精品肠病毒71型感染的神经系统变化课件

腸病毒71型感染的神經系統變化,童綜合醫療社團法人童綜合醫院 遲景上,EV 71 outbreaks (I) 腸病毒71型流行之國家,EV 71 outbreaks (II) 台灣腸病毒流行開始之年代,AFP=acute flaccid paralysis 急性肢體麻痺 AM=aseptic meningitis 無菌性腦膜炎 BSE=brainstem encephalitis 腦幹腦炎 E=encephalitis 腦炎 HA=herpangina; HFMD=hand-foot-mouth disease潰瘍性咽峽炎，手足口病,87至95年臺灣地區腸病毒感染併發重症病例數,Clinical course in critical EV 71 infection 腸病毒71型腦幹腦脊髓炎之臨床過程,Fever(發燒) Skin rashes(疹) Oral ulcers (咽峽潰瘍),Myoclonus(肌跳躍) Sleep interruption (睡眠中斷) Vomiting(嘔吐) Flaccid paralysis (肢麻痺或無力) Cranial nerves palsy (顱神經麻痺) Opsoclonus(眼亂跳) Tachycardia (心跳加速),Tachycardia(心跳加速) Hypertension(高血壓) Cold sweating(冒冷汗) Pale looking(臉蒼白) Altered level of consciousness (意識改變) Pul. edema(肺水腫) Pul. hemorrhage(肺出血) Heart failure(心臟衰竭) Rapid death(快速死亡),切記時間和症狀的順序,Staging in critical EV 71 infection 腸病毒分期,Clinical Features (臨床神經學表現),Neurological manifestations v.s. Neuroimaging findings 神經學症狀與神經影像學之對比,Aseptic meningitis 無菌性腦膜炎,History 病史 fever, vomiting, irritability, headache (發燒、嘔吐、燥動、頭痛等) PE: meningeal irritation (理學檢查：腦膜受到刺激的徵兆) CSF: 10 WBC/cumm and bacterial culture (-) (脊髓液分析：白血球增加，細菌培養陰性),切記年齡,Encephalitis 腦炎,Altered level of consciousness 意識程度之改變,Alert 清醒 Drowsy 嗜睡 Stupor 半昏迷 Coma 深昏迷,切記不要以意識狀態評估病情的嚴重性,不要以大腦MRI所見來評估病情之嚴重性,大腦磁振造影所見,腦幹背側功能異常及脊髓功能異常是病情演變的重點,Hypothalamic Nuclei 下視丘核,Sleep, Wakefulness Consciousness 意識之改變,III,IV,VII,IX,X,XII,V,Dorsal motor nucleus of vagus n 迷走神經之運動核,Swallowing吞嚥,Vasomotor control血管動力控制,Nuclear area for expiration吐氣,Nuclear area for inspiration吸氣,Nuclear pneumotaxic center,autonomic coordination of food intake,腦幹背側功能失調是疾病的特色,Upper mesencephalon 間腦部位,Corticospinal Fibers 錐體束,Nucleus of CN III 第三顱神經核,Nucleus of sup. Colliculus四疊體,Upward gaze paralysis往上動眼異常 Opsoclonus眼球亂跳 Pupils size 瞳孔異常,Red nucleus 紅核,眼球的徵兆可彰顯腦幹背側功能異常,Upper pons-isthmus 橋腦上部,Sup.cerebellar Peduncle 上小腦橋臂,Corticospinal& corticopontine Tracts 腦皮質脊膸及 腦皮質橋腦束,Med.longitudinal fasciculus 內縱纖維束,Nucleus of CN V 第五顱神經核,Med. lemniscus,Lat. lemniscus,Myoclonus肌跳躍,肌跳躍的症狀可早期提醒家長及醫療人員,Upper pons 橋腦上部,Sup.cerebellar Peduncle 上小腦橋臂,Med. lemniscus,Corticospinal& corticopontine tracts腦皮質脊膸及 腦皮質橋腦束,Ataxia步態不穩 Tremor顫抖,可出現小腦協調功能異常,Lower pons 橋腦下部,Sup.cerebellar Peduncle 上小腦橋臂,Inf.cerebellar peduncle 下小腦橋臂,Mid.cerebellar peduncle 中小腦橋臂,Corticospinal tracts 腦皮質脊髓束,Dentate nucleus 鋸齒核,Motor nucleus of CN VII 第7顱神經核,Nucleus of CN VI第6顱神經核,Cranial nerve palsy 顱神經麻痺(6或7),第六或第七顱神經功能失調表示腦幹背功能異常、,Upper medulla 延髓上部,Rootlets of CN IX 第9顱神經,Pyramids 錐體束,Med. lemniscus,Olivary nucleus 橄欖核,Inf.cerebellar peduncle 下小腦橋臂,Soiitary nucleus 孤獨核,Bulbar palsy顱神經功能異常 Tachycardia心跳加速 Ileus腸蠕動異常 Hypertension高血壓 Vomiting嘔吐,心跳過快、血壓高表示病情危急,Lower medulla 延髓下部,Soiitary nucleus孤獨核,Olivary nucleus 橄欖核,Inf.cerebellar Peduncle 下小腦橋臂,Med. lemniscus,Dor. motor nucleus of CN X 第10顱神經運動核,Bulbar palsy 顱神經功能失調 (Swallowing) (吞嚥困難) Tachycardia心跳加速 Ileus腸蠕動異常 Hypertension高血壓 Vomiting嘔吐,Nucleus ambiguus 疑核,嘔吐、心跳快、血壓高、吞嚥困難表示腦幹功能異常,Acute flaccid paralysis 急性肢體麻痺,acute onset of flaccid weakness reflex (-)急性肢體無力，肌腱反射減低或消失,CIBA 1972 ISBN 0-914168-01-0,切記早期只出現肢體麻痺並不代表病情不會惡化,C2-7,脊髓磁振造影,Neurology Cardiology 神經對心臟肌肉之影響,Pulmonary SA receptors,Arterial chemoreceptors,Arterial baroreceptors,Facial + laryngeal receptors,CVM,第10顱神經運動核及疑核 Dorsal motor N X Nucleus ambiguus,Inspiratory neurons 吸氣神經,NTS,Inspiratory drive 吸氣驅動,CVT,腦幹與心血管，呼吸之關聯,Solitary nucleus 孤獨核,Olivary nucleus 橄欖核,Inf.cerebellar Peduncle 下小腦橋臂,Med. lemniscus,Dor. motor nucleus of CN X第10顱神經運動核,CSP(Central sym.pathway) 中樞交感神經徑路,Pyramids錐體束,Nucleus ambiguus疑核,迷走神經功能低下及交感神經興奮病情惡化的主因 切記不要以胸部光片決定左心衰竭,腦幹延髓部,Neurological sequelae 神經後遺症,Cranial nerve palsy (顱神經麻痺) Flaccid paralysis / Limping gait (肢體麻痺/無力) Swallowing and sucking difficulty (吞食困難) Sleep disorder / Temper tantrum (睡眠異常/壞脾氣) Resp. problem : Ondine curse (自發性吸氣困難) Water - shed phenomenon (腦血流末端流量不足) HIE / Hypertension Encephalopathy (腦缺氧缺血腦症),Death 死亡 Sequelae 後遺症 Normal正常,EV 71腸病毒71型感染,Pul. edema 肺水腫或出血,CHI C.S.,HR BP Pale suddenly Sweating Coldness of limbs,Myoclonus AFP Vomiting,Series heart sono. 心臟超