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PPT Neurological syndromes in systemic diseases and general medicine - Karya Tulis Ilmiah

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(1)

Neurological syndromes Neurological syndromes in systemic diseases and in systemic diseases and

general medicine general medicine

Marta Lipowska Marta Lipowska

(2)

Encephalopathy

• Brain pathology of varies origins (metabolic, degenerative, genetic, posttraumatic, ischemic, hypoxic…)

• Generally it affects large parts of the brain instead of leading to identifiable focal

changes

• Often developes when the reason is outside the brain

(3)

Encephalopathy

• Deprivation of oxygen (hypoxia, diffuse ischemia), substrate (hypoglycemia) or metabolic cofactor (thiamine deficiency)

• Diseases of organs other than the brain:

– Liver (hepatic coma) – Kidney (uremia)

– Lung (CO2 narcosis) – Pancreas

– Pituitary

– Thyroid (myxedema, thyrotoxicosis) – Adrenal

• Exogenous poisons

• Abnormalities of ionic or acid-base environment

• Disordered temperature regulation (hypothermia, heat stroke)

• Primary neuronal or glial disorders

(4)

Ischemia Hypoxia Metabolic abnormalites Brain dysfunction

headache,

disorder of consciousness:

(drowsinessconfusion, stupor coma)

convulsions,

involuntary movements (mioclonic) focal neurological syndromes

(5)

Glasgow coma scale

Estimates the level of consciousness Scores:

Eye opening response (1-4 points) Verbal response (1-5 points)

Motor response (1-6 points) 3-8 points - coma

(6)

Seizures (convulsions) as a part of ecephalopathy

• Metabolic abnormalities: glucose, Na, Ca, Mg

• Toxic factors („irritating”)

• Drugs (neuroleptics)

• Acute brain disorders (stroke, inflammation, trauma)

(7)

a patient with pneumonia (secondary CNS hypoxia)

confusion

(8)

A patient with encephalopathy- how to diagnose?

Blood and urine tests

Chest X-ray, other pulmonary investigations Cardiological investigations etc.

Sometimes

Neurological examinations:

CT scan, MRI, CSF

(9)

• Brain MRI scan in metabolic encephalopathy (renal failure)?

(10)

• Brain MRI scan in metabolic encephalopathy (renal failure)?

• EEG reflects level of consciousness

(changes in the EEG correlate with the severity of cerebral dysfunction)

(11)

EEG

• Alert

• drowsy

• lethargic

• stuporous

• comatose

• brain dead

• Normal EEG

• Different

abnormalities

• Electrocerebral silence

Worse ence- phalo- pathy

(12)

Peripheral aquired neuropathies Peripheral aquired neuropathies

• metabolic (diabetic, uremic)

• associated with dietary states

• Vasculitic (usually associated with systemic diseases)

• Acromegalic, hypo- hyperthyroid

• paraneoplastic

• paraproteinemic

(13)

Signs and symptoms of Signs and symptoms of

neuropathy neuropathy

• Motor deficit- flaccid weakness

• Sensory deficit- pain, paresthesia, sensory loss, ataxia

• Autonomic involvement

(14)
(15)
(16)

Distribution of neuropathy Distribution of neuropathy

Polyneuropathy- symetric, diffuse lesions of Polyneuropathy- symetric, diffuse lesions of peripheral nerves, distal

peripheral nerves, distal

Mononeuropathy- disorder of a single nerveMononeuropathy- disorder of a single nerve

Mononeuropathy multiplex – focal involvement Mononeuropathy multiplex – focal involvement of two or more nerves

of two or more nerves

(17)
(18)

Cardiovascular disorders

• Brain ischemia during:

– Heart attack – Arrhythmia

– Blood pressure  or  – Heart failure

• Ischemic stroke with embolic material form heart:

– Artrial fibrillation

– Aortic or valve mitral disease, specially with bacterial vegetation

– Bacterial miocarditis

(19)

Lung diseases

• Pneumonia

– hipoxia

– Risk of bacterial meningitis

• Lung cancer

– Paraneoplastic syndromes – Metastases

– Pancoast`s syndrome – superior sulcus lungs tumors – brachial plexus damage

• Chronic pulmonary insufficiency

– Noctural headaches

(20)

Renal diseases- renal failure

• Uremic encephalopathy

• Uremic neuropathy

• Dialysis dysequilibrium syndrome (usually seen with rapid dialysis at the onset of dialysis

program)

– Headache, nausea, muscle cramps, rarely convulsion, delirium

• Neurologic complication of renal transplantation

(21)

Hematologic diseases

• Leukemias

– Hemorrhage socondary to thrombocytopenia – Infections secondary to low white blood cells

counts

– Tumors of CNS

– Meningeal invasion (of any acute lymphoma) – Complications of chemiotherapy

(22)

Hematologic diseases

• Polycythemia

– Large nad small vessel cerebral infaction (hyperviscosity)

– Hemorrhages socondary to thrombocytopenia

• Platelet disorders (primary or secondary)

– infarctions and hemorrhages

• Disorders of coagulation (deficiency of ATIII, factors involved in plasma coagulation)

– Ischemic stroke in young patiens

(23)

POEMS syndrome

• P-polyneuropathy

• O-organomegaly

• E-endocrynopathy

• M- monoclonal protein

• S-skin changes (angiomas, hiperpigmentation)

– In the course of solitary osteosclerotic plasmocytoma

(24)
(25)
(26)

Endocrine diseases

Thyroid – Hypothyroidism

• Changes in cognition and level of consciousness  myxedema coma

• Entrapment neuropathy- carpal tunnel

syndrome (attributed to the accumulation of acid mucopolysaccarides in the nerve

(27)

Endocrine diseases

Thyroid - hyperthyroidism

• Ophalmoplegia (Graves disease)

• Thyreotoxic myopathy – weakness,

wasting of the muscles, myasthenic signs

• Thyreotoxic periodic paralysis

• Irritation, anxiety

(28)
(29)

Endocrine diseases

Hypoparathyroidism

• Symptoms of hypocalcemia

– tetany – muscle spasms, paresthesia – Convulsions

– Irritation, insomia

(30)

Diabetes mellitus

Diabetic neuropathy- occurs in 80% of patients

• Distal symetric, predominantly sensory, with or without autonomic manifestations

(the main problem- pain)

• Mononeuropathies

– Liability to pressure palsies (CTS) – Cranial nerve palsies

(31)

Neurogenic diabetic foot- pathogenesis Neurogenic diabetic foot- pathogenesis

pain and temperature sensory loss – susceptibility to injurespain and temperature sensory loss – susceptibility to injures

autonomic nerves involvement –dry skin, vascular autoregulation disturbencesautonomic nerves involvement –dry skin, vascular autoregulation disturbences

(32)

Garland`s syndrome

-

femoral nerve damage (diabetic focal neuropathy)

(33)

Diabetes mellitus

• stroke risk factor

• hypo-, hyperglicemia:

– decrease of consciousness  coma – Convulsions

– Stroke-like episodes (focal syndromes)

(34)

Liver diseases

• Chronic liver disease, when portal

hypertension induces an excessive portal collateral circulation cerebral intoxication

Encepalopathy, hepatic coma

(35)

Viral hepatitis type C

- extrahepatic manifestations

• Cryoglobulinemia

• Peripheral neuropathies

(36)

Vitamin B12 (cyjanocobalamin) deficiency

• Megaloblastic anemia

• Classic clinical syndrome of subacute degeneration of spinal cord and

polineuropathy

(37)

Neurologic paraneoplastic syndromes

• Results from indirect effect of primary malignancy on the nervous system (or other organs)

• Usually autoimmune cause:

The host makes antibodies against antigens in the neoplasm and that these antibodies cross- react with neural antigens

(anti- onconeural antibodies, anty –Hu)

(38)

Neurologic paraneoplastic syndromes

• Usually precede primary neoplasm occurence !!! (the most strong

immunologic reaction at the beginning)

• Some patients may have easy controlled neoplasm but die from the neurologic

disorder

(39)

Neurologic paraneoplastic syndromes

May affect any part of peripheral and central nervous system

• Encephalomyelitis

• Limbic encephalitis

• Cerebellar degeneration

• Opsoclonus

• Sensory neuropathy

• Myasthenic Lambert-Eaton syndrome

• Dermatomyositis and polymyositis

(40)

Treatment

• Treatment of underlying malignancy

• Immunomodulatory therapy

(41)

Collagen-vascular diseases

• Periarteritis nodosa

• systemic lupus erythematosus,

• rheumatoid arthritis,

• Wegener granulomatosis

• Churg- Strauss vasculitis

Vasculitis syndromes

(42)

• Vasculitis of central and peripheral vessels of nervous system

• Encephalopathy- multiple infarcts

• Vasculitic neuropathy

(43)

Alcohol abuse

• Acute alcohol intoxication – decrease of consciousness (euphoria/dysphoria,

slurred speech and ataxic gait, stupor  coma)

• Ethanol withdrawal syndromes (in dependency) :

tremor, hallucinosis, seizures delirium tremens

(44)

Chronic alcohol abuse

• Wernicke-Korsakoff syndrome - Thiamine deficiency : dementia,

amnesia, sometimes with confabulation

• Alcoholic cerebellar degeneration

• Alcoholic neuropathy, myopathy

• head trauma

• Complications of head

trauma+withdrawal syndromes-

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