1
Q
- At Inferior frontal lobe
- Tested using coffee or soap
- Volatile substances like perfume must be avoided
o Don’t use injurious stimuli!
o Don’t use ammonia, or ammonia like substances(volatile substances), it will stimulate CN V and give a false reading - BUT ACCORDING TO DEMEYER: Use aromatic, nonirritating substance (camphor, perfume, coffee powder)
- May be absent when patient has colds
- Or when there is an inferior frontal brain tumor
A
CN I - OLFACTORY
2
Q
Proper way to test CN 1 (Olfactory Nerve)
A
o Proper way to test: close the patient’s eyes and waft the bottle. Don’t let the patient inhale directly from the bottle because small particles may be carried (i.e. when using coffee powder)
o Test one nostril at a time, giving a few minutes in between because smell develop tolerance very fast
3
Q
Examination Proper: CN I
A
Examine Nostril Separately (Occlude the other) ↓ With the patient’s eyes closed and one nostril occluded bring the test substance near the open one ↓ Ask patient to sniff and identify ↓ Repeat on the other side ↓ Compare 2 sides
4
Q
- At anterior frontal lobe
- Central vision/Visual acuity – use a Snellen or Jaeger chart testing eyes one at a time
- Peripheral Vision/Visual Fields – tested by visual confrontation
- Fundoscopic Examination
A
CN II: OPTIC
5
Q
Testing of Visual Acuity
A
Test each eye separately. The Pt keeps eye glasses on. Although glasses improve acuity by correcting for a refractive error, they do not improve acuity impaired.
6
Q
Examination Proper: CN II OPTIC
A
Central Vision/Visual Acuity – use a Snellen or Jaeger Chart
o Distance 20ft or 6m
o Jaeger chart held 14 inches or 35.5cm
o Use pinhole
7
Q
Testing of Visual Fields (by confrontation)
A
- Confront the Pt by stationing yourself directly in front. Start with your left eye directly in line with the Pt’s right eye, at a distance of about 50 cm—eye to eye but not breath to breath. The Pt covers the left eye with the left hand
- Hold up your left index finger just outside your own peripheral field, in the inferior temporal quadrant. Hold the finger about equidistant between your eye and the Pt’s. Ideally the finger should extend beyond the perimeter of the field. Wiggle the finger slowly and move it very slowly toward the central field. Request the Pt to say “now” as soon as the wiggling finger is seen. Try to match the perimeter of the Pt’s visual field against your own. Test all quadrants of each eye separately, each time starting at the limit of the field.
8
Q
Testing of Visual Fields (by confrontation) 2
A
- After surveying the visual field by the wiggling finger, you can refine the test by asking the Pt to count the number of fingers presented in each of the four quadrants of the visual field of each eye. Have the Pt close or cover the eye not being tested. Then randomly hold up one, two, or five digits (three or four is too complicated) in each quadrant for the Pt to count.
- Confrontational test: Detect the temporal visual field, making it possible to plot the visual eye fields of the patient.
9
Q
Any reflex observed on one side of the body when the other side has been stimulated. (i.e. Constriction of the pupil when one eye was lighted)
A
Consensual reflex
10
Q
Testing: Fundoscopy
A
- Inspect the cornea with and without the scope for opacities and for a circular ring near the limbus, which, if grayish-white, is an arcussenilis, or, if greenishbrown, a Kayser-Fleischer ring pathognomonic of Wilson hepatolenticular degeneration.
- Next focus on a retinal vessel by using whatever lens setting, from 0 to a strong plus or minus that is required to overcome refractive errors. After locating a retinal vessel, follow it along until you find the optic disc (optic papilla).
11
Q
Testing: Fundoscopy 2
A
- Next, identify the pigment ring around the disc, note the disc color, and the presence or absence of a physiologic cup.
- Look for venous pulsations where the veins bend over the edge of the physiologic cup.
- Follow each artery out as far as possible. Locate the macula, a darker, avascular area two disc diameters lateral to the disc. Note the pearl of light reflecting from the fovea centralis, the center of the macula. This light reflection fades in older persons.
*Right eye of the patient will be seen by the right eye of the doctor. The doctor must be on the side of the patient para di magkiss
12
Q
Examination Proper: CN II OPTIC (Fundoscope)
A
Use an Opthalmoscope ↓ Check if the gadget is in adequate setting ↓ Approach the patient from the side (you’ll see something red-orange reflex: those are your arteries and veins) ↓ Follow the red-orange reflex ↓ Look for hemorrhages
13
Q
CN II and III: OPTIC AND OCCULOMOTOR (Pupillary light reflex (Use 2 lights))
A
- Ask the patient to look into the distance, and shine a bright light obliquely into each pupil in turn. Both the distant gaze and the oblique lighting help to prevent a near reaction.
- Look for: The direct reaction (pupillary constriction in the same eye) or the consensual reaction (pupillary constriction in the opposite eye)
14
Q
CN III, IV and VI – OCULOMOTOR, TROCHLEAR and ABDUCENS
A
Test the extra ocular eye movements
o CN VI innervates the lateral recti (LR6)
o CN IV innervates the superior oblique muscles (SO4)
o CN III innervates all other muscles – the medial recti, superior and inferior recti and the inferior oblique muscle
- Weakness of the EOMs associated with ptosis may indicate myasthenia gravis
- Isolated CN VI palsy may occur in patients with diabetes
- CN III palsy associated with the headache is ominous and indicates a PCOM aneurysm
15
Q
Examination Proper: CN III, IV, and VI
A
- Check and observe the eyelids
- (Look for ptosis, exopthalmos, enopthalmos)
- The target should slowly trace a large letter H for the patient to follow
Test both eyes ↓ Ask the patient to follow your finger ↓ Move your finger up, down and sideways ↓ Report whether the patient can’t look up, down or sideway
16
Q
- At pons
- Facial sensation
- Also for mastication (Masseter and temporalis and pterygoids) - The most common ailment affecting this CN is trigeminal neuralgia (usually V1 & V2)
A
CN V - TRIGEMINAL
17
Q
CN V: Trigeminal Nerve
A
Motor (Strength):
o Check chewing movements. (What are the muscles innervated? TIME! Temporalis, Internal pterygoid, Masseter, External pterygoid)
Sensation:
o Test the forehead (Opthalmic), cheeks (Maxillary), and jaw (Mandibular)on each side for pain sensation. If you find an abnormality, confirm it by testing temperature sensation. Two test tubes, filled with hot and ice-cold water, are the traditional stimuli.
18
Q
Examination Proper: CN V Sensory
A
Ask patient to close the eyes ↓ Check for all part of face sensation ↓ Check if there are equal sensations (compare both sides)
19
Q
- touch the cornea (not just the conjunctiva) lightly with a fine wisp of cotton.
Direct corneal: stimulate one side, blink on same side
Consensual corneal: stimulate one side, both eyes blink, equally forcefuL
A
Corneal (Blink) reflex
20
Q
DIFFERENTIAL DIAGNOSIS
A
What if right side is stimulated but it is the left eye that blinks? Where is the problem (what part of the reflex arc has the problem – motor arc or sensory)? Motor! CN7!
What if the stimulation is applied but neither eye blinked? Sensory problem! CN5!
21
Q
With the patient’s jaw sagging loosely open, the examiner rests a finger across the tip and strikes it a crisp blow.
A
Jaw Jerk
22
Q
Exaggerated reaction in jaw jerk test may indicate problem in the __.
A
pons
23
Q
Examination Proper: CN V Motor (jaw jerk)
A
Ask patient to bite hard ↓ Palpate the temporalis area ↓ Observe contraction of muscles
24
Q
Motor: o Forehead wrinkling o Eyelid closure o Mouth retraction o Whistling or puffing out cheeks o Wrinkling of skin over the neck o Labial articulations
A
CN VII: FACIAL NERVE
25
- ”Wrinkle up your forehead” or “Look up at the ceiling”
- Inspect for asymmetry
* What muscle is tested?
Frontalis
26
- ”Close your eyes tight and don’t let me open them”
- Inspect for asymmetry of wrinkles; try to pull eyelids apart
* What muscle is tested?
Orbicularis oculi
27
- ”Pull back the corners of your mouth, as in smiling”
- Inspect for asymmetry of nasolabial fold
* What muscle is tested?
Buccinator
28
- "Wrinkle up the skin on your neck”or “Pull down hard on the corners of your mouth”
- Inspect for asymmetry
* What muscle is tested?
Platysma
29
CN VII: Facial (Sensory)
o Taste sensation in anterior 2/3 of the tongue
o Rarely assessed unless with peripheral VII nerve palsies. Use tongue depressor with single substances (e.g sugar crystals) applied to one side of the tongue. Instruct patient to protrude the tongue for application, then raise the hand once they have decided what the taste is.
30
- Can be tested grossly by rubbing fingers beside the ears one at a time
- Hearing: finger rub testing (if no tuning fork available).
- Tuning Fork Tests (Schwaback, Rinne, Webers)
CN VIII- VESTIBULO-COCHLEAR
31
Hearing: finger rub testing (if no tuning fork available).
o Rub your own thumb and index finger beginning 50cm from the test ear, bringing the stimulus closer to the patient’s head. Note the distance at which the stimulus is reliable perceived
32
Schwabach's Test
o Here bone conduction (BC) of patient is compared with that of the normal hearing person (examiner) but meatus is not occluded.
o It has the same significanceas absolute bone conduction test.
o Schwabach is reduced in sensorineural deafness and lengthened in conductive deafness.
o Place the vibrating tuning fork on the patient’s mastoid bone. When patient can no longer hear the sound, place the tuning fork on your mastoid bone. If there is still sound subject is positive for the test
33
Compare patient bone conduction to that of the examiners’
Schwabach's Test
34
Test for bone and air conduction.
Rinne Test
35
Rinne Test
- In this test air conduction of the ear is compared with its bone conduction. o A vibrating tuning fork is placed on the patient's mastoid and when he stops hearing, it is brought beside the meatus.
- When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. Here the “U” of the fork should face forward, thus maximizing its sound for the patient. Normally the sound is heard longer through air than through bone (AC > BC)
- Rinne test is called positive when AC is longer or louder than BC. It is seen in normal persons or those having sensorineural deafness.
- A negative Rinne (BC > AC) is seen in conductive deafness.
36
Test for Lateralization.
Weber Test
37
Weber Test
- In this test, a Vibrating tuning fork is placed in the middle of the forehead or the vertex and the patient is asked in which ear the sound is heard.
- Normally, it is heard equally in both ears. It is lateralised to the worse ear in conductive deafness and to the better ear in sensorineural deafness
38
Examination Proper: Tuning Fork Tests
Check if gross hearing is intact then use a tuning fork
↓
Vibrate the tuning fork and put it near (parallel position) one ear
↓
Ask the patient to tell you when the sound ends
↓
Check for both bone conduction and air conduction
39
Examination Proper: CN VII
```
Use a tuning fork
↓
Vibrate the tuning fork
↓
Place if over the center of the forehead
↓
Ask the patient where he/she can hear the sound of the tuning fork more
```
40
CN IX supplies only one muscle exclusively, the stylopharyngeus. Because this muscle aids in swallowing, its isolated function cannot be tested clinically.
CN IX and X: GLOSSOPHARYNGEAL and VAGUS
41
Testing of Palatal elevation
- Observe palatal elevation when patients says “Ah”
* Ask the patient to say “ah” or to yawn as you watch the movements of the soft palate and the pharynx. The soft palate normally rises symmetrically, the uvula remains in the midline, and each side of the posterior pharynx moves medially, like a curtain. The slightly curved uvula seen occasionally as a normal variation should not be mistaken for a uvula deviated by a lesion of CN X
- Test swallowing and gag reflex (using a tongue depressor, touching the roof of the mouth, the back of the tongue, the area around the tonsils and the back of the throat)
- The remaining branchial efferent fibers of CNs IX and X supply the pharyngeal constrictors. Because they act as a unit in swallowing, the isolated function of the individual constrictors cannot be tested at the bedside.
42
Testing of Gag Reflex
o Stimulate the back of the throat lightly on each side in turn and note the gag reflex which consists of elevation of the tongue and soft palate and constriction of the pharyngeal muscles
o Gag reflex is often impaired in patients with stroke – supratentorial or infratentorial, especially when multiple strokes are present
43
CN XI: SPINAL ACCESSORY
- Ask the patient to raise his shoulder (trapezius), add resistance by pushing it down
- Ask the patient to resist head turning with his jaw (SCM) while letting the head with your hand, face the opposite side of the resistance
44
CN XII: HYPOGLOSSAL
- Ask the patient to stick his tongue out
- The presence atrophy and fasciculatons indicates a lesion in the nucleus or in the nerve
o Seen in patients with ALS
45
Testing Tongue Motility and Deviation
o Say to the Pt, “Stick your tongue straight out as far as possible and hold it there.” Check for alignment of the median raphe of the tongue with the crevice between the medial incisor teeth.
o Then, if the history or findings suggest a bulbar problem, ask the Pt to move the tongue alternately to the right and to the left and to try to touch the tip of the tongue to the tip of the nose and then to the tip of the chin. On protrusion the tongue tip should extend well beyond the teeth.
46
Testing Tongue Strength
o Have the Pt press the tongue against the cheek while you press your finger against the cheek.
47
Review of Cerebellum
- Located behind the dorsal aspect of pons and medulla
- Separated from occipital lobe by tentorium
- Fills most of the posterior fossa
- Vermis - Midline portion; Separates two lateral lobes or hemispheres
- Folia - narrow, ridge-like folds; oriented transversely onexternal surface; Adjacent to 4th Ventricles
48
CEREBELLAR FUNCTIONS
- Coordinate skilled voluntary movements
- Receive collateral input from sensory and special sensory systems.
o Cerebellum processes sensory information.
o Does not influence motor neurons directly
49
(cerebellar signs)
o It is related to a depression of gamma and alpha motor neuron activity
o The least evident of the cerebellar abnormalities
o More apparent with acute than with chronic lesions
o Failure to check a movement - a closely related phenomenon (impairment of the check reflex)
Hypotonia
50
(cerebellar signs)
o Cerebellar sign par excellence”
o May affect the limbs, trunk or gait
Ataxia or dystaxia
51
(cerebellar signs)
o Lack of synergy of the various muscle components in performing more complex movements so that movements are disjointed and clumsy and broken up into isolated successive parts
Asynergia
52
(cerebellar signs)
o Abnormalities in the rate, range and force of movement
Dysmetria
53
(cerebellar signs)
o Abnormality in the rhythm of rapid alternating movements
Adiodochokinesis; Dysdiadochokinesis
54
(cerebellar dysarthria)
o similar to dysarthria from corticospinal disorders
Slurring dysarthria
55
(cerebellar dysarthria)
o Variable intonation (prosody) and abnormalities in articulation; described also as staccato, explosive, hesitant, slow altered accent, and garbled speech
Scanning dysarthria
56
o Usually gaze-evoked, upbeat, rebound with abnormal kinetic nystagmus if with midline cerebellar lesions; periodic alternating nystagmus with lesions of the uvula, nodulus; downbeat nystagmus with posterior midline lesions
Nystagmus
57
Other “cerebellar” eye signs
- ocular flutter,
- opsoclonus,
- ocular bobbing
- square wave jerks at rest,
- skew deviation,
- failure to suppress the vestibulo-ocular reflex
58
- Rhythmic oscillation of the eyes, analogous to a tremor in other parts of the body. Cerebellar lesions result in nystagmus, dysmetria of saccades, jerky rather than smooth pursuit, slowness in initiating eye movements, and skew deviation.
- Cerebellar __ occurs preeminently during volitional use of the eyes and thus is gaze evoked.
Nystagmus
59
o Have the Pt look straight ahead and place your index fingers in the temporal fields. Ask the Pt to look first at one finger and then the other and then direct the Pt to look rapidly from one to the other several times.
Saccadic Dysmetria Test
60
- overshooting the target
| - When the finger approaches the target, there is a side-to-side movement of the finger before reaching the target.
Hypermetria
61
- A rhythmic tremor of the head or upper trunk (three to four per second)
Titubation
62
DISORDER OF EQUILIBRIUM and GAIT
- Standing with feet together may be impossible
- In walking, the patient’s steps may be uneven and placement of the foot may be misaligned
- Wide-based stance with increased trunk sway, irregular stepping with a tendency to stagger as if intoxicated
- Impaired tandem walking
63
o Ask the patient to walk heel-to-toe in a straight line
| o May reveal an ataxia not previously obvious
Tandem Gait
64
o Ask the patient to Walk on the toes, then on the heels— sensitive tests, respectively, for plantar flexion and dorsiflexion of the ankles, as well as for balance
o May reveal distal muscular weakness in the legs. Inability to heel-walk is a sensitive test for corticospinal tract damag
Heel and Toe Walk
65
o The patient should first stand with feet together and eyes open and then close both eyes for 30 to 60 seconds without support. Note the patient’s ability to maintain an upright posture. Normally only minimal swaying occurs
Romberg’s Sign (Position sense test)
66
4 CEREBELLAR SYNDROMES
1. Hemispheric syndrome
2. Rostral vermis syndrome
3. Caudal vermis syndrome
4. Pancerebellar syndrome
67
o Incoordination of ipsilateral appendicular movements
| o Usual etiologies: Infarcts, neoplasms, abscesses
Hemispheric syndrome
68
o A wide-based stance and titubating gait
o Ataxia of gait, with proportionally little ataxia on the heel-to-shin maneuver with the patient lying down
o Normal or only slightly impaired arm coordination
o Infrequent presence of hypotonia, nystagmus, and dysarthria
Rostral vermis syndrome
69
o Axial disequilibrium (truncal ataxia) and staggering gait
o Little or no limb ataxia
o Sometimes spontaneous nystagmus and rotated postures of the head
Caudal vermis syndrome
70
o Bilateral signs of cerebellar dysfunction affecting the trunk, limbs, and cranial musculature
Pancerebellar syndrome
71
Some Etiologies in Pancerebellar syndrome
o infectious and parainfectious processes
o hypoglycemia
o hyperthermia
o paraneoplastic cerebellar degeneration associated with small cell lung cancer (anti-Hu antibodies), breast and ovarian carcinomas (anti-Yo antibodies), or Hodgkin's lymphoma (Tr antibodies)
o Toxic processes
72
Clinical tests for arm dystaxia
o Ask the patient to extend the arms straight out front
| o Do the finger to nose test.
73
o Ask the patient to touch your index finger and then his or her nose alternately several times. Move your finger about so that the patient has to alter directions and extend the arm fully to reach it. Observe the accuracy and smoothness of movements, and watch for any tremor. Normally the patient’s movements are smooth and accurate
Finger-to-Nose Test
74
Rapid Alternating Movements Test
o Show the patient how to strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the hand down on the same place. Urge the patient to repeat these alternating movements as rapidly as possible.
o Observe the speed, rhythm, and smoothness of the movements. Repeat with the other hand. The nondominant hand often performs somewhat less well.
o In cerebellar disease, one movement cannot be followed quickly by its opposite and movements are slow, irregular, and clumsy. This abnormality is called dysdiadochokinesis
75
Clinical tests for leg dystaxia
Heel-to-shin test
76
Heel-to-Shin Test
o Ask the patient to place one heel on the opposite knee, and then run it down the shin to the big toe. Note the smoothness and accuracy of the movements. Repetition with the patient’s eyes closed tests for position sense. Repeat on the other side
o Heel-tapping test
77
Clinical tests for dystaxia of station and gait
o Observe the patient’s stance
o Ask the patient to walk
o Tandem-walk
78
Clinical demonstration of hypotonia
o Inspect for hypotonia – rag doll postures
o Checking for hypotonia
o Pendulous or hypotonic muscle stretch reflexes
79
Overshooting and checking tests of arms
o Wrist-slapping test
| o Arm-pulling test
80
Eye movements, speech
o Check smooth pursuit
| o Listen to patient’s speech
81
Cerebellar System
* Pancerebellar syndrome – occurs usually from ethanol or drug intoxication
* Cerebellar Hemisphere syndrome – occurs from tumors or strokes
82
```
Dysarthria: +
Arm Overshoot: +
Hypotonia: +
Dystaxia of arms: +
Dystaxia of Gait and Trunk: +
Dystaxia of Legs: +
Nystagmus: Bidirectional coaser to side of lesion; fast component to side of gaze
```
Hemispheric Syndrom
83
```
Dysarthria: 0
Arm Overshoot: +/-
Hypotonia: +
Dystaxia of arms: +/-
Dystaxia of Gait and Trunk: +
Dystaxia of Legs: +
Nystagmus: 0
```
Rostral Vermis Syndrome
84
```
Dysarthria: 0
Arm Overshoot: 0
Hypotonia: +/-
Dystaxia of arms: 0
Dystaxia of Gait and Trunk: +
Dystaxia of Legs: +/-
Nystagmus: variable
```
Caudal Vermis Syndrome
85
```
Dysarthria: +
Arm Overshoot: +
Hypotonia: +
Dystaxia of arms: +
Dystaxia of Gait and Trunk: +
Dystaxia of Legs: +
Nystagmus: +(variable type)
```
Pancerebellar Syndrome
86
- The brain and the spinal cord are surrounded by three distinct connective tissue membranes or (meninges)
o Thick dura mater externally
o Delicate arachnoid
o Thin pia mater
THE MENINGES
87
Dura + arachnoid
Pachymeninges
88
- Pia + arachnoid
| - (meaning “thin & delicate”)
Leptomeninges
89
DURA MATER
Outer periosteal layer - rich in blood vessels and nerves and adherent to the cranium
Inner meningeal layer – closely attached to underlying arachnoid
At certain sites, these layers are separated and form large venous sinuses
90
- sickle shaped double layer of the dura matter,lying in between the cerebral hemisphere
Falx cerebri
91
- small sickle shaped projection between the cerebellar hemispheres
Falx cerebelli
92
- crescentic fold that supports theoccipital lobes and covers the cerebellum, divides the cranial cavity in supratentorial and infratentorial compartments
Tentorium cerebelli
93
- circular fold which covers the sella turcica separating the pituitary gland from the hypothalamus
Diaphragma sellae
94
MENINGES AND SPACES
- At the base of the brain and around the brainstem, the pia and arachnoid often are widely separated, creating subarachnoid cisterns
95
Cisterns
- Cisterna magna - Cerebellomedullary
- Pontine cisterns
- Interpeduncular cisterns
- Chiasmatic cisterns
- Superior cisterns
- Lumbar cistern - From the conus medullaris to about the 2nd sacral vertebra; contains the filum terminale and nerve roots of cauda equina
96
- As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally they should remain relaxed and motionless.
- Flexion of both the hips and knees is a positive __
Brudzinski’s Sign
97
- Flex the patient’s leg at both the hip and the knee, and then straighten the knee. Discomfort behind the knee during full extension occurs in many normal people, but should not produce pain.
- Pain and increased resistance to extending the knee are a positive __
Kernig’s Sign
98
NEURORADIOLOGIC HISTORY
```
- Before the advances in radiology, direct visualization of
intracranial compartment was norm
- Exploratory burrholes
Indications:
1. Rapidly deteriorating neurologic exam
2. Lack of scanning facilities
3. Inaccesible remote area
4. Patients unfit for transfer
```
99
1895- German physics professor discovered __. He referred to radiation as X, to indicate it as an unknown type of radiation. Xray was noted at that time to pass through human tissue but it could not pass thrugh bone or metal
Xray
100
1927- Portugese physician __ provided contrasted xray cerebral angiography in order to diagnose several kinds of nervous diease such as tumors, artery disease and AVM
Egas Moniz
101
1950s - __ gained in popularity
Ultrasound
102
1970s- Development of __
CT Scan
103
Eary 1980s- Development of __
MRI
104
DIAGNOSTIC TESTS
```
Neuroimaging
Indications:
o Rule out structural disorder
o Recurring progressive headaches
o Focal slowing on EEG
o Comorbid seizures
o Persistent unilateral headaches
o Assure anxious patient or his relatives
```
105
Photograph made with X-rays
ROENTOGRAM
106
- Picture of bones surrounding the brain
- Abnormal results may be due to: fracture, tumor, erosion or decalcification of bone and movement of the soft tissues
inside the skull
- AP view- Used to know the laterality of findings
- Frontal and lateral view- Used to look for functional defects
Interpreted as hypodense (dark part) or hyperdense (lighter
part; Possibly water or air)
Metal is Hyperdense (compared to bone)
Bullet is very heavy (could migrate from one area to another)
SKULL X-RAY
107
is performed to know if the area where bullet is desired to be extracted is accessible or no
Intraoperative x-ray
108
- Locate the anterior vertebral line and posterior vertebral line; Assess if normally aligned and check for hernia
- What to do if shoulder is obstructing the view? Pull down the shoulder. Do not just tilt it. Tilting it will obstruct the reading too.
- 3 views needed: AP; Lateral; Open mouth
CERVICAL X-RAY
109
- An xray of the twelve chest bones/ thoracic vertebrae. The vertebrae are separated by flat pads of cartilage called disks that provide a cushion between the bones
- Used to evaluate bone injuries, cartilage loss, diseases of
the bone, tumors of the bone
- Test can detect bone spurs, deformities of the spine, disk
narrowing, dislocations, fractures, thinning of the bones
(osteoporosis), degeneration of vertebrae
THORACIC X-RAY
110
- Uses reflected sound waves to produce pictures of the brain and the inner fluid chambers (ventricles) through which the CSF flows
CRANIAL ULTRASOUND
111
Cranial Ultrasound Indication
- Prematurity
- Persistent large fontanel
- Synostosis ***
- Infection
- Trauma
112
Limitations of the Cranial Ultrasound
```
a) Operator dependent-Di mo alam view ng operator,
mahirap i-orient ang sarili
b) Small acoustic window
c) Cannot assess myelination
d) Cerebellar lesions, infarcts
e) Small hemorrhages could be missed
f) Deeper: blurred
```
113
ACOUSTIC WINDOWS - FONTANELLES
- Anterior fontanelle (9-15 mos.); PATENT FROM 9 - 15
MOS., BY 15TH MO. NAGCLOCLOSE NA SIYA.
- Posterior fontanelle (CLOSED BY 3 mos.)
- TEMPORAL FONTANELLE - AROUND MGA 3 Y/O
- Mastoid fontanelle (24 mos.)
114
TWO MODALITIES FOR CRANIAL CT:
1. Cranial CT Plain
| 2. Cranial CT Contrast
115
CRANIAL CT PLAIN: Advantages
o Procedure of choice for acute hemorrhage and skull
fractures
o Cheaper than MRI
o Faster testing time
o Angiography: Vascular anomaly or aneurysm detection
(TO CHECK FOR INTRACRANIAL PRESENCE).
116
CRANIAL CT PLAIN: Disadvantages
o False negative results for small lesions
o Radiation exposure
o Allergic reaction (SOME PEOPLE HAVE ALLERGIC
REACTIONS TO THE CONTRAST BEING USED OR
TO THE IODINATED CONTRAST).
117
Things to Consider on Cranial CT Plain
o Pregnancy is a contraindication (contraindicated
because of radiation effect, they could place a radiation shield but as much as possible they do reduce the radiation
exposure of the patient).
o creatinine monitoring (your kidney is the one being used to excrete your contrast so you have to monitor that, check beforeyou give your contrast).
118
Indications for Cranial CT Plain
o Hemorrhage
o Ischemia
o Fractures
o Calcifications
119
- Iodinated contrast is injected to enhance imaging
- Indications
o Neoplasms(TUMOR)
o Vascular malformations(VASCULAR ANOMALIES)
o Meningitis(INFECTION)
CRANIAL CT CONTRAST
120
CT SCAN HAVE THREE MODALITIES:
(1) CONTRAST SCAN,
(2) PLAIN SCAN,
(3) BONE WINDOW
121
- 3D reconstruction
| - you give large dose of contrast then do scan then computer will reconstruct base on the flow of the contrast
CRANIAL CT ANGIOGRAPHY
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CRANIAL CT ANGIOGRAPHY: Advantages and Disadvantages
Advantages
o CT angio readily available
o Rapid processing - important for unstable patients
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Disadvantages
o More contrast used compared to conventional
angiogram
o Radiation
o User/Processor dependent
o Could not assess flow pattern
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CRANIAL CT PERFUSION
- The key to interpreting CT perfusion in the setting of acute
ischemic stroke is understanding and identifying the infarct
core and the ischaemic penumbra, as a patient with a small
core and a large penumbra is most likely to benefit from
reperfusion therapies.
- PENUMBRA - water shed,salvageable by further medication.
- in plain ct, you could not see the lesion yet.
- in perfusion scan, you could see the
infarcted area already.
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Two major Radiologic modalities in brain (and meninges/coverings) evaluation:
1. Anatomic Modalities
2. Functional Modalities
- Single photon emission computed tomography (SPECT), PCT imaging, Perfusion Weighted MRI, Diffusion weighted MRI imaging, functional MRI (fMRI), MRS
- Gives info about brain perfusion or metabolism
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- provide information mostly of structural nature
- include plain films of the skull, computed tomography (CT), magnetic resonance imaging (MRI), cerebral arteriography, ultrasonography
Anatomic Modalities
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- Single photon emission computed tomography (SPECT), PCT imaging, Perfusion Weighted MRI, Diffusion weighted MRI imaging, functional MRI (fMRI), MRS
- Gives info about brain perfusion or metabolism
Functional Modalities
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- Water soluble contrast injected in femoral or brachial artery (carotid or vertebral artery)
- gold standard for assessing vascular stenosis, atherosclerosis, vasculitis, cerebral aneurysms.
- Used in gray scale imaging and Doppler Effect evaluation of carotid artery in atherosclerosis, vasospasm in subarachnoid hemorrhage
- Used intraoperatively to demonstrate spinal cord and surrounding structures.
CEREBRAL ARTERIOGRAPHY
Neuroscience
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