Overview of Neurological Conditions Dr. David Lipson, MD FRCPC, Physical Medicine and Rehabilitation Purpose Overview of pertinent neurological conditions Build basic understanding of Diagnosis Presentation/manifestations Investigations Complications Issues on causation Management Basic understanding of associated functional limitations Agenda Acquired Brain Injury Traumatic Brain Injury Concussion Myelopathy Radiculopathy Peripheral nerve injury and peripheral neuropathy Specific neuro conditions Stroke, MS, GBS, CRPS, etc… Not covering cognitive as this is Dr. Zakzanis’ talk Acquired Brain Injury Catch all term that incorporates all non-congenital/non-developmental brain damage, including traumatic brain injury Brain damage in the first year or two of life is often categorized separately and will usually fall under Cerebral Palsy Includes Anoxic brain injury Traumatic Brain Injury Brain injury from metabolic disturbances Brain damage from seizures Brain damage from intoxication All forms of brain injury Acquired Brain Injury cont… In medical legal world usually most interested in traumatic brain injury Talk will focus more so on traumatic brain injury Important to note that other causes of acquired brain injury may coexist with traumatic brain injury and may be part of secondary injury cascade Traumatic brain injury Injury to the brain from an externally applied force Usually graded in severity on the basis of loss of consciousness (and duration), post-traumatic amnesia (duration), and GCS score 30-60 minutes post injury May or may not involve structural damage to the brain tissue Trauamtic brain injury severity Mild TBI Deficits associated with mild TBI may or may not be permanent Mild TBI may or may not be associated with identifiable structural damage on conventional neuroimaging Concussion is a subset of mild TBI Concussion A subset of mild TBI Functional, not structural disturbance in brain function Caused by trauma to the head, or trauma to the body with impulsive force transmitted to the head Standard neuroimaging is typically normal If traumatic abnormalities seen on conventional neuroimaging or if parameters of initial presentation exceed mild TBI, then diagnosis exceeds concussion. Concussion diagnosis Minimum criteria to diagnose a concussion not agreed upon Screening tools helpful to determine who should be assessed by MD In cases of LOC or decline in GCS following trauma, diagnosis more clear Diagnosis is usually made on the basis of an MD assessment who is familiar with the diagnosis of concussion Some form of early onset altered mental status is commonly relied upon to make diagnosis in setting of probable inciting event normally a clinical diagnosis Presentation of concussion Many different symptomatic complaints Some symptoms clear and some are very non-specific Some of the more clear presentations involve Loss/alteration of consciousness Confusion – cant speak coherently or cant follow instructions Lack of awareness of surroundings – cant orient to time or place Nausea and vomiting Loss of balance/disturbance in walking steadiness Severe dizziness Significant hearing and/or vision changes/ringing ears Seizure Concussion presentation cont… Some concussions associated with complaints that are less specific Headache Lethargy Emotionality Sleep disturbance Feeling of unwellness Light or sound sensitivity Difficulty concentrating Concussion: can easily be confused with Headache/migraine Neck sprain ADHD Intoxication Depression Other psychoemotional conditions Viral illness Disrupted sleep Hormonal changes – low thyroid, monthly cycles Fibromyalgia-like conditions Many eye/ear medical problems Concussion Timeline Normally presents immediately (no time lag) Can be initially missed in setting of more severe distracting injuries or if alone and unaware of what is transpiring Retrospective concussion diagnoses not always reliable Can progress over hours in minority of cases. Concussion Recovery In most cases, concussion follows a predictable course Onset of symptoms fast Usually not progressive, but in some cases can progress over minutes to hours Resolution usually follows a predictable pattern Most individuals (85% of adults) recover from concussion within 2 weeks Kids can take a little longer Almost everyone recovers within 3 months A small percentage have persistent complications Concussion treatment No proven treatment to augment recovery Care is supportive Should avoid early provocation and engage in a slow stepwise reintegration into activity Treatment for persistent symptoms in chronic stage may be appropriate. Evidence is not strong for specific concussion therapies. Some therapies may be worthwhile to try but others are highly contentious. Some people have risks for prolonged recovery Many prior concussions Many concussions in a short period of time Migraine headaches before the concussion Younger age kids History of ADHD Psychiatric issues More severe concussion with loss of consciousness Post-Concussion Syndrome Failure of concussion symptoms to recover within normal expected time No universally agreed upon definition Often thought to be polyfactorial because neurobiological effects of concussion are typically not thought to persist Ensure all factors explored: substance use, sleep, psychoemotional factors, etc… Structural Abnormalities – not a concussion Subdural hematomas Epidural hematoma Subarachnoid hemorrhage Intraparenchymal hemorrhage Diffuse axonal injury Subdural Hematoma Bleeding below the dura but outside brain parenchyma This is reason patients asked to be frequently awakened to ensure no progression SDH can slowly expand resulting in late progressive brain compression Epidural Hematoma Bleeding between the skull and dura Less threatening over long term because less likely to expand Late compromise is unlikely Subarachnoid hemorrhage Bleeding into subarachnoid space (a space closer to brain tissue than a subdural hematoma) Does not usually result in progressive mass effect, but can cause other late complications Vasospasm/stroke Very severe headaches Seizures Hydrocephalus Intraparechymal hemorrhages Bleeding into the substance of the brain In addition to direct damage and mass effect damage, can result in late damage from hydrocephalus as well Diffuse axonal injury This is the type of injury being caused by rotational forces May be little visible presentation on standard neuroimaging MRI could show hemosiderin deposition (blood products in characteristic patters) as well as tiny diffuse hemorrhages Rotational forces result in mass shearing of axons within the brain Complications of Traumatic Brain Injury Cognitive decrement in many domains Emotional lability/personality change/abulia/agitation Motor decline/mobility decline/gross and fine motor/balance decline Headaches Cognitive communication difficulties Dysphagia Incontinence Seizures Dizziness Care for Traumatic Brain Injury (with structural damage) Rehab should be interdisciplinary care process Work to retrain lost neuro function/remediate deficits Training can facilitate adaptive neuroplasticity Train to circumvent limitations May involve use of mobility aids or communication aids or alter fluid consistency etc… Manage complications Treat spasticity, treat aspiration pneumonia, treat pain, treat depression etc… Traumatic Brain Injury Recovery In moderate to severe traumatic brain injury, most recovery usually within 1st 6 months Most plateau in recovery around 1 year post-injury Some do exhibit late recovery, but not common Traumatic brain injury disability Can be devastating for Vocational performance Performance of activities of daily living Interpersonal relationships Pursuit of enjoyment of life Vertigo Common complaint and/or comorbidity after traumatic brain injury Can be related to the neurobiological effects of brain injury itself Can be related to bone fleck in inner ear – BPPV Can be related to other factors – substance use, labyrinthitis, menierre’s,etc.. Should be distinguished from light headedmenss Helpful to have ENT input Dix Hallpike maneuver should be assessed In BPPV, Dix Hallpike maneuver is normally provocative for a matter of seconds, not more than minutes Stroke Stroke is similar to traumatic brain injury but there are key differences Stroke is an acute onset neurological event Associated with a vascular disruption in the brain Occurs spontaneously Can be ischemic or hemorrhagic Neuro deficits correspond to neuroanatomy/pathology Term CVA (cerebrovascular event) no longer used Stroke cont… As compared to TBI, stoke deficits are usually more focal/less diffuse There is usually better correlation between neuroanatomical involvement and clinical findings May see much more localized deficits in areas such as aphasia/apraxia/agnosia Sensorimotor deficits also usually much more localized Can produce profound disability in many of same domains as TBI Causation is not usually the subject of disability litigation because not traumatically induced Stroke management Management of those with significant deficits should be interdisciplinary Treatment should focus on Remediation of deficits Circumvention of functional limitations Management of complications Secondary prevention Optimizing re-integration Recovery – most recovery occurs in 1st 3-6 months and usually plateau by 1 yr. Multiple sclerosis Progressive condition with poorly understood pathophysiology Lesions arise in the central nervous system (brain and spinal cord) that are demyelinating Also optic neuritis tends to occur Lesions and neurological dysfunction