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Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
Diagnostic methods
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Diagnostic methods

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  • 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. 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. <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. 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. 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. Corneal reflex (V and VII) <ul><ul><li>Afferent (V) </li></ul></ul><ul><ul><li>efferent (VII), </li></ul></ul>
  • 7. Babinski reflex
  • 8. Brisky :physiological pathological :brisky +pyramidal sign
  • 9. CT <ul><li>Ischemia, bleeding, tumor abscess, degeneration, trauma. </li></ul>
  • 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 <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. 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. 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. 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. 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. 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. 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. Stroke in the left MCA area MRI TCD CBF HMPAO-SPECT F-DG-PET Left MCA infarct
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Hypnoid type of disturbance of consciousness Either brain stem or Diffuse cortical damage or both
  • 39. <ul><li>Somnolent </li></ul><ul><li>Stupor </li></ul><ul><li>coma </li></ul>
  • 40. Glasgow coma scale Eye opening 1-4 Motor response 1-6 Verbal response 1-5
  • 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. 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 <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. 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. Brain death 1. <ul><li>Complete, irreversible </li></ul><ul><li>clinical investigations and course </li></ul><ul><li>ancillary instr. </li></ul>
  • 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. 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. 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. 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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