1. Alterations of Neurologic Function
Chapter 15

2. Brain Trauma Major head trauma
A traumatic insult to the brain possibly producing physical, intellectual, emotional, social, and vocational changes
Transportation accidents
Falls
Sports-related event
Violence

3. Brain Trauma Closed (blunt, nonmissile) trauma
Head strikes hard surface or a rapidly moving object strikes the head
The dura remains intact and brain tissues are not exposed to the environment
Causes focal (local) or diffuse (general) brain injuries
Open (penetrating, missile) trauma
Injury breaks the dura and exposes the cranial contents to the environment
Causes primarily focal injuries

4. Brain Trauma Coup injury- impact against an object(front of skull)
Injury directly below the point of impact
Contrecoup- impact within skull( front and back of skull)
Injury on the pole opposite the site of impact
Compound fractures
Basilar skull fracture

5. Brain Trauma

6. Focal Brain Injury Observable brain lesion
Force of impact typically produces contusions
Contusions can cause:
Extradural (epidural) hemorrhages or hematomas bleed between the dura mater , artery is usually the source of bleed, classically loose consciousness at injury,
Subdural hematomas-common in elderly or alcohol abuse, can be acute usually top of skull or chronic
Intracerebral hematomas – most common frontal and temporal lobes and associated with contusions, + bilateral Babinski reflex, ICP increased

7. Hematomas

8. Subdural (Epidural) Hematomas

9. Diffuse Brain Injury Categories: Mild concussion Classical concussion
Mild, moderate, and severe diffuse axonal injuries (DAI)
Shaking
Acceleration/deceleration
Axonal damage
Severity corresponds to the amount of shearing force applied to the brain and brain stem

10. Mild Concussion
Temporary axonal disturbance causing attention and memory deficits but no loss of consciousness
I: confusion, disorientation, and momentary amnesia momentary
II: momentary confusion and retrograde amnesia 5-10 min
III: confusion with retrograde and anterograde amnesia lasting less than 6 hours

11. Classic Cerebral Concussion
Grade IV
Loss of consciousness (<6 hours) reflexes fail, causing falls symptoms disappear after responsiveness returns. Transient breathing stops, bradycardia occurs and BP falls. Vitals quickly stabilize
Anterograde and retrograde amnesia may last for hours to days
Postconcussive syndrome- HZ+A< nervousness, anxiety, irritability, insomnia, depression forgetfulness inability to consentrate

12. Diffuse Axonal Injury
Produces a traumatic coma lasting more than 6 hours because of axonal disruption
Mild –prolong periods of stupor or restlessness
Moderate – unconsciousness for weeks usually permanent memory defect ,Glasgow coma scale 4-8
Posttraumatic antergrade and retrograde amnesia
Severe- ICP appears 4-6 days post injury . Severely Compromised movements, verbal and written communication problems , autonomic dysfunction
Should know DIA consequences p.181
Must look for secondary problems due to brain injury such as changes in neurotransmitters and electrolytes, breaking of blood brain barrier causing IICP

13. Spinal Cord Trauma
Most commonly occurs due to vertebral injuries
Simple fracture, compressed fracture, and comminuted fracture and dislocation ,very common in elderly due to degeneration
Traumatic injury of vertebral and neural tissues as a result of compressing, pulling, or shearing forces , swelling temporarily increases dysfunction
Most common locations: cervical (1, 2, 4-7), and T1-L2 lumbar vertebrae
Locations reflect most mobile portions of vertebral column and the locations where the spinal cord occupies most of the vertebral canal injury worse at the level of injury and below

14. Spinal Cord Trauma

15. Spinal Cord Trauma

16. Spinal Cord Trauma

17. Spinal Cord Trauma

18. Spinal Cord Trauma Spinal shock
Normal activity of the spinal cord ceases at and below the level of injury. Sites lack continuous nervous discharges from the brain.
Complete loss of reflex function (skeletal, bladder, bowel, sexual function, thermal control, and autonomic control) below level of lesion( hypothalamus can not control body heat thru vasoconstriction , now have increased metabolism so patient assumes temperature of surrounding air(poikilothermia)
Cervical spinal injury worse due to injury of diaphragm ( phrenic nerve that exit cord at C3-C5

19. Spinal Cord Trauma Paraplegia Quadriplegia
Autonomic hyperreflexia (dysreflexia) PRIORITY QUESTION
Massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
SS= Increase BP systolic , pounding HA, blurred vision, sweating above level so lesion , skin flushing, nasal congestion, nausea ,poiloerection caused by pilomotor spam and Bradycardia. Often associated with extended bladder and rectum.

20. Autonomic Hyperreflexia

21. Degenerative Disorders of the Spine
Degenerative disk disease (DDD)
Spondylolysis- defect in vertebral lamina
Spondylolisthesis- vetabra slides forward on the vertebra below( 4 grades of anterior slipage)
Spinal stenosis-narrowing of spinal canal causing spinal cord pressure
Low back pain-80% of population
Herniated intervertebral disk most common L4 – S1

22. Cerebrovascular Disorders
Cerebrovascular accident
Leading cause of disability
Third leading cause of death in United States
Classified
Global hypoperfusion- as in shock
Ischemia (thrombotic, embolic)
Hemorrhagic
Know factors who has increase likelihood of having stroke?

23. Cerebrovascular Disorders
Cerebrovascular accidents (CVAs)
Thrombotic stroke
Arterial occlusions caused by thrombi formed in arteries supplying the brain or in the intracranial vessels( atherosclerosis) break off and travel upstream. Causes – dehydration, hypotension, prolonged vasoconstriction
Transient ischemic attacks (TIAs)-temporarily decrease brain blood flow. Brief change in brain function-vision, speech, motor function, dizziness of loss of consciences- neurologic defects disappear in 24 hours
Embolic stroke
Fragments that break from a thrombus formed outside the brain

24. Cerebrovascular Disorders
Embolic stroke
Fragments that break from a thrombus formed outside the brain , heart ,aorta, common carotid. Risk factors MI, aerial fib, endocarditis, Rheumatic Ht. Dz., atria-septal-defect.
Hemorrhagic stroke-hypertension , rupture aneurysms
Lacunar stroke- Smoking, hypertension and DM
Cerebral infarction- brain looses blood supply because of vascular occlusion. Types are ischemic or hemorrhagic
Cerebral hemorrhage- primary cause is hypertension resulting in thickenig of vessels walls

25. Cerebrovascular Disorders
Clinical manifestations
Excruciating HA . Weakness, transient numbness and tingling transient speech disturbance
Signs- hemiparesis/paralysis, dysphasia, homonymous hemianopsia(Same side of stroke eye blindness)

26. Cerebrovascular Disorders
Intracranial aneurysm
Congenital
Diffuse arteriosclerotic changes

27. Intracranial Aneurysm

28. Cerebrovascular Disorders
Subarachnoid hemorrhage
Blood escapes from defective or injured vasculature into the subarachnoid space
Manifestations
Kernig sign- in sitting position have patient straighten knee , if has pain in neck and back = +
Brudzinski sign- passive neck flexion produces pain and rigidity

29. Infection and Inflammation of the CNS
Meningitis
Bacterial meningitis
Aseptic (viral, nonpurulent, lymphocytic) meningitis
Fungal meningitis
Tubercular (TB) meningitis

30. Infection and Inflammation of the CNS
Encephalitis
Acute febrile illness, usually of viral origin with nervous system involvement
Most common forms of encephalitis are caused by arthropod-borne viruses and herpes simplex virus

31. Neurologic Complications of AIDS
Human immunodeficiency-associated cognitive dysfunction
HIV myelopathy
HIV neuropathy
Aseptic viral meningitis
Opportunistic infections
CNS neoplasms

32. Demyelinating Disorders
Multiple sclerosis (MS)- autoimmune disorder. Onset yrs old
MS is a progressive, inflammatory, demyelinating axon disorder of the CNS- spares peripheral nervous system. Has exacerbations and remissions. Starts on one side of body, loss of strength and grip, diplopia, hyper-reflexia foot drag and stumbling. Lhermitte sign- shocking and tingling sensations. Heat and increase serum Ca+ bring on symptoms
MRI definitive test
All motor function eventfully lost
Amyotrophic lateral sclerosis (ALS)- muscle wasting Dz,
Onset 4—50 ys. Can be familiar. Classic bulbar palsy and muscular atrophy

33. Peripheral Nervous System Disorders
Amyotrophic lateral sclerosis (ALS)
Classic ALS—“Lou Gehrig disease”
Diffusely affects upper and lower motor neurons of the cerebral cortex, brain stem, and spinal cord (corticospinal tracts and anterior roots)
Disease leads to progressive weakness leading to respiratory failure and death
Patient has normal intellectual and sensory function until death

34. Peripheral Nervous System Disorders
Neuropathies
Generalized symmetrical polyneuropathies
Distal axonal polyneuropathy
Demyelinating polyneuropathy
Generalized neuropathies
Sensory neuropathies
Focal or multifocal neuropathies

35. Peripheral Nervous System Disorders
Guillain-Barré syndrome
Acquired inflammatory disease causing demyelination of the peripheral nerves with relative sparing of axons
Acute onset, ascending motor paralysis
Humoral and cellular immunologic reaction

36. Peripheral Nervous System Disorders
Myopathies-
Primary muscle disorder
Marked weakness
Symmetrical and proximal Radiculopathies
Radiculitis- sciatica , herpes zoster
Inflammation of the spinal nerve roots
Radicular pain – following dermatome pattern
Plexus injures- cCrvical C1-5. Brachial C6-8, Lumbar T12- S2
Involves the nerve plexus distal to the spinal roots but proximal to the formation of the peripheral nerves

37. Neuromuscular Junction Disorders
Myasthenia gravis
Chronic autoimmune disease . Nerve impulse transmission to neuromuscular junction is interrupted
Muscle weakness and fatigue of muscles of the eyes and the throat causing diplopia, difficulty chewing, talking, swallowing

38. Central Nervous System Tumors
Cranial tumors
Spinal cord tumors