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Dr. Roslaini
Departement of Neurology
Al ISLAM Hospital
Bandung
location
degree
fiber nerve
Onset
Neuropathy
It is condition where perifer nerve gets dysfunction and distruction.
Clinical manifestation of lower motor neuron paralysis included :
Sensory
Negative phenomenon :
Hypestesia, the loss of sense, pain, temperature and deep
sense
Positive phenomenon :
paresthesia
hiperalgesia
incomportable, burning sensation
Clinical symptom :
Distal gloves stocking hypesthesia
Dermatomel
Neuropathy ( contd )
Motoric
Weakness from light to severe especially distal
Loss of tendon reflex
Autonomic
Example :
Cool on limb
Postural syncope
Orthostatic hypotension
Hyperhidrosis
Contd
Approach
Peripheral nerve disorder
LMN
Polyneuropathies
Mononeuropathies
Acute
Subacute
chronic
Trauma
Pressure: CTS
Leprosy
Clinical symptoms
Diagnostic test :
Lumbal puncture : elevated cerebrospinal fluid protein
NCV - EMG
Criteria to make a diagnosis of GBS :
Rapid onset
lead to frank paralysis : Leg and arms
Sometimes respiratory muscle
Accompanied by sensoric abnormalities
Loss of deep tendon reflex / decrease
Elevated cerebrospinal fluid protein, and normal cell
Absence of other causes of peripheral neuropathy
Prognosis :
75 85 % spontaneus recovery
10 17 % recover with disability
8 % recurrent
5 % died
Therapy :
Self limiting
Corticosteroid
Immunoglobulin
Plasmapharesis
Diabetic Neuropathy
Complications of diabetes mellitus
Insidens 30 % - 70 % of DM patient
Definition :
A disorder somatic or autonomic perifer
nerve. Cause only by diabetes mellitus can
happen clinically or sub clinic without other
causes
Pathogenesa
Vascular
Metabolik
Other
Clinical features
Diabetic opthalmoplegia
Acute mononeuropathy
Rapidly evening painfull, asimetric, predominantly
motoric
Multiple neuropathy
Asimetric proximal motor weakness
Distal symetric, primarily sensory polineuropathy
Autonomic neuropathy
Painfull thoraco abdoment radiculopathy
Diagnostic test
Blood glucose level test
Nerve conduction study : NCV
Therapy
Maintenance of the blood glucose level
Microangiopathy antiplatelet agregasi ASA
Symptomatic theraphy for neuropathic pain
Psikotherapy, physiotherapy
Nutritional polineuropathy
Etiology :
Deficiency vitamin in daily food
Tight diet
Malabsorption
Post operatif GIT
Alcoholic
Patology anatomy feature : axonal degeneration
Clinical features
Sensoric :
Paresthesia, hyperalgeria, hyperaesthesia
Motoric : Paralysis
Fisiologi reflex decrease
Sistemic disorder : delirium anemi, etc
Diagnostic test
Serum level of vitamin B1, B6, B12, Folic acid
Electroneuromyography : NCS Nerve Conduction Study
NCV
Therapy
Vitamin suplement administration vitamin B1, B6, B12
Mononeuropathy
Radial nerve
Arises from the C. 5 8
Motor nerve innervated : the chief extensor of the
fore arm, wirst, and finger
Cause by external pressure in axilla and fracture
humerus
Pressure against some hard surface especially in
sleep : saturday night palsy
Radial Nerve
Median nerve
Arises from the C. 5 6 7 8 th I
Its fairly common as a result of compression of the
nerve by transverse carpal segment ( Carpal
tunnel syndrome / CTS )
The symptoms : severe pain often weakly patient
from sleep, usually in the thumb and index finger
Athrophy M. Thenar
Trauma axilla area ape hand
Median Nerve
Ulnar nerve
Arises from the C7 8 th I
It is frequently injured by gunshot, wound in
olecranon or head radius bone, most compressed
at elbow, leprosy, diabetic neuropathy
Clawn hand its on the ring finger
Ulnar Nerve
Sciatic nerve
Derived from the L 4 5 S1
Its commonly by fracture of pelvis or femur, wound of
the buttock and thigh.
Sciatic nerve
Common Peroneal
Nerve
Tibial nerve
Lession in tibial nerve are uncommon
Caused by trauma, and compression in tarsal tunnel
L3 4
L4 5
L5 S1
L4
L5
S1
Muscles affected
Quadriceps
Peroneals;
anterior tibial;
extensor
hallucis
longus
Gluteus
maximus;
gastrocnemius;
plantar flexors
of toes
Anterior thigh,
medial shin
Great toe,
dorsum of
foot
Lateral foot,
small toe
Reflex affected
Knee jerk
Posterior
tibial
Ankle jerk
Straight leg
raising
May not
increase pain
Aggravates
root pain
Aggravates
root pain
Disc space
Root affected
C4 5
C5 6
C6 7
C7 T1
C5
C6
C7
C8
Muscles
affected
Deltoid; biceps
Triceps; wrist
extensors
Intrinsic
hand
muscles
Area of pain
and sensory
loss
Shoulder, anterior
arm, radial
forearm
Thumb, middle
fingers
Index,
fourth, fifth
fingers
Reflex affected
Biceps
Triceps
Triceps
Myopathy
Diseases concerning with sceletal muscles
Symptoms of skeletal muscle disease :
Falique
Weakness
Atrophy
Muscle tic
Cramps
Painfull
Muscle distrophy
Clinical manifestation
Mostly find on children under 3 years age
Usually boy
The story late to walk often fallen, cant run
difficult to stand up from the squad position
( Gowers sign ) finally paralysis
Physical diagnostic
Atrophy on proximal muscle calf muscle
Pseudo hypertrophy
Progresifity variety
Fatal cases respiratory muscle failure and
secondary infection
Diagnostic test
Increases the CPK level
EMG, classical myogen feature
Muscle biopsy
Therapy
No medication for disease
Physiotherapy
Genetic conseling
Polymyositis
Disorders of sceletal muscle
Onset acute / subacute
PA infiltration of muscle by lymphocyt
Etiology
Unknown idiopathic polymyositis / autoimmun
Collagen vascular disease
Infection
Drug
Systemic disease
Endocrin disease
Metabolic disease
Toxic
Clinical manifestation
No family history
Progressition is measured in week / month
Symptom may improve spontaniously
Dysphagia, weakness neck / flexor muscle
Arthralgia, myalgia
Diagnostic test
EMG ; myopathy feature
Therapy
Corticosteroid and immuno supresif drug
Immunoglobulin intravenous
Myasthenia Gravis
Autoimmun disease
Causes by transmission disorders on neuro muscular
junction
Acetyl cholin receptor ist attack by antibody
Related with thymus gland
Clinical features
Fluctuated weakness of certain voluntary muscle
Viral, other infection, emotional, can worst the
symptom
The symptom response to anticholin esterase drug
Sporadically to all ages
Tendon reflex normal
No sensory deficit
Classification
1. Ocular myasthenia : 20 % cases
2. A. Mild generalized myasthenia
- Slow progression
No crisis drug respons
B. Moderate generalized myasthenia
- Severe secletal and bulbar involment
- No crisis drug respon less than statisfactory
3. Acute fulminating myasthenia
- Rapid progression of severe symptom
- Respiratory crisis high mortality
4. Late severe mysthenia
Diagnostic test
Tensilon test or prostigmin test
Measurement of receptor antibody for acetylcholine
Repetitive stimulating test : progressif decrement
Single fiber electromyography
X ray, CT Scan, MRI, for thymoma gland
Differential diagnostic :
Eaton lambert syndrome
Follow lung carcinoma
Myasthenia gravis related with drug, toxin
Therapy :
Anticholine esterase drug prostigmin
Cortico steroid
Thymectomy
Plasma pharesis and immunosupressan
Immunoglobulin
BIOPSY
Dr Roslaini
DEPARTEMENT OF NEUROLOGY
AL ISLAM HOSPITAL
Bandung
Biopsy
Biopsy done if no other diagnostic test
Clinical test is not suffition for disease
Supporting the diagnostic when biochemistry
test is positive
Neurology diagnostic biopsy done on the
primary tissue of skin, sceletal muscle, nerve,
bone marrow, and brain.
Skin biopsy
Storage disease
Neuroaxonal dystrophy
Mythochondrial cytopathies