RESPONSES

TO
NCM
ALTERED
PERCEPTION 116
 “
Neurologic
Disturbances

2
Multiple Sclerosis
● is a chronic disease that affects the
central nervous system, especially the
brain, spinal cord, and optic nerves
● can lead to a wide range of
symptoms throughout the body
● it is not possible to predict how MS
will progress in any individual
● means “scar tissue in multiple areas”

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Pathophysiology
● Autoimmune (the immune system attacks healthy tissue, just as it
might attack a virus or bacteria)
● In the case of MS, the immune system attacks the myelin sheath
that surrounds and protects the nerve fibers, causing inflammation.
Myelin also helps the nerves conduct electrical signals quickly and
efficiently.
● When the myelin sheath disappears or sustains damage in multiple
areas, it leaves a scar, or sclerosis (also called plaques or lesions)
● mainly affect: brain stem, cerebellum, spinal cord, optic nerves,
white matter in some regions of the brain
● As more lesions develop, nerve fibers can break or become
damaged. As a result, the electrical impulses from the brain do not
flow smoothly to the target nerve. This means that the body
cannot carry out certain functions.
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 Signs and Symptoms
Muscle weakness: due to
Numbness and tingling: A pins and
lack of use or stimulation
needles-type sensation in the face,
due to nerve damage
body, or arms and legs

Lhermitte’s sign: an
Bladder problems: difficulty emptying
electric shock sensation
bladder or need to urinate frequently or
when moving the neck
suddenly; incontinence

Bowel problems: constipation

can cause fecal impaction, which Fatigue: This can undermine
can lead to bowel incontinence a person’s ability to function
at work or at home

Dizziness and vertigo: These are

common problems, along with Sexual dysfunction: Both
balance and coordination issues. males and females may lose
interest in sex.
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 Signs and Symptoms
Spasticity and muscle spasms: caused Tremor: Some may
by damaged nerve fibers in the CNS, experience involuntary
particularly in the legs. quivering movements.

Emotional changes Vision problems: may experience double or

and depression: blurred vision, a partial or total loss of vision,
Demyelination and or red-green color distortion; usually affects
nerve-fiber damage one eye at a time. Inflammation of the optic
in the brain can nerve can result in pain when the eye moves.
trigger emotional
changes. Gait and mobility changes:
changes the way people walk, due
to muscle weakness and problems
Learning and memory with balance, dizziness, and fatigue.
problems: difficult to
concentrate, plan,
learn, prioritize, and Pain: Neuropathic pain is directly due to
multitask. MS. Other types of pain occur because
of weakness or stiffness of muscles. 6
Clinically isolated syndrome (CIS)
- a single, first episode, with symptoms lasting at least 24 hours
Types
Relapse-remitting MS (RRMS)
- the most common form, affecting around 85% of people with MS
- involves episodes of new or increasing symptoms, followed by periods
of remission, during which symptoms go away partially or totally

Primary progressive MS (PPMS)

- Symptoms worsen progressively, without early relapses or remissions
- may experience times of stability and periods when symptoms worsen
and then get better
Secondary progressive MS (SPMS)
- At first, people will experience episodes of relapse and remission, but
then the disease will start to progress steadily
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 Causes
● Age: Most people receive a diagnosis between the ages of 20 and 40
years.
and
● Sex: Most forms of MS are twice as likely to affect women than men. Risk
● Genetic factors: Susceptibility may pass down in the genes Factors
● Smoking: smokers appear to be more likely to develop MS; tend to have
more lesions and brain shrinkage than non-smokers.
● Infections: Exposure to Epstein-Barr virus, or mononucleosis, may
increase a person’s risk of developing MS, but research has not shown a
definite link. Other viruses include human herpes virus type 6 (HHV6) and
mycoplasma pneumoniae
● Vitamin D deficiency: more common among people who have less
exposure to bright sunlight; experts think that low levels of vitamin D
may affect the way the immune system works
● Vitamin B12 deficiency: The body uses vitamin B when it produces
myelin. A lack of this vitamin may increase the risk of neurological
diseases
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Note: No single test can confirm a diagnosis, so a doctor will use
several strategies when deciding whether a person meets the criteria Diagnosis
for a diagnosis.

❑ physical and neurological examination (ask about symptoms and

consider the person’s medical history)
❑ MRI scans of the brain and spinal cord (may reveal lesions)
❑ CSF analysis (identifies antibodies that suggest a previous infection)
❑ Evoked potential test (measures electrical activity in response to
stimuli)

If the doctor diagnoses MS, they will need to identify what type it is
and whether it is active or not.

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Evoked Potential Test
- measures the time it takes for nerves to respond to
stimulation; the size of the response is also measured

Types of responses:

✓ Visual evoked response or potential (VER or VEP):

- eyes are stimulated by looking at a test pattern
- commonly used in the diagnosis of MS

✓ Auditory brain stem evoked response or potential

(ABER or ABEP):
- hearing is stimulated by listening to a test tone

✓ Somatosensory evoked response or potential (SSER or

SSEP):
- nerves of the arms and legs are stimulated by an electrical
pulse

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Evoked Potential Test
(Procedure)
• typically takes half an hour or longer to do

• Each type of response is recorded from brain

waves by using electrodes taped to the head and
conducting gel applied to the scalp

• When VERs are recorded, the electrodes are

applied to the rear (occipital region) of the scalp Results:
over the brain areas that register visual stimuli.
Normal
The time between the stimulation and the nerve's response is
• For VER, stimuli are delivered by a strobe light or
a screen with a checkerboard pattern. within the normal range.

• Responses from the electrodes are recorded. The
time between the stimulation and the response is
called the latency, which indicates the speed at
which the nerves pass a signal.
Abnormal
Some people who are free from symptoms in the nerve area
tested will still have abnormal responses in that area.
Abnormal response times can also be associated with other
neurological diseases or with damaged optic nerves and eyes.
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 Treatment
There is no cure for MS, but treatment
is available that can:

● slow the progression and reduce the

number and severity of relapses

● relieve symptoms

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Medications to slow progression
o Disease-modifying therapies (DMTs) have approval from FDA for the relapsing forms of Treatment
MS; work by changing the way the immune system functions
o Drugs are used from the early stages; the person takes them when symptoms are not
yet severe

Injectable medications Oral medications Infused medications

● interferon beta 1-a ● teriflunomide ● alemtuzumab
(Avonex, Rebif) (Aubagio) (Lemtrada)
● interferon beta-1b ● fingolimod (Gilenya) ● Mitoxantrone
(Betaseron, Extavia) ● dimethyl fumarate (Novantrone)
● glatiramer acetate: (Tecfidera) ● ocrelizumab
(Copaxone, ● mavenclad (Ocrevus)
Glatopa) (cladribine) ● natalizumab
● peginterferon beta- ● mayzent (Tysabri)
1a) (Plegridy) (siponimod)
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Medications for relieving symptoms during a flare
● Taken when a person experiences a worsening of symptoms, Treatment
during a flare; Drugs do not need to be taken all the time

Corticosteroids
- reduce inflammation and suppress the immune system.
- can treat an acute flare-up of symptoms in certain types of MS.
- Examples:Solu-Medrol (methylprednisolone) and Deltasone
(prednisone)
- can have adverse effects if a person uses them too often, and they are
not likely to provide any long-term benefit

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Complementary Treatment

Behavioral changes: Problems with mobility Tremor Fatigue:

✓ recommend resting and balance ✓ A person may use ✓ Getting enough rest
the eyes from time ✓ Physical therapy and assistive devices or and avoiding heat
to time or limiting walking devices, attach weights to the
screen time
✓ Physical and
such as a cane, may limbs to reduce
occupational therapy
✓ A person with MS help. shaking
✓ Assistive devices,
may need to learn to ✓ The drug
such as a mobility
rest when fatigue dalfampridine
scooter, can help
sets in and to pace (Ampyra) may also
themselves so they prove useful ✓ Medication or
can complete counseling may help
activities boost energy by
improving sleep.

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Complementary Treatment

Pain Bladder and bowel Depression Cognitive changes:

✓ anticonvulsant or problems ✓ A doctor may ✓ Donepezil, a drug
antispasmodic drugs ✓ dietary changes can prescribe a for Alzheimer’s, may
or alcohol injections help resolve these selective serotonin help some people.
to relieve trigeminal reuptake inhibitor
neuralgia (a sharp
✓ a healthful diet with
plenty of fresh fruits, (SSRI), as these are
pain that affects the less likely to cause
vegetables, and
face) fatigue than
fiber
✓ Pain relief other antidepressant
medication drugs.
(gabapentin) may
help with body pain

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Rehabilitation
- helps improve or maintain a person’s ability to perform effectively at home and work

❖ Physical therapy: This aims to provide the skills to maintain and restore maximum movement
and functional ability.

❖ Occupational therapy: The therapeutic use of work, self-care, and play may help maintain
mental and physical function.

❖ Speech and swallowing therapy: A speech and language therapist will carry out specialized
training for those who need it.

❖ Cognitive rehabilitation: This helps people manage specific problems in thinking and
perception.

❖ Vocational rehabilitation: This helps a person whose life has changed with MS to make
career plans, learn job skills, get and keep a job.

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Experimental

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Myasthenia Gravis
● a relatively rare neuromuscular disease in
which the voluntary muscles easily
become tired and weak caused by a
problem with how the nerves stimulate
the contraction of muscles
● literally means “grave muscle weakness”
● many cases are mild, and life expectancy
is normal

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Pathophysiology
● an autoimmune disease; antibodies circulate in the
blood and attack healthy cells and tissues by mistake

● In the case of MG, the antibodies block or destroy

muscle receptor cells, resulting in fewer available
muscle fibers. As a result, the muscles cannot
contract properly, and they easily become tired and
weak.

● Exactly why this happens is unknown; the thymus

gland, located in the upper chest beneath the
breastbone, appears to play a key role

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Thymus Gland
● located behind sternum and between lungs
● only active until puberty; after puberty, the thymus starts to
slowly shrink and become replaced by fat
● Thymosin is the hormone of the thymus, and it stimulates the
development of disease-fighting T cells
● The thymus is special in that, unlike most organs, it is at its largest
in children. Once you reach puberty, the thymus starts to slowly
shrink and become replaced by fat. By age 75, the thymus is little
more than fatty tissue. Fortunately, the thymus produces all of
your T cells by the time you reach puberty.
**********
A significant number of adult patients with MG have an abnormally
large thymus gland, and about 1 in 10 patients with MG have a benign
tumor in the thymus gland.

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● Medications: drugs that may cause a worsening of
symptoms in susceptible patients include beta
blockers, calcium channel blockers, quinine, and
Causes
some antibiotics

● Genetic factors may play a role.

● Symptoms may worsen with emotional or mental stress,

illness, tiredness, or a high fever.

● Neonatal myasthenia affects newborns if they acquire

antibodies from a mother who has MG. The symptoms
usually disappear in 2 to 3 months, and MG in infants
and children is rare.

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 Signs and Symptoms
Fatigue: the most Ocular myasthenia gravis: Drooping in
prevalent symptom one or both eyelids (ptosis), double vision,
or both

Swallowing difficulties: may choke easily, Speaking problem:

and eating, drinking, and swallowing pills Speech may become
becomes harder; when the person drinks, soft or nasal.
liquid may come out of the nose

Facial expressions changes: Chewing problem: The muscles

A different or unusual smile used for chewing may weaken
may develop if certain facial during a meal, especially if the
muscles are affected. food is hard or chewy

Limb weakness: The arm

Symptoms often become
and leg muscles may
progressively worse during
weaken, affecting activities
periods of activity, but they
such as lifting or walking.
improve after resting.
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● A physician may suspect MG if a patient has drooping eyelids
but no problem feeling things, and if they are prone to muscle
Diagnosis
weakness that improves after rest.

● Diagnosis can be difficult, however, because MG shares

symptoms with other conditions, a neurologist may need to
confirm the diagnosis.

● People whose muscles are weak because of MG respond well

when ice is applied to the affected area. Some doctors try this
initially as they gather data to help them make a diagnosis.

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✓ Edrophonium Test
- involves injecting a substance into a vein and monitoring the reaction of the Tests
patient; muscle weakness may be temporarily relieved

✓ Blood tests
- identify certain antibodies

✓ Repetitive nerve stimulation

- involves attaching electrodes to the skin over the affected muscles and
sending small electrical pulses through the electrodes to measure how well
the nerves transmit the signal to the muscle
- If a person has MG, the signals will get weaker as the muscle tires.

✓ Single-fiber electromyography (EMG)

- measures the electrical activity that flows between the brain and the muscle;
involves inserting a very fine wire electrode through the skin, into the muscle.

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✓ Imaging tests (chest X-ray, CT scan or MRI)
- may be used to eliminate other conditions Tests

✓ Pulmonary function test or Spirometry

- assesses how well the patient can breathe by measuring the maximum
amount of air a person can expel from the lungs after breathing in deeply
- performed regularly, this test can help to monitor any gradual worsening of
muscular weakness in the lungs
- this is especially important for patients with severe symptoms, to avoid
severe breathing problems.

✓ Muscle biopsy
- can be done to eliminate another muscular condition

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 Treatment
There is no cure for MG, but treatment
is available that can:

● help control symptoms

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Medications
Treatment
Cholinesterase inhibitors:
- These improve communication between nerves and muscles,
and are effective in patients with mild symptoms of MG

Steroids (prednisolone) or immunosuppressants (azathioprine)

- may alter the body’s immune system so that it produces
fewer of the antibodies that cause MG
- usually takes about 4 weeks for steroids to take effect.
Azathioprine may take from 3 to 6 months, but it brings
about a significant reduction or complete removal of
symptoms.

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Short – term Treatment
- these treatments are effective, and they work quickly, but Treatment
the benefits last only a few weeks

● Thymectomy
- surgical removal of the thymus gland, in the case of a tumor

● Plasmapheresis
- involves depleting the body of blood plasma without depleting
the body of its blood cells, in order to remove the unwanted
antibodies

● Intravenous immunoglobulin therapy

- involves injecting the patient with normal antibodies that
change the way the immune system acts

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Parkinson’s Disease
● is a neurodegenerative disorder that
affects predominately dopamine-
producing (“dopaminergic”) neurons in a
specific area of the brain called substantia
nigra
● symptoms generally develop slowly over
years; the progression of symptoms is
often a bit different from one person to
another due to the diversity of the
disease

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Pathophysiology
● Parkinson’s disease is primarily associated with the gradual loss of
cells in the substantia nigra of the brain (responsible for the
production of dopamine)
● Dopamine is a chemical messenger that transmits signals
between two regions of the brain to coordinate activity. (i.e.
connects the substantia nigra and the corpus striatum to regulate
muscle activity)
● If there is deficiency of dopamine in the striatum, the nerve cells
in this region “fire” out of control (leaves the individual unable to
direct or control movements and leads to the initial symptoms of
PD; as the disease progresses, other areas of the brain and
nervous system degenerate as well causing a more profound
movement disorder)
● The exact cause for the loss of cells is unknown. Possible causes
include both genetic and environmental factors.
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 Causes
● Low dopamine levels: Dopamine plays a role in sending messages to
the part of the brain that controls movement and coordination. Low
and
dopamine levels can make it harder for people to control their Risk
movements. As dopamine levels fall in a person with PD, their
symptoms gradually become more severe.
Factors

● Low norepinephrine levels: Norepinephrine is important for

controlling many automatic body functions, such as the circulation of
the blood; explains why people with PD experience not only
movement problems but also fatigue, constipation, and
orthostatic hypotension (when blood pressure changes on standing)

● Lewy bodies: A person with Parkinson’s disease may have clumps

of protein in their brain known as Lewy bodies; causes dementia

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 Causes
● Genetic factors: PD appears to run in families, but it is not always
hereditary. Researchers are trying to identify specific genetic factors
and
that may lead to PD, but it appears that not one but a number of Risk
factors are responsible.
Factors
They suspect that a combination for genetic and environmental
factors may lead to the condition. Possible environmental factors could
include exposure to toxins, such as pesticides, solvents, metals, and other
pollutants.

● Autoimmune factors: Scientists reported in 2017 that they had found

evidence of a possible genetic link between Parkinson’s disease and
autoimmune conditions, such as rheumatoid arthritis. In 2018,
researchers investigating health records in Taiwan found that people
with autoimmune rheumatic diseases (ARD) had a 1.37-higher
chance of also having Parkinson’s disease than people without ARD.

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34
There is no single test or scan for Parkinson’s, but there are three Movement
telltale symptoms that help doctors make a diagnosis:
Symptoms
● Bradykinesia – slowness of movement
(Diagnosis)
● Tremor - rhythmic shaking movement in one or more parts of the
body
● Rigidity - inflexibility

Bradykinesia plus either tremor or rigidity must be present for a PD

diagnosis to be considered.

● Another movement symptom, postural instability (trouble with

balance and falls), is often mentioned, but it does not occur until
later in the disease progression.

Parkinsonism is a term used to describe the collection of signs and symptoms found
in Parkinson’s disease (PD)
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● Cramping (dystonia): sustained or repetitive twisting or tightening of muscle Additional
● Drooling (sialorrhea): while not always viewed as a motor symptom, excessive saliva Movement
or drooling may result due to a decrease in normally automatic actions such as
swallowing
Symptoms
● Dyskinesia: involuntary, erratic writhing movements of the face, arms, legs or trunk
● Festination: short, rapid steps taken during walking. May increase risk of falling and
often seen in association with freezing
● Freezing: gives the appearance of being stuck in place, especially when initiating a
step, turning or navigating through doorways. Potentially serious problem as it may
increase risk of falling
● Masked face (hypomimia): results from the combination of bradykinesia and rigidity
● Micrographia: small, untidy and cramped handwriting due to bradykinesia.
● Shuffling gait: accompanied by short steps and often a stooped posture.
● Soft speech (hypophonia): soft, sometimes hoarse, voice that can occur in PD.

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● Cognitive changes: problems
with attention, planning, language,
memory or even dementia
● Constipation
● Early satiety: feeling of fullness
after eating small amounts
● Excessive sweating, often when
wearing off medications
● Fatigue
● Increase in dandruff (seborrheic
dermatitis)
● Hallucinations and delusions
● Lightheadedness (orthostatic
hypotension): drop in blood
pressure when standing
● Loss of sense of smell or taste Non-
● Mood disorders, such as depression,
anxiety, apathy and irritability
Movement
● Pain
Symptoms
● Sexual problems, such as erectile
dysfunction
● Sleep disorders, such as insomnia,
excessive daytime sleepiness (EDS),
REM sleep behavior disorder (RBD),
vivid dreams, Restless Legs Syndrome
(RLS)
● Urinary urgency, frequency and
incontinence
● Vision problems, especially when
attempting to read items up close
● Weight loss
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 Stages of Parkinson’s
Stage One
● During this initial stage, the person has mild symptoms that generally do not interfere with daily
activities. Tremor and other movement symptoms occur on one side of the body only. Changes in
posture, walking and facial expressions occur.

Stage Two
● Symptoms start getting worse. Tremor, rigidity and other movement symptoms affect both sides
of the body. Walking problems and poor posture may be apparent. The person is still able to live
alone, but daily tasks are more difficult and lengthy.

Stage Three
● Considered mid-stage, loss of balance and slowness of movements are hallmarks. Falls are more
common. The person is still fully independent, but symptoms significantly impair activities such as
dressing and eating.

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 Stages of Parkinson’s

Stage Four
● At this point, symptoms are severe and limiting. It’s possible to stand without assistance, but
movement may require a walker. The person needs help with activities of daily living and is
unable to live alone.

Stage Five
● This is the most advanced and debilitating stage. Stiffness in the legs may make it
impossible to stand or walk. The person requires a wheelchair or is bedridden. Around-the-
clock nursing care is required for all activities. The person may experience hallucinations and
delusions.

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Rating Scales Parkinson's stages correspond both to the severity of movement symptoms
and to how much the disease affects a person’s daily activities.

Hoehn and Yahr Stages Unified Parkinson’s

- follow a simple rating scale,
first introduced in 1967
- clinicians use it to describe
how motor symptoms
progress in PD
- rates symptoms on a scale
of 1 to 5. On this scale, 1
and 2 represent early-stage,
2 and 3 mid-stage, and 4
and 5 advanced-stage
Parkinson's
Disease Rating Scale
(UPDRS)
- a more comprehensive tool
used to account for non-
motor symptoms, including
mental functioning, mood
and social interaction
- accounts for cognitive
difficulties, ability to carry
out daily activities and
treatment complications.

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Medications
Levodopa Treatment
● often regarded as the gold standard of Parkinson's therapy
● works by crossing the blood-brain barrier where it is converted into
dopamine
● levodopa is now combined with an enzyme inhibitor called carbidopa
(prevents levodopa from being metabolized in the gastrointestinal tract,
liver and other tissues, allowing more of it to reach the brain)
● a smaller dose of levodopa is needed to treat symptoms
● the combination advance helps reduce the severe nausea and vomiting
often experienced as a side effect of levodopa
● For most patients, levodopa reduces the symptoms of slowness,
stiffness and tremor; especially effective for patients that have a loss of
spontaneous movement and muscle rigidity. This medication, however,
does not stop or slow the progression of the disease.

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Medications
Dopamine Agonists Treatment
● Bromocriptine, pergolide, pramipexole and ropinirole are medications that mimic
the role of chemical messengers in the brain, causing the neurons to react as they
would to dopamine
● can be prescribed alone or with levodopa and may be used in the early stages of
the disease or administered to lengthen the duration of effectiveness of levodopa.

COMT Inhibitors
● Entacapone and tolcapone are medications that are used to treat fluctuations in
response to levodopa.
● Catechol-O MethylTransferase is an enzyme that metabolizes levodopa in the
bloodstream. By blocking COMT, more levodopa can penetrate the brain and, in
doing so, increase the effectiveness of treatment
● Tolcapone is indicated only for patients whose symptoms are not adequately
controlled by other medications, because of potentially serious toxic effects on the
liver.
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Medications
Selegiline Treatment
● This medication slows down the activity of the enzyme monoamine oxidase B
(MAO-B), the enzyme that metabolizes dopamine in the brain, delaying the
breakdown of naturally occurring dopamine and dopamine formed from levodopa
● When taken in conjunction with levodopa, selegiline may enhance and prolong the
effectiveness of levodopa.

Anticholinergic medications
● Trihexyphenidyl, benztropine mesylate, biperiden HCL and procyclidine work by
blocking acetylcholine, a chemical in the brain whose effects become more
pronounced when dopamine levels drop
● most useful in the treatment of tremor and muscle rigidity, as well as in reducing
medication-induced parkinsonism
● generally not recommended for extended use in older patients because of
complications and serious side effects.

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Medications
Amantadine Treatment
● This is an antiviral medication that also helps reduce symptoms
of Parkinson’s (unrelated to its antiviral components) and is
often used in the early stages of the disease. It is sometimes
used with an anticholinergic medication or levodopa. It may be
effective in treating the jerky motions associated with
Parkinson's.

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Surgery
Based upon the type and severity of symptoms, the deterioration of
a patient's quality of life and a patient’s overall health, surgery may
be the next step. The benefits of surgery should always be weighed
carefully against its risks, taking into consideration the patient’s
symptoms and overall health.

Stereotactic surgery
- requires the neurosurgeon to fix a metal frame to the skull
under local anesthesia
- Using diagnostic imaging, the surgeon precisely locates the
desired area in the brain and drills a small hole, about the size of
a nickel. The surgeon may then create small lesions using high
frequency radio waves within these structures or may implant a
deep brain stimulating electrode, thereby helping to relieve the
symptoms associated with Parkinson's.

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Surgery
Pallidotomy
Stereotactic
- may be recommended for patients with aggressive Parkinson's Surgery
or for those who do not respond to medication
- performed by inserting a wire probe into the globus pallidus –
a very small region of the brain, measuring about a quarter
inch, involved in the control of movement (this region
becomes hyperactive in Parkinson’s patients due to the loss of
dopamine)
- Applying lesions to the global pallidus can help restore the
balance that normal movement requires
- This procedure may help eliminate medication-induced
dyskinesias, tremor, muscle rigidity and gradual loss of
spontaneous movement.

46
Surgery
Thalamotomy
Stereotactic
- uses radiofrequency energy currents to destroy a small, but Surgery
specific portion of the thalamus
- The relatively small number of patients who have disabling
tremors in the hand or arm may benefit from this procedure
- does not help the other symptoms of Parkinson's and is used
more often and with greater benefit in patients with essential
tremor, rather than Parkinson’s.

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Surgery
Deep Brain Stimulation (DBS)
Stereotactic
- a safer alternative to pallidotomy and thalamotomy Surgery
- utilizes small electrodes which are implanted to provide an
electrical impulse to either the subthalamic nucleus of the
thalamus or the globus pallidus
- Implantation of the electrode is guided through MRI and
neurophysiological mapping, to pinpoint the correct location
- the electrode is connected to wires that lead to an impulse
generator or that is placed under the collarbone and beneath
the skin; patients have a controller, which allows them to turn
the device on or off
- This form of stimulation helps rebalance the control messages
in the brain, thereby suppressing tremor

48
 “
Neurologic
Disturbances

49
"cerebro“ - large part of the brain Cerebrovascular
"vascular“ - arteries and veins
Disease
“cerebrovascular” - blood flow in the brain

Cerebrovascular disease
• includes all disorders in which an area of the brain is
temporarily or permanently affected by ischemia or
bleeding and one or more of the cerebral blood vessels
are involved in the pathological process

• includes stroke, carotid stenosis, vertebral stenosis and

intracranial stenosis, aneurysms, and vascular malformations

• restrictions in blood flow may occur from vessel narrowing

(stenosis), clot formation (thrombosis), blockage (embolism)
or blood vessel rupture (hemorrhage); lack of sufficient
blood flow (ischemia) affects brain tissue

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Blood Flow in the Brain
● Cerebral circulation refers to the movement of blood
through the network of blood vessels supplying the brain

● The arteries deliver oxygenated blood, glucose, and other

nutrients to the brain and the veins carry deoxygenated
blood back to the heart, removing carbon dioxide, lactic
acid, and other metabolic products.

● The circle of Willis, a circulatory anastomosis that supplies

blood to the brain and surrounding structures while
providing redundancy in case of any interruption, is a key
protection; failure of these safeguards results in
cerebrovascular accidents, commonly known as strokes.

51
Blood Flow in the Brain
● Cerebral blood flow refers to the amount of blood that the
cerebral circulation carries

● In an adult, CBF is typically 750 milliters per minute or 15%

of the cardiac output; tightly regulated to meet the brain’s
metabolic demands

● Too much blood can raise intracranial pressure (normal

range: 5-15mmHg), which can compress and damage
delicate brain tissue

● Too little blood flow (ischemia) results in tissue death

● ischemic cascade is a biochemical cascade triggered when

the tissue becomes ischemic, potentially resulting in
damage to and death of brain cells.
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Cerebral angiography
(vertebral angiogram, carotid angiogram) Diagnostic
✓ patient is given a local anesthetic Tests
✓ the artery is punctured, usually in the leg, and a needle is
inserted into the artery
✓ A catheter is inserted through the needle and into the
artery; then threaded through the main vessels of the
abdomen and chest until it is properly placed in the arteries
of the neck
✓ This procedure is monitored by a fluoroscope (a special X-
ray that projects the images on a TV monitor)
✓ The contrast dye is then injected into the neck area
through the catheter and X-ray pictures are taken
Carotid duplex
(carotid ultrasound) Diagnostic
✓ In this procedure, ultrasound is used to help detect Tests
plaque, blood clots or other problems with blood flow in
the carotid arteries

✓ A water-soluble gel is placed on the skin where the

transducer (a handheld device that directs the high-
frequency sound waves to the arteries being tested) is
to be placed. The gel helps transmit the sound to the
skin surface.

✓ The ultrasound is turned on and images of the carotid

arteries and pulse wave forms are obtained.

✓ There are no known risks and this test is noninvasive

and painless.
Computed tomography (CT or CAT scan)

✓ A diagnostic image created after a computer reads x-

Diagnostic
rays Tests
✓ In some cases, a medication will be injected through a
vein to help highlight brain structures

✓ Bone, blood and brain tissue have very different

densities and can easily be distinguished on a CT scan

✓ A CT scan is a useful diagnostic test for hemorrhagic

strokes because blood can easily be seen; however,
damage from an ischemic stroke may not be revealed
on a CT scan for several hours or days and the
individual arteries in the brain cannot be seen
Doppler ultrasound
✓ A water-soluble gel is placed on the transducer and the skin Diagnostic
over the veins of the extremity being tested
✓ There is a "swishing" sound on the Doppler if the venous Tests
system is normal
✓ Both the superficial and deep venous systems are evaluated
Electroencephalogram (EEG)
✓ A diagnostic test using small metal discs (electrodes) placed on
a person's scalp to pick up electrical impulses
✓ These electrical signals are printed out as brain waves
Lumbar puncture (spinal tap)
An invasive diagnostic test that uses a needle to remove a sample
of CSF from the space surrounding the spinal cord
helpful in detecting bleeding caused by a cerebral hemorrhage
Magnetic Resonance Imaging (MRI)
✓ produces three-dimensional images of body structures Diagnostic
Tests
using magnetic fields and computer technology
✓ clearly show various types of nerve tissue and clear
pictures of the brain stem and posterior brain
✓ An MRI of the brain can help determine whether there are
signs of prior mini-strokes
✓ noninvasive, although some patients may experience
claustrophobia in the imager

Magnetic Resonance Angiogram (MRA)

✓ noninvasive study which is conducted in a Magnetic
Resonance Imager (MRI)
✓ magnetic images are assembled by a computer to provide
an image of the arteries in the head and neck
✓ shows the actual blood vessels in the neck and brain and
can help detect blockage and aneurysms
Stroke
● an abrupt interruption of constant blood flow to the
brain that causes loss of neurological function

● The interruption of blood flow can be caused by a

blockage, leading to the more common ischemic
stroke, or by bleeding in the brain, leading to the
more deadly hemorrhagic stroke

● occur suddenly, sometimes with little or no warning,

and the results can be devastating

58
Warning signs may include some or all of the following Warning
symptoms, which are usually sudden:
Signs
● Dizziness, nausea, or vomiting of
● Unusually severe headache
Stroke
● Confusion, disorientation or memory loss
● Numbness, weakness in an arm, leg or the face,
especially on one side
● Abnormal or slurred speech
● Difficulty with comprehension
● Loss of vision or difficulty seeing
● Loss of balance, coordination or the ability to walk

59
Ischemic Stroke Types
● the most common type of stroke, accounting for a large
of
majority of strokes Stroke
● two types of ischemic stroke:
A thrombotic stroke occurs when a blood clot, called a
thrombus, blocks an artery to the brain and stops blood flow
An embolic stroke occurs when a piece of plaque or
thrombus travels from its original site and blocks an artery
downstream. The material that has moved is called an embolus

● How much of the brain is damaged or affected depends on

exactly how far downstream in the artery the blockage
occurs.

60
Ischemic Stroke
● In most cases, the carotid or vertebral arteries do not become
completely blocked and a small stream of blood trickles to the brain

● The reduced blood flow to the brain starves the cells of nutrients and
quickly leads to a malfunctioning of the cells; as a part of the brain
stops functioning, symptoms of a stroke occur

● During a stroke, there is a core area where blood is almost completely

cut off and the cells die within five minutes; however, there is a much
larger area known as the ischemic penumbra that surrounds the core
of dead cells

● The ischemic penumbra consists of cells that are impaired and cannot
function, but are still alive. These cells are called idling cells, and they
can survive in this state for about three hours.

61
Ischemic Stroke (Treatment)
Goal: remove the obstruction and restore blood flow to the brain

tissue plasminogen activator (tPA)

● must be administered within a 3-hour window from the
onset of symptoms to work best
● unfortunately, only 3 to 5 percent of those who suffer a
stroke reach the hospital in time to be considered for this
treatment
● carries a risk for increased intracranial hemorrhage and is
not used for hemorrhagic stroke

62
Ischemic Stroke (Treatment) Types
Carotid endarterectomy
of
● a surgical procedure to remove a build-up of fatty deposits
Stroke
(plaque), which cause narrowing of a carotid artery
● can be carried out using either local anaesthetic or general
anaesthetic (the advantage of local anaesthetic is it allows
the surgeon to monitor brain function while you're awake)
● During the procedure, a 7 to 10cm (2.5 to 4 inch) cut is made
between the corner of the jaw and breastbone.
● A small cut is then made along the narrowed section of artery
and the fatty deposits that have built up are removed.
● The artery is closed with stitches or a patch and skin is also
closed with stitches

63
Ischemic Stroke (Treatment)
MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retriever
● corkscrew-shaped device used to help remove blood clots from
the arteries of stroke patients
● A small incision is made in the patient’s groin, into which a small
catheter is fed until it reaches the arteries in the neck
● At the neck, a small catheter inside the larger catheter is guided
through the arteries until it reaches the brain clot
● The Merci Retriever, a straight wire inside the small catheter
pokes out beyond the clot and automatically coils into a
corkscrew shape. It is pulled back into the clot, the corkscrew
spinning and grabbing the clot.
● A balloon inflates in the neck artery, cutting off blood flow, so
the device can pull the clot out of the brain safely.
● The clot is removed through the catheter with a syringe.

64
Hemorrhagic Stroke Types
● can be caused by hypertension, rupture of an aneurysm or
of
vascular malformation or as a complication of Stroke
anticoagulation medications

● An intracerebral hemorrhage occurs when there is bleeding

directly into the brain tissue, which often forms a clot
within the brain.

● A subarachnoid hemorrhage occurs when the bleeding fills

the cerebrospinal fluid spaces around the brain

● usually requires surgery to relieve intracranial pressure

caused by bleeding

65
Hemorrhagic Stroke (Treatment)
Goal: Surgery may be performed to seal off the defective blood vessel
and redirect blood flow to other vessels that supply blood to the same
region of the brain.

Endovascular treatment
▪ involves inserting a long, thin, flexible tube (catheter) into a
major artery, usually in the thigh, guiding it to the aneurysm
or the defective blood vessel and inserting tiny platinum
coils (called stents) into the blood vessel through the
catheter

▪ Stents support the blood vessel to prevent further damage

and additional strokes.

66
67
Important Interventions
Treatment
● Recovery and rehabilitation are important aspects of
stroke treatment. In some cases, undamaged areas of
the brain may be able to perform functions that were
lost when the stroke occurred. Rehabilitation includes
physical therapy, speech therapy and occupational
therapy.

● Regardless of what type of stroke has been suffered,

it is critical that victims receive emergency medical
treatment as soon as possible for the best possible
outcome to be realized.

68
Transient Ischemic Attack (TIA)
● a temporary cerebrovascular event that leaves no
permanent damage
● Most likely an artery to the brain is temporarily
blocked, causing stroke-like symptoms, but the
blockage dislodges before any permanent damage
occurs.
● Symptoms of a TIA may be similar to stroke, but
they resolve quickly; In fact, symptoms may be so
vague and fleeting that people just "brush" them off,
especially when they last just a few minutes.

69
● Sudden numbness or weakness of the face, arm or
leg, especially on one side of the body TIA
Symptoms
● Sudden confusion, trouble speaking or understanding

● Sudden trouble seeing in one or both eyes

● Sudden trouble walking, dizziness, loss of balance or

coordination

● Sudden, severe headache with no known cause

70
● While there is no treatment for the TIA itself, it is
Things
essential that the source of the TIA be identified and To
appropriately treated before another attack occurs Know
● seek emergency medical help and notify your primary
care physician immediately

● About 30 percent of all people who suffer a major

stroke experience a prior TIA, and 10 percent of all TIA
victims suffer a stroke within two weeks

● The quicker you seek medical attention, the sooner a

diagnosis can be made and a course of treatment
started. Early intervention is essential to effectively
preventing a major stroke.
71
● Smoking: risk may be increased further with the use of some
forms of oral contraceptives and are a smoker and there is Modifiable
recent evidence that long-term secondhand smoke exposure may Risk
increase the risk of stroke.
Factors
● High blood pressure: Blood pressure of 140/90 mm Hg or higher
is the most important risk factor for stroke. Controlling blood
pressure is crucial to stroke prevention.

● Carotid or other artery disease: The carotid arteries in the neck

supply blood to the brain. A carotid artery narrowed by fatty
deposits from atherosclerosis (plaque buildups in artery walls) may
become blocked by a blood clot.

● History of transient ischemic attacks (TIAs)

72
● Diabetes: It is crucial to control blood sugar levels; when untreated,
puts one at greater risk of stroke and has many other serious health Modifiable
implications Risk
Factors
● High blood cholesterol: A high level of total cholesterol in the blood
(240 mg/dL or higher) is a major risk factor for heart disease, which
raises the risk of stroke.

● Physical inactivity and obesity: Being inactive, obese or both can

increase the risk of high blood pressure, high blood cholesterol,
diabetes, heart disease and stroke.

● Recent research shows evidence that people receiving hormone

replacement therapy (HRT) have an overall 29 percent increased
risk of stroke, in particular ischemic stroke (for menopausal women)

73
● Age: People of all ages, including children, have strokes. But the
Non -
older you are, the greater your risk of stroke. Modifiable
Risk
● Gender: Stroke is more common in men than in women. Factors
● Heredity and race: There is a greater risk of stroke if a parent,
grandparent, sister or brother has had a stroke. Blacks have a much
higher risk of death from a stroke than Caucasians do, partly
because they are more prone to having high blood pressure,
diabetes and obesity.

● Prior stroke or heart attack: Those who have had a stroke are at
much higher risk of having another one. Those who have had a
heart attack are also at higher risk of having a stroke.

74
Cerebral Aneurysm
● A cerebral (or cranial) aneurysm is an area where
a blood vessel in the brain weakens, resulting in a
bulging or ballooning out of part of the vessel wall

● aneurysms develop at the point where a blood

vessel branches, because the "fork" is structurally
more vulnerable

● The disorder may result from congenital defects or

from other conditions such as high blood pressure,
atherosclerosis or head trauma.

75
Cerebral Aneurysm (Incidence)
● Aneurysms occur in all age groups, but the incidence
increases steadily for individuals age 25 and older

● most prevalent in people ages 50 to 60 and is

about three times more prevalent in women

● The outcome for patients treated before a ruptured

aneurysm is much better than for those treated
after, so the need for adequate evaluation of
patients suspected of having a cerebral aneurysm is
very important.

76
Cerebral Aneurysm (Diagnosis)
● Unruptured cerebral aneurysms can be
detected by noninvasive measures,
including MRA and a carotid angiogram.

● A rupture can be detected by a CT scan

or lumbar puncture. If these tests suggest
the presence of an aneurysm, formal
cerebral angiography may be performed.

77
Unruptured Aneurysm:
Warning
● Mostly no symptoms Signs
● cranial nerve palsy Ruptured Aneursym:
● dilated pupils
● double vision ● localized headache

● pain above and behind eye ● nausea and vomiting

● localized headache ● stiff neck

● blurred or double vision
● sensitivity to light
(photophobia)
● loss of sensation

78
Cerebral Aneurysm (Rupture)
● When cerebral aneurysms rupture, they usually
cause bleeding in the brain, resulting in a
subarachnoid haemorrhage
● Blood can also leak into the cerebrospinal fluid (CSF)
or areas surrounding the brain and cause an
intracranial hematoma (a blood clot).
● Blood can irritate, damage or destroy nearby brain
cells; may cause problems with bodily functions or
mental skills. In more serious cases, the bleeding may
cause brain damage, paralysis or coma.
● Ruptured brain aneurysms are fatal in about 50
percent of cases.

79
Cerebral Aneurysm (Treatment)
Surgical Clipping
● performed by doing a craniotomy (opening the skull
surgically), and isolating the aneurysm from the
bloodstream using one or more clips, which allows it
to deflate

● Surgical repair of cerebral aneurysms is not possible

if they are located in unreachable parts of the brain.

80
Cerebral Aneurysm (Treatment)
Endovascular therapy
- uses micro catheters to deliver coils to the site of
the enlarged blood vessel that occludes (closes up)
the aneurysm from inside the blood vessel
- A procedure called balloon assisted coiling uses a
tiny balloon catheter to help hold the coil in place
- A procedure called combination stent and coiling
utilizes a small flexible cylindrical mesh tube that
provides a scaffold for the coiling.

81
 “
Neurologic
Disturbances

82
Head
Injury
83
Head Injury
● any sort of injury to the brain, skull, or scalp
● can range from a mild bump or bruise to a
traumatic brain injury
● the consequences and treatments vary greatly,
depending on what caused your head injury and
how severe it is
● may either be closed or open:
➢ closed head injury - any injury that doesn’t
break the skull
➢ open (penetrating) head injury - something
breaks the scalp and skull and enters the brain

84
Causes Head Injury
● In general, head injuries can be divided into two
categories based on what causes them: due to
blows or due to shaking
● Head injuries caused by shaking are most common
in infants and small children; but can occur any time
one experiences violent shaking
● Head injuries caused by a blow to the head are
usually associated with:
❖ motor vehicle accidents
❖ falls
❖ physical assaults
❖ sports-related accidents
85
Major Types Head Injury
Hematoma
● a collection, or clotting, of blood outside the blood
vessels
● can be very serious if it occurs in the brain
● clotting can lead to pressure building up inside the
skull
● can cause loss consciousness or result in permanent
brain damage

86
Major Types Head Injury
Hemorrhage
● is uncontrolled bleeding
● there can be bleeding in the space around the brain,
called subarachnoid hemorrhage, or bleeding within
your brain tissue, called intracerebral hemorrhage
● Subarachnoid hemorrhages often cause
headaches and vomiting
● The severity of intracerebral hemorrhages depends
on how much bleeding there is, but over time any
amount of blood can cause pressure buildup

87
Major Types Head Injury
Concussion
● occurs when the impact on the head is severe
enough to cause brain injury
● thought to be the result of the brain hitting against
the hard walls of the skull or the forces of sudden
acceleration and deceleration
● the loss of function associated with a concussion is
temporary; however, repeated concussions can
eventually lead to permanent damage

88
Major Types Head Injury
Edema
● Any brain injury can lead to edema, or swelling
● Many injuries cause swelling of the surrounding
tissues; but it’s more serious when it occurs in the
brain
● the skull can’t stretch to accommodate the swelling;
leads to pressure buildup in the brain, causing it to
press against the skull

89
Major Types Head Injury
Skull fracture
● Unlike most bones in the body, the skull doesn’t
have bone marrow; this makes the skull very strong
and difficult to break
● A broken skull is unable to absorb the impact of a
blow, making it more likely that there’ll also be
damage to the brain

90
Major Types Head Injury
Diffuse axonal injury (sheer injury)
● an injury to the brain that doesn’t cause bleeding
but damages the brain cells
● The damage to the brain cells results in them not
being able to function. It can also result in swelling,
causing more damage
● Though it isn’t as outwardly visible as other forms
of brain injury, a diffuse axonal injury is one of the
most dangerous types of head injuries; can lead to
permanent brain damage and even death

91
 Symptoms
(Minor Head Injury)

Headache

Light-headedness

Spinning sensation

Temporary ringing in
the ears

Mild confusion

Nausea

92
Minor symptoms Symptoms
plus: (Severe Head Injury)

● a loss of ● balance or ● abnormal eye ● memory loss

consciousness coordination movements
problems
● changes in
● Seizures ● a loss of mood
● serious disorient muscle control
● vomiting ation
● CSF leakage
● a persistent or
● an inability worsening
to focus the headache
eyes

93
! Seek Medical Attention !

Loss of Consciousness

Confusion

Disorientation

94
Glasgow Coma Scale (GCS)
o is a 15-point test that assesses mental status
o A high GCS score indicates a less severe injury
Diagnostic
Procedure
History Taking
o The doctor will need to know the circumstances of the
injury
o Often, if a patient suffered a head injury, he/she won’t
remember the details of the accident
o If it’s possible, patient should bring someone with him/her
who witnessed the accident
o It will be important for the doctor to determine if the
patient lost consciousness and for how long if he/she did

Physical Examination
o The doctor will examine the patient to look for signs of
trauma, including bruising and swelling
Neurologic Examination
o The doctor will evaluate nerve function by assessing
Diagnostic
muscle control and strength, eye movement, and Procedure
sensation, among other things

Imaging tests
o commonly used to diagnose head injuries
o CT scan will help look for fractures, evidence of bleeding
and clotting, brain swelling, and any other structural
damage; are fast and accurate, so they’re typically the
first type of imaging the patient receives
o MRI scan can offer a more detailed view of the brain;
will usually only be ordered once the patient is in a
stable condition.
There are often no symptoms other than pain at the site
of the injury. In these cases, patient may be instructed to: Treatment
● take acetaminophen for the pain (Minor
● Avoid NSAIDs, such as ibuprofen or aspirin; these can Head
make any bleeding worse Injury)
● For an open cut, the doctor may use sutures or staples
to close it, then cover it with a bandage
● watch condition to make sure it doesn’t get worse
● it isn’t true that the patient shouldn’t go to sleep after
having injured his/her head; should be woken up every
two hours or so to check for any new symptoms
● Go back to the doctor if you develop any new or
worsening symptoms.

97
Medication
● anti-seizure medication Treatment
❑ Patients are at risk for seizures in the week (Severe
following the injury Head
● Diuretics Injury)
❑ Prescribed if injury has caused pressure build-up in
the brain
❑ cause excretion of more fluids; can help relieve
some of the pressure
● Medication for induction of coma
❑ For a very serious injury, this may be an
appropriate treatment if the blood vessels are
damaged
❑ When in a coma, the brain doesn’t need as much
oxygen and nutrients as it normally does
98
Surgery Treatment
(Severe
● necessary to prevent further damage to the brain Head
Injury)
● goals:
❖ remove a hematoma
❖ repair the skull
❖ release some of the pressure in the skull

99
 Treatment
Rehabilitation (Severe
● the aim is to regain full brain function Head
● the type of rehabilitation will depend on what Injury)
functionality was lost as a result of the injury

▪ Physical and occupational therapy – to regain

mobility
▪ Speech therapy – to address speaking difficulties

100
Concussion
● a mild traumatic brain injury (TBI)
● can occur after an impact to the head or after a
whiplash-type injury that causes the head and
brain to shake quickly back and forth
● results in an altered mental state that may include
becoming unconscious
● those who participate in impact sports such as
football or boxing have an increased risk
● usually not life-threatening, but can cause serious
symptoms that require medical treatment

101
 Concussion versus Contusion

● no physical damage to the brain; ● scattered areas of bleeding on the

surface of the brain, most commonly
characterized by an alteration in
along the undersurface and poles of the
the functioning of the brain
frontal and temporal lobes

● results when brain moves back ● occur when the brain strikes a ridge on
and forth in the the skull or a fold in the dura mater, the
brain’s tough outer covering

● may occur without other types of

bleeding or they may occur with acute
subdural or epidural hematomas

102
103
➢ Physical examination - to determine what Diagnostic
symptoms are present Procedure
➢ MRI scan or a CT scan of the brain - to
check for serious injuries

➢ Electroencephalogram - in the case of

seizures

➢ Special eye test (Eye Tracking) - to assess if

any visual changes are related to a
concussion
Surgery

● necessary to prevent further damage to the brain

Treatment
● Indications
○ bleeding in the brain
○ swelling of the brain
○ a serious injury to the brain

most concussions don’t require surgery or any major

medical treatment

105
Medication
● Ibuprofen/acetaminophen
❑ If the concussion is causing headaches

Lifestyle changes Treatment

● get plenty of rest
● avoid sports and other strenuous activities
● avoid driving a vehicle or riding a bike for 24 hours or
even a few months, depending on the severity of
your injury
● avoid drinking alcohol (might slow recovery)

106
Getting a second concussion before the first concussion is
Complications
healed can cause a condition known as second impact
syndrome:

● post-concussion syndrome - causes one to experience

concussion symptoms for weeks (or even months)
instead of just a few days
● post-traumatic headaches - may last for a few months
● post-traumatic vertigo or dizziness - lasts for up to
several months
● brain injuries from multiple TBIs

107
➢ Most people completely recover from their concussions,
Prognosis
but it may take months for the symptoms to disappear.

➢ In rare instances, people experience emotional, mental,

or physical changes that are more lasting

➢ Repeat concussions should be avoided because even

though they are rarely fatal, they can increase the
chances of getting permanent brain damage.

108
Skull Fracture
● a break in the skull bone

● may also be called a traumatic brain injury or

TBI

● A mild break may cause few problems and

heal over time; more severe breaks can lead
to bleeding in or around the brain, brain
damage, leaking of CSF, infection, and seizures

109
Types
Linear skull fracture
- a break in the bone, but the bone
does not move out of place.
Skull base fracture
- a break in the bone at the bottom of
the skull
(+) Battle’s sign – bruising behind
the ears
(+) raccoon eyes – bruising around
the eyes
(+) CSF leakage - because of a tear
in part of the covering of the brain
Depressed skull fracture Skull Fracture
- part of the skull bone is
sunken in from the injury;
needs surgery
Penetrating skull fracture
- a break from something going
through the bone, such as a
bullet, blade, or blast
fragments
- often causes severe injury
and bleeding in the brain
110
The most common causes of skull fracture in adults are: Causes
○ A fall

○ Motor vehicle accident

○ Being hit with an object

○ Physical assault

○ Sports injury

111
 Symptoms

Confusion Bleeding from the head

Dizziness Nausea and vomiting
Poor memory Loss of consciousness
Feeling very tired Seizures
Headache (+) Raccoon eyes, Battle’s sign
Swelling on the head CSF leakage

112
 Diagnostic
❑ CT scan Procedure
❑ MRI

❑ X-ray

❑ Blood tests – to check for signs of

infection
● Most skull fractures will heal by themselves (simple
linear fractures) Treatment
● The healing process can take many months; pain will
usually disappear in around 5 to 10 days.
● For an open fracture, antibiotics may be prescribed to
prevent an infection.
● For a severe or depressed fracture, surgery may be
needed to help prevent brain damage.
● During surgery, any pieces of bone that have been
pressed inwards can be removed and returned to their
correct position.
● If necessary, metal wire or mesh may be used to
reconnect the pieces of the skull.
● Once the bone is back in place, it should heal naturally.
114
115
Spinal
Injury
116
SPINAL CORD
- a long, fragile tubelike structure that begins at the
end of the brain stem and continues down almost
to the bottom of the spine

- consists of nerves that carry incoming and

outgoing messages between the brain and the rest
of the body

- the center for reflexes

- is covered by three layers of tissue (meninges)

117
The spinal cord is organized into segments and named
and numbered from top to bottom. Each segment marks
where spinal nerves emerge from the cord to connect to
specific regions of the body.

● Cervical spinal nerves (C1 to C8) control signals to the

back of the head, the neck and shoulders, the arms
and hands, and the diaphragm

● Thoracic spinal nerves (T1 to T12) control signals to

the chest muscles, some muscles of the back, and
parts of the abdomen.

118
● Lumbar spinal nerves (L1 to L5) control signals to the
lower parts of the abdomen and the back, the
buttocks, some parts of the external genital organs,
and parts of the leg.

● Sacral spinal nerves (S1 to S5) control signals to the

thighs and lower parts of the legs, the feet, most of
the external genital organs, and the area around the
anus.

● The single coccygeal nerve carries sensory

information from the skin of the lower back.

119
Spinal Injury
● occurs when there is damage to the spinal cord
either from trauma, loss of its normal blood supply,
or compression from tumor or infection

● is described as either complete or incomplete:

○ complete spinal cord injury - complete loss of

sensation and muscle function in the body
below the level of the injury

○ incomplete spinal cord injury - there is some

remaining function below the level of the
injury

120
 Spinal Cord
Causes Injury
● The most common cause of spinal cord injury is
trauma
❖ motor vehicle accidents
❖ falls from heights,
❖ violence (stabbing or gunshot wounds to the
spine), and
❖ sporting injuries (diving, football, rugby,
equestrian, etc.)
● Infections that form an abscess on the spinal cord
● blood supply failure to the spinal cord
❖ aneurysm
❖ compression of a blood vessel
❖ prolonged drop in blood pressure
121
● The location of the injury on the spinal cord Symptoms
determines what part of the body is affected and
how severe the symptoms are.
● Generally, the higher up the level of the injury is to
the spinal cord, the more severe the symptoms. For
example:

❑ an injury to the neck C1, C2, or the mid-

cervical vertebrae (C3, C4, and C5) affects the
respiratory muscles and the ability to breathe

❑ A lower injury, in the lumbar vertebrae, may

affect nerve and muscle control to the bladder,
bowel, and legs, and sexual function

122
● Quadriplegia is loss of function in the arms and legs. Symptoms
● Paraplegia is loss of function in the legs and lower
body.

The extent of the damage to the spinal cord determines

whether the injury is complete or incomplete.

● A complete injury means that there is no

movement or feeling below the level of the injury.
● An incomplete injury means that there is still some
degree of feeling or movement below the level of
the injury.

123
124
The most common symptoms of acute spinal cord Symptoms
injuries:

▪ Muscle weakness
▪ Loss of voluntary muscle movement in the chest,
arms, or legs
▪ Breathing problems
▪ Loss of feeling in the chest, arms, or legs
▪ Loss of bowel and bladder function

The symptoms of SCI may look like other medical

conditions or problems.

125
 Diagnostic
❑ Physical Exam Procedure
❑ CT scan

❑ MRI

❑ X-ray

❑ Blood tests
● SCI requires emergency medical attention on the Treatment
scene of the accident or injury.
(Acute)
● After an injury, the head and neck will be
immobilized to prevent movement. (This may be
very hard when the patient is frightened after a
serious accident)

127
 Treatment
Specific treatment for an acute spinal cord injury is (Acute)
based on:

o Age, overall health, and medical history

o Extent of the SCI
o Type of SCI
o How patient responds to initial treatment
o The expected course of the SCI
o Patient’s opinion or preference

128
 Treatment
● There is currently no way to repair a damaged (Acute)
or bruised spinal cord. But, researchers are
actively seeking ways to stimulate spinal cord
regeneration. The severity of the SCI and the
location determines if the SCI is mild, severe, or
fatal.

● Surgery is sometimes needed to evaluate the

injured spinal cord, stabilize fractured backbones,
release the pressure from the injured area, and
to manage any other injuries that may have
been a result of the accident.

129
● Observation and medical management in the ICU
Treatment
● Medicines, such as corticosteroids (to help decrease
Post-
the swelling in the spinal cord) surgery
● Mechanical ventilator
● Bladder catheter
● Feeding tube

Recovery from a SCI often requires long-term

hospitalization and rehabilitation. An interdisciplinary
team of healthcare providers, including nurses,
therapists, and other specialists work to control pain
and to monitor your heart function, blood pressure,
body temperature, nutritional status, bladder and bowel
function, and attempt to control involuntary muscle
shaking (spasticity).
130
 “
Disturbances in
Visual and Auditory
Function
131
 Cataract
● is a lens opacity or cloudiness
● upon visual inspection, the lens appear gray or milky

Classification
Most common types of senile cataracts (defined by their
location in the lens):

○ Nuclear cataract - caused by central opacity in the lens

and has a substantial genetic component
○ Cortical cataract - involves the anterior, posterior, or
equatorial cortex of the lens
○ Posterior subcapsular cataracts - occur in front of the
posterior capsule.
132
● Compaction and stiffening of the central lens Pathophysiology
material (nuclear sclerosis) as new layers of cortical
(outer lens) fibers continue to proliferate over time

● Abnormal changes in lens proteins (crystallins) resulting

in their chemical and structural alteration, leading to loss
of transparency

● Pigmentation of lens proteins (yellow-->brown)

● Changes in the ionic components of the lens

133
● Lifestyle. cigarette smoking, long-term use of
corticosteroids, sunlight and ionizing radiation, diabetes, Causes
obesity, and eye injuries.

● Myopia. Nuclear cataract is associated with myopia,

which worsens when the cataract progresses.

● Density. If dense, the cataract severely blurs vision.

● Cataract in the periphery. A cataract in the equator or

periphery of the cortex does not interfere with the
passage of light through the center of the lens.

● Degenerative changes. Senile cataracts develop in elderly

patients because of the degenerative changes in the
chemical state of lens proteins.
134
● Genetic defects. Congenital cataracts occur in neonates
as genetic defects or as a sequela of maternal infections
during the first trimester Causes
● Foreign body injury. Traumatic cataracts occur after a
foreign body injures the lens with sufficient force to
allow aqueous or vitreous humor to enter the lens
capsule and also dislocate the lens.

● Secondary effects. Complicated cataracts occur as

secondary effects in patients with uveitis, glaucoma, or in
the course of a systemic disease, such as diabetes

● Drug or chemical toxicity. Toxic cataracts result from drug

or chemical toxicity with prednisone, ergot alkaloids,
dinitrophenol, naphthalene, phenothiazines, or pilocarpine,
or from extended exposure to ultraviolet rays
135
Blurred vision Glare Symptoms
- is usually the first - refers to the pain felt
symptom of cataracts when the patient looks
directly into the light

Halos Double vision

- formed when the - also one of the early
patient looks at a bright symptoms of cataract
light and there is still
the vision of the light
after looking away

136
 Decreased visual acuity is directly
proportional to cataract density.
Diagnostic
Procedure
❑ Snellen visual acuity test. The Snellen
visual acuity test measures the degree of
visual acuity in the patient.

❑ Ophthalmoscopy. Ophthalmoscopy is used

to view the extent of cataract.

❑ Slit-lamp biomicroscopic examination. This

procedure is used to establish the degree
of cataract formation.
Surgical Management - Lens replacement
Treatment
(Surgery)
● Phacoemulsification.
In phacoemulsification, an ultrasonic oscillating probe is
inserted into the eye. The probe breaks up the center of the
lens. The fragments are suctioned from the eye at the same
time. A small incision that often does not require sutures to
close can be used since the cataract is removed in tiny pieces.
Most of the lens capsule is left behind and a foldable intraocular
lens implant, or IOL, is placed permanently inside to help focus
light onto the retina. Vision returns quickly and one can resume
normal activities within a short period of time

138
Surgical Management - Lens replacement
Treatment
● Phacoemulsification
(Surgery)

○ Aphakic glasses - objects are magnified by 25%, making

them appear closer than they actually are

○ Contact lenses - provide patients with almost normal vision,

but because contact lenses need to be removed
occasionally, the patient also needs a pair of aphakic glasses.

○ IOL implants. The most common IOL is the single focus lens
or monofocal IOL that cannot alter the visual shape;
multifocal IOLs reduce the need for eyeglasses;
accommodative IOLS mimic the accommodative response of
the youthful, phakic eye

139
Surgical Management - Lens replacement Treatment
● Extracapsular cataract extraction (ECCE) (Surgery)
❖ In extracapsular extraction, an incision is made in the side of the cornea at the
point where the cornea and sclera meet. Carefully entering the eye through the
incision, the surgeon gently opens the front of the lens capsule and removes the
hard center, or nucleus, of the lens. The soft lens cortex is then suctioned out
leaving the back of the capsule in place.

❖ An incision requiring sutures is necessary because the lens is removed in one

piece. IOL is substituted for the original lens. The implanted IOL allows light to
be focused on the retina.

❖ It may be up to six weeks before the sutures are removed and best-corrected
vision is achieved. During recovery, it may be necessary to avoid bending over
or lifting heavy objects.

140
● Activities. Activities to be avoided are instructed by the nurse.
Self-care
● Protective eye patch. To prevent accidental rubbing or poking of the eye,
Discharge
the patient wears a protective eye patch for 24 hours after surgery, followed Instructions
by eyeglasses worn during the day and a metal shield worn at night for 1 to
4 weeks.

● Expected side effects. Slight morning discharge, sone redness, and a

scratchy feeling may be expected for a few days, and a clean, damp
washcloth may be used to remove slight morning eye discharge.

● Notify the physician. Because cataract surgery increases the risk of retinal
detachment, the patient must know to notify the surgeon if new floaters in
vision, flashing lights, decrease in vision, pain, or increase in redness
occurs.
141
 Pre-
❑ Should start 2 days before surgery
✓ Vigamox- Antibiotic
operative
✓ Maxidex- Steroid Medications
✓ Nevanec - Anti-inflammatory

❑ Drops should be administered in the morning of the

surgery and to resume the drops when patient arrives
home from the surgery. On the day of surgery, it is
advisable to instill all drops every 2 hours. There is NO
overdose on these drops. The more the better on the
first day.

142
Glaucoma
● a group of eye conditions that damage the optic nerve
often caused by an abnormally high pressure in the eye

● one of the leading causes of blindness for people over

the age of 60; can occur at any age but is more
common in older adults

● have no warning signs; the effect is so gradual that a

change in vision may not be noticed until the condition is
at an advanced stage

● If the patient has the condition, the treatment is lifetime

143
● Glaucoma is the result of damage to the optic nerve.
As this nerve gradually deteriorates, blind spots Causes
develop in the visual field. This nerve damage is
usually related to increased IOP.

● Elevated eye pressure is due to a buildup of aqueous

humor that flows throughout the inside of the eye.
This internal fluid normally drains out through a tissue
called the trabecular meshwork at the angle where
the iris and cornea meet. When fluid is overproduced
or the drainage system doesn't work properly, the
fluid can't flow out at its normal rate and eye
pressure increases.

144
Open-angle glaucoma
● the most common form of the disease Types
● the drainage angle formed by the cornea and iris remains open,
but the trabecular meshwork is partially blocked; causing pressure
in the eye to gradually increase (pressure damages the optic
nerve)

Angle-closure glaucoma (a.k.a. closed-angle glaucoma)

● occurs when the iris bulges forward to narrow or block the
drainage angle formed by the cornea and iris; as a result, fluid
can't circulate through the eye and pressure increases
● some people have narrow drainage angles, putting them at
increased risk of angle-closure glaucoma.
● may occur suddenly (acute angle-closure glaucoma – medical
emergency) or gradually (chronic angle-closure glaucoma)

145
146
Normal-tension glaucoma
● optic nerve becomes damaged even though the eye
Types
pressure is within the normal range
● may have something to do with a sensitive optic nerve,
or due less blood being supplied to the optic nerve

Pigmentary glaucoma
● pigment granules from the iris build up in the drainage
channels, slowing or blocking fluid exiting the eye
● Activities such as jogging sometimes stir up the pigment
granules, depositing them on the trabecular meshwork
and causing intermittent pressure elevations

147
 Open-angle glaucoma Acute angle-closure
glaucoma Symptoms
✓ Patchy blind spots in your
side (peripheral) or central ✓ Severe headache
vision, frequently in both
✓ Eye pain
eyes
✓ Nausea and vomiting
✓ Tunnel vision in the
advanced stages ✓ Blurred vision
✓ Halos around lights
✓ Eye redness

If left untreated, glaucoma will eventually cause blindness. Even with

treatment, about 15 percent of people with glaucoma become blind in at
least one eye within 20 years.

148
❖ Measuring intraocular pressure (tonometry) Diagnostic
❖ Testing for optic nerve damage with a dilated eye Procedure
examination and imaging tests

❖ Checking for areas of vision loss (visual field test)

❖ Measuring corneal thickness (pachymetry)
❖ Inspecting the drainage angle (gonioscopy)
 Treatment
● The damage caused by glaucoma can't be reversed.
But treatment and regular checkups can help slow or
prevent vision loss, especially if the disease is caught in
its early stages.

● Glaucoma is treated by lowering the intraocular

pressure. Depending on the situation, options may
include prescription eyedrops, oral medications, laser
treatment, surgery or a combination of any of these.

150
 Eyedrops can help decrease eye pressure by improving Treatment
how fluid drains from the eye or by decreasing the amount of fluid
the eye makes. Depending on how low the eye pressure needs to
(Eyedrops)
be, more than one of the eyedrops may need to be prescribed:

● Prostaglandins
○ increase the outflow of aqueous humor, thereby
reducing the eye pressure

● Beta blockers
○ reduce the production of fluid in the eye, thereby
lowering the intraocular pressure

151
● Alpha-adrenergic agonists Treatment
○ reduce the production of aqueous humor and increase
outflow of the fluid in your eye
(Eyedrops)
● Carbonic anhydrase inhibitors
○ reduce the production of fluid in your eye

● Rho kinase inhibitor

o lowers eye pressure by suppressing the rho kinase
enzymes responsible for fluid increase

• Miotic or cholinergic agents

o increase the outflow of fluid from your eye

152
 Treatment
Important Instructions: (Eyedrops)
To minimize absorption to the bloodstream, close eyes for one
to two minutes after putting the drops in; may also press lightly
at the corner of the eyes near the nose to close the tear duct
for one or two minutes. Wipe off any unused drops from your
eyelid.

If patient has been prescribed multiple eyedrops or needs to use

artificial tears, space them out; wait at least five minutes in
between types of drops.

153
● Laser therapy Treatment
○ Laser trabeculoplasty is an option for (Surgery)
open-angle glaucoma. The doctor
uses a small laser beam to open
clogged channels in the trabecular
meshwork. It may take a few weeks
before the full effect of this
procedure becomes apparent.

● Filtering surgery
○ A Trabeculectomy creates an
opening in the sclera and removes
part of the trabecular meshwork.

154
● Drainage tubes Treatment
○ In this procedure, the eye surgeon inserts a small (Surgery)
tube shunt in the eye to drain away excess fluid to
lower the eye pressure.

● Minimally invasive glaucoma surgery (MIGS)

○ MIGS is a procedure done to lower eye pressure.
These procedures generally require less immediate
postoperative care and have less risk than
trabeculectomy or installing a drainage device. They
are often combined with cataract surgery.
● Peripheral Iridotomy
○ The doctor creates a small opening in the iris using a
laser. This allows aqueous humor to flow through it,
relieving eye pressure.

155
● Eat a healthy diet. Several vitamins and nutrients are important to eye health,
including zinc, copper, selenium, and antioxidant vitamins C, E, and A.
Self-care
Discharge
● Exercise safely. Regular exercise may reduce eye pressure in open-angle Instructions
glaucoma.

● Limit your caffeine. Drinking beverages with large amounts of caffeine may
increase eye pressure.

● Sip fluids frequently. Drink only moderate amounts of fluids at any given time
during the course of a day. Drinking a quart or more of any liquid within a short time
may temporarily increase eye pressure.

● Sleep with head elevated. Using a wedge pillow that keeps head slightly raised,
about 20 degrees, has been shown to reduce intraocular pressure while sleeping.

156
Retinal Detachment
● occurs when the retina at the back of the eye
pulls away from its normal position

● separates the retinal cells from the layer of blood

vessels that provides oxygen and nourishment

● the longer retinal detachment goes untreated, the

greater is the risk of permanent vision loss in the
affected eye

157
Rhegmatogenous Causes
● the most common type of retinal detachment (Types)

● caused by a hole or tear in the retina that allows fluid to pass

through and collect underneath the retina, pulling the retina away
from underlying tissues. The areas where the retina detaches lose
their blood supply and stop working, causing loss of vision

● the most common cause is aging. As one ages, VITREOUS, the gel-
like material that fills the inside of the eye, may change in
consistency and shrink or become more liquid. As the vitreous
separates or peels off the retina, it may tug on the retina with
enough force to create a retinal tear. Left untreated, the liquid
vitreous can pass through the tear into the space behind the retina,
causing the retina to become detached.

158
Tractional Causes
● This type of detachment can occur when scar tissue grows on the (Types)
retina's surface, causing the retina to pull away from the back of the
eye
● is typically seen in people who have poorly controlled diabetes or
other conditions

Exudative
● In this type of detachment, fluid accumulates beneath the retina, but
there are no holes or tears in the retina
● can be caused by age-related macular degeneration, injury to the
eye, tumors or inflammatory disorders

159
160
 Risk
Factors
❖ Aging — retinal detachment is more common in
people over age 50

❖ Previous retinal detachment in one eye

❖ Family history of retinal detachment

❖ Extreme nearsightedness (myopia)

❖ Previous eye surgery, such as cataract removal

❖ Previous severe eye injury

161
Retinal detachment itself is painless. But warning signs almost
always appear before it occurs or has advanced, such as: Symptoms

✓ The sudden appearance of many floaters — tiny specs

that seem to drift through the field of vision

✓ Flashes of light in one or both eyes (photopsia)

✓ Blurred vision

✓ Gradually reduced side (peripheral) vision

✓ A curtain-like shadow over one’s visual field

162
❑ Retinal examination Diagnostic
➢ The doctor may use an instrument with a
bright light and special lenses to examine the Procedure
back of the eye, including the retina
➢ This type of device provides a highly detailed
view of the whole eye, allowing the doctor to
see any retinal holes, tears or detachments.

❑ Ultrasound imaging
➢ doctor may use this test if bleeding has
occurred in the eye, making it difficult to see
the retina
Procedures to prevent retinal detachment (when a retinal tear Treatment
or hole hasn't yet progressed to detachment):
(Surgery)
● Laser surgery (photocoagulation). The surgeon directs a Retinal Tear
laser beam into the eye through the pupil. The laser
makes burns around the retinal tear, creating scarring that
usually "welds" the retina to underlying tissue.

● Freezing (cryopexy). After giving a local anesthetic to

numb the eye, the surgeon applies a freezing probe to the
outer surface of the eye directly over the tear. The
freezing causes a scar that helps secure the retina to the
eye wall.

164
 Treatment
PNEUMATIC RETINOPEXY (Injecting air/gas into the eye) (Surgery)
● the surgeon injects a bubble of air or gas into the vitreous
cavity Retinal
● If positioned properly, the bubble pushes the area of the
Detachment
retina containing the hole or holes against the wall of the
eye, stopping the flow of fluid into the space behind the
retina
● doctor also uses cryopexy during the procedure to repair
the retinal break
● Fluid that had collected under the retina is absorbed by
itself, and the retina can then adhere to the wall of the
eye. The bubble eventually will reabsorb on its own.

165
 Treatment
SCLERAL BUCKLING (Indenting the surface of the eye) (Surgery)

● involves the sewing (suturing) a piece of silicone material Retinal

to the sclera over the affected area Detachment
● This procedure indents the wall of the eye and relieves
some of the force caused by the vitreous tugging on the
retina.
● For several tears or holes or an extensive detachment,
the surgeon may create a scleral buckle that encircles
the entire eye like a belt. The buckle is placed in a way
that doesn't block the vision, and it usually remains in
place permanently.

166
 Treatment
(Surgery)
VITRECTOMY (Draining and replacing the fluid in the eye)
Retinal
● the surgeon removes the vitreous along with any tissue Detachment
that is tugging on the retina. Air, gas or silicone oil is
then injected into the vitreous space to help flatten the
retina.
● Eventually the air, gas or liquid will be absorbed, and the
vitreous space will refill with body fluid. If silicone oil
was used, it may be surgically removed months later.
● may be combined with a scleral buckling procedure.

167
 “
Disturbances in
Visual and Auditory
Function
168
Meniere’s Disease
● a.k.a IDIOPATHIC ENDOLYMPHATIC HYDROPS
● a disorder of the inner ear that can lead to dizzy spells
(vertigo) and hearing loss

● In most cases, affects only one ear

● can occur at any age, but it usually starts between

young and middle-aged adulthood

● considered a chronic condition, but various treatments

can help relieve symptoms and minimize the long-term
impact on one’s life

169
The cause of Meniere's disease is unknown. Symptoms
of Meniere's disease appear to be the result of an Causes
abnormal amount of fluid (endolymph) in the inner ear,
but it isn't clear what causes that to happen.

Factors that affect the fluid, which might contribute to

Meniere's disease, include:
○ Improper fluid drainage, due to a blockage or
anatomic abnormality
○ Abnormal immune response
○ Viral infection
○ Genetic predisposition

Because no single cause has been identified, it's likely that

Meniere's disease results from a combination of factors.
170
Recurring episodes of vertigo Hearing loss Symptoms
➢ a spinning sensation that starts ➢ may come and go,
and stops spontaneously particularly early on
➢ occur without warning and usually ➢ Eventually, most people will
last 20 minutes to several hours, have some permanent
but not more than 24 hours hearing loss
➢ Severe vertigo can cause nausea.

Tinnitus Aural fullness

➢ is the perception of a ringing, ➢ Feeling of fullness in the ear
buzzing, roaring, whistling or ➢ Feeling of pressure in an
hissing sound in the ear affected ear

171
A diagnosis of Meniere's disease requires:
Diagnosis
o Two episodes of vertigo, each lasting
20 minutes or longer but not longer
than 12 hours

o Hearing loss verified by a hearing test

o Tinnitus or a feeling of fullness in your

ear

o Exclusion of other known causes of

these problems

172
 Hearing Assessment Diagnostic
Audiometry Procedure
❑ assesses how well one detects sounds at
different pitches and volumes and how well one
distinguishes between similar-sounding words

❑ People with Meniere's disease typically have

problems hearing low frequencies or combined
high and low frequencies with normal hearing in
the midrange frequencies.
 Balance Assessment
Videonystagmography (VNG) Diagnostic
✓ evaluates balance function by assessing eye movement
✓ Balance-related sensors in the inner ear are linked to muscles Procedure
that control eye movement (this connection enables to move
one’s head while keeping the eyes focused on a point

Rotary-chair testing
✓ measures inner ear function based on eye movement
✓ Patient sits in a computer-controlled rotating chair, which
stimulates the inner ear

Vestibular evoked myogenic potentials (VEMP) testing

✓ test used for diagnosing and also monitoring Meniere's disease
✓ performed by stimulating one ear with repetitive pulse or click
sound stimulation and then measuring surface EMG responses
over selected muscles averaging the reaction of the muscle
electrical activity associated with each sound click or pulse
175
 Balance Assessment
Posturography
✓ This computerized test reveals which part of the balance system
Diagnostic
(vision, inner ear function, or sensations from the skin, muscles, Procedure
tendons and joints) you rely on the most and which parts may cause
problems
✓ While wearing a safety harness, you stand in bare feet on a
platform and keep your balance under various conditions.

Video head impulse test (vHIT)

✓ uses video to measure eye reactions to abrupt movement
✓ While you focus on a point, your head is turned quickly and
unpredictably.
✓ If your eyes move off the target when your head is turned, you
have an abnormal reflex.

Electrocochleography (ECoG)
✓ looks at the inner ear in response to sounds
✓ It might help to determine if there is an abnormal buildup of fluid in
the inner ear, but isn't specific for Meniere's disease.
177
 Tests to rule-out other Conditions

❖ Blood tests Diagnostic

❖ imaging scans (may be used to rule out Procedure
disorders that can cause problems similar to
those of Meniere's disease, such as a tumor in
the brain or multiple sclerosis)

▪ CT scan
▪ MRI
Medications for vertigo (to be taken during a vertigo episode Treatment
to lessen the severity of an attack) (Medications)
○ Motion sickness medications, such as meclizine or
diazepam (Valium), may reduce the spinning sensation
and help control nausea and vomiting

○ Anti-nausea medications, such as promethazine, might

control nausea and vomiting during an episode of
vertigo

Long-term medication use (helps control the severity and

frequency of Meniere's disease symptoms)
○ Diuretics to reduce fluid retention (combined with
limiting salt intake)

179
Middle ear injections
Treatment
- Medications injected into the middle ear, and then absorbed
(Medications)
into the inner ear, may improve vertigo symptoms
● Gentamicin, an antibiotic that's toxic to the inner ear,
reduces the balancing function of the ear, and the other
ear assumes responsibility for balance. There is a risk,
however, of further hearing loss.
● Steroids, such as dexamethasone, also may help control
vertigo attacks in some people. Although dexamethasone
may be slightly less effective than gentamicin, it's less
likely than gentamicin to cause further hearing loss.

180
Noninvasive therapies and procedures Treatment
(Therapies)
● Rehabilitation. If one has balance problems between
episodes of vertigo, vestibular rehabilitation therapy might
improve balance.

● Hearing aid. A hearing aid in the ear affected by Meniere's

disease might improve hearing.

● Positive pressure therapy. Involves applying pressure to the

middle ear to lessen fluid buildup. A device called Meniett
pulse generator applies pulses of pressure to the ear canal
through a ventilation tube. Treatment is done at home,
usually three times a day for five minutes at a time.

181
● Endolymphatic sac procedure
The endolymphatic sac plays a role in regulating inner ear fluid levels.
Treatment
During the procedure, the endolymphatic sac is decompressed, which can (Surgery)
alleviate excess fluid levels. In some cases, this procedure is coupled with the
placement of a shunt, a tube that drains excess fluid from your inner ear.
● Labyrinthectomy
With this procedure, the surgeon removes the balance portion of the
inner ear, thereby removing both balance and hearing function from the
affected ear. This procedure is performed only if you already have near-total
or total hearing loss in your affected ear.
● Vestibular nerve section
This procedure involves cutting the nerve that connects balance and
movement sensors in your inner ear to the brain (vestibular nerve). This
procedure usually corrects problems with vertigo while attempting to preserve
hearing in the affected ear. It requires general anesthesia and an overnight
hospital stay.
182
 Hearing
Impairment
Lit in Canvas

183