1. Department of Neurology UPJŠ LF Košice 16.5.2018
Neurological complications of alcoholism collagenous disorders, electrolyte disturbances and endocrinopathies
Department of Neurology
UPJŠ LF Košice

2. Neurological complications of acute alcohol intoxication and alcoholism

3. Alcohol and nervous system
Acute intoxication
Abstinence and withdrawal syndrome
Alcohol and dementia, Wernicke´s encefalopathy

4. Alcohol and nervous system
Acute intoxication
Changes in behavior, agressivity, incoordination of movement and gait, slurred speach
Drowsiness, stupor, coma, problems with breathing

5. Alcohol and nervous system
Abstinence and withdrawal syndrome
Tremulousness
Hallucinations
Epileptic seizures
Confusion
Psychomotor and autonomic overactivity, which develops several hours or days after an addictive drinker abstains from alcohol

6. Alcohol and nervous system
Delirium tremens
In 10% starts with seizures
Profound confusion, gross tremor, hallucinations, autonomic overactivity – fever, tachycardia, dilated pupils
48-96 hours after cessation of drinking

7. Alcohol and nervous system
Alcohol and dementia
Chronic abuse of alcohol – cognitive deficit (loss of neurons, brain atrophy)
Wernicke´s encefalopathy (hemorhagic)
Korsakov´s syndrom

8. Alcohol and nervous system
Wernicke´s encefalopathy
Confusion, eye movement problems, ataxia – dysarthria, ataxia of body and extremities, residual signs
Loss of neurons, axons, myelin, small hemorrhagies – corpora mamillaria, around aqueductus, III. and IV. ventricles
Th.: Thiamin 100 mg/day i.m. or i.v. , B-vitamin complex

9. Alcohol and nervous system
Korsakov´s syndrom - amnestic syndrom with amnesia, confabulations
Marchiafava-Bignami syndrom - demyelinisation of corpus callosum (MRI - hyperintense lesions
Confusion, seizures, dementia

10. Alcohol and nervous system
Alcoholic degeneration of cerebellum- cerebellar atrophy
Alcoholic polyneuropathy
Alcoholic myopathy:
Acute necrotisans myopathy
Chronic myopathy

11. Neurological complications of liver diseases

12. Liver encefalopathy Increased ammonium in blood
Apathy, cognitive disturbances
Pyramidal signs
Apraxia
Unconsciousness
Brain MRI- hyperintensive signals

13. Neurological complications of endocrinopathies

14. Endocrine disturbances
Hypotyreosis
Polyneuropathy – axonal type
Tinnitus, loss of hearing, dizziness
Ptosis
Myalgia
Hypo- arreflexia (tendon reflexes) – 75%
Apathy, concentration problems
Problems with memory
Depression
Seizures

15. Endocrinne disturbances
Hypertyreosis
Tyreotoxic myopathy – weakness of proximal muscles
Dif.dg. : myasthenia gravis, myopathy
Epileptic seizures

16. Neurological complications of diabetes mellitus

17. Diabetes mellitus - neurological complications
Acute metabolic decompensation:
1. Diabetic ketoacidosis, DM 1. type
2. Hyperosmolar encephalopathy - non-ketotic “coma” , DM 2. type, extreme hyperglycaemia (40–80 mmol/l) with hypernatraemia, hyperosmolality, change of consciousness, stupor or coma, seizures, dystonic movements; these neurological features resolve completely when the metabolic state has returned to normal
3. Cerebral edema - potentially fatal, diabetic ketoacidosis
Etiology: electrolyte exchanges in and out of cells with a net influx of sodium into the cells
4. Hypoglycaemia - glucose less than 3 mmol/l; autonomic stimulation, cognitive dysfunction, restless,violent behaviour, unconsciousness, seizures, dysarthria, rarely reversible hemiplegia
Chronic diabetic complications:
1. Hyperglycaemic neuropathy
2. Generalised neuropathies
3. Focal and multifocal neuropathies
4. Superimposed chronic inflammatory demyelinating polyneuropathy (CIDP)
5. Cerebrovascular disease, ischaemic stroke
6. Diabetic myopathy

18. Diabetes mellitus Hypoglycemia General signs, headache
Neurological signs – seizures, coma, acute hemiparesis
Autonomic symptoms – sweating, nausea, blushing, heart pounding, chest pressure, headache
Cerebral symptoms - epi seizures, disturbances of consciousness, focal neurological symptoms - acute hemiparesis
Recurrent hypoglycaemia - reduction of intellectual and cognitive functions, dementia

19. Diabetic polyneuropathy
After 5-10 years of DM, 10 % - earlier than DM
Pathogenesis: metabolic and ischemic changes of vasa nervorum (hyalinisation)
Metabolic changes of peripheral nerves = earlier problems with sensitivity, myelin fibers are resistant against ischemia
1. Hyperglycaemic neuropathy
2. Generalised neuropathies: - Sensorimotor polyneuropathy
- Acute painful sensory neuropathy  
- Autonomic neuropathy
3. Focal and multifocal neuropathies: Cranial neuropathies, Thoracolumbar radiculoneuropathy, Focal limb neuropathies (including compression and entrapment neuropathies), Proximal diabetic neuropathy
4. Superimposed chronic inflammatory demyelinating polyneuropathy (CIDP)

20. Diabetic polyneuropathy
Symmetric diabetic polyneuropathy
Mainly distal localization (LL)
Lower extremities – more often affected
Loss of proprioception - leads to ataxia
Neuropatic pain

21. Diabetic polyneuropathy
Proximal asymmetric diabetic PNP
Rare
Starts with night pain
Proximal (ischias) localization
Muscle atrophy
Symmetric proximal weakness
Mononeuropathy
Cranial nerves lesions
ANS – impotence, impairment of bladder and bowel function

22. Neurological complications kidney disorders (uraemia, dialysis) and electrolyte disturbances

23. Uraemic syndrome and dialysis
Uraemia:
1. Encephalopathy
2. Neuropathy - affect cranial, peripheral and autonomic nerves
3. Uraemic proximal myopathy – caused by secondary hyperparathyroidism
Etiology: retention of uraemic toxins – main cause of uraemic encephalopathy and neuropathy
Chronic dialysis:
1. Dialysis disequilibrium syndrome - can occur in any patient who receives hemodialysis; neurologic deterioration that is seen in patients who undergo hemodialysis during or immediately after their first treatment (abnormal osmotic gradient)
Th: starting dialysis with a low dose and progressively increasing the dialysis dose in subsequent dialysis sessions
Brain edema symptoms , increased intracranial pressure or acute hyponatremia
Seizures , restlessness, headache, mental confussion, increased nervous irritability, spasms, coma
2. Dialysis dementia - results from aluminium overloading
3. Nerve entrapment - carpal tunnel syndrome - caused by beta2-microglobulin amyloidosis

24. Kidney - Uremia Uremic encephalopathy Concentration problems
Cognitive impairment
Motor problems
Polyeuropathy
Seizures, multifocal myoclonus
Delirium
Coma

25. Electrolytes disturbances
Metabolic encephalopathies
Etiology: rapid change of blood osmolality value
- over mmol/l or
- less than 270 mmol/l

26. Electrolytes disturbances
Hyponatremia a hypoosmolality
Water – to CSF and brain cells = brainedema – decreased K+ concentration – decreased action potential at membrane – incerased neuronal irritability
Decreased brain blood flow
Headache
Problems with concentration
Halucinations
Seizures
Coma

27. Electrolytes disturbances
Hypernatremia a hyperosmolality
Reason: lack of water
Water from brain cells a CSF to a body = decreased brain function
Cognitive impairment
Focal signs
Coma
Trombosis of capillaries

28. Central pontinne myelinolysis
Pontinne demyelinisation (Osmotic demyelinisation syndrome)
Rapid change of the electrolytes level
Pontinne syndrome:
Dysphagia, dysarthria, tetraparesis
Oculomotor disturbances
Occurance: often in alcoholics after rapid hyponatriemy correction

29. Neurological complications of collagenous disorders

30. Neurological complications of collagenous (rheumatic) disorders
Central and peripheral NS is affected
The spectrum of neurological complications is very broad and variable
- Vascular disease (microangiopathy, macroangiopathy, vasculitis) of the brain, spinal cord, and peripheral nerves  
Compressive neuropathy (peripheral nerves)
Rheumatoid arthritis /RA/- myelitis
SLE - neuropsychiatric disorders

31. Systemic lupus erythematodes
SLE, multiorgan disease: rheumatologic, vascular, skin, heart, pulmonary, renal and neuro-psychological symptoms
Neurological complications % (central and peripheral NS), in 3 % - the first manifestation SLE
Headache
Mood problems – depression, anxiety
Confussion, halucinations, psychosis, mental and behavioral problems
Hemiparesis, paraparesis, aphasia
Myelopathy- transversal spinal cord lesions
Mononeuritis (e.g. optic neuritis), Polyneuritis (polyneuropathy)
Polymyositis, myalgie
Stroke - brain infarctions
Cognitive deficit – attention problems, dementia (15 – 66 %)
Uncousciousness, epileptic seizures
Cranial nerves lesions (optic nerve)
Dyskinesis (chorea)

32. Systemic lupus erythematodes
Causes of brain infarctions
Lupoid-like anticoagulans antiphospholipid antibodies (LA, aCLA)
Cardiogenous embolisation to the brain
Vasculitis
CSF – pleocytosis, OCB positive
EEG – diffuse abnormalities
Brain MRI – multiple subcortical white matter lesions

33. Rheumatoid arthritis (RA)
Neurological complications - due to vasculitis, inflammatory cells infiltration, or rheumatic nodes
Symptoms:
Sensitive problems, paresthesias, paresis, epileptic seizures, cranial nerve lesions
Spinal cord and spinal root compression –myelopathy, radiculopathy
Atlanto-axial arthritis a subluxation - loosening the transverse tendon leads to cervical spine compression
Kompressive neuropathies - peripheral nerve compression at anatomically predilectional sites and proliferative changes in joints (paraesthesia, pain, sensory and motor deficit in the innervation zone of the damaged nerve), most often n. median in the carpal tunnel
Vasculitis may affect n. peroneus and n. ulnaris, or polyneuropathy

34. RA MRI- cervical spinal cord: Dnes axis dorsal deviation and shift
Basilar impression due to atlanto-axial arthritis in a patient with RA
Dens axis compresses anterior part of medulla oblongata and cervical spinal cord

35. Sjögren syndrome (SS)
Visceral disorders: pulmonary, cardial, renal, lymphadenopathy, hepatosplenomegaly, central and peripheral nervous system
Senzitive polyneuropathy or
Senzitive-motoric polyneuropathy
Senzitive ganglionitis - pain, ataxia
Trigeminal nerve neuropathy and  CIDP – rarely
Stroke
Transverzal myelitis – truncal sense problems, autonomic disturbance, urinary retention
Pupiler abnormalities
Dermatomyozitis and polymyositis – rarely

36. NeuroBehçet disease Nervous system complications in 5 – 10 % Symptoms:
Aseptic meningitis
Encephalitis
Intracranial venous and sinus thrombosis
Peripheral neuropathy - rarely

37. Sclerodermia (Progressive systemic sclerosis)
Polyneuropathy
Trigeminal nerve neuropathy
Compressive neuropathies
Focal cerebral lesions, stroke, demyelinations
Epileptic seizures
Encephalopathy

38. Temporal arteritis (Horton´s arteritis)
Older patients
Vasculitis , large vessels, a. temporalis and a. carotis externa branches
Symptoms: severe headache of temporal area, diplopia, blurred vision, or amaurosis fugax
Visual problems may lead to blindness (40 %) due to optic nerve ischemia
Lab. tests: inflamm.markers (FW, CRP), vessel biopsy – vasculitic changes (infiltration of vessel wall with mononuclear cells, gigantic cells)
Th: high doses of corticoids (Prednison 40 – 80 mg/d)

39. Sarcoidosis
The nervous system is affected in about 5% of cases, it may be the first manifestation of sarcoidosis
Cranial nerves - mononeuropathy n. abducens or n. facialis
Polyneuropathy, Guillain-Barre Syndrome, Plexopathy
Bazilar meningitis with multiple cranial nerve lesions
Diencephalic syndrome (hypersomnia, diabetes insipidus)
Chronic granulomatous pachymeningitis
Rarely leads granuloma to hydrocephalus
Polyneuropathy
Painless granulomatous polymyositis
Myelopathy
Optic nerve papila edema
CSF: increased ACE
MRI: thickening of meninges, with postcontrast enhancement