神经病学总论.ppt

Neurology (in General) Lin Yin, MD Chief, Professor,Teaching/research Section of Neurology and Psychiatry The 2nd Clinical College of Dalian Medical University,Chapter 1 Introduction,Definition Neurology means clinical neurology, which is a branch of internal medicine. Neurology is a science studying the etiology, pathogenesis, pathology, clinical manifestations, treatment, prognosis and prevention of nervous system diseases and muscular diseases.,Chapter 1 Introduction,Neurology and Psychiatry Neurological diseases are close to but different from Psychiatric diseases. Psychiatric diseases refer to disturbance of the normal function of the brain esp. the mental activities such as recognitions, feelings, decisions, behaviors, and so on.,Chapter 1 Introduction,Working protocol Similar to internal medicine. First take the medical history, then do physical exam, and then do some medical exams. So we 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 examinations 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，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 Resonance 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 Potentials,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,Arrangement Lectures: 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 Cranial nerves,Do you remember what are the 12 pairs of cranial nerves? ，Olfactory nerve,Temporal,nasal,Optic N.,chiasm,Optic tract,Optic radiation,Lateral Geniculate body,Visual cortex,Lesion sites and clinical,Section 1 Cranial nerves ，Optic nerve,Anatomy and pathway Retina(rods,cones)ganglion cellsoptic nerveoptic chiasm(nasal half fibers cross, temporal half fibers uncross)optic tractlateral geniculate bodyposterior limb of the internal capsuleoptic radiationoccipital (calcarine)cortex (visual center),Section 1 Cranial nerves ，Optic nerve,Clinical Findings: Vision 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 hemianopsia. *. 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 macular sparing.,8,Temporal,nasal,Optic N.,chiasm,Optic tract,Optic radiation,Lat.eral Geniculate body,Visual 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 side 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 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 outward,Sub-neuclei,E-W,Section 1 Cranial nerves ,(Oculomotor N,Trochlear N,Abducens N),Diagram of eye muscle action,Section 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., 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, the 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 constriction 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) ciliary 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 nerves ,(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 ,(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, inward, 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) 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) 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) Supranuclear 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) produce 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 ophthalmoplegia (self study),，Trigeminal nerve,Anatomy and physiology Sensory pathway： V1opthalmic br. V2 maxillary br. trigeminal semilunar ganglion V3 mandibular br. Nucleus of main sensory (touch) Nucleus of spinal tract (pain, temprature) fibers cross to the opposite of medulla trigeminal lemniscus ventroposterior medial nucleus (VPMN) of the thalamus posterior limb of the internal capsule postcentral 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 sensory (touch)facial N.orbicular m. of eye,Section 1 Cranial nerves ，Trigeminal nerve,Motor pathway precentral gyrus corticobulbar tract internal capsule the bilateral trigeminal motor nuclei(pons) join the mandibular nerve(V3) muscles of mastication(masseter, temporal, internal and external pterygoid).,Section 1 Cranial nerves ，Trigeminal nerve,Clinical 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: 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 meatus, meninge), as well as paralysis of the muscles of mastication.,Section 1 Cranial nerves VII, Facial nerve,Anatomy and pathway Bilateral corticobulbar tract sup. part of facial nucleus Contralateral corticobalbar tract inf. part of facial nucleus facial nerveinternal acoustic meatus facial canal (chorda 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 Clinical Findings,Peripheral facial palsy Location of lesion: Facial nucleus, or facial nerve Manifestation : 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.2/3 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 Findings,Central facial palsy (supranuclear paralysis) : Location of lesion: the corticobulbar tract Manifestation : On the contralateral side: All the peripheral facial palsy signs are present, except: Wrinkles on the forehead does not become flat Palpebral fissure does not become larger The patient has no difficulty to: wrinkle his forehead, or close his eye. Because the sup. part of facial 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 nerve,1Vestibular Nerve pathway (pure sensory N.) Vestibular apparatus in the inner ear (3 semicircular canals) vestibular ganglion vestibular nerve internal acoustic meatus group of vestibular nuclei(medial, lateral, sup., spinal) Vestibulospinal tract spinal ant. horn cells Vestibulocerebellar tract cerebellum Medial longitudinal fasciculus(MLF) ocular motor nerves (III,IV,VI) Functon: feel 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 Findings 1. Vertigo A motor hallucination. The patient feels surrounding objects are moving or rotating, with nausea and vomiting. 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 vestibular 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, vertical, rotatory, etc.,Section 1 Cranial nerves , Vestibulocochlear nerve,2Cochlear 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. colliculus 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 nerve 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 conductive 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,1Anatomy and physiology Motor: Precentral gyrus bilateral corticobubar tract nucleus 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 larynx Taste sensation in post.1/3 of the tongue,These two nerves are motor and sensory mixed nerves which have a close relationship in anatomy and function.,Section 1 Cranial nerves ，Glossopharyngeal and vagus nerves,2.Clinical Findings Unilateral IX and X palsy: 1) Hoarseness, 2)dysphagia(difficulty in swallowing), may be with regurgitation of fluids) 3)loss of sensation in pharynx 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 nerves,Section 1 Cranial nerves ，Accessory nerve,1, Anatomy (pure motor nerve) Bilateral corticobulbar tracts Ambiguous nucleus(medulla)medullary br. reccurrent laryngeal rinsic 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 shrug 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 the tongue Hyoglossal m.(舌骨舌肌):Contract the tougue,Section 1 Cranial nerves Hypoglossal nerve palsy,Section 2 Sensory System Classification of sensation,Sensation 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, touch. 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 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(parietal 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 the 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 gracilis, 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. capsulepostce