INTRODUCTION TO NEUROLOGY

Dr Muhammad Wazir Ali Khan

Assistant Professor Neurology Sheikh Zayed Medical College/Hospital Rahim Yar Khan

Neurology
Central Nervous system
Brain Spinal cord

Peripheral Nervous System

Roots Plexus Peripheral nerves NMJ Muscle

Neurology- Major diseases

Vascular
Stroke Vascular malformations
Multiple sclerosis Transverse myelitis Meningitis Encephalitis

Inflammatory Infections

Degenerative

Parkinsons disease Alzheimers disease

Neurology- Major diseases

Motor neuron disease

AIDP/GBS Polymyositis/dermatomyositis Myasthenia Gravis

Muscular dystrophies

Neurological Investigation
NEURO-RADIOLOGY
Skull and Spinal X-rays Computed Tomography: CT Magnetic Resonance Imaging: MRI Doppler Studies

Digital Cerebral and Spinal Angiography

Isotope Bone Scanning Positron Emission Tomography (PET) Single Proton Emission Computed Tomography (SPECT)

Neurological Investigation
NEURO-PHYSIOLOGY.
Electroencephalography (EEG), Electromyography and Nerve Conduction Studies. Cerebral-evoked Potentials.

LABORATORY TESTS.

Cerebrospinal Fluid (CSF) Examination. Specialized Tests in Specific Diseases. Auto-antibodies. Serum copper and ceruloplasmin. Blood lactate, S. phytanic acid, S. long-chain FA. Brain, muscle and nerve histopathology. Genetic studies.

Skull and Spinal X-rays

Fractures of the skull vault or base, destructive and degenerative changes. Osteomyelitis, Paget's disease, abnormal skull foramina, fibrous dysplasia. Enlargement or destruction of the pituitary fossa intrasellar tumour, raised intracranial pressure. Intracranial calcification - tuberculoma, cysticercosis. oligodendroglioma, wall of an aneurysm.

Skull and Spinal X-rays

Skull and Spinal X-rays

Computed tomography: CT

Computed tomography: CT
Introduced in mid-1970s. A collimated X-ray beam moves synchronously across slices of brain. Hounsfield number assigned to its density (air = -1000 units; water = 0; bone = +1000units). Helpful in early diagnosis of hemorrhage.

Infarct, tumor, blood and edema.

I.V contrast enhances areas of increased vascularity.

Computed tomography: CT
Spinal CT for fractures and deformities. CT myelography for cord compression and spinal tumors. Fast multi-slice scanners take less time. 3-D resolution with newer scanners. CT cerebral and spinal angiography.

Computed tomography: CT

Frontal Lobe Frontal Horn

Temporal Lobe
Parietal Lobe

Basal Ganglia Calcification

Occipital Horn

Computed tomography: CT

Cerebellum

Brainstem

Air Sinus

MAGNETIC RESONANCE IMAGING: MRI

The hydrogen nucleus is a proton whose electrical charge creates a local electrical field. Protons are subject to radiofrequency waves at right angles to their alignment. The protons resonate and spin, then revert to their normal alignment. As they do so, images are made at different phases of relaxation, known as T1, T2, T2 'STIR', diffusion-weighted imaging (DWI) and other sequences.

From these sequences, referred to as different weightings, recorded images are compared. Gadolinium is used as an intravenous contrast medium.

MAGNETIC RESONANCE IMAGING: MRI

MAGNETIC RESONANCE IMAGING: MRI

MRI: Advantages over CT

MR distinguishes brain white and grey matter. Spinal cord and nerve roots are imaged directly.

Pituitary imaging.
MRI has greater resolution than CT (0.5cm). No radiation is involved. Magnetic resonance angiography(MRA & MRV). It is useful in muscle disease, e.g.myositis. Tumours, infarction, haemorrhage, clot, MS plaques, posterior fossa, foramen magnum and spinal cord.

MRI: Limitations
Time and cost. Imaging one region takes about 20 minutes. Patients do need to cooperate. Claustrophobia.

A general anaesthetic may be necessary.

Patients with pacemakers or with metallic bodies in the brain cannot be imaged. MR imaging for some days after lumbar puncture frequently shows diffuse meningeal enhancement with gadolinium.

CT and MRI Imaging characteristics of various tissues

Doppler Studies
B-mode and color ultrasound are valuable in detection of stenosis of the carotid arteries

Digital cerebral and spinal Angiography

Contrast is injected intraarterially or intravenously. Mortality and risk of stroke (<1%). Sequences of the aorta, carotid and vertebral arteries demonstrate occlusion, stenoses, atheroma and aneurysms. Spinal angiography images cord arteriovenous malformations.

Digital cerebral & Spinal Angiograms

Isotope Bone Scanning

Radiolabelled isotopes used to demonstrate uptake by areas of increased vascularity. Useful in identifying bone metastases.

Isotope Bone Scan

Positron Emission Tomography (PET)

Single Proton Emission Computed Tomography (SPECT)

These techniques image function more than anatomy by tracking the uptake and metabolism of radioisotopes. Currently employed for research purpose.

PET Scan-Parkinsons Disease

MR SPECT Scan-Epilepsy

Electroencephalography (EEG)
EEG recorded from scalp electrodes. Valuable in diagnosing epilepsy and diffuse brain diseases and confirmation of brain death in certain cases.

EEG-Normal

Electromyography and Nerve Conduction Studies

Nerve conduction study is performed by electrical stimulation of superficial nerve.
EMG is performed with concentric needle electrode inserted into voluntary muscles. Valuable in the diagnosis of neuromuscular junction disordes, myopathies and neuropathies.

Nerve Conduction Studies

Electromyography

Cerebral-Evoked Potentials
Visual-evoked potentials record the time for a visual stimulus to reach the occipital. Their value is chiefly to confirm previous retrobulbar neuritis which leaves a permanently delayed latency despite clinical recovery. Similarly auditory and somatosensory potentials (from a limb) are also used to monitor brain and cord during neurosurgery.

Cerebral-Evoked Potentials

Cerebrospinal Fluid (CSF) Examination

Diagnosis of meningitis and encephalitis. Measurement of CSF pressure, e.g. idiopathic intracranial hypertension. Removal of CSF therapeutically, e.g. idiopathic intracranial hypertension. Diagnosis of miscellaneous conditions, e.g. MS, neurosyphilis, sarcoidosis, Behcet's disease, neoplastic involvement, polyneuropathies. Intrathecal injection of contrast media and drugs. Headache, worse on standing is a common complaint for

several days (or more) following LP.

Lumbar Puncture

Characteristic CSF formulas

Biopsy
Brain biopsy: Diagnoses of tumors, Infectious agents. Muscle Biopsy: Histology, Immunostaining for myopathies and myositis. Nerve Biopsy: Diagnoses of certain hereditary and acquired diseases of nerves.

Muscle Biopsy

Nerve Biopsy

Specialized tests in specific diseases

Anticardiolipin and lupus anticoagulant antibody and detailed clotting studies in stroke. Acetylcholine receptor antibody in myasthenia gravis. Serum copper and ceruloplasmin in Wilson's disease. Blood lactate studies (failure to rise on exercise) in McArdle's syndrome. Serum phytanic acid (elevated ) in Refsum's disease.

Serum long-chain fatty acid - adrenoleucodystrophy.

NeuroGenetics
Genetic studies - e.g.
Huntington's disease. Hereditary sensorimotor neuropathies. Duchene muscular dystrophy.