This document summarizes the medical history and examination findings of a 16-year-old male patient presenting with occipital headache, neck pain, loss of pain and temperature sensation in the left upper limb, and laxity of the left shoulder joint. Examination revealed loss of sensation from C3 to T2 on the left side and absent biceps and supinator reflexes on the left. MRI showed Arnold-Chiari malformation type 1 with syringomyelia involving the cervical and thoracic spinal cord. The patient was diagnosed with syringomyelia related to Arnold-Chiari malformation.
This ppt describes various movement disorders found commonly in elderly persons. It also describes hyper and hypokinetic disorder categorization with cause and pathophysiology of movement disorders.
This ppt describes various movement disorders found commonly in elderly persons. It also describes hyper and hypokinetic disorder categorization with cause and pathophysiology of movement disorders.
This is my first presentation friends, it was my project and I selected this topic and this was my presentation, I hope it will be informative for all of you.
I am in T.Y.B.pharmacy, MGV's College of Pharmacy, Nashik.
If there is any mistake or any problem in this presentation, please let me know......, thank you.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
2. 16/ male c/o head ache, neck pain -4 yrs abnormal mobility of left shoulder jt &loss of pain sensation in left UL for 2 yrs
3. HISTORY OF PRESENTING ILLNESS Head ache-4yrs lasting for 1-2 hrs daily;mostly in morning; not progressive Occipital Relieved by drugs ↑ by coughing ,sneezing, playing Not associated with diminished visual acuity no vomiting,aura
4. H/O neck pain -4yrs More in left side Insidious , not progressive Dull aching, continuous, not radiating ↑ by playing, not associated with shock like sensation Not ↑ by neck movements H/O abnormal excessive mobility of lt shoulder-2 yrs No trauma Mild dull aching pain, no swelling While abducting left shoulder –he can dislocate & reduces him self voluntarily
5.
6. H/O loss of pain & temperature in lt UL & nape of neck -2 yrs Able to feel clothing No h/o tingling, numbness no H/O weakness No H/O unsteadiness while walking No H/O incoordination in the dark No H/O involuntary movements
7. No history suggestive of cranial nerve involvement, No h/o sweating disturbance No h/o bladder , bowel involvement No h/o seizure
8. summary 16/m Occipital headache Neck pain Loss of pain & temperature in left upper limb Laxity of left shoulder jt
9. Conscious , oriented , Afebrile No pallor ,jaundice ,lymph adenopathy Height : neck ratio =11 Upper lower segment ratio-1 height: arm span ratio -normal No neurocutaneous markers No trophic changes in left UL NO nerve thickening, No digital ulcer
10. vitals BP LYING POSITION-110/80 mmhg STANDING- 108/80 mmhg RR- 12/MIN PR -78/ MIN
11. CVS,RS – NAD CNS HMF –normal Cranial nerves –normal Spino motor system Bulk , power , tone – normal Superficial reflex -normal
13. SENSORY SYSTEM PAIN ,TEMPERATURE ABSENT IN LEFT UL NAPE OF NECK LEFT SIDE ANGLE OF MANDIBLE PECTORAL REGION UP TO T2
14. CO ORDINATION TEST – NORMAL IN BOTH UL&LL NO NYSTAGMUS CEREBELLAR SIGNS -ABSENT NO INVOLUNTARY MOVEMENT GAIT – NORMAL NO MENINGEAL SIGNS SPINE & CRANIUM -NORMAL
15. Summary of the findings Loss of pain & temperature from C3 to T2 in left side Absent biceps,supinator reflex left side Chonic head ache & neck pain increased by coughing, sneezing
16. Opthal opinion – vision 6/6 BE FUNDUS – NORMAL CBC- Hb-12 gms% Pcv -40 TC-6000 DC-P60L40 ESR -10/20 RBS-120 mg% Urea-24mg Creatinine-0.7mg Na-140 K-4.5 VDRL –NEG HIV I & II -NEG
23. Charcot shoulder Rare rapid destruction of the proximal humerus and glenoid related to neuropathic disease Clinical Evaluation Presents with swelling ,pain and stiffness. May present with dislocated shoulder. Generally decreased active and passive ROM. Charcot Shoulder Xray Most common finding is resorption of the humeral head. May have glenoidresorption or shoulder dislocation. Look for pathologic fracture.
24. Abnormal , excessive movements only in lt shoulder- hyperlaxity No swelling , redness No joint destruction in x ray Preserved proprioception Multi dimensional instabiltity of shoulder
26. Arnold–Chiari malformations Chiari malformations, types I-IV, refer to a spectrum of congenital hindbrain abnormalities affecting the structural relationships between the cerebellum, brainstem, the upper cervical cord, and the bony cranial base.
27. CM TYPE I A congenital malformation. Most common Herniation of cerebellartonsils Syndrome of occipitoatlantoaxialhypermobility An acquired Chiari I Malformation in patients with hereditary disorders of connective tissue. Patients who exhibit extreme joint hypermobility and connective tissue weakness as a result of Ehlers-Danlossyndromeor Marfan Syndrome are susceptible to instabilities of the craniocervical junction and thus acquiring a Chiari Malformation. This type is difficult to diagnose and treat.
28. TYPE II Usually accompanied by a lumbar myelomeningocele leading to partial or complete paralysis below the spinal defect. a larger cerebellarvermian displacement. Low lying torcularherophili, tectalbeaking, and hydrocephalus with consequent clivalhypoplasia
29. TYPE III Causes severe neurological defects. It is associated with an occipital encephalocele. TYPE IV Characterized by a lack of cerebellar development.
31. Type I True incidence –not known m: f ratio-2:3 Common in adult & paediatric age group Incidence syrinx- 25—70% syringohydromyelia - secondary to pathologic CSF dynamics
32. SYMPTOMS Disruption of CSF flow through foramen magnu MC symptom-head ache headache and neck pain in Chiari I are often exacerbated by cough and Valsalva manoeuvre syringomyelia and central cord symptoms such as hand weakness and dissociated sensory loss
33. symptoms Compression of medulla and upper spinal cord, myelopathy lower cranial nerve palsies nuclear dysfunction. Compression of cerebellum ataxia, dysmetria, nystagmus, dysequilibrium.
34. William's theory herniated tonsil at foramen magnum – valve like action. Pressure differrence increases. The increase in subarachnoid fluid pressure from increased venous pressure during coughing or Valsalvamaneuvers is localized to the intracranial compartment. increase cisterna magna pressure occurs simultaneously with a decrease in spinal subarachnoid pressure. This craniospinal pressure gradient draws CSF caudally into the syrinx.
35. New concept In chiari , pressure in veins & capillary around central canal very high Coughing , sneezing , even heart beat put more stress on blood vessels, Leakage of plasma – form syrinx
36. syringomyelia Frequently associated developmental abnormalities vertebral column (thoracic scoliosis, fusion of vertebrae, or Klippel-Feil anomaly), base of the skull (platybasia, basilar invagination), cerebellum and brain (type I Chiari malformation) 90 percent of cases of syringomyelia have type I Chiari malformation
37. TYPES CONGENITAL- associated with chiari malformations ACQUIRED - Spinal cord tumors (usually intramedullary, especially hemangioblastoma) Traumatic myelopathy Spinal arachnoiditis and pachymeningitis Secondary myelomalacia from cord compression (tumor, spondylosis), infarction, hematomyelia IDIOPATHIC
38. Depending on the connection with fourth ventricle A-Communicating B- Non communicating C-Extra canalicular
39. Symptoms begins unilaterally Syrinx gradually destroys: 1- decussating S/T tracts 2- ant. horn cells 3- lateral C/S tracts 4- sympathetic tracts 5- trigeminal, 1X, X, X1 & X11 cranial N nuclei and vestibular system as syrinx extends to the medulla.
40.
41. in either or both arms, or in a shawl like distribution ,
42. Dysesthetic pain, a common complaint in syringomyelia, usually involves the neck and shoulders, but may follow a radicular distribution in the arms or trunk.
51. X ray cervical spine Osseous anomalies of the skull base and skeletal system are observed in 25-50% of pts Platybasia, basilar invagination (25-50%) Atlantooccipital assimilation (1-5%) Klippel-Feil syndrome (5-10%) Incomplete ossification of C1 ring (5%) Proatlantal remnant spina bifida at the C1 level Retroflexed odontoid process (26%) Scoliosis (42%) Kyphosis Increased cervical lordosis Cervical ribs Fused thoracic ribs
52. CT SCAN CT scanning is reliable in detecting osseous abnormalities. Obliterated cisterna magna Hydrocephalus Flattened spinal cord Tonsillarectopia. Peglikecerebellar tonsils Normally positioned fourth ventricle Rarely, spinal CT scans may show syringomyelia. In the past, CT cisternography and/or myelography, supplemented by image reconstruction in nonaxial planes, was used to assess tonsillar position and configuration. CT myelograms do not demonstrate the lower brainstem and bulbomedullary junction in sufficient detail. Associated syringomyelia is often missed.
53. MRI Displacement of cerebellar tonsils below the level of the foramen magnum Pointed and/or peglike tonsils Narrow posterior cranial fossa Elongation of the fourth ventricle, which remains in the normal position Hindbrain abnormalities Obstructive hydrocephalus Associated abnormalities such as syringomyelia and skeletal abnormalities
54. Tonsillarectopia Tonsillar tips that extend less than 3 mm below the landmark are normal. Tonsillarherniation should be primary and not secondary to an intracranial mass lesion to meet the criteria for congenital Chiari I malformation. The most reliable criterion is herniation of at least 1 cerebellar tonsil that is 5 mm or more below the plane of the foramen magnum, Tonsillarectopia of 5 mm is 100% specific and 92% sensitive for Chiari I malformation.
55. Tonsillarherniation of less than 5 mm does not exclude the diagnosis. Herniation of both tonsils that are 3-5 mm below the foramen magnum, accompanied by certain other features, may suggest Chiari I malformation.
56. Cerebellar tonsils ascend with age. Some authorities suggest the following criteria for tonsillarectopia: (1) herniation of 6 mm in those aged 0-10 years, (2) herniation of 5 mm in those aged 10-30 years, (3) herniation of 4 mm in those aged 30-80 years, and (4) herniation of 3 mm in those aged 80-90 years
57. OTHER FINDINGS IN MRI Narrowing or obliteration of the retrocerebellar CSF spaces - lower pole of the cerebellar tonsils. The height of supraocciput is reduced, The slope of tentorium is increased. The posterior cranial fossa volume, expressed as a ratio of supratentorial volume (posterior fossa ratio), is significantly smaller; however, mean brain volumes did not differ in patients and control subjects.
58. The cervical subarachnoid space below the level of the C2-3 disks is markedly narrowed in patients with syringomyelia as a result of spinal cord expansion. The posterior subarachnoid space below the tip of the cerebellar tonsils may be completely obliterated.
59. Cine MRI CSF flow study with phase-contrast cine MRI. Brain pulsations results in caudad and cephalad flow of CSF across foramen magnum during systole and diastole. The reversal in the direction of flow is picked up by alternating light and dark appearance of CSF in front and behind the medulla and upper spinal cord on phase-contrast cine MRI.
61. the complete absence of CSF flow behind (arrowheads) and focal constriction of CSF flow (arrows) in front of cervicomedullary junction.
62. CSF flow analysis through foramen magnum with phase-contrast cine MRI helps distinguish symptomatic Chiari I from asymptomatic cerebellarectopia and helps predict response to surgical decompression
63. Treatment Analgesics - for head ache & neck pain Surgery – decompressivesx Suboccipital and cervical decompression. Laminectomy and syringotomy (dorsolateralmyelotomy)
64. Shunts Ventriculoperitoneal shunt - Indicated if ventriculomegaly and increased intracranial pressure are present Syringosubarachnoid dorsal root entry zone shunt Syringoperitoneal shunt Fourth ventriculostomy
65. Neuroendoscopic surgery A fibroscope inserted through a small myelotomy allows inspection of the intramedullary cavity. This technique is particularly useful in evaluating and treating multiple septatesyrinxes. Septa are fenestrated, either mechanically or by laser. Fluid from the cavity is then shunted into the subarachnoid space
66. Operative Results The most commonly-performed surgery is suboccipital craniectomy (essentially opens up the foramen magnum), with or without C1 laminectomy and dural graft patch. Patients with pain as primary complaint respond best to surgery; weakness less responsive, but overall ~80% of patients report favorable results. Presence of muscle atrophy, ataxia, and duration of symptoms >2 yrs all associated with poorer outcome.
67. Does the size of the malformation matter? Traditionally, Chiari Malformation has been defined as the cerebellar tonsils descending more than 3-5mm out of the skull. However, research has shown there is no real correlation between the amount of descent (or herniation) and clinical symptoms. Some people with herniations of less than 3mm are extremely symptomatic and some people with quite large herniations are symptom free. The current theory is that disruption of CSF flow is a more important measure than the size of the herniation.