神经病学总论(2016七年制英文)

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1、Neurology(in General) Lin Yin, MDChief, ProfessorTeaching/research Section of Neurology and Psychiatry The 2nd Clinical College of Dalian Medical University Chapter 1 IntroductionDefinitionNeurology means clinical neurology, which is a branch of internal medicine. Neurology is a science studying the

2、 etiology, pathogenesis, pathology, clinical manifestations, treatment, prognosis and prevention of nervous system diseases and muscular diseases. Chapter 1 IntroductionNeurology and Psychiatry Neurological diseases are close to but different from Psychiatric diseases. Psychiatric diseases refer to

3、disturbance of the normal function of the brain esp. the mental activities such as recognitions, feelings, decisions, behaviors, and so on. Chapter 1 IntroductionWorking protocol Similar to internal medicine. First take the medical history, then do physical exam, and then do some medical exams. So w

4、e get the correct diagnosis and begin to treat the patient.Some differences to Internal Medicine Need to master the thorough and systemic examination skills of the nervous system, Focus on the localization diagnosis and etiological diagnosis of the disease. Selectively choose some medical examinatio

5、ns from so many available today, such as lumbar puncture (LP), CT, CTA, MRI, MRA, DSA, ECT, EEG, EMG, etc. 第 一 章 绪 论工 作 思 维 方 法 与 内 科 大 体 相 同 ， 通 过 病 史 、 体 格 检 查 、 辅 助 检 查 ，来 进 行 诊 断 、 治 疗 和 预 防 。 与 内 科 不 同 之 处 在 于 ： 1、 需 要 掌 握 神 经 系 统 检 查 方 法 。 2、 强 调 疾 病 的 定 位 诊 断 与 定 性 诊 断 。 3、 辅 助 检 查 发 展 的 很 快

6、， 有 腰 穿 、 CT、 MRI、 PET（ 正 电 子 发 射 断 层 扫 描 ） 、 DSA（ 脑 血 管 造 影 ） 等 ，要 有 针 对 性 地 选 择 。 4 治 疗 原 则 ： 治 愈 （ 脑 炎 、 脑 膜 炎 、 GBS） 、 缓 解（ EPI,PD,MS） 、 对 症 (AD,OPCA,PMD,ALS) CT- Computerized Tomography Chapter 1 Introduction Importance of Neurology CTA- Computerized Tomography Angiography MRI-Magnetic Resonanc

7、e Imaging MRA- Magnetic Resonance Angiography DSA-Digital Substration Angiography ECT Emission Computerized Tomography : PET (Positron Emission Tomography) SPECT (Single Photon Emission CT) Neurophysiolgy: EEG-Electroencephlography EMG-Electromyography MEG-Magnetoencephlography CEP-Cerebral Evoked P

8、otentials 第 一 章 绪 论神 经 系 统 疾 病 的 种 类 感 染 、 血 管 病 、 肿 瘤 、 外 伤 、 免 疫 、 变性 、 遗 传 、 中 毒 、 先 天 、 营 养 代 谢 、 等 。 第 一 章 绪 论神 经 症 状 的 分 类 缺 损 症 状 （ 脑 血 管 病 ） 刺 激 症 状 （ 肿 瘤 、 腰 凸 ） 释 放 症 状 （ 锥 体 束 征 、 强 笑 强 哭 ） 休 克 症 状 （ 脑 休 克 、 脊 髓 休 克 ） 第 一 章 绪 论神 经 病 学 的 特 点 及 重 要 性 大 脑 是 人 体 的 “ 司 令 部 ” ， 支 配 和 调 节 全 身 各系

9、 统 的 功 能 。 中 枢 神 经 一 旦 发 生 损 害 难 于 治 疗 ，原 因 是 中 枢 神 经 元 不 能 再 生 。 神 经 解 剖 复 杂 、 难 学 、 难 懂 ， 但 是 它 非 常 有 条理 、 逻 辑 性 强 ， 只 要 入 门 ， 有 兴 趣 ， 就 不 难 。 神 经 病 学 大 有 前 途 ， 随 着 社 会 的 发 展 ， 寿 命 的延 长 ， 发 病 率 明 显 增 加 ， 脑 血 管 病 已 成 为 三 大死 亡 疾 病 之 一 ， 我 们 将 来 无 论 干 那 一 科 都 用 得上 神 经 科 的 知 识 。 Chapter 1 Introduction

10、ArrangementLectures: General information: 8 hours (Cranial nerves, motor system, sensory system, reflex system, localization.) Individual information: 20 hrs (CVD, spinal diseases, Epilepsy, muscular disease)Internship: 2 times,8 hours Chapter 2 FUNDAMENTAL NEUROANATOMY AND LOCALIZATION Section 1 Cr

11、anial nerves Do you remember what are the 12 pairs of cranial nerves? ， Olfactory nerve Temporal nasalOptic N. chiasmOptic tractOptic radiation LateralGeniculatebody Visual cortex Lesion sites and clinicalSection 1 Cranial nerves ， Optic nerve Anatomy and pathway Retina(rods,cones)ganglion cellsopti

12、c nerveoptic chiasm(nasal half fibers cross, t e m p o r a l h a l f f i b e r s uncross)optic tractlateral geniculate bodyposterior limb of the internal capsuleoptic r a d i a t i o n o c c i p i t a l (calcarine)cortex (visual center) Section 1 Cranial nerves ， Optic nerveClinical Findings: Vision

13、 and Visual Field Defects(Visual loss)a. Optic nerve: total blindness (visual loss) of the ipsilateral eye. b. Optic chiasm(such as pituitary tumor) : bitemporal hemianopsia. c. Perichiasmal area(such as calcified ICA): ipsilateral nasal hemianopsia.d. Optic tract: contralateral total homonymous hem

14、ianopsia. *. Optic radiation: e. complete lesion can cause contralateral total homonymous hemianopia. f. lower portion cause contralateral sup. quadrantanopsia; g. upper portion cause contralateral inf. quadrantanopsia; h. Occipital lobe: often produces contralateral homonymous hemianopia with macul

15、ar sparing. 8Temporal nasalOptic N. chiasmOptic tractOptic radiation Lat.eralGeniculatebodyVisual cortex Lesion sites and clinical Section 1 Cranial nerves ， Optic nerve“macular sparing”: the visual field in the central portion of the hemianopia side is preserved and the light reflex in the same sid

16、e still exists. Macular sparing is a characteristic of central hemianopsia. Section 1 Cranial nerves ， Optic nerve Optic disk changes (with ophthalmoscope) Papilledema Bleeding of retina Fundus change of blood hypertention Optic atrophy Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens

17、 N)Anatomy and Physiology group of nuclei (midbrain) : muscle function levator palpebrae m. open the eye superior rectus m. move the eye upward medial rectus m. move the eye medially inferior rectus m. move the eye downward inferior oblique m. move the eye upward and outward sphincter m. of iris( 虹

18、膜 ) constrict the pupil ciliary muscle thicken the lens nucleus (midbrain) superior oblique m. rotates the eye downward and outward nucleus (pons) lateral rectus m. rotates the eye outwardSub-neucleiE-W Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N)Diagram of eye muscle action Se

19、ction 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N)Clinical terms: Intraocular m.: refer to sphincter m. of iris(constrict the pupil ), ciliary muscle(thicken the lens) and dilator m. of iris (dilate the pupil), which are involuntary muscles Extraocular m.: refer to levator palpebrae m.

20、, superior rectus m., medial rectus m., inferior rectus m., inferior oblique m., superior oblique m., and lateral rectus m., all are voluntary muscles Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N)Clinical terms: Diplopia (double vision): When one extraocular muscle paralyzed, th

21、e eye can not move toward the direction that this paralyzed muscle works, and the patient see two separate images of the same object in visual space when both eyes viewing. Accommodation reflex: When both eyes follow an object brought from a distance up close to the face, both eyes converge with con

22、striction of pupils. Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N)Clinical terms: Light reflex Refers to: Constriction of the pupil when light is thrown on the retina. Pathway of light reflex: lightretina-optic nerve (II) optic chiasm midbrain E-W nuclei oculomotor nerve(III) ci

23、liary ganglionpostganglionic fibersthe sphincter m. of iris. Diameter of the pupil : Normally, there is a balance between the sphincter m. of iris and the dilator m. of iris, so the diameter of the pupil has a constant range from 3 mm to 4 mm. Pupil constriction (miosis): 5mm Section 1 Cranial nerve

24、s , , (Oculomotor N,Trochlear N,Abducens N)Clinical terms: Horners sign: when the cervical sympathetic nerve or its pathway was injured, it can produce Horners sign. The affected side shows: miosis, narrowed palpebral fissure, enophthalmos, absence of sweating of the face. Section 1 Cranial nerves ,

25、 , (Oculomotor N,Trochlear N,Abducens N)Clinical types of ophthalmoplegia(1) Peripheral ophthalmoplegia: caused by lesion of oculomotor nerves themselves. Paralysis of CN III: Ptosis or dropping of the upper eyelid, external (divergent) squint (strabismus), eye difficult to move upward, downward, in

26、ward, diplopia(double vision), dilatation of the pupil, loss of light and accommodation reflexes(see next slide). Paralysis of CN IV: Paralysis of superior oblique muscle cause diplopia on looking downward, so the patient has difficulty in descending stairs Paralysis of CN VI: Internal (convergent)

27、strabismus, the eye cannot move outward, diplopia male， 81yrs， complete paralysis of left CN III Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N) Clinical types of ophthalmoplegia(2) Nuclear ophthalmoplegia Location of the lesion: Nucleus of III(midbrain), IV(midbrain) or VI(pons)

28、Characteristics: besides oculomotor nucleus, often involves the nearby structure esp. the pyramidal tract Clinical manifestation: crossed hemiplegia, such as Weber syndrome Weber syndrome Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N) Clinical types of ophthalmoplegia(3) Supranuc

29、lear ophthalmoplegia Location of the lesion: conjugate gaze center ( post. portion of mid. frontal gyrus, area 8), which moves both eyes simultaneously and horizontally to the opposite side. Clinical manifestation: paralysis of the conjugate gaze to the opposite side. Destructive lesions (eg. CH) pr

30、oduce conjugate deviation of the eyes to the side of the lesion, irritative lesions (eg. tumor) produce conjugate deviation of the eyes to the opposite side of the lesion. Section 1 Cranial nerves , , (Oculomotor N,Trochlear N,Abducens N) Clinical types of ophthalmoplegia(4) Intranuclear ophthalmopl

31、egia (self study) ， Trigeminal nerveAnatomy and physiology Sensory pathway：V1opthalmic br. V2 maxillary br. trigeminal semilunar ganglionV3 mandibular br. Nucleus of main sensory (touch) Nucleus of spinal tract (pain, temprature) fibers cross to the opposite of medulla trigeminal lemniscus ventropos

32、terior medial nucleus (VPMN) of the thalamusposterior limb of the internal capsulepostcentral gyrus. Section 1 Cranial nerves ， Trigeminal nerve Corneal reflex: Blinking of the eye upon gentle irritation of the cornea with a small piece of absorbent cotton. Its pathway: corneaV1Nucleus of main senso

33、ry (touch)facial N.orbicular m. of eye Section 1 Cranial nerves ， Trigeminal nerveMotor pathway precentral gyruscorticobulbar tract internal capsule the bilateral trigeminal motor nuclei(pons) join the mandibular nerve(V3) muscles of mastication(masseter, temporal, internal and external pterygoid).

34、Section 1 Cranial nerves ， Trigeminal nerveClinical Features:(1)Lesion involving V1: Abnormal sensation (pain, loss of sensation) of the skin supplied by V1 (forehead, eye, nose, paranasal sinus, part of the nasal mucosa , temple, meninge ), as well as loss of corneal reflex. (2)Lesion involving V2:

35、 Abnormal sensation of the skin supplied by V2 (upper jaw, upper teeth, upper lip, cheek, hard palate, maxillary sinus, nasal mucosa). (3)Lesion involving V3: Abnormal sensation of the skin supplied by V3 (lower jaw, lower teeth, lower lip, bucca mucosa, tongue, part of the external ear, auditory me

36、atus, meninge), as well as paralysis of the muscles of mastication. Section 1 Cranial nerves VII, Facial nerveAnatomy and pathwayBilateral corticobulbar tract sup. part of facial nucleusContralateral corticobalbar tract inf. part of facial nucleus facial nerveinternal acoustic meatus facial canal (c

37、horda tympanitaste of of the ant.2/3 of the tongue)geniculate ganglion stylomastoid foramen upper:frontalis m.(wrinkle foreheads), expressive orbicular m. of eye(wink or close eye)muscles of the face lower: buccal (smile) orbicular m. of mouth(show teeth) Section 1 Cranial nerves VII, Facial nerve C

38、linical FindingsPeripheral facial palsyLocation of lesion: Facial nucleus, or facial nerveManifestation : On the affected side: Wrinkles on the forehead becomes flat Palpebral fissure becomes larger Nasolabial sulsus becomes flat Mouth droops and may draw to the other side Loss of taste of the ant.2

39、/3 of the tongue (when chorda tympani affected) The patient has difficulty to: wrinkle his forehead, close or tightly close his eye, show his teeth, whistle. 2 Section 1 Cranial nerves VII, Facial nerve Clinical FindingsCentral facial palsy (supranuclear paralysis) :Location of lesion: the corticobu

40、lbar tract Manifestation : On the contralateral side: All the peripheral facial palsy signs are present, except:Wrinkles on the forehead does not become flatPalpebral fissure does not become largerThe patient has no difficulty to: wrinkle his forehead, or close his eye. Because the sup. part of faci

41、al nucleus receives bilateral corticobulbar tracts innervation, but the inf. part of facial nucleus only receives contralateral corticobulbar tract innervation. 1 Section 1 Cranial nerves , Vestibulocochlear nerve1 Vestibular Nerve pathway (pure sensory N.)Vestibular apparatus in the inner ear(3 sem

42、icircular canals) vestibular ganglion vestibular nerve internal acoustic meatus group of vestibular nuclei(medial, lateral, sup., spinal) Vestibulospinal tract spinal ant. horn cellsVestibulocerebellar tract cerebellum Medial longitudinal fasciculus(MLF) ocular motor nerves (III,IV,VI) Functon: feel

43、 the position and movement of head and body in the space, reflectively adjust the equilibration (balance) of the body. Section 1 Cranial nerves , Vestibulocochlear nerve Clinical Findings1. Vertigo A motor hallucination. The patient feels surrounding objects are moving or rotating, with nausea and v

44、omiting. Two types:(1)Peripheral vertigo: symptoms are usually serious and last short time. Usually caused by Vestibular apparatus (eg, Meniere disease) or extracranial vestibular nerve disease.(2)Central vertigo: symptoms are usually slight and last longer time. Usually caused by intracranial vesti

45、bular N.(eg, tumnor), vestibular nucleus or pathway disease (eg, ischemia, inflammation). 2. Equilibration Imbalance of gait, shake of the body, easy to dump to the affected side, Rombergs sign (+).3. Nystagmus An involuntary, rhythmic , quick and to-and-fro eyeballs movement. Types: horizontal, ver

46、tical, rotatory, etc. Section 1 Cranial nerves , Vestibulocochlear nerve 2 Cochlear Nerve pathway (pure sensory N.) Organ of Cortispiral ganglion in the inner ear cochlear nerve internal acoustic meatus(ant. and post.) cochlear nucleus(pons) bilateral ascending fibers (lateral lemniscus) inf. collic

47、ulus medial geniculate body acoustic radiations sup. temporal gyrus(acoustic center). Section 1 Cranial nerves , Vestibulocochlear nerve Clinical Findings:Deafness:1. Nerve deafness is due to cochlea (eg. Meniere disease) or cochlear nerve (eg. acoustic nerve tumor) disease, which interrupt the nerv

48、e pathway. 2. Conductive deafness is due to middle or external ear disease, such as otitis media, perforation of tympanic membrane.3. Mixed deafness: both of above, often see in old person.Tinnitus: A subjective and lasting noise caused by an irritative disease in the sound perceiving organ or condu

49、ctive pathway. Generally, sound perceiving organ disease is high-pitched tone (eg. Whistling), conductive pathway disease is low-pitched tone (eg. humming). Section 1 Cranial nerves ， ， Glossopharyngeal and vagus nerves 1 Anatomy and physiologyMotor: Precentral gyrus bilateral corticobubar tract nuc

50、leus ambiguous (疑 核 ) in medulla Glossopharyngeal Nstylopharyngeus m. (茎 突 咽 肌 )(raise the pharyngeal vault) Vagus nerve muscles of the pharynx, larynx and soft palate Sensations (IX): General sensations in pharynx and larynxTaste sensation in post.1/3 of the tongueThese two nerves are motor and sen

51、sory mixed nerves which have a close relationship in anatomy and function. Section 1 Cranial nerves ， ， Glossopharyngeal and vagus nerves2.Clinical FindingsUnilateral IX and X palsy:1) Hoarseness, 2)dysphagia(difficulty in swallowing), may be with regurgitation of fluids)3)loss of sensation in phary

52、nx and larynx,4) soft palate can not be raised,5)deviation of the uvula to the well side, 6) loss of the gag reflex, Section 1 Cranial nerves ， ， Glossopharyngeal and vagus nervesBulbar palsy Pseudobulbar palsy Common points: hoarseness、 dysphagia、 regurgitation Different points:1.location of lesion

53、 2.exaggerate crying or laughter 3.sensation in pharynx and larynx 4.gag reflex5.jaw jerk reflex XI/X or their nucleinononono bilateral corticobulber tractsyesyesyesyes Section 1 Cranial nerves ， Accessory nerve 1, Anatomy (pure motor nerve) Bilateral corticobulbar tracts Ambiguous nucleus(medulla)m

54、edullary br. reccurrent laryngeal n.intrinsic m. of larynx Accessory nucleus (ant. horn of C1-5) spinal branchsternocleidomastoid m. trapezius m. Section 1 Cranial nerves ， Accessory nerve 2.Clinical Finding: unilateral accessory n. paralysis produce: can not rotate head to the well side can not shr

55、ug affected shoulder atrophy of SCM and trapezius m. dropping of the shoulder Section 1 Cranial nerves ， Hypoglossal nerve 1, Pathway (pure motor nerve) Contralateral corticobulbar tracthypoglossal nucleus(medulla)hypoglossal n.hypoglossal canal muscles of tongue: Genioglossus m(颏 舌 肌 ).: protrude t

56、he tongue Hyoglossal m.(舌 骨 舌 肌 ):Contract the tougue Peripheral type Central typeLesion location Deviation of the tongue on protrusion to Atrophy of the affected side of tongue hypoglossal n., or its nucleus affected side yes motor cortex, orcorticobulber tract well side no Section 1 Cranial nerves

57、 Hypoglossal nerve palsy Section 2 Sensory SystemClassification of sensationSensation is a reflection of different stimuli in the brain. Sensation can divided into: Special sensation: smell, taste, optic, acoustic, General sensation: Superficial sensation (from skin, mucosa): pain, temperature, touc

58、h. Deep sensation (from muscle, tension, joint): movement sense, position sense, vibration sense. Complex sensation (from cerebral cortex): stereognosis, topognosis, 2-point discrimination Section 2 Sensory System pathways(1) pathway of pain and temperature sense Skin, mucosa (receptors in the nerve

59、 endings)post. spinal root ganglionthe spinal cordrun up 2 to 3 spinal segmentscells in post. horncross through the ant. white commissure to the other side lat. spinothalamic tract brainstem and midbrain ventroposterior lat. nucleus of the thalamuspost. limb of the int. capsulepostcentral gyrus(pari

60、etal lobe). Section 2 Sensory System pathways pathway of touch (tactile)sense : Skinpost. spinal root ganglionspinal cord, dividing two routes: (1)Tactile discrimination: post. white column (funiculus) join the deep sensation pathway (describe below)(2)light touch: cells in post. horncross through t

61、he ant. white commissure to the other side join the pain and temperature sense pathway (describe above) Section 2 Sensory System pathways pathway of deep sensation: Muscle, tendon, periosteum(骨膜 ),joint post. spinal root gangliondorsal rootpost. spinal cord ascending in the ipsilateral fasciculus gr

62、acilis, fasciculus cuneatusipsilateral nuclei of gracilis and cuneatus (in medulla)cross in the decussation of medial lemniscus to the opposite side ventroposterior lat. neucleus of thalamuspost. limb of int. capsulepostcentral gyrus. Section 2 Sensory System Segmental cutaneous innervation Each pos

63、t. spinal root is from one spinal segment and supply a certain area of skin, this area is called dermatome or dermatomic area. Thus, the number of dermotome (31)= the number of spinal roots, ie. C8、 T12、 L5、 Sacral5 、Coccygeal1 Segmental cutaneous innervation is best seen in the thoracic area: T4nip

64、ple T7costal arch T10navel(umbilicus) T12L1groin Section 2 Sensory System Arrangement of sensation conductive fasciculi in spinal cord Post. white column( funiculi): fibers in posterior funiculi are arranged in a somatotopic order: those carrying the impulses from legs, lower trunk run in the fascic

65、ulus gracilis, those carrying the impulses from chest, arms and neck run in the fasciculus cuneatus. Spinothalamic tract : Like the fibers of the posterior funiculi, those from the legs run most peripherally, and those from the neck run most centrally(medially). Section 2 Sensory System Clinical typ

66、es of sensory disturbance Irritative symptoms Caused by an irritative lesion in the sensation pathway. Including the following: Hyperesthesia（ 感 觉 过 敏 ） : increased tactile sensibility. Slight stimulation cause strong sensation. Hyperpathia（ 感 觉 过 度 ） :decreased tactile sensibility. Dysesthesia(感 觉 倒 错 ):non-painful stimulation cause painful sensation, cold stimulation cause warm sensation. Paraesthesia（ 感 觉 异 常 ） :when no stimulation is given, the patient may feel abnormal sensations, eg. numbn