SAMENVATTING
NEUROLOGIE
Neurokinesitherapie 2
P. De Deyn
,1. Neurologisch onderzoek ............................................................................................................................. 10
1.1 Inleiding ...................................................................................................................................................... 10
1.2 Neurologisch onderzoek.............................................................................................................................. 10
1.2.1 Mental status exam ............................................................................................................................. 10
1.3 Craniale zenuwen ........................................................................................................................................ 14
I. N. olfactorius ............................................................................................................................................. 14
II. N. Opticus ................................................................................................................................................. 14
II en III. Pupilrespons .................................................................................................................................... 15
V. sensoriek vh aangezicht EN motoriek kauwspieren ................................................................................. 15
VII. Spieren voor gezichtsuitdrukking en smaak ........................................................................................... 16
VIII. Gehoor en evenwicht ............................................................................................................................ 16
IX en X. Elevatie vh palatum en gag-reflex ................................................................................................... 17
V, VII, IX, X, XII Spieren voor articulatie ........................................................................................................ 17
XI. Sternocleidomastoideus en trapezius spieren ........................................................................................ 17
XII. N. Hypoglossus ....................................................................................................................................... 17
1.4 Motorisch onderzoek .................................................................................................................................. 18
1.5 Sensorisch onderzoek .................................................................................................................................. 20
2. Technische neurologische onderzoeken ..................................................................................................... 21
2.1 Elektro-encefalografie (EEG) ....................................................................................................................... 21
2.1.1 Werking EEG ........................................................................................................................................ 21
2.1.2 10-20 systeem ..................................................................................................................................... 22
2.1.3 Eigenschappen EEG ............................................................................................................................. 22
Frequentie EEG ............................................................................................................................................. 22
2.1.4 Voornaamste indicaties voor EEG ....................................................................................................... 23
2.1.5 Voorbeelden EEG................................................................................................................................. 23
2.2 Polysomnografie ......................................................................................................................................... 24
2.3 Uitgelokte potentialen (= Evoked potentials, EP’s) ..................................................................................... 24
Averaging methods ...................................................................................................................................... 24
Eigenschappen EP......................................................................................................................................... 24
2.3.1 Visuele evoked potentials (VEP’s) ....................................................................................................... 25
2.3.2 Sensory evoked potentials (SEP) ......................................................................................................... 25
2.3.3 Brainstem auditory evoked potentials (BAEP) .................................................................................... 26
2.4 Lumbaalpunctie .......................................................................................................................................... 26
2.4.1 Werking lumbaalpunctie ..................................................................................................................... 26
2.4.2 Indicaties voor lumbaalpunctie ........................................................................................................... 27
2.4.3 Waarden voor normaal cerebrospinaal vocht (CSF) ............................................................................ 27
2.4.4 Risico’s lumbaalpunctie ....................................................................................................................... 27
2.5 Ophtalmoscopie .......................................................................................................................................... 27
2.6 Structurele neuro-imaging .......................................................................................................................... 28
2.6.1 CT (= Computerised tomography) ....................................................................................................... 28
2.6.2 MRI (= Magnetic Resonance Imaging) ................................................................................................. 28
2.6.3 Vergelijking MRI met CT ...................................................................................................................... 28
2.7 Angiografie ................................................................................................................................................. 29
Conventionele angiografie ........................................................................................................................... 29
Conventionele angiografie ........................................................................................................................... 29
2.8 Functionele neuro-imaging ......................................................................................................................... 30
1
,3. Cerebrovasculaire aandoeningen ............................................................................................................... 31
3.1 Inleiding ...................................................................................................................................................... 31
3.1.1 Definitie CVA ....................................................................................................................................... 31
3.1.2 Epidemiologie CVA .............................................................................................................................. 31
3.1.3 Algemene benadering CVA .................................................................................................................. 31
3.1.4 Anatomie ............................................................................................................................................. 32
3.1.5 Classificatie CVA .................................................................................................................................. 34
3.2 Ischemisch CVA ........................................................................................................................................... 35
3.2.1 Pathofysiologie .................................................................................................................................... 35
3.2.2 Klinische syndromen ........................................................................................................................... 39
3.2.3 Aanvullende onderzoeken ................................................................................................................... 42
3.2.4 Behandeling ......................................................................................................................................... 43
3.3 Hemorragisch CVA ...................................................................................................................................... 44
3.3.1 Pathofysiologie .................................................................................................................................... 44
3.3.2 Intercerebrale bloeding ....................................................................................................................... 44
3.3.3 Subarachnoidale bloeding ................................................................................................................... 46
3.3.4 Subdurale / epidurale bloeding ........................................................................................................... 47
4. Craniocerebrale traumata .......................................................................................................................... 48
4.1 Inleiding ...................................................................................................................................................... 48
4.2 Commotio cerebri ....................................................................................................................................... 48
4.5.1 Intracerebrale hematomen (in hersenweefsel) ................................................................................. 49
4.5.2 Subdurale hematomen (tussen dura mater en arachnoidea) ........................................................... 50
4.5.3 Subarachnoidale (SAH) (tussen arachnoidea en pia mater, i/d subarachnoidale ruimte) ............... 51
4.5.4 Epidurale hematomen (tussen schedel en dura mater) .................................................................... 51
4.6.1 Postcommotioneel syndroom ............................................................................................................. 51
4.6.2 Posttraumatische epilepsie ................................................................................................................. 51
4.7.1 hersenherniatie bij epiduraal hematoom ........................................................................................... 52
4.7.2 Traumatische subarachnoidale bloeding ............................................................................................ 52
4.7.3 Epiduraal Hematoom .......................................................................................................................... 52
4.7.4 Subduraal hematoom .......................................................................................................................... 53
4.7.5 Diffuus axonaal letsel .......................................................................................................................... 53
4.7.6 Penetrerend letsel ............................................................................................................................... 53
Complicaties - langdurige sequellen............................................................................................................. 54
5. Parkinson ................................................................................................................................................... 55
5.1 Inleiding: Voorkomen vd ziekte van Parkinson ........................................................................................... 55
5.2 Motore verschijnselen ................................................................................................................................. 56
5.3 Niet-motore verschijnselen ......................................................................................................................... 57
5.4 Conclusie ..................................................................................................................................................... 58
5.5 Differentiaaldiagnose ................................................................................................................................. 58
5.6 Behandeling ................................................................................................................................................ 58
2
,6. Perifere neuropathieën .............................................................................................................................. 60
6.1 Algemeen .................................................................................................................................................... 60
6.1.1 Definities ............................................................................................................................................. 60
6.1.2 Evaluatie .............................................................................................................................................. 60
6.2 Mononeuropathieën ................................................................................................................................... 61
6.2.1 Ulnaire neuropathie ............................................................................................................................ 61
6.2.2 Carpaal tunnel syndroom .................................................................................................................... 61
6.2.3 Tarsaal tunnel syndroom ..................................................................................................................... 61
6.2.4 Bell’s palsy ........................................................................................................................................... 61
6.3 Polyneuropathieën ...................................................................................................................................... 62
6.4 Diabetis ....................................................................................................................................................... 62
6.5 HIV .............................................................................................................................................................. 62
6.6 Ziekte van Lyme .......................................................................................................................................... 62
6.8 Zuiver motore neuropathieën ..................................................................................................................... 63
6.8.1 Amyotrophic lateral sclerosis (ALS) ..................................................................................................... 63
6.8.2 Poliomyelitis ........................................................................................................................................ 63
6.8.3 Muscular atrophies.............................................................................................................................. 63
6.8.4 Guillain-Barre syndrome...................................................................................................................... 63
6.8.5 Myasthenia gravis................................................................................................................................ 63
6.9 Motore en Sensore neuropathieën ............................................................................................................. 64
6.9.1 Carpaal tunnel ..................................................................................................................................... 64
6.9.2 Chronic inflammatory demyelinating polyneuropathy (CIDP) ............................................................ 64
6.10 Paraneoplastische perifere neuropathieën ............................................................................................... 64
6.11 Autonome neuropathie ............................................................................................................................. 64
6.12 Plexopathieën ........................................................................................................................................... 65
6.13 Mononeuritis Multiplex............................................................................................................................. 65
7. Epilepsie ..................................................................................................................................................... 66
7.1 Wat is een epilepsie-aanval? ...................................................................................................................... 66
7.2 Epidemiologie ............................................................................................................................................. 66
7.3 Indeling obv presentatievorm ..................................................................................................................... 66
7.3.1 Partiële aanvallen ................................................................................................................................ 66
7.3.2 Gegeneraliseerde aanvallen ................................................................................................................ 66
7.4 Kenmerken epilepsie ................................................................................................................................... 66
7.5 Wat te doen bij een aanval? ....................................................................................................................... 69
7.6 Oorzaak ....................................................................................................................................................... 69
7.6.1 Éénmalige aanval ................................................................................................................................. 69
7.6.2 Epilepsie .............................................................................................................................................. 69
7.7 Classificatie epilepsie .................................................................................................................................. 69
7.8 Diagnose ..................................................................................................................................................... 70
7.9 Differentiaaldiagnose ................................................................................................................................. 70
7.10 Behandeling .............................................................................................................................................. 70
7.10.1 Behandelingsstrategie ....................................................................................................................... 70
7.10.2 Behandeling ....................................................................................................................................... 71
7.11 Refractaire epilepsie ................................................................................................................................. 71
3
,8. Cerebellaire aandoeningen ......................................................................................................................... 72
8.1 Anatomie .................................................................................................................................................... 72
8.2 Cerebellaire somatotopie ............................................................................................................................ 75
8.3 Functie van het cerebellum ......................................................................................................................... 76
8.4 Werking van het cerebellum ....................................................................................................................... 76
8.5 Symptomen van cerebellaire dysfunctie ..................................................................................................... 76
8.5.1 Algemeen............................................................................................................................................. 76
8.5.2 Symptomen lokalisatie ..................................................................................................................... 76
8.5.3 Samenvatting ....................................................................................................................................... 77
8.6 Aandoeningen van het cerebellum ............................................................................................................. 77
8.6.1 Cerebellaire aandoeningen bij kinderen ............................................................................................. 78
8.6.2 Cerebellaire aandoeningen bij volwassenen ....................................................................................... 80
9. Spierziekten ............................................................................................................................................... 81
9.1 Inleiding ...................................................................................................................................................... 81
9.1.1 Definitie ............................................................................................................................................... 81
9.1.2 Symptomatologie ................................................................................................................................ 81
9.1.3 Classificatie .......................................................................................................................................... 81
9.1.4 Diagnostiek .......................................................................................................................................... 81
9.1.5 Behandeling ......................................................................................................................................... 82
9.2 Hereditaire (aangeboren) spierziekten ....................................................................................................... 82
9.2.1 Spierdystrofie ...................................................................................................................................... 82
9.2.2 Myotonie ............................................................................................................................................. 87
9.3 Verworven spierziekten ............................................................................................................................... 87
9.3.1 Polymyositis & dermatomyositis ......................................................................................................... 87
9.3.2 Andere verworven spierziekten .......................................................................................................... 89
9.4 Neuromusculaire junctiestoornis ................................................................................................................ 89
9.4.1 Myasthenia Gravis (MG) ...................................................................................................................... 89
9.4.2 Lambert Eaton syndroom (LEMS) ........................................................................................................ 91
10. Dementie.................................................................................................................................................. 92
10.1 Definitie..................................................................................................................................................... 92
10.2 Mild cognitive impairment ........................................................................................................................ 93
10.3 Typologie van de dementie ....................................................................................................................... 93
10.4 Indeling van dementies ............................................................................................................................. 93
10.5 Belang van de diagnose ............................................................................................................................ 93
10.6 Belangrijkste klinische beelden ................................................................................................................. 94
10.6.1 Ziekte van Alzheimer ......................................................................................................................... 94
10.6.2 Fronto-temporo lobaire degeneratie (FTLD) ..................................................................................... 94
10.6.3 Vasculaire dementie (VaD) ................................................................................................................ 95
10.6.4 Dementie met Lewy lichaampjes (DLBD) (Belangrijk! -> kennen) ..................................................... 95
4
,11. Neuropsychologische en functionele onderzoeken .................................................................................. 96
11.1 MMSE: Mini-Mental State Exam............................................................................................................... 96
11.1.1 Tijdsduur ............................................................................................................................................ 96
11.1.2 Benodigdheden ................................................................................................................................. 96
11.1.3 Wie wordt ondervraagd? .................................................................................................................. 96
11.1.4 Wat wordt onderzocht? .................................................................................................................... 96
11.1.5 Uitleg over de test ............................................................................................................................. 96
11.1.6 Score .................................................................................................................................................. 96
11.1.7 Opmerkingen ..................................................................................................................................... 96
11.2 ADAS-COG: Alzheimer’s Disease Assessment Scale - Cognitive SubScale ................................................. 98
11.2.1 Tijdsduur ............................................................................................................................................ 98
11.2.2 Benodigdheden ................................................................................................................................. 98
11.2.3 Wie wordt ondervraagd? .................................................................................................................. 98
11.2.4 Wat wordt onderzocht? .................................................................................................................... 98
11.2.5 Uitleg over de test ............................................................................................................................. 98
11.2.6 Score .................................................................................................................................................. 98
11.2.7 Opmerkingen ..................................................................................................................................... 98
11.3 b-ADL en I-ADL: Basic and Instrumental Activities of Daily Living ............................................................ 99
11.3.1 Tijdsduur ............................................................................................................................................ 99
11.3.2 Benodigdheden ................................................................................................................................. 99
11.3.3 Wie wordt ondervraagd? .................................................................................................................. 99
11.3.4 Wat wordt onderzocht? .................................................................................................................... 99
11.3.5 Uitleg over de test ............................................................................................................................. 99
11.3.6 Score .................................................................................................................................................. 99
11.3.7 Opmerkingen ................................................................................................................................... 101
11.4 NPI: Neuropsychiatric Inventory ............................................................................................................. 102
11.4.1 Tijdsduur .......................................................................................................................................... 102
11.4.2 Benodigdheden ............................................................................................................................... 102
11.4.3 Wie wordt ondervraagd? ................................................................................................................ 102
11.4.4 Wat wordt onderzocht? .................................................................................................................. 102
11.4.5 uitleg over de test............................................................................................................................ 102
11.4.6 Score ................................................................................................................................................ 102
11.4.7 Opmerkingen ................................................................................................................................... 103
11.5 GDS: Global deterioration scale .............................................................................................................. 103
11.6 Overzicht ................................................................................................................................................. 105
12. Amyotrofe lateraalsclerose (ALS) ........................................................................................................... 106
12.1 Wat is ALS? ............................................................................................................................................. 106
12.2 Hoofdsymptomen ................................................................................................................................... 106
12.3 Diagnose ................................................................................................................................................. 106
12.4 ALS mimics (nabootsende ziekten).......................................................................................................... 107
12.4.1 ALS mimics perifeer (LMN) .............................................................................................................. 107
12.4.2 ALS mimics centraal (UMN) ............................................................................................................. 107
12.4.3 ALS mimics perifeer en centraal (LMN + UMN) ............................................................................... 107
12.5 Red flags ................................................................................................................................................. 107
12.6 Aanvullend onderzoek............................................................................................................................. 108
12.7 Extra opmerkingen ALS ........................................................................................................................... 111
5
,13. Ruggenmergaandoeningen ..................................................................................................................... 112
13.1 Anatomie ................................................................................................................................................ 112
13.1.1 Motorisch systeem .......................................................................................................................... 112
13.1.2 Sensorisch systeem ......................................................................................................................... 113
13.2 Algemene symptomen ............................................................................................................................ 116
13.2.1 Hoogtebepaling ............................................................................................................................... 116
13.2.2 Volledige dwarslaesie ...................................................................................................................... 116
13.2.3 Onvolledige lesies ............................................................................................................................ 117
13.3 Enkele ruggenmergsyndromen ............................................................................................................... 119
13.3.1 Compressie ...................................................................................................................................... 119
13.3.2 Gecombineerde strengsclerose ....................................................................................................... 121
13.3.3 Syringomyelie .................................................................................................................................. 121
13.3.4 Transverse Myelitis.......................................................................................................................... 122
13.3.5 Spinaal infarct .................................................................................................................................. 122
14. Hoofdpijn ............................................................................................................................................... 123
14.1 Grootorde en belang vh probleem .......................................................................................................... 123
14.2 Definitie................................................................................................................................................... 123
14.3 Pijngevoelige structuren ......................................................................................................................... 123
14.4 Classificatie ............................................................................................................................................. 124
14.5 Anamnese ............................................................................................................................................... 125
14.6 Klinisch onderzoek .................................................................................................................................. 125
14.7 Primaire hoofdpijn .................................................................................................................................. 126
14.7.1 Migraine .......................................................................................................................................... 126
14.7.2 Spanningshoofdpijn (= Tension type headache) ............................................................................. 127
14.7.3 Clusterhoofdpijn .............................................................................................................................. 128
14.7.4 Primaire donderslag hoofdpijn (‘thunderclap headache’) .............................................................. 128
14.8 Secundaire hoofdpijn .............................................................................................................................. 129
14.8.1 Hoofdpijn tgv intracraniële of cervicaal vasculaire stoornis ........................................................... 129
14.8.2 Hoofdpijn tgv niet-vasculaire intracraniële stoornis ....................................................................... 129
14.8.3 Hoofdpijn tgv infectie ...................................................................................................................... 129
14.8.4 Hoofdpijn tgv middelengebruik of ontwenning .............................................................................. 130
14.9 Craniale neuralgie, centrale of primaire aangezichtspijn en andere vormen ......................................... 130
14.9.1 Trigeminusneuralgie ........................................................................................................................ 130
14.10 Rode vlaggen ........................................................................................................................................ 131
6
,15. Infantiele encephalopathieën / Cerebral palsy ....................................................................................... 132
15.1 Definitie................................................................................................................................................... 132
15.2 Classificaties............................................................................................................................................ 132
15.2.1 Topografisch .................................................................................................................................... 132
15.2.2 Fysiologisch ..................................................................................................................................... 132
15.2.3 Functioneel ...................................................................................................................................... 132
15.2.4 Lokalisatie van hersenletsel............................................................................................................. 132
15.2.5 Pathologisch .................................................................................................................................... 133
15.3 Neuropathologie ..................................................................................................................................... 133
15.4 Ernstigheid .............................................................................................................................................. 133
15.5 Etiologie .................................................................................................................................................. 133
15.5.1 Prenataal ......................................................................................................................................... 133
15.5.2 Perinataal ........................................................................................................................................ 133
15.5.3 Postnataal ........................................................................................................................................ 133
15.6 Kenmerken .............................................................................................................................................. 134
15.7 Diagnose ................................................................................................................................................. 135
15.8 Types ....................................................................................................................................................... 135
15.8.1 Spastische diplegie .......................................................................................................................... 135
15.8.2 Spatische Quadriplegie .................................................................................................................... 135
15.8.3 Spastische hemiplegie ..................................................................................................................... 136
15.8.4 Extrapiramidale CP .......................................................................................................................... 136
15.9 Differentiële diagnose ............................................................................................................................. 136
15.10 Evaluatie ............................................................................................................................................... 136
15.10.1 Assessment of general health ....................................................................................................... 136
15.10.2 Neurologische evaluatie ................................................................................................................ 136
15.10.3 Beweging en houding .................................................................................................................... 137
15.10.4 Spiertonus ..................................................................................................................................... 137
15.10.5 Cognitie en gedrag......................................................................................................................... 137
15.10.6 Zicht en gehoor.............................................................................................................................. 137
15.10.7 Spraak en taal ................................................................................................................................ 137
15.10.8 Voeding en nutritie ........................................................................................................................ 137
15.10.9 Orthopedische problemen ............................................................................................................ 137
15.10.10 Epilepsie ...................................................................................................................................... 137
15.10.11 Neuroimaging .............................................................................................................................. 137
15.10.12 Disabling conditions .................................................................................................................... 138
15.10.13 Thuissituatie ................................................................................................................................ 138
15.11 Management ........................................................................................................................................ 138
15.11.1 Comprehensive assessment .......................................................................................................... 138
15.11.2 Kinesitherapie ................................................................................................................................ 138
15.11.3 Occupational Therapy ................................................................................................................... 138
15.11.4 Play therapy ................................................................................................................................... 139
15.11.5 Assistive and adaptive devices ...................................................................................................... 139
15.11.6 Spasticiteit ..................................................................................................................................... 139
15.11.7 Parent Counselling......................................................................................................................... 139
7
,16. Neurologische infecties .......................................................................................................................... 140
16.1 Indelingen van neurologische infecties ................................................................................................... 140
16.1.1 Indeling obv lokalisatie .................................................................................................................... 140
16.1.2 Indeling obv verwekker ................................................................................................................... 140
16.2 Meningitis ............................................................................................................................................... 140
16.2.1 Algemeen......................................................................................................................................... 140
16.2.2 Acute meningitis .............................................................................................................................. 140
16.2.3 Chronische meningitis ..................................................................................................................... 141
16.2.4 Lumbaalpunctie ............................................................................................................................... 141
16.2.5 Bacteriële meningitis ....................................................................................................................... 142
16.3 Encefalitis ................................................................................................................................................ 143
16.3.1 Algemeen......................................................................................................................................... 143
16.3.2 Acute encefalitis .............................................................................................................................. 143
16.4 Hersenabces ............................................................................................................................................ 144
16.5 Zona ........................................................................................................................................................ 145
16.6 Perifere facialisparese ............................................................................................................................. 145
16.7 Neurologische complicaties van AIDS ..................................................................................................... 145
16.7.1 Cerebrale toxoplasmosis ................................................................................................................. 145
17. Intracraniële neuroplasiën ..................................................................................................................... 146
17.1 Algemene wetenswaardigheden ............................................................................................................ 146
17.1.1 Indeling RIP (= Ruimte Innemend Proces) ....................................................................................... 146
17.1.2 Kliniek .............................................................................................................................................. 146
17.1.3 Differentiaal Diagnose ..................................................................................................................... 147
17.1.4 Technische onderzoeken ................................................................................................................. 147
17.1.5 Behandeling ..................................................................................................................................... 148
17.2 Benigne tumoren .................................................................................................................................... 149
17.2.1 Meningeoom (multiple) .................................................................................................................. 149
17.2.2 Hypofysetumor ................................................................................................................................ 149
17.2.3 Craniopharyngeoom ........................................................................................................................ 150
17.2.4 Acousticusneurinoom ...................................................................................................................... 150
17.3 Maligne tumoren .................................................................................................................................... 150
17.3.1 Glioom ............................................................................................................................................. 150
17.3.2 Medulloblastoom ............................................................................................................................ 150
17.3.3 Lymfoom.......................................................................................................................................... 151
17.4 Cerebrale metastasen ............................................................................................................................. 151
8
, 18. Hydrocefalie en spina bifida ................................................................................................................... 152
18.1 Anatomie van de meningen (KENNEN) ................................................................................................... 152
18.1.1 Dura mater ...................................................................................................................................... 152
18.1.2 Arachnoïdea .................................................................................................................................... 153
18.1.3 Pia mater ......................................................................................................................................... 153
18.1.4 Medulla spinalis ............................................................................................................................... 154
18.2 Cerebrospinaal vocht: productie en circulatie......................................................................................... 155
18.2.1 Productie CSF................................................................................................................................... 156
18.3 Hydrocefalie ............................................................................................................................................ 156
18.3.1 Obstructieve hydrocefalie ............................................................................................................... 156
18.3.2 Communicerende hydrocephalie .................................................................................................... 158
18.4 Spina bifida ............................................................................................................................................. 159
18.4.1 Spina bifida occulta ......................................................................................................................... 159
18.4.2 Meningocoele .................................................................................................................................. 159
18.4.3 Meningomyelocoele ........................................................................................................................ 160
19. Multiple sclerose .................................................................................................................................... 161
19.1 Wat is MS? .............................................................................................................................................. 161
19.2 Typische symptomen .............................................................................................................................. 161
19.2.1 Typische (begin) symptomen (Relapsing Remitting) ....................................................................... 161
19.2.2 Typische (laattijdige) symptomen (Relapsing Remitting) ................................................................ 161
19.2.3 Typische begin symptomen van Primair Progressieve MS .............................................................. 161
19.3 Enkele definities ...................................................................................................................................... 162
19.3.1 Opflakkering (aanval, relaps, opstoot) ............................................................................................ 162
19.3.2 Pseudo-aanval ................................................................................................................................. 162
19.4 Pathofysiologie ....................................................................................................................................... 162
19.5 Epidemiologie ......................................................................................................................................... 163
19.5.1 Leeftijd ............................................................................................................................................. 163
19.5.2 Verschillende vormen progressie .................................................................................................... 163
19.5.3 Geografische distributie .................................................................................................................. 163
19.6 Aanvullend onderzoek............................................................................................................................. 164
19.7 Behandeling ............................................................................................................................................ 164
9
NEUROLOGIE
Neurokinesitherapie 2
P. De Deyn
,1. Neurologisch onderzoek ............................................................................................................................. 10
1.1 Inleiding ...................................................................................................................................................... 10
1.2 Neurologisch onderzoek.............................................................................................................................. 10
1.2.1 Mental status exam ............................................................................................................................. 10
1.3 Craniale zenuwen ........................................................................................................................................ 14
I. N. olfactorius ............................................................................................................................................. 14
II. N. Opticus ................................................................................................................................................. 14
II en III. Pupilrespons .................................................................................................................................... 15
V. sensoriek vh aangezicht EN motoriek kauwspieren ................................................................................. 15
VII. Spieren voor gezichtsuitdrukking en smaak ........................................................................................... 16
VIII. Gehoor en evenwicht ............................................................................................................................ 16
IX en X. Elevatie vh palatum en gag-reflex ................................................................................................... 17
V, VII, IX, X, XII Spieren voor articulatie ........................................................................................................ 17
XI. Sternocleidomastoideus en trapezius spieren ........................................................................................ 17
XII. N. Hypoglossus ....................................................................................................................................... 17
1.4 Motorisch onderzoek .................................................................................................................................. 18
1.5 Sensorisch onderzoek .................................................................................................................................. 20
2. Technische neurologische onderzoeken ..................................................................................................... 21
2.1 Elektro-encefalografie (EEG) ....................................................................................................................... 21
2.1.1 Werking EEG ........................................................................................................................................ 21
2.1.2 10-20 systeem ..................................................................................................................................... 22
2.1.3 Eigenschappen EEG ............................................................................................................................. 22
Frequentie EEG ............................................................................................................................................. 22
2.1.4 Voornaamste indicaties voor EEG ....................................................................................................... 23
2.1.5 Voorbeelden EEG................................................................................................................................. 23
2.2 Polysomnografie ......................................................................................................................................... 24
2.3 Uitgelokte potentialen (= Evoked potentials, EP’s) ..................................................................................... 24
Averaging methods ...................................................................................................................................... 24
Eigenschappen EP......................................................................................................................................... 24
2.3.1 Visuele evoked potentials (VEP’s) ....................................................................................................... 25
2.3.2 Sensory evoked potentials (SEP) ......................................................................................................... 25
2.3.3 Brainstem auditory evoked potentials (BAEP) .................................................................................... 26
2.4 Lumbaalpunctie .......................................................................................................................................... 26
2.4.1 Werking lumbaalpunctie ..................................................................................................................... 26
2.4.2 Indicaties voor lumbaalpunctie ........................................................................................................... 27
2.4.3 Waarden voor normaal cerebrospinaal vocht (CSF) ............................................................................ 27
2.4.4 Risico’s lumbaalpunctie ....................................................................................................................... 27
2.5 Ophtalmoscopie .......................................................................................................................................... 27
2.6 Structurele neuro-imaging .......................................................................................................................... 28
2.6.1 CT (= Computerised tomography) ....................................................................................................... 28
2.6.2 MRI (= Magnetic Resonance Imaging) ................................................................................................. 28
2.6.3 Vergelijking MRI met CT ...................................................................................................................... 28
2.7 Angiografie ................................................................................................................................................. 29
Conventionele angiografie ........................................................................................................................... 29
Conventionele angiografie ........................................................................................................................... 29
2.8 Functionele neuro-imaging ......................................................................................................................... 30
1
,3. Cerebrovasculaire aandoeningen ............................................................................................................... 31
3.1 Inleiding ...................................................................................................................................................... 31
3.1.1 Definitie CVA ....................................................................................................................................... 31
3.1.2 Epidemiologie CVA .............................................................................................................................. 31
3.1.3 Algemene benadering CVA .................................................................................................................. 31
3.1.4 Anatomie ............................................................................................................................................. 32
3.1.5 Classificatie CVA .................................................................................................................................. 34
3.2 Ischemisch CVA ........................................................................................................................................... 35
3.2.1 Pathofysiologie .................................................................................................................................... 35
3.2.2 Klinische syndromen ........................................................................................................................... 39
3.2.3 Aanvullende onderzoeken ................................................................................................................... 42
3.2.4 Behandeling ......................................................................................................................................... 43
3.3 Hemorragisch CVA ...................................................................................................................................... 44
3.3.1 Pathofysiologie .................................................................................................................................... 44
3.3.2 Intercerebrale bloeding ....................................................................................................................... 44
3.3.3 Subarachnoidale bloeding ................................................................................................................... 46
3.3.4 Subdurale / epidurale bloeding ........................................................................................................... 47
4. Craniocerebrale traumata .......................................................................................................................... 48
4.1 Inleiding ...................................................................................................................................................... 48
4.2 Commotio cerebri ....................................................................................................................................... 48
4.5.1 Intracerebrale hematomen (in hersenweefsel) ................................................................................. 49
4.5.2 Subdurale hematomen (tussen dura mater en arachnoidea) ........................................................... 50
4.5.3 Subarachnoidale (SAH) (tussen arachnoidea en pia mater, i/d subarachnoidale ruimte) ............... 51
4.5.4 Epidurale hematomen (tussen schedel en dura mater) .................................................................... 51
4.6.1 Postcommotioneel syndroom ............................................................................................................. 51
4.6.2 Posttraumatische epilepsie ................................................................................................................. 51
4.7.1 hersenherniatie bij epiduraal hematoom ........................................................................................... 52
4.7.2 Traumatische subarachnoidale bloeding ............................................................................................ 52
4.7.3 Epiduraal Hematoom .......................................................................................................................... 52
4.7.4 Subduraal hematoom .......................................................................................................................... 53
4.7.5 Diffuus axonaal letsel .......................................................................................................................... 53
4.7.6 Penetrerend letsel ............................................................................................................................... 53
Complicaties - langdurige sequellen............................................................................................................. 54
5. Parkinson ................................................................................................................................................... 55
5.1 Inleiding: Voorkomen vd ziekte van Parkinson ........................................................................................... 55
5.2 Motore verschijnselen ................................................................................................................................. 56
5.3 Niet-motore verschijnselen ......................................................................................................................... 57
5.4 Conclusie ..................................................................................................................................................... 58
5.5 Differentiaaldiagnose ................................................................................................................................. 58
5.6 Behandeling ................................................................................................................................................ 58
2
,6. Perifere neuropathieën .............................................................................................................................. 60
6.1 Algemeen .................................................................................................................................................... 60
6.1.1 Definities ............................................................................................................................................. 60
6.1.2 Evaluatie .............................................................................................................................................. 60
6.2 Mononeuropathieën ................................................................................................................................... 61
6.2.1 Ulnaire neuropathie ............................................................................................................................ 61
6.2.2 Carpaal tunnel syndroom .................................................................................................................... 61
6.2.3 Tarsaal tunnel syndroom ..................................................................................................................... 61
6.2.4 Bell’s palsy ........................................................................................................................................... 61
6.3 Polyneuropathieën ...................................................................................................................................... 62
6.4 Diabetis ....................................................................................................................................................... 62
6.5 HIV .............................................................................................................................................................. 62
6.6 Ziekte van Lyme .......................................................................................................................................... 62
6.8 Zuiver motore neuropathieën ..................................................................................................................... 63
6.8.1 Amyotrophic lateral sclerosis (ALS) ..................................................................................................... 63
6.8.2 Poliomyelitis ........................................................................................................................................ 63
6.8.3 Muscular atrophies.............................................................................................................................. 63
6.8.4 Guillain-Barre syndrome...................................................................................................................... 63
6.8.5 Myasthenia gravis................................................................................................................................ 63
6.9 Motore en Sensore neuropathieën ............................................................................................................. 64
6.9.1 Carpaal tunnel ..................................................................................................................................... 64
6.9.2 Chronic inflammatory demyelinating polyneuropathy (CIDP) ............................................................ 64
6.10 Paraneoplastische perifere neuropathieën ............................................................................................... 64
6.11 Autonome neuropathie ............................................................................................................................. 64
6.12 Plexopathieën ........................................................................................................................................... 65
6.13 Mononeuritis Multiplex............................................................................................................................. 65
7. Epilepsie ..................................................................................................................................................... 66
7.1 Wat is een epilepsie-aanval? ...................................................................................................................... 66
7.2 Epidemiologie ............................................................................................................................................. 66
7.3 Indeling obv presentatievorm ..................................................................................................................... 66
7.3.1 Partiële aanvallen ................................................................................................................................ 66
7.3.2 Gegeneraliseerde aanvallen ................................................................................................................ 66
7.4 Kenmerken epilepsie ................................................................................................................................... 66
7.5 Wat te doen bij een aanval? ....................................................................................................................... 69
7.6 Oorzaak ....................................................................................................................................................... 69
7.6.1 Éénmalige aanval ................................................................................................................................. 69
7.6.2 Epilepsie .............................................................................................................................................. 69
7.7 Classificatie epilepsie .................................................................................................................................. 69
7.8 Diagnose ..................................................................................................................................................... 70
7.9 Differentiaaldiagnose ................................................................................................................................. 70
7.10 Behandeling .............................................................................................................................................. 70
7.10.1 Behandelingsstrategie ....................................................................................................................... 70
7.10.2 Behandeling ....................................................................................................................................... 71
7.11 Refractaire epilepsie ................................................................................................................................. 71
3
,8. Cerebellaire aandoeningen ......................................................................................................................... 72
8.1 Anatomie .................................................................................................................................................... 72
8.2 Cerebellaire somatotopie ............................................................................................................................ 75
8.3 Functie van het cerebellum ......................................................................................................................... 76
8.4 Werking van het cerebellum ....................................................................................................................... 76
8.5 Symptomen van cerebellaire dysfunctie ..................................................................................................... 76
8.5.1 Algemeen............................................................................................................................................. 76
8.5.2 Symptomen lokalisatie ..................................................................................................................... 76
8.5.3 Samenvatting ....................................................................................................................................... 77
8.6 Aandoeningen van het cerebellum ............................................................................................................. 77
8.6.1 Cerebellaire aandoeningen bij kinderen ............................................................................................. 78
8.6.2 Cerebellaire aandoeningen bij volwassenen ....................................................................................... 80
9. Spierziekten ............................................................................................................................................... 81
9.1 Inleiding ...................................................................................................................................................... 81
9.1.1 Definitie ............................................................................................................................................... 81
9.1.2 Symptomatologie ................................................................................................................................ 81
9.1.3 Classificatie .......................................................................................................................................... 81
9.1.4 Diagnostiek .......................................................................................................................................... 81
9.1.5 Behandeling ......................................................................................................................................... 82
9.2 Hereditaire (aangeboren) spierziekten ....................................................................................................... 82
9.2.1 Spierdystrofie ...................................................................................................................................... 82
9.2.2 Myotonie ............................................................................................................................................. 87
9.3 Verworven spierziekten ............................................................................................................................... 87
9.3.1 Polymyositis & dermatomyositis ......................................................................................................... 87
9.3.2 Andere verworven spierziekten .......................................................................................................... 89
9.4 Neuromusculaire junctiestoornis ................................................................................................................ 89
9.4.1 Myasthenia Gravis (MG) ...................................................................................................................... 89
9.4.2 Lambert Eaton syndroom (LEMS) ........................................................................................................ 91
10. Dementie.................................................................................................................................................. 92
10.1 Definitie..................................................................................................................................................... 92
10.2 Mild cognitive impairment ........................................................................................................................ 93
10.3 Typologie van de dementie ....................................................................................................................... 93
10.4 Indeling van dementies ............................................................................................................................. 93
10.5 Belang van de diagnose ............................................................................................................................ 93
10.6 Belangrijkste klinische beelden ................................................................................................................. 94
10.6.1 Ziekte van Alzheimer ......................................................................................................................... 94
10.6.2 Fronto-temporo lobaire degeneratie (FTLD) ..................................................................................... 94
10.6.3 Vasculaire dementie (VaD) ................................................................................................................ 95
10.6.4 Dementie met Lewy lichaampjes (DLBD) (Belangrijk! -> kennen) ..................................................... 95
4
,11. Neuropsychologische en functionele onderzoeken .................................................................................. 96
11.1 MMSE: Mini-Mental State Exam............................................................................................................... 96
11.1.1 Tijdsduur ............................................................................................................................................ 96
11.1.2 Benodigdheden ................................................................................................................................. 96
11.1.3 Wie wordt ondervraagd? .................................................................................................................. 96
11.1.4 Wat wordt onderzocht? .................................................................................................................... 96
11.1.5 Uitleg over de test ............................................................................................................................. 96
11.1.6 Score .................................................................................................................................................. 96
11.1.7 Opmerkingen ..................................................................................................................................... 96
11.2 ADAS-COG: Alzheimer’s Disease Assessment Scale - Cognitive SubScale ................................................. 98
11.2.1 Tijdsduur ............................................................................................................................................ 98
11.2.2 Benodigdheden ................................................................................................................................. 98
11.2.3 Wie wordt ondervraagd? .................................................................................................................. 98
11.2.4 Wat wordt onderzocht? .................................................................................................................... 98
11.2.5 Uitleg over de test ............................................................................................................................. 98
11.2.6 Score .................................................................................................................................................. 98
11.2.7 Opmerkingen ..................................................................................................................................... 98
11.3 b-ADL en I-ADL: Basic and Instrumental Activities of Daily Living ............................................................ 99
11.3.1 Tijdsduur ............................................................................................................................................ 99
11.3.2 Benodigdheden ................................................................................................................................. 99
11.3.3 Wie wordt ondervraagd? .................................................................................................................. 99
11.3.4 Wat wordt onderzocht? .................................................................................................................... 99
11.3.5 Uitleg over de test ............................................................................................................................. 99
11.3.6 Score .................................................................................................................................................. 99
11.3.7 Opmerkingen ................................................................................................................................... 101
11.4 NPI: Neuropsychiatric Inventory ............................................................................................................. 102
11.4.1 Tijdsduur .......................................................................................................................................... 102
11.4.2 Benodigdheden ............................................................................................................................... 102
11.4.3 Wie wordt ondervraagd? ................................................................................................................ 102
11.4.4 Wat wordt onderzocht? .................................................................................................................. 102
11.4.5 uitleg over de test............................................................................................................................ 102
11.4.6 Score ................................................................................................................................................ 102
11.4.7 Opmerkingen ................................................................................................................................... 103
11.5 GDS: Global deterioration scale .............................................................................................................. 103
11.6 Overzicht ................................................................................................................................................. 105
12. Amyotrofe lateraalsclerose (ALS) ........................................................................................................... 106
12.1 Wat is ALS? ............................................................................................................................................. 106
12.2 Hoofdsymptomen ................................................................................................................................... 106
12.3 Diagnose ................................................................................................................................................. 106
12.4 ALS mimics (nabootsende ziekten).......................................................................................................... 107
12.4.1 ALS mimics perifeer (LMN) .............................................................................................................. 107
12.4.2 ALS mimics centraal (UMN) ............................................................................................................. 107
12.4.3 ALS mimics perifeer en centraal (LMN + UMN) ............................................................................... 107
12.5 Red flags ................................................................................................................................................. 107
12.6 Aanvullend onderzoek............................................................................................................................. 108
12.7 Extra opmerkingen ALS ........................................................................................................................... 111
5
,13. Ruggenmergaandoeningen ..................................................................................................................... 112
13.1 Anatomie ................................................................................................................................................ 112
13.1.1 Motorisch systeem .......................................................................................................................... 112
13.1.2 Sensorisch systeem ......................................................................................................................... 113
13.2 Algemene symptomen ............................................................................................................................ 116
13.2.1 Hoogtebepaling ............................................................................................................................... 116
13.2.2 Volledige dwarslaesie ...................................................................................................................... 116
13.2.3 Onvolledige lesies ............................................................................................................................ 117
13.3 Enkele ruggenmergsyndromen ............................................................................................................... 119
13.3.1 Compressie ...................................................................................................................................... 119
13.3.2 Gecombineerde strengsclerose ....................................................................................................... 121
13.3.3 Syringomyelie .................................................................................................................................. 121
13.3.4 Transverse Myelitis.......................................................................................................................... 122
13.3.5 Spinaal infarct .................................................................................................................................. 122
14. Hoofdpijn ............................................................................................................................................... 123
14.1 Grootorde en belang vh probleem .......................................................................................................... 123
14.2 Definitie................................................................................................................................................... 123
14.3 Pijngevoelige structuren ......................................................................................................................... 123
14.4 Classificatie ............................................................................................................................................. 124
14.5 Anamnese ............................................................................................................................................... 125
14.6 Klinisch onderzoek .................................................................................................................................. 125
14.7 Primaire hoofdpijn .................................................................................................................................. 126
14.7.1 Migraine .......................................................................................................................................... 126
14.7.2 Spanningshoofdpijn (= Tension type headache) ............................................................................. 127
14.7.3 Clusterhoofdpijn .............................................................................................................................. 128
14.7.4 Primaire donderslag hoofdpijn (‘thunderclap headache’) .............................................................. 128
14.8 Secundaire hoofdpijn .............................................................................................................................. 129
14.8.1 Hoofdpijn tgv intracraniële of cervicaal vasculaire stoornis ........................................................... 129
14.8.2 Hoofdpijn tgv niet-vasculaire intracraniële stoornis ....................................................................... 129
14.8.3 Hoofdpijn tgv infectie ...................................................................................................................... 129
14.8.4 Hoofdpijn tgv middelengebruik of ontwenning .............................................................................. 130
14.9 Craniale neuralgie, centrale of primaire aangezichtspijn en andere vormen ......................................... 130
14.9.1 Trigeminusneuralgie ........................................................................................................................ 130
14.10 Rode vlaggen ........................................................................................................................................ 131
6
,15. Infantiele encephalopathieën / Cerebral palsy ....................................................................................... 132
15.1 Definitie................................................................................................................................................... 132
15.2 Classificaties............................................................................................................................................ 132
15.2.1 Topografisch .................................................................................................................................... 132
15.2.2 Fysiologisch ..................................................................................................................................... 132
15.2.3 Functioneel ...................................................................................................................................... 132
15.2.4 Lokalisatie van hersenletsel............................................................................................................. 132
15.2.5 Pathologisch .................................................................................................................................... 133
15.3 Neuropathologie ..................................................................................................................................... 133
15.4 Ernstigheid .............................................................................................................................................. 133
15.5 Etiologie .................................................................................................................................................. 133
15.5.1 Prenataal ......................................................................................................................................... 133
15.5.2 Perinataal ........................................................................................................................................ 133
15.5.3 Postnataal ........................................................................................................................................ 133
15.6 Kenmerken .............................................................................................................................................. 134
15.7 Diagnose ................................................................................................................................................. 135
15.8 Types ....................................................................................................................................................... 135
15.8.1 Spastische diplegie .......................................................................................................................... 135
15.8.2 Spatische Quadriplegie .................................................................................................................... 135
15.8.3 Spastische hemiplegie ..................................................................................................................... 136
15.8.4 Extrapiramidale CP .......................................................................................................................... 136
15.9 Differentiële diagnose ............................................................................................................................. 136
15.10 Evaluatie ............................................................................................................................................... 136
15.10.1 Assessment of general health ....................................................................................................... 136
15.10.2 Neurologische evaluatie ................................................................................................................ 136
15.10.3 Beweging en houding .................................................................................................................... 137
15.10.4 Spiertonus ..................................................................................................................................... 137
15.10.5 Cognitie en gedrag......................................................................................................................... 137
15.10.6 Zicht en gehoor.............................................................................................................................. 137
15.10.7 Spraak en taal ................................................................................................................................ 137
15.10.8 Voeding en nutritie ........................................................................................................................ 137
15.10.9 Orthopedische problemen ............................................................................................................ 137
15.10.10 Epilepsie ...................................................................................................................................... 137
15.10.11 Neuroimaging .............................................................................................................................. 137
15.10.12 Disabling conditions .................................................................................................................... 138
15.10.13 Thuissituatie ................................................................................................................................ 138
15.11 Management ........................................................................................................................................ 138
15.11.1 Comprehensive assessment .......................................................................................................... 138
15.11.2 Kinesitherapie ................................................................................................................................ 138
15.11.3 Occupational Therapy ................................................................................................................... 138
15.11.4 Play therapy ................................................................................................................................... 139
15.11.5 Assistive and adaptive devices ...................................................................................................... 139
15.11.6 Spasticiteit ..................................................................................................................................... 139
15.11.7 Parent Counselling......................................................................................................................... 139
7
,16. Neurologische infecties .......................................................................................................................... 140
16.1 Indelingen van neurologische infecties ................................................................................................... 140
16.1.1 Indeling obv lokalisatie .................................................................................................................... 140
16.1.2 Indeling obv verwekker ................................................................................................................... 140
16.2 Meningitis ............................................................................................................................................... 140
16.2.1 Algemeen......................................................................................................................................... 140
16.2.2 Acute meningitis .............................................................................................................................. 140
16.2.3 Chronische meningitis ..................................................................................................................... 141
16.2.4 Lumbaalpunctie ............................................................................................................................... 141
16.2.5 Bacteriële meningitis ....................................................................................................................... 142
16.3 Encefalitis ................................................................................................................................................ 143
16.3.1 Algemeen......................................................................................................................................... 143
16.3.2 Acute encefalitis .............................................................................................................................. 143
16.4 Hersenabces ............................................................................................................................................ 144
16.5 Zona ........................................................................................................................................................ 145
16.6 Perifere facialisparese ............................................................................................................................. 145
16.7 Neurologische complicaties van AIDS ..................................................................................................... 145
16.7.1 Cerebrale toxoplasmosis ................................................................................................................. 145
17. Intracraniële neuroplasiën ..................................................................................................................... 146
17.1 Algemene wetenswaardigheden ............................................................................................................ 146
17.1.1 Indeling RIP (= Ruimte Innemend Proces) ....................................................................................... 146
17.1.2 Kliniek .............................................................................................................................................. 146
17.1.3 Differentiaal Diagnose ..................................................................................................................... 147
17.1.4 Technische onderzoeken ................................................................................................................. 147
17.1.5 Behandeling ..................................................................................................................................... 148
17.2 Benigne tumoren .................................................................................................................................... 149
17.2.1 Meningeoom (multiple) .................................................................................................................. 149
17.2.2 Hypofysetumor ................................................................................................................................ 149
17.2.3 Craniopharyngeoom ........................................................................................................................ 150
17.2.4 Acousticusneurinoom ...................................................................................................................... 150
17.3 Maligne tumoren .................................................................................................................................... 150
17.3.1 Glioom ............................................................................................................................................. 150
17.3.2 Medulloblastoom ............................................................................................................................ 150
17.3.3 Lymfoom.......................................................................................................................................... 151
17.4 Cerebrale metastasen ............................................................................................................................. 151
8
, 18. Hydrocefalie en spina bifida ................................................................................................................... 152
18.1 Anatomie van de meningen (KENNEN) ................................................................................................... 152
18.1.1 Dura mater ...................................................................................................................................... 152
18.1.2 Arachnoïdea .................................................................................................................................... 153
18.1.3 Pia mater ......................................................................................................................................... 153
18.1.4 Medulla spinalis ............................................................................................................................... 154
18.2 Cerebrospinaal vocht: productie en circulatie......................................................................................... 155
18.2.1 Productie CSF................................................................................................................................... 156
18.3 Hydrocefalie ............................................................................................................................................ 156
18.3.1 Obstructieve hydrocefalie ............................................................................................................... 156
18.3.2 Communicerende hydrocephalie .................................................................................................... 158
18.4 Spina bifida ............................................................................................................................................. 159
18.4.1 Spina bifida occulta ......................................................................................................................... 159
18.4.2 Meningocoele .................................................................................................................................. 159
18.4.3 Meningomyelocoele ........................................................................................................................ 160
19. Multiple sclerose .................................................................................................................................... 161
19.1 Wat is MS? .............................................................................................................................................. 161
19.2 Typische symptomen .............................................................................................................................. 161
19.2.1 Typische (begin) symptomen (Relapsing Remitting) ....................................................................... 161
19.2.2 Typische (laattijdige) symptomen (Relapsing Remitting) ................................................................ 161
19.2.3 Typische begin symptomen van Primair Progressieve MS .............................................................. 161
19.3 Enkele definities ...................................................................................................................................... 162
19.3.1 Opflakkering (aanval, relaps, opstoot) ............................................................................................ 162
19.3.2 Pseudo-aanval ................................................................................................................................. 162
19.4 Pathofysiologie ....................................................................................................................................... 162
19.5 Epidemiologie ......................................................................................................................................... 163
19.5.1 Leeftijd ............................................................................................................................................. 163
19.5.2 Verschillende vormen progressie .................................................................................................... 163
19.5.3 Geografische distributie .................................................................................................................. 163
19.6 Aanvullend onderzoek............................................................................................................................. 164
19.7 Behandeling ............................................................................................................................................ 164
9
