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Copyright © 2016, Elsevier Inc. All Rights Reserved. 1

Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Essentials of Human Diseases and Conditions

6th edition

Margaret Schell FrazierJeanette Wist Drzymkowski


Chapter 13

Neurologic Diseases and Conditions


Learning ObjectivesLesson 13.1: Vascular Disorders, Head Trauma, and Spinal Cord Injuries

1. Name the main components of the nervous system.

2. Describe how data are collected during a neurologic assessment.

3. Name the common symptoms and signs of a cerebrovascular accident (CVA).

4. Name the three vascular disorders that may cause a CVA.

5. Define a transient ischemic attack (TIA).


6. List some of the problems to which the nervous system is susceptible.

7. Distinguish between (a) epidural and subdural hematomas and (b) cerebral concussion and cerebral contusion.

8. Describe three mechanisms of spinal injuries.

9. Name the goals of treatment of spinal cord injuries.

Learning ObjectivesLesson 13.1: Vascular Disorders, Head Trauma, and Spinal Cord Injuries (Cont.)


Orderly Function of the Nervous System

A complex network composed of:Ø Neurons (nerve cells that make up the brain)Ø Spinal cordØ Nerves

Composed of two divisionsØ Central nervous system (brain and spinal cord)Ø Peripheral nervous system


Brain and Spinal Cord


Neurons


Central Nervous System (CNS)

Processes and stores sensory and motor information, governs state of consciousnessØ Frontal lobe of the cerebrum controls intellectual functions of thinking, willing, remembering, deciding, and personality

Ø Coordination, equilibrium, and posture coordinated in the cerebellum of the brain

Ø Hypothalamus regulates secretion of hormones from pituitary gland

Ø Medulla oblongata has vital centers that regulate heart rate, blood pressure, and respiration


Functional Areas of the Brain

From Gould BE, Dyer RM: Pathophysiology for the health professions, ed 4, St Louis, 2012, Saunders.


Neurologic Assessment

Methods to evaluate neurologic statusØ Take thorough medical historyØ Test speech, language, and writing skillsØ Test cranial nerve function Ø Test muscle strength and toneØ Test coordination and balanceØ Test sensory function (diminished or abnormal sensation)


Peripheral Nervous System (PNS)

Peripheral nerves connect with the spinal cord;; the information they carry travels to and from brain and spinal cordØ Sensory (afferent) nerves transmit impulses from parts of the body to the spinal cord and brain

Ø Motor (efferent) nerves transmit impulses away from the CNS and produce responses in muscles and glands

The PNS contains 12 pairs of cranial nerves


PNS and Cranial Nerves


Spinal Nerves


Nervous System

Four major blood vessels supply the brain with essential oxygen and nutrientsØ The carotid arteries (two internal and two external) are located in the anterior portion of the neck

Ø Two vertebral arteries join with the two anterior and posterior cerebral arteries and the two anterior and posterior communicating arteries • Circle of Willis is formed by these arteries


Autonomic Nervous System


Circle of Willis


Nervous System Problems

Vascular compromise and circulatory deficits Injury Infection Inherited defect Congenital defect Degeneration Tumor


Cerebrovascular Accident (CVA)


Cerebrovascular Accident (Stroke)

Common stroke symptoms include: Ø Sudden severe headache, aphasia, dysphasiaØ Sudden weakness, numbness, paralysisØ Sudden confusion or loss of vision, blurred visionØ Sudden dizziness, loss of balance or coordination

CVAs result from occlusion of an artery caused by an atheroma, sudden obstruction by an embolus, or a cerebral bleed


Treatment of Cerebrovascular Accident (Stroke)

Immediate medical intervention within 3 hours may limit brain damage

Includes:Ø Immediately chewing an aspirinØ Surgery to improve circulation and remove clotsØ Surgery to repair broken or bleeding blood vessels and drugs to prevent or reverse brain swelling


Arteriovenous Malformations

Formed during fetal development, arteriovenous malformations are abnormal structures of the blood vessels

Although usually found in the brain, AVMs may be located in any vascular structureØ Arterial blood moves directly into the veins, giving the blood vessels the appearance of a tangled mass

Diagnosis made by assessment of the clinical signs and imaging studies


Cerebral Aneurysms

Abnormal localized weakening, thinning, or dilation of the wall of a cerebral artery or vein resulting in a ballooning of the blood vessel

Cerebral aneurysms often cause no symptoms and go unnoticed until rupture or leakage occurs

Etiology may be a congenital defect, atherosclerosis, hypertension, infection, cancer, drugs, or trauma to the head


Transient Ischemic Attack

Often are referred to as “little strokes”Ø Individual may report sudden weakness and numbness down one side of the body, dizziness, dysphagia, confusion, difficulty seeing with one eye, and/or loss of balance

Most common cause of TIA is a piece of plaque, which breaks away from the wall of an artery and travels to the brain

Treatment depends on the location of the TIA and the underlying cause


Transient Ischemic Attack (Cont.)


Transient Ischemic Attack (Cont.)

Anticoagulant therapy may include heparin, enoxaparin, warfarin, aspirin, ticlopidine, and dipyridamole

Prognosis varies according to extent and duration of the ischemia

Prevention includes positive lifestyle changes to reduce controllable risk factors

Instructions should be given concerning possible symptoms of an impending stroke


Epidural and Subdural Hematomas

Epidural hematoma: Mass of blood that forms between the skull and the dura mater

Subdural hematoma: A similar mass, but it forms beneath the dura mater

Symptoms of an epidural hematoma typically appear within a few hours of head traumaØ Sudden headache, dilated pupils, nausea and often vomiting, increased drowsiness


Epidural and Subdural Hematomas (Cont.)


Epidural and Subdural Hematomas (Cont.)

Result when blood from ruptured vessels seeps into and around the meningeal layers

If the person loses consciousness, rapid medical attention is neededØ A craniotomy may be necessary

A patient not losing consciousness but displaying symptoms should be seen ASAP

Provide postsurgical instructions for care of incision


Cerebral Concussion

Patients may experience a loss of consciousness;; respirations become shallow, pulse rate is depressed, and muscle tone is flaccid

A cerebral concussion is an injury resulting from impact with a blunt object, either by receiving a blow to the head or by falling

Treatment is bed rest and observation for signs of behavioral changes

Prognosis is unpredictable, depends on the extent


Head Injuries


Cerebral Contusion

Symptoms and signs of a contusion vary according to the site and extent of the injuryØ When conscious, the person may report a severe headache and hemiparesis;; may appear drowsy and lethargic or hostile and combative

Caused by a blow to the head or impacting against a hard surface

Patients need to be hospitalized so that their vital signs can be monitored and rapid medical intervention can be available


Closed Head Injuries

From Stevens A, et  al: Core pathology, ed 3, London, 2010, Mosby/Elsevier.


Depressed Skull Fracture

Symptoms depend on the site of the fractureØ A bone fragment pressing on the motor area of the brain may cause hemiplegia

Ø Signs include bleeding from the wound, ears, nose, or around the eyes;; changes in pupils;; clear or bloody drainage from ears or nose

Direct impact on the skull with a blunt object is the most common cause

Treatment: Craniotomy and bone elevation;; head protection is worn until healed


Skull Fractures


Types of Paralysis


Paraplegia and Quadriplegia

Paraplegia: Loss of nerve function below the waist, resulting in paralysis of the lower trunk and legs

Quadriplegia: Loss of nerve function below the cervical region, resulting in paralysis of arms, hands, trunk, and legs

When the spinal cord is injured, a part or parts of the body inferior to the point of injury may be affected


Symptoms of Paraplegia and Quadriplegia

ParaplegiaØ Loss of motor and sensory control in lower extremities and trunk

Ø Loss of bladder, bowel, and sexual function Quadriplegia

Ø Loss of motor and sensory control in upper and lower body

Ø HypotensionØ HyperthermiaØ Bradycardia Ø Respiratory problems


Paraplegia and Quadriplegia (Cont.)

Spinal cord injuries that cause paraplegia and quadriplegia are the result of vertebral fractures or vertebral dislocationØ Trauma to the thoracic and lumbar regions of the spine (T1 and below) usually results in paraplegia

Ø Trauma to the cervical vertebrae (C5 or above) may result in quadriplegia

Treatment: Restoration of normal alignment and stability of spine;; decompression of spinal cord;; early rehabilitation


Spinal Injuries


Effects of Spinal Cord Damage

From Gould BE, Dyer RM: Pathophysiology for the health professions, ed 4, St Louis, 2012, Saunders.


Learning Objectives Lesson 13.2: Intervertebral Disk

Disorders and Functional Disorders10. Explain the neurologic consequences of the deterioration or rupture of an intervertebral disk.

11. Explain why cephalalgia sometimes is considered a symptom of underlying disease.

12. Describe the symptoms of a migraine.13. Describe first aid for seizures.14. Explain how the symptoms of Parkinson disease are controlled.


15. Describe the progression of amyotrophic lateral sclerosis (ALS).

16. Discuss restless legs syndrome (RLS).

Learning Objectives Lesson 13.2: Intervertebral Disk

Disorders and Functional Disorders (Cont.)


Degenerative Disk Disease

When pain occurs, it radiates down the nerve path, may be described as burning, and can become intractableØ May be accompanied by loss of some motor functions in the legs

As a person ages, the water in the disk decreases, causing degenerative disk disease

The present treatment includes advising the patients to be as active as possible


Treatment of Degenerative Disk Disease

Narcotic analgesics and NSAIDs Oral steroids Epidurals or selective nerve root blocks Physical therapy Surgical intervention might be necessary When surgical intervention is not an option, lidocaine topical (Lidoderm) patches may be prescribed


Transcutaneous Electrical Nerve Stimulation

Small electronic units operate with 9-volt power to produce high frequency electrical impulses that are transmitted to the surface of the skin through electrodes

TENS units and the nondrug therapy option permit many with chronic pain to return to a fairly normal lifestyle

TENS units may be ordered for pain relief of chronic back pain, spinal stenosis, sciatica, arthritis, and postherpetic neuralgia


Herniated and Bulging Disk

Each disk acts as a shock-absorbing cushion for the vertebrae and gives the back its flexibility

The nucleus pulposus is contained within the annular wall in a bulging disk

The rupture can cause severe back pain and even disability if it presses against or pinches the spinal nerves

Most herniated disks occur in the lower back


Herniated and Bulging Disk


Herniated Disk


Herniated and Bulging Disk (Cont.)

Herniated and bulging intervertebral disks usually result from accumulated trauma

Physical examination of the back is performed to rule out other possible causes of the patient’s symptoms

Conservative treatment consists of the use of hot or cold packs and the administration of muscle relaxants and analgesics

Prognosis depends on the extent and duration


Sciatic Nerve Injury:Spinal Stenosis

Rupture of one or more disks or their nuclei produces severe, sharp pain radiating from the sciatic nerve down the leg and to the foot Ø The pain may be continuous or intermittent

Trauma to the sciatic nerve may result from a fall, poor body mechanics, or gunshot or stab wounds


Treatment of Sciatic Nerve Injury: Spinal Stenosis

Strengthening core muscles (after inflammation subsides)

Medications (analgesics, muscle relaxants, antiinflammatories, and, in some cases, narcotics)

Physical therapy may help relieve pain Corticosteroid epidural injections may relieve pain and reduce inflammation

Surgical intervention


Headache

May be acute or chronic and located in the frontal, temporal, or occipital regions of the head

The type of pain may vary from dull and aching to almost unbearable

Brain tissues themselves never ache because they do not contain sensory nerves

Is sometimes a symptom of an underlying disorder or disease


Headache (Cont.)

Irritation factors The first cause is strain on facial, neck, and scalp muscles resulting from tension

The second cause is edema within the blood vessels of the head

The cause of the headache determines the type of treatment chosenØ For no underlying cause: Use analgesics, muscle relaxants, minor tranquilizers, muscle massages, and relaxation


Migraine

Warning signs include visual auras and photophobia

Persons feel abnormally fatigued and irritable;; numbness or tingling in one arm or on one side of the body, dizziness, and temporary mental confusion

It is not known why some people are subject to migraines or what triggers themØ There is a strong suspicion of inherited or genetic aspects


Treatment of Migraines

Bed rest in a quiet, dark room Analgesics Drug therapy (vasoconstrictors) to constrict blood vessels

Antiemetics (to control vomiting) Triptans Relaxation therapy Biofeedback


Epilepsy: A Seizure Disorder

Epilepsy takes many forms and has a variety of manifestationsØ Generalized seizures cause a diffuse electrical abnormality within the brain and include absence and tonic-clonic attacks

Ø Tonic-clonic seizures may begin with a loud cry, followed by falling to the ground and loss of consciousness

Ø Status epilepticus occurs when one seizure follows another with no recovery of consciousness between attacks


Epilepsy: A Seizure Disorder (Cont.)

In idiopathic epilepsy, no apparent cause for the abnormal electrical discharge is found

In symptomatic epilepsy, a known abnormality in the brain resulting from a pathologic process seems to trigger seizures

Anticonvulsant medications are the treatment of choice for epilepsyØ Close monitoring and adjustments of dosage to attain good therapeutic control are essential


First Aid for Seizures

From Epilepsy Foundation, www.epilepsy.com.


Parkinson Disease

Symptoms may be associated with aging until the recognizable paradigm of Parkinson disease emergesØ A primary symptom is tremor or trembling in hands, arms, jaw, face, and legs

Ø There is a rigidity or stiffness of limbs and trunk, causing the posture to be stooped

What causes the degeneration of nerves in the motor system of the brainstem is not known


Posture and Gait of Parkinson


Parkinson Disease (Cont.)

Diagnosis is based on the characteristic history and careful neurologic examination

Treatment is individualized to the patient Parkinson disease cannot be cured Medical management consists of supportive measures and control of symptoms with the administration of drugs

Physical therapy helps the patient maximize mobility within the limitations


Huntington Chorea

Has an insidious onset, with the loss of musculoskeletal control exhibited by subtle, semipurposeful movementsØ The arms and face are the first areas to be involved, with movements ranging from mild fidgets to tongue smacking

Disruption in personality and personality changes may occur

Transmitted by an autosomal-dominant trait that can be inherited by either sex


Treatment of Huntington Chorea

Treatment is supportive, symptomatic, and protective

Haloperidol (Haldol) and fluphenazine (Prolixin) are prescribed in an attempt to control choreic movements and to reduce agitation

At the present time, no cure for Huntington chorea is known


Amyotrophic Lateral Sclerosis (ALS)

Fasciculations and accompanying atrophy and weakness are noted in the forearms and hands

These patients progress to having difficulties in speech, chewing, swallowing, and breathing;; eventually, a ventilator is required

Although the etiology of ALS is uncertain, some cases may be caused by autosomal inherited traits


Treatment of ALS

Treatment involving a team of caregivers consists of supportive measures and therapy directed at controlling symptoms

Drug therapy includes tizanidine and baclofen Other medications are used to reduce fatigue, spasticity, pain, sleep difficulties and excess saliva


Restless Legs Syndrome (RLS)

There are feelings that often are described as itching, burning, jittery, creepy-crawly, pulling, tugging, and/or painful sensations in the legs

The inability to sit for extended periods of time often interferes with normal activities

The exact cause of RLS is unknown Blood tests may show low blood iron content Treatment involves identifying the underlying cause of the disorder and treating that


Learning Objectives Lesson 13.3: Peripheral Nerve Disorders,

Infectious Disorders, and Intracranial Tumors17. Discuss transient global amnesia.18. Distinguish between trigeminal neuralgia and Bell palsy.

19. List the diagnostic tests used for meningitis, and explain how the causative organism is identified.

20. Name the common causes of encephalitis.21. Explain the pathologic course of Guillain-Barré syndrome.

22. Explain what is meant by post-polio syndrome.


Transient Global Amnesia

The learning process is completely blocked and memory disturbances are involvedØ Repetitive asking of questions such as “Where are we going?” “Why are we going there?” “Where am I?” and “Why did we do that?” is typical

Usual tasks are performed without difficulty and neurologic signs are normal

Etiology is unknown Treatment is supportive


Peripheral Neuritis/Neuropathy

Unless the precipitating factors are severe infection or chronic alcohol intoxication, the onset is insidiousØ Clumsiness and loss of sensation in the hands and feet are followed by a flaccid paralysis and a wasting of muscles in these areas

Ø Deep tendon reflexes become diminished, and tenderness is noted in the atrophied muscles

There are several causative factors


Treatment of Peripheral Neuritis/Neuropathy

Eliminate exposure to toxic substances Correct any nutritional deficiencies Control underlying diseases Patient must avoid all alcohol in any form Administration of anticonvulsants and tricyclic antidepressants

Physical therapy


Trigeminal Neuralgia (Tic Douloureux)

Transient, excruciating pain of trigeminal neuralgia radiates along the fifth cranial nerve distributionØ When the ophthalmic branch is affected, pain is experienced in the eye and forehead

Ø The maxillary branch involves the nose, upper lip, and cheek

Ø The mandibular branch involves the lower lip, the outer portion of the tongue, and the area of the cheek close to the ear


Trigeminal Nerve


Trigeminal Neuralgia (Tic Douloureux) (Cont.)

Cause is uncertain, although some cases have been found to be related to compression of a nerve root by a tumor or vascular lesion

Analgesics are prescribed for pain Recent drug therapy includes the use of anticonvulsant drugs

The addition of muscle relaxants may be more effective


Bell Palsy

The patient may be aware of pain or a drawing sensation behind the ear, followed by an inability to open or close the eye and drooping of the mouth and drooling of saliva

The patient is unable to smile, whistle, or grimace, and the facial expression is distorted

Taste perception may be diminished The cause of Bell palsy is not always certain


Bell Palsy (Cont.)

From Lewis SM, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 6, St Louis, 2004, Mosby.


Treatment of Bell Palsy

Warm, moist gentle heat and massage Facial exercises to stimulate muscle tone Prednisone to reduce edema of facial nerve Analgesics Artificial tears and an eye patch Electrotherapy to stimulate nerves and prevent atrophy of muscles


Bell Palsy (Cont.)

Differences between Bell palsy and trigeminal neuralgiaØ Bell palsy

• Sudden paralysis • Motor function impaired• Prognosis is good if treated early

Ø Trigeminal• Extreme pain • No motor function impairment• Prognosis varies


Meningitis

Early symptoms of meningitis include vomiting and a headache that increases in intensity with movement or shaking of the head

Deep tendon reflexes increase, and the patient exhibits irritability, photophobia, and a hypersensitivity of the skin

Meningitis can be either bacterial or viral


Bacterial Meningitis

From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders/Elsevier. Courtesy of Dr. John J. Kepes, Kansas City, KS.


Treatment of Meningitis

Aggressive antibiotic therapy Anticonvulsive drugs to control seizure activity

Glucocorticoids may be administered to reduce cerebral inflammation and edema

Aspirin or acetaminophen for headache Dark and quiet environment


Encephalitis

May have an insidious or sudden onset Primary symptoms include a headache and elevated temperatureØ The patient experiences a stiffness in the neck and back, muscular weakness, restlessness, visual disturbances, and lethargy

It is caused by viruses or the toxins from chickenpox, measles, or mumps.

Most cases are the result of a bite from an infected mosquito


Treatment of Encephalitis

Antiviral agents effective against herpes simplex encephalitis

Otherwise:Ø Mild analgesics for painØ AnticonvulsantsØ Antibiotics for any present infection

Stress the use of mosquito repellant when in an outdoor environment


Guillain-Barré Syndrome

The individual experiences numbness and tingling of the feet and hands at the onset of the disease, followed by increasing muscle pain and tenderness

Progressive muscle weakness and paralysis usually start in the lower extremities and move up the body

The syndrome is thought to have an autoimmune basis


Treatment of Guillain-Barré Syndrome

Hospitalization required for observation Plasmapheresis washes the plasma to remove antibodies, thereby shortening the time required for recovery

Intravenous human immunoglobulin may be beneficial

No method of prevention is known


Brain Abscess

The primary symptom of a brain abscess is a headache

Other symptoms and signs depend on the location and extent of the abscess

CNS abscesses may be the result of a local infection or may be secondary to infections elsewhere in the body


Brain Abscess (Cont.)

From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders/Elsevier.


Bacterial Infections of the CNS

From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders/Elsevier.


Treatment of a Brain Abscess

Intravenous antibiotics Mannitol or steroids to reduce cerebral edema

Surgical drainage of abscess to relieve pressure

Prognosis varies depending on the location, size, and causative agent of the abscess


Poliomyelitis and Postpolio Syndrome

The patient with poliomyelitis has a low-grade fever, a profuse discharge from the nose, and malaise

These symptoms are followed by a progressive muscle weakness, stiff neck, nausea and vomiting, and a flaccid paralysis of the muscles involved

Poliovirus enters the body through the nose and throat, crosses into the gastrointestinal tract, and reproduces in the lymphoid tissue


Treatment of Poliomyelitis and Postpolio Syndrome

Analgesics Moist heat Bed rest Physical therapy Leg braces Mechanical ventilation A monovalent Sabin vaccine also is available, which grants immunity to only one form


Intracranial Tumors (Brain Tumors)

Primary tumors can arise from any cell within the CNS

Regardless of the tumor cell type, symptoms and signs result from displacement and compression of normal brain tissue by the tumor

Primary brain tumors are classified histologically according to the predominant cell type


Brain Tumor


Increased Intracranial Pressure

From Gould BE, Dyer RM: Pathophysiology for the health professions, ed 4, St Louis, 2012, Saunders/Elsevier.


Intracranial Tumors (Brain Tumors) (Cont.)

Evaluation of a patient with a suspected brain tumor includes a detailed history, a neurologic examination, and diagnostic neuroimaging studies

Although brain tumors can be malignant or benign, the distinction is blurred in the brain



Treatment: Primary tumorsØ SurgeryØ RadiotherapyØ ChemotherapyØ Immunotherapy



Treatment: Secondary tumorsØ Focuses on relief of neurologic symptoms and long-term tumor control

Ø Patients with solitary brain lesions and no other sites of metastasis undergo:• Surgery• Whole brain radiation therapy

No methods are known to prevent intracranial neoplasms



PrognosisØ Five-year survival rate for all types of brain tumors combined is 32%, which is among the lowest for all types of cancer

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