Neurological

Disorders
Paul Kelner, M.D.

Neurological Disorders
Overview and Organization of
the Nervous System

Central Nervous System

brain and spinal cord
Peripheral nervous
system cranial nerves
and spinal nerves

Divisions of the Nervous System

Neurological Disorders:
Organization of the Nervous System

The Central Nervous System

The Brain
The Spinal Cord
Motor pathways (in spinal cord) efferent
Sensory pathways (in spinal cord)
- afferent

Central Nervous System

Afferent and Efferent Pathways

Neurological Disorders:
Organization of the Nervous System

Peripheral Nervous System

Cranial nerves
Spinal nerves
Somatic nerves
Autonomic nervous system
Sympathetic
Parasympathetic

Neurological disorders
Cranial Nerves

Cranial Nerves

Cranial Nerves Reviewed

Autonomic Nervous System

Neurological disorders
Cells of the Nervous System
The Neuron
Neuroglia and Schwann cells
The Nerve Impulse
Synapses
Neurotransmitters
Myelin Formation:
Peripheral NS Schwann cells
Central NS Oligodendrocytes

Neuron

Neuroglia

Saltatory Conduction

http://s3.amazonaws.com/pp
t-download/nerve-impulse28770.ppt#256,1,NERVE
IMPULSE/ACTION
POTENTIAL
Web Site with AP
transmission animation

The Synapse

The Brain

The Brain (Functional Areas)

Neurological disorders
Protective structures
Cranium
Meninges
Cerebrospinal fluid and the
ventricular system
Vertebral column
Blood supply

Neurological disorders

The Meninges

Cerebral Ventricular System

MRI of Spinal Cord within

Vertebrae

Cerebral Blood Supply

Circle of Willis

Part II

Pain
A Summary of Important
Concepts

Pain

Pain (definitions)

Pain Threshold point at which a stimulus is

perceived as pain
Pain Tolerance amount of pain a person will
tolerate before outwardly responding to it
Nociceptive pain pain resulting from direct
tissue injury
Non-nociceptive pain neuropathic pain

Neuropathic (non-nociceptive
pain)

Neurological disorders
Pain (continued)
Acute versus chronic pain
Acute pain is a protective
mechanism
Chronic pain is persistent, lasting > 6
months

Neurological disorders
Clinical manifestations of pain
Acute pain
Somatic pain
Visceral pain
Referred pain
Chronic pain
Neuropathic pain
Hyperesthesias
Phantom limb pain
Cancer
Reflex sympathetic dystrophy(RSD)

Referred Pain

Alterations in
Neurological
Function
Part III

Neurological Disorders

Alterations in Cognitive Systems

Alterations in arousal Coma
Structural vs. metabolic vs. psychogenic
causes
Grouped according pathologic process
Infectious
Vascular
Neoplastic
Traumatic
Congenital
Degenerative
Polygenic
Metabolic

Coma
By definition, coma (decreased arousal) is
produced by:
Bilateral hemispheric damage
Suppression by hypoxia,hypoglycemia,
drugs or toxins
Brain stem lesion or metabolic
derangement that suppresses Reticular
Activating System (RAS)

Neurological disorders
Coma
Clinical manifestations
Level of consciousness
Pattern of breathing (cheyne-stokes)
Pupillary changes
Oculomotor responses (ie. Dolls
eyes)
Motor responses

Posturing
Decorticate
Flexion of arms, wrists, fingers
Adduction of upper extremities
Extension of lower extremities
Decerebrate
Extremities in extension
Pronation of forearms and plantar
extension of feet

Decorticate
->

<Decerebrate

Glasgow Coma Scale (GCS)

Neurological disorders
Outcomes
Mortality
Brain death brain stem death no
potential for recovery no control of
homeostasis
Cerebral death death of cerebral
hemispheres not including the brain
stem vegetative state
Morbidity
Recovery of consciousness
Residual cognitive dysfunction
Psychosocial domain
Vocational domain

Neurological disorders
Seizures a sudden, explosive
disorderly discharge of cerebral neurons
Characterized by sudden, transient
alterations in brain function
Clinical manifestations Motor,
Sensory, Autonomic, Psychic, Level of
arousal
Epilepsy term applied to seizures in
which no underlying cause is found
General term for primary condition
causing seizures

Neurological disorders
Conditions associated with seizure
disorders
Any disorder that alters neuronal
environment
Metabolic defects
Congenital conditions
Genetic predisposition
Peri- or post-natal injury
Infections
Tumors
Drugs or alcohol

Neurological disorders
Terminology
Aura
Prodroma
Tonic phase
Clonic phase
Postictal state

Generalized Seizures
Generalized Seizures
(Produced by the entire brain) Symptoms
1. "Grand Mal" or Generalized tonic-clonic
Unconsciousness, convulsions, muscle
rigidity
2. Absence Brief loss of consciousness
3. Myoclonic Sporadic (isolated), jerking
movements
4. Clonic Repetitive, jerking movements
5. Tonic Muscle stiffness, rigidity
6. Atonic Loss of muscle tone

Partial Seizures

Partial Seizures
(Produced by a small area of the brain) Symptoms
1. Simple (awareness is retained)
a. Simple Motor
b. Simple Sensory
c. Simple Psychological a. Jerking, muscle rigidity, spasms,
head-turning
b. Unusual sensations affecting either the vision, hearing, smell
taste or touch
c. Memory or emotional disturbances
2. Complex
(Impairment of awareness) Automatisms such as lip smacking,
chewing, fidgeting, walking and other repetitive, involuntary but
coordinated movements
3. Partial seizure with secondary generalization Symptoms that
are initially associated with a preservation of consciousness that
then evolves into a loss of consciousness and convulsions.

Neurological disorders

Types of seizure disorders

Generalized seizures
Partial seizures
Status epilepticus
Absence
Pseudo-seizures
Treatment of seizure disorders
Medications
Patient education
surgery

Neurological Disorders
Data processing defects
Agnosia failure to recognize form
and nature of objects
Dysphasia impairment in
understanding or production of
language
Expressive
Echolalia
Aphasia loss of ability to
understand or produce language

Neurological disorders
Dementia
Progressive failure of multiple cerebral
functions
Syndrome with many causes
Loss of intellect with impaired mental
abilities
Disoriented
Memory problems (recent and remote)
Language problems
Attentional focus
Alterations in behaviors

Neurological Disorders
Evaluation of cause
Neuropsychological testing
Laboratory and diagnostic testing
Treat underlying cause
Infections
Nutritional issues
Progressive dementias
Goal is to maintain current
function and prevent continued
deterioration

Neurological disorders
Alzheimer disease (AD)
Most common cause of severe cognitive dysfunction in
older persons
Familial, early-onset occurs in persons before
age 65
Familial, late-onset known as FAD
Non-hereditary, late-onset AD occurs in 70% of
cases
Exact cause is not known several theories
Loss of neurotransmitter stimulation by choline
acetyltransferase
Mutations in genes that code amyloid proteins
Alterations in apolipoprotein E (binds beta
amyloid)
Neurofibrillary tangle
Senile plaques diagnostic of Alzheimers Disease
Diagnosis
Treatment

Alzheimers Atrophy

Pet Scan and AD

Alzheimers Disease Microscopic

Pathology

Neurological disorders:
Trauma and Bleeds
Hematomas
Extradural hematomas
Subdural hematomas
Subarachnoid hemorrhage
Intracerebral hemorrhage

Epidural Hematoma

Subdural Hematoma

Subarachnoid Hemorrhage

Intracerebral Hemorrhage

Neurological disorders

Cerebrovascular accidents (Stroke)

Occurs in 600,000 persons per year
Third leading cause of death in US
Most common in persons > 65 years
More common in women
More common in African-Americans and Asians
Heredity component

CVA on CT

Neurological disorders

Risk factors for CVA

Hypertension
Smoking
Diabetes
Insulin resistance
Polycythemia and thrombocythemia
Elevated lipoprotein-a
Impaired cardiac function
Hyperhomocysteinemia
Atrial fibrillation
Estrogen deficiency

Carotid Artery Disease

Carotid Artery Disease

Neurological disorder
Thrombotic strokes
Due to arterial occlusion caused by thrombi
Classified secondary to clinical manifestations
Transient ischemic attacks (TIA)
Caused by thromboembolic particles
Abrupt onset of symptoms
Strokes-in-evolution (Sometimes called
RIND reversible ischemic neurologic deficit)
Intermittent progression of neuro deficits
over hours to days
Completed strokes
Maximum amount of destruction has
occurred

Neurological disorders

Embolic strokes
Fragment of clot
breaks off from
thrombi outside of
brain
Most common from
heart, aorta, carotid
artery or thorax
Risk factors atrial
fibrillation, MI,
endocarditis, valve
replacements
Tumors, fat and air
can also cause
strokes

Hemorrhagic strokes
Third most
common cause of
CVA
Risk factors
Hypertension
Aneurysms
Bleeding
disorders
Tumors
Trauma
Drug use

Neurological disorders

Symptoms of CVA
Depend upon which artery is obstructed
Weakness
Facial drooping
Loss of or trouble with speech
Loss of function of limbs hemiparesis
Loss of or changes in vision
Headache
Inability to recognize objects or persons
Changes in level of consciousness

Neurological disorders

Treatment of CVA
Time is Brain treatment within 6 hours of
onset of symptoms
Interventional and drug therapy
Clot busters thrombolytics TPA
Improve blood flow - vasodilators
Stenting of vessels
Prevention of thrombus anti-platelet drugs
Physical, emotional and mental rehabilitation
Education of patient and family

Aneurysms

Many etiologies (can be inherited)

Dilation or outpouching of vessels
Usually go undiagnosed until they bleed
Treated surgically

Aneurysm

Aneurysm Clip

Neurological disorders

Headaches Most common neurological disorder

Can be a symptom of serious illness
Can be a symptom of being a nursing student
Migraines - Benign recurring headache provoked
by a trigger
Affects 11 million person in the U.S.
Prevalent in women ages 15-55 years and can
occur in children
Auras can occur
Most common is migraine without aura

Tension Vs. Migraine Headaches

Symptom
A
Tension
B
Migraine
Intensity, Duration and Quality of Pain
Mild or moderate pain intensity

Severe

Duration of headache
30 min 7 days
4-72 hours

Intense pounding, throbbing and/or debilitating

Symptom

A
Tension

B
Migraine

Intensity, Duration and Quality of Pain

Mild or moderate pain intensity

Severe
Duration of headache
30 min 7 days
4-72 hours

Intense pounding, throbbing and/or debilitating

Distracting but not debilitating

Steady ache

Location of Pain

One side of head

Both sides of head

Associated Symptoms
Nausea/vomiting

Sensitivity to light and/or sounds

Aura before onset of headache such as visual symptoms

Neurological disorders

Basis of migraines is multifactorial

Serotonin
Vasoactive substances
Inflammatory processes
Treatment of migraine
Avoidance of triggers
Rest or sleep in a dark, quiet room
Compresses, cold or warm
Medications
Serotonin antagonists (Imitrex)
Beta or calcium channel blockers
Aspirin, caffeine, NSAIDS
Magnesium supplements

Migraine On MRI

Neurological disorders

Meningitis infection & inflammation of meninges

Caused by bacteria, viruses, fungi, parasites or
toxins
Acute, subacute or chronic
Bacterial vs. aseptic meningitis
Symptoms
Fever, chills, petechial rash
Headache, photophobia, otophobia, neck
stiffness
Nuchal rigidity, decrease consciousness,
seizures, hemiparesis, hemiplegia

Meningitis

Neurological disorders
Treatment
Supportive measures - Quiet, dark
room
Antibiotics or anti-viral medications
Vaccinations are available for
bacterial form
Chemoprophylaxis for exposed
persons

Neurological disorders
Parkinsons disease
Common degenerative disease of basal
ganglia involving the dopaminesecreting cells
Onset after age 40, most common in
men
Primary vs. secondary

Degeneration of the Substantia Nigra

Parkinsons
Disease

NORMAL

Neurological disorders
Symptoms
Resting tremor
Rigidity
Akinesia hypokinesia and
bradykinesia
Stooped posture
Shuffling gait, equilibrium disorders
Orthostatic hypotension,
gastric/urinary retention and
constipation
Depression

Neurological disorders

Treatment
Administration of dopaminergic drugs -> LDopa
Antihistamines, amantadine reduce akinesia
Drugs lose effects over time
Stem cell research
Slow, progressive disease
Total loss of function
Death is commonly due to pneumonia

Neurological disorders

Multiple sclerosis (MS)

Common immune disorder involving CNS
Demyelinating disorder
Onset between 20 and 50 years
Females affected twice as often as males
Most prevalent in northern countries
Genetic susceptibility
Previous viral insult in a genetically susceptible
person T cells reactive to myelin
Destruction of myelin leads to slowing and
eventual blockage of conduction

MS on MRI

Neurological disorders
MS (continued)
Different types of MS
Mixed, spinal, cerebellar, amaurotic
forms
Different clinical courses
Relapsing-remitting
Primary progressive
Secondary progressive
Progressive relapsing

Neurological disorders

MS (continued)
Symptoms
Optic neuritis
Visual changes
Dizziness
Nystagmus
Weakness
Numbness, tingling
Ataxia, tremor
Bladder and bowel changes

Neurological disorder

MS (continued)
Diagnosis with CT scan or MRI
CSF exam
Treatment
Acute management of exacerbations
Reducing frequency of relapses or disease
progression
Steroids
Interferon
Immunosuppressive agents
Symptom management
Physical and occupational therapy
Patient education
Support of patient and family

Intracranial Neoplasms
50 60% of all adult intracranial
neoplasms are malignant gliomas and/or
astrocytomas
Approximately 25% of patients with
primary tumors outside of the CNS will
develop intracranial metastases. Most of
these develop secondary to lung cancer.

Glioblastoma on MRI

Glioblastoma on MRI
GLIOBLASTOMA

Cerebral Edema

Elevated Intracranial Pressure (ICP)

Medical Emergency
Symptoms include headache, vomiting
and changes in LOC
Medically treated with mannitol and other
agents
Definitive treatment involves correction of
underlying pathology
Complications include herniation