Neurological Pathology. Anatomy - CNS Anatomy - PNS.

Neurological PathologyNeurological Pathology

Anatomy - CNSAnatomy - CNS

Anatomy - PNSAnatomy - PNS

MeningesMeninges

3 main layers3 main layers Dura Mater – outerDura Mater – outer Arachnoid – middleArachnoid – middle CSFCSF Pia Mater – innerPia Mater – inner

Signs & Symptoms of Neurological Signs & Symptoms of Neurological ProblemsProblems

1. Syncope or Coma1. Syncope or Coma

2. Paresthesia2. Paresthesia

3. Abnormal motor control, coordination3. Abnormal motor control, coordination

4. Seizure 4. Seizure Petit-mal vs Grand-malPetit-mal vs Grand-mal

S/S cont.S/S cont.

5. HA5. HA

6. Change in vision, pupils, hearing, 6. Change in vision, pupils, hearing, sensessenses

7. Changes in mental status7. Changes in mental status

8. Bowel/bladder incontinence8. Bowel/bladder incontinence

Neurological ConditionsNeurological ConditionsBrain TraumaBrain TraumaCardiovascular event – stroke, aneurysmCardiovascular event – stroke, aneurysmSubdural or Epidural HematomaSubdural or Epidural HematomaPost-concussion syndromePost-concussion syndromeSeizureSeizureEpilepsyEpilepsyCerebral palsyCerebral palsySpina BifidaSpina BifidaMultiple Sclerosis - MSMultiple Sclerosis - MSReflex Sympathetic DystrophyReflex Sympathetic DystrophyAmyotrophic Lateral Sclerosis - ALSAmyotrophic Lateral Sclerosis - ALSPeripheral NeuropathyPeripheral NeuropathyEncephalitisEncephalitisMeningitisMeningitisGuillain-Barre Syndrome Guillain-Barre Syndrome Spinal Cord TraumaSpinal Cord Trauma

Brain TraumaBrain TraumaFootball injuries associated with the brain occur at a rate of one in every Football injuries associated with the brain occur at a rate of one in every 3.5 games3.5 gamesMore than 60,000 HS athletes suffer concussions each yearMore than 60,000 HS athletes suffer concussions each yearFootball is responsible for more than 250,000 mild brain injuries in the Football is responsible for more than 250,000 mild brain injuries in the USUSIn any given season, 10% of all college player and 20% of HS player In any given season, 10% of all college player and 20% of HS player sustain brain injuriessustain brain injuriesFootball players with brain injuries are 6x as likely to sustain new Football players with brain injuries are 6x as likely to sustain new injuriesinjuriesAbout 5% of soccer players sustain brain injuries as a result of their About 5% of soccer players sustain brain injuries as a result of their sportsportThe head is involved in more baseball injuries than any other body part. The head is involved in more baseball injuries than any other body part. The human brain isn’t fully developed until the third decade of lifeThe human brain isn’t fully developed until the third decade of lifeMore than 50% of concussions are grade IMore than 50% of concussions are grade IFewer than 10% of concussions result in LOCFewer than 10% of concussions result in LOCConcussions are an EVOLVING process; either (+) or (-)Concussions are an EVOLVING process; either (+) or (-)

Affects ALL SportsAffects ALL Sports

Brain TraumaBrain Trauma

AKA AKA - - Mild Traumatic Brain Injury (MTBI), Cerebral Contusion (brain Mild Traumatic Brain Injury (MTBI), Cerebral Contusion (brain bruise), Concussionbruise), Concussion

Concussion:Concussion: a transient disturbance of neurological function a transient disturbance of neurological function caused by trauma with or without LOCcaused by trauma with or without LOC

Second Impact Syndrome:Second Impact Syndrome: when a player returns to activity when a player returns to activity beforebefore symptoms of a first concussion have completely symptoms of a first concussion have completely resolved and sustains a second blow resolved and sustains a second blow

Post Concussion Syndrome:Post Concussion Syndrome: The presents of lingering S/S The presents of lingering S/S following a concussionfollowing a concussion

Brain TraumaBrain Trauma

MOI:MOI: Compressive Force, Tensile Force, Rotational Force (Shearing)Compressive Force, Tensile Force, Rotational Force (Shearing)

Early S/SEarly S/S: Confusion, HA, Blurred vision, Amnesia, Nausea, Ringing in the ears, Dizziness, : Confusion, HA, Blurred vision, Amnesia, Nausea, Ringing in the ears, Dizziness, Light headedness, Pupil irregularity, Drowsiness, Balance problems, Change in behavior, Light headedness, Pupil irregularity, Drowsiness, Balance problems, Change in behavior, Motor skill deficitMotor skill deficit

Late S/SLate S/S: Sleep disturbance, Fatigue, Memory deficit, Unable to concentrate, Decrease : Sleep disturbance, Fatigue, Memory deficit, Unable to concentrate, Decrease cognitive speed, Irritablecognitive speed, Irritable

TX: TX: MonitoringMonitoring is the best treatment for the athleteis the best treatment for the athleteHopefully compare to BASELINE neuropsychological examHopefully compare to BASELINE neuropsychological examEvery 5 minutes- recheck for changesEvery 5 minutes- recheck for changesGCS- see eval formGCS- see eval formHistory – previous concussionsHistory – previous concussionsNeurological examNeurological examMotor functionMotor functionMemoryMemory

Brain TraumaBrain Trauma

TX: contTX: cont If any signs/symptoms increase…must send in to If any signs/symptoms increase…must send in to

ERER While monitoring, hang on to necessary item…While monitoring, hang on to necessary item…

helmet, shoe – Whatever it takes to protect your helmet, shoe – Whatever it takes to protect your athlete! athlete!

THEY ARE NOT THINKING CLEARLY!THEY ARE NOT THINKING CLEARLY!

Brain TraumaBrain Trauma

Return to Play Decision:Return to Play Decision: The final decision must be after an exertional test – 40 yard dash, sit-The final decision must be after an exertional test – 40 yard dash, sit-

ups, push-ups, jumping jacksups, push-ups, jumping jacks All S/S must be clear at rest and during exertionAll S/S must be clear at rest and during exertion If S/S subside within 15 mins, player may return to competitionIf S/S subside within 15 mins, player may return to competition If not gone in 15 mins or returns with exertion, no return is allowed…If not gone in 15 mins or returns with exertion, no return is allowed…

need MD clearanceneed MD clearance Usual protocol: Once S/S have ended, hours, days, weeks…. The athlete must Usual protocol: Once S/S have ended, hours, days, weeks…. The athlete must

stay out at least one weekstay out at least one week The time held out is dependent in length of experienced S/SThe time held out is dependent in length of experienced S/S Final decision is up to the MDFinal decision is up to the MD

Brain Trauma – Termination of Brain Trauma – Termination of SeasonSeason

Grade 1 = 3Grade 1 = 3

Grade 2 = 2Grade 2 = 2

Grade 3 = 1 – CantuGrade 3 = 1 – Cantu

Estabilish with your MD what your grading criteria is!!!!!Estabilish with your MD what your grading criteria is!!!!!

Areas of Concern: # 1= Loss of ConsciousnessAreas of Concern: # 1= Loss of Consciousness

# 2= Second Impact Syndrome# 2= Second Impact Syndrome

# 3= Accumulative effect# 3= Accumulative effect

Brain Trauma – Take Home Brain Trauma – Take Home MessagesMessages

If you do not know athlete’s baseline If you do not know athlete’s baseline neuropsychological status, it is neuropsychological status, it is difficult to judge normal!difficult to judge normal!

Athletes can NOT return to any Athletes can NOT return to any activity until ALL symptoms are activity until ALL symptoms are gonegone

Subdural HematomaSubdural Hematoma

Venous bleedingVenous bleeding

Several hrs to days to developSeveral hrs to days to develop

Lucid intervalsLucid intervals

Can be deadlier because people assume they are fineCan be deadlier because people assume they are fine

Epidural HematomaEpidural Hematoma

Arterial bleedingArterial bleeding

Side effects ~ 10 mins- hour afterSide effects ~ 10 mins- hour after

Pupil/vision problemsPupil/vision problems

Projectile vomitProjectile vomit

Cardiovascular EventCardiovascular EventSTROKESTROKE

AKA – Cerebral Vascular Accident (CVA)AKA – Cerebral Vascular Accident (CVA)

Caused by lack of O2 to the brain leading to reversible or Caused by lack of O2 to the brain leading to reversible or irreversible paralysis and neurological damage – d/t bld irreversible paralysis and neurological damage – d/t bld clot or aneurysm clot or aneurysm

RED FLAGS: RED FLAGS: 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6.6.

STROKESTROKE

Special Tests:Special Tests: CN testing will help determine location of brain injuryCN testing will help determine location of brain injury Frankenstein testFrankenstein test CT scan / MRICT scan / MRI Doppler Blood tests – dye given, look and vessels for Doppler Blood tests – dye given, look and vessels for

blockageblockage

TX: 911TX: 911 Meds – ASAMeds – ASA Post-stroke rehab immediatelyPost-stroke rehab immediately

Epilepsy/SeizureEpilepsy/Seizure

Chronic condition consisting of unprovoked, randomly Chronic condition consisting of unprovoked, randomly reoccurring seizuresreoccurring seizures

1% - 2% of population; dx after 2 seizures 1% - 2% of population; dx after 2 seizures Result of Result of electrical neuronal brain dysfunctionelectrical neuronal brain dysfunctionMOI (seizure): pre-existing epilepsy, old head MOI (seizure): pre-existing epilepsy, old head trauma, brain tumor, stroke, infection, high fever trauma, brain tumor, stroke, infection, high fever (febrile), sleep deprivation, heat stroke, drugs, (febrile), sleep deprivation, heat stroke, drugs, alcohol, extreme stress, most are idiopathicalcohol, extreme stress, most are idiopathicTX: Protect head, left side-lying, nothing in mouth, TX: Protect head, left side-lying, nothing in mouth, airway protection, O2 postairway protection, O2 postUsually last less then 5 minutesUsually last less then 5 minutes

SeizureSeizure

Referral needed if:Referral needed if:> 5 mins> 5 minsFirst seizureFirst seizurePregnantPregnantHead injury or get injured during convulsionsHead injury or get injured during convulsionsABCs not stable afterABCs not stable afterRecurrent convulsionsRecurrent convulsions

Are allowed to participate in almost every sport Are allowed to participate in almost every sport except for inherent risk involved (water, equipment) except for inherent risk involved (water, equipment) Must be under control 1Must be under control 1st, st, understand effects of understand effects of medications on performancemedications on performance

Cerebral PalsyCerebral Palsy

An anoxic, metabolic or ischemic brain injury An anoxic, metabolic or ischemic brain injury during birth resulting in postural deficiencies and during birth resulting in postural deficiencies and voluntary movement issuesvoluntary movement issuesMost common type is spastic – hypertonicity – Most common type is spastic – hypertonicity – dependant on brain region damageddependant on brain region damaged

Cerebral PalsyCerebral PalsyNot progressive and can’t be transmitted Not progressive and can’t be transmitted geneticallygeneticallyATCs – may encounter mild CP athletes; ATCs – may encounter mild CP athletes; may have hx of corrective surgeries, may have hx of corrective surgeries, injuries, weakness, injuries, weakness, ↓ ROM↓ ROM

Spina BifidaSpina Bifida

Congenitally incomplete formation of the neural tube Congenitally incomplete formation of the neural tube (vertebral arch & Meninges)(vertebral arch & Meninges)

Varying degrees, most diagnosed at birthVarying degrees, most diagnosed at birth

Impairment distal to defectImpairment distal to defect

ATCs – spina bifida occultaATCs – spina bifida occulta Incomplete formation of the posterior vertebral arch Incomplete formation of the posterior vertebral arch

without herniation of meninges or cordwithout herniation of meninges or cord Discovered with X-ray after back pain c/c, faun’s Discovered with X-ray after back pain c/c, faun’s

beard, skin discolorationbeard, skin discoloration Requires core strengthening or rarely surgeryRequires core strengthening or rarely surgery

Multiple SclerosisMultiple Sclerosis

Forms regions of intermittent plaques Forms regions of intermittent plaques in the CNS causing demyelization of in the CNS causing demyelization of surrounding neuronsurrounding neuron

Affects both sensory and motor functions in no pattern; Affects both sensory and motor functions in no pattern; plaques lapse and recur affecting new regions of the plaques lapse and recur affecting new regions of the CNS. Eventually causing permanent nerve damageCNS. Eventually causing permanent nerve damage

Most commonly appearing in early adulthood (onset 20-Most commonly appearing in early adulthood (onset 20-40), cause unknown; no cure; females more than males40), cause unknown; no cure; females more than males

22ndnd to trauma in western cultures as cause of to trauma in western cultures as cause of neurological disability neurological disability

MS; contMS; cont

S/S – vary; dependant on site S/S – vary; dependant on site 1.1. 2. 2. 3. 3. 4. 4. 5.5. 6. 6.

Tx: symptomatic, counseling, speech therapyTx: symptomatic, counseling, speech therapy Avoid heat – makes it worseAvoid heat – makes it worse

Lifespan isn’t affected except if severely progressive Lifespan isn’t affected except if severely progressive forms. Impairment becomes the issue.forms. Impairment becomes the issue.

Reflex Sympathetic DystrophyReflex Sympathetic DystrophyRSD – RSD – over activity of the sympathetic nervous system over activity of the sympathetic nervous system after minor injury or from unknown etiologyafter minor injury or from unknown etiology

Classic Symptom – pain out of proportion to the degree Classic Symptom – pain out of proportion to the degree of injuryof injury

Usually post ligament, bone or nerve injuryUsually post ligament, bone or nerve injury In adults – common in shoulderIn adults – common in shoulder In adolescent – common in lower extremity – ankle/foot sprainsIn adolescent – common in lower extremity – ankle/foot sprains

S/S: S/S: hypersensitivity to touch, hypersensitivity to touch, ↓ ROM, prolonged injury recovery, ↓ ROM, prolonged injury recovery, anxiety, depression, poor peripheral vascular controlanxiety, depression, poor peripheral vascular control

Tx: pain control, maintain ROM, desensitize extremityTx: pain control, maintain ROM, desensitize extremity

RSD, cont.RSD, cont.

Amyotrophic Lateral Sclerosis Amyotrophic Lateral Sclerosis ALS; Lou Gehrig’s DiseaseALS; Lou Gehrig’s DiseaseCause unknownCause unknownOccur in middle adulthoodOccur in middle adulthood

S/S: gradual progressive muscle weakness (motor S/S: gradual progressive muscle weakness (motor neurons)neurons)

Starts c hands/arms. As progresses may notice hypersensitive Starts c hands/arms. As progresses may notice hypersensitive reflexes, reflexes, ↓speech, ↓ swallowing, then breathing↓speech, ↓ swallowing, then breathing

Tx: maintain function as long as possibleTx: maintain function as long as possible

No cure and most die within 3 years d/t respiratory No cure and most die within 3 years d/t respiratory failure failure

Peripheral NeuropathyPeripheral Neuropathy

Generic term for peripheral nerve damageGeneric term for peripheral nerve damage

Only affects peripheral nervesOnly affects peripheral nerves

Causes: diabetes, trauma, toxicity, Causes: diabetes, trauma, toxicity, infectioninfection

Tx: recovery depends on disorderTx: recovery depends on disorder

EncephalitisEncephalitis

““Inflammation of the brain”Inflammation of the brain”

Cause – Cause – viral infection or by immunizations or vaccinesviral infection or by immunizations or vaccines

Primary Primary vsvs Secondary Secondary

S/S: within 5-15 days after bite. Fever, HA, vomit, S/S: within 5-15 days after bite. Fever, HA, vomit, photophobia, stiff neck/back, clumsiness, irritable, rash, photophobia, stiff neck/back, clumsiness, irritable, rash, seizure, memory loss, comaseizure, memory loss, coma

Tx: Viral? Antiviral meds – Acyclovir – earlyTx: Viral? Antiviral meds – Acyclovir – earlyTreat symptoms, recovery dependant on severityTreat symptoms, recovery dependant on severity

MeningitisMeningitis

Inflammation of the meninges and CSF around Inflammation of the meninges and CSF around the brain & cordthe brain & cordViral Viral vsvs BacterialBacterial

S/S: malaise, upper respiratory infection, sudden S/S: malaise, upper respiratory infection, sudden high fever, HA, cervical rigidity (+) Kernigs & high fever, HA, cervical rigidity (+) Kernigs & Brudzinski’s sign (bacterial will also have Brudzinski’s sign (bacterial will also have hypotension, tachycardia, tachypnea, myalgia)hypotension, tachycardia, tachypnea, myalgia)Tx: Viral – supportiveTx: Viral – supportive Bacterial - antibioticsBacterial - antibiotics

Guillain-BarreGuillain-Barre´́ Syndrome Syndrome

Acquired demyelinating polyneuropathyAcquired demyelinating polyneuropathyAffects the spinal roots and peripheral nervesAffects the spinal roots and peripheral nervesAcute, progressive & severeAcute, progressive & severeCause- some lymphocytes produce antibodies Cause- some lymphocytes produce antibodies against components of the myelin sheath against components of the myelin sheath disrupting nerve conductiondisrupting nerve conductionS/S: sudden onset of disabling weakness in both S/S: sudden onset of disabling weakness in both legs, progresses to arms, loss of deep tendon legs, progresses to arms, loss of deep tendon reflexes, no fever, hx of recent viral URI, rapid reflexes, no fever, hx of recent viral URI, rapid loss of respiratory functionloss of respiratory functionTx: no cure, rarely recover completelyTx: no cure, rarely recover completely

Spinal Cord TraumaSpinal Cord Trauma

Complete vs incompleteComplete vs incomplete

Complete - All voluntary and autonomic function distal to Complete - All voluntary and autonomic function distal to the injury is immediately and permanently lostthe injury is immediately and permanently lost

Secondary: contusion, edema, Secondary: contusion, edema, compression within the cord, may compression within the cord, may Decrease rapidly c steroid admin.Decrease rapidly c steroid admin.

After acute injury (spinal shock),After acute injury (spinal shock), assessment of function lossassessment of function loss takes placetakes place

Neurological EvaluationNeurological Evaluation

Cranial NervesCranial NervesI – OlfactoryI – OlfactoryII – OpticII – OpticIII – OculomotorIII – OculomotorIV – TrochlearIV – TrochlearV – TrigeminalV – TrigeminalVI – AbducensVI – AbducensVII – FacialVII – FacialVII – VestibulocochlearVII – VestibulocochlearIX – GlossopharyngealIX – GlossopharyngealX – VagasX – VagasXI – AccessoryXI – AccessoryXII - HypoglossalXII - Hypoglossal

Neurological ExamNeurological Exam

DermatomesDermatomes

Neurological ExamNeurological ExamMyotomeMyotome

C1—cervical flexionC1—cervical flexion C2—cervical flexion & rotationC2—cervical flexion & rotation C3—lateral flexionC3—lateral flexion C4—shoulder shrugC4—shoulder shrug C5—abductionC5—abduction C6—Biceps-elbow flxC6—Biceps-elbow flx C7—Triceps-elbow extC7—Triceps-elbow ext C8—Finger flxC8—Finger flx T1—Finger abductionT1—Finger abduction T2 – T9: intercostalsT2 – T9: intercostals T10: Rectus abdominusT10: Rectus abdominus T 11: Internal ObliquesT 11: Internal Obliques T12: External ObliquesT12: External Obliques L1: Quadratus Lumborus & hip flxL1: Quadratus Lumborus & hip flx L2: IliopsoasL2: Iliopsoas L3: knee ext & adductorsL3: knee ext & adductors L4: Tibialis AnteriorL4: Tibialis Anterior L5: Ext hall longus & glut medL5: Ext hall longus & glut med S1: Gastroc/Soleus, peroneals & glut maxS1: Gastroc/Soleus, peroneals & glut max S2: Flx hall longus S2: Flx hall longus

Neurological ExamNeurological Exam

ReflexesReflexes

Neurological ExamNeurological Exam

Inspection – PosturingInspection – Posturing

Evaluate – mood, coordination, mental Evaluate – mood, coordination, mental function, balancefunction, balance

Tinel’sTinel’s

Beevor’s Sign - AbdonimalBeevor’s Sign - Abdonimal

Kernig’s Sign/Brudzinski’s SignKernig’s Sign/Brudzinski’s Sign