神经内科学：Neurology

1、Neurology,Main Contents,（一）Outline （二）Location 1. Depending high brain function to localization (1).Conscoiusness evaluation and classification (2).High cortical function (3).High subcortical function 2.Other: Meningeal irritation sign 3.From cranial nerve to localization 4.From sensory system to lo

2、calization （1）Superficial sense （2）Deep sense 5.From motor system to localization （1）Pyramidal tract (muscle force) （2）Extracorticospinal tract (muscule tone) （3）Cerebellar,主要内容,（一）概论 （二）定位 1.依靠高级脑功能定位 (1).意识的评估及分类 (2).高级皮层功能检查 (3).高级皮层下功能 2.其他: 脑膜刺激征 3.利用12对脑神经检查来定位 4.利用感觉系统检查的定位 （1）浅感觉检查 （2）深感觉检查

3、5.利用系统病变来定位 （1）锥体束系统（肌力） （2）锥体外系统：基厎神经节症状与体证（肌张力） （3）小脑系统,神经系统定位诊断 (Localization of nervous system),高级皮层功能定位(The localization from cortex function) 皮层下定位（Subcortex: basal ganlia to localization） 颅神经损害的定位 (cranial nerve) 脊髓节段定位(Spinal segment localization) 运动系统(motor system) 感觉系统分布来定位(sensory system)

4、 深反射节段(deep reflex),General Introduction,The most frequent neurological disorders,Epilepsy (60-800/100000),(tension type: 40-60%, migraine: females 9-12%,males 4-6%),Neurological disorders,Two contents are addreesd,Peripherial systems symptoms and exemination (周围神经系统证状与体征) Central nerve system syste

5、ms and exemination (中枢神经系统证状与体征),定位(Localization) Depending high brain function to localization (依靠高级脑功能定位) Conscoiusness evaluation and classification (意识的评估及分类),FROM CEREBRAL CORTEX: LOCALIZATION OF FUNCTION AND ASSOCIATION PATHWAYS,The cerebral cortex is organized into functional regions.,In addi

6、tion to specific areas devoted to sensory and motor functions, there are areas that integrate information from multiple sources.,Eye Opening spontaneous -4 to speech -3 to pain -2 nil -1,Glasgow Coma Scale,Best motor response obeys -6 localizes -5 withdraws -4 abnormal flexion -3 extension response

7、-2 nil -1,A strong predictor of outcome 13: mild brain injury 9-12:moderate brain injury 8:severe brain injury (coma),Verbal reponse oriented -5 confused conversation -4 inappropriate words - 3 incomprehensible sounds -2 nil -1,From Special symptoms:Basal ganglia disorder symptoms,Movement involunta

8、ry,Spasticity Continue clonic contraction, upper motor neuron( HSP)MOV Myoclonus: A single sudden jerk or a short series occurring in slow :such as CJD, Metabolic Encephalitis,Clonus-VCDVCD3 001.MOV,Tic disorders,Sudden, repetitive, stereotyped, purposeles brief actions, gestures, sounds,The prototy

9、pe tic disorder Tourette syndrome,Chorea,HD and Wilson disease ussually seen 1.HD family111.mpg 2 .2.MPG视频总集HD family11(转).wmv 3.HD cheng jianxin.avi 4.HD2.mpg,Denotes rapid irregular muscle jerks that occur involuntarily and unpredictably in different parts of the body,Tremor,Intension tremor: cere

10、bellar Rest tremor: PD(4-6 Hz):PD brother 012.mpg PD. tremor1.mpg Action tremor: Essential Postural tremor: metabolism(8-12 Hz) Dystonia tremor PatientsVCD.mpg,A rhythmic oscillatory movement best characterized by its relationship to voluntary motor activity,Midbrain hemorrhage,VCD,Athetosis,Definit

11、ion,In contrast to chorei form movements, these are slower,When writing, resembling the actions like a worm or snake,Coordination,Principally evaluates cerebellar function Dependent on other components of movement,Incoordination: ataxia,Coordination for cerebellar function,Cerebellar-VCD 001.MOV,Sen

12、sory (posterior spinal column),Motor,Cortical integration,Cerebellar /Vestibular systems,Multiple system involved,Observation important,Gait,VCDPD-PISA.MOV,Muscle disorder (DMD)-muscle duck gait.MOV,Muscle,Useful but often overlooked,Gait,Spasticity gait: gait.MOV,Casual patient walks several meters

13、, have turn quickly to R, return and turn quickly to L,Examination,Heel/Toetandem,Not necessarily for localizing but sensitive to the presence of a problem,Romberg test,Removes the use of vision to compensate for balance defect Patient is asked to stand with comfortable stance and then close eyes,Sp

14、ecific test for posterior spinal column impairment,Positive loss of balance Negative sway/no change in stance,Other tests,Postural maintenance (“drift”),Objective, not specific Arms forward, palms up with fingers spread If no drift, attempt to dislodge,Alternating movements,Specific for cerebellar d

15、isease Nonspecific for UMN or parietal lesions,VCD,From Cranial nerve to localization,1.嗅神经 2.视神经 3.动眼神经 4.滑车神经 5.三叉神经 6.外展神经 7.面神经 8.位听神经 9.舌咽神经 10.迷走神经 11.副神经 12.舌下神经 ,Cranial nerve I - Olfactory nerve,Noxious substances not suggested (such as Ammonia or alcohol),false positive response,Close eye,

16、Identified familiar odors,peppermint,coffee,cloves,Cranial nerves( II ) Optic Nerve,Major function: vision,Optic nerve,Vision examination,Vision examination,Visual acuity,Words or letter,Fingers 1m,Movements of hand,Flash a light,Snellen charts testing,20/20 feet and 6/6 meters normal,Normal Fundi,E

17、dema fundi,Visual fields,Cranial nerves( III ) Oculomotor(IV) Trochlear (VI) Abducent,Major function: III: eyelid and eyeball movement IV: innervates superior oblique turns eye downward and laterally VI: turns eye laterally,Pretectum & Pupillary Light Reflex,Pupillary Constrictor muscle,The pretectu

18、m controls the action of the pupillary constrictor muscle via its projection to both Edinger-Westphal nuclei,Pretectum & Pupillary Light Reflex,The pretectum bilateral projections to the Edinger-Westphal nuclei ensure that both eyes react to light: shining a light into each eye can elicit a direct a

19、nd a consensual pupillary reflex.,This light reflex tells us about ones visual pathways status.,Pretectum & Pupillary Light Reflex,In summary, pupillary reflexes are clinically important because they indicate the functional state of the afferent and efferent pathways mediating them. The absence of p

20、upillary reflexes in an unconscious patient is a symptom of damage to the pretectum.,Cranial nervesTrigeminal Nerve (V),Major function: chewing face & mouth touch & pain,三叉神经痛临床特点,三叉神经分布区 无客观定位体征 发作性、短暂性：数秒钟 有触发因数：如讲话、漱口等 治疗：卡马西平等,Cranial nerves(VII)Facial Nerve,Major function: controls most facial

21、expressions secretion of tears & saliva taste,Central & peripheral facial paralysis,Paralysis involving all divisions of the nerve is peripheral, and that sparing the forehead is central.,Facial paralysis diagnosis and treatment (面神经炎诊断与治疗),Peripheral facial paralysis(周围性瘫) Hormone treatment(激素治疗) V

22、itaminB(维生素) Acupuncture and physical treatment (理疗针灸等),Cranial nerves (VIII) Vestibulocochlear Nerve,Major function: hearing equillibrium sensation,Hearing,Otoscopic inspection of the auditory canals and tympanic membranes,assessment of auditory acuity Weber test (256 Hz tuning fork): unilateral se

23、nsorineural hearing loss (from lesion of the cochlea or cochlea nerve). Conductive(external or middle ear),Vestibular portion,Nystagmus Video 1 (wmv 2M).wmv is rhythmic oscillation of the eyes.,pendular nystagmus, onset infancy with equal velocity in both direction.,jerk nystagmus is characterized b

24、y slow phase of movement followed a fast phase in the opposite direction,Dix- Hallpike (Maneuver for benign positional vertigo),Positional nystagmus test,Vertigo and dizzy,Vertigo is the illusion of movement of the body or the environment,Dizzy is sensations of light-headedness, faintness, or giddin

25、ess not associated with an illusion of movement,Rombergs sign,Assessment of hearing loss,Weber test Rinne test Normal sound perceived as coming midline air bone conduction,Sensorineural hearing loss,air conduction bone conduction,Conductive hearing loss,bone conduction air conduction on affected sid

26、e,sound perceived as coming from affected ear,sound perceived as coming normal ear,Cranial nerves(IX) Glossopharyngeal Nerve,Major function: taste senses carotid blood pressure,Cranial nerves (X)Vagus Nerve,Major function: senses aortic blood pressure slows heart rate stimulates digestive organstast

27、e,Glossopharyngeal nerve (、）,Sense and motor examination Pharynx(gag) reflex with nause by touching the back of tongue with a tongue blade Pharynx (open mouth and say “ah”): uvula rise symmetry Larynx: watch laryngeal contours rise with swallowing Swallow some water (if paralysis induced coughing or

28、 reflux into the posterior nose, hoarseness may be unilateral vocal cord paralysis (dysdipsia) Dispnea and inspiratory stridor (bilateral involvement) Disphagia,Cranial nerves (XI) Accessory Nerve,Major function: controls trapezius & sternocleidomastoidcontrols swallowing movements,Accessory nerve,O

29、nly motor fiber Two muscles Trapezum and sternocleidomastoid Palpate the upper borders of the trapezii Look for scapular Sternocleidomastoid (turn head test),Cranial nerves (XII) Hypoglossal Nerve,Major function: controls tongue movements,Hypoglossal nerve,Only motor fiber Oboservation the tremors,

30、atrophy and fasciculations (When the tongue protrudes) Deviation toward to paralysis,Paralysis of the hypoglossal nerve affects the tongue. It impairs speech (it sounds thick) and causes the tongue to deviate toward the paralyzed side. In time, the tongue diminishes in size (atrophies).,Hypoglossal

31、tumor,Tongue atrophy in left side,感觉系统(From spinal and sensory system to localization),For example, when the C6 nerve is pinched, there is pain and numbness in the thumb and index finger.,List of Dermatomes of Commonly Injured Nerve Roots,C5 The area over the shoulder. C6 The thumb and part of the f

32、orearm. C7 The middle finger. C8 The smallest fingers and part of the forearm. L4 The thigh. L5 The medial part of the calf and foot, the big toe. S1 The lateral part of the calf and foot, the smaller toes.,Sensory function examination,Testing pain sense Reduced (hypalgesia) absent(analgesia) Increa

33、sed (hyperalgesia) Testing tactile sense,Sensory function examination,Grade: normal,anesthetic,hypesthetic Testing temperature sense (hot 40-45 and cold water 5-10),Light touch,Use piece of cotton End-point touch Lack of response to a touched hair is not normal,Pain,Use a pin Demonstrate sharp stimu

34、li v. dull Skin on the sole or palm not as sensitive,Temperature,Testing should be done slowly (2 sec.of stimuli, large area) Ideally use test tubes of hot and cold water Compare to normal area,运动系统(From motor system),锥体束传导通路,Thalamus infarction,Brain stem infarction,Motor system,Objective Evaluate

35、pyramidal and extrapyramidal systems Not a wrestling match Shorter the muscle, greater the power,Motor examination,Myotrophy, tone and strength Involuntary movement Coordination Abnormal muscle activities,Testing muscle tone,Hypotonia: lower motor neuron injury(poliomyelitis, root syndrome,and perip

36、heral neuropathy, cerebellar and central lesions(acute stage) Hypertonia: increased resting muscle tone Extrapyramidal lesions: PD(cogwheel rigidity),Motor examination,Bulk-observe the bare appendicular muscles, shoulder-girdle and palpate Resistance to passive manipulation (tone)-supinate the hand

37、(forearm muscles) Wrist extension passive knee flexion (quadriceps),Strength evaluation,Grade 0: no muscle movement Grade 1: muscle movement without joint motion Grade 2: body part moves with gravity limited Grade 3: body part moves against gravity but not resistance Grade 4: body part moves against

38、 gravity and some resistance Grade 5: normal,Abnormal muscle activities,Fasciculations definition: damage to the supplying muscle results in spontaneous motor unit firing that is visible as a twitching of muscle fibers Cramps: spontaneous contraction of part or whole of a muscle(calf muscle) eg: mot

39、or neuron and metabolic disease,Abnormal muscle activities,Fibrillations: twitch of individual muscle fibers, invisible But it can be demostrated by EMG,Upper motor neuron paralysis & Lower motor neuron paralysis,These changes in muscle performance vary depending on the site and the extent of the le

40、sion, and may include: * Muscle weakness * Decreased control of active movement * Brisk tendon jerk reflexes * Spasticity: a velocity-dependent change in muscle tone * Clasp-knife response: where initial higher resistance to movement followed by a lesser resistance * Babinski sign is present * incre

41、ase deep tendon reflex * EMG: nerve conduction was normal and no loss of nerve potentials.,An upper motor neuron lesion is a lesion of the neural pathway above the anterior horn cell or motor nuclei of the cranial nerves.,Upper motor neuron paralysis & Lower motor neuron paralysis,One major characte

42、ristic used to identify a lower motor neuron lesion is flaccid paralysis - paralysis accompanied by muscle loss. This is in contrast to a upper motor neuron lesion, which often presents with spastic paralysis - paralysis accompanied by severe hypertonia. * Muscle paresis or paralysis * fibrillations

43、 * fasciculations * Hypotonia or atonia * Areflexia or hyporeflexia * EMG: nerve conduction was abnormal and loss of nerve potentials.,A lower motor neuron lesion is a lesion which affects nerve fibers traveling from the anterior horn of the spinal cord to the relevant muscle(s) - the lower motor ne

44、uron.,List of Myotomes of Commonly Injured Nerve Roots,C5 The deltoid muscle (abduction of the arm at the shoulder). C6 The biceps (flexion of the arm at the elbow). C7 The triceps (extension of the arm at the elbow). C8 The small muscles of the hand. L4 The quadriceps (extension of the leg at the k

45、nee). L5 The tibialis anterior (upward flexion of the foot at the ankle). S1 The gastrocnemius muscle (downward flexion of the foot at the ankle).,How can I tell if weakness is related to the peripheral or central nervous system?,Peripheral Nervous System Deep Tendon Reflexes Decreased or Normal Pat

46、hological Reflexes Absent Fatigue- MG Atrophy Fasiculations,Central Nervous System Deep Tendon Reflexes Increased Pathological Reflexes “Babinski Sign” Present Increased Tone: Spasticity,FROM Deep Reflex:,SPINAL REFLEX PATHWAYS,Proprioception and Reflex Pathway,Position sense or proprioception invol

47、ves input from cutaneous mechanoreceptors, Golgi tendon organs, and muscle spindles (middle figure of upper panel). Both monosynaptic reflex pathways (middle figure of upper panel) and polysynaptic pathways involving several spinal cord segments (top and bottom figures of upper panel) initiate muscle contraction reflexes. The lower panel shows the somatotopic distribution of the motor neuron cell bodies in the ventral horn of the spinal cord that innervate limb muscles (flexor and extens