NEUROLOGIC DISORDERS

DISEASE DEFINITION RISK FACTORS SIGNS AND SYMPTOMS DIAGNOSTIC EXAMS MANAGEMENT Assess sign of neurologic deterioration Assess using triage neurologic assessment, LOC, pupil size, shape and reaction, brainstem reflexes, and motor response A Asepsis S Steroids; Seizure control (Phenytoin) A Airway D Diuretics (Furosemide) ; Drainage H Hypothermic blanket O Osmotic diuretics (Mannitol) S Safety E Elevate HOB Anti-Epileptic Drugs P Phenytoin - SE: Bone marrow suppression C Carbamazepine - SE: Drowsy; Sedation V Valproic Acid - SE: Hepatotoxic P Phenobarbital - SE: Blood dyscrasias Neurosurgery Required V Vascular Problems A Abscesses T - Tumors

Pressure exerted in the cranium by its contents: brain, blood, cerebrospinal fluid SKULL hard, bony vault filled with brain tissue, blood and CSF Increased Intracranial Pressure BLOOD has cerebral artery: - Circle of Willis a. Basilar Artery b. Vertebral Artery c. Internal Carotid Artery NORMAL ICP = 5-15 mmHg

I increase temperature - Increase headache Ophthalmoscope C Change in LOC (disorientation; bleeding in the lethargic) optic disc -Cheyne-stokes respiration Slit Lamp Exam -Convulsions Sixth Nerve -Cushings Triad: Palsy a. Increase systolic pressure - Dulls Eye b. Decrease pulse - Papilledema c. Decrease respiratory rate P Papilledema NOTE: No lumbar - Projectile vomiting puncture with - Pupillary change dilated increase ICP to prevent herniation Children Bulging fontanels but can be with - High pitched cry infection Idiopathic before age of 30 Neonates - Hypoxia - Genetic disorders 1-12 y/o - Trauma - Febrile Seizures Adolescent - Trauma - Idiopathic E Epilepsy C Cries L LOC Changes I Incontinence P Pupillary changes S Signs (aura) E EEG abnormalities D - Dyspnea

Seizures

Abnormal discharge of electrical impulse 1. Partial Seizures Simple: focal motor or sensory effect; no change in LOC Complex: cognitive, psychosensory, psychomotor or affective; brief change in LOC 2. Generalized Seizures Absence: brief transient LOC w/or w/o mirror motor movements of eyes, head or extremities Myoclonic: brief, transient rigidity/jerking movements Tonic-Clonic (Grand mal): aura, LOC, rigidity, followed by tonic and clonic movements, interruption of respiration, loss of bladder and bowel control

EEG classify
the type of seizure - Avoid coffee, alcohol, tea

3.

Status Epilepticus prolonged partial/generalized

seizures, no recovery between attack DISEASE TYPES: DEFINITION RISK FACTORS SIGNS AND SYMPTOMS DIAGNOSTIC EXAMS MANAGEMENT

Ischemic caused by
thrombotic or embolic blockage of blood flow to brain; 83% of stroke a. Transient Ischemic Attack symptoms last 24-72 hours then resolve; precursor to CVA b. Ischemic Penumbra presence of dying cells involving stroke c. Large Vessel Stroke (Thrombotic) narrowing of lumen of artery d. Cardiogenic Emboli Stroke moving clot or thrombosis from left heart to brain e. Small Vessel Stroke Hemorrhagic bleeding into brain tissue or subarachnoid space; 17% a. Thalamic Stroke rupture of blood vessels results bleeding into brain tissue b. Cerebellar Stroke herniation of brain tissue results from compressing medulla c. Subarachnoid Hemorrhage weakens artery leading to leaking or rupture of artery

Stroke and CVA

Atheroscleroti c Plaque Age Sex Heart Disease Diabetes Mellitus Prior to stroke

Sudden headache (unilateral) Pain on back of neck Visual disturbances Tinnitus, dizziness, hemiparesis

P Ptosis/paresis/plegia R Rigidity U Unilateral headache T Tinnitus A Abnormal LOC S Sudden increase ICP with rupture

CT Scan Magnetic Resonance Imaging Cerebral Angiography

Surgical clipping or ligation Ca-channel blockers (Nimodepine) Mannitol Neuroradiology CSF drainage Aspirin first line for stroke

SIGNS AND SYMPTOMS OF LEVELS OF INJURY

C1 to C3 tetraplegia w/ loss of muscular and

Common in cervical and lower thoracic upper lumbar vertebrae Autonomic Hyperreflexia exaggerate sympathetic response to nervous stimuli - Occurs in injury above T6 stimuli - Distended bladder or other visceral organs - Pressure ulcer, tactile, pain and thermal

Spinal Cord Injury

respiratory function C4 to C5 tetraplegia w/impaired poor pulmonary capacity; complete dependency ADL C6 to C7 tetraplegia w/ some arm and hand movement; independence in ADL T2 to L1 tetraplegia w/ intact arm function for intercostals and abdominal muscles L1 to L2 mixed motor sensory loss; bowel bladder dysfunction MANIFESTATIONS 1. Extreme hypertension 2. Pounding headache 3. Flushing diaphoresis 4. Blurred vision, Bradycardia, and Restlessness SIGNS AND SYMPTOMS

GOAL: prevent further spinal cord

injury and observe for symptoms of progressive neurologic deficits Resuscitate Laminectomy surgical management Keep back as straight as possible

DISEASE Brain Tumor

DEFINITION Benign Malignant - Lack differentiation - Invasive - Metastasize TYPES:

RISK FACTORS Increase ICP

MANAGEMENT Radiation/chemotherapy (Brachytherapy) Stereotaxic laser surgery Craniotomy/Craniectomy 1. Airway - Position to side prevent aspiration - Vigorous coughing is contraindicated 2. Positioning a. Supratentorial (cerebral hemispheres, thalamus, midbrain, hypothalamus) Avoid on operated site - Vigorous coughing is contraindicated b. Infratentorial (pons, medulla, spinal cord) Keep flat; either side aligned to spinal column 3. Complications - Increase ICP - Meningitis - Seizures 4. Monitor for infection 5. Pain medications for headache 6. Nutrition

1.

Primary intracranial tumors of CNS tissue neuron, neuralgia 2. Primary intracranial tumors that originate in skull meninges, pituitary and pineal 3. Metastatic tumors CLASSIFICATIONS 1. Meningioma benign (normal life expectancy); meninges tumor; no signs and symptoms unless become large 2. Gliomas malignant; composed of neuroglia - Astrocytoma 6-15 year; resembles astrocytes - Glioblastoma glial cells - Oligodendroglioma - > 5 years;

D - Deficits Aphasia Brocas (3rd frontal convulsion left hemisphere) loss of ability to produce language Wernickes (posterior or superior temporal lobe) Global all functions which makes up speech Neologism word salad Anomia can recognize but cannot name words Adipsia (hypothalamus) absence of thirst/avoidance of drinking Agnosia loss of ability to recognize objects, shapes, smell while sense is not used Astereognosia (occipito-temporal) difficult to recognize by touching but can recognize if picture Anosmia loss of odor Gustatory (parietal) taste Visual (left occipital and temporal lobe) Autotopagnasia (parietal) inability to orient parts of body Anosognosia inability to gain feedback mechanism Ataxia (cerebellar, sensory, speech, truncal, gait) loss of involuntary muscle control Dysarthria inability to move tongue I Increased ICP

oligodendrocytes 3. Acoustic neuroma and optic nerve spongioblastoma 30% mortality 4. Hemangioblastoma and angioma blood and lymphatic system 5. Metastatic tumors poor prognosis; lung and breast

E EEG abnormalities Consent, wash and dry hair 24-48 hours before no tranquilizers, barbiturates, and sedatives Sleep 4-5 hours 8 hours prior no coffee, chocolates Hemangioblastoma cerebral angiogram, MRI and CT Scan BASED ON TUMORS Frontal: personality, focal seizures, blurred vision, hemiparesis, aphasia Temporal: papilledema, aphasia, seizures, headache Parietal: Jacksonian convulsion, visual loss Occipital: Focal seizures, visual hallucinations Cerebellar: ataxia, papilledema DIAGNOSTIC EXAMS CT Scan without contrast diagnostic of choice Lumbar Puncture CI: in Increase ICP

7. Avoid: - Suctioning nose - Trendelenburg position - Flexing neck - Position on operated site - Temperature orally - Sedating heavily MEDICATIONS Chemotherapy - Nitrosureas commont; not neurotoxic - Methotrexate CNS lymphoma; depletes intracellular folate - Cisplatin primary tumors binds DNA Steroids (Dexamethasone) Anticonvulsants Osmotic diuretics

DISEASE Head Injury

DEFINITION Insult to the brain that is capable of producing physical, intellectual, emotional, social and vocational changes Persistent Vegetative State No thinking abilities Normal sleep pattern Breathing and circulation intact Eyes open in response to stimuli Appear normal but cannot speak TYPES OF PRIMARY: 1. Focal Brain Injury force of impact usually produces contusions from direct contact that in turn produces epidural hemorrhage and subdural and intracerebral hematoma CONTUSION: Petecchiation and Hemorrhage in cortex +/- edema and necrosis; leading to focal signs which can resolve or progress - Found in Frontal and Temporal - Less common in parietal and occipital lobes 2. Diffuse Brain Injury CONCUSSION: transient loss of function without obvious structural drainage - Loss of consciousness <5 minutes

SIGNS AND SYMPTOMS A Altered sensory function L Level of consciousness changes Labored breathing I ICP increase Indifference to surrounding S Signs of bleeding: Raccoons and Battles Sign MANIFESTATION (Focal Brain Injury): Changes in attention MANIFESTATION (Diffuse Brain Injury): Rhinorrhea discharge of thin watery mucus from nose due to escape of CSF Halo sign clear drainage that separates from bloody drainage suggest presence of CSF Raccoon Sign per orbital ecchymosis

MANAGEMENT M Mechanical Ventilation Hypertension = Cerebral vasonconstriction to lower ICP A Adequate fluid (750ml/day) and Dexamethasone for electrolyte balance G Glucocorticoids and Loop/Osmotic Diuretics A Anticonvulsants = Phenytoin (Dilantin) H High dose barbiturate (Pentobarbital) A Anti-hypertension S Surgery A - Altered Level of Consciousness

- Post-traumatic amnesia TYPES AND MECHANISM OF INJURY 1. Intracerebral Hemorrhage contusion caused by forceful impact, usually vehicular accidents or fall from distance 2. Penetrating Injury missiles, bullets, knives 3. Diffuse Axonal Injury moving object strike hard - Blood from skull tracking down into 4. Extradural Hemorrhage vehicular accidents, soft tissue around eyes minor falls, sporting accidents Battle Sign mastoid 5. Subdural Hemorrhage vehicular accidents or ecchymosis falls esp. in elderly person with chronic alcohol - Indication of fracture of base of abuse posterior portion of skull may 6. Coup a combined injury at the point of impact suggest underlying trauma 7. Contrecoup injury on the side opposite from Otorrhea discharge from movement of brain auditory meatus, especially one that is micro purulent FRACTURES Linear simple break Depressed results in fragment of bone penetrating the tissue HEMORRHAGE Epidural Dura and skull Subdural Dura and arachnoid

NEUROMUSCULAR DISORDERS
DISEASE Dementia Alzheimers Disease DEFINITION SIGNS AND SYMPTOMS DIAGNOSTIC EXAMS MANAGEMENT

Progressive decline in cognitive function (motor, attention, language, problem solving, orientation) Irreversible Most common form of dementia Aphasia Agnosia Apraxia learned movements Amnesia

Carbidopa/Levodopa (Sinemet) Akinesia inability to initiate involuntary

Loss of dopamine Increase acetylcholine Basal ganglia damage to extrapyramidal Common with male Begins at 40 Peaks age of 58-62 years old Increase dopamine

Parkinsons Disease

muscular action Tremor first in arms and hands Rigidity stiffness of body Posture Pill-rolling and Cogwheeling (Jerky movement of extremities) Micrographia Freezing phenomenon Shuffling gait Fatigue and weakness Numbness Poor coordination Loss of balance Ptosis and diplopia Dysarthria and dysphagia Ptosis and diplopia Ocular weakness Dysarthria No sensory deficit No loss of reflexes Lumbar PunctureIncrease CSF protein and Gamma globulin MRI 3-4 lesion > 3mm diameter on brain

Anticholinergic (Cogentin)
Decrease acetylcholine

Antiparkinsonian (Symmetrel,
Artane) Increase calories and protein Warm bath and massage Small, frequent feedings Special walking technique Increase fluids Full ROM muscle function

Multiple Sclerosis

Myasthenia Gravis

Demyelinating disease of CNS which impair transmission of nerve impulses Affects T-lymphocytes secondary to viral Affects neuromuscular junction characterized by muscle weakness and fatigability Decrease acetylcholine associated with dysfunction of thymus gland Can be myasthenia and cholinergic crisis

Avoid hot baths sensory loss lead to brain Apply warm packs Encourage swimming Cholinesterase inhibitor (Pyridostigmine mestinon) Corticosteroids (Prednisone and Prednisolone) Electrophoresis Thymectomy remove thymus

Physical Exam
determine extent of weakness Electromyography response of muscles to stimuli Tensilon test cholinesterase inhibitor; IV stimulation

MYASTHENIA CRISIS Exacerbation of disease Severe muscle weakness Quadriparesis or plegia

 Respiratory insufficiency with SOB Extreme difficulty swallowing CHOLINERGIC CRISIS Cause: Overmedication Abdominal cramps Nausea and Vomiting Blurred vision Hypotension, Pallor and Diarrhea DISEASE DEFINITION TENSION HEADACHE Frequency Daily Duration Constant Onset Gradual Pain Bilateral Gender Equal distribution SIGNS AND SYMPTOMS CLUSTER HEADACHE Frequency 1-3x/day Duration 30-90 minutes Onset Sudden Pain Unilateral Gender 10:1 Male Steady, Severe, Characteristics Steady, dull headache Characteristics Excruciating Verapamil Aspirin Corticosteroids Drugs Drugs Acetaminophen Lithium Carbonate Exercises NonNonNone Relaxation pharmacological pharmacological technique MIGRAINE Frequency 2-3x/month Duration 4 hours to 2 days Onset Gradual Pain Moderate to severe Gender 3:1 Female Characteristics Throbbing, Pulsating Dihydroergotamine Drugs Sumtriptan NonStress management, pharmacological Relaxation Involuntary choreiform Dystonia movement and dementia Akathisia motor Autosomal dominant restlessness recessive TRIAD Motor, Cognitive, Emotional -Determine myasthenia crisis

DIAGNOSTIC EXAMS

MANAGEMENT

Headache

CT Scan MRI

Analgesics Triptan Ergotamine

Huntingtons Disease

Cerebral cortex dementia Basal ganglia chorea Amyotrophic Lateral Sclerosis GuillainBarre Syndrome Progressive muscle weakness Cramps and Atrophy Fasciculation (Twitching) Dysphagia, Dysarthria, Dysphonia Respiratory difficulties Uncoordinated lower and upper motor neuron 20-50 years of Ascending weakness from age distal to proximal Male = Female Riluzole (Rilutex) shows deterioration of motor neurons Baclofen, Dantrolene used for spasticity/muscle relaxant Quinine for muscle cramps Respiratory function - Oxygenation Plasmapharesis plasma removed from blood cells

Degenerative involving lower and upper motor neuron

Polyradiculoneuritis Demyelination of spinal cord and medulla

DISORDERS OF THE CRANIAL NERVES

DISEASE DEFINITION RISK FACTORS Intrinsic lesions Abnormalities of axon or myelin Extrinsic lesions Mechanical compression by tumors, vascular anomalies, dental abscesses or jaw malformation SIGNS AND SYMPTOMS DIAGNOSTIC EXAMS MANAGEMENT

Trigeminal Neuralgia

Chronic irritation of the fifth cranial nerve Characterized by paroxysms of pain similar to an electrical shock or burning sensation Also called tic douloureux Three divisions: ophthalmic, maxillary, and mandibular

Skin surface pain characteristic symptom Trigger zones - Light touch - Eating Angiography - Swallowing CT Scan - Talking MRI - Shaving - Brushing teeth Shooting and stabbing pain

Avoid massage Small frequent feedings Minimize accessory unnecessary conversations Minimize exposure to cold wind Use electrical razor when shaving

Bells Palsy

Affects motor aspects of facial nerve Common type of peripheral facial paralysis Unilateral paralysis of facial muscles of expression Central facial paralysis upper motor neuron paralysis

Herpes virus Lyme disease

D Dec. lacrimation D Dec. facial sensation Electromyography I Inability to close eyes P Photophobia MRI H Hyperacusis (Ear) CT Scan A Ageusia (loss of sense of taste

Artificial tears Facial massage Periodic eye closing Dim light Minimize noise

PEDIATRIC DISORDERS
DISEASE Cerebral Palsy DEFINITION Nonspecific term applied to neurologic disorders characterized by early onset and impaired movement and posture Nonprogressive disorders of upper motor neuron impairment that results in motor dysfunction Abnormal involuntary movement(choreiform and dystonic movements) CEREBRAL PALSY TYPES 1. Spastic Type 40% of affected children; Inc. muscle tone a. Hemiplegia half body b. Quadriplegia both arms and legs c. Diplegia or Paraplegia lower extremities RISK FACTORS Unknown Associated with low birth weight, premature birth or birth injury Brain anoxia Infections such as meningitis or encephalitis Intrauterine infection Head trauma Asepsis SIGNS AND SYMPTOMS Hypotonia Floppiness - Dec. reflex Hypertonia rigidity - Spastic - Exaggerated reflex Poor head control after 3 months of age Stiff or rigid arms or legs Pushing away or aching back Floppy or limp body posture Uses only one side of the body, or only the arms to crawl Hand preference demonstrated before 18 months Reflex abnormalities DIAGNOSTIC EXAMS Neurologic examination and history Magnetic Resonance Imaging MANAGEMENT THERAPEUTIC Establish locomotion and selfhelp Brace and splint Urinary sphincter MEDICAL Botulinum toxin type A reduce contracture deformities Oral muscle relaxant Dec. spasticity Anticonvulsant control seizure Baclofen and Diazepam improve muscle coordination SE: Hepatotoxicity, Drowsiness, Fatigue, and Muscle Weakness

SURGICAL Orthopedic surgery Tendon-lengthening procedures Release of spastic wrist flexor muscles Correction of hip and adductor muscle spasticity

2. Ataxic awkward,
wide- based gait

3. Dyskinetic or
Athetoid wormlike; limp and flaccid 4. Mixed/Dystonic 10%; both spasticity and athetoid; Dorsal rhizotomy

Mild viral infection 24-48 A toxic encephalopathy

Reyes Syndrome associated with other characteristic organ involvement particularly liver

Influenza A&B
Varicella Epstein barr Adenovirus

Vomiting w/ or w/o fever Confusion, fear, irritability Flat affect Change in sensorium into coma-like state Decorticate & Decerebrate Death = 203 days of onset SIGNS AND SYMPTOMS Sunset eyes Head grows Tense and bulging fontanels Scalp is shiny Veins are dilate Vomiting Poor feeding Macewens sign cracked pot sound produced when skull becomes thin and sutures palpably separated

Liver Biopsy

DISEASE Hydrocephalu s

DEFINITION

Excess amount of fluid

that surrounds brain and spinal cord called CSF Excess CSF results in an abdominal/abnormal widening of spaces in brain called Ventricles TYPES - Communicating/ Non Obstructive impaired absorption of CSF within subarachnoid space - Non Communicating/ Obstructive obstruction to flow through ventricular system

RISK FACTORS Acquired Congenital Unknown Toxoplasmosis Intravenous Hemorrhage Tumors Meningitis

DIAGNOSTIC EXAMS Fetal ultrasonography (14 weeks) Echoencephalography - neonate CT Scan Magnetic Resonance Imaging Skull X-rays Infants Macrocranium with wide cranial sutures Adolescent Split sutures with beaten silver

Neuromuscular blocking agents Sedatives and Analgesics Electrolytes and glucose Vitamin K and fresh frozen plasma Neomycin correct ammonia thru NGT Mannitol Edema Benzodiazepines/Phenytoin anti-seizures MANAGEMENT MEDICAL Antibiotic Anticonvulsant SURGICAL Comp: Infection Ventriculoperitoneal shunt neonates and young infants Ventricles Peritoneum Ventriculoatrial shunt older children Ventricles Atrium SIGNS OF SHUNT INFECTION - Ventriculitis Nausea Body malaise Low grade fever - Blood cultures Inc. leukocytes - CSF Inc. WBC, Inc. CHON, and Dec. glucose - Sepsis fever and weakness OVERDRAINING VENTRICLES - Apnea - Change in respiratory pattern

 Midline defects involving failure of the osseous spine to close TYPES Spina bifida cystica refers to a visible defect with an external saclike protrusion - Meningocele encases meninges and spinal fluid, but no neural elements - Myelomeningocele contain meninges, spinal fluid and nerves Spina bifida occulta defect that is not visible externally - Occurs commonly in lumbosacral area(L5-S1) Cause: 1st 4-8 weels = Drugs, radiation, chemicals, nutrition

Spina Bifida

SPINA BIFIDA CYSTICA Secondary disturbances Below second lumbar vertebra - Partial paralysis of lower extremities - Lack of bowel control - Overflow incontinence Below third sacral vertebra - No motor impairment - Bladder and anal sphincter paralysis Joint deformities Kyphosis UTI and Constipation SPINA BIFIDA OCCULTA No observable manifestations Dark tufts of hair Skin depression or dimple SIGNS AND SYMPTOMS

MRI CT Scan Skull X-ray AFP test detect neural tube defects Ultrasound Transillumination

- Change BO - Nausea and Vomiting - Dec. HR THERAPEUTIC Catheter Prevent sac from drying MEDICAL Ditropan and Detrol for bladder storage and continence

SURGICAL Vesicostomy create stoma of abdominal wall for urinary drainage Post op Prone position Decompression

DISEASE

DEFINITION

DIAGNOSTIC EXAMS

MANAGEMENT

CATEGOR Y A

CHARACTERISTICS Awake, minimum injury Fully conscious Mild hypothermia Mild ABG abnormalities Blunted sensorium Moderate injury Obtunded, Stuporous ABG abnormalities Abnormal chest radiographs Comatose Severe Anoxia Unarousable Abnormal response to pain Arrythmias Metabolic acidosis Flexion, Cheyne-Stoke syndrome Extension, Central hyperventilation Flaccid, apneustic or cluster breathing Flaccid, apneic, no detectable circulation

MANAGEMENT Symptomatic treat Oxygen administration Lab assessment of electrolytes Well enough to be discharged in 12-24 hours

Drowning - death from asphyxia while submerged,

Drowning regardless of whether fluid has entered the lungs Near drowning survival at least 24 hours after submersion in a fluid medium C

Symptomatic Regular monitoring of neurologic and respiratory status Correction of acidosis Furosemide to stimulate diuresis

C1 C2 C3 C4 Botulism

Invasive life-support measurements Mechanical ventilation for 12-24hours Symptomatic management

Acute flaccid paralysis

produced by the anaerobic bacillus Clostridium Botulinum

TYPES Food-borne Botulism source is sterilized home canned foods Infant Botulism caused by ingestion of spores or vegetative cells of C. Botulinum and the subsequent release of

FOOD-BORNE BOTULISM Diplopia Generalized weakness Progressive respiratory paralysis INFANT BOTULISM Mild constipation to progressive loss of neurologic function Deep tendon reflexes are diminished

History Physical Examination Laboratory detection of toxin EMG

Botulism Immunoglobulin
Intravenous - Trivalent Equine Botulism Antitoxin - Bivalent Equine Botulism Antitoxin Honey not given younger than 12 years old Mechanical intubation Observe for signs of poor feeding, constipation and muscle

the toxin from organisms colonizing GI tract Wound Botulism wounds contaminated with C. Botulinum and subsequent elaboration of toxin

Cranial nerves VII, IX, X, and XI are deficit Dec. spontaneous movement Loss of head control Poor feeding, weak cry Reduced gag reflex

impairment

INTRACRANIAL INFECTIONS