BSN TINE TAG Wie, Se-5, FINS Ibyety Ns HIiVleN Tole Tee ICONCGi = FACULTY OF MEDICINE UNIVERSITY OF HASANUDDIN roxoo Ooo oO o oC Only after thorough and meticulous clinical history taking and neurological examination. Only after the formulation of a clinical differential diagnosis, in which all of the competing diagnoses are ranked by probability. ‘The study that should be performed is the ane whose result is most likely to be important for further diagnostic and therapeutic management, but only if this will be of clear benefit to the patient, and only if the risks of performing the study do not outweigh any potential benefit that its findings might bring. Multiple studies providing the same diagnostic information should not be performed merely for repeated confirmation of the findings. Astudy should not be performed if, regardless of its result, another study will have to be performed that is likely to yield at least as much information. Only very rarely should studies be performed to confirm a diagnosis that is already practically certa Ifa genetic study is contemplated, the potential consequences should be discussed thoroughly with the patient and his or her family before the study is performed. The costs must not be forgotten.* Indications — Lumbar puncture is useful in the diagnosis of diseases affecting the meninges, the brain and spinal cord, and the nerve roots, which can manifest themselves with changes in the biochemical or cellular properties of the cerebrospinal fluid.neil) fale arors Tevet) ventricle Feieis-lah Monro cicshveineils) e eee peer nn fem (ylvius) foramen of foramen of Luschka Megendie* Technique Cerebrospinal fluidis usually obtained by lumbar puncture (LP) below the level of the conus medullaris, i. ¢., at L4-5 (occasionally at [3-4 or L5-S1). Suboccipital punctureis fraught with a much higher rate of complicationsand isperformed only when meningitisis suspected and no fluid can be obtained by lumbar puncture (“dry tap”), or when LP is contraindicated because ofa known purulent process in the lumbar region. LPis performed with sterile technique on patientin the lateral decubitus position (or, occasionally, sitting up). The physician performing the puncture measures the CSF pressure witha manometer and visually assesses the color of the fluid. The laboratory tests to be performed include cell count, glucose and protein content, and others (esp. cultures), depending on the clinical situation.Patient position for lumbar punctureogee hep Acai Jecuin paca yStigol slotcemal GuboteetpttadlRoutinely performed tests pressure color (turbidity? xanthochromia? bloody tinge?) cell count and differential protein glucose Tests to be performed under special circumstances immunoglobulins IgG-albumin index oligocional bands measurement of specific IgG, IgA, and IgM against Borrelia, para- sites, and viruses cultures: bacterial, fungal. viral, mycobacterial gram and Ziehl-Neelsen staining. touch prep VDRL and FTA tests for syphilis cytological examination for malignant cells DNA amplification (polymerase chain reaction) in suspected tuberculosis or viral diseases statin C in amyloid angiopathy antineuronal antibodies in suspected paraneoplastic syndromesOTechnique ORadiculomyelography (the visualization of intraspinal structures with contrast medium) is generally performed after the injection of 10-15 ml of watersoluble contrast medium into the subarachnoid space via lumbar puncture—or, rarely, via suboccipital puncture. UThe passage of contrast medium through the subarachnoid space, including the nerve root sleeves, can then be followed on the radiologic image and any obstructions to the flow of contrast medium can be identified (e. g., spinal tumors). UThe nerve roots appear as filling voids within the nerve root sleeves. UThe bony spine is seen on the myelographic images as well and can be evaluated at the same time.Undications UO Clinically evident lumbar radiculopathy with unclear CT findings O Suspected radiculopathy, but no clear segmental localization USuspected spinal cord compression O Suspected spinal stenosis O Clinically evident spinal stenosis USuspected myelopathy due to cervical spondylosis O Suspected myelitis or demyelinationExtradural Intramedullary Abnormal spinal Intradural tumor ‘tumor blood vessel extramedullary Imor Typical findings in contrast myelography& Imaging Studies® Conventional Skeletal Radiographs © Skullradiographs — Skull radiographs are performed for very few purposes nowadays and are hardly ever indicated. — (They cannot be used as a substitute for CT in head trauma; if a CT is indicated, but unavailable for some reason, then the patient should probably be transported toa center where a CT can be performed.) — Plain films of the skull enable visualization of: * fractures (though much less well than on CT) * congenital malformations of the bony skull, and * various developmental disorders — Skull radiographs are useless in the diagnostic evaluation of headache or intracranial processes.* Conventional Skeletal Radiographs * Plain radiographs of the spine — Plain radiographs of the spine are sometimes useful for the demonstration of: * fractures, bony tumors (which, however, are more easily seen by CT or MRI), degenerative diseases and slippage (olisthesis) of the spine, infections involving bone, axial skeletal deformities, dynamic abnormalities (abnormal mobility or instability of individual spinal segments; their demonstration requires special radiological techniques, socalled “functional studies”).Ss Conventional Skeletal Radiographs ‘Skull fracture seen in a plain skull radiograph. The (a) and (b) images both reveal a fracture line medial to the lambdoid suture on the right (arrow).Computed Tomography (CT) Normal CT scan of the head. a Note the symmetrical, normal-sized frontal and occipital homs of the lateral ventricles. |The cerebral cortex and deep white matter can be disinguished irom each other, and he fabxcerebri ‘canbe seen in both the frontal and occipital regions. A number of blood vessels can be seen. Alsonote the bilateral calcifications of the choroid plexus of the lateral ventricles. b. Some of the blood vessels around the base of the brain (arrows) are well seen after the ‘administration of contrast medium.On Ray aa oi ® SS >" 4 a eo Fa | BFW ~ Ae Ae * \Wiee o/ ‘fies | a-h Normal MRI of the brain in 5 mm sections from the base of the brain to the vertexComparative indications of CT and MRI of the head Location and type of pathology MRI Brain atrophy ‘Acute infarct ‘Older infarct Lacunar state Intraparenchymal hemorrhage ‘Subarachnoid hemorrhage ‘Aneurysm ‘Venous thrombosis Brain tumor (cerebral hemispheres) Pituitary tumor Brain metastases CCarcinomatous meningitis, Hydrocephalus Traumatic bran injury ‘Acute subdural or epidural hematoma ‘Meningoencephaltis, Abscess Parasitic cyst(s) Arachnoid gst Posterior fossa Pathology of the white matter + Multiple sclerosis He Atlanto-occpital joint + ote ‘Skull lesions HH ‘Steet tpeE grate pega egla iAngiography with Radiological Contrast Media * Diagnostic imaging of the cerebral blood vessels is indicated when a vascular stenosis, occlusion, or malformation is suspected as the cause of a neurological illness.Angiography with Radiological Contrast Media * Indications for angiography of the intracranial vessels — Visualization of saccular aneurysms — Visualization of arteriovenous malformations and fistulae — Detailed representation of saccular aneurysms (after diagnosis by — MRI, asan aid to treatment by neurosurgical or interventional neuroradiological methods) — Detailed representation of arteriovenous malformations (after diagnosisby MRI, as an aid to treatment by neurosurgical or interventional neuroradiological methods) — Visualization of other vascular anomalies: * moya-moya * agenesis of vessels and other developmental anomalies * vascularstenosis or occlusion * arterial dissectionAngiography with Radiological Contrast Media Interventional Neurology* Principle — The surface EEG registers fluctuations in electrical potential that are generated by the cerebral cortex. — These represent the sum of the excitatory and inhibitory synaptic potentials.¢ The main indications for electroencephalography — Confirmation of the diagnosis of epilepsy — Determination of the type of epilepsy that is present — Brief, episodic impairment of consciousness of unknown etiology — Longer-lasting disturbances of consciousness, delirium — Metabolic disturbances — Creutzfeldt—Jakob disease — Sleep studies (e. g., in suspected narcolepsy)Placement of EEG electrodes according to the 10-20 systemNormal EEG. a Monopolar recording, b bipolar recording.- Technique — Polysomnographyis a special application of EEG in which the EEG is recorded simultaneously with a number of other electrophysiological parameters. — Itis used to assess sleep and sleep disturbances. — The EEG changes that normally occur during sleep are related to the progression of the individual through various sleep stages, including deep or REM sleep (REM = “rapid eye movement”). — The recorded parameters include eye movements (by electro- oculography), respiratory excursion, airflow in the nostrils, muscle activity (by surface EMG), cardiac activity (by ECG), and the partial pressure of oxygen (by transcutaneous pulse oximetry)+ Indications — The most important indication for a sleep study is aclinical suspicion of sleep apnea syndrome on the basis of a characteristic history obtained from the patient or bed partner, together with related physical findings and a low partial pressure of oxygen measured during sleep by pulse oximetry. — Polysomnography is also indicated for the diagnosis of narcolepsy, as well as for the assessment of excessive fatigue and daytime somnolence.tet Biceps brachii EMG Right EEG [Respiratory | N25, [volume | ovat Thoracic Respiratory | breathing effort [Abdominal breathing saturation | metry left Tibalis anterior | EMG Right+ Indications — Indisorders affecting muscle, EMG can be used to determine whether the underlying pathological process is located in the muscle itself (myopathic process), in the nerve innervating it (neuropathic Process), or at the neuromuscular junction. Itcan also be used to grade the severity of muscle denervation and the extent of reinnervation. In combination with electroneurography (see below), EMGisa very importanttype of ancillary study for the diagnosis of neuromusculardiseases.CCondition/suspected pathology EMG (needle ENG Remarks rmyography) Suspected anterior hom cel disease ” Negative Suspected nerve rot lesion + ++(Fwave) imaging studies may be ‘more important Suspected plexus lesion differentiation from peripheral + ++(Fwave) reve Focal peripheral nerve lesion ” Severity of injury, signs ‘of regeneration, localiza tion of injury Polyneuropathy + ” Myopathy “ Normal Ischemic muscle damage im Myasthenia gravis Repetitive stimulation, jter phenomenon We indicated test + = may be addtionay usefulUltrasonography * There are two main types of ultrasound study: — Dopplersonography — duplexsonographyUltrasonography Indications — The velocity and flow profile (laminar or turbulent) of the blood flowing within a particular vessel depend, among other things, on the vessel's caliber and on the nature of its wall. — Ultrasound studies aid in the detection of vascular stenosis and occlusion, vessel wall irregularities, abnormalities of the speed and direction of blood flow, and turbulent flow. — Insonation of the extra- and intracranial vessels (e. g., of the middle cerebral a. through the thin bone of the \ “temporal window,” or of the basilar a. through the \ foramen magnum) yields an informative picture of the current state of blood flow in the brain. \ Sy ayUltrasonography B92 Done study ofaUltrasonography* Tissue Biopsies — Muscle biopsy — Nerve biopsy — Brain biopsy * Perimetry * Static computed perimetryPerimetry is used to detect visual field defects> Save Our Brain ...For Complex Situation Simple Solutions... 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