Transcript Alzheimer Disease

© Irene Mueller EdD, RHIA
May 16, 2013

Review Common Brain Pathologies for ICD-10CM/PCS Coding
Circulatory pathologies affecting brain
 Neurological pathologies affecting brain
 ICD-10-CM/PCS Terminology (Integrated)

Did you Complete the PRE-Test?
Circulatory pathologies affecting brain
 Neurological pathologies affecting brain


Affect Cerebral & Precerebral blood vessels
Atherosclerosis
 Aneurysm

Stroke
 Non-traumatic hemorrhage
 Infarction/obstruction
 Occlusion/Stenosis


Build up of waxy plaque on inside of blood vessels
(inner layer only), can block blood flow





Gk, athere = gruel, skleros = hard Atherosclerosis
Type of arteriosclerosis
Arteriosclerosis = general term for hardening of arteries
(inner/middle layers of artery wall)
Arteriosclerosis can occur in several forms, including
atherosclerosis
Plaque composed of fatty substances, cholesterol,
waste products from cells, calcium, and fibrin

Inner artery wall thickens,
Artery's diameter reduced,
 Blood flow and oxygen delivery are decreased
(stenosis, stricture)


Plaques can rupture or crack open


Sudden formation of blood clot (thrombus,
embolus)
Complete blockage

Stroke if located in precerebral/cerebral arteries

Response to endothelial Heredity
damage
 Parents have AD,

High cholesterol, High
blood pressure, &
cigarette smoking



Physical inactivity,
diabetes, & obesity
High levels of



All 3 = 8X more likely
Homocysteine
Lipoproteins
Low levels of HDL


atherosclerosis, or stroke early
African-Americans (HTN)
Sex – Males 45+, Women 55+

Equal risk after 60

Localized, blood-filled
dilation of blood vessel
caused by disease/weakening
of vessel wall


Often incidental finding
Berry aneurysm


small (size of berry) saccular
aneurysm of cerebral artery,
usu. at junction of vessels in
Circle of Willis
Narrow opening into artery
http://www.nhlbi.nih.gov/health/healthtopics/topics/arm/printall-index.html

3 to 5 million people in US have cerebral
aneurysms
Most do NOT produce symptoms
 0.5 - 3 % of people may suffer from bleeding


Usually develop at arteries’ branching points
Caused by constant pressure from blood flow
 Often enlarge slowly/become weaker


One aneurysm = 15 to 20 % chance of more
aneurysms


Subarachnoid hemorrhage due to rupture of
cerebral aneurysm - most common ages 20 to 60
 Slightly more common in women than men
Precipitators of aneurysm rupture
 Heavy lifting/straining can cause pressure to rise
in brain
 Strong emotions (upset/angry) can raise blood
pressure
 Blood “thinners” (warfarin, etc.)
 Some meds/prescription drugs (also stimulant
diet pills such as ephedrine and amphetamines)
 Harmful drugs like cocaine can cause aneurysms
to rupture and bleed

Other blood vessel disorders

Fibromuscular dysplasia, cerebral
arteritis or arterial dissection

VERY unusual
Infections
 Drugs (amphetamines/cocaine) that
damage brain blood vessels
 Direct brain trauma from accident

Elderly = Falls
 Young = MVAs


Size





Shape




Small = < 5 mm (1/4 inch)
Medium = 6–15 mm (1/4 to 3/4 inch)
Large = 16–25 mm (3/4 to 1 inch)
Giant = > 25 mm (1 inch+)
Saccular (sack-like) with a well-defined neck
Saccular with wide neck
Fusiform (spindle shaped) without a distinct neck
Location


Cerebral aneurysm –usu. located along major arteries deep
within brain structures
Anterior OR posterior circulation
AKA - Brain attack, CVA, CVI
(Cerebrovascular Insult), Infarct, Apoplexy
 Sudden death of brain cells in localized area
due to inadequate blood flow

Single most costly disease
 3.4 million women in the US living
 w/disabilities resulting from stroke


Lifestyle
 Tobacco Use &
Smoking
 Alcohol Use
 Physical Inactivity
 Obesity

Medical
 High Blood Pressure
 Atrial Fibrillation
 High Cholesterol
 Diabetes
 Atherosclerosis/Circulation
Problems
 Migraine




esp. women <55
Sickle Cell Disease
Sleep Apnea
TIA







55 +
Male (Female in later years)
African American, Hispanic or Asian/Pacific Islander
Family Hx of stroke or TIA
Fibromuscular Dysplasia
PFO (congenital heart defect)
Low birth weight

Study showed weight < 5 lb., 8 oz. at birth = 2X stroke
risk as weight of 8 lb., 13 oz +

SUDDEN (Men & Women)





Numbness/weakness of face,
arm or leg – especially one
side of body
Confusion, trouble speaking
or understanding
Trouble seeing in one or both
eyes
Trouble walking, dizziness,
loss of balance or
coordination
Severe headache
w/no known cause


Women may report
unique stroke symptoms
SUDDEN







Face and limb pain
General weakness
Palpitations
Chest pain
Hiccups
Nausea
SOB

Common stroke symptoms








Loss of balance or coordination
Dizziness (Vertigo – spinning sensation)
Slurred speech (Dysphasia)
Loss of previous ability to speak/understand spoken or
written language (Aphasia) NOT Aphagia
Dysphagia/Aphagia (poor, NO swallowing)
Paralysis, numbness, or weakness on one side of the
body (Hemiparesis, Hemiplegia)
Blurred, double, or blackened vision (Diplopia)
Sudden, severe headache (Cephalalgia, encephalgia)
30-Day Death Rates
for Different Types of Stroke
Ischemic
Hemorrhagic
Stroke
Stroke
Women
7%
30%
Men
8%
35%
45 to 64 y-o
8% to 12%
37%
65 y-o +
8%
45%
PT Sex/Age
Female DEATH
Male DEATH
Female 2nd Stroke
Male 2nd Stroke
Female (60-69) AVG Survival
Male (60-69) AVG Survival
Female (80+)
Male (80+)
w/i1 yr
(40+) 24%
21%
w/I 5 yrs
51%
47%
22%
13%
7.4 years
6.8 years
3.1 years
1.8 years
50% to 70% of stroke survivors eventually
regain functional independence
 15% to 30% permanently disabled
 65 +y-o survivors of ischemic stroke had
disabilities 6 mos. post-stroke







50% hemplegia
35% depressive symptoms
30% couldn’t walk w/o assistance
26% in nursing home
26% dependent in ADLs
19% aphasia

Ischemic (80 +%)





Thrombus (Clot)
Embolus (MOVING Clot)
Occlusion
Stenosis
Hemorrhagic (More Severe)


Blood vessel in brain leaks or
ruptures
Common types include
 Intracerebral
 Subarachnoid
 Extradural/epidural
 Subdural hemorrhages
http://www.nhlbi.nih.gov/health/healthtopics/topics/stroke/printall-index.html

AKA – Hemorrhagic Stroke

Subarachnoid
Outside brain
 Between Arachnoid and Pia mater


Intracerebral


Within brain
Causes
Intracranial aneurysm (most common)
 AV malformation, Tumor, Infection


AKA – Ischemic stroke
Blood supply to brain site is interrupted or
severely reduced
 Brain tissue is starved of O2 and nutrition



Ischemia
Necrosis
Causes

Thrombus or embolus blocks blood flow in
cerebral OR precerebral arteries

Occlusion L, occludere, to close up



blockage in a canal, vessel, or passage of body; state of
being closed
AKA – obstruction of precerebral/cerebral arteries
Stenosis [Gr.] stricture;




AKA - arctation, coarctation, stricture
Abnormal narrowing or contraction of duct or canal
Narrowing of artery can decrease blood supply to brain
Increases risk of CVA
Has blood supply loss caused DEATH of brain
cells/tissue?
 Evidence of Death of brain cells =

Speech/language deficits
 Monoplegia
 Hemiplegia
 Other cognitive or functional deficits


Occlusion w/ or w/o cerebral infarction

Classified separately based on IF infarct results
from occlusion

Symptoms similar, BUT TIA symptoms  RIND - Reversible Ischemic
usually resolve w/in 24 hours

Neurologic Deficit
 AKA Little/Mini stroke – Most
 CVA/w deficits such as
common cause is embolus
hemiplegia, dysphagia,
 Precursor to Stroke in many cases
slurred speech lasting
longer than TIA
 Signs/Symptoms include:
 Numbness/weakness in face, extremity -  May persist for as long
usu one side
as six months
 Confusion; Difficulty walking
 BUT eventually resolve



Difficulty speaking OR understanding
Vision change in one/both eyes
Dizziness; Loss of balance/coordination

Sequela/Sequelae are residual effects or conditions
produced after acute phase of illnes/injury has
ended



Cerebrovascular disease sequelae



NO time limit on when sequela code can be assigned
Residuals may be apparent early on such as in cerebral
infarction, or they can occur months or years later
Include aphasia, dysphagia, monoplegia, or hemiparesis
Arise from any condition classifiable to categories I60-I67
Sequalae ICD-10-CM codes REQUIRE type of
Cerebrovascular Disease (has unspecified option)

Memory Loss




Agnosia - Inability to recognize specific familiar object,
(e.g., own body hand, face, shape, or sound)


Ability to remember names/faces/shapes can be compromised
Difficulty learning new information or skill
Difficulty organizing thoughts/perform sequential tasks (Frontal
lobe)
Ex: "finger agnosia" due to stroke in dominant language
parietal lobe, pt can easily recognize/name car or TV, but not
own thumb
Agraphia - Loss of writing ability resulting from damage to
language areas of brain

After stroke often incomplete, many stroke survivors can rapidly
re-learn to write some words/sentences

Alexia - injury prevents people from being
able to read, but not to write


AKA: word blindness, pure word blindness, text
blindness, or visual aphasia
Agraphia - Loss of writing ability resulting
from damage to language areas of brain
After stroke, agraphia often incomplete
 Many stroke survivors rapidly re-learn to write
some words/sentences








Apraxia
Ataxia
Dystonia
Weakness or paralysis on side of body opposite stroke
Unmasking of primitive reflexes (instinctive sucking,
grasping, & groping
Compulsive mimicking of facial gestures made by
others
Compulsive repetition of movement (motor
perseveration)
Distribution of weakness = Important clue to
location of nerve damage
 "-plegia," = Gk, - "stroke"
 Classified by region






Monoplegia - only one limb
Diplegia - same body region on both sides of body (both
arms, for example, or both sides of face)
Hemiplegia - one side of body
Paraplegia - both legs and trunk
Quadriplegia (Tetra-) - all four limbs and trunk
Right-hand patient = right-side dominant
 Left-handed patient = left-hand dominant
 When affected side is documented, but NOT
specified as dominant/non-dominant AND
classification system does not indicate default
 Code selection

For ambidextrous patients, default = dominant
 Left side affected, default = non-dominant
 Right side affected, default = dominant


Pt admitted for outpatient PT
therapy for monoplegia of left leg
affecting non-dominant side due to
spontaneous subarachnoid
hemorrhage 2 weeks ago
I69.044, Monoplegia of lower limb
following nontraumatic
subarachnoid hemorrhage
affecting left non-dominant side
A patient presents for follow-up 1 month after
suffering cerebral infarction
 Dr. notes pt suffers from right-sided
hemiplegia due to infarction & recommends
continued PT and OT

I69.351 Hemiplegia and hemiparesis following
cerebral infarction affecting right dominant
side







Pt presents w/new R middle cerebral artery
embolism & infarction causing aphasia
Pt suffered ruptured cerebral aneurysm one
year prior w/residual oral phase dysphagia
I63.411 Cerebral infarction due to embolism of
right middle cerebral artery
*I69.320 Aphasia following cerebral infarction
I69.091 Dysphagia following nontraumatic
subarachnoid hemorrhage
R13.11 Dysphagia, oral phase
*Sequalae = neurologic deficits that persist after
initial onset of conditions
65-yo female seen for Tx of unstable angina. She has Hx of
2-vessel CABG about 18 months ago. Recent cardiac
catheterization shows continued evidence of coronary
atherosclerosis, but grafts are patent. Also, pt suffered CV
Infarction 3 yrs ago, which resulted in R-sided (dominant)
hemiparesis
I25.110 Angina (attack) (cardiac) (chest) (heart) (pectoris)
(syndrome) (vasomotor), with atherosclerotic heart
disease – see Arteriosclerosis, coronary (artery), native
vessel with angina pectoris, unstable
I69.351 Hemiparesis – see Hemiplegia, following,
cerebrovascular disease, cerebral infarction
Z95.1 Status (post), aortocoronary bypass


I69.35 Hemiplegia and hemiparesis following cerebral infarction

I69.351 Hemiplegia and hemiparesis following cerebral
infarction affecting right dominant side

I69.352 Hemiplegia and hemiparesis following cerebral
infarction affecting left dominant side

I69.353 Hemiplegia and hemiparesis following cerebral
infarction affecting right non-dominant side

I69.354 Hemiplegia and hemiparesis following cerebral
infarction affecting left non-dominant side

I69.359Hemiplegia and hemiparesis following cerebral
infarction affecting unspecified side

Strokes in sensory cortex of parietal lobe can
cause profound numbness

Astereognosis = inability to identify object by
sense of touch

AKA tactile agnosia
Alogia - Complete lack of speech
 Aphonia - Complete speechlessness resulting
from inability to produce normal sounds due to
organic (–eg, laryngeal disease or mental cause)
 Dysphonia - Any disorder of phonation affecting
voice quality/ability to produce voice
 Apraxia: Inability to execute voluntary motor
movement despite being able to demonstrate
normal muscle function



NOT lack of understanding or physical paralysis
Problem in brain cortex

Aphasia - condition characterized by partial or total loss of ability to
communicate verbally/written words


Pt may have difficulty speaking, reading, writing, recognizing names of
objects, or understanding what other people say
Caused by brain injury
Traumatic injury
 Oxygen deprivation during stroke
 Brain tumor
 Alzheimer
 Infection, like encephalitis




Temporary or permanent
Does NOT include speech impediments caused by loss of muscle control
Dysphasia - partial or complete impairment of the ability to communicate
resulting from brain injury - used more in Europe
Gentleman seen in clinic for followup of previous
stroke. He had cerebrovascular infarction 6
months ago, which left him with aphasia and leftsided hemiparesis on his non-dominant side. Pt is
referred to Outpt Rehab for ST, PT, and OT.
I69.354
Hemiparesis – see Hemiplegia,
following, cerebrovascular disease, stroke
I69.320
Aphasia, following cerebrovascular
disease, cerebral infarction

Aphagia -condition characterized by
loss of ability to swallow


Result of organic disease or psychologic
causes such as cerebrovascular accident
or anxiety
Dysphagia - difficulty in swallowing





Numerous underlying causes
Stroke/other neurologic conditions
Local trauma and muscle damage
Tumor/swelling partially obstructing
passage of food
Ranges from mild discomfort, such as
feeling a lump in throat, to severe
inability to control muscles needed for
chewing and swallowing
Acute CV Infarction due to embolism of left
cerebellar artery with dysphagia and right
hemiplegia.
I63.442 Infarct, infarction, cerebellar – see Infarct,
cerebral. (See also Occlusion, artery, cerebral, or
precerebral, with infarction). Occlusion, occluded
artery, cerebellar (anterior inferior) (posterior inferior)
(superior) with infarction, due to, embolism
R13.10 Dysphagia
G81.91 Hemiplegia

I63 Cerebral infarction

Includes: occlusion and stenosis of cerebral and
precerebral arteries, resulting in cerebral infarction
Use additional code, if applicable, to identify
status post administration of tPA (rtPA) in
different facility within last 24 hours prior to
admission to current facility (Z92.82)
 Excludes1 sequelae of cerebral infarction (I69.3-)


I63.4 Cerebral infarction due to embolism of cerebral arteries

I63.44 Cerebral infarction due to embolism of cerebellar artery

I63.441 Cerebral infarction due to embolism of right cerebellar
artery

I63.442 Cerebral infarction due to embolism of left cerebellar artery

I63.449 Cerebral infarction due to embolism of unspecified
cerebellar artery

I69.391 Dysphagia following cerebral infarction

47
Use additional code to identify the type of dysphagia, if known (R13.1-)

R13.1 Dysphagia
Code first, if applicable, dysphagia following
cerebrovascular disease (I69. with final characters
-91)
 Excludes1: psychogenic dysphagia (F45.8)


R13.19 Other dysphagia


Cervical dysphagia
Neurogenic dysphagia






Motor
Weakness or paralysis on side of body opposite stroke
Unmasking of primitive reflexes (instinctive sucking,
grasping, & groping
Compulsive mimicking of facial gestures made by others
Compulsive repetition of movement (motor perseveration)
Abulia - Lack of motivation/desire to perform task




In stroke, most often due to damage to frontal lobe
Ex:s. Stroke survivor fails to move arm/leg, even though part of
brain required to carry out movement is intact
Apraxia of gait
Urinary incontinence

Cognition and Intellect



Lack of initiative, vacillation, mood changes & inattentiveness
Difficulty solving problems (goal-directed behavior) in
different areas of cognition including psycholinguistic,
constructive, logical, and arithmetical
Behavior and Personality





Profound lack of initiative and motivation
Spontaneous expression of socially inappropriate remarks
Irritability
Carelessness and apathy
Inappropriate & seemingly random persistence & repetition
of certain behaviors
Speech and Language
 Broca aphasia - stroke affects dominant
language hemisphere

http://en.wikipedia.org/wiki/File:BrocasAreaSmall.png

Broca’s Aphasia – AKA, Motor Aphasia




Wernicke’s Aphasia





Production of language is affected, (speaking) But other aspects of language
are mostly preserved
Usu. prevents forming own intelligible words/sentences, but still ability to
understand others. Some aphasics can say few words - telegraphic speech
Often w/other impairments –hemiparesis/hemiplegia on R side of body,
alexia and agraphia
Pts can’t understand others’, or even their own speech
Speech is incomprehensible, but pt feels being understood. (Anosagnosia)
Ex: “My door sat through the lamp in the sky.” (Logorrhea)
With time, Wernicke’s aphasics may know others can’t understand them might become angry, paranoid, & depressed
Global Aphasia



Involves both areas
Pts can’t understand spoken language or speak
Some pts can still communicate by using written language


Visual Symptoms
Homonimous quadrantanopsia


AKA quadrantanopsia; quadrantic anopsia; quadrantic hemianopia
Nerve fibers carry information from lower parts of visual field



Difficulty interpreting visual information in surroundings, such as length,
depth, & size of objects
Hand-Eye Incoordination



When damaged by parietal strokes causes vision in lower quarter of side
opposite stroke to be lost
Spatial Dysperception


Travel through parietal lobes to occipital lobe
Difficulty bringing hand to spot where looking
EX: Pt looks at coffee mug on table, means to pick it up, but hand
overshoots, and can’t grab mug.
Inability to visually scan surroundings

Has full eye movement, but prevents seeing objects, people, and other
visual stimuli presented in peripheral vision

Abnormalities of Self-Perception

Hemineglect: parietal strokes in non-dominant language side of
brain tendency to completely ignore opposite side of body
 Ex: Hemiplegia due to stroke affecting both motor& sensory
cortices
 Pts ignore fact that one side of body completely paralyzed,
but also can't recognize own body parts on that side
 So fail to shave or wear lipstick on side affected by stroke
Finger agnosia
 Selective inability to name fingers
Right-left confusion
 Profound inability to differentiate R from L
Difficulty w/reading, writing, and math



Sensory Symptoms
 Sensory loss

Strokes in sensory cortex (in parietal lobe) can
cause profound numbness
 Astereognosis


Other
Inattentiveness
 Apathy
 Dullness


Constructional apraxia



Eye-opening apraxia


Inability to build whole from its single parts
Ex: inability to assemble simple 4-piece puzzle
Inability to open eye despite will and physical ability
Ideomotor apraxia

Inability to mimic learned motor task/behavior
(combing hair) Pt is unable to pantomime how to
comb Results from damage to dominant-side parietal
lobe

Language
Wernicke aphasia
 Word-finding difficulties
 Pure word deafness

Can’t hear words, but can recognize bells, buzzers, etc.
 Can’t write when asked, but can write spontaneously


Transcortical aphasia


Uncommon
Amnestic dysnomia

Difficulty retrieving names for things/people


Hearing
Hearing loss



Mild when one temporal lobe
affected
Complete deafness possible when 
both affected , but very rare
Auditory agnosia



Difficulty recognizing combinations
of sounds such as songs, musical
tones, and complex conversations
Auditory verbal agnosia = pure
word deafness
Auditory illusion

Aberrant perception of
normal sounds - feel unusual,
strange, repeated, or loud
Auditory hallucinations

Hearing sounds NOT there




Complex = sound of song on
radio
Simple = whistles or siren
May occur w/visual
hallucinations
Pts may/may not realize
these are hallucinations

Memory, Emotion and
Behavior






Loss of short or long term
memory
Fits of rage
Violent/aggressive behavior
Placidity
Lack of interest
Abnormally enhanced
sexuality

Other


Vertigo (type of balance
problem)
Abnormal perception of
time




Feelng that time stands
still /goes extremely
quickly
Intermittent loss of sense
of year, season or month
Disturbances of smell and
taste
Seizures

Stroke Affecting Entire Occipital Lobe on One Side


Homonomous Hemianopia – Pt not able to see
objects on opposite side of body
Stroke Affecting Occipital Pole – 'Central Vision
Defect‘



Central Vision = Seen at center of visual field
when looking straight ahead
Large blind spot in middle of visual field on
affected side
Pt looking straight ahead at someone’s face


May not be able to see nose, upper lip, &
lower half of eye on affected side
But could see shoulder and top of head on
that side

Stroke Affecting Occipital Lobes on Both Sides – 'Cortical
Blindness‘


Blindness
Also sometimes also suffer from visual anosagnosia


AKA Anton syndrome
Other






Visual Illusions - Distortion of movement, form, size or color in
visual field
Visual Hallucinations
Visual Agnosias
Balint Syndrome
Prosopagnosia - Inability to recognize identity of familiar faces
Alexia W/O Agraphia
http://en.wikipedia.org/wiki/File:Dean_Franklin_-_06.04.03_Mount_Rushmore_Monument_%28bysa%29-3_new.jpg

Group of 3 symptoms occurring together

Result of stroke at border of parietal and occipital
lobes
Inability to voluntarily look around in space
 Inability to grab object while looking at object,
due to dis-coordination of eye/hand
movements
 Tendency to only see one object in visual field
at one time

 Difficulty
w/ coordination & posture, as
well as ability to execute fluid movement

Common effects of cerebellar strokes include
 Inability to walk, problems with
coordination and balance (ataxia)
 Dizziness
 Headache
 Nausea
 Vomiting

Common effects of stroke in brain stem include
problems with
Breathing and heart functions
 Body temperature control
 Balance and coordination
 Weakness or paralysis in all four limbs
 Chewing, swallowing, and speaking
 Vision
 Coma


Death is common

Acute cerebral infarction, thrombosis of left
anterior cerebral artery with residual right-sided
hemiplegia
I63.322 Infarct, infarction, cerebral – (see also
Occlusion, artery, cerebral or precerebral, with
infarction). Occlusion, artery, cerebral, anterior,
with infarction, due to, thrombosis OR Infarct,
infarction, cerebral, due to thrombosis, cerebral
artery.
G81.91 Hemiplegia

G89.9 Hemiplegia, unspecified

G89.90 Hemiplegia, unspecified affecting unspecified side

G89. 91 Hemiplegia, unspecified affecting right dominant side

G89. 92 Hemiplegia, unspecified affecting left dominant side

G89. 93 Hemiplegia, unspecified affecting right nondominant
side

G89. 94 Hemiplegia, unspecified affecting left nondominant side

Parkinson’s disease
Neurons producing dopamine die in basal ganglia
 Causes difficulty initiating movement


Huntington’s disease
Genetic mutation causes over-production of
glutamate
 Kills neurons in basal ganglia
 Uncontrollable twisting/writhing


Alzheimer’s disease –



Blows to brain or stroke damage


Unusual proteins build up in & around neurons in neocortex &
hippocampus
Control memory, causing inability to remember or do everyday
tasks
Can kill neurons outright OR slowly starve of oxygen and
nutrients
Spinal cord injury


Can disrupt communication between brain & muscles
Neurons lose connection to axons located below site of injury;
which may still live, but lose ability to communicate
Inflammation of encephalon (part of nervous
system within cranium (brain))
 Usually viral
 West Nile encephalitis

Severe form of infection
 Neuroinvasive affecting brain
 20 % mild/moderate signs/symptoms
 <1 % encephalitis/meningitis/poliomyelitis


Headache, high fever, stiff neck, stupor, coma, paralysis

Varicella Virus

Chicken Pox, can cause Herpes Zoster (Shingles)
Virus lies dormant in nerve cells
 Reactivated = burning, itching, tingling,
sensitive skin, then rash and blisters (usually
one area on one side of body - dermatomes)
 Herpes zoster encephalitis
 Herpes zoster meningitis

Inflammation of membranes covering brain &
spinal cord
 Usu/ dura mater and/or arachnoid

AKA arachnoiditis
 AKA pachymeningitis

Bacterial, Viral, Non-infectious
 Acute or Chronic

Pt admitted with high fever, stiff neck, chest pain, and
nausea. Lumbar puncture results were positive for
meningitis. Chest X-ray showed pneumonia. Sputum
culture grew pneumococcus. Pt tx with antibiotics.
Dx: Pneumococcal meningitis and pneumococcal
pneumonia.
G00.1 Meningitis, pneumococcal
J13
Pneumonia, pneumococcal, (broncho)
(lobar)

G00 Bacterial meningitis, NEC

Includes: bacterial arachnoiditis




bacterial leptomeningitis
bacterial meningitis
bacterial pachymeningitis
Excludes1: bacterial:
meningoencephalitis (G04.2)
meningomyelitis (G04.2)



G00.0 Hemophilus meningitis
Meningitis due to Hemophilus
influenzae
G00.1 Pneumococcal
meningitis









Pneumonia (acute) (double)
(migratory) (purulent) (septic)
(unresolved) J18.9
-- pneumococcus J13
J13 Pneumonia due to Streptococcus
pneumoniae
Bronchopneumonia due to S.
pneumoniae
Code first: associated influenza, if
applicable (J09.X1, J10.0-, -J11.0-)
Code also: associated abscess, if
applicable (J85.1)
Excludes1:
congenital pneumonia due to S.
pneumoniae (P23.6)
lobar pneumonia, unspecified organism
(J18.1)
Motor neuron diseases
 Affect Muscle control/strength
 Many have Hereditary component



Atrophy
 Palsy
 Progressive, acquired decrease
 Complete or partial muscle
in size of normally developed
paralysis, often accompanied
cell, tissue, or organ
by loss of sensation &
 May result from decrease in cell
uncontrollable body
size, # of cells, or both
movements or tremors
 L, atrophia, Grk, from atrophos
ill-fed
 Sclerosis
Ataxia
 Condition characterized by
 Loss of ability to coordinate
hardening of tissue resulting
muscular movement, most
from any of several causes
frequently resulting from
disorders in brain/spinal cord
 AKA Induration
 AKA Dyssynergia,
Incoordination
Decrease in size and wasting of muscle tissue
 Muscles that lose their nerve supply can
atrophy; simply waste away

http://www.nlm.nih.gov/medlinep
lus/ency/imagepages/9680.htm




Disease of motor neurons
 Upper Motor Neurons - Nerve cells
reaching from brain to spinal cord
 Spasms & tonic limbs
 Abnormal reflexes
 Lower Motor Neurons –from spinal cord
to peripheral nerves that control muscle
movement
 Muscle wasting
 Fasciculations (Twitching)
AKA - Lou Gerhrig’s Disease, motor neuron
disease
Cause Unknown
Prognosis –
 50% of pts die w/in 3 years
 80% die w/in 5 years
 10 % Live more than 8 years
http://en.wikipedia.org/wiki/
File:Gehrig_cropped.jpg

Hereditary spastic paraplegia (HSP) - group of
inherited disorders characterized by
progressive weakness & spasticity (stiffness)
of legs


AKA familial spastic paraparesis (FSP)
20 genes responsible for several forms of HSP
now identified

Variable prosnoses

Uncomplicated, Complicated

Inherited degenerative disorder of cerebral cortex & corpus
striatum



HD gene located on short arm of chromosome 4





AKA Huntington Chorea, hereditary chorea, chronic progressive
chorea; degenerative chorea; degenerative chorea; Huntington
disease, Woody Guthrie's disease
George, U.S. physician, 1850-1916 described in 1872
Dominant gene
Affects males and female
Can be inherited from either parent (also w/HD).
50% chance of passing it to each Child
Begins usu. in 30s-50s

3 categories

Motor or movement symptoms
Dystonia
 Sustained abnormal postures, including facial grimaces, twisted neck, or
arched back


Chorea
 Involuntary jerking, twisting or writhing motions

Slowness of voluntary movements
Can’t control speed or force of movements
Can’t initiate movement
Slowed reactions
Difficulty speaking and swallowing
Localized/generalized weakness
Impaired balance ability
Rigidity, especially in late-stage disease








Personality and behavioral changes



Depression, irritability, anxiety and apathy
May become impulsive, aggressive or socially withdrawn
Cognitive decline




Loss of ability to plan and execute routine tasks
Slowed thought
Impaired or inappropriate judgment. Short-term memory
loss usually occurs, although long-term memory is usually
not affected
Pt w/ late-stage HD


Usu. retains knowledge of environment
Recognizes family members or other loved ones



Parkinsonism = clinical definition of variety of different
underlying pathologies causing Parkinson’s-like
symptoms - slowing of movement, tremor,
rigidity/stiffness, & balance problems
Several disorders produce symptoms referred to as
Parkinsonisms - Parkinson disease is ONLY ONE
Typical Parkinson patient has Lewy bodies in brain
neurons


When patient given dopamine replacement therapy (e.g.,
Sinemet), symptoms go away
Parkinsonisms (AKA atypical Parkinson) – add’l
symptoms do NOT respond to dopamine replacement
therapy
James Parkinson, English physician and
paleontologist (1817)
 AKA - Parkinson's, idiopathic parkinsonism,
primary parkinsonism, PD, hypokinetic rigid
syndrome/HRS, or paralysis agitans


"Involuntary tremolous motion, with lessened
muscular power, in parts not in action and even
when supported; with a propensity to bend trunk
forewards, and to pass from a walking to a running
pace: senses and intellect being uninjured."
http://www.umm.edu/patiented/articles/what_parkins
ons_disease_what_causes_it_000051_1.htm
http://students.cis.uab.edu/kelseycp/Parkinson%
27s.html


Tremor – Resting, Pill-Rolling
Slowed movement (Bradykinesia)




Rigid muscle - any body part, limiting ROM & causing pain
Impaired posture and balance



Posture may become stooped, may have balance problems
Loss of automatic movements


Over time, reduced ability to move/slow movement
Steps may become shorter, difficult to get out of chair, shuffling walk
Decreased ability to perform unconscious movements, including blinking,
smiling or swinging arms when walking, may no longer gesture when talking
Speech changes - may speak softly, quickly, slur or hesitate before
talking, more monotonous, less inflections
Writing changes - may appear small and become difficult



Primary (75%)
Idiopathic Parkinson's disease
No cause determined








RARE Causes of 2ndary
Metabolic


Hypoparathyroidism w/ basal
ganglia calcification


Hypo/Hyperthyroidism

Miscellaneous

Repeat trauma
(notably from boxing)
Structural lesions



Tumors
Infarctions
Hydrocephalus

Postencephalitic – Neurosyphilis - AIDS
Toxins



Secondary (25%)
Vascular disease
Infectious and postinfectious
Manganese
Cyanide
Methanol
Carbon monoxide
1-methyl-4-phenyl-1,2,3,6tetrahydropyridine (MPTP)
Pesticides
Medications





Neuroleptics
Metoclopramide
Dopamine-depleting agents (reserpine)
Methyldopa
Lithium
Calcium-channel blockers
Valproic acid
Fluoxetine

Parkinson pts also face 'freezing'


Feet freeze in place, but rest of body keeps moving,
causing a fall – Some pts tend to become sedentary,
reluctant to move, and reclusive
Parkinson's helper dogs are trained to identify
when person with Parkinson's is 'freezing'




If dog touches pt’s foot, it breaks freeze and pt can
continue walking
Medical experts do not know why this works
Dogs are taught to prevent pts falling by
counterbalancing & helping regain footing
IF pt does fall, dog can help the person up
Pt taking Haloperidol as prescribed for paranoid
schizophrenia. Seen for change in facial
expressions and stiffness in arms and legs.
 Dx: 2ndary Parkinsonism due to Haloperidol.
G21.11
Parkinsonism (idiopathic) (primary),
secondary, due to drugs, neuroleptic
T43.4X5A Refer to Drug and Chemical Table,
Haloperidol, adverse effect
F20.0
Schizophrenia, paranoid (type)



G21 Secondary parkinsonism
Excludes1:






dementia with Parkinsonism (G31.83)
Huntington's disease (G10)
Shy-Drager syndrome (G90.3)
syphilitic Parkinsonism (A52.19)
G21.1 Other drug-induced secondary parkinsonism
G21.11 Neuroleptic induced parkinsonism
 Use additional code for adverse effect, if applicable, to
identify drug (T43.3X5, T43.4X5, T43.505,T43.595)
Neuroleptic = Major Tranquilizer
Haloperidol fits this category
Also: Drug Table sends to this
Fluid Exchanges
Ryder Dennehy
95
Caused by Surge of electrical signals in all/part
of brain
 Seizure manifestations/duration vary widely

Convulsions, LOC, blank staring, jerky movements
 Few seconds to several minutes

Epilepsy dx = 2+ incidents of unprovoked
seizure
 Many different types of epileptic seizures


30+, one pt may have several types of seizures

Localization-related






AKA focal or partial
Specific area of one
hemisphere
Simple = still conscious
Complex = Consciousness
impaired/LOC
May spread to become
generalized
Auras

Generalized



Both hemispheres
affected from start of
seizure
Tonic clonic (grand mal);
Myoclonic; Absence
(petit mal); and Atonic
Add’l definition based
on


Intractable or Not
w/wo status epilepticus

Specificity for
Seizures of localized onset
 Complex partial seizures
 Intractable -Dr. must document w, w/o



AKA pharmacoresistent , pharmacologically resistant,
treatment resistant, refractory (medically), and poorly
controlled (acceptable for coding Intractable)
Status epilepticus -Dr. must document w, w/o
Recurrent or continuous for 30+ minutes
 Emergency - Can be life-threatening


Juvenile myoclonic (JME)



Tonic clonic (grand mal)

Tonic = Stiffening; Clonic =


Lapse of Awareness/staring
Few seconds

Falls, possible injuries
Common – 5% of epileptics
Jerking of limbs and face
Begins in
 Myoclonic
childhood/adolescence
 Rapid, brief contractions of
muscles
Multiple Identified genes
 Absence (petit mal)
increase risk



GABRA1 & EFHC1 + others
Seizures more likely w/sleep Atonic
deprivation/alcohol use
 Loss of muscle tone

Ex: Pt w/ localization-related (focal) (partial) epilepsy and epileptic
syndromes with complex partial seizures, without mention of intractable
epilepsy

ICD-10-CM has two possible codes




G40.201, localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures, not intractable, with
status epilepticus
G40.209, localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures, not intractable, without
status epilepticus
If your Drs don’t note w/ or w/o status epilepticus, start asking for it now
If your Drs don’t note Intractable/Not intractable, start asking for it now

62 y-o

ICD-10-CM 2013 Index
Seizure(s) (see also Convulsions) R56.9
recurrent G40.909

G40.909 Epilepsy, unspecified, not intractable, without status
epilepticus






seen for Tx of recurrent seizures
Epilepsy NOS
Epileptic convulsions NOS
Epileptic fits NOS
Epileptic seizures NOS
Recurrent seizures NOS
Seizure disorder NOS


62 y-o seen for Tx of
seizure disorder 2ndary
to stroke that occurred 2
yrs ago

ICD-10-CM 2013 Index

Use additional code to identify
sequelae
Sequelae (of) —see also condition
stroke NOS
specified effect NEC I69.398

Codes:
I69.398 Other sequelae of
cerebral infarction
G40.909 Epilepsy, unspecified,
not intractable, without status
epilepticus




Seizure(s) (see also Convulsions)
R56.9
disorder (see also Epilepsy)
G40.909
I69.398 Other sequelae of
cerebral infarction


Alteration of sensation following
cerebral infarction
Disturbance of vision following
cerebral infarction

62 y-o seen for treatment ICD-10-CM 2013 Tabular
of seizure




ICD-10-CM Index
Seizure(s) (see also Convulsions) R56.9
R56 Convulsions, not elsewhere
classified
Excludes1:



dissociative convulsions and seizures
(F44.5)
epileptic convulsions and seizures (G40.-)
newborn convulsions and seizures (P90)
R56.9 Unspecified
convulsions




Convulsion disorder
Fit NOS
Recurrent convulsions
Seizure(s) (convulsive)
NOS



Recurring attacks of moderate to severe throbbing/pulsing
pain, often on one side of head
 Sensitivity to light & sound
 May have N&V
3 X more common in women
Auras = flashing lights/zigzag lines/temporary loss of vision


Precursor
Migraine Triggers





Anxiety
Stress
Lack of food or sleep
Exposure to light
Hormonal changes (in women)

Now believed to have genetic cause
Overactive nerve cells responding to low levels of pain
 TRESK gene


Diagnosis (International Headache Society)

Type of pain & number of attacks
Minimum of 5 attacks
 Duration of 4-72 hours, if untreated

Classical migraine = with Aura
 Intractable



Terms that describe intractable migraine include:
pharmacoresistant or pharmacologically resistant,
treatment resistant, refractory, and poorly
controlled.
Status migrainosus
Migraine attack >72 hours AND
 Severe Intensity

Pt (Type 2 Diabetic with neuropathy) with weakness of left arm
and leg. Brought to Ed where he could speak but not use left
arm/leg. Pt recovered and had no neurologic deficits w/in 24
hrs. During encounter he was also treated for an intractable
classical migraine.
Dx: TIA
G45.9 Attack, attacks, transient ischemic (TIA)
E11.40 Diabetes, diabetic (mellitus) (sugar), type 2, with,
neuropathy
G43.119 Migraine, classical – see Migraine, with aura
Migraine, with aura, intractable
Alzheimer Disease
Frontotermoral dementia
Senile Degeneration of Brain NEC
Degeneration due to Alcohol Abuse

Significant loss of intellectual
abilities, such as memory
capacity, severe enough to
interfere with social or
occupational functioning


Criteria for Dx include impairment
of attention, orientation, memory,
judgment, language, motor and
spatial skills, and function
Types of Dementia





Alzheimer – Most common
Vascular
Lewy Bodies
Frontal Temporal (Pick Disease)
Traumatic

Other causes









AIDS
Alcoholism
Brain tumors
Drug toxicity,
Infection
Creutzfeldt-Jakob disease
Meningitis
Syphilis
Hypothyroidism

Lewy bodies – accumulated bits of alpha-synuclein
protein – inside nuclei of neurons in brain areas
controlling particular aspects of memory/motor
control

Alpha-synuclein accumulation also linked to Parkinson
disease, multiple system atrophy, and several other
disorders, - synucleinopathies
Dementia with Lewy Bodies (DLB) 1.3 Million in US
 Parkinson 1 million+ in US (with Dementia
 Alzheimer 5 million+ in US (4% - Early-onset)


= 6th leading cause of death

Lewy body proteins are
found

Area of brain stem where
they deplete
neurotransmitter dopamine


= Parkinsonian symptoms
Lewy body Dementia abnormal proteins diffuse
thru other areas of brain,
inclu. cerebral cortex

Acetylcholine depleted

Disruption of perception,
thinking, and behavior
(Dementia)
http://missinglink.ucsf.edu/lm/ids_104_neurodegenerative/case2/case2micro.htm
http://depts.washington.edu/adrcweb/DIMSp11/DIMSp11story1.html

Progressive, degenerative disease of brain


Most common form of dementia
Commonly affects elderly





Early Onset/Younger Onset AD – Before 65
Associated w/development of amyloid plaques in
cerebral cortex
Characterized by confusion, disorientation, memory
failure, speech disturbances, and eventual dementia
Unknown cause
Named for German psychiatrist Alois Alzheimer (18641915) (1906 autopsy)

65+ - Risk of Alzheimer’s doubles about every five years after
age 65


Family hx



After age 85, risk is nearly 50 %
Parent, sibling or child w/ Alzheimer’s -more likely to develop
Risk increases if more family members
Heredity

Risk genes – Increase likelihood of disease, but do NOT guarantee



Deterministic genes - Directly cause disease, guarantee




Risk gene with strongest influence is apolipoprotein E-e4
APOE-e4 may be factor in 20 -25 % of Alzheimer cases
Genes coding three proteins: amyloid precursor protein (APP), presenilin-1
(PS-1) and presenilin-2 (PS-2)
Autosomal dominant Alzheimer’s disease (ADAD) or Familial AD
< 5% of all cases
5 more genes related to AD found in 2012

Head trauma


May be strong link between serious head injury & risk of
Alzheimer’s
Esp. when trauma occurs repeatedly or involves LOC


Buckling seat belt, wear helmet during sports, and “fall-proof”
home
Heart-head connection



Every heartbeat pumps about 20 -25 % of blood to head
Brain cells use at least 20% of food and oxygen in blood
High blood pressure cholesterol, Heart disease, Stroke,
Diabetes (Insulin Resistance)
Amyloid plaques
 Neurofibrillary tangles
 Loss of neuron connections
 Spread to Hippocampus
 Mild Cognitive Impairment (MCI)


Cause: Mix of genetic,
environmental, and lifestyle
factors

Stage 1: No impairment (normal function)
Person does not experience any memory problems. Interview w/ medical professional
shows no evidence of symptoms of dementia

Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest signs
of Alzheimer's disease)
May feel having memory lapses — forgetting familiar words or location of everyday
objects. No symptoms detected during medical exam or by friends, family or co-workers

Stage 3: Mild cognitive decline (early-stage Alzheimer's Dx in some, but not all,
individuals w/these symptoms)
Friends, family or co-workers begin to notice difficulties. Detailed History by Drs may
detect problems in memory/concentration. Common stage 3 difficulties include:






Noticeable problems coming up with right word or name
Trouble remembering names when meeting new people
Noticeably greater difficulty performing tasks in social/work settings
Forgetting material that was just read
Losing/Misplacing a valuable object
Increasing trouble w/planning or organizing

Stage 4: Moderate cognitive decline (Mild or early-stage
Alzheimer's disease)
Careful medical interview able to detect clear-cut
symptoms in several areas





Forgetfulness of recent events
Impaired ability for challenging mental arithmetic — for
example, counting back from 100 by 7s
Greater difficulty performing complex tasks - planning dinner for
guests, paying bills
Forgetfulness about own personal history
Becoming moody/withdrawn, especially in socially or mentally
challenging situations

Stage 5: Moderately severe cognitive decline (Moderate
or mid-stage Alzheimer's disease)
Gaps in memory & thinking are noticeable, need help with
ADLs






Unable to recall own address/telephone number or high
school/college
Become confused about place or what day it is
Trouble w/ less challenging mental arithmetic; such as counting
backward from 40 by subtracting 4s or from 20 by 2s
Need help choosing proper clothing for season/occasion
Still remember significant details about themselves and family
Require no assistance with eating or using toilet

Stage 6: Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease)
Memory continues to worsen, personality changes may occur & individuals need extensive
help w/ADLs. Individuals may









Lose awareness of recent experiences as well as of surroundings
Remember own name but have difficulty w/personal history
Distinguish familiar & unfamiliar faces but trouble remembering name of
spouse
Need help to dress properly
Experience major changes in sleep — sleeping in day & restless at night
Need help handling toileting (i.e., flushing toilet, wiping or disposing of
tissue)
Increasingly frequent trouble controlling bladder or bowels
Major personality/behavioral changes, inclu. suspiciousness & delusions
(believing caregiver is impostor) or compulsive, repetitive behavior
Tend to wander or become lost

Stage 7: Very severe cognitive decline (Severe or
late-stage Alzheimer's disease)
Individuals lose ability to respond to environment, to
converse and to control movement. May still say
words or phrases.



Need help with much of daily personal care, including
eating or using toilet
May also lose ability to smile, to sit w/o support & to hold
head up
Reflexes become abnormal. Muscles grow rigid.
Swallowing impaired.
http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp
52-y-o
having increased dementia  F02 Dementia in other diseases
and forgetfulness. Wanders off from
classified elsewhere
his home & forgets where he is &
 Code first underlying
what he is doing.
physiological condition, such
Dx: Dementia due to Early-onset
as:Alzheimer's (G30.-)
Alzheimer

G30 Alzheimer's disease

Alzheimer's dementia senile and
presenile forms

Use additional code to identify:
delirium, if applicable (F05)
dementia with behavioral
disturbance (F02.81)
dementia without behavioral
disturbance (F02.80)





G30.0 Alzheimer's disease with
early onset

F02.81 Dementia in other
diseases classified elsewhere
with behavioral disturbance
Dementia in other diseases classified
elsewhere with aggressive behavior
 Dementia in other diseases classified
elsewhere with combative behavior
 Dementia in other diseases classified
elsewhere with violent behavior
Use additional code, if applicable, to
identify wandering in dementia in
conditions classified elsewhere (Z91.83)





20 Million alcoholics in US
50% have mild to severe
neuropsychological
difficulties
Effect depends on
multiple variables






Alcohol–induced
persisting amnesic
disorder
Amount of alcohol consumed
Age began drinking
Duration of drinking
Pt’s age, level of education,
gender, genetic background,
and family hx of alcoholism
Neuropsychiatric risk factors


Alcohol exposure before birth
General health status
Comorbiditieso
http://pubs.niaaa.nih.gov/publications/arh27-2/125-133.htm
1 oz of alcohol = 1 drink
 128 oz/gallon X 625 g = 80,000 drinks
 128 oz/gallon X 20 g = 2,560 drinks
 40 years (57-40 = 17 yo) = 480 months

80,000 = 167/mo = 42/wk = 6/day

480
 2,560

480 = 5/mo


Medical conditions



Neurological conditions




Malnutrition
Liver and Cardiovascular diseases
Head injury,
Encephalopathies
Fetal alcohol syndrome
Psychiatric conditions





Depression
Anxiety
PTSD,
Schizophrenia
Other drug use

Neuropsychiatric disorder caused by thiamine deficiency,
most often due to alcohol abuse


Combines features of Wernicke's encephalopathy and
Korsakoff's syndrome
Korsakoff's syndrome


Syndrome of anterograde & retrograde amnesia wconfabulation
associated w/alcoholic or nonalcoholic polyneuritis
Wernick encephalopathy



Common condition in pts w/long-term alcoholism, resulting largely
from thiamin deficiency and characterized by disturbances in
ocular motility, pupillary alterations, nystagmus, and ataxia with
tremors
AKA superior hemorrhagic polioencephalitis, Wernicke disease

Dementia with Lewy Bodies

Dementia symptoms consistent with DLB develop first







REM sleep disorder is more common
Hallucinations, delusions, and misidentification of familiar people
Both dementia symptoms & movement symptoms present at diagnosis
Movement symptoms develop w/in year after DLB Dx
Disruption of ANS
Blood pressure drop on standing, dizziness, falls & urinary incontinence
Parkinson's disease dementia


Movement symptoms first
Dementia symptoms don't appear until year + later

Due to cerebrovascular disease, usually with stepwise deterioration








Series of small strokes
Patchy distribution of neurologic deficits affecting some
functions and not others
Symptoms include confusion, problems with recent
memory, wandering or getting lost in familiar places,
bladder or bowel incontinence, emotional problems
difficulty following instructions, and problems handling
money.
Change is noticeable only as series of small steps
Over time, more small blood vessels in brain blocked, so
more noticeable gradual mental decline.
Begins between 60 and 75
Affects men more than women
AKA multi-infarct dementia
Any condition causing damage to
protective covering (myelin sheath)
surrounding nerve fibers in brain and
spinal cord
Nerve impulses slow or even stop,
causing neurological problems
Vision or Hearing loss
 Headache
 Seizures
 Muscle spasms and weakness
 Loss of coordination
 Paralysis
 Loss of sensation




Most common
Demyelination Disease
AKA – Disseminated
sclerosis
Thought to be an
autoimmune disease

Combination of factors

Infection, Genes, etc.
http://en.wikipedia.org/wiki/File:Symptoms_of_multiple_scler
osis.svg



Age - can occur at any age, but most commonly 20s – 40s
Gender - Women 2 X more likely
Family hx - 1 parent/sibling = 1-3% chance General Population = 0.10%



Certain infections - Variety of viruses, such as Epstein-Barr virus and
others, appear to be associated with multiple sclerosis.
Ethnicity - White people with North European heritage = highest risk


AAsian, African or Native American descent =
Geographic regions - Europe, southern Canada/northern US, New
Zealand & southeastern Australia



Identical twin has 30% chance of getting IF twin has MS
Child moving from high-risk area to a low-risk area, or vice versa = acquires
risk level of new home.
Move after puberty, young adult usually retains risk level of first home
Other autoimmune diseases 
Thyroid disease, type 1 diabetes or inflammatory bowel disease

Optic neuritis w/demyelination
Inflammation or demyelination of optic nerve
 AKA retrobulbar neuritis
 ~ 66% of people with MS have at least one
episode of optic neuritis
 Frequently first symptom of MS
 One eye at a time, may be pain also


Usually clears in 4-12 weeks

AKA Periaxial encephalitis, Schilder disease
Affects children
 Dementia, cortical blindness, cortical deafness,
spastic hemiplegia, and pseudobulbar palsy

Many Classification Systems
for Cerebral Palsy
ICD-10-CM uses terms
Spastic
Athetoid
Quadraplegic
Diplegic

Group of nonprogressive disorders of movement and
posture


AKA Static encephalopathy
Caused by abnormal development of, or damage to,
motor control centers of brain



Events before, during, or after birth
5-10% of CP attributed to birth trauma
Other possible causes include






Abnormal development of brain
Prenatal factors directly /indirectly damaging neurons
Preemature birth – 5 X risk; Mulitiple
Brain injuries in first few years
Most cases are Spastic CP or mixed CP
10,000 new cases in US every year

Maternal health







German measles (rubella), viral infection prevented w/ vaccine
Chickenpox (varicella), Viral infection prevented with vaccine
Cytomegalovirus, very common virus causes flu-like symptoms
 Birth defects possible if mother has first active infection during
pregnancy
Toxoplasmosis, parasitic infection in soil and feces of infected cats
Syphilis
Exposure to toxins, such as methyl mercury
Other conditions
 Thyroid problems, mental retardation or seizures

Infant illness




Bacterial meningitis
Viral encephalitis
Severe or untreated jaundice
Other factors of pregnancy and birth




Premature birth < 37 weeks = higher risk of cerebral palsy. <28
weeks = 50% chance
Low birth weight < 5.5 pounds (2.5 kilograms) = higher risk ,
which increases as birth weight decreases
Breech births
Multiple babies. Risk rises number of babies sharing uterus


1+ babies die risk that survivors may have cerebral palsy increases
Low Apgar Score at birth

Most common manifestation- 70- 80%
Hypertonia, or muscle tightness
 Can affect 1 side of body or just legs
 Quadriplegia = all four limbs w/spasticity


~ 25 % of CP
AKA dyskinetic cerebral palsy
 Manifests as slow, involuntary muscle movement
accompanied by mixed muscle tone
 Some muscles have too high tone, while others
too low


Least common type of CP
5 -10 %
 Characterized by poor muscle tone and difficulty
coordinating movements in arms, legs and torso
(Cerebellum)


10 % of CP
Several different types of CP in one individual
 Most common combination (~ 10 percent of all
mixed CP cases)



Spastic & athetoid movements together
All other combinations are also possible, but rarer





Excessive accumulation of fluid in brain
 Water on the Brain - actually CSF
 Ventricles abnormally widen – pressure
on tissues
 Blockage of normal CSF flow or
absorption
Congenital OR Acquired
Communicating OR Non-communicating
Hydrocephalus ex-vacuo
 Compensatory replacement by CSF of
volume of tissue lost in brain atrophy
NPH

Normal Pressure Hydrocephalus
http://php.med.unsw.edu.au/embryology/index.ph
p?title=File:Hydrocephalus.jpg

Dilatation of cerebral ventricles, usually occurring
2ndary to obstruction of CSF pathways



Communicating


Accumulation of CSF w/in skull
Typically enlargement of head, prominence of
forehead, brain atrophy, mental deterioration, and
convulsions
Free access of fluid between ventricles brain and
spinal canal
Non-communicating (AKA Obstructive)

Due to obstruction of CSF flow within brain ventricles
or through their exit foramina

CSF balance disrupted




May cause normal pressure
hydrocephalus
Ventriculmegaly
Most often in older people
Idiopathic OR 2ndary



May be result of traumatic fall or
injury or illness
Can sometimes be reversed (Shunt)
S&S



Gait and balance problems
Urinary incontinence
Dementia
http://en.wikipedia.org/wiki/Fi
le:Hydrocephalus.jpg
Brain tumors more common than spinal
tumors
 B9 or malignant
 Almost ½ of brain tumors are B9



Can recur, be fatal
Brain common site for 2ndary metastatic brain
tumors (from lung, breast ca, etc.)
Most common type of nervous system tumors
 Connective tissue differentiates








Astrocytoma
Brain stem glioma
Ependymoma
Oligodendroglioma
Medullablastoma
Meningioma
Neuroma
Most common
glioma ~1/2 of all
primary brain &
spinal cord tumors
 Most often in
cerebrum
 Classification




Low grade
astrocytomas (10%)
Anaplastic
astrocytomas
Glioblastomas
Anaplastic astrocytoma
Before and After Surgery,
Radiation, and Chemo
http://commons.wikimedia.org/wiki/File:Anaplastic_astrocytoma.jpg
Brain stem glioma



Low grade to high grade
Most often in children 3- 10 y-o (75%)
Can occur in adults
http://www.mypacs.net/cases/BRAIN-STEM-GLIOMA-682746.html
Ependymoma

Rare type of glioma (85% B9)



Thought to develop from
precursor cells to ependymal
cells lining ventricles and central
canal of spinal cord
3rd most common form of
pediatric brain tumors
3-6 % CNS tumors in adults



5% of gliomas in adults, mostly in
spine
Slightly higher incidence rate in
Males & Whites
Usually arise from floor of 4th
ventricle

Can cause Hydrocephalus http://commons.wikimedia.org/wiki/File:Ependymom_sag_FLAIR.jpg
Oligodendroglioma






Develops from glial cells (2%
of brain tumors)
Occurs frequently in
frontal/temporal lobes
Can be classified as low grade
or high grade
Common in males and
females 20-49 y-o
 More common in men than
women
Can occur in children
Low to High Grade
 B9  Malignant
CT
http://commons.wikimedia.org/wiki/File:Oligode
ndroglioma_002.jpg




Most common at midline of
cerebellum & roof of 4th
ventricle
25% of all pediatric brain
cancers
Presents w/ N&V, headache,
ataxia, papilledema,
nystagmus, irritability,
lethargy, cranial nerve palsy,
dizziness, altered vision
If cells get into CSF,
medulloblastoma can spread
to other areas of CNS
http://www.scielo.br/scielo.php?pid=S0004
-282X2003000200008&script=sci_arttext

B9, slow-growing tumor of
meninges, usually next to dura
mater







May invade skull or cause
hyperostosis
Often causes increased
intracranial pressure
Most common in Adults
Usually vascular
After radiation
2 X more common in women
WHO classification



Grade I: Benign Meningioma
Grade II: Atypical Meningioma
Grade III: Malignant (Anaplastic)
Meningioma
http://upload.wikimedia.org/wikipedia/commons/
f/fb/Contrast_enhanced_meningioma.jpg
Contrast-enhanced CT of Brain


General term for any
neoplasm derived from
cells of nervous system
Acoustic neuroma




AKA Vestibular schwannoma
Slow-growing B9 tumor of
nerve connecting ear to brain
(VIII Cranial)
Can damage several
important nerves as enlarges
S&S usually begin in 30s
http://en.wikipedia.org/wiki/Vestibular_schwannoma

Disruption of normal brain function

Caused by bump, blow or jolt to head or penetrating
head injury
1.7+ million every year in US
 75% mild (concussion)

~18% of all TBI-related ED visits involved children
aged 0 - 4 years
 ~22% of all TBI-related hospitalizations involved
adults 75 years +
 Males more often diagnosed with TBI (59%).

TBI Causes
http://www.cdc.gov/TraumaticBrainInjury/causes.html

Leading cause of TBI
in US

50% of TBIs among
children 0 - 14 years

61% of all TBIs
among adults 65
years +
http://en.wikipedia.org/wiki/File:Construction_workers_
not_wearing_fall_protection_equipment.jpg




In all age groups, MVAs & traffic-related
incidents 2nd leading cause of TBI (17.3%)
Largest percentage of TBI-related deaths
(31.8%)
2.3 million+ adult drivers/passengers
treated in EDs due to MVAs in 2009
Lifetime costs of crash-related
deaths/injuries for drivers/passengers =
$70 billion in 2005

Hematoma - collection of blood outside of
blood vessel
Epidural
 Subdural
 Intracerebral

Concussion
 Cerebral Contusion
 Basilar Skull Fx


Trauma, often to temple
Middle meningeal artery
 Accumulation of blood
epidural space

Outside (Above) Dura Mater
 Due to Dura’s attachment to
skull, small hematomas can
cause significant pressure

1- 3% of head injuries
 15-20% are fatal

http://en.wikipedia.org/wiki/File
:Epidural_Hematoma.jpg



Collection of blood on brain’s
surface
Due to ruptured veins
Acute Subdural = one of deadliest
head traumas



Serious head injury
Bleeding rapidly puts pressure on
brain tissue
Chronic Subdural = common in
elderly



Can be cause by minor injury (Fall)
Can be unnoticed for days/weeks
Shrinking brain = more space
http://en.wikipedia.org/wiki/File
:Subduralandherniation.PNG
 Within

brain tissue
Caused by bleeding from
Uncontrolled high blood
pressure
 Aneurysm leak or rupture
 Trauma
 Tumor
 Stroke

http://en.wikipedia.org/wiki/File:Intracerebr
al_heamorrage.jpg
L, concutere, to shake
violently
 Trauma-induced loss of
consciousness, transient or
prolonged


Due to a blow to head; may
be transient amnesia, vertigo,
nausea, weak pulse, and
rapid/slow respiration
http://en.wikipedia.org/wiki/File:C
oncussion_mechanics.svg
Bruise of Brain tissue
 20–30% of severe head
injuries
 Cerebral laceration is
similar



BUT pia-arachnoid
membranes are torn over
Injury site
Contrecoup contusion

Blow on one side of head
with damage on opposite
side by transmitted force
http://en.wikipedia.org/wiki/File:Contrecoup.svg

Fx involving base of cranium
S&S May be asymptomatic
 Raccoon eyes
 Battle sign
 Hemotympanum
 CSF Rhinorrhea
 Imaging: Plain skull film may not reveal fx


CT or MRI more reliable
http://www.nlm.nih.gov/medlineplus/en
cy/imagepages/3067.htm
Trauma
 Disease


Common symptom = Ataxia
Lack of muscle coordination
 Speech pattern changes
 Abnormal gait

http://www.fieldsobrietytests.net/horizontalgazenystagmusfieldsobrietytest.html
Trauma can be fatal when Reflex centers
damaged
 Non-fatal injuries

Cranial nerve malfunction
 Paralysis
 Loss of sensation
 Respiratory Irregularities


TBI in early/midlife =
increased risk of
dementia in late life


Head injury is 3rd most
common cause of
dementia, after
infection and alcoholism
Most common causes of head injury



Moderate/severe TBIs =
2-4 X increased risk
People < 50 y-o





MVAs (50%)
Falls (21%)
Assault or GSW (12%)
Sports - boxing (dementia pugilistica),
other recreational activity (10%)
Use of alcohol/substances factor in ~1/2
Children


Infants


Bicycle accidents
Shaken baby syndrome
Elderly persons

Especially falls
Homework
Select at least
TWO of the
following sites
and review the
brain
pathologies of
your choice
Complete the
Post -Test
173
H
O
M
E
W
O
R
K

Brain Tour. Alzheimer’s Association.


Brain Cancer. X-plain Module.


http://www.brain-surgery.us/brain_tumor.html
Hulman, G. Cerebral Ischaemia and Infarction. Pathology minitutorial. Nottingham University Hospitals.


http://www.nlm.nih.gov/medlineplus/tutorials/braincancer/htm/index.ht
m
Khurana, V. Brain Tumor Education Resource. 2 Tutorials.


http://www.alz.org/braintour/3_main_parts.asp
http://podcast.ulcc.ac.uk/accounts/UniversityofNottingham/mrzghms3/Cerebral_ischaemia_and_infarction___Medium.mp4
Brain Aneurysms. Toronto Brain Vascular Malformation Study
Group. 2001.

http://brainavm.oci.utoronto.ca/swf/description_full.html

Parkinson’s Disease. X-plain module.


Seizures & Epilepsy. X-plain module


http://www.afterdeployment.org/topics-traumatic-brain-injury
Traumatic Brain Injury. X-plain Module.


http://www.nlm.nih.gov/medlineplus/tutorials/seizuresandepilepsy/htm/index.htm
mild Traumatic Brain Injury. US DOD AfterDeployment.org


http://www.nlm.nih.gov/medlineplus/tutorials/parkinsonsdisease/htm/index.htm
http://www.nlm.nih.gov/medlineplus/tutorials/traumaticbraininjury/htm/index.htm
Getting It: A Disease... A Vaccine. National Meningitis Association.
Video in 3 parts, 25 min. total.

http://www.youtube.com/watch?v=_m6RKgrdS8M

Brain Quiz. AARP.


Alzheimer's disease and other types of dementia. FunTrivia.com


http://www.funtrivia.com/trivia-quiz/SciTech/Alzheimers-disease-andother-types-of--dementia-277016.html
What Do You Know About Alzheimer's Disease? Yale Medical Group.
10 questions.


http://www.aarp.org/health/brain-health/info-04-2013/brain-healthquiz.html
http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW022215
Howe, M. How Much Do You Know About Epilepsy? 10 questions.

http://www.funtrivia.com/trivia-quiz/SciTech/How-Much-Do-You-KnowAbout-Epilepsy-339804.html

Brain Injury Awareness Quiz - HensonFuerst, Raleigh Brain
Injury Lawyers. 8 questions


Brain Attack. FunTrivia.com


http://www.funtrivia.com/trivia-quiz/SciTech/Brain-Attack326081.html
Stroke Quiz: Test Your Medical IQ. eMedicineHealth.


http://www.youtube.com/watch?v=7RnRY_-4kqs
http://www.emedicinehealth.com/stroke_quiz_iq/quiz.htm
You've Probably Never Heard of It.

http://www.funtrivia.com/trivia-quiz/SciTech/Youve-Probably-NeverHeard-of-It-351768.html

Take the Huntington's Disease Quiz. University of
Rochester Medical Center. 8 questions.


Health Library. Quizzes. Roper St. Francis
Healthcare.


http://www.urmc.rochester.edu/encyclopedia/document.aspx?Conten
tTypeID=40&ContentID=HuntingtonDiseaseNeuQuiz
http://healthlibrary.rsfh.com/InteractiveTools/Quizzes/
Meningitis Quiz: Test Your Infectious Disease IQ.
eMedicineHealth.

http://www.emedicinehealth.com/meningitis_quiz_iq/quiz.htm
C.
D.
Exocrine system.
Limbic system.
1. Motor
2. Myelinated nerve
fibers
2. Limbic system
3. Carries signals from
the outer parts of the
body to the CNS
4. Cerebrum
5. Gyri
6. Cerebellum
7. Medullar Oblongata
2.
3.
4.
5.
6.
7.
8.
20%
Brainstem
Pineal Gland
2
Smell
Ventricular
12
[email protected]
180

Medical Dictionary. The Free Dictionary.


Brain and Nerves. MedlinePlus.


http://codapedia.com/article_548_ICD-10-Session-11-Chapter-Six-Diseasesof-the-Nervous-System.cfm
WebMD. Brain & Nervous System Health Center


http://podbay.fm/show/343794004
McGuire, N. ICD10 Session 11 Chapter 6. Codapedia. 32 Min. video


http://www.nlm.nih.gov/medlineplus/brainandnerves.html
Hulman, G. Pathology mini-tutorials. Nottingham University Hospitals.


http://medical-dictionary.thefreedictionary.com
http://www.webmd.com/brain/default.htm
WebMD. Medical References Related to Brain & Nervous System

http://www.webmd.com/brain/medical-reference-index

Alzheimer's Disease. Alzheimer’s Association. Includes Videos.


Alzheimer's Disease Fact Sheet. NIA (NIH).


http://www.alz.org/alzheimers_disease_1973.asp
http://www.nia.nih.gov/alzheimers/publication/alzheimers
-disease-fact-sheet
Peterson, R. Mild Cognitive Impairment Research. 20
min. Video. HBO, NIH, Alzheimer’s Assoc.

http://www.alz.org/research/video/alzheimers_videos_an
d_media_identifying.asp

Aneurysm in the brain. MedlinePlus.


http://www.nlm.nih.gov/medlineplus/ency/article/001414.htm
Brain aneurysm. Mayo Clinic.
http://www.mayoclinic.com/health/brain-aneurysm/DS00582

What You Should Know About Cerebral Aneurysms. American
Stroke Association.

http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/
HemorrhagicBleeds/What-You-Should-Know-About-CerebralAneurysms_UCM_310103_Article.jsp

Howard, A. Coding for Seizures and Epilepsy. For The Record, Vol.
24 No. 10 P. 28, 5/21/2012


Bielby, J. A. Diagnosis Coding of Seizures, Epilepsy and Other Related
Terms. CodeWrite, 11/2011.


http://blogs.hcpro.com/icd-10/2012/07/epilepsy-codes-in-icd-10-cmrequires-additional-documentation/
MedlinePlus. Epilepsy.


https://newsletters.ahima.org/newsletters/Code_Write/2011/November/sei
zures.html
Leppert, M. Epilepsy codes in ICD-10-CM requires additional
documentation. 7/20/2012.


http://www.fortherecordmag.com/archives/052112p28.shtml
http://www.nlm.nih.gov/medlineplus/epilepsy.html
Epilepsy Foundation. Types of Seizures.

http://www.epilepsyfoundation.org/africanamerican/whatisepilep
sy/Types-of-Seizures.cfm

Astrocytoma Tumors. American Association of
Neurological Surgeons.


http://www.aans.org/en/Patient%20Information/Conditio
ns%20and%20Treatments/Astrocytoma%20Tumors.aspx
Ependymoma Overview. Collaborative Ependymoma
Research Foundation (CERN).

http://www.cern-foundation.org/Content.aspx?id=564

Parkinson's disease and Parkinsonism: Are they the
same thing? Parkinson’s Action Network.


Parkinson's disease. Mayo Clinic.


http://www.parkinsonsaction.org/news/parkinsonsdisease-and-parkinsonism-are-they-same-thing
http://www.mayoclinic.com/health/parkinsonsdisease/DS00295
Understanding Parkinson’s Disease. Medical News
Today. Video, 3 minutes.

http://medicalnewstoday.healthology.com/hybrid/hybridautodetect.aspx?content_id=2856&focus_handle=parkins
ons-disease&brand_name=medicalnewstoday

Am I at risk for a stroke? Nat’l Stoke Association.


Coding for Cerebral Infarction. For The Record Vol. 21 No. 21 P.
24


http://medicalcenter.osu.edu/patientcare/healthcare_services/stroke/
effects/Pages/index.aspx
Stroke. MedlinePlus


https://newsletters.ahima.org/newsletters/Code_Write/2012/August/seq
uelae.html
Effects of Stroke. Wexner Med. Ctr. Ohio State Univ.


http://www.fortherecordmag.com/archives/110909p24.shtml
Coding Sequelae of Cerebrovascular Disease in ICD-10-CM.
CodeWrite, August 2012. AHIMA.


http://www.stroke.org/site/PageServer?pagename=RISK
http://www.nlm.nih.gov/medlineplus/ency/article/000726.htm
Stroke. Medical Dictionary.

http://medical-dictionary.thefreedictionary.com/stroke

Stroke – Rehabilitation. HeartHealthyWomen.org – Joint project
of Cardiovascular Research Foundation, Office on Women's
Health, DHHS and WomenHeart: the National Coalition for
Women with Heart Disease.


What Are the Effects of a Frontal Lobe Stroke? About. Com
Source: Allan Ropper and Robert Brown, Adam's and Victor's
Principles of Neurology, 8th Edition McGraw-Hill Companies Inc,
United States of America, 2005, pp 417-430.


http://www.hearthealthywomen.org/cardiovascular-disease/stroke/stroke-page5.html
http://stroke.about.com/od/unwantedeffectsofstroke/f/FrontalStroke.htm
What is a stroke? Nat’l Heart, Blood, and Lung Institute. NIH.

http://www.nhlbi.nih.gov/health/health-topics/topics/stroke/printallindex.html

Division of Disability and Aging Services. Vermont. Traumatic
Brain Injury. 3 tutorials with workbooks and quizzes.


Injury Prevention & Control: Traumatic Brain Injury. CDC.


http://www.cdc.gov/TraumaticBrainInjury/index.html
Wedro, B. Hematoma. MedicineNet.


http://www.ddas.vermont.gov/ddas-policies/policies-tbi/policies-tbidefault-page
http://www.medicinenet.com/hematoma/article.htm
Brain Injury Guide and Resources. Missouri DHSS and MU DH.
CEUs.

http://braininjuryeducation.org/

Acoustic neuroma. MedlinePlus.


Gray, L. ICD-10-CM Diagnosis Coding for Pain Medicine.
CodeitRight Insights. 3/5/2013.


http://www.codeitrightonline.com/ciri/icd-10-cm-diagnosiscoding-for-pain-medicine.html
Hereditary Spastic Paraplegia Information Page. NINDS. NIH.


http://www.nlm.nih.gov/medlineplus/ency/article/000778.htm
http://www.ninds.nih.gov/disorders/hereditary_spastic_paraplegia/heredit
ary_spastic_paraplegia.htm
Hydrocephalus Fact Sheet. NINDS. NIH.

http://www.ninds.nih.gov/disorders/hydrocephalus/detail_hydro
cephalus.htm

Multiple sclerosis. Mayo Clinic.


Oscar–Berman, M. , Marinkovic, K. Alcoholism and the Brain:
An Overview. NIAAA, NIH.


http://www.mayoclinic.com/health/multiple-sclerosis/DS00188
http://pubs.niaaa.nih.gov/publications/arh27-2/125-133.htm
Pfefferbaum, A. Sullivan, E. V, Mathalon, D. H., & Lim, K. O.
Frontal lobe volume loss observed with magnetic resonance
imaging in older chronic alcoholics. Alcoholism: Clinical and
Experimental Research 21:521–529, 1997.

http://pubs.niaaa.nih.gov/publications/arh27-2/125-133.htm