Diagnostic methods

  • 593 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
593
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
29
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

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