14. Nervous System II - Pathologies Flashcards
Raised Intracranial Pressure: definition
Increase in pressure within the cranial cavity
Raised Intracranial Pressure: pathophysiology
Compression of blood vessels leads to reduced oxygen perfusion to the brain
Raised Intracranial Pressure: aetiology
- Tumours - gliomas (primary), metastases
- Haemorrhage - subdural (venous, slow), subarachnoid (arterial, rapid)
- Hydrocephalus - excess CSF
- Meningitis - inflammation of meninges
- Encephalitis - inflammation of brain tissue
- Intracranial abscess
Raised Intracranial Pressure: signs and symptoms
Headache - worse on awakening*, when coughing or moving head
Vomiting - often without nausea
Visual disturbance - if damage to optic nerve
Pupil fixed/dilated in one eye
Impaired mental state
Altered speech
Seizures
Papilloedema - bulging of the optic disc
Elevated blood pressure, slow irregular pulse, slow breathing
*CSF at daily peak
Hydrocephalus: definition
Abnormal accumulation of CSF in the cerebral ventricles and subarachnoid space
Hydrocephalus: pathophysiology
Impaired absorption or excessive secretion
Results in ventricular dilation
CSF permeates through the ependymal lining into the surrounding white matter
Hydrocephalus: aetiology - young children
Infection or congenital malformation
Hydrocephalus: aetiology - older children/adults
Tumour
Trauma
Meningitis
Hydrocephalus: signs and symptoms
Headache - worse on awakening - CSF doesn’t drain well whilst lying down
Infants - increase in head circumference and dliated scalp veins
Vomiting, nausea
Blurred or double vision
Neck pain
Hydrocephalus: allopathic treatment
Diuretics - inhibit CSF secretion
Shunt, ventricular drain, lumbar puncture
Emergency - to prevent white matter scarring/brain damage/death
Meningitis: definition
Infection or inflammation of the meninges
Can be life-threatening if leads to intracranial pressure
Meningitis: aetiology
Viral meningitis (herpes simplex) - most common cause (90%). Less severe
Bacterial infection - more serious
Fungal/parasitic micro-organisms
Non-infective - brain tumour
Meningitis: signs and symptoms
Can initially resemble flu:
~~~
Fever
Sudden onset of severe headache
Neck stiffness
Photophobia
Vomiting
~~~
Petechiae - small purple/red spots on skin as result of tiny haemorrhages that don’t disappear under pressure (non-blanching)
Kernigs sign - pain resistance to knee extension when lying with the hips fully flexed
Brudzinski sign - neck flexion causes flexion of hip and knee
Meningitis: diagnostics
Lumbar puncture: withdraw CSF between L4-L5
Meningitis: complications
Swelling
Raised ICP*
Septicaemia
Seizures
*Intracranial pressure
Meningitis: allopathic treatment
Antibiotics, antivirals, corticosteroids
Analgesics, antipyretics (to lower temperature)
Intravenous fluids
Concussion: definition
Temporary loss of neuronal function
Concussion: aetiology
Significant blow to the head
Concussion: signs and symptoms
Loss of consciousness
Memory loss of events surrounding the injury
Headache
Disorientation
Nausea/vomiting
Concussion: allopathic treatment
Rest
If any consciousness lost, avoid any vigorous activity for 3 months
Cerebral Contusion: definition
Traumatic brain injury that causes bruising of the brain with ruptured blood vessels and oedema
Cerebral Contusion: aetiology
Blunt blow to the head
Cerebral Contusion: signs and symptoms
Headache Confusion Dizziness Loss of consciousness Nausea Vomiting Seizures Difficulty with co-ordination/movement Impaired memory, vision, speech, hearing
Cerebral Contusion: allopathic treatment
Medical emergency
Coup injury: definition
Injury to the site of primary impact
Contrecoup injury: definition
Damage to the brain at a site contra-lateral to the site of trauma
The skull acts to stop acceleration of the brain away from the site of impact, causing damage to the opposite side
Headaches: aetiology
- Dehydration
- Cervicogenic (from the neck)
- TMJ* - jaw headache (structural)
- Tension (muscular)
- Congested sinuses
- Hypoglycaemia
- Migraine/cluster (Trigeminal nerve)
- Medication - e.g. paracetamol
- Intra-cranial - e.g. brain tumour, haemorrhage
- Organ referral
*Temporomandibular joint
Cervicogenic headache:
location, duration, severity, pain character
Occipital to frontal/temporal
1 hr to weeks
Moderate to severe
Non-throbbing pain, dull and deep
Tension headache:
location, duration, severity, pain character
Diffuse (bilateral)
Hours to days
Mild to moderate
Dull pain
Migraine headache:
location, duration, severity, pain character
Retro-orbital (behind eyes)
4-72 hrs
Moderate to severe
Throbbing, pulsating
Cervicogenic headache: aetiology
Neck movement, sustained postures
Cervicogenic headache: signs and symptoms
Reduced neck range of movement (ROM)
Cervicogenic headache: allopathic treatment
Stretching
Supporting neck
Massage
Tension headache: aetiology
Stress
Muscle tension
Tension headache: signs and symptoms
Reduced appetite
Photophobia
Tension headache: allopathic treatment
Rest
Massage
Relaxation
Migraine headache: definition
Neurological condition that results in recurrent, severe headaches
Migraine headache: aetiology
Strong links with genetics - more common in women
Food allergies
Food additives - tyramine, nitrates, MSG, aspartame, histamine, alcohol
Emotions - stress
Hormonal changes
Poor sleep
Low levels of serotonin (link with digestive function)
Complex series of intracranial vascular changes - vasoconstriction (aura) and subsequent vasodilation (headache)
Induced by cerebral depolarisation - this secretes vasodilators and pain mediators
Migraine headache: signs and symptoms
Aura - occurs hours to days before headache (tingling, changes in vision, smell)
Unilateral, pulsating headache (retro-orbital)
Moderate to severe intensity, worsened by movements
Photophobia
Phonophobia
Nausea, vomiting (which can improve symptoms)
Migraine headache: allopathic treatment
Analgesics - ibuprofen
5-HT agonists*
Bind to and activate 5-HT (serotonin) receptors in the brain.
Headaches: red flags
First onset of headache over 50 yrs old
Thunderclap headache (subarachnoid haemorrhage)
Signs of intracranial pressure:
Worsening morning headaches, uneven pupils, double vision, tunnel vision, papilloedema, vomiting but no nausea
Signs of meningitis:
Headache, neck stiffness, non-blanching rash, positive Kernig/Brudzinski tests
Epilepsy: definition
Sudden, hyper-excitable and uncontrolled neuronal activity in the brain
Epilepsy: aetiology
Idiopathic Brain tumour Cerebral infarction/haemorrhage Congenital malformation Head trauma CNS infections - meningitis Degenerative brain disease Some drugs Chemical imbalances - hypoglycaemia/calcaemia
Epilepsy: triggers
Flickering lights Stress Drugs/alcohol Dehydration Sleep deprivation Fever Hypoglycaemia Pesticides
Epilepsy: signs and symptoms
Petit mal seizure - non convulsive
Grand mal seizure - convulsive
Epilepsy: allopathic treatment
Anti-epileptic drugs - gabapentin, sodium valproate (adverse effects)
Petit mal seizure: definition
Non-convulsive seizure
‘Absence’ seizure
Lasts 10-30 seconds
Mainly in children
Usually no lingering confusion
Grand mal seizure: definition
‘Tonic-clonic’, convulsive seizure
Tonic phase - contraction of all body muscles, causing patient to fall if sitting or standing
Clonic phase - rapid contraction and relaxation of muscles causing convulsions. Ranging from exaggerated twitches to violent shaking
Usually lasts around 1 min
Followed by physical and nervous exhaustion
Spina Bifida: definition
Incomplete closure of the embryonic neural tube
Results in failure of the spinal column to fully enclose the spinal cord
At what junction does spina bifida usually occur?
Lumbosacral junction - L5/S1
What are the two types of spina bifida?
Spina bifida occulta - overlying skin intact
Spina bifida cystica - visible cystic mass
Spina Bifida: risk factors
Lack of folate (vit B9) during and before pregnancy
Sodium valproate link
Spina Bifida: complications
Meningitis*
Hydrocephalus
Reduced bowel and bladder function
*Especially in Spina bifida cystica because openings for bacteria
Disc Herniation: definition
The nucleus pulposus of the intervertebral disc leaks out into the annulus fibrosus, often compressing the spinal nerves
At which junctions are disc herniations likely to affect?
Tends to affect discs with the highest fluid content, most commonly L5, S1 (sacrum), then the cervical spine (C1-7)
What age group is more likely to be affected by a disc herniation?
30-40 yrs old
Discs are most hydrated at this stage
Disc Herniation: signs and symptoms
Radiating pain (sharp and linear)
Worse in the extremity
Aggravated by coughing/sneezing
Positive straight leg raise test*
*Reproduces the symptoms
Disc Herniation: allopathic treatment
Manual therapy
Muscle strengthening
Sciatica: definition
Compression or irritation of the sciatic nerve
Sciatica: aetiology
Disc herniation at L4/5 or L5/S1
Compression against piriformis muscle
Tumours in spinal canal or pelvis
Sciatica: signs and symptoms
Pain in lower back and buttock Pain radiating down posterior leg - usually unilateral Pins and needles, numbness Weak calf muscles and 'foot drop' Often absent ankle jerk reflex
Sciatica: diagnostics
Straight leg raise test
Loss of sensation in sciatic nerve dermatome
Absent ankle jerk reflex
Sciatica: allopathic treatment
Physiology
Steroid injection
Surgery
What is the SLRT (straight leg raise test) used to diagnose?
Nerve tethering in the lower lumbar spine
A positive SLRT is generally suggestive
of a disc herniation
What does a positive straight leg raise test generally suggest?
Disc herniation
What does a positive straight leg raise test show?
Reproduced pain/symptoms in the buttock and posterior leg*
*Sciatic nerve distribution
How is a straight leg raise test performed?
- Patient lies supine
- Practitioner raises one leg at a time
- Symptoms usually experienced at 45 degrees
What is aspartame?
A non-carbohydrate artificial sweetener
How much sweeter than sugar is aspartame?
200 times
How many foods and drinks contain aspartame?
Approx 6000
Why is aspartame considered harmful?
Aspartame is a neurotoxin
It has neuroexcitatory properties (excitotoxin)
What sort of damage can aspartame cause?
Widespread neurological damage
MS
Parkinson’s disease
Balance problems
What does a neurological examination test for?
Abnormal neurological function
What might a neurological examination include?
Signs - tremor, rigidity
Motor (power) testing
Cranial nerve exam
Dorsal column testing - light touch, vibration, proprioception
Spinothalamic tract testing - pin prick, temperature
Gait analysis/Romberg’s - proprioception
Cutaneous (i.e. foot) and deep tendon reflexes
What does the Romberg’s test assess?
Proprioception
How is Romberg’s test performed?
Ask patient to stand with feet together
Ask patient to close eyes
Maintain position for 20-30s
What is a positive Romberg’s test?
If patient sways after closing eyes
What does a positive Romberg’s test indicate?
A problem with the
proprioceptive system
* Damage of dorsal columns in spinal cord
* B12 deficiency
What does a knee jerk test assess?
Deep tendon reflexes
How is a knee jerk test performed?
Tap the patellar tendon
What can an absent knee jerk indicate?
Disc herniation
Peripheral nerve compression
Hypothyroidism
What can an exaggerated knee jerk indicate?
CNS dysfunction e.g. spinal cord,
MND
Hyperthyroidism
What does an ankle jerk test assess?
Deep tendon reflexes
How is an ankle jerk test performed?
Tap the Achilles tendon whilst foot is dorsiflexed
What does a knee jerk test simulate?
Contraction of the quadriceps muscle
What does an ankle jerk test simulate?
Plantar flexion of the foot
What can an absent ankle jerk indicate?
Nerve damage - peripheral neuropathy, sciatic nerve compression
Hypothyroidism
What can an exaggerated ankle jerk indicate?
CNS dysfunction e.g. spinal cord
MND
Hyperthyroidism
How is a plantar response/Babinski sign performed?
Stroke the lateral margin of the sole of the foot
What is a normal plantar response/Babinski sign?
Plantar flexed* toes
*Curled toes
What is the Babinski sign?
Big toe extending (dorsiflexing) while other toes fan out
Considered normal only below 2years of age, pathological afterwards
What does an abnormal plantar response indicate?
Corticospinal tract damage
MS
MND
How is an abdominal reflex performed?
Patient should be supine and relaxed
Practitioner strokes medially across the upper and lower quadrant of abdomen towards the belly button
What should happen in an abdominal reflex?
Brisk contraction of abdominal muscles
What does an absent abdominal reflex indicate?
Corticospinal tract damage
MS
MND
Who is more likely to be affected by meningitis?
Immuno-compromised populations - elderly, HIV, organ transplants, cancer patients
Hydrocephalus: diagnostics
CT scans
MRI
Migraine headache: natural treatment
- Avoid allergens / food intolerances
- Low GL diet
- Avoid amine-containing foods (vasodilators) (tyramine, histamine)
- Magnesium + B6
- Herbs (e.g. feverfew)
- Acupuncture, osteopathy.
- Homeopathy.
Brain tumour: pathophysiology
Often secondary malignant tumours
Can be primary (originate within the brain).
Gliomas (most common type is astrocytoma).
Meningiomas and pituitary tumours (less aggressive)
Brain tumour: signs and symptoms
- Morning headaches, increasing in frequency
- Nausea and vomiting
- Uneven pupils and double vision
- Papilloedema
Epilepsy: natural treatment
Ketogenic diet (increases GABA that surpresses the excessive electrical activity)
Dietary and supplements: EFAs,
magnesium.
Smoking cessation.
Acupuncture,
Sleep hygiene, stress management. Homeopathy.
Disc Herniation: natural treatments
Anti-inflammatory
diet
Supplements (bromalaine, tumeric, ginger, boswellia, magnesium, epsom salts, serrapeptase*)
Homeopathy
Herbs
acupuncture.
*proteolytic enzyme, natural anti-inflammatory
Sciatica: natural treatment
Magnesium, epsom salts (if related to muscle contraction)
Manual therapies
Herbs for pain, nerve support
Acupuncture
Homeotherapy
