1. Neurological syndromes in systemic diseases and general medicine
Marta Lipowska

2. Encephalopathy
Brain pathology of varies origins (metabolic, degenerative, genetic, posttraumatic, ischemic, hypoxic…)
Generally it affects large parts of the brain instead of leading to identifiable focal changes
Often developes when the reason is outside the brain

3. Encephalopathy
Deprivation of oxygen (hypoxia, diffuse ischemia), substrate (hypoglycemia) or metabolic cofactor (thiamine deficiency)
Diseases of organs other than the brain:
Liver (hepatic coma)
Kidney (uremia)
Lung (CO2 narcosis)
Pancreas
Pituitary
Thyroid (myxedema, thyrotoxicosis)
Adrenal
Exogenous poisons
Abnormalities of ionic or acid-base environment
Disordered temperature regulation (hypothermia, heat stroke)
Primary neuronal or glial disorders

4. disorder of consciousness:
Ischemia Hypoxia Metabolic abnormalites
Brain dysfunction
headache,
disorder of consciousness:
(drowsinessconfusion, stupor coma)
convulsions,
involuntary movements (mioclonic)
focal neurological syndromes

5. Glasgow coma scale Estimates the level of consciousness Scores:
Eye opening response (1-4 points)
Verbal response (1-5 points)
Motor response (1-6 points)
3-8 points - coma

6. Seizures (convulsions) as a part of ecephalopathy
Metabolic abnormalities: glucose, Na, Ca, Mg
Toxic factors („irritating”)
Drugs (neuroleptics)
Acute brain disorders (stroke, inflammation, trauma)

7. a patient with pneumonia (secondary CNS hypoxia) confusion

8. A patient with encephalopathy- how to diagnose?
Blood and urine tests
Chest X-ray, other pulmonary investigations
Cardiological investigations etc.
Sometimes
Neurological examinations:
CT scan, MRI, CSF

9. Brain MRI scan in metabolic encephalopathy (renal failure)?

10. Brain MRI scan in metabolic encephalopathy (renal failure)?
EEG reflects level of consciousness (changes in the EEG correlate with the severity of cerebral dysfunction)

11. EEG Alert drowsy lethargic stuporous comatose brain dead Normal EEG
Worse ence-phalo-pathy
Alert
drowsy
lethargic
stuporous
comatose
brain dead
Normal EEG
Different abnormalities
Electrocerebral silence

12. Peripheral aquired neuropathies
metabolic (diabetic, uremic)
associated with dietary states
Vasculitic (usually associated with systemic diseases)
Acromegalic, hypo- hyperthyroid
paraneoplastic
paraproteinemic

13. Signs and symptoms of neuropathy
Motor deficit- flaccid weakness
Sensory deficit- pain, paresthesia, sensory loss, ataxia
Autonomic involvement

16. Distribution of neuropathy
Polyneuropathy- symetric, diffuse lesions of peripheral nerves, distal
Mononeuropathy- disorder of a single nerve
Mononeuropathy multiplex – focal involvement of two or more nerves

18. Cardiovascular disorders
Brain ischemia during:
Heart attack
Arrhythmia
Blood pressure  or 
Heart failure
Ischemic stroke with embolic material form heart:
Artrial fibrillation
Aortic or valve mitral disease, specially with bacterial vegetation
Bacterial miocarditis
Hypertensive encephalopathy

19. Lung diseases Pneumonia Lung cancer Chronic pulmonary insufficiency
hipoxia
Risk of bacterial meningitis
Lung cancer
Paraneoplastic syndromes
Metastases
Pancoast`s syndrome – superior sulcus lungs tumors – brachial plexus damage
Chronic pulmonary insufficiency
Noctural headaches

20. Renal diseases- renal failure
Uremic encephalopathy
Uremic neuropathy
Dialysis dysequilibrium syndrome (usually seen with rapid dialysis at the onset of dialysis program)
Headache, nausea, muscle cramps, rarely convulsion, delirium
Neurologic complication of renal transplantation
CNS lymphoma, unusual infections

21. Hematologic diseases Leukemias
Hemorrhage socondary to thrombocytopenia
Infections secondary to low white blood cells counts
Tumors of CNS
Meningeal invasion (of any acute lymphoma)
Complications of chemiotherapy

22. Hematologic diseases Polycythemia
Large nad small vessel cerebral infaction (hyperviscosity)
Hemorrhages socondary to thrombocytopenia
Platelet disorders (primary or secondary)
infarctions and hemorrhages
Disorders of coagulation (deficiency of ATIII, factors involved in plasma coagulation)
Ischemic stroke in young patiens

23. POEMS syndrome P-polyneuropathy O-organomegaly E-endocrynopathy
M- monoclonal protein
S-skin changes (angiomas, hiperpigmentation)
In the course of solitary osteosclerotic plasmocytoma

26. Thyroid – Hypothyroidism
Endocrine diseases
Thyroid – Hypothyroidism
Changes in cognition and level of consciousness  myxedema coma
Entrapment neuropathy- carpal tunnel syndrome (attributed to the accumulation of acid mucopolysaccarides in the nerve and surranding tissues)

27. Thyroid - hyperthyroidism
Endocrine diseases
Thyroid - hyperthyroidism
Ophalmoplegia (Graves disease)
Thyreotoxic myopathy – weakness, wasting of the muscles, myasthenic signs
Thyreotoxic periodic paralysis
Irritation, anxiety

29. Endocrine diseases Hypoparathyroidism Symptoms of hypocalcemia
tetany – muscle spasms, paresthesia
Convulsions
Irritation, insomia

30. (the main problem- pain)
Diabetes mellitus
Diabetic neuropathy- occurs in 80% of patients
Distal symetric, predominantly sensory, with or without autonomic manifestations
(the main problem- pain)
Mononeuropathies
Liability to pressure palsies (CTS)
Cranial nerve palsies

31. Neurogenic diabetic foot- pathogenesis
pain and temperature sensory loss – susceptibility to injures
autonomic nerves involvement –dry skin, vascular autoregulation disturbences
other factors

32. Garland`s syndrome - femoral nerve damage (diabetic focal neuropathy)

33. Diabetes mellitus stroke risk factor hypo-, hyperglicemia:
decrease of consciousness  coma
Convulsions
Stroke-like episodes (focal syndromes)

34. Encepalopathy, hepatic coma
Liver diseases
Chronic liver disease, when portal hypertension induces an excessive portal collateral circulation cerebral intoxication
Encepalopathy, hepatic coma

35. Viral hepatitis type C - extrahepatic manifestations
Cryoglobulinemia
Peripheral neuropathies

36. Vitamin B12 (cyjanocobalamin) deficiency
Megaloblastic anemia
Classic clinical syndrome of subacute degeneration of spinal cord and polineuropathy

37. Neurologic paraneoplastic syndromes
Results from indirect effect of primary malignancy on the nervous system (or other organs)
Usually autoimmune cause:
The host makes antibodies against antigens in the neoplasm and that these antibodies cross- react with neural antigens
(anti- onconeural antibodies, anty –Hu)

38. Neurologic paraneoplastic syndromes
Usually precede primary neoplasm occurence !!! (the most strong immunologic reaction at the beginning)
Some patients may have easy controlled neoplasm but die from the neurologic disorder

39. Neurologic paraneoplastic syndromes
May affect any part of peripheral and central nervous system
Encephalomyelitis
Limbic encephalitis
Cerebellar degeneration
Opsoclonus
Sensory neuropathy
Myasthenic Lambert-Eaton syndrome
Dermatomyositis and polymyositis

40. Treatment
Treatment of underlying malignancy
Immunomodulatory therapy

41. Collagen-vascular diseases
Periarteritis nodosa
systemic lupus erythematosus,
rheumatoid arthritis,
Wegener granulomatosis
Churg- Strauss vasculitis
Vasculitis syndromes

42. Vasculitis of central and peripheral vessels of nervous system
Encephalopathy- multiple infarcts
Vasculitic neuropathy

43. Alcohol abuse
Acute alcohol intoxication – decrease of consciousness (euphoria/dysphoria, slurred speech and ataxic gait, stupor  coma)
Ethanol withdrawal syndromes (in dependency) :
tremor, hallucinosis, seizures delirium tremens

44. Chronic alcohol abuse
Wernicke-Korsakoff syndrome - Thiamine deficiency : dementia, amnesia, sometimes with confabulation
Alcoholic cerebellar degeneration
Alcoholic neuropathy, myopathy
head trauma
Complications of head trauma+withdrawal syndromes- „alcoholic” epilepsy