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Department of Neurology
• 1st semester
– 15 lectures
– 5x2 hours practices
+ 1 week block practice
11-14. weeks
• 2nd semester
– 10 lectures
– 5x2 hours practices
Suggested readings: Lectures Selected topics of Neurology Neurology and Neurosurgery Illustrated
Homepage: different !!! http://www.neurology.dote.hu/ Participation on the lectures is strongly recommended!!! Competition questions are based on the lectures!!! Exam at the end of the 1st and 2nd semesters of the 5th year: test exam (grade is offerred for the best students by the result of the competition) Exam at the 6th year FOR EVERYBODY: - Minimum questions (computer) - Practical exam - Oral exam
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Main neurological diseases • Stroke • Epilepsy • Headaches, pain syndromes • Vertigo • Tumors of the nervous system • Extrapyramidal diseases (e.g.: Parkinson’s disease) • Demyelinating diseases (MS) • Dementias (e.g. Alzheimer’s disease) • Diseases of the peripheral nerves • Neuromuscular diseases (e.g. Myasthenia gravis) • Infectious diseases (meningitis, encephalitis) • Head traumas • Disorders of spinal cord, roots… (e.g.: disc hernia)
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Neurological examination
• History • Inspection (see, smell, hear), palpation,
auscultation • Examination of
– meningeal signs – cranial nerves (I-XII) – motor system (muscle bulk, tone, power) – sensory system – reflexes (pathological and physiological reflexes) – co-ordination, cerebellum – speech – conscious state – + short psychiatric examination
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Nervous system
• Central nervous system
– brain
– spinal cord
• Peripheral nervous system
– lower motor neuron – anterior radix – peripheral nerve – NMJ – muscle
– sensory receptors – peripheral nerve – posterior radix – sensory ganglion
INTRODUCTION
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Neurological examination
• Aim: – to localize the lesion
• central or peripheral – brain or spinal cord, if central
– motor or sensory neuron, radix, plexus, nerve, NMJ, or muscle, if peripheral
– to determine if one lesion may cause the symptoms
– to determine the damaged system (motor, sensory, vegetative or mixed)
– to find the etiology
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After localizing the lesion, different investigations may confirm our suspicion regarding the location
and etiology...
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Investigations in neurological practice
• CT, MRI
• CTA, MRA, DSA
• CSF sampling, CSF analysis
• ENG, EMG, repetitive stimulation
• EEG
• Evoked potentials
• Duplex ultrasound and transcranial Doppler
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1919-2004
Nobel prize in 1979
Sir Godfrey N. Hounsfield
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CT (native or post-contrast) Lesion can be hypodense, isodense, or hyperdense
Calcified pineal gland
Calcified chorioid plexus
Bone
hyperdens
+blood, metal contrast material
hypodens: air, water, CSF, fat
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Hypodensities on CT Air CSF Ischemic lesion
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Importance of CT in stroke
Similar symptoms of hemorrhagic and ischemic strokes!!! The 2 main types of stroke cannot be differentiated only by symptoms!
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CT in stroke
• There is no visible hypodensity in the hyperacute phase of ischemic stroke
• In cerebral hemorrhage, the hyperdensity can be seen immediately
In hyperacute stroke, the CT is suitable to exclude cerebral hemorrhage!!!
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Consequence of MCAO
Ischemic stroke Infarction Emollition
Ischemic stroke
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CT-angiography (contrast material in the vessels)
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Consequences of head traumas • Cerebral concussion (neg. CT)
• Cerebral contusion
• Subdural hematoma
• Epidural hematoma
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Oedema on CT
CYTOTOXIC OEDEMA Cell swelling
Intracellular edema Grey-white matter margin lost
Treatment: osmotic dehydration (Mannitol)
VASOGENIC OEDEMA Increased permeabilty of capillaries
Extracellular edema Grey matter is preserved finger-like oedema Treatment: stabilisation of capillary permeabilty
(steroid – dexamethason)
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Contraindications of CT
• Pregnancy
• Hypersensitivity to iodine (contrast agent) native CT can be performed
Relative contraindication
• Young age/radiation exposure
• Renal insufficiency
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Radiation hazard
Number of chest x ray for equivalent effective dose
20x
80x
100-200x
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CT-MR examinations CT
• Ionizing radiation
• Not suggested in pregnancy .
• Worse resolution
• Not suitable for examination of spinal cord and MS
• Simple
• Lasts for seconds/minutes (good for confused pts too)
• No claustrophobia
• Better for hemorrhagic stroke
• Better for bones
• Metals do not limit the CT .
MR
• No ionizing radiation
• Not suggested in pregnancy, but if necessary, can be performed
• Better resolution
• Good for examination of spinal cord, and MS!!!
• Complicated
• Lasts for more than 10 minutes (not suitable for confused pts)
• Claustrophobia may limit the MR
• Worse for hemorrhagic stroke
• Metals limit the MR (pacemaker,…) MR compatible life support equipment is necessary
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The tissue and imaging characteristics are a lot more complicated in MR images than in case of CT. There are several sequences. Each sequence has to be acquired separately, which means that an MRI will take a lot
longer to perform than a CT.
MRI planes
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MRI sequences
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MRI: not density, but intensity! E.g. CSF is hyperintense on T2WI
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Diffusion weighted image in acute ischemic stroke
Positive already minutes after the onset of ischemic stroke
FLAIR is positive about 3 hours after the onset of ischemic stroke
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MRI in multiple sclerosis (MS)
CT is not suitable in MS Do not order CT
in suspicion of MS
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Flow voiding
Normal flow-related signal loss
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MRA - aneurysms
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CONTRAINDICATIONS TO MRI
● Implanted devices and other metallic devices - Pacemakers and other implanted electronic devices - Aneurysm clips and other magnetizable materials - Cochlear implants - Some artificial heart valves ● Intraocular metallic foreign bodies - Screening CT of the orbits if history suggests possible metallic foreign body in the eye ● Unstable patients (most resuscitation equipment cannot be brought into the scanning room) ● Pregnancy (relative contraindication due to unknown effects on the fetus) ● Other – severe agitation, or claustrophobia (may require anesthesia assistance)
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Digital subtraction agiography
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CSF sampling
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Characteristics of CSF
CSF Lumbar puncture Cisternal puncture
Colour Clear, colourless Clear, colourless
Number of cells
1-4/mm3 1-2/mm3
Protein content
0.2-0.5 g/L 0.1-0.2 g/L
Glucose level 2/3 of the serum glucose 2/3 of the serum glucose
Pressure positive negative
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Meningitis - CSF
Bacterial meningitis
>1000 cells/mm3
mostly leukocytes
glucose: decreased
protein: increased
Viral meningitis
<1000 cells/mm3
mostly lymphocytes
glucose: normal
protein: increased
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The worst headache in my life…
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Subarachnoidal hemorrhage, meningitis
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Supernatant after centrifuge
Yellowish: supports SAH Clear: supports artefically bloody CSF
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Electroneurography (ENG)
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Electromyography (EMG)
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Electroencephalography (EEG)
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Focal seizure
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Evoked potentials (based on EEG) Averaging of EEG waves, detected by a properly
localised electrode, after a certain stimulus
Evoked signal is augmented Background noise is decreased
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Ultrasound
B-mode US
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Carotid B-mode US
CCA
ICA
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CCA
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CCA LT
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ICA LT
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CCA ICA
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Transcranial Doppler (TCD)
TCD
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Summary
• CT, MRI
• CTA, MRA, DSA
• CSF sampling, CSF analysis
• ENG, EMG, repetitive stimulation
• EEG
• Evoked potentials
• Duplex ultrasound and transcranial Doppler