Neurological Diseases 1.Manifestations 2.Cerebrovascular Diseases 3.Inflammatory Diseases 4.Degenerative Diseases 5.Nerve and Muscle disease 6.Infections of Nervous System 7.Intracranial Mass lesions and Raised ICP

Cerebrovascular diseases A 56 year old woman is bought to emergency department by her daughter, complaining of SUDDEN ONSET of Right upper extremity weakness, that began while she was watching TV this morning. The daughter became concerned when her mother was unable to talk in response to her question. Neurologic examination shows Rt Upper extremity weakness with pronator drift with right facial palsy. When questioned, the patient seems to understand what is being said but cannot clearly respond.

Definition Of Stroke/CVA Sudden onset on focal neurological deficit “A clinical syndrome consisting of rapidly developing clinical signs of focal(or global in case of Coma) disturbance of cerebral function lasting for more than 24 hrs or leading to death with no apparent cause other than a vascular origin” WHO TIA (Transient Ischemic Attack) recovery is complete within 24 hours. 10% of patients will go on to have a complete stroke.

Risk factors Modifiable HTN Smoking Cardiac – A. fib – Inf Endocarditis – Recent MI OCP Carotid stenosis Obesity TIA Sickle cell diseases Potentially modifiable DM Hyperhomocystinuria Non modifiable Age- doubles the risk for each decade after 55 Familial

Sub-types Of Stroke Ischaemic – obstruction to one of major cerebral arteries, brainstem strokes are less common. Haemorrhage – 9% are caused by haemorrhage to the deep parts of the brain. Patients are usually hypertensive.

Stroke Classification TACI (Total Anterior Circulation Infarct) PACI (Partial Anterior Circulation Infarct) LACI (Lacunar Infarct) POCI (Posterior Circulation Infarct)

Classification Infarction (85%) – Atherosclerosis (60%) – Non Atherosclerotic (40%) Emboli (50%) Others (50%) Hemorrhagic (15%) – ICH(85%) HTN (70%) AVM+Others (30%) – SAH(15%) Ruptured aneurysms (85%) Idiopathic (15%)

Clinical presentations Acute onset of focal neurological deficit MCA occlusion: Contralateral hemiplegia Hemisensory loss Homonymous hemianopia, eyes deviated TOWARDS cortical lesion Aphasia- Dominant hemisphere involvement Preserved speech- nondominant hemisphere involvement but comprehension with confusion, apraxia with spatial and constructional deficits

Clinical presentations ACA occlusion Contralateral weakness + sensory loss in lower limbs>upper limbs Urinary incontinence Confusion Behavioral disturbances

Clinical presentations PCA Contralateral homonymous hemianopia Visual hallucinations Agnosias If penetrating branches of PCA are occluded CNIII palsy with contralateral hemiplegia (Weber Syndrome) Or Contralateral ataxia or athetosis (Benedict syndrome)

Investigations CT head – Noncontrast  hemorrhagic and no hemorrhagic stroke Diffusion-weighted MRI Other diagnostic workup  ECHO, Duplex, 24 hr Holter monitor, Blood glucose, ECG, Markers of cardiac ischemia, PT/INR, APTT, Oxygen saturation For selected patients- LFT, Toxicology scan, Blood alcohol levels, ABG, CXR, LP (SAH), EEG(Seizures)

Management 5 mainstays 1.Treatment of general condition that needs to be stabilized 2.Specific therapy directed against particular aspect of stroke pathogenesis 3.Prophylaxis and treatment of complications- neurological/ medical 4.Early 2⁰ prevention 5.Early rehabilitation

Treatment TPA-If pt presents within 3 hrs Aspirin- 1 st line for 2⁰ prevention Dipyridamole/ Clopidegrol is added with antiplatelets if – Failed aspirin therapy/ Aspirin allergy Heparin (↓no of recurrent strokes-Afib/basilar artery thrombosis/stroke in evolution) ↓ rate of recurrent CVA/ Afib/2 nd incidence Carotid endarterectomy- When occlusion exceeds 70% of arterial lumen

Contraindications for using TPA Stroke/serious head trauma within three months Hemorrhage(GI/ Genitourinary) within 21 days Surgery within 14 days H/O intracranial Hge BP>185/110 mm of Hg Recent use of anticoagulants Platelets<100,000/mm³ Glucose>400mg/dl or <50mg/dl Coagulopathy(PT>15 seconds)

!!Avoid Dextrose containing fluids in non- hypoglycemic patients Excessive reduction of BP Excessive IVF

Cranial Nerve Major Functions I Olfactory smellOlfactory II Optic vision Optic III Oculomotor eyelid and eyeball movementOculomotor IV Trochlear innervates superior oblique turns eye downward and laterally Trochlear V Trigeminal chewing face & mouth touch & painTrigeminal VI Abducens turns eye laterally Abducens VII Facial controls most facial expressions secretion of tears & saliva tasteFacial. VIII Vestibulocochlear (auditory) hearing equillibrium sensation Vestibulocochlear IX Glossopharyngeal taste senses carotid blood pressure Glossopharyngeal X Vagus senses aortic blood pressure slows heart rate stimulates digestive organs taste Vagus XI Spinal Accessory controls trapezius & sternocleidomastoid controls swallowing movementsSpinal Accessory XII Hypoglossal controls tongue movementsHypoglossal