신경외과 환자의 신경학적 검사

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신경외과 환자의 신경학적 검사

  1. 1. Overview of Neurosurgicalpatient management
  2. 2. Brain 대뇌 (Cerebrum) 소뇌 (Cerebellum) 뇌간 (Brain Stem) 변연계 (Limbic System)
  3. 3. Brain cortex
  4. 4. 전두엽 일차운동영역
  5. 5. 전두엽 일차운동영역
  6. 6. 전두엽 일차운동영역의 분포
  7. 7. 전두엽 전운동영역
  8. 8. 전두엽 전운동안구영역
  9. 9. 두정엽 일차 체성감각영역체감각연합영역삼차연합영역
  10. 10. 후두엽일차 시각영역시각연합영역
  11. 11. 측두엽 청각수용영역Wernicke 영역
  12. 12. Diagnostic approach ofdysphasia Content Fluency Comprehension Expression Repetition
  13. 13. Dysphasia Broca’s aphasia Wernicke’s aphasia Global aphasia Conductive aphasia
  14. 14. Skull
  15. 15. Cranial N. Cbr: 1,2 Midbrain:3,4 Pons:5,6,7,8 Medulla oblongata:9,10,11,12
  16. 16. Intracranial artery
  17. 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. 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. 19. Plane
  20. 20. Plane
  21. 21. Plane
  22. 22. Plane
  23. 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. 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. 25. MRI overview (T1/T2) T1 CSF appears black White matter brighter than gray matter T2 CSF apperars white
  26. 26. Tumor??
  27. 27. Pneumocephalus
  28. 28. Meningioma
  29. 29. Meningioma
  30. 30. Hydrocephalus
  31. 31. Basal ganglia ICHThalamic ICH
  32. 32. Lt.F infarction(Broca area)
  33. 33. Rt.Cbll infarction
  34. 34. Pontine ICH
  35. 35. Lt.MCA infarctionSAH(Subarachnoid hemorrhage)
  36. 36. CT angiography
  37. 37. Trauma
  38. 38. Chronic SDH
  39. 39. EDH c skull Fx.
  40. 40. T12 bursting Fx.
  41. 41. Brain death(Reversal sign)
  42. 42. Orbital wall Fx.
  43. 43. Spine
  44. 44. Cord
  45. 45. Dermatome
  46. 46. Compression Fx.(L1)
  47. 47. HNP
  48. 48. Spinal stenosis
  49. 49. Spondylolysis
  50. 50. Spineinjury
  51. 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. 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. 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. 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. 55. Alteration in consciousness Alert Confusion Obtundation Drowsy(Lethargy) Stupor Coma
  56. 56. Vegetative state Preservation of autonomic function and primitive reflex. No meaingful interaction for external stimuli.
  57. 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. 58.  Convulsion(Involuntary jerky movement) Seizure(with epileptic discharge, episodic event,LOC,EBD,drooling etc.drug,Uremia, encephalopathy) Epilepsy(recurrent,chronic)
  59. 59. Muscle strengthGrade Strength0 No contraction1 Flickering2 Movement with gravity eliminated3 Movement against gravity4 Against resistance(4-,4 ,4+)5 normal
  60. 60. Muscle tone Hypotonia Flaccidity Spasticity( 강직 ):clasp-knife Rigidity( 경직 ):Cogwheel ridigity,lead pipe rigidity
  61. 61. CSF pathway
  62. 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. 63. Cushing’s response Hypertension Bradycardia Irregular respiration
  64. 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. 65. Lumbar tapping Contra Ix. -skin infection -IICP -Degenerative spondylosis -bleeding tendency
  66. 66. IICP precipitating factor Hypercapnia(Paco2>45mmHg) Hypoxemia(PaO2<50mmHg) Respirtory procedure(Suction,PEEP,ambu bagging) Position(angulation) Valsalva maneuver Anxiety,coughing,
  67. 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. 68. Bell’s palsy
  69. 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. 70. Bell’s palsy
  71. 71. Ocular movement
  72. 72. Disorder of gaze
  73. 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. 74. Ischemic CVD Atherothrombotic infarction Embolic infarction(Atrial fibrillation) Lacunar infarction Hemodynamic infarction
  75. 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. 76. Thrombolytic agents Plasminogen to plasmin Degradation of fibrin Canal recanalization * t-PA:only drug approved by FDA
  77. 77. t- PA administration Inclusion -18yr older -Signs of measurable neurological deficit -Onset≤3hrs
  78. 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. 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. 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. 81. Pain-sensitive structure Venous sinuses Cortical veins Artery Dura mater Scalp vessels and muscle
  82. 82. Classfication(Headache) Sinusits Migrane Cluster headache Post traumatic Drug-induced HA Menigitis Hydrocephalus Tension HA Cervicalgia Hemorrhage
  83. 83. History taking Character,site,mode of onset Frequently duration Timing Associated symptoms Precipitating factors
  84. 84. Meningeal irritation sign Photophobia Neck and back pain Brudzinski’s sign

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