NEUROLOGY

Dr. MURALIDHAR VARMA

INTRODUCTION TO NEUROLOGY
FUNCTIONAL ANATOMY OF BRAIN
1) Cerebral hemispheres
Highest level of neuronal function
Anterior half-execution; posterior half-receiving and perceiving
Basal ganglion collection of neuronal cells deep inside the brain. Basal
ganglion is involved in motor control
Thalamus involved in sensory perception.
Limbic system emotional and memory
CSF discussed later along with lumbar puncture
2) Brain stem
Brain stem has motor and sensory pathways and cranial nerve nuclei and
connections to cerebellum
Cerebellum- regulates motor function.
3) Spinal cord
Spinal cord contain afferent and efferent path ways
Grey matter for local reflexes
4) Peripheral nervous system
Sensory cell bodies are in dorsal root ganglion. Motor nuclei are in anterior
horn cells
Form grey matter of spinal cord, roots are formed which later form plexus
and peripheral nerves
Peripheral nerves supply the muscles via neuromuscular junction(NMJ)
5) Autonomic system
Unconscious neuronal control
This system controls cardiovascular system, respiratory system, GIT, bladder and
reproductive organs and various glands of the body
Autonomic system is mainly controlled by brain stem, limbic system and frontal
lobes.
It has 2 functional modes namely
1) Sympathetic
2) Para sympathetic
Both these systems functioning in tandem.

# Upper motor neuron - Upper motor neuron cell bodies are situated in the motor
cortex and project axons via the corticospinal tracts to the anterior horn cells of spinal
cord.
# # Lower motor neuron - lower motor neuron cell bodies arise from anterior horn
cells and end at neuromuscular junction.
6) CSF
CSF is secreted from choroids plexus into ventricles. It circulates in ventricles and
enters subarachnoid space from 4th ventricle.
It is finally absorbed in venous system . Daily about 150ml of CSF is secreted.

Investigations
A) Tests for function of nervous system
1) EEG (electroencephalogram)
Electrical activity of the brain is recorded using scalp electrodes on 16 channels
simultaneously
Different wave forms can be seen namely ,, theta
Indications of EEG
Epilepsy-type, site
Diffuse brain damage like encephalitis etc
50% of the epileptic patients have normal EEG .
Evoked potentials can be recorded following visual, auditory or somato sensory
pathways, may indicate damage to relevant pathways
2) EMG (Electromyography) and NCV (nerve conduction velocities)
EMG is done using needle electrode in the muscle and amplified recording is
viewed on the oscilloscope
EMG will give information about
1) Denervation and renervation
2) Myopathic and myasthenic changes
NCV is study of peripheral nerve action potentials and velocities using 2
electrodes placed at 2 sites
NCV gives following information of nerve
1) Focal or diffuse pattern
2) Axonal or demyelinating

B) IMAGING
i) X-rays
X-rays are now mainly used for fractures and sinus diseases
ii) CT scan (Computerised Tomography)
Principal collimated X-ray beam moves synchronously across slice of
brain between 2-23 mm of sections.

 Difference in attenuation (density) between bone (+1000 hounsfield units),

water (0 units) and air (-1000) enable recognition of normal, infracted, tumor,
blood and edema.
Contrast (ionic and non ionic) can be used for identifying vessels and
vascular tissues.
Common indications of CT scan
Cerebral tumors
Stroke
Subdural and extradural haematoma
Subarachnoid haemorrhage
Spinal trauma (with CT myelography)
Limitation of CT scan
Lesions under 1 cm diameter may be missed.
Lesions with attenuation close to that of bone may be missed if near the
skull.
Lesions with attenuation similar to that of brain are poorly imaged (e.g.
Multiple sclerosis plaques, isodense subdural haematoma).
CT sometimes misses lesions within the posterior fossa. .
iii) MRI (Magnetic Resonance Imaging)
Principal- change in alignment of proton of hydrogen nucleus in sudden
strong magnetic field and reverting back to normal alignment releases energy
in the form of radiofrequency.
This causes different phases of relaxation like T1,T2,DWI etc
Gadolinium is used as IV contrast material.
Advantages
MR distinguishes between brain white and grey matter.
Spinal cord and nerve roots are imaged directly.
Pituitary imaging.
MRI has greater resolution than CT (around 0.5 cm).
No radiation is involved.
Magnetic resonance angiography (MRA) images blood vessels without
contrast.
Limitations
Time-Imaging one region takes about 20 minutes. Patients do need to
cooperate.
MRI is very costly than CT scan
iv) PET scan (Positron Emission tomography) &
SPECT (Single Photon Emission Computer Tomography)
These scans give the functional aspect of brain based on utilization of glucose
by the brain.

v) MRI angiography and CT angiography with 3D reconstruction

These scans are done after IV or intra-arterial contrast agent.
Useful for vascular abnormalities like stenosis and aneurysms, occlusions.
Conventional angiography is more invasive but has better results.
vi) Doppler scan
B-mode and clour ultrasound is used for detection of stenosis or thrombosis of
carotid or vertebral artery for stroke work up.
Doppler is mainly used for extra cranial cerebral vessels.
vii) Biopsy
Biopsy of brain, muscle and nerve is very important tool for neurological
diagnosis
Brain biopsy is used to diagnose inflammatory and degenerative brain diseases.
CT- and MR-guided stereotactic biopsy of intracranial mass lesions is now
standard procedures
Muscle biopsy, with light microscopy, electron microscopy and biochemical
analysis where appropriate, elucidates diagnosis of inflammatory, metabolic and
dystrophic disorders of muscle
Nerve biopsy, usually of one sural nerve (ankle) or superficial branch of a radial
nerve aids diagnosis in polyneuropathies (e.g. vasculitis).
viii) Psychometric testing

Psychometric testing is valuable for measuring cognitive function

Value of routine investigations in neurology

Test

Yield

Condition

Urinalysis

Glycosuria

Polyneuropathy

Ketones

Coma

Bence Jones protein

Cord compression

MCV

B12 deficiency

ESR

Giant cell arteritis

Hypoglycaemia

Coma

Hyperglycaemia

Coma

Hyponatraemia

Coma

Hypokalaemia

Weakness

Hypocalcaemia

Tetany, spasms

Raised

Muscle disease

Lytic bone or mass lesion

Bronchial cancer, thymoma

Blood picture
Blood glucose
Serum electrolytes
Serum calcium
Serum creatine phosphokinase
Chest X-ray

lumbar puncture
Cerebrospinal fluid (CSF) is a clear fluid that circulates in the space surrounding
the brain and spinal cord. It acts like a shock absorber and protects the brain and
spinal cord from injury
Lumbar puncture (LP) is a procedure to collect the cerebrospinal fluid to check for
the presence of disease or injury. It is called a lumbar puncture because the spinal
needle is inserted usually between the 3rd and 4th lumbar vertebrae in the lower
spine.
Technique
The patient is placed on the edge of the bed in the left lateral position with the
knees and chin as close together as possible.
The third and fourth lumbar spines are marked. The fourth lumbar spine usually
lies on a line joining the iliac crests.
Using sterile precautions, 2% lidocaine (lignocaine) is injected into the dermis by
raising a bleb in either the third or fourth lumbar interspace.
The special lumbar puncture needle is pushed through the skin in the midline. It is
pressed steadily forwards and slightly towards the head, with the head and spine
bolstered horizontally with pillows.
When the needle is felt to penetrate the dura mater, the stylet is withdrawn and a
few drops of CSF are allowed to escape.
The CSF pressure can now be measured by connecting a manometer to the needle.
The patient's head must be on the same level as the sacrum.
Specimens of CSF are collected in three sterilized test-tubes and sent to the
laboratory.
Indications for lumbar puncture (LP) :
Diagnostic
Meningitis and encephalitis
Subarachnoid haemorrhage (sometimes)
Diagnosis of miscellaneous conditions, e.g. MS, neurosyphilis, sarcoidosis,
Behet's disease, neoplastic involvement, polyneuropathies
Measurement of CSF pressure, e.g. idiopathic intracranial hypertension
Therapeutic
Removal of CSF therapeutically, e.g. idiopathic intracranial hypertension
Intrathecal injection of contrast media and drugs.
Contraindications for lumbar puncture
Suspicion of a mass lesion in the brain or spinal cord. Caudal herniation of the
cerebellar tonsils ('coning') may occur if an intracranial mass is present and the
pressure below is reduced by removal of CSF.
Any cause of raised intracranial pressure.

Local infection near the site of puncture.

Congenital lesions in the lumbosacral region (e.g. meningomyelocele).
Platelet count below 40 109/L and other clotting abnormalities, including
anticoagulant drugs.

# Unconscious patients and with papilloedema must have a CT scan before lumbar
puncture.
Complications of LP
Headache
Meningitis and disc space infections
Bleeding into spinal meningeal spaces
Normal CSF
Appearance

Crystal clear, colourless

Pressure

60-150 mm of H2O with patient recumbent

Cell count

< 5/mm3
No polymorphs
Mononuclear cells only

Protein

0.2-0.4 g/L

Glucose

to of blood glucose

IgG

< 15% of total CSF protein