Neurologic Disorder

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 Definition of Terms
• Neurology: is the medical specialty of studies about the
causes of Ns malfunction, and looks for interventions
that can prevent it or treat it.

• Neuroscience: is the field of science that focuses on the

study of the nervous system.

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 Headache
 Headache, or cephalgia, is one of the most common of
all human physical complaints.
 Headache is actually a symptom rather than a disease
entity.

• It may indicate :
organic disease (neurologic or other disease),
 a stress response,
vasodilatation (migraine),
skeletal muscle tension (tension headache), or a
combination of factors.
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 Headache…
Classification
1.A primary headache is one for which no organic cause
can be identified. This includes :

a. Migraine headache

b. Tension headache and

c. Cluster headache

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 Headache…
2. A secondary headache is a symptom associated
with an organic cause: brain tumor or an aneurysm.

• Most headaches do not indicate serious disease,

although persistent headaches require further
investigation.
• Serious disorders related to headache include:
– brain tumors,
– subarachnoid hemorrhage,
– stroke, severe hypertension,
– meningitis, and head injuries.
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 A. Migraine Headache
 It is characterized by periodic and recurrent attacks of
severe headache.
 The cause of migraine has not been clearly understood,
but it
is primarily a vascular disturbance
Is more commonly in women and
has a strong familial tendency
The typical time of onset is puberty, and
the incidence is highest in adults 20 to 35 years of age.

 Most patients have migraine without an aura.

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 Migraine Headache…
Pathophysiology
• Abnormal metabolism of serotonin, a vasoactive
neurotransmitter found in platelets and cells of the
brain, plays a major role.

• The headache is preceded by a rise in plasma serotonin,

which dilates the cerebral vessels, but migraines are
more than just vascular headaches.
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 Migraine Headache…
Clinical Manifestations
• The migraine with aura has four phases:
1. The prodrome phase is experienced by 60% of patients.
Yawning ,Excitability, depression, irritability,
feeling cold,
cravings or distaste food, anorexia,
change in activity level,
increased urination, diarrhea, or constipation.

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 Migraine Headache…
2. Aura occurs in up to 31% of patients .

• This period is characterized by:

 Visual disturbances (light flashes & bright spots)
 hemianopia (affecting only half of the visual field).
 numbness and tingling of the lips, face, or hands;

mild confusion;
slight weakness of an extremity;
drowsiness; and dizziness.
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 Migraine Headache…
3. Headache Phase
60% of patients experience unilateral throbbing
headache

It is severe and incapacitating and

photophobia, nausea, and vomiting.

Its duration varies, ranging from 4 to 72 hours

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 Migraine Headache…
4. Recovery Phase
• Muscle contraction in the neck and scalp which is
associated with:
 muscle ache and localized tenderness,

exhaustion, and
mood changes

• Any physical exertion exacerbates the headache pain

• In the postdrome, the pain gradually subsides.
• patients may sleep for extended periods.

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 Migraine Headache…
Additional symptoms:
Pallor
Nausea and vomiting
Anorexia
Sweating

Throbbing pain that is synchronous with the pulse

Edema
Unilateral headache

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 Migraine Headache…
Triggering factors
– Stress
– Alcohol(wine)
– Foods like chocolate, cheese, etc
– Menses
– OCP
– Infection
– Trauma
– Vasodilators
– Excitement
– Bright vision
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 Diagnosis
– Investigations to exclude
– Medical History
secondary causes:
– Headache diary EEG

– Migraine triggers CT Brain

MRI

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 Medical Management
A. The triptans, serotonin receptor agonists anti migraine
agents avalable.
Sumatriptan25-300 mg po/d , rizatriptan 10 mg po/d,
zolmitriptan , and almotriptan.
cause vasoconstriction,
reduce inflammation, and
may reduce pain transmission.

B. Ergotamine tartrate 1-6 mg po/d acts on smooth

muscle, causing prolonged constriction of the cranial
blood vessels.
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C. Cafergot, a combination of ergotamine and caffeine,
can arrest or reduce the severity of the headache if
taken at the first sign of an attack.
D. Non –specific Therapy
Drug Dose Route

Aspirin 500-650 mg Oral

Paracetamol 500 mg-4g Oral

Diclofenac 50-100 mg oral

Ibuprofen 200-300mg oral

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 Migraine Headache…
E. Anti-nauseant drugs for migraine
treatment
Drug Dose (mg)/d Route
Metoclopramide 5-10 mg Oral/IV

Promethazine 50-125 mg Oral/IM

Chlorpromazine 10-25 mg Oral/IV

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 Migraine Headache…
Prevention
• Avoiding specific triggers factors: noise, light, odors, and
problems.
• Two beta-blocking agents: propranolol and metoprolol ,
inhibit the action of beta receptors-cells in brain that
control the dilation of blood vessels.

• Amitriptyline hydrochloride ,Valproate, flunarizine, and

several serotonin antagonists

• Prophylactic medication:beta-blockers ergotamine

tartrate ‘lithium, naproxen .
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 B. Tension headache
• is also called muscle-contraction headache.

• is the most common type of headache and

• is also more chronic.

• Due to prolonged muscle contraction in the face, head,

and neck that cause irritation of sensitive nerve endings
in the head, jaw, and neck from.

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 Tension headache…
Clinical manifestation…
– The pain is usually bilateral often in the back of neck
– It does not interfere with sleep

– Characteristic of the pain is:

• Tight, Squeezing
• Band like pressure/ “a weight on top of my head”
• Chronic, Dull and persistent
 Precipitating factors include fatigue, stress, and poor
posture.
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 Tension headache…
Management: Rule out any intra cranial or extra cranial
diseases
1. Physical therapy
• Massage, hot packs,
• cervical collars, and
• correction of faulty posture.

2. Pharmacologic therapy
• Aspirin, acetaminophen
• Tranquilizesr - a calming effect, relieve anxiety
• Codeine- has sedative effects
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 C. Cluster Headache
• Cluster headaches are unilateral & come in clusters of 1 to
8 times daily
• The pain:
– radiates to the facial and temporal regions.
– localized to the eye and orbit.
– is accompanied by watering of the eye and nasal
congestion.
– is often described as penetrating & steady
– frequent in men than in women by ratio of 5:1
• Neither the cause nor the Pathophysiology of headache is
fully known.
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 Cluster Headache…
Clinical manifestation
• Abrupt onset with a peak of 5 minutes and lasts 60 min.
– conjunctivitis,
– increased lacrimation, and
– nasal congestion on the side of the headache
– constriction of the pupil and
– ptosis (dropping) of the eye lid on the affected side

• The patient cries out, does bizarre things, and dislikes

being touched.

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 Cluster Headache…
• Intensely severe pain

• Unilateral headache

• Periorbital pain

• Nausea and vomiting is uncommon

• No aura

• Alcohol intolerance

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 Cluster Headache…
Management:
• The medical management of an acute attack may
include:

– Ergotamine tartrate,

– sumatriptan,

– steroids

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 Nursing Management of headache
 Reduces env’tal stimuli: light, noise, movement, etc.

 Light massage to muscles in neck, scalp, back

 Apply warm, moist heat to areas of muscle tension

 Teach progressive muscle relaxation to treat and prevent

tension headache
 Aware triggering factors and early symptoms

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 Stroke/CVA

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• Cerebrovascular disorders is an umbrella term that
refers to a functional abnormality of the CNS that occurs
when the normal blood supply to the brain is disrupted.

A stroke, or CVA, occurs when blood supply to part of the

brain is disrupted, causing brain cells to die.

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 Stroke/CVA…
• Strokes can be divided into two major categories:
Ischemic (85%): vascular occlusion and significant
hypoperfusion occur, and
Hemorrhagic (15%): there is extravasations of blood
into the brain or subarachnoid space.
• Blood flow can be compromised by a variety of
mechanisms:
 Thrombosis, Embolism, Hypoperfusion, bleeding..
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 Stroke/CVA…
• The brain represents only 2% of the body's weight. But,
– It uses about 25 % of the body's oxygen supply and
70 % of the glucose.
– Unlike muscles, the brain cannot store nutrients.

– If the blood supply is interrupted for:

– 30 seconds-unconsciousness and

– 4 minutes- Permanent brain damage result in.

– When brain cells die, they are not replaced

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 Stroke/CVA…

• The brain has high metabolic rate, sensitivity to changes

in blood flow, and dependence on continuous blood flow.

• In response to ischemia, the cerebral auto regulatory

mechanisms compensate for a reduction in CBF by:
– Local vasodilatation,
– Opening the collaterals, and
– increasing the extraction of oxygen and glucose from
the blood.

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 Stroke/CVA…
• When the CBF is reduced to below 20 ml/100g/min, an
electrical silence result and synaptic activity is greatly
diminished in an attempt to preserve energy stores.

• CBF of less than 10ml/100g/min results in irreversible

neuronal injury.

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 Risk factors for CVA/Etiology
• High blood pressure and atrial fibrillation .
• High blood cholesterol levels
• Diabetes
• Cigarette smoking (active and passive)

• Heavy alcohol consumption

• Lack of physical activity
• Obesity
• Red meat consumption and unhealthy diet.
• Drug use
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 Risk factors /Etiology
1. Blood pressure
Hypertension accounts for 35-50% of stroke risk.

Lowering B/P prevent both ischemic and hemorrhagic

strokes.
intensive antihypertensive therapy results in a greater
risk reduction

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 Risk factors /Etiology…

2. Atrial fibrillation
• Patients with atrial fibrillation have a risk of 5% each
year to develop stroke.

Aspirin is warranted for stroke prevention.

3. Blood lipids
 High cholesterol levels

Statin has lipid-lowering effects

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 Risk factors /Etiology…
4. Diabetes mellitus
 Patients with DM are 2 to 3 times more likely to develop
stroke, and have hypertension and hyperlipidemia.
 Intensive disease control may reduce nephropathy and
retinopathy

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 Risk factors /Etiology…
5. Heavy alcohol consumption-

could predispose to ischemic stroke, and subarachnoid

hemorrhage via multiple mechanisms:
 Hypertension

Atrial fibrillation

Platelet aggregation and clotting disturbances .

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 Risk factors /Etiology…
6. Drug use

Cocaine: Increase BP & cause narrowing of vessels in

the brain.
Amphetamines causing hemorrhagic stroke

 Brain tissue ceases to function if deprived of oxygen and

thereby irreversible injury
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 Pathophysiology…
A. Ischemic stroke occurs because of a loss of blood supply
to part of the brain, initiating the ischemic cascade.

There are three reasons why ischemic stroke might occur:

• Thrombosis (obstruction of a blood vessel by a blood clot
forming locally)
• Embolism (obstruction due to an embolus from elsewhere
in the body,
• Systemic hypo perfusion ( blood supply, e.g. shock)
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 Pathophysiology…
Atherosclerosis may disrupt the blood supply by :
 Narrowing the lumen of blood vessels or

 formation of blood clots within the vessel, or

 Releasing showers of small emboli  reduction of blood

flow

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 Pathophysiology…
Embolic infarction occurs as a consequence of atrial
fibrillation, or occlude the cerebral circulation.

 Then the brain becomes low in energy  anaerobic

respiration which produces less ATP to fuel
depolarization but releases a by-product called lactic acid.

 Lactic acid is an irritant acid which disrupts acid-base

balance in the braindestroy brain cells
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 Pathophysiology…
B. Hemorrhagic Stroke

Intracranial hemorrhage is the accumulation of blood

anywhere within the skull vault.
Epidural hematoma

Subdural hematoma

Subarachnoid hemorrhage

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 Pathophysiology…
 Hemorrhagic strokes result in tissue injury by causing
compression of tissue from an expanding hematomas.

 The pressure leads to a loss of blood supply to affected

tissue with resulting infarction, and

 The blood released to brain also have direct toxic

effects on brain tissue
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 Sign and symptoms…

There are the five major signs of stroke:

1. Sudden numbness or weakness of the face, arm or leg,

especially on one side of the body.
 Arm drift -when asked to raise both arms,
involuntarily lets one arm drift downward)
 Complete or partial loss of voluntary movement &/or
sensation.
 Tingling sensation in the affected area.
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 Sign and symptoms…
2. Sudden confusion or trouble speaking or understanding.
Abnormal speech
3. Sudden trouble seeing in one or both eyes.

4. Sudden trouble walking, dizziness, loss of balance or

coordination

5.Sudden, severe headache with no known cause

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 Diagnosis
 Angiography-“gold standard” identifies occlusion or
stenosis of large and small vessels
 CT scans

 MRI

 Doppler ultrasound, and

 Arteriography.

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 Diagnosis…
 Physical examination

 Neurological examination

 Medical history of the symptoms and

 Neurological status, helps giving an evaluation of the

location and severity of a stroke.

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 Treatment
A. General Management
– A, B, Cs

– IV, oxygen, monitor, elevate head of bed slightly

– Treat dehydration and hypotension

– Avoid over hydration – cerebral edema

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 Treatment
B. Treatment of ischemic stroke
 Definitive therapy is aimed at removing the blockage:

• thrombolysis, or

• thrombectomy

 The more rapidly blood flow is restored to the brain, the

fewer brain cells die.

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 Treatment…
Treatment of ischemic stroke…
• Antiplatelet agents

– ASA50-300 mg: ↓ risk by 20-25%.

– Dipyridamole 200mg BID alone: ↓ risk by 15%.

– Plavix 75 mg po qid : ↓ 0.5% absolute annual risk

reduction when compared to ASA.

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 Treatment….
C. Treatment of hemorrhagic stroke
 Neurosurgical evaluation: Intracerebral hemorrhage
require to detect and treat the cause of the bleeding

 Anticoagulants and antithrombotic: cannot be used in

Intracerebral hemorrhage

 monitoring level of consciousness, and B/P, blood

sugar, and oxygenation are kept at optimum levels.

 Surgery to repair the aneurysm may be done.

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 Prevention of another stroke
• Control The Risk Factors For Stroke, Such As:
– High blood pressure,
– Atrial fibrillation,
– High cholesterol, and
– Diabetes
Changes in lifestyle will be an important to reduce risks:
Limit alcohol, Avoid smoking or 2nd hand smokers
At least 30 minutes of exercise Walking is a good
choice.
Stay at a healthy weight, Eat a balanced diet that is
low in cholesterol, saturated fats, and salt.
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 Epilepsy

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 Epilepsy
• Epilepsy is characterized by recurrent, disorganized,
abnormal electrical firing in brain cells, which can
disrupt normal functioning of the brain.
• In epilepsy, the normal pattern of neuronal activity
becomes disturbed:
– causing strange sensations, emotions, and behavior, or

– convulsions, muscle spasms, and loss of consciousness

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 Epilepsy…
• Epilepsy is usually controlled, but not cured, with
medication.
• However, over 30% of people with epilepsy do not have
seizure control even with the best available medications.

• Some form of epilepsies are confined to particular stages

of childhood.

• Epilepsy is considered as a syndrome with vastly

divergent symptoms.

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 Epilepsy…
Common factors contribute to the cause of epilepsy
include:
– Stroke or transient ischemic attack
– Dementia, such as Alzheimer's disease
– Traumatic brain injury
– Infections(brain abscess, meningitis, encephalitis &
HIV)

– Congenital brain defect- Hydrocephalus,

microcephalus
– Brain injury during or near birth-hypoxia…
– Hypoglycemia…
– Brain tumor
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 Epilepsy…
Etiology…
 Idiopathic- In 60-70% of patients, no specific cause for
their seizures can be identified.

 Infants/children: congenital malformations, perinatal

hypoxia, developmental neurologic disorders, injury, and
infection are common causes of seizures.

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 Epilepsy…
Etiology…
 Young Adults: head trauma, brain tumors, infection,
illicit drug use and alcohol withdrawal and arteriovenous
malformations are common causes of seizures.

 Elderly: cerebrovascular disease, CNS degenerative

diseases, and brain tumors are common causes.

 Genetic - risk increased 2-3 times in individuals with first

degree relative with epilepsy.

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 Epilepsy…
Clinical Classification of seizures:
• Absence seizure (petit mal)

• Simple partial seizure (focal motor or aura)

• Complex partial seizure ( temporal lobe)

• Generalized tonic-clonic seizure (grand mal)

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 Epilepsy…
Type of Seizure

1. Partial seizure/focal motor/-Seizure activity begins

focally in cerebral cortex & undergo limited spread to
adjacent cortical area of the brain.

2. Generalized seizure-seizure activity is conducted widely

through both hemispheres of the brain.

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 Epilepsy…
1. Partial seizures /focal seizures
A. Simple partial seizures - consciousness is not impaired
– Convulsion of a single limb or a group of muscles.

B. Complex partial seizures - consciousness is impaired.

 Begins as a Simple partial , followed by impairment

of consciousness at onset

Attack of confusion, bizarre behavior when

consciousness impaired.
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 Epilepsy…
2. Generalized seizure
1. Absence seizures/petit mal/- involve an interruption to
consciousness.
– Person become unresponsive for a short period of time
(usually up to 30 seconds).
– Slight muscle twitching may occur.

2.Myoclonic seizures- involve an extremely brief muscle

contraction and can result in jerky movements of muscles
or muscle groups.
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 Epilepsy…
3. Tonic–clonic seizures/Grand mal/- involve an initial
contraction of the muscles (tonic phase) which may
involve:

 Tongue biting,
Urinary incontinence and
The absence of breathing.

• This is followed by rhythmic muscle contractions

(clonic phase).

• This type of seizure is referred to 'epileptic fit'

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 Epilepsy…
4. Clonic seizures- Consists of sudden rapid contraction of
muscle.
– Myoclonus are regularly repeating at a rate typically
of 2-3 per second.

5. Atonic seizures- involve the loss of muscle tone, causing

the person to fall to the ground.
These are sometimes called 'drop attacks.
If muscles of the neck, trunk & limbs are involved, pt
may suddenly collapse.

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 Epilepsy…
6. Febrile Seizure- common in children < 5 years typically
manifest as generalized tonic clonic convulsion of short
duration.

7. Status Epilepticus- is seizure persists for 30 minutes or

more.
– Consciousness is lost, tachycardia,elevetion of BP &
hyperthermia.
– Hypoglycemia & acidosis. This condition requires
immediate medical attention.
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 Epilepsy…
Phases of General Seizure
1. Preictal phase:
Consists of vague emotional changes (depression,
anxiety, nervousness).
 It lasts for minutes to hours. Followed by an "aura.“

 Aura is usually a sensory "cue" (odor or sound) or

sensation "cue" (weakness, numbness).
It warns the patient that a seizure is imminent.
Preictal phase may or may not be present in all patients.

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 Epilepsy…
Phases of General seizure….
2. Tonic-clonic phase.
 Loss of consciousness
Skin may become cyanotic,
Breathing is spasmodic,

 Jaws are tightly clenched, and

Tongue and inner teeth may be bitten
Urinary and fecal incontinence usually occur
 Phase may last one or more minutes.

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 Epilepsy…
 Tonic activity is characterized by rigid contraction of the
muscles.
 Clonic activity is characterized by alternate contraction
and relaxation of muscles, causing jerking movements
of the arms and legs.

3. Postictal phase.
Phase will vary in symptoms
Deep sleep which may last for several hours.
Headache, fatigue, confusion, and nausea.

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 Epilepsy…
Pathophysiology
• A seizure occurs basically due to excessive firing of the
neurons and fast spread of these impulses over the brain.
• Seizures may then spread to involve adjacent areas of the
brain or through established anatomic pathways to other
distant areas.
• The millions of neurons in the brain fire excessively in
addition bringing on a seizure.
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 Epilepsy…
Pathophysiology…
• There are two phenomenon in the Pathophysiology of a
seizure:-

– Hyper-excitability of a neuron
– Hyper synchronization

 Hyper synchronization leads to excessive excitability of a

large group of surrounding neurons.
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 Epilepsy…
Pathophysiology…
 Seizures can be viewed as resulting from an imbalance
between excitatory and inhibitory processes in the brain.

 The Proposed mechanisms for the generation and spread

of seizure activity within the brain is due to:
 Enhanced excitatory neurotransmission which is
primarily mediated by glutamate.

 Decreased inhibitory neurotransmission which is

primarily by (GABA), or
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 Clinical features…
Cardiac: Palpitations, chest pain, tachycardia, bradycardia,
arrhythmia…
– More common in right temporal mesial foci; potential
sudden death with arrhythmia.

Respiratory: Apnea, hyperventilation, hypoxia, cough

Particularly in temporal foci, hippocampal, and insular
involvement; potential sudden death with apnea.
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 Clinical feature…
Gastrointestinal: dyspepsia, pain, hunger, borborygmi,
nausea, vomiting, belching, urge to defecate, fecal
incontinence
 Particularly in temporal mesial foci; vomiting in

occipital.
Urinary: Incontinence, urgency
Genital: erection, orgasm ,Genital sensation in sensory
cortex;
• sexual arousal in limbic and temporal cortex
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 Clinical feature…

Cutaneous: Flushing, erythema, cyanosis, blanching,

pallor, piloerection

Papillary: Mydriasis (dilation of the pupil), miosis, Can

be unilateral; must be distinguished from cerebral
Herniation.

Secretory-Perspiration, salivation, lacrimation

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 Epilepsy…
Complication
• Falling - head injure or bone fracture

• Drowning- epileptic patients are 13 times more likely to

be drown while swimming.

• Car accidents: A seizure may cause loss of awareness

or control while driving a car or operating machines.

• Many states have driver's-licensing restrictions

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 Epilepsy…
Complication…
Pregnancy complications. Seizures during pregnancy
pose dangers to both mother and baby, and
– Anti-epileptic medications increase the risk of birth
defects.

Emotional health issues. People with epilepsy are more

prone to have psychological problems, especially
depression, anxiety and, in extreme cases, suicide.
– This could be due to difficulties dealing with the
condition itself as well as medication side effects.
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 Diagnosis…
1. Confirm patient has epilepsy
 Consider DDX: pseudo seizures, syncope, narcolepsy,
hemiplegic migraines, drug toxicity, transient ischemia
attack.
Pseudo seizures - psychogenic seizures basis, "hysterical
seizures.
Diagnostic Evaluation
 Medical history of patient and family history

 Description of seizure - details of episode from patient

and/or observer.
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 Diagnosis…
2. Description of seizure should include :
• Events preceding seizure: What was happening before the seizure
?
• Does patient recognize onset of seizure by a smell, visual
disturbance, sound or odd feeling ?
• Events during the seizure: What are the initial events ? Is
consciousness lost or altered ? What kind of body movements
occurred ? How long did the seizure last ? Did the person urinate
or bite his/her tongue ?
 Events after the seizure (i.e. postictal period). Is the patient alert,
drowsy, or confused ?
 Was there any numbness or weakness ?

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 Diagnosis…
3.Identify Factors known to precipitate epilepsy in
susceptible patients include:
 Sleep deprivation,
Fever, emotional stress,
Lack of food,
Alcohol/drug withdrawal,
Pregnancy, menses, and
Various sensory stimuli (E.g, Photosensitivity,
television, reading, eating, music).
 Identification and avoidance, of these factors may assist
in reducing the frequency of seizures if possible
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 Diagnosis…

 Physical and Neurological Examination

 Clinical Laboratory data

 Electroencephalography (EEG)

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 Epilepsy…
First aid measures
• Protect the person from injury - (remove harmful objects from
nearby)
• Cushion their head

• Look for an epilepsy identity card or identity jewelery.

• Aid breathing by gently placing them in the recovery position once

the seizure has finished.
• Stay with the person until recovery is complete

• Be calmly reassuring
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 Epilepsy…
Do not do…
• Restrain the person’s movements
• Put anything in the person’s mouth

• Try to move them unless they are in danger

• Give them anything to eat or drink until they are fully
recovered
• Attempt to bring them round

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 Epilepsy…
Medical Management
First-generation Second- generation
 Phenytoin  Lamotrigine

Carbamazepine Levitiracetam

Topiramate
Valproate

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 Epilepsy…
Mechanism of action of Carbamazepine..
 Blockade of Na+ channels that reduce the propagation of
abnormal impulses in the brain
 inhibit the generation of repetitive action potential
 Inhibit the release of glutamate
Drug of choice in
– Partial seizures.
– Tonic-clonic seizures
– Neuropathic pain
– Mood stabilizer
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 Epilepsy…
Side effects….
• GIT upset.
• Hypersensitivity reactions
• Drowziness , ataxia, headache & diplopia

• Blood dyscrasis such as leukemia

• Hyponatrimia & water intoxication
• Teratogenicity ( neural tube defects ).
• Induction of hepatic Cytochrome /CYP450

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 Surgery
• When medication fails and the area of the brain where the seizure
occurs is known, surgery may be performed to treat epilepsy.
• Temporal Lobe Surgery - This is performed to remove brain tissue
where the epileptic seizure starts. This type of surgery often
removes part of the cortex of the temporal lobe, hippocampus and
Amygdala.
• Corpus Callosotomy ("Split Brain“ operation) - is separation of
the right and left cerebral hemispheres. This is done to prevent the
spread of the seizure from one side of the brain to the other.

• Hemispherectomy - One cerebral hemisphere is removed.

• This surgery often results in trouble using their arm on the side of
the body opposite to the surgery.
• In some surgeries, only specific lobes of the brain are removed.
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 Epilepsy…
NURSES’ ROLES
• Advise patients on diagnosis and antiepileptic drug
changes .
• Identify and document seizure activity,
• perform appropriate interventions,
• recognize signs of AED toxicity and
• share the responsibility of taking care of Epilepsy
• dissemination of accurate information to the clients,
• performing Epilepsy Audit towards creation of a profile
of Epilepsy in general practice to improve care and
devising treatment plans and goals
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 Epilepsy…
Care for Epileptic Women
• In woman, Epilepsy affects sexual development,
menstrual cycle, contraception, fertility and
reproduction.

• Pregnant woman with seizure disorder face possible

risks of increased seizure frequency, reduced anti-
epileptic drug levels and life-threatening Status
Epilepticus .

• Women with Epilepsy are also at increased risk of

Fractures, Osteoporosis and Osteomalacia(softening
of bone).
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 Meningitis

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 Introduction
Meninges is a membrane covering the brain and spinal
cord.
• The arachnoid and pia mater separated by subarachnoid
space containing CSF.
• CSF is secreted by specialized epithelial cells found in
the capillaries called choroid plexuses.
• Additional amounts are secreted in the third and fourth
ventricles.
• CSF formed in the ventricles circulates and enters the
subarachnoid space.
• After which it circulates around the brain and spinal
cord.
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 Introduction…
• Although 500 to 800 mL of CSF are formed daily, only
125 to 150 mL are normally present.

• Thus, almost all of the CSF formed is reabsorbed via

arachnoid granulations, into the venous sinuses, and is
subsequently returned to the venous circulation.

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 Function of CSF

 Protects the brain against shocks and blows

 Brings nutrients to CNS neurons

 Maintaining a stable concentration of ions in the

central nervous system and
 Providing for removal of wastes.

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 Meningitis
• Meningitis is an inflammation of the meninges, the
protective membranes that surround the brain and spinal
cord.
• Aseptic meningitis, the cause is :

– viral or

– secondary to lymphoma, leukemia, or

– brain abscess

• Septic meningitis refers to meningitis caused by bacteria.

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 Cause
 Meningitis is most frequently caused by bacterial or viral
agents.

 Bacterial meningitis is considered a medical

emergency.

 viral meningitis is usually self-limiting and, is often

described as benign.

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 Cause…
• Acute meningitis is most often caused by bacteria that have
capsules:
– Neisseria meningitidis, Haemophilus influenzae, and
Streptococcus pneumoniae)
• These organisms are passed from person to person by droplet
during close contact.

• Cryptococcus neoformans (yeast) cause acute meningitis in

immune compromised patients.

(e.g, HIV/AIDS, steroids, or other forms of immuno-suppression)

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 Predisposing factor

• Patients who have pre existing ear infections are at

greater risk of having infections with S. pneumoniae.

• An URTIs, sinusitis, or mumps.

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 Pathophysiology
Meningeal infections generally originate in one of two
ways:
– Through the bloodstream as a consequence of other
infections, or
– By direct extension,
 after a traumatic injury to the facial bones, or

secondary to invasive procedures.

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 Pathophysiology…
• N. meningitidis concentrates in the nasopharynx and is
transmitted by secretion.

• Bacterial or meningococcal meningitis also occurs as an

opportunistic infection in patients with HIV/AIDS.

• S. pneumoniae is the most frequent causative agent of

bacterial meningitis associated with AIDS
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 Pathophysiology…
 Once the causative organism enters the bloodstream, it crosses the BBB
and causes an inflammatory reaction in the meninges.
 Inflammation of the subarachnoid space and pia mater occurs.
• A purulent exudate is released, and spread to other areas of the brain by
the cerebrospinal fluid (CSF).

• If it is left untreated, the CFS becomes thick and blocks the normal
circulation of the CFS.

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 Pathophysiology…
• Since there is little room for expansion within the
cranial vault, the inflammation may cause increased
intracranial pressure.
• Long-term effects of the illness causes a decreased
cerebral blood flow because of increased ICP or toxins.

• If the infection invades the brain tissue itself, the

disease is then classified as encephalitis.
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 Signs and symptoms
• Headache and fever are frequently the initial symptoms.

• Fever tends to remain high throughout the course of the

illness.
• The headache is usually severe as a result of meningeal
irritation.
• Neck rigidity (stiff neck) is an early sign. Any attempts
at flexion of the head are difficult because of spasms in
the muscles of the neck.
• Forceful flexion causes severe pain.
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 Signs and symptoms
• Photophobia: extreme sensitivity to light; this finding is
common although the cause is unclear.
• Disorientation and memory impairment are common
early in the course of the illness.
• As the illness progresses :

– lethargy,

– unresponsiveness, and

– coma may be develop.

– Seizures and increased ICP.

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Positive Kerning's sign: When the patient is lying with
the thigh flexed on the abdomen, the leg cannot be
completely extended .

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Positive Brudzinski’s sign: When the patient’s neck is
flexed, flexion of the knees and hips is produced.

when passive flexion of the lower extremity of one side is

made, a similar movement is seen in the opposite
extremity.

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 Diagnostic Method

• Bacterial culture and

• Gram staining of CSF and blood are key diagnostic

tests
• Physical Examination

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 Medical Management
• Successful outcomes depend on the early administration of an
antibiotic that crosses the blood–brain barrier into the
subarachnoid space
– Penicillin antibiotics (Ampicillin) or
– Cephalosporins (ceftriaxone sodium, cefotaxime sodium)
may be used.
– Vancomycin hydrochloride alone or in combination with
rifampin may be used if resistant strains of bacteria are
identified.
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 Cont’d
 Dexamethasone has been shown to be beneficial therapy
in the treatment of acute bacterial meningitis.

• Fluid volume expanders-Dehydration and shock

• Phenytoin—to control seizures

• Sedatives -- to treat irritability or restlessness

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 Prevention
• People in close contact with patients with meningococcal
meningitis should be treated with antimicrobial
chemoprophylaxis using
– Rifampin, or
– Ciprofloxacin hydrochloride or
– Ceftriaxone sodium.

• Vaccination should also be considered as an adjunct to

antibiotic chemoprophylaxis for any one living with a
person who develops meningococcal infection.

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 Nursing Assessment
• Neurologic status and vital signs are continually
assessed.
• Pulse oximetry and arterial blood gas values are used to
identify the need for respiratory support.
• As the increasing ICP compromises the brain stem.
• mechanical ventilation may be necessary to maintain
adequate tissue oxygenation.

• Arterial blood pressures are monitored to assess for

incipient/early shock, which preceded cardiac or
respiratory failure.

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 Nursing Intervention
• Monitoring body weight, serum electrolytes, and urine
volume,
• Protecting the patient from injury secondary to seizure
activity or altered level of consciousness.

• Preventing complications associated with immobility,

such as pressure ulcers and pneumonia.

• Manage Medication
• Regulate body temperature
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 Nursing Intervention…

• Instituting infection control precautions until 24 hours

after initiation of antibiotic therapy (oral and nasal
discharge is considered infectious)

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 INCREASED INTRACRANIAL PRESSURE

The cranium is a closed cavity filled with contents that

are virtually non-compressible.

The rigid cranial vault contains:

brain tissue (1,400 g),

blood (75 mL), and

CSF (75 mL) .

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 INCREASED INTRACRANIAL PRESSURE

 The volume and pressure of these three components are

usually in a state of equilibrium and produce the ICP.

 ICP is usually measured in the lateral ventricles; normal

ICP is 10 to 20 mm Hg.

 An increase in any one of the components causes a

change in the volume of the
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others.
SL 2016 116
 INCREASED INTRACRANIAL PRESSURE …
Rapid or prolonged increases in ICP is a serious threat to
life. This increased pressure may result from:
edema,
 bleeding,
 trauma, or
 space-occupying lesions.

• Once the pressure exceeds the accommodation point, the

brain will herniate through weak points (the foramen
magnum).

– Irreversible neurological damage or death will result.

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 Clinical Manifestation

 Change in level of consciousness

 Headache--increases in severity with coughing,
sneezing, or straining at stool
 Vomiting

 Papilla edema/optic disc/pupil changes.

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 Nursing Management
1. Monitor vital signs closely
2. Maintain patent airway
3. Administer medications as ordered(Mannitol, Dilantin
& Antibiotics)

4 Elevate head of bed (30 0)

5 Administer hypertonic I.V. solutions as ordered

6. Protect patient from injury during seizures

7. Maintain normal body temperature.

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