neurology powerpoint snagit

Chapter 31Chapter 31NeurologyNeurology

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ObjectivesObjectives Describe nervous system anatomy and Describe nervous system anatomy and

physiologyphysiology

Outline pathophysiological changes in the Outline pathophysiological changes in the nervous system that may alter cerebral nervous system that may alter cerebral perfusion pressureperfusion pressure

Describe assessment of patients with central Describe assessment of patients with central nervous system disordersnervous system disorders


ObjectivesObjectives Describe pathophysiology, signs and Describe pathophysiology, signs and

symptoms, and management techniques for:symptoms, and management techniques for: ComaComa StrokeStroke HeadacheHeadache Seizure disordersSeizure disorders Brain neoplasmBrain neoplasm Brain abscessBrain abscess Degenerative disease Degenerative disease Intracranial bleedingIntracranial bleeding


ScenarioScenario

Your patient is a 58-year-old man who awoke Your patient is a 58-year-old man who awoke with drooping on the right side of his face and with drooping on the right side of his face and slurred speech. He has a history of seizures slurred speech. He has a history of seizures and high blood pressure. He is very anxious and high blood pressure. He is very anxious and crying as you begin your assessment and crying as you begin your assessment and care.and care.


DiscussionDiscussion What additional assessments should you What additional assessments should you

perform on this patient?perform on this patient?

List some possible causes of his facial droopingList some possible causes of his facial drooping

What is the significance of his medical history?What is the significance of his medical history?

Describe some interventions that you will Describe some interventions that you will consider for this manconsider for this man


Nervous System AnatomyNervous System Anatomy Two partsTwo parts

Central nervous system Central nervous system (CNS)(CNS)

Peripheral nervous system Peripheral nervous system (PNS)(PNS)

CNSCNS BrainBrain Spinal cordSpinal cord

• Both encased in and Both encased in and protected by boneprotected by bone


Peripheral Nervous SystemPeripheral Nervous System 43 pairs of nerves 43 pairs of nerves

originate from CNS to originate from CNS to form PNSform PNS 12 pairs of cranial nerves12 pairs of cranial nerves

• Originate from brainOriginate from brain 31 pairs of spinal nerves31 pairs of spinal nerves

• Originate from spinal cordOriginate from spinal cord


Cells of the Nervous SystemCells of the Nervous System Neurons—fundamental units Neurons—fundamental units

Neuroglia—connective tissue cellsNeuroglia—connective tissue cells Protect and hold neurons togetherProtect and hold neurons together

NeuronsNeurons Cell body—single nucleus and nucleolusCell body—single nucleus and nucleolus Dendrites—branching projections Dendrites—branching projections Axon—single, elongated projectionAxon—single, elongated projection


Cells of the Nervous SystemCells of the Nervous System

Neuron with dendrites,Neuron with dendrites,cell body, axoncell body, axon

Segment of myelinated axon

Neuron


Cells of the Nervous SystemCells of the Nervous System Dendrites transmit impulses to neuron cell Dendrites transmit impulses to neuron cell

bodiesbodies

Axons transmit impulses away from cell Axons transmit impulses away from cell bodiesbodies Bundles of parallel axons with sheaths are white Bundles of parallel axons with sheaths are white

• White matterWhite matter


Cells of the Nervous SystemCells of the Nervous System In PNS, bundles of axons and their sheaths In PNS, bundles of axons and their sheaths

are called are called nervesnerves Collections of nerve cells are gray Collections of nerve cells are gray

• Gray matterGray matter

Gray matter is integration site within nervous Gray matter is integration site within nervous systemsystem


Types of NeuronsTypes of Neurons Classified by impulse transmission direction:Classified by impulse transmission direction:

Sensory neuronsSensory neurons Motor neuronsMotor neurons InterneuronsInterneurons


Impulse TransmissionImpulse Transmission Nervous system transmission similar to Nervous system transmission similar to

electrical impulse conduction in heartelectrical impulse conduction in heart

Unmyelinated axonsUnmyelinated axons

Myelinated axonsMyelinated axons


Nerve Impulse ConductionNerve Impulse Conduction

Unmyelinated fiberUnmyelinated fiber

Myelinated fiberMyelinated fiber


SynapseSynapse Membrane-to-membrane contactMembrane-to-membrane contact

Separates axon endings of one neuron (presynaptic Separates axon endings of one neuron (presynaptic neuron) from dendrites of another neuron neuron) from dendrites of another neuron (postsynaptic neuron)(postsynaptic neuron) Presynaptic terminalPresynaptic terminal Synaptic cleftSynaptic cleft Plasma membrane of postsynaptic neuronPlasma membrane of postsynaptic neuron

Presynaptic terminals have synaptic vesicles Presynaptic terminals have synaptic vesicles containing neurotransmitter chemicals containing neurotransmitter chemicals

NeurotransmittersNeurotransmitters


Components of a Synapse Components of a Synapse


ReflexesReflexes Receive stimulus and generate responseReceive stimulus and generate response

Unidirectional impulse conductionUnidirectional impulse conduction• Sensory receptorSensory receptor

• Sensory neuronSensory neuron

• InterneuronsInterneurons

• Motor neuronMotor neuron

• Effector organEffector organ

Vary in complexityVary in complexity


Neural Pathway Involved inNeural Pathway Involved inPatellar (“Knee Jerk” ) ReflexPatellar (“Knee Jerk” ) Reflex


Blood SupplyBlood Supply Arterial blood supply to brainArterial blood supply to brain

Vertebral arteriesVertebral arteries Internal carotid arteriesInternal carotid arteries

Circle of WillisCircle of Willis Safeguard to ensure blood supply to all parts of Safeguard to ensure blood supply to all parts of

the brain if vertebral or internal carotid arteries are the brain if vertebral or internal carotid arteries are blockedblocked


Blood SupplyBlood Supply


VeinsVeins Veins that drain blood from head form venous Veins that drain blood from head form venous

sinusessinuses

Drain into internal jugular veinsDrain into internal jugular veins

Internal jugular veins join subclavian veins on Internal jugular veins join subclavian veins on each side of the bodyeach side of the body


Venous Sinuses AssociatedVenous Sinuses Associatedwith the Brainwith the Brain


Ventricles of the BrainVentricles of the Brain Lateral ventricleLateral ventricle

Space in cerebral Space in cerebral hemispheres is filled hemispheres is filled with cerebrospinal fluidwith cerebrospinal fluid


Divisions of the Adult BrainDivisions of the Adult Brain Brain stemBrain stem

MedullaMedulla PonsPons MidbrainMidbrain

CerebellumCerebellum

DiencephalonDiencephalon HypothalamusHypothalamus ThalamusThalamus

CerebrumCerebrum


Neurological PathophysiologyNeurological Pathophysiology Cerebral blood flow (CBF) interrupted by:Cerebral blood flow (CBF) interrupted by:

Structural changes or damageStructural changes or damage Circulatory changesCirculatory changes Alterations in intracranial pressure (ICP)Alterations in intracranial pressure (ICP)

Three structures in intracranial space:Three structures in intracranial space: Brain tissueBrain tissue BloodBlood WaterWater


Intracranial SpaceIntracranial Space Brain tissueBrain tissue

Mostly water, intracellular and extracellularMostly water, intracellular and extracellular

BloodBlood Major arteries in base of brainMajor arteries in base of brain Arterial branches, arterioles, capillaries, Arterial branches, arterioles, capillaries,

venules, veins within brain substance venules, veins within brain substance Cortical veins and dural sinusesCortical veins and dural sinuses


Intracranial SpaceIntracranial Space Water in:Water in:

Ventricles of brainVentricles of brain Cerebrospinal fluidCerebrospinal fluid Extracellular and intracellular fluidExtracellular and intracellular fluid


Cerebral Perfusion Pressure (CPP)Cerebral Perfusion Pressure (CPP)

Cerebral blood flow depends on cerebral Cerebral blood flow depends on cerebral perfusion pressureperfusion pressure Pressure gradient across brainPressure gradient across brain


Cerebral Blood FlowCerebral Blood Flow Cerebral blood flow controls oxygen and Cerebral blood flow controls oxygen and

glucose deliveryglucose delivery Cerebral perfusion pressure (CPP) and cerebral Cerebral perfusion pressure (CPP) and cerebral

vascular bed resistancevascular bed resistance CPP determined by:CPP determined by:

• Mean arterial pressure (MAP): (Diastolic pressure + Mean arterial pressure (MAP): (Diastolic pressure + ⅓⅓ pulse pressure) minus intracranial pressurepulse pressure) minus intracranial pressure


Cerebral Blood FlowCerebral Blood Flow As ICP approaches MAP:As ICP approaches MAP:

Gradient for flow decreasesGradient for flow decreases Cerebral blood flow restrictedCerebral blood flow restricted

When ICP increases, CPP decreasesWhen ICP increases, CPP decreases As CPP decreases, cerebral vasodilation As CPP decreases, cerebral vasodilation Increases cerebral blood volume (increasing Increases cerebral blood volume (increasing

ICP) and further cerebral vasodilationICP) and further cerebral vasodilation


Goals of Emergency CareGoals of Emergency Care Airway controlAirway control

Stabilization and support of cardiovascular systemStabilization and support of cardiovascular system

Intervention to interrupt ongoing cerebral injuryIntervention to interrupt ongoing cerebral injury

Protection from further harmProtection from further harm

Transport to an appropriate medical facilityTransport to an appropriate medical facility


Initial AssessmentInitial Assessment Level of consciousnessLevel of consciousness

Ensure patent airwayEnsure patent airway

Immobilize cervical spineImmobilize cervical spine

Airway adjuncts if indicatedAirway adjuncts if indicated Monitor for respiratory arrestMonitor for respiratory arrest

Ventilatory support and supplemental oxygen for any Ventilatory support and supplemental oxygen for any neurological emergencyneurological emergency


Physical ExaminationPhysical Examination Important elementsImportant elements

Patient historyPatient history History of eventHistory of event Vital signsVital signs Respiratory patternsRespiratory patterns


HistoryHistory History of event from patient, family, History of event from patient, family,

bystandersbystanders

If loss of consciousness, ascertain events prior If loss of consciousness, ascertain events prior to unconscious state:to unconscious state: Patient position (sitting, standing, lying down)Patient position (sitting, standing, lying down) Complaints of a headacheComplaints of a headache Seizure activitySeizure activity FallFall


HistoryHistory When no history is available, assume the When no history is available, assume the

onset of unconsciousness was acute and that onset of unconsciousness was acute and that an intracranial hemorrhage is likelyan intracranial hemorrhage is likely


Vital SignsVital Signs Assess and record frequentlyAssess and record frequently

May change rapidly May change rapidly Monitor ECG for dysrhythmiasMonitor ECG for dysrhythmias

Cushing’s triad, if increased ICP:Cushing’s triad, if increased ICP: Increase in systolic pressure (widening pulse Increase in systolic pressure (widening pulse

pressure)pressure) Decrease in pulse rateDecrease in pulse rate Irregular respiratory patternIrregular respiratory pattern


Respiratory PatternsRespiratory Patterns Normal or abnormalNormal or abnormal

Abnormal respiratory patternsAbnormal respiratory patterns Cheyne-Stokes respirationCheyne-Stokes respiration Central neurogenic hyperventilationCentral neurogenic hyperventilation Ataxic respirationAtaxic respiration Apneustic respirationApneustic respiration Diaphragmatic breathingDiaphragmatic breathing


Respiratory PatternsRespiratory Patterns


Neurological EvaluationNeurological Evaluation AVPU and Glasgow Coma ScaleAVPU and Glasgow Coma Scale

Determine baseline neurological statusDetermine baseline neurological status Allow comparisonsAllow comparisons

Report and record patient information with Report and record patient information with specific descriptive termsspecific descriptive terms


Posturing, Muscle Tone, and ParalysisPosturing, Muscle Tone, and Paralysis

Disturbances of posture result from:Disturbances of posture result from: Flexor spasmsFlexor spasms Extensor spasmsExtensor spasms FlaccidityFlaccidity



Decorticate rigidityDecorticate rigidity FlexionFlexion Abnormal flexor responses of one or both arms Abnormal flexor responses of one or both arms

with extension of legswith extension of legs Structural impairment of certain cortical regions of Structural impairment of certain cortical regions of

brainbrain



Decerebrate rigidityDecerebrate rigidity ExtensionExtension Abnormal extensor response of arms and legs Abnormal extensor response of arms and legs Worse prognosis than decorticate rigidityWorse prognosis than decorticate rigidity Impairment of subcortical regions of brainImpairment of subcortical regions of brain

FlaccidityFlaccidity Brain stem or cord dysfunctionBrain stem or cord dysfunction Dismal prognosisDismal prognosis


PosturingPosturing

Abnormal extension (decerebrate posturing)

Abnormal flexion (decorticate posturing)


Assessment—Abnormal ReflexesAssessment—Abnormal Reflexes

Positive Babinski's signPositive Babinski's sign Plantar reflexPlantar reflex Dorsiflexion of great toe Dorsiflexion of great toe

with or without fanning of with or without fanning of toestoes

Relaxation of sphincter Relaxation of sphincter tone with evacuation of tone with evacuation of bowels and/or bladderbowels and/or bladder


Pupils at DifferentPupils at DifferentLevels of ConsciousnessLevels of Consciousness


Extraocular MovementsExtraocular Movements Conjugate gazeConjugate gaze

Dysconjugate gazeDysconjugate gaze


Conjugate Gaze Conjugate Gaze


Dysconjugate GazeDysconjugate Gaze


ComaComa Abnormally deep state of unconsciousnessAbnormally deep state of unconsciousness

Cannot arouse by external stimuliCannot arouse by external stimuli

Two mechanismsTwo mechanisms Structural lesions Structural lesions Toxic metabolic states Toxic metabolic states


ComaComa CausesCauses

AEIOU-TIPSAEIOU-TIPS

AssessmentAssessment

ManagementManagement


Stroke and Intracranial HemorrhageStroke and Intracranial Hemorrhage

Stroke (“brain attack”)Stroke (“brain attack”)

Sudden interruption in brain blood flow Sudden interruption in brain blood flow

Results in neurological deficitResults in neurological deficit IncidenceIncidence Morbidity/mortalityMorbidity/mortality Risk factorsRisk factors


Stroke PathophysiologyStroke Pathophysiology Blood supply to brain through four vesselsBlood supply to brain through four vessels

Carotid arteriesCarotid arteries• 80% of cerebral blood flow80% of cerebral blood flow

Vertebral arteriesVertebral arteries• Form basilar arteryForm basilar artery• 20% of cerebral blood flow20% of cerebral blood flow

Interconnected at various levelsInterconnected at various levels• Circle of WillisCircle of Willis

Onset and symptoms depend on area of brain Onset and symptoms depend on area of brain involvedinvolved


Types of StrokeTypes of Stroke Neurological manifestations of decrease in Neurological manifestations of decrease in

blood flow to brainblood flow to brain

Ischemic and hemorrhagic strokesIschemic and hemorrhagic strokes Both can be life threateningBoth can be life threatening Ischemic stroke rarely causes death in first hourIschemic stroke rarely causes death in first hour Hemorrhagic stroke can be rapidly fatalHemorrhagic stroke can be rapidly fatal


Ischemic StrokeIschemic Stroke 85% of strokes are ischemic85% of strokes are ischemic

Cerebral thrombosis due to:Cerebral thrombosis due to: Atherosclerotic plaquesAtherosclerotic plaques Extrinsic pressure brain massExtrinsic pressure brain mass

Thrombotic strokeThrombotic stroke Slower to develop than cerebral hemorrhageSlower to develop than cerebral hemorrhage


Cerebral EmbolusCerebral Embolus Intracranial vessel occluded by foreign Intracranial vessel occluded by foreign

substance from outside CNSsubstance from outside CNS

Sources of cerebral emboliSources of cerebral emboli

Signs and symptomsSigns and symptoms Similar to thrombotic strokeSimilar to thrombotic stroke Usually develop more quicklyUsually develop more quickly Often have identifiable causeOften have identifiable cause


Hemorrhagic StrokeHemorrhagic Stroke IncidenceIncidence

Morbidity/mortalityMorbidity/mortality

CausesCauses Cerebral aneurysmsCerebral aneurysms Arteriovenous (AV) malformationsArteriovenous (AV) malformations HypertensionHypertension

Signs and symptomsSigns and symptoms


Transient Ischemic AttacksTransient Ischemic Attacks Focal cerebral dysfunction lasting from minutes Focal cerebral dysfunction lasting from minutes

to several hoursto several hours

Return to normal Return to normal <<24 hrs24 hrs

No permanent neurological deficitNo permanent neurological deficit Indication of impending strokeIndication of impending stroke



Differentiating between Ischemic and Differentiating between Ischemic and Hemorrhagic StrokeHemorrhagic Stroke

Ischemic StrokeIschemic Stroke Hemorrhagic StrokeHemorrhagic Stroke

Most commonMost common Least commonLeast common

Atherosclerosis or tumor within Atherosclerosis or tumor within brainbrain

Cerebral aneurysms, AV Cerebral aneurysms, AV malformations, hypertensionmalformations, hypertension

Slow onsetSlow onset Abrupt onsetAbrupt onset

Long history of vessel diseaseLong history of vessel disease Stress or exertionStress or exertion

Valvular heart disease and atrial Valvular heart disease and atrial fibrillationfibrillation

Cocaine and other Cocaine and other sympathomimetic aminessympathomimetic amines

Hx of angina, previous strokesHx of angina, previous strokes May be asymptomatic before May be asymptomatic before rupturerupture


AssessmentAssessment Emergency care prioritiesEmergency care priorities

Maintain patent airwayMaintain patent airway Provide adequate ventilatory supportProvide adequate ventilatory support OxygenOxygen Thorough historyThorough history

ManagementManagement Time in field must be reducedTime in field must be reduced Establish time of symptom onset (if possible)Establish time of symptom onset (if possible) Supportive measuresSupportive measures


Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale

Evaluates three physical findings:Evaluates three physical findings: Facial droopFacial droop Arm driftArm drift SpeechSpeech


Los Angeles Prehospital Stroke Screen Los Angeles Prehospital Stroke Screen (LAPSS)(LAPSS)

AgeAge HistoryHistory Symptom durationSymptom duration Baseline disabilityBaseline disability

Identifies asymmetry in:Identifies asymmetry in:• Facial smile/grimaceFacial smile/grimace

• GripGrip

• Arm strengthArm strength

Asymmetry in any category indicates a possible strokeAsymmetry in any category indicates a possible stroke


Prehospital Stroke ManagementPrehospital Stroke Management

Rapid transportRapid transport Determine time of symptom onsetDetermine time of symptom onset Manage airwayManage airway Oxygen if SaO2 <92%Oxygen if SaO2 <92% Monitor vital signs and ECGMonitor vital signs and ECG Initiate IV en routeInitiate IV en route Assess blood glucoseAssess blood glucose Control seizures with benzodiazepinesControl seizures with benzodiazepines


Seizure DisordersSeizure Disorders Temporary alteration in behavior or consciousness Temporary alteration in behavior or consciousness

Caused by abnormal electrical activity of neurons in brainCaused by abnormal electrical activity of neurons in brain

IncidenceIncidence


CausesCauses


Types of SeizuresTypes of Seizures All seizures pathologicalAll seizures pathological

Arise from almost any region of brainArise from almost any region of brain• Have many clinical manifestationsHave many clinical manifestations

Most common typesMost common types• GeneralizedGeneralized

• Partial (focal)Partial (focal)


Generalized SeizuresGeneralized Seizures No definable origin (focus) in brainNo definable origin (focus) in brain

May progress to generalized seizureMay progress to generalized seizure

Petit mal (absence seizures)Petit mal (absence seizures)

Grand mal (tonic-clonic) seizuresGrand mal (tonic-clonic) seizures


Petit Mal SeizuresPetit Mal Seizures Often in children 4-12 y/oOften in children 4-12 y/o

Brief lapses of consciousness without loss of postureBrief lapses of consciousness without loss of posture

Often no motor activity although may have:Often no motor activity although may have: Eye blinkingEye blinking Lip smackingLip smacking Isolated clonic activityIsolated clonic activity


Grand Mal SeizuresGrand Mal Seizures CommonCommon

Associated with significant morbidity and Associated with significant morbidity and mortalitymortality

May be preceded by an aura (olfactory or May be preceded by an aura (olfactory or auditory sensation)auditory sensation) Warning of imminent convulsionWarning of imminent convulsion


Grand Mal SeizureGrand Mal Seizure——CharacteristicsCharacteristics

Sudden loss of consciousness with loss of Sudden loss of consciousness with loss of organized muscle toneorganized muscle tone Tonic phaseTonic phase Clonic phaseClonic phase Postictal phasePostictal phase

If prolonged or recur before patient regains If prolonged or recur before patient regains consciousness:consciousness: Status epilepticusStatus epilepticus


Partial SeizuresPartial Seizures Arise from identifiable cortical lesionsArise from identifiable cortical lesions

Simple or complexSimple or complex


Simple Partial SeizuresSimple Partial Seizures Seizure activity in motor or sensory cortexSeizure activity in motor or sensory cortex

Simple motor seizuresSimple motor seizures

Simple sensory seizuresSimple sensory seizures

Jacksonian seizureJacksonian seizure


Complex Partial SeizuresComplex Partial Seizures Focal seizures in temporal lobe (psychomotor)Focal seizures in temporal lobe (psychomotor)

Manifest as changes in behaviorManifest as changes in behavior

Classic complex partial seizureClassic complex partial seizure Preceded by auraPreceded by aura Abnormal repetitive motor behavior Abnormal repetitive motor behavior Typically less than 1 minuteTypically less than 1 minute Regains normal mental status quicklyRegains normal mental status quickly May progress to tonic-clonic seizureMay progress to tonic-clonic seizure


Hysterical Seizures (Pseudoseizures)Hysterical Seizures (Pseudoseizures)

Mimic true seizureMimic true seizure

Psychological causesPsychological causes Not considered true seizuresNot considered true seizures No organic originNo organic origin Do not respond to normal treatmentDo not respond to normal treatment

Usually terminated by sharp commands or Usually terminated by sharp commands or painful stimulipainful stimuli


History and Physical ExamHistory and Physical Exam History of seizuresHistory of seizures

FrequencyFrequency• Medication complianceMedication compliance

Description of seizure Description of seizure Duration Duration Pattern of seizure Pattern of seizure AuraAura Generalized or focalGeneralized or focal IncontinenceIncontinence Tongue bitingTongue biting


History and Physical ExamHistory and Physical Exam HistoryHistory

Recent or past history of head traumaRecent or past history of head trauma Recent history of fever, headache, nuchal rigidityRecent history of fever, headache, nuchal rigidity Significant past medical historySignificant past medical history

Physical examinationPhysical examination


Syncope versus SeizureSyncope versus Seizure May be difficult to determineMay be difficult to determine

Differentiating characteristics are in symptoms Differentiating characteristics are in symptoms before and after eventbefore and after event


ManagementManagement Prevent physical injuryPrevent physical injury

Oxygen via nonrebreather maskOxygen via nonrebreather mask

Move away from onlookersMove away from onlookers

Transport for physician evaluationTransport for physician evaluation


Status EpilepticusStatus Epilepticus Seizure activity >30 min or recurrent seizure Seizure activity >30 min or recurrent seizure

without intervening period of consciousnesswithout intervening period of consciousness

EmergencyEmergency

CausesCauses

Associated complicationsAssociated complications


Status Epilepticus Status Epilepticus ManagementManagement

Secure airway, ventilate, oxygenate Secure airway, ventilate, oxygenate

Protect from injuryProtect from injury

Initiate IVInitiate IV

Benzodiazepines to control seizuresBenzodiazepines to control seizures


HeadacheHeadache Categorized by underlying cause:Categorized by underlying cause:

Tension headachesTension headaches MigrainesMigraines Cluster headachesCluster headaches Sinus headachesSinus headaches

Common medical complaintCommon medical complaint


Tension HeadachesTension Headaches Muscle contractions of face, neck, scalpMuscle contractions of face, neck, scalp

CausesCauses




MigrainesMigraines Severe, incapacitating headachesSevere, incapacitating headaches

Often preceded by visual or GI disturbancesOften preceded by visual or GI disturbances

Intense, throbbing pain on one side of headIntense, throbbing pain on one side of head May spreadMay spread Often nausea and vomitingOften nausea and vomiting

Constriction and dilation of blood vesselsConstriction and dilation of blood vessels Imbalance of serotonin or hormone fluctuationsImbalance of serotonin or hormone fluctuations


MigrainesMigraines Also triggered by:Also triggered by:

Excessive caffeine useExcessive caffeine use Various foodsVarious foods Changes in altitudeChanges in altitude Extremes of emotionsExtremes of emotions



Cluster HeadachesCluster Headaches Occur in bursts (clusters)Occur in bursts (clusters)

Often several hours after asleepOften several hours after asleep

PainPain SevereSevere Usually around one eyeUsually around one eye Often nasal congestion and tearingOften nasal congestion and tearing Often lasts 30 min to 2 hrs, and recurs a day or so laterOften lasts 30 min to 2 hrs, and recurs a day or so later May occur every day for months before long periods of May occur every day for months before long periods of

remissionremission


Cluster HeadachesCluster Headaches Histamine headachesHistamine headaches

Release of histamine from tissuesRelease of histamine from tissues SymptomsSymptoms

• Dilated carotid arteriesDilated carotid arteries

• Fluid accumulation under eyesFluid accumulation under eyes

• Tearing Tearing

• RhinorrheaRhinorrhea



Sinus HeadachesSinus Headaches Pain in forehead, nasal area, and eyesPain in forehead, nasal area, and eyes

Feeling of pressure behind faceFeeling of pressure behind face

Inflammation or infection of membranes lining Inflammation or infection of membranes lining sinus cavities or allergiessinus cavities or allergies



Brain NeoplasmBrain Neoplasm Mass in cranial cavityMass in cranial cavity

Malignant or benignMalignant or benign

Risk factorsRisk factors




Brain AbscessBrain Abscess Accumulation of purulent material (pus) Accumulation of purulent material (pus)

surrounded by a capsule within brainsurrounded by a capsule within brain

CausesCauses

Clinical manifestationsClinical manifestations

Management Management


Muscular DystrophyMuscular Dystrophy Inherited muscle disorderInherited muscle disorder

Unknown causeUnknown cause

Slow, progressive degeneration of muscle Slow, progressive degeneration of muscle

Different forms classified by:Different forms classified by: Age symptoms appearAge symptoms appear Rate of disease progressionRate of disease progression How inheritedHow inherited

Duchenne muscular dystrophyDuchenne muscular dystrophy Most common typeMost common type


Multiple Sclerosis (MS)Multiple Sclerosis (MS) Progressive CNS disease Progressive CNS disease

Scattered patches of myelin in brain and Scattered patches of myelin in brain and spinal cord are destroyedspinal cord are destroyed CauseCause IncidenceIncidence Morbidity/mortalityMorbidity/mortality Clinical manifestationsClinical manifestations ManagementManagement


DystoniaDystonia Local or diffuse alterations in muscle tone Local or diffuse alterations in muscle tone

Usually abnormal muscle rigidityUsually abnormal muscle rigidity

CausesCauses Painful muscle spasmsPainful muscle spasms Unusually fixed posturesUnusually fixed postures Strange movement patternsStrange movement patterns


DystoniaDystonia Localized dystoniaLocalized dystonia

Torticollis (painful neck spasm)Torticollis (painful neck spasm) Scoliosis (abnormal curvature of the spine)Scoliosis (abnormal curvature of the spine)

Generalized dystoniaGeneralized dystonia Parkinson diseaseParkinson disease StrokeStroke

Also feature of schizophrenia or side effect of Also feature of schizophrenia or side effect of antipsychotic drugsantipsychotic drugs



Parkinson DiseaseParkinson Disease Degeneration or damage to nerve cells within basal Degeneration or damage to nerve cells within basal

ganglia in brainganglia in brain

Leading neurologic disability in persons over 60 yoLeading neurologic disability in persons over 60 yo

Characterized by :Characterized by : Muscle rigidityMuscle rigidity Tremors (start on one side)Tremors (start on one side) WeaknessWeakness Shuffling gaitShuffling gait May lead to dementiaMay lead to dementia


Central Pain SyndromeCentral Pain Syndrome Infection or disease of trigeminal nerve (cranial nerve Infection or disease of trigeminal nerve (cranial nerve

V)V) Tic douloureux (trigeminal neuralgia)Tic douloureux (trigeminal neuralgia)

• Common form Common form • Excruciating painExcruciating pain

Affects one side of faceAffects one side of face

Brief attacks of intense painBrief attacks of intense pain

May be associated with MS in persons under 50 yoMay be associated with MS in persons under 50 yo


Bell’s Palsy (Facial Palsy) Bell’s Palsy (Facial Palsy) Paralysis of facial musclesParalysis of facial muscles

Inflammation of seventh cranial nerveInflammation of seventh cranial nerve Usually one sided and temporaryUsually one sided and temporary Often develops suddenlyOften develops suddenly

Affects 1 in 60 or 70 peopleAffects 1 in 60 or 70 people

Often spontaneous recoveryOften spontaneous recovery


Bell’s Palsy Bell’s Palsy


Amyotrophic Lateral Sclerosis (ALS)Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s diseaseLou Gehrig’s disease

Rare disorders (motor neuron disease)Rare disorders (motor neuron disease)

Nerves that control muscular activity degenerate within Nerves that control muscular activity degenerate within brain and spinal cordbrain and spinal cord

Often begins with weakness in the arms and handsOften begins with weakness in the arms and hands

Paralysis progresses to include respiratory musclesParalysis progresses to include respiratory muscles

Death often within 2-4 years of diagnosisDeath often within 2-4 years of diagnosis


Peripheral NeuropathyPeripheral Neuropathy Diseases and disorders affecting peripheral nervous Diseases and disorders affecting peripheral nervous

system, including:system, including: Spinal nerve rootsSpinal nerve roots Cranial nervesCranial nerves Peripheral nervesPeripheral nerves

Damage or irritation of axons or myelin sheathsDamage or irritation of axons or myelin sheaths

Affect different areas of bodyAffect different areas of body

Many medical causesMany medical causes


MyoclonusMyoclonus Rapid and uncontrollable muscular Rapid and uncontrollable muscular

contractions (jerking) or spasms of muscle(s)contractions (jerking) or spasms of muscle(s) Occur at rest or with movementOccur at rest or with movement

Associated with:Associated with: Disease of nerves and musclesDisease of nerves and muscles Brain disorder (e.g., encephalitis)Brain disorder (e.g., encephalitis) Seizure disorderSeizure disorder

May occur in healthy personsMay occur in healthy persons


Spina BifidaSpina Bifida Congenital defectCongenital defect

One or more vertebrae fail to develop completelyOne or more vertebrae fail to develop completely Leaves portion of spinal cord exposedLeaves portion of spinal cord exposed

Most common in lower backMost common in lower back

IncidenceIncidence


Cause is unknownCause is unknown


Types of Spina BifidaTypes of Spina Bifida Severity depends on how much nerve tissue Severity depends on how much nerve tissue

is exposed after neural tube closureis exposed after neural tube closure Spina bifida occultSpina bifida occult MeningoceleMeningocele MyeloceleMyelocele EncephaloceleEncephalocele


MeningoceleMeningocele


MyelomeningoceleMyelomeningocele


Polio (Poliomyelitis)Polio (Poliomyelitis) Caused by Caused by poliovirus hominispoliovirus hominis

Incidence declined in 1950s after vaccineIncidence declined in 1950s after vaccine

Risk if unvaccinated and traveling abroadRisk if unvaccinated and traveling abroad

Febrile illness with or without paralysisFebrile illness with or without paralysis

Can cause breathing difficultyCan cause breathing difficulty


ConclusionConclusionAcute disorders of the nervous system Acute disorders of the nervous system

require rapid assessment and management. require rapid assessment and management. Paramedics can help reduce mortality and Paramedics can help reduce mortality and

morbidity, and produce maximal potential for morbidity, and produce maximal potential for rehabilitation and recovery.rehabilitation and recovery.


Questions?Questions?


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