Investigation of CNS

.After finishing the history and the clinical

examination, hoping to answer the 2
questions of the path. & the site of the
lesion.
.Sometimes it is difficult to arrive at a definite
diagnosis.
.A provisional diagnosis is given and we
restore to some accessory methods of
investigations, to reach final and definite
diagnosis.
#adiography:
The skull:
.Plain radiography
.Contrast radiography :
-Digital subtraction angiography
-Cerebral angiography
The Spine
.Plain radiography
.Contrast radiography
-Myelography
-Myeloscan
. occipital - AP, lat., fronto Plain skull radiography
1- Size and shape of the skull and state sutures
a)-Might show microcephaly, hydrocephaly
b)-Might show separation of sutures or craniosynostosis.
- Abnormalities in the bones
a) Generalized changes
Thickening: as in Paget disease.
Thinning: ( finger printing) due to CP.
b) Vascular markings of the vault : due to meningeal
arteries.
c) Local erosions of the bone : in meningioma, acoustic
neuroma.
d) Changes in sella turcica (12 mm in length, 10 mm in
depth)
by an intrasellar tumor. : allooning
erosion of the clinoid processes and lattening due to. :
dorsum sella by either a tumor above sella or by down
word pressure of floor of the 3
rd
. ventricle.
- Intracranial calcification:
Normal calcifications ( pineal body, dura mater, choroid
plexus).
Pathological calcifications:
: gliomas, meningioma, craniopharyngioma. Tumor - a
: Aneurysm, Angioma, Ch. haematoma. Vascular lesions - b
: Tuberculoma, cysticercosis, Toxoplasmosis. Infections - c
calcification. : Hypoparathyrodism metabolic disorder - d
: Tuberous sclerosis. Miscellaneous - e
- Displacement of midline structures
the pineal body and flax cerebri if calcified may be
displaced to the opposite side by S.O.L.
Cerebral Angiography
To visualize the cerebral blood vessels by injecting a radio
opaque substance (usually iodine based), by
catheterization.
Indications:
1- Vascular abnormalities:
a)- Aneurysm, angioma (A-V) and tumors with
hypervascularities (glioma, meningioma)
b)- Arterial occlusion.
c)- subdural haematoma cause avascular area by pushing
vessels.
- Avascular tumors: by
a) Displacement of the cerebral arteries
b) Producing an area strikingly devoid of vessels.
Complication:
The dye is irritating damage to the endothelium of the
capillaries edema& punctuate hemorrhage
convulsions and hemiplegia or even death.
Digital subtraction angiography
.Less invasive way of demonstrating
cerebral vasculature by computer
enhancing techniques.
.The contrast is injected either by central
venous bolus or a low dose arterial
injection
. with V is less risk than angiography.
.t is used to exclude a major stenosis of
cervical carotid and vertebral arteries.
The spine
Plain or contrast, the latter could be either myelography or
myeloscan.
( AP, lateral ,oblique ) PIain spine radiography
1- Vertebral body - body texture (e.g. Potts disease ,
metastasis, angiomatosis)
-The vertebral margins (sclerosis or
osteophyte formation)
2. The pedicles : the interpedicular distance which indicate
the transverse diameter of the spinal canal .
3. The intervertebral foramen : in the oblique views either :
- Narrow ( spondylosis )
- Wide ( nerve root tumor, neurofibromatosis)
yelography
-Lumbar puncture , cervical puncture or cisterna
puncture
-n this method visualization of the spinal sub
arachnoid space is made by injection of an
opaque substance through L.P ( to see spinal
cord and roots)
Indication:
t is useful when a lesion producing sub arachnoid
block is suspected ( tumor , disc protrusion or
arachnoiditis )
Complication:
.Aseptic irritation of the meninges and nerve roots
pain (headache)
.An arachnioditis or meningitis , muscle spasm,
seizures
Computerized axial tomography (CAT scan)
.Simple, safe, give a series of pictures through the head
.Non invasive methods
.The method is very sensitive and will show the normal
outlines of the brain, cerebral ventricles & CSF spaces
.After i.v contrast injection -->to see large blood vessels.
.CT demonstrate : cerebral hemorrhage , tumors , cysts , &
abscesses. Also hydrocephalus ,cerebral atrophy ,
infarction ,subdural hematomas
.Can distinguish bet. nfarct. & hemorrhage.
.Less useful to see the brain stem ,cerebellum& spinal cord
but with modifications of the technique, can be
demonstrated, and also can identify brain edema.
.Spinal CT scanning is used increasingly to outline disc
protrusions , spinal canal stenosis & intramedullary
lesions.
agnetic #esonance Imaging (#I, #A)
.This is another break through in the field of imaging after CAT .
.t is advantage over the CAT is that no radiation ( X-ray), are used .
.t is very expensive used the protons of hydrogen atom of tissues
which altered by magnetic field
.t is sensitive to difference bet. grey & white matter and show
demyelination (M.S)
.Good images for posterior fossa (cerebellum, brainstem), spinal cord.
.Multiple directions, axial, coronal, and sagittal images can be
generated without changes the pt. orientation.
.nitial axial image sequences routinely include T1, T2, FLA#, and
DW.
.Magnetic resonance angiography (M#A) has revolutionized
visualization of cerebrovasculature by providing a noninvasive
means of imagine large and medium-sized intracranial blood
vessels.
.A complementary technique, magnetic resonance venography (M#V)
images dura venous sinuses and other components of the
intracranial venous system.
ncephalopathy - cho
.On direction of ultrasound through the skull by an
ultrasonic probe ,it will reflected from the skull
walls , ventricles and structures in between them
.Echo carotid study
Transcranial Doppler Sonography
.TCD is now an accepted tool for measuring
physiologic parameters of blood flow in the major
intracranial arteries and for evaluating several
intracranial vascular pathologic process.
.t can display occlusion of the MCA trunk if not its
branches, of the ACA, and, less easily, of the
basilar and PCA.
lectroencephalography (G) & rain mapping
To record the electrical activity of the brain by means of
electrodes on the scalp.
I- rain waves seen under normal condition
1. Frequency:
Delta < 4/sec. can arise from all cortical area
Theta 4-6/sec. arise mainly from temporal cortex
Alpha 7-13/sec. arise mainly from occipital cortex
Beta > 13/sec. arise mainly from frontal & central cortex
2. Amplitude : it varies from 10-300 mic/v
II- rain waves seen under abnormal (Path.) conditions.
It helps us in
.The diagnosis of epilepsy : ctal & interictal changes ..
.The localization of cerebral cortical lesions.
: three types pathological waves are of
:indicates an irritative cortical lesion #apid waves
(epileptogenic focus), they are episodic, single
or in groups and of 2 main types:
.$pikes: monophasic or biphasic, the duration is
0.03sec.
.$harp waves: the same characters as the spike but of
longer duration.
: Delta and Theta may occur either in: Slow waves
.Episodes and this is seen in epilepsy.
.Constant: seen in destructive cortical lesion (neoplasm,
vascular or inflammatory
Slow wave and spike complexes:
Usually bilateral, generalized and episodic. seen in
cases of petit mal and some cases of grand mal and
myoclonic epilepsy.
:
.Hyperventilation, photic stimuli, sleep and drug
are used.
.#ecord EEG from ambulant patient for 24hrs or
longer also used.
.Video-monitoring of the patient and his EEG
simultaneously used.
.40% with clinical epilepsy may have normal
routine EEG.
.Abnormal EEG record doesn't establish a
diagnosis of epilepsy in the absence of
appropriate history.
.n the patient with severe epilepsy, intracranial
electrodes may be used to identify an epileptic
focus (for resection).
voked Potential #ecording
.t record very small cerebral or spinal event related potentials.
.Stimulation of sense organs or peripheral nerves evokes a response in
the appropriate cortical receptive areas and number of subcortical
relay stations as well.
Visual voked Potential (VP):
.light stimulate occipital lobes and are recorded with an array of scalp
electrodes over occipital region.
.Lesions of the retina, optic nerve, chiasma, tract, radiation of cortex
may all disrupt or delay the response.
.A delay VEP in patient with clinically normal vision (MS)
Auditory voked Potentials (AP):
t is sensitive means of detecting lesions of 8
th
. cranial nerve (acoustic
neuroma and other tumors of cerebello-pontine angle) and the
auditory pathways of brain stem also used in M.S
Somatosensory voked Potentials (SSP):
To confirm lesion in the somatic sensory systems
.Ulnar nerve for upper limb (recording the evoked potentials, in brachial
plexuses, cervical spine and contra lateral parietal area).
.SSEP less useful than VEP for detecting subclinical demyelination
.t can help in lesions of brachial plexus, spinal roots and cord.
lectromyography (G, NCV)
.To study muscle and nerve action potential.
.Electrical stimulation of peripheral nerves--
compound action potentials.
.t is used for diagnosis of muscle diseases,
nerve diseases and neuromuscular
junction disease (myasthenia gravis).
.Motor NCV test and sensory NCV test.
xamination of Cerebrospinal luid (CS)
t is done by (L. P.) lumber puncture, occasionally
cisternal p.
.Therapeutic
Drugs
Decrease the pressure
.Diagnosis
: ndications for C$ examination
.nfections: meningitis and encephalitis.
.Sub arachnoid Hemorrhage: if C.T. scan negative or unavailable.
.nflammatory conditions: MS (multiple sclerosis), sarcoidosis, acute
polyneuritis, systemic lupus erythromatus (SLE) and $.
nfiltrative conditions: carcinomatous meningitis, lymphoma, leukemia.
.To confirm raised intracranial pressure (CP) when C.T. scan excludes
danger of brain stem herniation: benign intracranial hypertension
(BH), cerebral venous thrombosis.
.Administration of drugs (antibiotics in meningitis, anti mitotic as
oncology).
.nstillation of contrast media or isotopes: Myelography, cisternography.
Condition under which L.P. is not
- performed:
.Depressed consciousness especially if focal
neurological signs present.
.Papilloedema.
Preparation for L. P. and cisternal P.
.Funduscopy.
.Between L3 L4 and in cistern.
M. S.
multiple
sclerosis
Viral
meningitis
Tuberculous
meningitis
Pyogenic
meningitis
Subarachnoid
hemorrhage
Normal Criteria
Normal Normal
Normal /
increased
Normal /
Increased
increased
50 180
mm CSF
pressure
Clear Clear Clear / cloudy Cloudy
Blood stain
xanthochromia
Clear Color
Lymphocyte
0 10
Lymphocyte
10 -- 2000
Lymphocytes
50 -- 5000
Polymorph
1000
50.000
Increase RBCs
0
4/mm
3
Cell count
Normal Normal Decreased Decreased Normal
2/3 blood
level
Glucose
Normal /
increased
Normal /
increased
Increased Increased Increased
< 500
mg/L
Protein
Increased -- --
Not
routinely
measured
-- < 13
IgG/ total
protein.
Increased -- --
Not
routinely
measured
-- < 0.45 IgG index
Present -- --
Not
routinely
measured
-- Absent
Oligoclonal
IgG band
Sterile
Sometime
viruses
Organism on
ZN stain
culture
Organism
on gram
stain and
culture
Sterile sterile Microbiology
C$ parameters in heaIth and some common disorders}
iochemical Test
Tests of muscle breakdown:
.Enzyme released from muscles increase in
concentration in blood in muscle diseases
(Active polymyositis, muscular dystrophy)
.The most commonly measured are:
1) creatinine phosphokinase (CPK), aldolase and
2) lactate dehydrogenase (LDH)
Neurogenetics
-Patterns of inheritance
-Chromosomes and genes
-Mitochondrial and genes
-DNA analysis and gene mapping and linkage
analysis.
uscle and Nerve iopsy
.Histological examination, enzyme
histochemistery and electron microscopy
may be helpful in defining with type of
muscles of nerve fibers is affected.
e.g. any inflammation, excess glycogen, lipid
amyloid)