Neuro 1

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maps504
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248935
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Neuro 1
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2013-11-25 00:38:26
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neuro 1
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  1. Structure
    1.      Cerebrum:  left, right hemisphere.  frontal, temporal, parietal, occipital lobes.

    •             Functions:  motor sensory functions, language, memory,
    • visual-spatial relationships, higher order process.

    •             Contains:  hypothalamus (endocrine, autonomic
    • functions), thalamus (relays sensory and motor inputs to cortex), basal ganglia
    • (voluntary, autonomic mov’t), limbic system (emotional behavior, basic drives)

     

    •   2. 
    • Brainstem:  vital functions.  Contains: 
    • midbrain, pons, medulla, reticular formation, reticular activating
    • system. 

     

    •   3. 
    • Cerebellum:  coordinates voluntary
    • mov’t, maintain balance, posture
  2. Protective
    Components
    Skull:  bony structure

              

      2.  Meninges:  protective membranes

    •             a.  dura mater: 
    • outermost layer.  Tough, strong
    • connective tissue.  Epidural space =
    • between dura and skull.  Subdural space =
    • between dura and arachnoid membrane 

                b.  arachnoid membrane:  spongy, spiderweb like.  Subarachnoid space =  between arachnoid and pia mater.   

    •             c.  pia mater:  thin layer, provides support for blood
    • vessels. 

     

    •   3. 
    • Cerebrospinal fluid (CSF): 
    • circulates throughout ventricles and subarachnoid space.  Reabsorbed into venous circulation through
    • arachnoid villi which protrudes from venous sinuses into arachnoid space.  Provides cushioning, dec force of impact,
    • carries nutrients.
  3. .  Intracranial
    Pressure
    A.  Definition/Measurement/Regulation

    •             ICP – pressure exerted by total
    • volume from components within skull – brain tissue (80%), blood (10%), CSF
    • (10%).  Normal ICP 5-15mmHg
  4. .  Increased
    Intracranial Pressure
    • A.    Pathophysiology:  Inc in ICP, compensates by dec in production
    • of CSF, displacement of CSF.  If ICP
    • continues, blood volume altered -> results in intracranial HTN

    • 1.  Stage
    • 1:  vasocontriction, external compression

    •             2. 
    • Stage 2:  ICP exceeds brain’s
    • compensatory capacity to adjust. 
    • Pressure compromises oxygenation, arterial vasoconstriction occurs.

    •             3. 
    • Stage 3:  ICP begins to approach
    • arterial pressure.  Brain tissue
    • experiences hypoxia, hypercapnea.  Loss
    • of autoregulation -> vasodilation occurs causing BP to drop, blood volume
    • inc -> more ICP. 

    •             4. 
    • Stage 4:  brain tissue shifts
    • -> herniation, more ICP, compression of brain stem

     

     

    B.  Clinical Manifestations of Inc ICP

    •   1. 
    • change in LOC  

    •   2. 
    • change in vital signs:  late sign
    • – Cushing’s triad

    •             a. 
    • inc in SBP

    •             b. 
    • bradycardia

                c.  irregular respiratory pattern

    •   3. 
    • occular signs

    •   4.  dec
    • motor function:  hemiparesis, posturing

    •             decorticate:  flexion of arms, wrists, fingers with
    • adduction of upper extremities

    •             decerebrate:  extension, internal rotation of upper
    • extremities, wrist flexion 

    •   5. 
    • headache

    •   6. 
    • vomiting

     

    C.  Treatment of Inc ICP

    •   1. 
    • treat and manage cause

    •   2. 
    • diuretics

    •   3. 
    • corticosteroids

    •   4. 
    • mechanical ventilation
  5. Specific Disorders that
    cause Inc ICP
    • Cerebral
    • Edema:  Inc fluid content of brain tissue -> inc
    • in tissue volume -> inc ICP

     

    B.  Hydrocephalus

    •   1. 
    • Definition:  abnormal inc CSF
    • volume

    •   2. 
    • Caused by:

    a.       overproduction

    b.      obstruction of flow

    c.       defective reabsorption

    •   3. 
    • Types:

    •             a. 
    • noncommunicating: flow within subarachnoid space and ventricles
    • obstructed

    •             b. 
    • communicating:  impaired
    • absorption within subarachnoid space or inc secretion

    •   4. 
    • Treatment:

    •             a. 
    • treat cause

    •             b. 
    • shunting procedure
  6. Head Trauma
    A.  Categories: 

    •             1. 
    • Closed (blunt) trauma:  head
    • striking hard surface, or object striking head. 
    • Dura intact.  Causes contusions
    • (focal) and concussions (diffuse)

    •             2. 
    • Open (penetrating) trauma:  injury
    • tears scalp tissue and exposes skull, dura mater or brain.  Causes skull fractures or brain lacerations.

     

     

     

     

     

     

    B.  Closed Head Injury

    1.  Focal Brain Injuries - Contusions

    •     a. 
    • Definition/Etiology:  bruising of
    • brain tissue    

    •     b. 
    • Pathophysiology:  damage results
    • from compression of skull at point of impact and rebound.  Small tears in blood vessels. 

    •     c. 
    • Types:

                1.  coup:  bruising under injury site 

                2.  countercoup:  bruising opposite traumatized site

    •     d.  Clinical
    • Manifestations: 

    1.      loss of consciousness

    2.      loss of reflexes

    3.      brief dec in HR, BP

    4.      residual deficits

    •     e. 
    • Diagnosis:  x-rays, MRI, CT scans

    •     f. 
    • Treatment:  controlling ICP,
    • managing symptoms
  7. 2.  Diffuse Brain Injuries
    .  Concussion

    • 1.      Definition:  sudden transient mechanical head injury with
    • disruption of neural activity

    2.      Clinical Manifestations:

    a.       disruption in LOC                        

    • b.      loss of reflexes causing
    • falls

    c.       amnesia about event         

    •                  
    •       d.   headache

                            e.   nausea

                            f.   fatigue

    •             Post-concussion syndrome – HA,
    • dizziness, poor concentration and memory, fatigue, irritability, depression,
    • personality and behavioral problems. 

     

    b.  Diffuse axonal injury

    •             1. 
    • Definition:  widespread axonal
    • damage, due to shaking effect.  Causes
    • axon swelling, disconnection.    

    •             2. 
    • Clinical Manifestations:

    •                    a. 
    • unconsciousness

    •                    b. 
    • permanent deficits in memory, attention, reasoning, problem-solving

                3.  Treatment:

    •                    a. 
    • maintain airway

    •                    b. 
    • manage inc ICP
  8. Open
    Head Trauma
    • Can
    • lead to fractures and brain lacerations. 
    • Open channel between environment and brain – inc risk of infection.  Bone fragments cause lacerations of brain
    • tissue, damage of cranial nerves.

    •             1. 
    • Clinical Manifestations

    •                    a. 
    • loss of consciousness

    •                    b. 
    • linear fracture – bleeding, hematoma

    •                    c. 
    • basal skull – tear in dura, leakage of CSF out nose (rhinorrhea) and
    • ears (otorrhea)

    •                    d. 
    • severe lacerations – bleeding, inc ICP

    •             2. 
    • Treatment:

    •                  
    • a.  debridement of traumatized
    • tissue

    •                  
    • b.  manage inc ICP           

    •                   c. 
    • antibiotics                                

    •                  
    • d.  observe for infection

                           

    D.  Complications of Head Trauma

    1.  Epidural Hematoma   (extradural)

    •             a. 
    • Def/Patho:  bleeding in epidural
    • space, usually arterial.  Develops
    • rapidly, high pressure -> rapid compression of brain

    •             b. 
    • Clinical Manifestations:

    •                  
    • 1.  unconsciousness

    •                  
    • 2.  if brain herniation – LOC
    • lost, ipsilateral pupil dilation, contralateral hemiparesis

    •             c. 
    • Treatment:  emergency surgical
    • intervention

     

    2.  Subdural Hematoma

    •             a. 
    • Def/Patho:  bleeding in subdural
    • space, usually venous

    •             b. 
    • Types:

    1.      acute

    2.      subacute

          3.   chronic

    •             c. 
    • Clinical Manifestations:

    •                  
    • 1.  acute/subacute:  inc ICP, HA, drowsiness, agitation,
    • restlessness, confusion

    •                  
    • 2.  chronic:  HA, tenderness over hematoma, progressive
    • confusion, memory loss

    •             d. 
    • Treatment:  craniotomy

     

    3.  Intracerebral Hematoma

    •             a. 
    • Def/Patho:  small blood vessels
    • traumatized by penetrating injury or shearing forces

    •             b. 
    • Clinical Manifestations: 

    •                  
    • 1.  change in LOC

    •                  
    • 2.  contralateral hemiplegia

    •                  
    • 3.  inc in ICP – lead to
    • herniation

    •             c. 
    • Treatment:  dec ICP, allow
    • hematoma to reabsorb
  9. Infections/Inflammatory
    Conditions
    .  Meningitis

    •    1. 
    • Definition:  acute inflammation of
    • meninges

               

    •    2. 
    • Etiology:  infection – bacterial,
    • starts in blood or bacteria enters CNS through nose, ears, sinus

               

    •    3. 
    • Pathophysiology:  Bacteria enters
    • CNS, infection spreads into ventricles and CSF -> causes irritation and
    • inflammation.  Irritated meninges
    • hyperemic and permeable so blood cells migrate into subarachnoid space
    • producing exudate -> thickens CSF -> obstructs arachnoid villi and
    • produces hydrocephalus.  Or exudate can
    • also extend into cranial and spinal nerves causing nerve irritation.

               

    •    4. 
    • Clinical Manifestations:

    a.       fever

    b.      HA

    c.       lethargy

    d.      stiff neck

    e.       vomiting

    f.       photophobia

    g.      convulsions

    h.      altered LOC

    • i.       
    • impaired communication         

    • Check
    • for meningeal irritation: 

    •             Brudzinski sign - flex head and neck
    • to chest – causes hips and knees to flex  


    •             Kernig’s sign – flex leg at hip at
    • 90 degrees – can’t extend leg without hamstring pain

     

    •    5. 
    • Diagnostic Tests:  culture of CSF,
    • blood

               

    •    6. 
    • Treatment:  antibiotics

     

    B.  Encephalitis

    •    1. 
    • Definition:  acute febrile illness
    • with inflammation of brain -> nervous system involvement

               

       2.  Etiology:  viral infection.  Herpes simplex virus, type 1

     

    •    3. 
    • Pathophysiology:  meningeal
    • involvement with damage to nerve cells of brain and cerebral edema.  Edema causes inc ICP, can lead to herniation.

               

    •    4. 
    • Clinical Manifestations:

    •                 
    • a.  fever                                         

    •                 
    • b.  HA

    •                 
    • c.  disorientation

    •                 
    • d.  seizures

    •                 
    • e.  paralysis/paresis

     

    •    5. 
    • Diagnostic Tests:

    •                 
    • a.  CSF eval

    •                 
    • b.  WBC count

    •                 
    • c.  MRI or CT

               

    •    6. 
    • Treatment:

    •                
    • a.  antivirals  (acyclovir)

    •                
    • b.  dec cerebral edema with
    • diuretics, steroids

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