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DR.SRINATH.CHANDRAMANI
Asst.Prof & ICU in-charge
K.J.Somaiya Medical College,
Mumbai
Introduction
Methods of approach
Pathology based approach
Etiology based approach
Anatomical axis based approach
Infective
Vascular
Traumatic
Drug and toxin induced
Degenerative
Neoplastic
Miscellaneous
CNS
Pyramidal System
LMN
Cortex
Sub Cortex
Internal Capsules
Brainstem
Spinal Cord
CORTEX
Altered sensorium
Convulsion
Aphasia
Memory/calculation Impairment
Apraxia
Homonymous hemianopia
Cortical sensation loss
SUBCORTEX
Dementia
Homonymous Hemianopia
Brought in vogue by :
o HIV PML &
o Dementia syndromes
Internal Capsule
Complete Hemiplegia
Dense hemiplegia
Involvement of UMN facial on same side
of Hemiplegia
Brainstem
Crossed Hemiparesis
BRAINSTEM CIRCULATION
A.
Midbrain
Syndromes
B.
C. Pontine
Syndromes
D. Medullary
syndromes
MIDBRAIN SYNDROMES
SYNDROME
SITE
CRANIAL N.
OTHER FEATURES
IPSILATERAL 3RD
NERVE
IPSILATERAL 3RD
NERVE
CONTRALATERAL HEMIPLEGIA
WEBERS
CEREBRAL PEDUNCLE
BENEDICTS
RED NUCLEUS
NOTHNAGELS
SUPERIOR CEREBELLAR
PEDUNCLE
IPSILATERAL 3RD
NERVE
CONTRALATERAL CEREBELLAR
ATAXIA
CLAUDES
RED NUCLEUS +
SUPERIOR CEREBELLAR
PEDUNCLE
IPSILATERAL 3RD
NERVE
CONTRALATERAL TREMOR,
CHOREA, ATHETOSIS &
CEREBELLAR ATAXIA
CONTRALATERAL TREMOR,
CHOREA, ATHETOSIS
PONTINE SYNDROMES
SYNDROME
SITE
FOVILLES
DORSAL
PONS
MILLARD
GUBLER
VENTRAL
PONS
CRANIAL N.
OTHER FEATURES
IPSILATERAL
LATERAL GAZE PALSY,
6TH, 7TH NERVE CONTRALATERAL
HEMIPARESIS
IPSILATERAL
ONLY ABDUCENS PALSY,
7TH. 6TH ONLY
CONTRALATERAL
FASCICLE
HEMIPARESIS
MEDULLARY SYNDROMES
SYNDROME
MEDIAL
MEDULLARY
SYNDROME
LATERAL
MEDULLARY
SYNDROME
CRANIAL
NERVE
Ipsilateral
12TH nerve
OTHER FEATURES
Ipsilateral 5th
nerve
Ipsilateral
fibers of
9th & 10th
nerves
Misc syndromes
Compete Medullary syndrome due to
occlusion of Vertebral artery.
SPINAL CORD
Symmetrical, Bilateral
Root pain, Cord pain, Funicular pain
Radicular pain
Motor + Sensory affection
Bladder/Bowel involvement
Flexor spasms
Clonus
Radicle / Plexus
Symptoms involving nerve root
distribution
Typical presentation
E.g. erbs palsy
Peripheral nerve
Motor /+ sensory
Sensory symptoms
positive/negative
Asymmetrical at onset
Neuro-Muscular junction
Fluctuating motor weakness
E.g. Myasthenia gravis
Muscle
Pure motor
Fasciculations
Atrophy / pseudo-hypertrophy
Involvement in groups
SUMMARY
UPPER MOTOR NEURON
FROM CORTEX TO SPINAL CORD
SPASTICITY / HYPERTONIA
FLACCIDITY/ HYPOTONIA
EXAGERATED DEEP TENDON JERKS DIMINISHED/ABSENT DTR
ABSENT ABDOMINAL REFLEX
PRESENT
EXTENSOR BABINSKIS
NO MUSCLE WASTING
NO FASCICULATION
ABSENT BABINSKIS
WASTING COMMON
FASCICULATION COMMON
Extra-pyramidal system
Accessory nervous system
Controls co-ordination, balance and
fine-tuning of motor movements.
Presents as involuntary movements
MOVEMENT
INTENTION TREMOR
SITE
CEREBELLUM
DESCRIPTION
TREMOR ONLY ON ACTION
RESTING TREMOR
SUBSTANTIA NIGRA
RED NUCLEUS
CORTEX
AT REST ONLY.
ABOLISHED BY ACTION
INTERMITTENT MUSCLE
RELAXATION
HYPERTONIA OF BOTH AGONIST &
ANTAGONIST
SLOW, RHYTMIC MOVEMENTS
ASTEREXIS
RIGIDITY
CHOREA
HEMIBALLISMUS
SUBSTANTIA NIGRA
PUTAMEN
CAUDATE NUCLEUS
SUBTHALAMIC
NUCLEUS
DYSTONIA/ATHETOSIS PUTAMEN
DESCRIPTION
RAPID, RHYTHMIC, SHOCK
LIKE MUSCLE JERKS
CAUSES
IN SLEEP, MYOCLONIC EPILEPSY
FASCICULATION
NON-RHYTMIC MUSCLE
FASCICLE CONTRACTION.
TWICTHING OF SINGLE
MUSCLE FIBRE
DENERVATION
HYPERSENSITIVITY. BEST TONGUE
DESCRIPTION
CONTRACTION OF
BUNDLE OF MUSCLE
FASCICLES
CAUSE
MOST COMMON
INVOLUNTARY
MOVEMENT. EG.
ORBICULARIS OCULI
CHRONIC DENERVATION
WITH RENERVATION. MND.
MINIPOLYMYOCLONUS
TREMOR-LIKE IN SMALL
JOINTS
TITUBATION
TEST 1
CEREBRO-VASCULAR ACCIDENTS
Thrombo-embolic stroke
Hemorrhagic stroke
Small-vessel disease
Intra-cranial hemorrhage
Cerebral venous sinus thrombosis
Sub-archnoid hemorrhage
Transient ischemic attack
Special types Todds paralysis.
CEREBRAL
CIRCULATION
Classification on Territory
involved
Parameter
Age
Onset
Progression
Convulsion
Differences in presentation
Raised ICT
Embolic
Young
Hyperacute
Max at onset
Most
common
Uncommon
Time of event
Treatment
Prognosis
Morning
Self resolving
Excellent
Thrombotic
Old
Step-ladder
Over hours
Rare
Hemorrhagic
Middle age
Acute
Over mins
Occasional
Common
Evenings
Conservative
Poor
Thrombolysis in stroke
CLINICAL FEATURES
PROPTOSIS, PTOSIS, OPTHALMOPLEGIA,
PAPILLEDEMA. OPT.div. 5TH NERVE
SUPERIOR
SAGGITAL SINUS
TRANSVERSE
SINUS
Intracerebral bleed
Hypertension most important risk
factor
Putamen most common site
Subthalamus rarest
Treatment
SAH
8% of all strokes
Rupture of aneurysym most common
cause.
Clinical features
Diagnosis
Treatment
Prognosis
MULTIPLE SCLEROSIS
Paraparesis, Tingling
Multiple Sclerosis
Diagnostic criteria
Types
Neuromyelitis Optica / Devics disease
Treatment
Prognosis
Epilepsy
Partial
Simple, Complex, Secondary generalisation
Generalised
GTC, Absence, Myoclonic epilepsy.
Unclassified
Status epilepticus
Todds Paralysis
Anti-Epileptic agents
Levotiracetam
Phenytoin / Fosphenytoin
Carbamazepine / Oxcarbamazepine
Sodium Valproate
Diazepam/Lorazepam
Phenobarbitone
Vigabratine/ lamotrigine Add-on only
Headache
Primary vs. Secondary headache
Primary Headache :
Migraine-type
Tension-type
Cluster headache
CNS INFECTIONS
Acute Pyogenic Meningitis.
Brain abscess.
TBM
HSV meningoencephalitis
PML JC virus
CJD
Cryptococcal meningitis
Dementia
Progressive memory impairment
Anterograde more common
Alzheimers : Gene defect APP gene,
Presenilin 1
Presenilin 2
Apo-E
Characterised by neurofibrillary tangles.
Most pathology in Nucleus basalis of Meynert.
Drug used is Tetrahydroacramine (Tacrine)
Neuro-regressive disorders
SSPE
Epilepsy
Wilsons disease
Glycogen storage disorders
Halloverden Spatz
Mitochondrial mutations (MELAS)
Treatable Dementia
Test 2
Compressive Myelopathy
All myelopathies are compressive till
otherwise proved !!!
Extradural lesions
Intradural lesions
- Extramedullary
- Intramedullary
Non-compressive myelopathy
Transverse Myelitis
Post-infective phenomenon
Commonly demyelinating, self-limiting.
Campylobacter jejuni, Borrelia, viral ,etc
Progression Plateau Recovery
Treatment : IVIG, Steroids, Plasmapheresis
Prognosis
SCD of cord
Syringomyelia
Commonly congenital
Progresses with growth, but rarely
symptomatic
Dissociate anaesthesia
Cape and Hood type of anaesthesia
Treatment
Prognosis
Peripheral neuropathy
AIDP / GBS
CIDP
SENSORY NEUROPATHY
PURE MOTOR NEUROPATHY
AUTONOMIC NEUROPATHY
MIXED
Subtypes of
GBS
Association
EMG
Treatment
MYASTHENIA
Post-synaptic
F >> M
Young
Diplopia, Ptosis
Anti-AcHr in 80%
Anti MuSK (muscle
specific kinase) in 40-50%
Thymoma
Decremental response
EATON-LAMBERT
Pre-synaptic
M >> F
Elderly
Proximal muscle weakness
Anti-P/Q type
calcium channels
in 85%
Small cell Ca Lung
Incremental response
Anti-Cholinergic,
ImmunoSupressio
Muscle disorders
Muscular Dystrophy
Duchennes
Beckers
Limb Girdle
Facio-Scapulo-humeral
Oculopharyngeal
Muscle disorders
Myopathy
Endocrine, Toxin, etc
Myositis
Dermato/Polymyositis
Inclusion body myositis
Test 3
Parkinsonism
Parkinsonism vs. Parkinsons disease
Triad Bradykinesis
Rigidity
Resting tremor
Huntingtons disease
Freidricks ataxia
Heriditary telengectasia
Sturge Weber syndrome
Histiocytosis
Neurocutaneous syndromes
Neurofibromatosis
Tuberous sclerosis
Sturge Weber syndrome
Spina bifida
Ataxia telengectasia
Neurofibromatosis
Genetic diseases with Autosomal transmission. Presents in 2 forms :
NF-1 (Von Recklinghausen/peripheral NF)
NF-2 (central NF) bilateral acoustic neur
Caf-au-lait spots
Lisch nodules pigmented nodules on iris
Cutaneous Neurofibroma
Skeletal and spinal deformity.
Tuberous Sclerosis
Adenoma sebaceum
Shagreen patch
Ash leaf macules
Manifests as Mental retardation, Seizures,
CNS hamartomas
Ataxia-Telengectasia
Osler-Rendu-Weber syndrome
Multiple AV malformations in the Liver, lung,
CNS and mucous membranes.
Manifests as Progressive ataxia.
Treatment is surgical and temporary.
Prion disease
Prion is the only non-nucleated
pathogen to cause human infections.
It is also called Transmissable
spongiform encephalopathy.
It is unique in the way that the etiology
maybe genetic, sporadic or infectious.
Prion disease
CNS tumours
Most common intracranial tumours in Metastasis.
Most Common tumour to metastasise to the brain Lung Ca
Most common glial tumour - Astrocytoma
Most common site In children - Posterior fossa
Most common CNS tumour to spread
Medulloblastoma
CNS tumours
Cerebellar Hemangioblastoma seen in VonHippel Lindau syndrome
Primary CNS lymphoma is characterised by
being diffuse histiocytic in type. Common in
AIDS patient, Since it is multicentric,
Chemotherapy is definitive treatment.
THANK YOU !