balamurugan neuro diagnostic

8/14/2019 Balamurugan Neuro Diagnostic

http://slidepdf.com/reader/full/balamurugan-neuro-diagnostic 1/103

Neuro-diagnostic

procedure



Uses :As an adjunct to a complete clinical

examination. To evaluate the effectiveness of

various treatment modalities.



1.History /physical examination2.Radiographic studies

skull radiography• Spine radiography• Computed tomography• Magnetic resonance imaging• Cerebral angiography• Myelography



3.Cerebro spinal fluid evaluation4.Biophysical studies•

Carotid Doppler imaging• Transcranial Doppler imaging5.Electrophysiologic studies• Electro encephalography

• Electromyography• Evoked potential studies



6.Nuclear medicine testingPositron emission tomography

7.Special sense testingCaloric testingAudiometric studiesVisual field testing



HistoryPhysical examination

Cerebral function testCranial nerve testMotor function test

Sensory function test



Now a days very rare

because of CT .Findings Presence of fracture Displacement of

pineal body

Sinuses Hematomas



Radiography of specific region of spine areusually ordered in traumatised patients

Usually AP,oblique,and lateral views are ordered

FindingsVertebral fracture Traumatic dislocationSublaxationCollapsed vertebra,scoliosis,spondylosis



Patient preparationHelp to reduce anxiety

Neck stabilization with cervical collarin case of suspected injury

Patient mouth open for C1 andC2Downward traction of arms for C6

andC7Flexion and extension views



Post procedure care Immobilization

Patient neurologic status should bereassessed



It uses a narrow X-ray beams to scan thehead in successive layer

The images provide cross sectional views

of brain with distinguishing difference intissue density of skull, cortex, sub corticalstructure and ventricles.

The patient lies on a table and moved in

and out of a dougnut like device calledgantry The image is photographed and stored

digitally



Can be done with contrast or plain CT IndicationDetect brain infection like abscessDetect ventricular enlargementDetermine any tumourDetermine multiple sclerosis

Determine the size and location of lesioncausing a stroke



Differentiate among hematomaContra indication

Patient allergic to shell fish oriodinated dyePatients who are claustrophobicPatients who are pregnantPatient with dehydration



Pre procedure Inform and consentObtain history of allergiesRecord the date of last menstrual period

Obtain list of medication in useExplain about duration 30-60 minutes

explain about insertion of IV line Inform about experience of nausea

,feeling of warmth, a salty metallic tasteor transient headache



Instruct the patient to remove jewellery,dentures etc

Intra testEnsure that the patient has compiled

with pretesting preparationHave emergency equipment readily

available administer orderedprophylactic steroids or anti histaminebefore procedure



Instruct the patient to cooperate and remainstill throughout the procedure

Establish an IV line

Administer anti anxiety drug when necessary If contrast medium is used contrast medium

is injected and a rapid series of images aretaken during and after filling of the vessel



Post testMonitor for complication

Remove needle and apply pressureRenal function should be evaluatedMonitor vital signs and neurologic

function Instruct patient to increase fluid

intake



Magnetic resonance imaging uses amagnet and radio waves to produce

a energy fields that can be displayedon an imageUse of magnetic fields with the aid of

radiofrequency energy produces

images primarily based on watercontent of tissue



MRI produces cross sectional imagesof pathologic lesion of the brain in

multiple planes without the use of ionising radiationMRI can be done with contrast or

without a contrast agent



IndicationLocate brain tumour

Detect cause of CVAEvaluate cerebral changesassociated with dementia

Evaluate demylenating disorderEvaluate intracranial infection



Evaluate optic and auditory nerve evaluate the potential cause of

headache ,vomiting, visual lossEvaluate the vascularity of the brain



Contra indicationPatient with metal prosthesis

, valves, aneurysm clips, ortho pedichard ware and other metallic objectsPatients with pace maker, cochlear

implantsPatients with IUD patients who are claustrophobic



Preprocedure Inform and consent

Obtain history of allergic agentsObtain history of any implants Inform about duration of procedure

usually 30-60 minutes

Inform patient that he will be placedin supine position on a flat table in alarge cylindrical scanner



Tell patient to expect to hear loudbanging from the scanner and flickeringlight in the visual field

Explain that an IV line may be inserted instruct the patient to remove

dentures, jewellery including watches,

hairpins, credit card and other metallicobjects



Intra testEnsure that the patient has removed all

metallic objects prior to procedureHave emergency equipment readily availableAdminister prophylactic steroids or

antihistamine before the procedurePatient are given a gown and instructed to

void before the procedure Instruct the patient to remain still during the

procedure



Supply ear plugs to patient to block out theloud , banging sound that occur during thetest

The patient can communicate with thetechnologist with he microphone attached

establish IV lineAdminister anti anxiety drugs

Contrast medium are injected and series of images are taken



Post testObserve for delayed allergic reaction

Instruct the patient to reportimmediately symptoms like fastheart rate, difficulty breathing, skinrash, decreased urine output



It is an X-ray study of cerebralcirculation with a contrast agentinjected into selected artery

IndicationVascular aneurysmArteriovenous malformation

Before craniotomyVascular blockage or other disruption



Contra indicationPatients with allergic to shell fish or

iodinated dyePatient with bleeding disorder patient who are pregnant dehydrated patients renal failure



Pre procedure Inform and consentObtain history of allergic agentsRecord the date of menstrual periodsObtain list of medication patient is

taking to affect bleeding

Review the procedure with he patientExplain about symptoms experienced

during contrast agent



Intra testEnsure the patient is compiled with all

necessary restrictionHave emergency equipment availableEstablish IV line The location of appropriate peripheral

pulses are done Instruct patient to remain still during

procedure



Encourage to increase fluid intake ice packs to be applied to reduce

edema Immobilise extremity for 6-8 hoursObserve for delayed reaction of dye



Lumbar puncture is a procedure thatinvolves the introduction of a hallow

needle and stylet between twovertebrae into sub arachnoid space of the lumbar part of of the spinal canal

below the level of spinal cordPurposeDiagnostic Therapeutic



IndicationCSF measurementWith drawl of CSF to reduce Increased

ICPEvaluation of canal for the presence of

of CSF blockage or tumour

Evaluation of signs of haemorrhageLab analysis of CSF for infection Therapeutic administration of drugFor spinal anaesthesia



Pre procedure Inform and consent

review the procedure with thepatientNo dietary restriction is requiredBase line neurologic examination Inform patient about the position Inform to void



position on one side of edge of bed wth backfacing towards physician ,thighs ang legs flexedas much as possible

Pillow is placed under patient head to maintainthe spine in horizontal position The nurse must assist in maintaining position The area of L4-L5 is prepared with iodine or

alcohol and covered with sterile drapes



a imaginary line is drawn from tip of illiac crest to help locate site

Aesthetic agent is injected ,afterwhich a spinal needle with obturatoris inserted below fourth lumbarvertebrae



Once the physician feels that the needle is insubarachnoid space the obturator is removed

Collect CSF in 3 vials separately

If pressure is to be measured a sterilemanometer is attached to spinal needle

Queckenstedt’ s testPost test

Apply pressure to the area for severalminutes and put a a sterile covering



Some physician prefer patient onprone with a pillow in abdomen

Encourage intake of fluid and keeptheir head flat foe several hoursMonitor for vital signsActivity restricted for 6-8 hours



Electroencephalography It is a non invasive study that

measures the brain activity andrecords that activity on a graph

Electrodes placed at 8-20 sites onthe patient scalp transmit different

frequency and amplitude of the brainelectrical activity to the EEG

machine



IndicationDetect seizure activity and focusConfirm brain deathDetect cerebral ischemia during

endartectomyDetect intracranial cerebrovascular

lesionDetermine the presence of tumour evaluate sleep apnoea



Inform and reassureObtain medication histroyExplain about the duration30-60

minutes and even days in VEEG Inform patient that he or she may be

asked to alter breathing, follow simple

commands like opening , closing,blinking or swallowing, stimulated withbright light or given drug to inducesleep



Instuct patient to clean the hair and torefrain from using any hair spray

under medical supervision the patient

should avoid sedative,anticonvulsant,anxiolytics alcohol, andstimulants such as caffeine and nicotine

for 24 to 48 hours before the test Instruct patient to limit sleep to 5 hours

for adult and 7 hours for child the nightbefore the study



Intra testEnsure pre procedure instruction are

followed

Ensure that the patient is able to relaxplace patient in supine position or in semi

recumbent position on a recliner in a specialroom protected from any noise or electrical

interference that could affect tracing



Remind patient to relax and not to moveany muscle or parts of the face or head.

The eletrode are applied to scalp over

frontal,temporal,parietal and occipital lobeRecordings are made with the patientrest,drowsy,and sleep period based onpatient clinical condition

Procedures eg. Light stimulation,hyperventilation and sleep induction aredone



Observation of seizure activity are carriedout during the study and description andtime of activity is noted by the technician

Post testClean the hairsAllow patient to recover from sleep, bed side

rails are put in the raised position for safety

Resume medication as ordered



It measures the skeletal muscle activityduring rest, voluntary contraction andelectrical stimulation

Per cutaneous extracellular needleelectrode containing fine wires areinserted into selected muscle group to

detect neuromuscular abnormality andmeasure nerve and electricalconduction property of skeletal muscle



Comparison and analysis of theamplitude ,duration, number andconfiguration of the muscle activityprovide diagnostic information aboutextent of nerve or muscleinvolvement in the detection of

primary muscle disease, includinglower motor neuron, anterior horncell, or neuro muscular junction



Detect muscle disorder caused bydisease of lower motor neuroninvolving the nerve root such asgullian barre syndrome

Detect neuromuscular disorder likeperipheral neuropathy etc



ContraindicationExtensive skin infectionPatients with anti coagulant therapy



Intra test ensure that the patient has refrained from

smoking and drinking caffeine containing

beverages for 3 hours before the procedure have patient remove clothing, patients are givena gown to wear and instructed to void beforeprocedure

Ask patient to remain still and relaxed and to

cooperate with instruction



Administer mild analgesic asordered to promote a restful statebefore the procedure

Cleanse skin with alcohol, thenectrode are applied to the skin

During the test muscle activity is

tested while the patient is at est andduring varying degree of musclecontraction



Post testRemove electrodeMonitor electrode site fir bleeding

hematomaMild analgesic and warm compress

are applied



It is a physiological studies performed tomeasure the brain electrical response tovarious visual, auditory and somato

sensory stimuli. EP studies help diagnoselesion of the nervous system by evaluatingthe integrity of visual, sensory and auditorynerve path ways

Three responses are measured visual evoked

response, auditory brainstem response,and somato sensory evoked response



IndicationVERDetect retro bulbar neuritis detect lesion of optic nerve evaluate optic pathway lesion and

visual cortex defectsABRDetect abnormality in brain stem or

auditory nerve areas



detect acoustic neuromaSERDetect multiple sclerosis and

gullianbarre syndromeDetect sensorimotor neuropathy and

cervical pathologies

Evaluate spinal cord and brain injuryand function



Pre-test informReview the procedure with the

patientExplain the duration of procedure

30-2 hours instruct the patient to

clean the hairs and refrain fromusing any spray

No food restriction



Intra testEnsure the patient is able to relax In VERpatient in comfortable position

about 1 meter from the stimulationsource attach electrode to theoccipital area. A light emitting

stimulation is provided



In AER electrode are placed in scalp atvertex lobe area on each ear lobe. Earphone are placed in patients ears and a

clicking noise stimulus is delivered In SER electrodes are placed at nerve

sites of wrist,knee, and ankle

Post testRemove electrode and clean skin



Positron emission tomography It combines the biochemical properties

of nuclear medicine with the accuracy

of computed tomographyPET uses specific nucleotide to produce

functional images of bodyAfter the radio nucleotide becomes

concentrated in brain, PET images of blood flow or metabolic process atcellular level can be obtained



Commonly used radio nucleotide areflourine-18 in the form of flurodeoxyglucose, it is a glucose

analogue IndicationDetect parkinsons disease, huntingtons

diseaseDetermine the biochemical activity of the brain

Evaluate Alzheimer's disease



Identify focal seizureContraindicationPregnancyPreprocedure InformObtain history of allergic agent

Review the procedure and explainabout the duration of the procedureusually 60-120 mt



The patient should restrict food for 4hours; restrict alcohol, nicotine andcaffeine containing foods

Intratest Ensure the patient is compiled with

dietary regimen

Patient are given gown , foot coveringand instructed to void before theprocedure



Instruct he patient to cooperate andremain still during the procedure

After radio nucleotide is injectedimages are taken after 30 minutes

The patient may be asked to performdifferent cognitive activities like

reading to measure changes in brainactivity



The patient may be blindfolded orasked to use earplug to decreaseauditory and visual stimuli

Wear glove during injection and patientexcretaMonitor for any complicationPost test

Advise patient to report symptoms likefast heart rate, difficult breathing, skinrash, decreased urine output



Instruct the patient to take increasedamount of water to increase theelimination of radio nucleotide

Instruct all care giver to wear glovefor 24 hour



Carotid Doppler imaging It provides a non-invasive means for

monitoring intracranial

hemodynamic at bedsideDoppler imaging uses ultrasonic

technology to provide information

about patency of the carotid arteryUsed to assess the location and

extent of plaque and flow velocity



Trans cranial Doppler It uses the same non-invasive

technique as carotid flow studiesexcept that it records the blood flowvelocities of intracranial vessel

Flow velocities of basal artery can be

measured through thin areas of temporal and occipital bones of theskull



indication TIAs related to arteriostenosis or

with atherosclerosisCerebro vascular diseaseVasospasm secondary to

subarachnoid haemorrhage ,

following aneurysm clippingNursing implication Inform and educate



Caloric testing for vestibular function It is used to evaluate the vestibular part of

eighth cranial nerve by irrigating auditory

canal with warm or cold water.Normal finding include rotatary nystagmus

away from the side being irrigated withcold water. Hot water conversely induces

nystagmus toward the side being irrigated



In abnormal test result no nystagmus is produced.

Contra indicated in perforated ear drumPreprocedure Inform and explainNPO before 6-8 hours before the procedurePost procedure The patient should lie down until untoward

effects such as nausea, vertigo, resume diet.



Audiometric studies Individual with injury to auditory branch of

eighth cranial nerve or hearing loss may be

reffered for a routine battery of audiologicstudies. The test include voice, tuning fork, a ticking

watch and a electronic audiometer to assess

the hearing loss.



Visual field testing It is used to evaluate peripheral vision.Gross visual field testing may be performed

by means of confrontationFor more precise testing visual field are

evaluated by perimeter It is used to detect lesion of the retina or

optic nerve and hemianopia caused bycompression of optic tract



UsesVarious classificationRadiographic studies

Cerebrospinal fluid analysisNuclear medicine testingBiophysical methodsElectrophysiological methodsspecial sense testing



Thank you

balamurugan neuro diagnostic

Documents