14. Nervous System II Pathologies Flashcards
Raised Intracranial Pressure
- Raised intracranial pressure describes an increase in the pressure within the cranial cavity.
- Compression of blood vessels leads to reduced oxygen perfusion to the brain.
Raise Intracranial Pressure: Causes
• Tumours (e.g. glioma or
• Haemorrhage (e.g. subdural,
• Hydrocephalus (excess cerebrospinal
• Meningitis (meningeal inflammation) and
Encephalitis (inflammation of brain tissue) both causing brain swelling.
• Intracranial abscess.
Raise Intracranial Pressure: Signs and Symptoms
• Headache (worse on awakening, coughing and moving head).
• Vomiting (often without nausea earlier on).
• Visual disturbance (if damage to optic nerve, which is vulnerable due to its anatomical course through the cranium).
• Pupil fixed/dilated in one eye.
• Impaired mental state: lethargy, irritable.
• Altered speech and seizures.
•‘ Papilloedema’(“bulging of the optic disc”
seen only with ophthalmoscopy).
• Elevated blood pressure, slow &
irregular pulse, slow breathing.
Cushing Triad
Systolic Hypertension: Widening pulse pressure, systolic over 180
Bradypnea
Bradycardia -> below 50bpm
Hydrocephalus
- An abnormal accumulation of cerebrospinal fluid (CSF) occupying the cerebral ventricles & subarachnoid
- Usually due to impaired absorption but can be due to excessive secretion.
- Results in ventricular dilation and subsequently CSF permeates through the ependymal lining into the surrounding white matter.
Hydrocephalus: Causes
• Small children: infection or congenital
malformation.
• Older children and adults: tumours,
trauma, meningitis.
Hydrocephalus: SIgns and Symptoms
• Headache worse in the morning after waking up (CSF doesn't drain well whilst lying down). • Increase in head circumference & dilated scalp veins in infants. • Vomiting (& nausea) • Blurred or double vision. • Neck pain.
Hydrocephalus: Treatment
- Diuretics inhibit CSF secretion.
- Emergency (to prevent white matter scarring/brain damage/death).
- Shunt, ventricular drain, lumbar puncture.
Meningitis
- Infection or inflammation of the meninges.
* Can be life threatening when it leads to raised intracranial pressure - a medical emergency.
Meningitis: Causes
• Viral meningitis is the most common cause (90%) and is less severe e.g. herpes simplex.
• More severe cases may involve be bacterial.
• May also be fungal or parasitic micro
organisms.
• Affects immuno compromised populations: elderly, HIV, organ transplants, cancer patients.
• Can be non infective e.g. brain tumour.
Meningitis: Signs and Symptoms
• Fever and sudden onset of severe headache.
• Marked neck stiffness, photophobia and
vomiting.
• Petechiae: small purple/red spots on the
skin as a result of tiny haemorrhages
non blanching (does not disappear when
pressed with a finger or a glass tumbler).
• Kernig’s sign - pain resistance to knee
extension when lying with the hips fully
flexed.
• Brudzinski sign - neck flexion causes
flexion of hip & knee.
Meningitis: Diagnosis
Lumbar puncture (withdraw CSF between approx. L4-L5).
Mengitis: Treatment
- Antibiotics, antivirals & corticosteroids.
- Analgesics & antipyretics.
- Intravenous fluids.
Meningitis: Complications
- Swelling (& raised ICP).
- Septicaemia.
- Seizures.
Kernig’s Sign
• Kernig’s sign - pain resistance to knee
extension when lying with the hips fully
flexed.
Brudzinski Sign
• Brudzinski sign - neck flexion causes
flexion of hip & knee.
Concussion
• Concussion describes a temporary loss
of neuronal function.
• It is a reversible head injury resulting from a significant blow to the head disrupting neurological function.
Concussion: Signs and Symptoms
- Vary from mild to severe and depending on area of brain. Could ultimately lead to a haemorrhage.
- Loss of consciousness, memory loss of events surrounding the injury, headache, disorientation.
Concussion: Treatment
- Emergency: Rest, if consciousness was lost avoid any vigorous activity for ~ 3 months.
- Homeopathy (i.e. arnica is excellent).
Cerebral Contusion
- A type of traumatic brain injury that causes bruising of the brain with ruptured blood vessels and oedema.
- Usually caused by a blunt blow to the head.
Cerebral Contusion: Signs and Symptoms
- Headache, confusion, sleepiness, dizziness, loss of consciousness, nausea, vomiting, seizures, difficulty with coordination & movement.
- Impaired memory, vision, speech, hearing.
Cerebral Contusion: Treatment
- Allopathic: Medical emergency.
* Alternative: Homeopathy ( Arnica & others in high potency).
Coup and Contrecoup injury
• A coup contrecoup injury is a term
applied to traumatic head injuries and
most often cerebral contusions.
• It refers to the common pattern of injury,
as summarised below:
• Coup : injury to the site of primary impact.
• Contrecoup : 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 on the opposite side.
Headaches
- Common type of head pain with many causes.
- A new onset of a worsening headache that is of high pain intensity and associated with pupil dilation is a concerning presentation.
Headaches: Causes
- Dehydration.
- Cervicogenic (from the neck)
- TMJ (structural problems)
- Tension headache.
- Congested sinuses.
- Hypoglycaemia.
- Migraines & cluster headaches.
- Medication induced i.e. paracetamol.
- Intra cranial: e.g. brain tumour, haemorrhage etc.
- Organ referral.
Cervicogenic Headache
Location: Occipital to frontal/temporal.
Retro orbital frontal.
Duration: 1 hour to weeks.
Severity: Moderate - severe.
Pain character: Non- throbbing. Usually starts in neck.
Aggravating factors: Neck movement,
sustained postures. (tender/reproduced
when palpating upper cervical spine).
Relieving factors: Stretching and supporting neck, massage
Associated symptoms: Reduced neck ROM, (+/- neck discomfort)
Migraine
Location: Retro orbital frontal.
Duration: 4- 72 hrs (usually <24 hrs)
Severity: Moderate - severe.
Mild - moderate.
Pain character: Throbbing, pulsating.
Aggravating factors: Exertuibm certain foods (dairy, caffeine), stress, light, noise
Relieving factors: Being in a dark room, rest, sleep
Associated symptoms: Photophobia, phonophobia, nausea/vomiting, visual changes, tingling (aura).
Tension Headache
Location: Diffuse (bilateral)
Duration: Hours to days.
Severity: Mild - moderate.
Pain character: Dull.
Aggravating factors: Stress, muscle tension
Relieving factors: Rest massage, relaxation
Associated symptoms: Occasionally decreased appetite and photophobia
MIgraine
- A neurological condition that results in recurrent, severe headaches.
- More common in women, usually beginning in childhood. Strong links with family history (genetics).
Migraine: Causes
• Hypothesised that a complex series of intracranial vascular changes occurs, including initial vasoconstriction (aura) and subsequent vasodilation (headache) headache). Induced by cerebral depolarisation (this secretes vasodilators and pain
• Low levels of serotonin.
• Food allergies, food additives (tyramine,
nitrates, MSG, aspartame), histamine, alcohol.
• Emotions (stress), hormonal changes, poor sleep.
Migraine: Signs and Symptoms
- Aura (15%) occurs hours to days before headache: unusual visual, olfactory & sensory experiences preceding the headache.
- Unilateral, pulsating headache with a moderate severe intensity, worsened by movements.
- Associated with photophobia & phonophobia.
- Nausea & vomiting (in up to 60%).
Migraine: Treatment
Analgesics (i.e. ibuprofen, 5 HT agonists).
Brain Tumour
• Even benign tumours can be life threatening as they increase intracranial pressure.
• Often secondary malignant tumours but can be primary (originate within the brain).
• Mostly gliomas (most common type is
astrocytoma). Other, less aggressive tumours include meningiomas and pituitary tumours.
Brain Tumour: Signs and Symptoms
- Morning headaches , increasing in
- Nausea & vomiting.
- Uneven pupils & double vision.
- Papilloedema.
Headache red flags
- First onset of headache over 50 years of age.
- “Thunderclap headache” subarachnoid haemorrhage.
- Signs of meningitis Headache, neck stiffness, non blanching rash, positive Kernig/Brudzinski sign.
- Signs of increased intra cranial pressure- Worsening morning headaches, uneven pupils, double vision, tunnel vision,
Epilepsy
Sudden, hyper excitable and uncontrolled neuronal activity in the brain. It is a symptom of a disease.
Epilepsy: Causes
- Idiopathic, brain tumours, cerebral infarction or haemorrhage.
- Congenital malformation, head trauma (loss of consciousness).
- CNS infections (i.e. meningitis), degenerative brain disease, some drugs, chemical imbalances (i.e. hypoglycaemia/calcaemia).
Epilepsy: Triggers
• Hypoglycaemia , fever (febrile seizures), sleep deprivation, dehydration, stress, flickering lights, drugs and alcohol
(alters brain chemistry). Pesticides (they can inhibit GABA!)
Epilepsy: Signs and Symptoms
• Petit mal seizures (non convulsive), grand mal seizures (convulsive).
Grand mal seizures
• A ‘tonic clonic’ seizure.
• Tonic phase: contraction of all body muscles (causing patient to fall if sitting or standing)
• Clonic phase: rapid contraction &
relaxation of muscles causing convulsions.
• Ranges from exaggerated twitches to violent shaking.
• Usually lasts around a minute.
• Followed by physical and nervous exhaustion.
Petit mal seizures
- Absence seizure.
- Lasts 10 30 seconds.
- Seen mainly in children.
- Abnormal neuronal activity in brain.
- Usually no lingering confusion.
- Can be idiopathic or due to birth trauma, brain injury or family history
Epilepsy: Treatment
Anti epileptic drugs anti convulsants
such as Gabapentin, sodium valproate
side effects! effects!). Emergency care.
Spina Bifida
• Incomplete closure of the embryonic
neural tube resulting in failure of the
spinal column to fully enclose the spinal cord .
• Most commonly occurs at the lumbosacral junction (L5/S1).
• Divided into spina bifida ‘occulta’ (overlying skin intact) & ‘cystica’ (visible cystic mass).
Spina Bifida: Risk factors
Lack of folate (vitamin B9) during and before pregnancy. Sodium valproate linked.
Spina Bifida: Complications
Meningitis, hydrocephalus, reduced bowel & bladder function.
Herniated Disc
- The nucleus pulposus of the disc leaks through the annulus fibrosis, often compressing on spinal nerves.
- Most commonly occurs between 30 40 years of age. Commonly in low lumbar spine (L4/5/S1).
- The classic mechanism of injury is combined lumbar spine flexion and rotation (bending and twisting).
Herniated Disc: Signs and Symptoms
Radiating pain (sharp & ‘linear’), positive straight leg raise rest. Pain aggravated by coughing/sneezing.
Herniated Disc: Treatment
Manual therapy, muscle strengthening, anti inflammatory diet & supplements, homeopathy, herbs, acupuncture.
Sciatica
• Sciatica is pain due to the compression
or irritation of the sciatic nerve.
• The sciatic nerve is the longest and widest nerve in the body.
Sciatica: Signs and Symptoms
• Pain in the lower back & buttock. • Pain radiating down the posterior leg , often into the foot. Usually unilateral. • ‘Pins and needles’ and • Weak calf muscles & ‘foot drop’. • Often absent ankle jerk reflex.
Sciatica: Causes
• Disc herniation at L4/5 or L5/S1.
• Compression against ‘ muscle
(in buttock).
• Tumours in the spinal canal or pelvis.
Sciatica: Diagnosis
Straight leg raise test, loss of sensation
in sciatic nerve dermatome, absent ankle
jerk reflex.
Sciatica: Treatment
Steriod injection, surgery
Straight Leg Raise Test (SLRT)
• The straight leg raise test is used to assist the diagnosis of nerve tethering in the lower lumbar spine
• A positive SLRT is generally suggestive
of a disc herniation. A positive result includes reproduced pain/symptoms into the buttock and posterior leg (sciatic nerve
• To perform this test, the patient lies supine, whilst the practitioner raises one leg at a time.
Symptoms experienced up to about 45 degrees indicate a positive result.
Aspartame
• Aspartame is a non carbohydrate artificial
sweetener, 200 times sweeter than sugar.
• Used in approximately 6000 foods & drinks.
• Aspartame has been the subject of much
controversy its toxic side effects are well
documented. It has also been shown not to
help with weight loss but cause weight gain!
• Aspartame is a neurotoxin with neuro
excitatory properties.
• Linked to wide spread neurological damage and a variety of symptoms/conditions:
• MS, Parkinson’s, Balance problems.
Neurological Examination
• A neurological examination will assess
for the presence of abnormal
neurological function and might highlight
the location/source of a session.
Testing might include the following:
• Observation of signs (e.g. tremor, rigidity).
• Motor (power) testing (corticospinal
• Cranial nerve exam.
• Dorsal columns testing: light touch, vibration, proprioception.
• Spinothalamic tract testing: pin prick,
temperature.
• Gait analysis & Romberg’s (proprioception).
• Cutaneous (i.e. foot) and deep tendon reflexes.
Romberg’s Test
• Romberg’s test assess proprioception
(awareness of body
• Ask the patient to stand with feet together.
• The patient should be able to do this easily because of eye and ear input (indicates good cerebellar function).
• Ask the patient to now close their eyes. If the patient sways after closing their eyes -> Positive Romberg’s
• A positive test indicates a problem with the proprioceptive system i.e. damage of dorsal columns in spinal cord (often a B12 deficiency).
Deep Tendon Reflexes: Knee Jerk
The knee jerk: • Tapping the patellar tendon triggers a stretch reflex to stimulate contraction of the quadriceps muscles. • This is a protective mechanism to stop excessive joint movement. • An absent knee jerk can indicate: Disc herniation, peripheral nerve compression. Slowed in hypothyroidism. • An exaggerated knee jerk can indicate: CNS lesion e.g. spinal cord or hyperthyroidism.
Deep Tendon Reflexes: Ankle Jerk
The ankle jerk (Achilles reflex):
• Tapping the Achilles tendon whilst the foot is dorsiflexed triggers a stretch reflex to stimulate plantar flexion of the foot.
• An absent reflex can indicate:
Nerve damage (peripheral neuropathy, Sciatic nerve compression). Hypothyroidism.
• An exaggerated reflex may indicate:
CNS lesion e.g. spinal cord, MND.
Cutaneous Reflexes: Plantar
Plantar response / Babinski sign:
• Stroking the lateral margin of the sole of the foot normally causes the toes to flex.
• In patients with an abnormal response, the stimulus will cause the big toe to extend (dorsiflex) and the other toes to fan out.
• This is called the ‘Babinski
• An up going plantar response is normal in infants due to incomplete myelination of nerve fibres, but pathological after.
• An abnormal response indicates:
Corticospinal tract damage, Multiple Sclerosis (MS) & Motor Neuron Disease (MND).
Cutaneous Reflexes: Abdominal
• The patient should be supine and relaxed.
• Stroke medially across the upper and
lower quadrant of the abdomen towards
the umbilicus.
• This should result in brisk contraction of
abdominal muscles.
• This reflex can be lost in corticospinal tract damage, MS and MND.
• An absent abdominal reflex may be
physiological.
Homeostasis: Whole Body
The nervous system works closely with the endocrine system to regulate most body functions.
Homeostasis: Integumentary
Controls sweating and arrector pili
Homeostasis: Skeletal
Pain receptors in bone tissue warn of trauma or damage.
Homeostasis: Muscular
- Motor neurons stimulate muscular contractions.
* The cerebellum co ordinates skilled movements.
Homeostasis: Cardiovascular
Medulla oblongata is the home of the CV control centre. It governs cardiac output and regulates blood pressure.
Homeostasis: Endocrine
- Hypothalamus regulates the pituitary gland.
* ANS regulate hormone (e.g. adrenaline).
Homeostasis: Lymphatic and immune
Certain neurotransmitters help regulate
immune response.
Homeostasis: Respiratory
- Respiratory areas in the brain stem control breathing rate and depth.
- ANS regulates airway diameter.
Homeostasis: Digestive
- ANS & enteric nervous system regulate digestion.
* PNS stimulates digestive processes.
Homeostasis: Urinary
- The ANS regulate blood flow to the kidneys.
* The CNS governs emptying of the urinary bladder.
Homeostasis: Reproductive System
- Hypothalamus and limbic system govern sexual behaviour.
- The ANS governs erection and ejaculation.
- Hypothalamus regulates the release of pituitary hormones which influence the gonads.
- Nerve impulses elicited by suckling cause the release of oxytocin and milk ejection in nursing mothers.
