Investigation of CNS

After finishing the history and the clinical.

examination, hoping to answer the 2
questions of the path. & the site of the
.lesion
Sometimes it is difficult to arrive at a definite.
.diagnosis
A provisional diagnosis is given and we.
restore to some accessory methods of
investigations, to reach final and definite
.diagnosis
 Skull radiography
Very limited indication for it in neurology. •
The lat. View is of particular value in the .
assessment of the size and shape of pituitary
.fossa
The inclined PA projection allows identification of.
the post. wall of the orbits, the superior orbital
.fissures, and the frontal air sinus
The inclined AP view(Towne’s projection).
displays the petrous temporal bones and the
.dorsum sella
.The vertico sub mental view→ the skull base. •
 :Cerebral Angiography
For visualization of intracranial vessels and spinal cord
arteries, by injecting a radio opaque substance (usually
.iodine based), by catheterization
:Indications
:Vascular abnormalities -1
a)- Aneurysm, angioma (A-V) and tumors with
hypervascularities (glioma, meningioma)
.b)- Arterial occlusion
c)- subdural hematoma cause avascular area by pushing
.vessels
Avascular tumors: by -2
a) Displacement of the cerebral arteries
.b) Producing an area strikingly devoid of vessels
:Complication
The dye is irritating damage to the endothelium of the
capillaries edema& punctuate hemorrhage
.convulsions and hemiplegia or even death
 :Digital subtraction angiography

Less invasive way of demonstrating cerebral .

.vasculature by computer enhancing techniques
The contrast is injected either by central venous .
bolus or a low dose arterial injection
.with IV is less risk than angiography .
It is used to exclude a major stenosis of cervical .
.carotid and vertebral arteries
Produce fine details of the extracranial and .
.entracranial vessels
 Spinal radiography

Performed widely for patients with spinal. •

.injury
.AP, lateral and oblique views. •
The oblique views → intervertebral. •
.foramina
Cervical spine views in flexion and extension. •
.→ instability of the spine
:The spine
Plain or contrast, the latter could be either myelography or
.myeloscan
Plain spine radiography ( AP, lateral ,oblique )
Vertebral body - body texture (e.g. Pottʼs disease , -1
metastasis, angiomatosis)
The vertebral margins (sclerosis or-
)osteophyte formation
The pedicles : the interpedicular distance which indicate .2
. the transverse diameter of the spinal canal
: The intervertebral foramen : in the oblique views either .3
Narrow ( spondylosis ) -
Wide ( nerve root tumor, neurofibromatosis) -
 :Myelography
Lumbar puncture , cervical puncture or cisterna-
puncture
To visualization of the spinal sub arachnoid space.-
-Is made by injection of an opaque substance
through lumbar puncture, cervical puncture or
cisternal puncture ( to see spinal cord and roots)
:Indication
It is useful when a lesion producing sub arachnoid
block is suspected ( tumor , disc protrusion or
arachnoiditis )
:Complication
Aseptic irritation of the meninges and nerve roots .
pain (headache)
An arachnoiditis or meningitis , muscle spasm,.
seizures
 CT Myelography
CT myelography has largely displaced the older .
.radiological technique
The procedure allow the identification of the .
lumbar and cervical nerve root pouches together
.with the shape and size of the spinal cord
Delayed scanning after an interval of several hours .
allows identification of any contrast material, which
has entered the spinal cord itself(e.g. in
.syringomyelia)
 :Computerized Axial Tomography (CAT scan)

Simple, safe, give a series of pictures through the.

head .Non invasive methods, and has revolutionized
.neurodiagnosis
The method is very sensitive and will show the normal.
outlines of the brain, cerebral ventricles & CSF spaces
.i.v contrast injection -->to see large blood vessels .
CT demonstrate : cerebral hemorrhage , tumors , cysts , &.
abscesses. Also hydrocephalus ,cerebral atrophy ,
.infarction , and subdural hematomas
Less useful to see the brain stem ,cerebellum& spinal cord.
but with modifications of the technique, can be
.demonstrated, and also can identify brain edema
Spinal CT scanning is used increasingly to outline disc.
.protrusions , spinal canal stenosis
 :Magnetic Resonance Imaging (MRI, MRA)
. This is another break through in the field of imaging after CAT.
. It is advantage over the CAT is that no radiation ( X-ray), are used .
It is very expensive – used the protons of hydrogen atom of tissues .
which altered by magnetic field
It is sensitive to difference bet. grey & white matter and show.
demyelination (M.S)
.Good images for posterior fossa (cerebellum, brainstem), spinal cord .
Multiple directions, axial, coronal, and sagittal images can be.
.generated without changes the pt. orientation
Initial axial image sequences routinely include T1, T2, FLAIR, and .
.DWI
Magnetic resonance angiography (MRA) has revolutionized .
visualization of cerebrovasculature by providing a noninvasive
means of imagine large and medium-sized intracranial blood
.vessels
A complementary technique, magnetic resonance venography (MRV) .
images dura venous sinuses and other components of the
.intracranial venous system
‘
 :Non invasive scanning of the carotid arteries
Duplex scanning combines an ultrasound image with a pulsed.
.Doppler flow detector
The neck vessels are fist imaged with the ultrasound system, and.
then scanned with the pulsed Doppler system to identify any
.significant stenosis and the direction of flow
The common, internal and external carotid arteries can be.
scanned, followed by assessment of the subclavian and vertebral
.arteries
TCD sonography has been used to document the existence of.
vasospasm and to confirm brain death.(distal carotid siphon,
.proximal segment of ACA, PCA, MCA)
 Single photon emission tomography

Single photon emission tomography(SPECT).

could be carried out using either multi
.detector or rotating gamma camera systems
The system allows quantitative assessment .
.of regional cerebral flow
‫تصوير طبي بأشعة غاما او التصوير المقطعي‬
.‫المحسوب بإصدار فوتون واحد‬
 Positron emission tomography

Positively charged electrons(positrons)are emitted during.

.the decay of certain unstable nuclei
The isotopes used are oxygen, carbon and nitrogen, with.
.a fluorine isotope substituted for hydrogen
Cerebral perfusion and blood volume are.
measured. .Assessment of metabolic activity is achieved
either by calculating an oxygen extraction fraction by the
use of a labeled glucose analogue or a marker that has an
.affinity for the relevant receptor
‫التصوير المقطعي باإلشعاع البوزيتروني هو تقنية تصوير‬
‫في الطب النووي تبين صور ثالثية االبعاد لبعض اعضاء‬
‫الجسم وهو مفيد في الكشف عن العديد من الحاالت و‬
 Electroencephalography (EEG) & Brain
:mapping

EEG recording uses usually16-20 scalp recorders to.

amplify and convert the basic brain rhythm into traces
.drawn on paper moving at 3cm/s

During maturation the basic EEG rhythms accelerated, so .

that the initially predominant theta- and delta activity(5-7
.)Hz and < 5Hz respectively

In adult, replaced by a dominant alpha rhythm, at 8-13Hz,.

.most conspicuous in the post-central areas
.
 I- Brain waves seen under normal condition
:Frequency .1
.Delta < 4/sec., theta 4-6/sec. alpha 7-13/sec., beta > 13/sec
Amplitude : it varies from 100 µv on scalp, and 1-2 mV on the .2
.surface of the brain
II- EEG is of particular value in epilepsy not for diagnosis, but
: rather for
Proper classification of epilepsy .
.Choice of drug therapy.
.Follow-up and in preparation for surgery.
Computer assisted EEG interpretation has been used to permit a.
.topographic representation of normal and abnormal activity
:Pathological waves are of three types
Rapid waves :indicates an irritative cortical lesion
(epileptogenic focus), they are episodic, single or in
:groups and of 2 main types
Spikes: monophasic or biphasic, the duration is.
.0.03sec
Sharp waves: the same characters as the spike but of.
.longer duration
:Slow waves: Delta and Theta may occur either in
.Episodes and this is seen in epilepsy.
Constant: seen in destructive cortical lesion (neoplasm,.
vascular or inflammatory
:Slow wave and spike complexes
Usually bilateral, generalized and episodic. seen in
cases of petit mal and some cases of grand mal and
.myoclonic epilepsy
:N.B
Hyperventilation, photic stimuli, and sleep .
deprivation are used to identify silent epileptic
.foci
Record EEG from ambulant patient for 24hrs or .
.longer also used
Video-monitoring of the patient and his EEG .
.simultaneously used
with clinical epilepsy may have normal 40%.
.routine EEG
Abnormal EEG record doesn’t establish a .
diagnosis of epilepsy in the absence of
.appropriate history
In the patient with severe epilepsy, intracranial .
electrodes may be used to identify an epileptic
.focus (for resection)
 :??Evoked Potential Recording
.It record very small cerebral or spinal event related potentials .
Stimulation of sense organs or peripheral nerves evokes a response in .
the appropriate cortical receptive areas and number of subcortical
.relay stations as well
:Visual Evoked Potential (VEP)
Stimulation of the retina by an alternating pattern of light and dark .
.squares produces a well-defined positive potential over the occipital
Lesions of the retina, optic nerve, chiasma, tract, radiation of cortex .
.may all disrupt or delay the response
A delay VEP in patient with clinically normal vision --(MS).
:Auditory Evoked Potentials (AEP)
It is sensitive means of detecting lesions of 8th. cranial nerve (acoustic
neuroma and other tumors of cerebello-pontine angle) and the
auditory pathways of brain stem also used in M.S
:Somatosensory Evoked Potentials (SSEP)
To confirm lesion in the somatic sensory systems.
Ulnar nerve for upper limb (recording the evoked potentials, in brachial .
.plexuses, cervical spine and contra lateral parietal area)
SSEP less useful than VEP for detecting subclinical demyelination.
.It can help in lesions of brachial plexus, spinal roots and cord .
 :Nerve Conduction Studies(NCV)

NCV are of great value in assessment of .

.peripheral nerve function
Conduction velocity in the fast conducting fibers .
within the nerve can be expressed as a distal
.latency or as an actual velocity
Motor ncv test and sensory ncv test should be .
.done
Repetitive stimulation is used in the evaluation of .
.the neuromuscular junction
Significant decrement of the evoked muscle .
.potentials is diagnostic in myasthenia gravis
 :Electromyography(EMG)
Most sampling of muscle for analysis of motor unite .
.activity is done with a concentric needle electrode
In the relaxed state, no spontaneous activity can be .
.recorded
Abnormal spontaneous activity is associated with .
denervation of muscle particularly with motor neuron
.disease
It is used for diagnosis of muscle diseases, nerve .
diseases and neuromuscular junction disease
.(myasthenia gravis)
 :Examination of Cerebrospinal Fluid (CSF)
CSF is normally obtained from the lumbar subarachnoid space, but can
be obtained from the subarachnoid space in the cervical region, the
.cisterna magna or from the lat. Ventricle

Therapeutic.
 Drugs
 Decrease the pressure
Diagnosis.
:Indications for CSF examination
.Infections: meningitis and encephalitis.
.Sub arachnoid Hemorrhage: if C.T. scan negative or unavailable.
Inflammatory conditions: MS (multiple sclerosis), sarcoidosis, acute.
.polyneuritis, systemic lupus erythematous (SLE) and syphilis
.Infiltrative conditions: carcinomatous meningitis, lymphoma, leukemia.
To confirm raised intracranial pressure (ICP) when C.T. scan excludes.
danger of brain stem herniation: benign intracranial hypertension
.(BIH), cerebral venous thrombosis
Administration of drugs (antibiotics in meningitis, anti mitotic as.
.oncology)
.Instillation of contrast media or isotopes: Myelography, cisternography.
Condition under which L.P. is not
-:performed
Depressed consciousness especially if focal.
.neurological signs present
.Papilledema.

.Preparation for L. P. and cisternal P

.Funduscopy.
.Between L3 – L4 and in cistern.
 {CSF parameters in health and some common disorders}:
Subarachnoid Pyogenic Tuberculous Viral M. S. multiple
Criteria Normal
hemorrhage meningitis meningitis meningitis sclerosis

50 – 180 Normal / Normal /

pressure increased Normal Normal
mm CSF Increased increased
Blood stain
Color Clear Cloudy Clear / cloudy Clear Clear
xanthochromia
Polymorph
Lymphocytes Lymphocyte Lymphocyte
Cell count 0 – 4/mm 3
Increase RBCs
50 -- 5000 10 -- 2000 0 – 10
1000 – 50.000
2/3 blood
Glucose Normal Decreased Decreased Normal Normal
level
Normal / Normal /
Protein < 500 mg/L Increased Increased Increased
increased increased

IgG/ total Not routinely

< 13 % -- -- -- Increased
protein. measured

Not routinely
IgG index < 0.45 -- -- -- Increased
measured

Oligoclonal IgG Not routinely

Absent -- -- -- Present
band measured

Organism on
Organism on ZN Sometime
Microbiology sterile Sterile gram stain Sterile
stain culture viruses
and culture
 :Biochemical Test
:Tests of muscle breakdown
Enzyme released from muscles increase in .
concentration in blood in muscle diseases
(Active polymyositis, muscular dystrophy)
:The most commonly measured are.
creatinine phosphokinase (CPK), aldolase and )1
lactate dehydrogenase (LDH) )2
:Neurogenetics
Patterns of inheritance-
Chromosomes and genes-
Mitochondrial and genes-
DNA analysis and gene mapping and linkage -
.analysis
 :Muscle and Nerve Biopsy
Muscle and nerve biopsy is sometimes of.
value when attempting to clarify the
diagnosis or classification of certain
muscle(e.g. myositis) or peripheral n.(e.g.
.leprosy) disorders
Histological examination, enzyme.
histochemistry and electron microscopy
may be helpful in defining with type of
.muscles or nerve fibers is affected
e.g. any inflammation, excess glycogen, lipid
.??)amyloid
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