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B. PATHOPHYSIOLOGY 1.

) Anatomy and Physiology FUNDAMENTALS OF NERVOUS SYSTEM CONDUCTION Within the brain and nervous system are specialized cells, known as neurons. The neurons are responsible for delivering chemical messages to other cells to achieve some response. This is the basis of how our nervous system works. Within the brain, there are approximately 100 billion neurons. Neurons are typically classified by the direction that they send information. Sensory, or afferent, neurons send impulses from sensory receptors in the periphery or some organ to the central nervous system. Motor, or efferent, neurons send impulses away from the central nervous system to muscles or glands. Neurons have specialized extensions called dendrites and axons. Dendrites bring information to the cell body (soma) and axons take information away from the cell body. Some neuronal axons are myelinated (have a fatty substance coating them that speeds impulse transmission) and some are not. Nodes of Ranvier are short unmyelinated segments of an axon.

Courtesy of the National Cancer Institute,2004 www.nci.gov Information from one neuron flows to another neuron across synapses. The synapse is a small gap separating neurons. The synapse consists of: a pre-synaptic ending that contains neurotransmitters, mitochondria and other cell structures, a postsynaptic ending that contains receptor sites for neurotransmitters, and a synaptic space between the pre-synaptic and postsynaptic endings. Communication of information between neurons is accomplished by movement of chemicals across these small synaptic gaps. Neurotransmitters are released from one neuron at the pre-synaptic nerve terminal.

Neurotransmitters then cross the synapse where they may be accepted by the next neurons receptor site. The action that follows activation of a receptor site may be either depolarization (excitatory in nature) or hyperpolarization (inhibitory in nature). If the neuron is depolarized, its response is excitatory. If the neuron is hyperpolarized, the response is inhibitory. There are three major categories of substances that act as neurotransmitters. They are amino acids, peptides, and monoamines, plus acetylcholine. The major neurotransmitters of the brain are glutamic acid and GABA. The peripheral nervous system has only two neurotransmitters. They are acetylcholine and norepinephrine. Neurotransmitters vary greatly in the response they enact upon particular cells or receptor sites. Acetylcholine, for example, can be excitatory or inhibitory depending upon which receptor site it binds to. The following is a list of several known and well-studied neurotransmitters. Neurotransmitter Function Acetylcholine Mostly excitatory Dopamine Excitatory and inhibitory Epinephrine Excitatory Norepinephrine Excitatory Serotonin Excitatory Glutamate Excitatory Glycine Mostly inhibitory g-Aminobutiric acid (GABA) Inhibitory Central Nervous System The nervous system can be subdivided into the central nervous system and the peripheral nervous system. The central nervous system is composed of the brain and spinal cord. The brain is protected by the cranium and the meninges. Bones of the Skull The human skull is a hard, unbending container that protects the delicate brain. The bones are very thick in some places, such as the occipital region, and very thin in others such as in the temporal, sinus region. The bones of the skull are referred to as the cranium. It is the first mechanism in the protection of our brain. Meninges

The meninges cover the brain and spinal cord and protect them as well. There are three meningeal layers. They are the dura mater, arachnoid mater, and pia mater.

Courtesy of the National Cancer Institute,2004 www.nci.gov Dura Mater The dura mater is the outer, tough layer of the meninges. It lines the inside of the skull. The dura mater also separates specific portions of the brain. The falx cerebri is a portion of the dura mater that separates the right and left hemispheres of the brain. The tentorium cerebelli is a portion of the dura mater that separates the cerebrum from the cerebellum (AACN, 1998). Arachnoid Mater The arachnoid mater is the middle layer of meninges. It is a web-like structure that allows the passage of blood vessels and through it. Between the arachnoid mater and the pia mater, is the subarachnoid space. Cerebral spinal fluid (CSF) flows freely here (AACN, 1998). Pia Mater The pia mater is the thin, translucent, inner layer of the meninges. It covers the surface of the brain. It is the most vascular layer (AACN, 1998). Potential Spaces There are potential spaces between the meninges. CSF fluid may accumulate in these potential spaces. The epidural space is the space above the dura, between the dura mater and the skull. The subdural space is the space below the dura, between the dura and the arachnoid mater. The

subarachnoid space, as discussed earlier is the space below the arachnoid, between the arachnoid and the pia mater (AACN, 1998). THE BRAIN The brain in an adult is one of the bodys largest organs. It weighs about three pounds and is divided into four major parts: the cerebrum, diencephalon, brain stem, and cerebellum (Tortora, 1989). Cerebrum The cerebrum is the largest portion of the brain. It covers the diencephalon. The surface of the cerebrum is composed of gray matter and is known as the cerebral cortex. During embryonic development the gray matter grows in increased proportion to the underlying white matter. This increased growth rate causes the gray matter to fold into itself and create convolutions known as gyri. The deep grooves between the folds are known as fissures. The shallow grooves between the fold are known as sulci. The most noticeable fissure is the one that nearly separates the right and left hemispheres of the brain the longitudinal fissure. The hemispheres remain connected by the corpus collosum, a transverse bundle of nerve fibers. Additionally, between the hemispheres is an extension of the dura mater known as the falx cerebri. Each cerebral hemisphere is subdivided into lobes. The central sulcus separates the frontal from the parietal lobe. The frontal and the temporal lobes are separated by the lateral cerebral sulcus. The parietal lobe and the occipital lobe are separated by the parieto-occipital sulcus.

Courtesy of the National Cancer Institute, 2004 www.nci.gov

The precentral gyrus, is located immediately anterior to the central sulcus and is the major motor area of the brain. The post central gyrus is located immediately posterior to the central sulcus and is the major motor area of the brain. White Matter -The white matter that is underneath the cerebral cortex and consists of three different types of nerve fibers. Association fibers transmit impulses between gyri in the same hemisphere. Commisural fibers transmit nerve impulses from gyri on one hemisphere with the corresponding gyri in the opposite hemisphere. Finally, protection fibers transport nerve impulses from parts of the cerebrum to other parts of the brain and spinal cord (Tortora, 1989). Limbic System - The limbic (border) system is composed of certain components of the cerebrum and the diencephalons. The components of this system are the limbic lobe, the hippocampus, amygdaloid nucleus, the mamillary bodies of the hypothalamus, and the anterior nucleus of the thalamus. Basically, the limbic system encircles the brainstem and functions in the emotional aspects of behavior that are essential to our survival. It also plays a role in memory, although the exact mechanism is not understood fully. The limbic system is also thought to play some part in how we sense pleasure, pain, anger, rage, fear, sadness and sexual feelings. Because of its role in these core emotions, it is also known as the visceral or emotional brain (Tortora, 1989). Frontal Lobe - The frontal lobe is located in front of the central sulcus. It is concerned with reasoning, planning, parts of speech and movement (motor cortex), emotions, and problem solving. The frontal lobe has been labeled our emotional control and personality center. The frontal lobe is also involved in spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. In most people, the left frontal lobe is involved in controlling language related movement, whereas the right frontal lobe plays a role in non-verbal abilities. Frontal lobe damage seems to have an impact on flexibility and problem solving ability, sexual behaviors, personality changes, motor control, facial expression and Broca's aphasia, or difficulty in speaking (Brown, 1972; Tortora, 1987).

Parietal Lobe - The parietal lobe is located behind the central sulcus. It is concerned with perception of stimuli related to touch, pressure, temperature, and pain. The parietal lobes can be divided into two functional regions, involving sensation and perception. The overall role of the parietal lobe is to integrate sensory information to form a single perception (cognition) (Kandel, Schwartz and Jessel, 1991).

Temporal Lobe - The temporal lobe is located below the lateral fissure. It is concerned with sensory perception and recognition of auditory stimuli (hearing) and memory (hippocampus) (Read, 1981; Tortora, 1989). Individuals with temporal lobes lesions have difficulty placing words or pictures into categories. The temporal lobes are highly associated with memory skills and language. Temporal lobe damage may result in impaired memory, difficulty recognizing words or speaking, and recall of non-verbal stimuli such as music or drawings (Tortora, 1989).

Occipital Lobe - The occipital lobe is located at the back of the brain, behind the parietal lobe and temporal lobe. It is concerned with many aspects of vision. Lesions or damage to the occipital lobe typically results in visual changes, even producing visual hallucinations.

Diencephalon The diencephalon is above the brain stem and houses the thalamus and hypothalamus. Thalamus - The thalamus constitutes about eighty percent of the diencephalon. The thalamus is composed of two masses of grey matter. The thalamus serves as a communication station for all sensory impulses that reach the cerebral cortex from the spinal cord, brain stem, cerebellum, and parts of the cerebrum. The thalamus also functions as an understanding center for some sensory impulses such as pain, temperature, light, touch, and pressure. Hypothalamus - The primary functions of the hypothalamus are to integrate and control the autonomic nervous system, reception and integration of sensory impulses from the viscera, coordinates the endocrine response of many hormones within the endocrine

system. The hypothalamus is also known as the master gland of the endocrine system, for this reason. It produces and releases hormones that stimulate the pituitary gland. This connection or relationship with the pituitary gland is referred to as the hypothalamicpituitary axis. The three major hormones that stimulate the hypothalamus are growth hormone releasing hormone (GRH), thyrotropic releasing hormone (TRH), and corticotropin releasing hormone (CRH) (AACN, 1998). These hormones travel to the pituitary via the hypothalamic pituitary stalk. Once in the pituitary, they act to produce or release other hormones from the pituitary gland. The hypothalamus is also responsible for the mind over body phenomenon. When strong emotions are produced by the cerebral cortex, nerve impulses travel down through the hypothalamus to the body. Likewise, continued psychological stress traveling upward through the hypothalamus may produce long-term, very, real, systemic illnesses. The hypothalamus also plays a role in feelings such as rage and aggression and regulates body temperature, hunger, thirst, sleep and wake cycles. Brain Stem The brain stem consists of the medulla oblongata, pons, and mid-brain, or mesencephalon.

Courtesy of the National Cancer Institute,2004 www.nci.gov Medulla - The medulla oblongata, or medulla, is merely a continuation of the upper part of the spinal cord which forms the inferior part of the brain stem. It contains all ascending and descending nerve tracts between the brain and spinal cord. The medulla is also the origin of several cranial nerves. They are cranial nerves VIII, IX, X, XI, and XII (Tortora, 1989).

Pons - Pons means bridge. The pons is the bridge that connects the spinal cord with the brain and certain parts of the brain with each other. These connections occur via fibers that run in two major directions. The transverse fibers connect with the cerebellum. The longitudinal fibers connect the spinal cord or medulla with the upper parts of the brain stem.

Mid-Brain - The mid-brain, or mesencephalon, extends from the pons to the lower portion of the diencephalons. The cerebral aqueducts travels through the mid-brain and connects the third and fourth ventricles. Within the midbrain, there are nerve fibers that convey nerve impulses from the cerebral cortex to the pons and spinal cord. The midbrain also has some reflex centers that control eye, head, and neck movements. The midbrain is also the origin of cranial nerves II and IV (Tortora, 1989).

The Reticular Activating System - The reticular activating system is so named because it resembles the reticular system of a leaf. It is a network of neurons located in the central core of the brainstem that serves to monitor the state of the body in functions such as arousal, sleep, and muscle tone. The reticular activating system is the attention center in the brain. The reticular activating system is connected at its base to the spinal cord where it receives information projected directly from the ascending sensory tracts. The brain stem reticular formation runs all the way up to the midbrain. As a result, the reticular activating system serves as a point of union for signals from the outside world to our inner brain. When functioning normally, it provides the neural connections that are needed for the processing and learning of information, and ability to focus on particular tasks. If the reticular activating system doesnt excite the neurons of the cortex as much as it should, difficulty learning, poor memory, and limited selfcontrol, may be expressed. If the reticular activating system failed to activate the cortex at all, unconsciousness and coma would be the result.

Cerebellum - Behind the brain stem, is the cerebellum. It is the second largest area of the brain. It is located in the inferior and posterior portion of the brain. The cerebellum is concerned with the subconscious movements of the skeletal muscles. It is chiefly responsible for maintenance of balance and gait. It helps to maintain equilibrium and control posture. It also functions to predict the future movement of body parts prior to implementation of certain tasks.

Cerebrospinal Fluid The cerebral spinal fluid, or CSF, protects and cushions the brain from injury. The CSF acts as a shock absorber from injuries that would normally send the brain crashing up against the inside of the skull. By nature of its circulatory abilities, it also delivers nutrients filtered from the blood to the brain and spinal cord and removes wastes and toxic substances produced by the brain and spinal cord (Tortora, 1989). It circulates in the subarachnoid space, around the brain, the spinal cord and the ventricles of the brain. The ventricles, like the hearts ventricles are spaces. In the brain, there are two lateral ventricles located in each hemisphere of the brain, just under the corpus collosum. There is a third ventricle just in between and below the thalamus. Finally, there is a fourth ventricle, just below the brain stem and beside the cerebellum. All four ventricles may circulate CSF between them by way of foramen (narrow oval openings), aqueducts (canal-like passages), and apertures (openings) (Tortora, 1989).

Courtesy of the National Cancer Institute,2004 www.nci.gov The CSF is produced by the choroid plexus of the ventricles. A small amount is produced by the blood vessels of the brain and spinal cord. There is approximately 500 milliliters (ml) of CSF produced daily. However, the entire central nervous system only holds about 120-150 ml at any given time (AACN, 1998; Tortora, 1989). Normal pressures of the CSF are 75-180 ml/H20. However, in a sitting position, you may observe normal pressures of 250-300 ml/ H20 that is also considered normal (AACN, 1998). Cerebrovascular Circulation The internal carotid arteries supply blood to the Circle of Willis, anteriorly. The posterior vertebral arteries provide blood supply to the Circle of Willis posteriorly. The Circle of Willis

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unites the anterior and posterior blood supply to the brain. This is a unique mechanism of cerebral circulation that allows the brain to have a backup system if one source of blood is interrupted.

The cerebral arteries arise from the Circle of Willis and supply specific areas of the brain. The posterior cerebral artery (PCA) supplies blood to the occipital lobe, midbrain, thalamus, and part of the temporal lobes. The middle cerebral artery (MCA) supplies blood to parts of the frontal, parietal and temporal lobes. The anterior cerebral artery (ACA) supplies blood to different areas of the frontal, parietal and temporal lobes (AACN, 1998). Blood supply is vital to the proper functioning of the brain. Even though the brain is only about two percent of the entire weight of the body, it requires about twenty percent of the total oxygen consumed by the body (Tortora, 1989). The principle nutrient in the blood that supplies the brain with fuel to function properly is glucose. Carbohydrate storage in the brain is extremely limited. Therefore, a constant supply of glucose is needed for normal brain functioning. Cranial Nerves The cranial nerves arise directly from the central nervous system. Most often, a neurological problem is detected through the assessment of these nerves. The cranial nerves are composed of twelve pairs of nerves that stem from the nervous tissue of the brain. Some nerves have only a sensory component, some only a motor component, and some both. The motor

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components of cranial nerves transmit nerve impulses from the brain to target tissue outside of the brain. Sensory components transmit nerve impulses from sensory organs to the brain. A summary of the functions of the cranial nerves is listed in the table below. Cranial Nerve Cranial Nerve I: Cranial Nerve II: Cranial Nerve III: Cranial Nerve IV: Major Functions Sensory Sensory Sensory and Motor Primarily Motor Sensory and Motor Primarily Motor Sensory and Motor Sensory and Motor Primarily Motor Sensory and Motor

Olfactory Optic Oculomotor Trochlear

Cranial Nerve V: Cranial Nerve VI: Cranial Nerve VII:

Trigeminal Abducens Facial

Cranial Nerve VIII: Cranial Nerve IX:

Vestibulocochlear (auditory) Glossopharyngeal

Sensory Sensory and Motor

Cranial Nerve X:

Vagus

Sensory and Motor

Cranial Nerve XI:

Spinal Accessory

Sensory and Motor Primarily Motor

Cranial Nerve XII:

Hypoglossal

Sensory and Motor Primarily Motor

Smell Vision Eyelid and eyeball movement Innervates superior oblique Turns eye downward and laterally Chewing Face and mouth touch and pain Turns eye laterally Proprioception Controls most facial expressions Secretion of tears and saliva and Taste Hearing Equilibrium sensation Taste Senses carotid blood pressure Muscle sense proprioception Senses aortic blood pressure Slows heart rate Stimulates digestive organs Taste Controls trapezius and sternocleidomastoid controls swallowing movements Muscle sense proprioception Controls tongue movements Muscle sense -

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proprioception Spinal Cord The spinal cord is the primary structure that connects the brain and peripheral nervous system. It is protected by the vertebrae of the spinal column. The spinal cord is located in the vertebral foramen and is made up of 31 segments: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal vertebrae. While a pair of the spinal nerves exit from each segment of the spinal cord, the spinal cord itself extends down to only the last of the thoracic vertebrae. The spinal nerves that branch from the spinal cord from the lumbar and sacral levels must run in the vertebral canal for a distance before they exit the vertebral column. This collection of nerves in the vertebral canal is called the cauda equina (horses tail).

Receptors in the periphery send impulses to the spinal cord through the spinal nerves. The cell bodies for these nerve fibers are located in the dorsal root ganglion. These cell bodies are sensory in nature. The cell bodies in the ventral horn are motor in nature and send axons through the ventral root to muscles to control and coordinate how we move. The nerve fibers enter the spinal cord through the dorsal root. Some fibers make synapses with other neurons in the dorsal horn, while others continue up to the brain. Reflexes

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Reflexes are rapid, involuntary responses to stimuli which are mediated over simple nerve pathways called reflex arcs. Involuntary reflexes are very fast, traveling in milliseconds. The fastest impulses can reach 320 miles per hour (Sherwood, 1997). Reflexes can be categorized as either autonomic or somatic. Autonomic reflexes are not subject to conscious control, are mediated by the autonomic division of the nervous system, and usually involve the activation of smooth muscle, cardiac muscle, and glands. Somatic reflexes involve stimulation of skeletal muscles by the somatic division of the nervous system.

When peripheral reflexes are intact, a sensory stimulus travels to the spinal cord. That stimulus is then converted to a motor stimulus within the spinal cord. The motor stimulus travels back to the site of sensory input and usually causes muscle contraction. An example is the kneejerk reflex or placing your hand on a hot stove. The sensory stimulus does not need to travel all the way to the brain to be interpreted and then back to the site of potential injury (Sherwood, 1997). Reflex testing is an important diagnostic tool for assessing the condition of the nervous system. Distorted, exaggerated, or absent reflex responses may indicate collapse or pathology of portions of the nervous system. For example, if the spinal cord is damaged, then reflex tests can help determine the area of injury. For example, motor nerves above an injured area may be unaffected, whereas motor nerves at or below the damaged area may be unable to perform the usual reflex activities. Another example is what occurs in head traumas. Closed head injuries that may produce increased intracranial pressure may be diagnosed by reflex testing. The oculomotor nerve stimulates the muscles in and around the eyes. If increased intracranial pressure is present, such as in some head traumas, then the pressure exerted on cranial nerve III may cause variations in the eye reflex responses.

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PERIPHERAL NERVOUS SYSTEM The peripheral nervous system is subdivided into the somatic nervous system and the autonomic nervous system. The somatic nervous system consists of the twelve pairs of cranial nerves and thirty-one pairs of spinal nerves. Somatic Nervous System The somatic nervous system is typically under voluntary control. The somatic nervous system includes all nerves controlling the muscular system and external sensory receptors. The somatic nervous system has both motor and sensory divisions. Motor fibers are efferent fibers which innervate skeletal muscle. They are present in spinal nerves and cranial nerves III, IV, VI and XII and terminate at the skeletal muscles. Sensory fibers are afferent fibers that relay sensations such as touch, pain and temperature from the skeletal muscles via peripheral, spinal, and cranial nerves V, VII, IX and X to the central nervous system (Tortora, 1989). Autonomic Nervous System In contrast, the autonomic nervous system is not voluntary. It is also a good thing it is not. If it was voluntary, we would have to think about every heart beat we had, the amount of blood we delivered to specific tissues, the dilation of our pupils, and how much digestive motility our gastrointestinal tract needed. In other words, the autonomic nervous system regulates the activities of the internal organs (Sherwood, 1997). The autonomic nervous system has two main parts, the sympathetic and the parasympathetic systems. These two opposite systems often operate in opposition to each other. Many internal organs are stimulated by both systems. When one stimulates an organ, the other tends to depress the organ. The sympathetic nervous system is responsible for the fight-orflight" response. This response prepares us for emergency situations. The parasympathetic nervous system, oppositely, tends to inhibit these reactions. The response of our body depends on the proportionate strength of stimulation supplied by each system at any given instance (Sherwood, 1997). Sympathetic Nervous System Activation of the sympathetic nervous system increases heart rate, contractility, conduction velocity of myocardial tissue. Additionally, in blood vessels, sympathetic activation constricts arteries and arterioles. This increases central blood flow and decreases distal blood flow. In other words blood is shunted away from the periphery to the heart, brain and skeletal

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muscles (Tortora, 1989). Sympathetic stimulation also dilates the pupils, dilates the trachea and bronchi, stimulates the conversion of glycogen into glucose, inhibits peristalsis in the gastrointestinal tract, and inhibits contraction of the bladder and rectum. The overall effect of sympathetic activation is to increase cardiac output, systemic vascular resistance (both arteries and veins), and increase arterial blood pressure. Enhanced sympathetic activity is particularly important during exercise, emotional stress, and during hemorrhagic shock (AACN, 1998; Sherwood, 1997). Parasympathetic Nervous System When the parasympathetic system is activated, it works to decrease heart rate, contractility, and conduction velocity of the myocardial tissue via the vagus nerve, cranial nerve X. Parasympathetic nerves mainly innervate salivary glands, gastrointestinal glands, and genital erectile tissue where they cause vasodilation (Tortora, 1989). The parasympathetic system returns the body functions to normal after they have been altered by sympathetic stimulation. In times of danger, the sympathetic system prepares the body for aggressive activity. The parasympathetic system reverses these changes when the danger is over. Parasympathetic stimulation causes slowing down of the heartbeat, lowering of blood pressure, constriction of the pupils, increased blood flow to the skin and viscera, and decreased peristalsis of the gastrointestinal tract (AACN, 1998; Sherwood, 1997). 2.) Readings When a person has a stroke, the injury to the brain can manifest itself in various ways. Stroke can affect movement, speech, behavior, memory and emotions. What might be less obvious about strokes effects is the increased chance of developing seizures. Seizures are brain malfunctions that alter a persons awareness. During a seizure, the brain cells fire large bursts of energy, a departure from the normal on-and-off firing pattern. The seizure may last only a few seconds or minutes and trigger involuntary body movements, strange sensations or blackouts. The Epilepsy Foundation estimates that seizures strike 22 percent of stroke survivors. A Scar in the Brain Seizures occur whenever there is a scar in the brain, said Ralph L. Sacco, M.D., professor of neurology and epidemiology at Columbia University Medical Center. When stroke

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injures part of the brain, it leaves a scar, and this scar can then trigger abnormal electrical activity that can start a seizure.

Dr. Sacco said that bleeding (hemorrhagic) strokes are more likely to produce seizures than ischemic strokes. That accounts for many of the seizures that hit 26 percent of stroke survivors in the first 30 days, making seizure risk the greatest during that period. Focusing on Treatment Although research has led to a greater understanding of how to treat seizures, no cure has been found. Physicians focus on controlling seizures with medicine while keeping side effects to a minimum. Once a seizure occurs, getting help quickly is essential. Promptly treating seizures seems to lower the risk of having more seizures, Dr. Sacco said, and increases the chance of becoming seizure-free. Medications may be less successful once seizures and their consequences become established. The longer you go seizure-free on medicine, the lower your risk and the more reasonable it may be to take you off medicine. If you have seizures early in the period of a stroke, yes, you are still at risk for long-term seizures. However, suppose that you have them early, get treated and remain seizure-free. You may be over the acute period and be able to come off the drugs. Doctors treat a post-stroke seizure in much the same way they treat epilepsy. Although it takes more than one seizure to classify someone as epileptic, Dr. Sacco said, almost all poststroke seizures are treated with the same anticonvulsant drugs given for recurrent epilepsy, including phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital (Solfoton), valproic acid (Depakote) and lamotrigine (Lamictal). Epilepsy, a general term covering all types of recurrent seizures, affects about 2.3 million Americans. Although people of all ages are affected, particularly the young and elderly, nearly half of all cases develop before the age of 10. Epilepsy in young people comes from a variety of causes, including head injuries, poisoning, stroke, brain tumors, genetic factors, serious illness and problems in brain development before birth. In older people, the cause is more likely related to physical changes from aging, including cardiovascular

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disease, stroke, brain tumors and Alzheimers disease. Of these, stroke is the most frequent cause. If you are a stroke survivor and havent had seizures yet, having another stroke is going to increase your risk of seizures, Dr. Sacco said. Effective lifestyle changes to reduce the risk of seizures are the same as those to reduce the risk of recurrent stroke. Controlling weight and blood pressure, increasing physical activity and eating nutritious food will help. Out of Control With most seizures, the effects last only a few seconds or minutes, and normal physical and mental functions are restored. But a condition called status epilepticus, in which a person has an abnormally long seizure or does not regain consciousness between seizures, is lifethreatening. A seizure lasting longer than five minutes, for practical purposes, should be treated as a status epilepticus condition. Immediate medical help is necessary. Status epilepticus has been known to cause further injury (to the brain), especially if its occurring around the time of the stroke, Dr. Sacco said. Status epilepticus in anybody will increase the risk of mortality. Drug Interaction Stroke survivors who take blood thinners such as warfarin must be carefully watched by their doctors. Warfarin, an anticoagulant, fights the formation of blood clots, which could cause another stroke. Because it affects the liver, warfarin magnifies the detrimental effect that antiseizure medicines have on the liver. For the same reason, Dr. Sacco recommends that alcohol, whose harmful effects on the liver are well known, be avoided while taking antiseizure medicine. Common drugs used to prevent recurrent stroke aspirin, clopidogrel and aspirindipyridamole are not as dangerous when taken with anti-seizure medicines, he said. When to Medicate Should anti-seizure medicine be given before a seizure occurs? Opinions and practices vary. Some doctors start medicine soon after a stroke as a preventive measure, and others prefer to wait until after the first seizure. For most strokes you wait until you have the seizure, Dr. Sacco said. For some bleeding strokes, some people have advocated prophylactic (preventive) anti-seizure medications only in the early period after a stroke. But for the general stroke patient, you would not medicate until you have the seizure.

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All drugs have risks, and you dont want to use a drug if you dont need it. Not every stroke patient has a seizure. Epilepsy is the commonest neurologic disorder with therapeutic indications. Prevalence of epilepsy is 0.5-1%. Seizure is a clinical manifestation where you have a neuron which fires excessively, so there is hyper-excitability of a neuron coupled with hyper synchronization. Hyper synchronization means that a hyper-excitable neuron will lead to excessive excitability of a large group of surrounding neurons and you end with millions of neurons in the brain firing excessively leading to the clinical manifestations of the seizure. The phenotype of the seizure depends on the site it occurs at. If the seizure comes from the limbic system you will end up with temporal lobe or emotional disturbances. If it occurs in the rolandic area you will have motor seizure. If it starts in both sides of the brain you will end up with generalized seizure. Seizure is a sudden time limited involuntary alteration of behavior with or without loss of consciousness accompanied by an abnormal electrical discharge. Epilepsy is a disorder of the CNS whose symptoms are seizures. Seizures are a symptom of epilepsy. Seizures ("fits," convulsions) are episodes of disturbed brain function that cause changes in attention or behavior. They are caused by abnormally excited electrical signals in the brain. A single seizure may be related to a temporary medical problem (such as brain or tumor withdrawal from alcohol). If repeated seizures do not happen again once this underlying problem is corrected, the person does not have epilepsy. A single, first seizure that cannot be explained by a temporary medical problem has about a 25% chance of returning. After a second seizure occurs, there is about a 70% chance of future seizures and the diagnosis of epilepsy. TYPES OF EPILEPSY Epilepsy is generally classified into two main categories based on seizure type:

Partial (also called focal or localized) seizures. These seizures are more common than generalized seizures and occur in one or more specific locations in the brain. In some

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cases, partial seizures can spread to wide regions of the brain. They are likely to develop from specific injuries, but in most cases the exact origins are unknown (idiopathic ).

Generalized seizures. These seizures typically occur in both sides of the brain. Many forms of these seizures are genetically based. There is usually normal neurologic function.

PARTIAL SEIZURES (ALSO CALLED FOCAL SEIZURES) These seizures are subcategorized as "simple" or "complex partial."

Simple Partial Seizures. A person with a simple partial seizure (sometimes known as Jacksonian epilepsy) does not lose consciousness, but may experience confusion, jerking movements, tingling, or odd mental and emotional events. Such events may include deja vu, mild hallucinations, or extreme responses to smell and taste. After the seizure, the patient usually has temporary weakness in certain muscles. These seizures typically last about 90 seconds.

Complex Partial Seizures. Slightly over half of seizures in adults are complex partial type. About 80% of these seizures originate in the temporal lobe, the part of the brain located close to the ear. Disturbances there can result in loss of judgment, involuntary or uncontrolled behavior, or even loss of consciousness. Patients may lose consciousness briefly and appear to others as motionless with a vacant stare. Emotions can be exaggerated; some patients even appear to be drunk. After a few seconds, a patient may begin to perform repetitive movements, such as chewing or smacking of lips. Episodes usually last no more than 2 minutes. They may occur infrequently, or as often as every day. A throbbing headache may follow a complex partial seizure. In some cases, simple or complex partial seizures evolve into what are known as

secondarily generalized seizures. The progress may be so rapid that the partial stage is not even noticed. GENERALIZED SEIZURES Generalized seizures are caused by nerve cell disturbances that occur in more widespread areas of the brain than do partial seizures. Therefore, they have a more serious effect on the patient. They are further subcategorized as tonic-clonic (or grand mal), absence (petit mal), myoclonic, or atonic seizures.

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Tonic-Clonic (Grand Mal) Seizures. The first stage of a grand mal seizure is called the tonic phase, in which the muscles suddenly contract, causing the patient to fall and lie stiffly for about 10 - 30 seconds. Some people experience a premonition or aura before a grand mal seizure. Most, however, lose consciousness without warning. If the throat or larynx is affected, there may be a high-pitched musical sound (stridor) when the patient inhales. Spasms occur for about 30 seconds to 1 minute. Then the seizure enters the second phase, called the clonic phase. The muscles begin to alternate between relaxation and rigidity. After this phase, the patient may lose bowel or urinary control. The seizure usually lasts a total of 2 - 3 minutes, after which the patient remains unconscious for a while and then awakens to confusion and extreme fatigue. A severe throbbing headache similar to migraine may also follow the tonic-clonic phases. Absence (Petit Mal) Seizures. Absence or petit mal seizures are brief losses of consciousness that occur for 3 - 30 seconds. Physical movement and loss of attention may stop for only a moment. Such seizures may pass unnoticed by others. Young children may simply appear to be staring or walking distractedly. Petit mal may be confused with simple or complex partial seizures, or even with attention deficit disorder. In petit mal, however, a person may experience attacks as often as 50 - 100 times a day. Myoclonic. Myoclonic seizures are a series of brief jerky contractions of specific muscle groups, such as the face or trunk. Atonic (Akinetic) Seizures. A person who has an atonic (or akinetic) seizure loses muscle tone. Sometimes it may affect only one part of the body so that, for instance, the jaw slackens and the head drops. At other times, the whole body may lose muscle tone, and the person can suddenly fall. A brief atonic episode is known as a drop attack. Simply Tonic or Clonic Seizures. Seizures can also be simply tonic or clonic. In tonic seizures, the muscles contract and consciousness is altered for about 10 seconds, but the seizures do not progress to the clonic or jerking phase. Clonic seizures, which are very rare, occur primarily in young children, who experience spasms of the muscles but not tonic rigidity. Epilepsy has no identifiable cause in about half of those who have the condition. In the other half, the condition may be traced to various factors.

Genetic influence. Some types of epilepsy, which are categorized by your type of seizure, run in families, making it likely that there's a genetic influence. Researchers have linked some types of epilepsy to specific genes, though it's estimated that up to 500 genes

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could be tied to the condition. For most people, genes are only part of the cause, perhaps by making a person more susceptible to environmental conditions that trigger seizures.

Head trauma sustained during a car accident or other traumatic injury can cause epilepsy. Medical disorders. Events like strokes or heart attacks that result in damage to the brain also can cause epilepsy. Stroke is responsible for up to one-half of epilepsy cases in those over age 35.

Dementia is a leading cause of epilepsy among older adults. Diseases such as meningitis, AIDS and viral encephalitis can cause epilepsy. Prenatal injury. Before birth, babies are susceptible to brain damage caused by an infection in the mother, poor nutrition or oxygen deficiencies. This can lead to cerebral palsy in the child. About 20 percent of seizures in children are associated with cerebral palsy or other neurological abnormalities.

Developmental

disorders. Epilepsy

can

sometimes

be

associated

with

other

developmental disorders, such as autism and Down syndrome.

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Seizures occur whenever there is a scar in the brain, said Ralph L. Sacco, M.D., professor of neurology and epidemiology at Columbia University Medical Center. When stroke injures part of the brain, it leaves a scar, and this scar can then trigger abnormal electrical activity A seizure (from the Latin sacireto take possession of) is the clinical manifestation of an abnormal, excessive, hypersynchronous discharge of a population of cortical neurons. Epilepsy is a disorder of the central nervous system characterized by recurrent seizures unprovoked by an acute systemic or neurologic insult. Epileptogenesis is the sequence of events that turns a normal neuronal network into a hyperexcitable network. Recognizing the distinction between seizures and epilepsy is essential. Epilepsy may require chronic treatment (with antiepileptic medication and, in some cases, surgery) whereas therapy for an isolated seizure is directed toward the underlying cause and may not require antiepileptic drugs (AEDs). Furthermore, epilepsy often has profound psychosocial ramifications for the patient, and is thus a diagnosis to be assigned with care.

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Seizures are one of the most common complications of stroke. Overall, 5%-15% of stroke patients will experience seizure within 2 years of stroke. The reported risk factors for and incidence of seizures after stroke vary widely, likely secondary to differences in study design, study populations, and use of antiepileptic drugs (AEDs). In previous studies, the main risk factors for poststroke seizures include stroke subtype, location and severity. Poststroke seizures rates are highest in those with intraparenchymal hemorrhage and large supratentorial ischemic strokes, and lowest after transient ischemic attacks, lacunar infarcts, and brainstem strokes. Although frequently encountered in clinical practice, there are few evidence-based guidelines for therapy of poststroke seizures. Poststroke seizures are classified as early or late according to their temporal proximity to the stroke. Early seizures, also termed acute symptomatic seizures, occur within the first week following stroke. These early seizures are likely provoked by the metabolic and physiologic derangements associated with acute infarction or hemorrhage. Late seizures are thought to result from epileptogenesis, changes in neurons that result in permanent hyperexcitability. (Herman, Susan T. MD.2011. Bech Israel Deaconess Medical Center, Harvard Medical School. Boston, MA) The following factors increase your chance of developing some seizure disorders: Previous brain injury-seizure disorder usually develops within one year of injury Previous brain infection Brain tumor History of stroke History of complex febrile seizures Use of certain medications or recreational drugs Stopping the use of medications, recreational Drug Abuse and Drug Addiction , or Alcohol Abuse and Alcoholism Drug overdose Exposure to toxins (eg, Arsenic Toxicity , Lead Poisoning , or Carbon Monoxide Poisoning ) Family history of seizure disorders Alzheimer's Disease Pre-eclampsia

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Chemical abnormalities (decreased or excess blood sodium or glucose, low blood calcium) Liver or Kidney Failure Severe, untreated High Blood Pressure Chronic diseases (eg, Systemic Lupus Erythematosus , Polyarteritis Nodosa , Porphyria , Sickle Cell Anemia , Whipple's Disease ) Syphilis

If you already have a seizure disorder, the following factors can increase your chance of having a seizure: Sleep deprivation Alcohol Hormonal changes (such as those that occur at points during the menstrual cycle) Stress Flashing lights, especially strobe lights Use of certain medicines Missing doses of anti-epileptic medicines

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3) Schematic Diagram NERVOUS SYSTEM

ETIOLOGY FACTORS - an electrical disturbance (genetic, in the nerve cells in one defects) section of the brain, causing (hypoxemia, them to emit abnormal, insufficiency, recurring, uncontrolled, head injury, electrical discharges CNS infections, conditions,

PREDISPOSING - idiopathic developmental - acquired vascular fever (childhood), hypertension, metabolic and toxic brain tumor, drug and

alcohol withdrawal, and allergies)

CELLULAR/ METABOLIC CHANGES PHYSIOLOGIC MANIFESTATION

GROSS ANATOMICAL PHYSICAL CHANGES

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- when the integrity of the neuronal cell

- involuntary movements may spread centrally and involve the entire limb, including one side of the face and lower extremities. the client also may exhibit changes in posture or spoken utterances

epigastric sweating,

sensations, pallor, membrane is altered, the cell begins firing flushing, goose flesh with increased frequency and amplitude. pupillary dilation, When the intensity discharges reaches the and tachypnea. threshold, the neuronal firing spreads to adjacent neurons, ultimately resulting to seizure. Inhibitory neurons in epilepsy have slow neuronal firing in the cortex, anterior thalamus, and basal ganglia. Once the inhibitory processes develop or the epileptogenic neurons are exhausted, the seizure stops then later events depress the CNS activity and impair consciousness

(piloerection), tachycardia,

SIGNS AND SYMPTOMS TONIC PHASE: - fall, loss of consciousness, yell or tonic cry, brain, focal abnormalities, extension of arms, legs, and/or face, fingers and jaw clenched. AUTONOMIC SYMPTOMS type and location of the include increase in blood pressure, heart rate and bladder pressure, flushing, sweating, zone so that the

LABORATORY FINDINGS - MRI may detect lesions in the and cerebral degenerative changes - EEG may allow diagnosis of the occurring seizure. - SPECT may identify the epileptogenic

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increased salivation and bronchial secretion, seizures can be removed and apnea CLONIC PHASE: - muscles relax completely, then muscle tone returns which causes rhythmic jerking of head and body. POST-ICTAL PHASE: - biting of the tongue, cheek or lip, and urinary incontinence are common

area in the brain giving rise to surgically.

SEIZURE

COMPLICATIONS Hypoxic brain damage and mental retardation may follow repeated seizures Depression and anxiety may develop. Long-term social isolation may also occur

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