li></ul><ul><li>CT, MR-orient., tumor, lymphoma </li></ul><ul><li>Rectal, skin </li></ul><ul><li>Amyloidosis </li></ul><ul><li>Lactate-test </li></ul><ul><li>metab. myopathia, anaerob glycogenolysis, glycolysis </li></ul><ul><li>before and after effort (3-4 x), </li></ul><ul><ul><li>aldolase, kreatinkinase, myoglobin </li></ul></ul>
  37. 37. Others 3. <ul><li>Hormones </li></ul><ul><li>GH, FSH, LH </li></ul><ul><li>Neuronspecific enolase </li></ul><ul><li>If 30 ng/ml poor prognosis </li></ul><ul><li>Antineural AB </li></ul><ul><li>Paraneoplasia </li></ul><ul><li>Tumormarkers </li></ul><ul><li>Ach-Receptor AB </li></ul><ul><ul><li>Myasthenia </li></ul></ul>
  38. 38. Hypnoid type of disturbance of consciousness Either brain stem or Diffuse cortical damage or both
  39. 39. <ul><li>Somnolent </li></ul><ul><li>Stupor </li></ul><ul><li>coma </li></ul>
  40. 40. Glasgow coma scale Eye opening 1-4 Motor response 1-6 Verbal response 1-5
  41. 41. 1. Brainstem <ul><ul><li>Hyperglyc </li></ul></ul><ul><ul><li>hypercapnia </li></ul></ul><ul><ul><li>uremia/vese </li></ul></ul><ul><ul><li>hyperammon./máj </li></ul></ul><ul><ul><li>hyperosmol. </li></ul></ul><ul><ul><li>Hypernatr. </li></ul></ul><ul><ul><li>Hypercalc. </li></ul></ul><ul><ul><li>hyperthermia </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>hypoglyc. </li></ul></ul><ul><ul><li>Hyponatr. </li></ul></ul><ul><ul><li>Hypocalc. </li></ul></ul><ul><ul><li>hypothermia </li></ul></ul><ul><ul><li>endocrin </li></ul></ul>5.Extracorporal factors bact. viral inf. drugs, poisons <ul><li>Ischemia </li></ul><ul><li>bleeding </li></ul>2.Trauma? Subcutan hem. Fract linear impres. epidural h. Subdural h.S SAH Commotion Contusion (SAH) <ul><li>4. Large focal lesion </li></ul><ul><li>with sec. edema </li></ul><ul><ul><li>tumor </li></ul></ul><ul><ul><li>Ischemia </li></ul></ul><ul><ul><li>bleedinh </li></ul></ul>3. Dysequilibrium of homeostasis/metab. Supratentorial Infratentorial Causes of disturbances of unconsciousness
  42. 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
  43. 43. Non-hypnoid types of disturbance of conscioussness <ul><li>Locked in : corticospinal and corticobulbar pathways intact vertical </li></ul><ul><li>Apallic synd .: intact brain stem, cortex damage, opened eyes </li></ul><ul><li>Akinetic mutism : frontal lobe/ efferent pathways. Lack of motivation </li></ul><ul><li>Delir </li></ul><ul><li>Amentiform syndr.: desorientation + halluc. </li></ul>
  44. 44. Brain death <ul><li>Complete and irreversible lack of brain functions rostal from foramen magnum </li></ul><ul><li>Diagnosis: </li></ul><ul><li>coma </li></ul><ul><li>lack of motor functions (no seizure, no spasticity or rigor) </li></ul><ul><li>general muscle hypotony </li></ul><ul><li>lack of pupil, corneal, vestibular, pharyngeal, palatal refl., </li></ul><ul><li>no response to caloric stimul. </li></ul><ul><li>Doll’s head phenomen. Diabetes insip. </li></ul><ul><li>Missing rhytm. of body temperature </li></ul><ul><li>lack of heart and vasomotor regulation (apnoe test) </li></ul>
  45. 45. Brain death 1. <ul><li>Complete, irreversible </li></ul><ul><li>clinical investigations and course </li></ul><ul><li>ancillary instr. </li></ul>
  46. 46. Exclusion <ul><ul><li>intox., drug, neuromusc; </li></ul></ul><ul><ul><li>shock; </li></ul></ul><ul><ul><li>metabolic or endocrine? </li></ul></ul><ul><ul><li>hypothermia (below 35 ºC); </li></ul></ul><ul><ul><li>brain stem encephalitis, cranial polyneuritis) </li></ul></ul>
  47. 47. Criteria <ul><li>coma (no spont. motor., seizure, extrapyramidal.) </li></ul><ul><li>no rigor, spasm, decortic. or decerebr. posture). </li></ul><ul><li>Spinal automatism? </li></ul>
  48. 48. No breath <ul><ul><li>apnoe-test : </li></ul></ul><ul><ul><ul><li>a-pCO 2 38-42 mmHg </li></ul></ul></ul><ul><ul><ul><li>10 min 100% oxygen </li></ul></ul></ul><ul><ul><ul><li>6 liter/min O2 </li></ul></ul></ul><ul><ul><ul><li>art. pCO 2 higher than </li></ul></ul></ul><ul><ul><ul><li>60 mmHg!! </li></ul></ul></ul>
  49. 49. Diagnosis in stroke <ul><li>From blood </li></ul><ul><ul><li>BSR, counts </li></ul></ul><ul><ul><li>glucose, ions </li></ul></ul><ul><ul><li>hemostasis </li></ul></ul><ul><ul><li>lipids, </li></ul></ul><ul><ul><li>Immunological </li></ul></ul><ul><ul><li>(in youngs) </li></ul></ul>Heart <ul><li>Functional </li></ul><ul><ul><li>BP monitoring </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Holter ECG </li></ul></ul><ul><li>Morphological </li></ul><ul><ul><li>TTE </li></ul></ul><ul><ul><li>X-ray </li></ul></ul><ul><ul><li>TEE </li></ul></ul>TEE <ul><li>Carotid, vertebral </li></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>CTA </li></ul></ul><ul><ul><li>MRA </li></ul></ul><ul><ul><li>DSA </li></ul></ul><ul><li>Brain imaging </li></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><ul><li>Diff. WI </li></ul></ul></ul><ul><ul><ul><li>Perf. WI </li></ul></ul></ul><ul><ul><li>TCD </li></ul></ul><ul><ul><li>Angiogr.(DSA, MRA) </li></ul></ul><ul><ul><li>SPECT, PET </li></ul></ul>

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