IMPAIRMENT OF CONSCIOUSNES
S (ACS)
Dr. Boroumand
CONSCIOUSNESS
Cortex:Awareness (HCF)
Brain Stem:Awakeness = ARAS
Posterior Fossa
LEVEL OF CONSCIOUSNESS (AWAKNESS)(MEANS : ARAS)
Full Awake(alert)
Drowsiness
Stupor
Coma
Acute Confusional
States
Or Delirious
State
COMA
Pathologic Sleep
BRAIN STEM AND ARASBrain Stem:
1-Awakeness2-Respiration3-Eye Fixation4-Sleep Cycle5-Weight gain
6-Yaupping7-Cardiac Rhythm
8-Bilateral Long Tract Pathways (Hemi to Tetra paresis)Posterior Fossa
VEGETATIVE STATE
Means : Cortex (off) + Brain Stem
(on)(cortical Death)
Loss of AwarenessDuration > 6 m/o = PVS
LOCKED IN SYNDROME
Localization : Bilateral Ventral Pontine Lesions
Quadriplegia + Lower Cranial Nerve Palsy Causes:
1 -Pontine Stroke
2 -CPM
3 -MS 4 -ALS
5 -Alzhiemer’s Disease
6 -GBS
7 -NMJ-Blockers Drugs
8 -Brain stem lesions (Lymphoma-Glioma- TB- Syphilis)
BRAIN DEATH
Syn.: Irriversible Coma
Cortex off + Brain Stem off + Obvious Lesion + Irriversible Damage
Obvious Lesion Means: Bilateral Cortical Damage or Structural Lesion in BS
In Brain Death: EEG is flat
BRAIN DEATH CRITERIA
: مغزی مرگ کرایتریای باشد کوما در بیمار خودبخودی تنفس وجود عدم مغزی ساقه های رفلکس فقدان در EEGسکوت مغزی خون جریان فقدان مانند مغزی پذیر برگشت علت هرگونه فقدان
فنوباربیتال با مسمومیت
Irriversible Coma = Brain Death
PHENOBARBITAL INTOXICATION
Cortex Off Brain Stem Reflexes off EEG is completely Flat
BUT:
Obvious lesion (-) CT and MRI (NL)
TX IN PHEN. TOXICITY
Forced Alkaline Diuresis
AS A RULE:
↓ in LOC means:
1- Bilateral Cortical Damage
2- Brain stem Structural Damage
3- Unilateral Supratentorial Damage extending toward the brain stem or the other Side
LEVEL OF CONSCIOUSNESS (AWAKNESS)
Full Awake(alert)
Drowsiness (Normal Stimulation)
Stupor (Painfull/Forcefull Stimulation)
Coma (Unresponsiveness) or Loss of Verbalization
↓LOC & EEG
EEG ∝ ↓LOC
EEG can determine the level of
consciuosness
NOTE:
Attention
Concentration
Acute Confussional State(↓LOC) : No At. + No Con.
Dementia : Attention Ok + No Concentration
Dementia: ↓ in COC ( not: ↓ in LOC)
TEMPORARY LOSS OF CONSCIOUSNESS
caused by: impaired cerebral perfusion (syncope,
fainting), cerebral ischemia, migraine, epileptic seizures, metabolic disturbances, sudden increases in intracranial
pressure sleep disorders.
SYNCOPE
Syncope may result from:
1. Cardiac,
2. Noncardiac
3. Undetermined causes
CARDIAC CAUSES OF SYNCOPE
decreased cardiac output secondary to cardiac arrhythmias,
outflow obstruction,
hypovolemia,
orthostatic hypotension,
decreased venous return
CEREBRAL ISCHEMIA
Cerebrovascular disturbances due to:
transient ischemic attacks of the posterior or anterior cerebral circulations,
cerebral vasospasm from migraine,
subarachnoid hemorrhage
hypertensive encephalopathy
EPILEPTIC SEIZURES
Absence seizures
Generalized tonic-clonic seizures
Complex partial seizures
SEIZURE OR SYNCOPE?
METABOLIC DISTURBANCES
Cardiac encephalopathy, hepatic encephalopathy, uremia, hypoglycemia, hypoxia, hyponatremia, hypo-/hypercalcemia, hypo-/hypermagnesemia, other electrolyte disturbances toxic and industrial exposures (carbon
monoxide, organic solvent, lead, manganese, mercury, carbon disulfide, heavy metals)
STEP BY STEP MANAGMENT
LOC Detection
6 Step Assessment
IV-Line x2
TNG
ECG
Dizepam
Refer to Specialist
باشید موفق
HEADACHE
Dr. Boroumand
USEFUL QUESTIONS سردرد نوع و تعداد سردرد شروع نحوه سردرد پریودیسیتی و فرکانس برسد خود اوج به سردرد تا کشد می طول چقدر کدامند سردرد تریگر عوامل. میکند پیشرفت چگونه و شود می شروع کجا از درد ضرباندار یا است مداوم خیر یا هست سردرد شروع برای درآمدی پیش آیا سردرد کننده تشدید عوامل. کدامند سردرد دهنده تخفیف عوامل. دارد خود سردرد علت از ای ایده چه بیمار خود
RECENT ONSET Definition:1. American Academy of Neurology
guidelines as a one-month interval.2. a 6- to 12-month interval.
“WORST EVER” HEADACHE An increasingly severe headache,
Change for the worse in an existing headache pattern
all means the possibility of an
expanding intracranial lesion.
HEADACHES OF INSTANTANEOUS ONSET Means an intracranial hemorrhage, usually in the
subarachnoid space but also can be caused by : intracerebral hemorrhage, cerebral venous thrombosis, Embolic cerebellar infarction arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, benign angiopathy of the central nervous system
(CNS), (reversible cerebral vasoconstriction syndrome)
acute hypertensive crisis, idiopathic “primary thunderclap headache”
SAH Explosive Severe Exertinal Resistant Usually with no focal neurological signs
(unless 3th nerve plasy, …) Papilledema and subhyaloid
hemorrhage. Neck stiffness
CVT (CEREBRAL VEIN THROMBOSIS) Female Hypercoagulability state (dehydration,
OCP, pregnancy, delivery) Gradual increasing headache but
sometimes suddenly onset. Resisitant to treatment May have focal neurological signs.
ATTENTION!A history of antecedent head or neck
injury should be sought; even a
relatively minor injury can be associated with:
1. the subsequent development of epidural, subdural, subarachnoid, or intraparenchymal hemorrhage
2. posttraumatic dissection of the carotid or vertebral arteries
EXERTIONAL HEADACHE AND HEADACHE ASSOCIATED WITH SEXUAL ACTIVITY BOTH ARE WORRISOME
1. A primary headache disorder unassociated with structural disease
2. can be associated with migraine
BUTThese must be excluded with the
first occurrence of such headaches. Subarachnoid hemorrhage Arterial dissection, which
CAROTID ARTERY DISSECTION
Commonly manifests with:
1. Neck, face, and head pain ipsilateral to the dissection,
2. Frequently is associated with an ipsilateral Horner's syndrome,
3. Often follows head or neck trauma
4. May cause CRA or Ophthalmic Occlusion and finally Blindness.
5. Tenderness
LOCATION AND TRIGER ZONES Asking the patient to show the location of his or
her pain with a finger often is helpful.
Trigeminal neuralgia is confined to one or more branches of the trigeminal nerve.
Lancinating face pain triggered by facial or intraoral stimuli occurs with trigeminal neuralgia. (CBZ)
Glossopharyngeal neuralgia typically is triggered
by chewing, swallowing, or talking, although cutaneous trigger zones in and about the ear occasionally are present.
HEADACHE AND FOCAL NEUROLOGICAL SIGNS Aura in Migraine Headache
Intracranial Hemorrahges
Carotid Dissection
Neuralgias
Basialr Type Migraine
GCA
MIGRAINE WITH FOCAL NEUROLOGICAL SIGNS
Aura in Migraine Headache:
Some patients with migraine have premonitory symptoms that precede a migraine headache by
hours.
These can include: 1. psychological changes, such as depression,
euphoria, or irritability, or
2. somatic symptoms, such as constipation, diarrhea, abnormal hunger, fluid retention, or increased urination.
MIGRAINE WITH FOCAL NEUROLOGICAL SIGNS–AURA focal cerebral symptoms associated with a migraine
attack. most commonly last 20 to 30 minutes but can last 1 hour. Aura symptoms usually have a gradual onset and
increase over minutes. usually precede the headache. But At other times, the
aura may continue into the headache phase or arise during the headache phase.
Visual symptoms are most common and may consist of either positive or negative phenomena or both.
Other hemispheric symptoms, such as somatosensory disturbances (numbness and/or tingling) or language dysfunction, may occur with or without visual symptoms.
If more than one symptom occurs (e.g., visual plus somatosensory), the onsets usually are staggered and not simultaneous.
3 FINDINGS WHICH CAN DIFFERENTIATE MAIGRAINE INDUCE AURA FROM CVA
1. Positive symptoms 2. the slow spread of
symptoms,
3. staggered onsets help
BASILAR TYPE MIGRAINESymptoms originating from the brainstem
or both cerebral hemispheres simultaneously, such as:
1. vertigo, 2. dysarthria, 3. ataxia, 4. auditory symptoms, 5. diplopia, 6. bilateral visual symptoms in both eyes, 7. bilateral paresthesias,8. decreased level of consciousness,
CVA The location of the pain is a poor predictor of
the vascular territory involved. cortical infarction > deep cerebral
hemisphere infarctions. either steady or throbbing and is rarely as
explosive or as severe as the headache of subarachnoid hemorrhage.
the pain is usually of at least moderate size, TIAs transient head pain in up to 40% of
patients. carotid distribution ischemia frontotemporal
head pain vertebrobasilar ischemia occipital headache.
PSEUDOTUMOR CEREBRI Female/ Obesity/Visual blur.) Drugs (/COPD/hirsutism/PCO Papilledema 6th carnial nerve paresis No special focal neurological signs No other findings in routin lab No special finding in neuroimagining LP/Prednisone/Acetazolimide
GIANT CELL ARTRITIS (TA) Most common feature: headache of an
unknown cause. most common symptom headache
(72%) The headache is most often throbbing + scalp tenderness. often generalized focal tenderness on the affected
superficial temporal > occipital artery. Fisrt step: ESR
RED FLAG OF HEADACHE New Headache Explosive headaches Worsening headaches Focal neurological sings Neck regidity Fever Trauma Inceasing pain with valsalva maneuver Confusion and decrease LOC AIDS Papilledema Old age Tenderness on the scalp Seizure Vomiting
YELLOW FLAGS OF HEADACHE
خواب از بیمار کردن بیدار باشد سر یکطرف در همیشه که سردردی. سردرد تشدید در پوسچر تغییر واضح تأثیر
VERTIGO
Dr. Boroumand
DIZZINESS Dizziness is a term patients use to describe a
variety of symptoms including:
1. spinning or movement of the environment (vertigo),
2. lightheadedness, 3. presyncope,4. Imbalance5. visual distortion, 6. internal spinning, 7. nonspecific disorientation8. anxiety
VERTIGO
sensation of spinning of the environment,
indicates a lesion within the vestibular pathways,
either peripheral or central
VERTIGO
Associated ear symptoms such as
hearing loss and tinnitus
can suggest a peripheral localization, to the inner ear or eighth nerve.
USEFUL QUESTIONS AND SIGNS Associated ear symptomes
Positional dependency
Onset pattern
Focal neurological signs
Risk factors
PHYSICAL EXAM Alertness Changes in severtiy by position
changing Blood pressure (R/o for Ortho. Hypo.) Cranial Nerve Exam (at least 5,6,7,8) Ocular motor function Ataxia Coordination tests Sensation (specially vibration) Focal neurological signs.
OCULAR MOTOR FUNCTION Peripheral pattern of nystagmus:1. A peripheral pattern of spontaneous
nystagmus is unidirectional; that is, the eyes beat only to one side.
2. It usually has a horizontal greater than torsional pattern
3. Suppression with visual fixation, 4. Increase in amplitude with gaze in the
direction of the fast phase5. Decrease with gaze in the direction
opposite that of the fast phase.
SPECIAL PHYSICAL EXAM OKN and VOR-suppression Head thrust test Positing test Fistula test Otoscopy
باشید موفق