《神经病学》（英文）PPT电子课件

NeurologyDepartmentofNeurology,The2ndaffiliatedhospital,HarbinMedicalUniversityChapter1.

Introduction神经病学(Neurology)TheObjectsofNeurology:CNS、PNSandmusculardisordersThecontentsofstudy:EtiologyandPathogenesisPathologyClinicalfeaturesDiagnosisandDifferentialdiagnosis,TreatmentandPreventionPrognosisNervoussystemCentralnervoussystem:brainspinalcordPeripheralnervoussystem:cranialnervesspinalnervesNervoussystemNeurologyisapartofneuroscience,including:

Neuroanatomy,Neurophysiology,

Neurobiochemistry,Neuropathology,

Neurogenetics,Neuroimmunology,

Neuroepidemiology,Neuroiconography神经影像学,

Neurophamacology,

Neuropsychology,

ExperimentalNeurology,Neurobiology,

MolecularBiologyCatalogueoftheneurologicaldiseasesVasculardiseasesInfectiousdiseasesTumorsTraumaticdiseasesCatalogueoftheneurologicaldiseasesAutoimmunediseases(someofthemaredemyelinativediseases脱髓鞘疾病)HereditaryandmetabolicdisordersCongenitaldysplasia先天性发育障碍IntoxicationNutritionaldisturbancesSymptomsofNervousSystemcoulddividedtofourclasses:Deficitsymptomsdeficitsorlossonthenormalfunctions(hemiparalysis,aphasia)Irritativesymptomsexcessiveexcitementsthatnervousstructuresappearedwhentheywerestimulated(seizures,radicalpain)SymptomsofNervousSystemcoulddividedtofourclasses:Liberatedsymptoms

Whenthehighercenterswereimpaired,thefunctionofthelowercenterthatnormallycontrolledbytheformerwasliberated(pyramidalsigns锥体束征).SymptomsofNervousSystemcoulddividedtofourclasses:ShockSymptoms

CNS急性局部严重病变，引起与之功能相关的远隔部位神经功能短暂缺失

Brainshock:cerebralhemorrhage

Spinalshock:intheacutestageoftotalcordtransverse,thereisaflaccidparalysiswithlossoftendonandotherreflexes,accompaniedbysensorylossbelowthelevelofthelesionandbyurinaryandfecalretention.Supplementedexaminneurologicaldiseases1.LumbarpunctureandCSFanalysis:Appearance,Pressure,DynamicsRoutineexamBiochemicalexaminationsCSF-IgGindex,OBCytologicexamSpecificantibodies(MBP,AChR)Supplementedexam2.Imagingstudies:

plainX-raysoftheskullandthespine,myelographyCT,MRI(magneticresonanceimaging),MRADSA(digitalsubtractionangiography)Supplementedexam3.Electrophysiologicstudies:EEG(electroencephalography)EMG(electromyography)NCV(nerveconductionvelocity)VEP(visualevokedpotentials)BAEP(brianstemauditoryevokedpotentials)SEP(somatosensoryevokedpotentials)

4.Transcranialdoppler(TCD)

SupplementedexamRadioisotopeexaminations(放射性同位素)SPECT(singlephotoncomputedtomography)PET(positronemissiontomography)Immunologicandvirologicdetections(免疫学及病毒学检测)：suchasMBP、AChRandcysticercusantibodies,(HSV)PCRBiopsy:muscles,nervesandbrainChapter2.

SymptomatologyoftheNeurologicalDiseasesSection1.

DisordersofConsciousnessDisturbancesoftheLevelofConsciousness

Consciousnessisawarenessoftheinternalorexternalworld.意识(awareness)指大脑的觉醒(arousal)程度，是机体对自身和周围环境的感知和理解功能，并通过语言、躯体运动和行为表达出来；是CNS对内、外环境刺激应答反应的能力。该能力减退或消失就意味着不同程度的意识障碍(disordersofconsciousness)。意识(consciousness)-ConceptConsciousnessdescribesthatsetsofneuralprocessesthatallowanindividualtoperceive,comprehend,andactupontheinternalandexternalenvironments.Itisusuallyenvisionedintwoparts:arousalandawareness.Arousaldescribesthedegreetowhichtheindividualappearstobeabletointeractwiththeseenvironments;thecontrastbetweenwakingandsleepingisacommonexampleoftwodifferentstatesofarousal.

Arousalrequirestheinterplayofboththereticularformationandthecerebralhemispheres.Thereticularcomponentsnecessaryforarousalresideinthemidbrainanddiencephalon;thepontinereticularformationisnotnecessaryforarousal.Awarenessreflectsthedepthandcontentofthearousedstate.Awarenessisdependentonarousal,sinceonewhocannotbearousedappearstolackawareness.Awarenessdoesnotimplyanyspecificityforthemodalityofstimulation.Thisstimulationmaybeexternal(e.g.,auditory)orinternal(e.g.,thirst).

Attentiondependsonawarenessandimpliestheabilitytorespondtoparticulartypesofstimuli(modality-specific).Stuporreferstoaconditioninwhichthepatientislessalertthanusual,butcanbestimulatedintoresponding.Obtundation

(意识模糊)describesapatientwhoappearstobeasleepmuchofthetimewhennotbeingstimulated.Thiseyes-closedstateisnotelectroencephalographicsleep,however.Stuporous/obtundedpatientswillrespondtonoxiousstimulibyattemptingtodeflectoravoidthestimulus.PatientwithComalieswitheyesclosedanddoesnotmakeanattempttoavoidnoxiousstimuli.Suchapersonmaydisplayvariousformsofreflexposturing,butdoesnotactivelytrytoavoidthestimulus.Vegetativestate,inwhichtheeyesopenandclose,thepatientmayappeartotrackobjectsabouttheroom,andmaychewandswallowfoodplacedinthemouth.However,thevegetativepatientdoesnotrespondtoauditorystimuli,anddoesnotappeartosensepain,hunger,orotherstimuli.Thisisastateinwhichthereisarousalbutnoawareness.Deliriumisdefinedasadisturbanceofconsciousnessthatisaccompaniedbyachangeincognitionthatcannotbebetteraccountedforbyapreexistingorevolvingdementia.Thedisturbancedevelopsoverashortperiodoftime,usuallyhoursordays,andtendstofluctuateduringthecourseoftheday.Thereisevidencefromthehistory,physicalexamination,orlaboratoryteststhatthedeliriumisadirectphysiologicalconsequenceofageneralmedicalcondition,substanceintoxicationorwithdrawal,useofamedication,ortoxinexposure,oracombinationofthesefactors.DisordersofConsciousnessAnatomicalbasisofalertingsystem(维持意识清醒的重要结构):脑干上行性网状激活系统(ascendingreticularactivatingsystem)

广泛的大脑皮质神经元的完整性(Cerebralcortexandtheafferentpathways)(中枢整合机构)Themaintenanceofconsciousnessrequiresafinebalanceofactivitybetweenthecerebralcortexandthereticularsystem.Disordersofconsciousness-Clinicalclassification意识障碍：指意识水平下降嗜睡(somnolent):患者处于睡眠状态，唤醒后定向力基本完整，但注意力不集中，记忆稍差，如不继续对答，又进入睡眠。Theearlystageofconsciousnessdisorder,itisoftenafeatureofraisedintracranialpressure.

Disordersofconsciousness-Clinicalclassification昏睡状态(stupor)：处于较深睡眠状态，较重的疼痛或言语刺激方可唤醒，作简单模糊的回答，旋即熟睡。Thepatientcanberousedonlybrieflybypainstimulationorloudspeech.Disordersofconsciousness-

Clinicalclassification

昏迷(coma):thepatientisunresponsiveandunarousable)

意识丧失，对言语刺激无应答反应，

可分为浅、中、深昏迷。Disordersofconsciousness

-ClinicalclassificationDisordersofconsciousnessaffectingthecontentsofconsciousness

意识模糊(confusion)或朦胧状态(twilightstate)意识轻度障碍，表现意识范围缩小，常有定向力障碍，突出表现是错觉，幻觉较少见，情感反应与错觉相关，可见于癔症。Disordersofconsciousness

-ClinicalclassificationDisordersofconsciousnessaffectingthecontentofconsciousness谵妄状态(deliriumstate)

定向力(orientation)、自知力障碍，注意力涣散(attention)，不能与外界正常接触。常有hallucinations、delusions，以错视为主，形象生动逼真，可有恐惧、外逃或伤人行为。Acute:fever,intoxicationsuchasAtropine

Chronic:chronicalcoholismDisordersofconsciousness

-Clinicalclassification特殊类型意识障碍--醒状昏迷(comavigil)1.去皮层综合征(decorticate)

无意识睁眼闭眼，光、角膜反射(cornealreflex)存在，对外界刺激无反应，去皮层强直状态(decorticaterigidity)，病理征(+)上行网状激活系统未受损，保持觉醒-睡眠周期，无意识咀嚼和吞咽缺氧性脑病、大脑皮质广泛损害CVD及外伤等Disordersofconsciousness

-Clinicalclassification2.无动性缄默症(akineticmutism)：对外界刺激无意识反应，四肢不能动，不语。无目的睁眼或眼球运动，睡眠-醒觉周期可保留。伴自主神经功能紊乱，体温高、心跳或呼吸节律不规则、多汗、尿便潴留或失禁，无锥体束征。脑干上部或丘脑网状激活系统及前额叶-边缘系统损害。Disordersofconsciousness

-ClinicalclassificationDifferentialdiagnosis(1)意志缺乏症

清醒状态，但不讲话，无自主活动。对刺激无反应、无欲望，严重淡漠状态。双侧额叶病变。

闭锁综合征(locked-insyndrome)脑桥基底部病变，皮质核束&皮质脊髓束双侧受损(Lacunarinfarct,Multiplesclerosis)表现几乎全部运动功能丧失Quadriplegiccranialnervespalsythatcomefromponsorbelowthepons闭锁综合征(locked-insyndrome)Theyareconsciousbyopeningtheireyesormovingtheireyesverticallyoncommand,buttheyarespeechless,motionlessandtheycan’tswallow.Section2.

AphasiaAphasia-Concept

失语症(aphasia)：脑损害所致的语言交流能力障碍，后天获得性各种语言符号(口语、文字、手语等)表达及认识能力受损或丧失。

Pointsfordiagnosis：Alert,normalmentalstate,nosevereintelligentdisturbancesNovisualandauditorydeficits,nopalsyorataxiaonthemusclesofvocalorgans(mouth,pharynxandlarynx)Aphasia-classification目前国内常用的失语症分类外侧裂周围失语综合征共同点：病灶都在外侧裂周区,共同特点是均有复述障碍(repetitiondisorder)。-Broca失语(Brocaaphasia,BA)-Wernicke失语(Wernickeaphasia,WA)-传导性失语(conductionaphasia,CA）Aphasia-classification经皮层性失语(transcorticalaphasia)---分水岭区失语综合征病灶位于分水岭区,共同特点是复述相对保留。经皮层运动性失语(transcorticalmotoraphasia,TCMA)经皮层感觉性失语(transcorticalsensoryaphasia,TCSA)经皮层混合性失语(mixedtranscorticalaphasia,MTA)Aphasia-classification完全性失语(globalaphasia,GA)命名性失语(anomicaphasia,AA)皮层下失语综合征(subcorticalaphasiasyndrome)丘脑性失语(thalamicaphasia,TA)底节性失语(basalganglionaphasia,BaA)BrocaAphasia

-Clinicalfeatures

obviousexpressiondisturbancetypicallynonfluent,paucityofspeech,difficulttotalk,

difficulttogivewords,telegraphic,lossofgrammar,disordersofrepetition,naming,readingandwriting.BrocaAphasia

-LesionsBrocaaphasia累及优势半球Broca区(额下回后部)相应皮层下白质脑室周围白质及顶叶岛叶损害WernickeAphasia

-Clinicalfeaturesnocomprehensionfluent，dashalong，speechnodifficultclearpronunciation，normaltunealotsemanticparaphasia(语义错语，如帽子—袜子)neologism(新语)，答非所问与理解一致的复述、听写障碍(dictationdisorder)WernickeAphasia

-LesionsWernickeaphasia位于优势半球Wernicke区(颞上回后部)ConductionAphasia

-Clinicalfeaturesrepetitionlostnlost(不成比例地)preservedspontaneousspeechnormalunderstanding不能讲出自发讲话时较易说出的词或句子，或以错语复述---语音错语(铅笔—“先北”)，找词困难、犹豫、停顿ConductionAphasia

-Lesions优势半球缘上回皮质或深部白质内弓状纤维TranscorticalAphasia

-Clinicalfeatures复述较其它语言功能好，甚至是不成比例地好TranscorticalAphasia

-Lesions因病变部位不同，临床表现亦不同，临床特点及病变部位如表2-3AnomicAphasia

-Clinicalfeatures以命名不能为主要特征呈选择性命名障碍，找词困难，赘语在所给的供选择名称中能选出正确的名词AnomicAphasia

-Lesions在优势半球颞中回后部或颞枕交界区GlobalAphasia

-Clinicalfeatures所有语言功能口语、听理解、复述、命名、阅读、书写均严重障碍表现为哑，刻板性语言（吗、吧、哒等）GlobalAphasia

-Lesions优势半球大范围病变，如大脑中动脉区大病灶SubcorticalAphasia

-Clinicalfeatures皮层下病变产生失语较皮质病变少见，症状不典型，但仔细观察仍可发现其特点

Classification:

-thalamicaphasia：表现为音量小、语调低、表情淡漠、不主动讲话，且有找词困难，可伴错语。-basalganglionaphasia：表现自发性言语受限、音量小、语调低Apraxia-ConceptApraxia:inabilitytoperformpreviouslylearnedtask企图作有目的或细巧动作时，不能准确执行所了解的随意性动作。如不能按要求做伸舌、吞咽、洗脸、刷牙、划火柴和开锁等简单动作但病人在不经意时却能自发地做这些动作脑部疾患时，患者无瘫痪、共济失调、肌张力障碍和感觉障碍，无意识及智能障碍病变部位多在左侧缘上回Agnosia-ConceptAgnosia：不能通过某种感觉辨认以往熟悉的物体，却能通过其它感觉通道识别如看到手表不知为何物，触摸表外形或听表走动声音，可知是手表脑损害时，无视觉、听觉、触觉、智能及意识障碍。是少见的神经心理学障碍Agnosia-classificationTactileAgnosia:cannotrecognizeafamiliarobjectsplacedinhishandsifhiseyesareclosed.VisualAgnosia:thereisimpairmentofrecognitionoffamiliarobjects,symbolsorpersonsAuditoryAgnosia:cannotappreciatethesignificanceofwellknownsoundsDisturbancesofVisionand

EyeMovementsSection3.DisturbancesofVision

-AnatomyandPhysiologyVisualpathways：retina→opticnerve→opticchiasm(a)→optictract→lateralgeniculatenuclei→opticradiations→calcarinecortex(posteriorpolesoftheoccipitallobes)视神经、视束及视放射纤维均按严格的排列顺序与视网膜的每一点有精确的对应关系。视交叉处视神经纤维的重组则成为偏盲或象限盲的基础如图2-2。DisturbancesofVision

-AnatomyandPhysiology

Decreasedvisualacuityinoneeye:Acutelossofvision:obstructionoftheophthalmicarteryorthecentralretinalartery)Transientmonocularblindness:TIAofinternalcarotidartery,ocularmigraineProgressivelossofvision:severalhours,days(ON、MS)不规则视野缺损，之后视力障碍或失明—compressivelesionsontheopticnerves:tumors,aneurysm,Foster-KennedysyndromeDisturbancesofVision

-AnatomyandPhysiologyDecreasedvisualacuityinbotheyes:Transientrecurrentamaurosis:TIAofvisualcentersonbilateraloccipitallobes,obstructioncanledtocorticalblindness(positivepupillaryreactiontolight)Progressiveblindness：intoxicationopticneuropathycausedbyinnutritionprimaryopticatrophypapilledema(tumor,hemorrhages,inflammation,increasedintracranialpressure)

DisturbancesofVision

-AnatomyandPhysiologyVisualfielddefects

Anatomicalbases:图2-2

双颞侧偏盲(Bitemporalhemianopia)垂体瘤、颅咽管瘤等使视交叉中部受损.DisturbancesofVision

-AnatomyandPhysiology对侧同向性偏盲(homonymoushemianopia)Clinicalfeatures：双眼病变对侧视野的同向偏盲Lesions：lateralgeniculatebodies,wholedamageofopticradiationandcalcarinecortex

图2-2DisturbancesofVision

-AnatomyandPhysiology对侧视野同向象限盲(homonymousquadrantanopia)双眼同向上象限盲(homonymoussuperiorquadrantanopia):见于颞叶后部病变使视辐射下部受损所致双眼对侧视野同向下象限盲(homonymousinferiorquadrantanopia):见于顶叶病变(肿瘤或血管病)使视辐射上部受损引起EyeMovementDisorders-

Clinicalfeatures

解剖生理基础:图2-3眼肌麻痹(ocularpalsy)Peripheralocularpalsy

动眼神经麻痹(oculomotornervepalsy):

ptosis,outwarddeviation,diplopia,瞳孔散大、光反射消失，lossofreactiontoaccommodationEyeMovementDisorders-

Clinicalfeatures解剖生理基础:图2-3眼肌麻痹(ocularpalsy)Peripheralocularpalsy

trochlearnervepalsy：Thesuperiorobliquemusclepalsy,diplopiaismostpronouncedwhenthepatientlooksdownwardabducensnervepalsy：inwarddeviation,failureofattemptedabduction,diplopiaEyeMovementDisorders-

Clinicalfeatures

Nuclearophthalmoplegia合并邻近神经结构损害：展神经核受损常累及面神经和锥体束等.产生分离性眼肌麻痹：动眼神经核性损害更可选择性损害个别眼肌,也可累及双侧眼肌。Thelesionsareusuallyvasculardiseasesofbrainstem,inflammatorydiseases,ortumors.EyeMovementDisorders-

Clinicalfeatures核间性眼肌麻痹(internuclearophthalmoplegia)

前核间性眼肌麻痹Lesions:lesionslieinthemediallongitudinalfasciculus,anunilateralascendingpathwayinthebrainstem图2-4Clinicalfeatures:Onlateralgaze,excursionoftheabductingeyeisfull(withnystagmusornot),butadductionofthecontralateraleyeisimpaired.Convergenceispreserved.EyeMovementDisorders-

Clinicalfeatures后核间性眼肌麻痹一侧内侧纵束下行纤维受损Onlateralgaze,theadductionofthecontralateraleyeisfull,buttheabductionoftheipsilateraleyeisimpaired.EyeMovementDisorders-

Clinicalfeatures一个半综合征(oneandahalfsyndrome)一侧脑桥被盖部病变引起该侧副外展神经核或PPRF受损，Asymptomthatcombinesinternuclearophthalmoplegiawithaninabilitytogazetowardsthesideofthelesion.图2-4EyeMovementDisorders-

Clinicalfeatures中枢性---核上性眼肌麻痹(Supranuclearopthalmoplesia)Lesions：皮层眼球水平同向运动中枢(lateralgazecenter)

Clinicalfeatures：palsyofconjugatehorizontalmovement双眼水平同向运动障碍即凝视麻痹(gazepalsy)，即双眼向病灶侧凝视刺激性病灶引起双眼向病灶对侧的同向偏斜图2-4EyeMovementDisorders-

Clinicalfeatures帕里诺(Parinaudsyndrome))Clinicalfeatures:upgazeparalysisLesions：上丘眼球垂直同向运动皮质下中枢损害

EyeMovementDisorders-

ClinicalfeaturesPupillaryabnormalitiesanatomyandphysiologyPupilssize:Inabrightlyilluminatedexaminingroom,normalpupilsare2~4mmindiameterinadults.瞳孔调节:支配瞳孔括约肌的动眼神经副交感纤维支配瞳孔散大肌的来自superiorcervicalganglion交感纤维共同调节EyeMovementDisorders-

ClinicalfeaturesPupillarylightreflex:Pathway:

retina→opticnerves→opticchiasma→optictract→pretectalarea(中脑顶盖前区)→Edinger-Westphalnucleus→oculomotornerves→ciliaryganglion(睫状神经节)→postgangliarfibers→pupillaryconstrictormuscles(瞳孔括约肌)光反射传入纤维，外侧膝状体之前视觉径路病变、中脑病变、传出纤维即动眼神经损害均可使光反射减弱或消失EyeMovementDisorders-

ClinicalfeaturesReactiontoaccommodation(调节反射,集合反射)Whentheeyesconvergetofocusonanearerobject,thepupilsnormallyconstrict缩瞳反应和会聚动作不一定同时受损，调节反射路径尚不确切阿罗(Argyll-Robertson)瞳孔

negativepupillarylightreflex,positiveaccommodationreflex顶盖前区光反射径路受损所致

neurosyphilisistheusualcause.EyeMovementDisorders-

Clinicalfeatures艾迪瞳孔又称强直性瞳孔(tonicpupil)Clinicalfeatures:

Unilaterallargerpupil,reactssluggishlyandonlytopersistentbrightlight光照停止后瞳孔缓慢散大。调节反射同样缓慢出现，缓慢恢复

EyeMovementDisorders-

Clinicalfeatures霍纳征(Hornersign)

clinicalfeatures:

unilateralsmallpupil(myosis),

ptosis(眼裂变小:睑板肌麻痹)、

enophthalmus(眼球内陷:眼眶肌麻痹)，lackofsweatingintheipsilateralface.Lesions：见于颈上交感神经径路损害及脑干网状结构的交感纤维损害(图2-5)。Section4.

VertigoandAuditoryDisordersVertigo-concept眩晕(vertigo)istheillusionofmovementofthebodyortheenvironment.患者主观感觉自身或外界物体呈旋转感或升降、直线运动、倾斜、头重脚轻等感觉。是对自身平衡觉和空间位象觉的自我体会错误头晕(dizziness)

常缺乏自身或外界物体的旋转感，sensationsoflight-headedness,faintnessorgiddinessVertigo-Clinicalfeatures

andclassification1.Systemicvertigo

Etiology：causedbylesionsonvestibulesystem,maincauseofvertigo,accompaniedbyequilibriumdisorder,眼球震颤anddysaudia。(1)Peripheralvertigo(真性眩晕)病变见于前庭感受器及前庭神经颅外段(未出内听道)，如迷路炎、中耳炎、前庭神经元炎、内耳眩晕症(Meniere病)等。Vertigo-Clinicalfeatures

andclassification(2)Centralvertigo(假性眩晕)病变在前庭神经颅内段、前庭核（vestibularnuclei）、核上纤维、内侧纵束及皮质和小脑的前庭代表区图2-6Usuallyoccurintransientischaemiaofvertibro-basalarteries;tumorsincerebellum,brainstem,andthefourthventricle;increasedintracranialpressure;auditoryneuroma;epilepsyetal.系统性眩晕的鉴别Vertigo-Clinicalfeatures

andclassification2.Non-systemicvertigoetiology：causedbyothersomaticdiseases,forinstanceeyediseases,anemia,hematonosis,heartfailure,infection,intoxicationandneurasthenia(神经功能失调),andsoon.features：是头晕眼花或轻度站立不稳，无眩晕感，seldomaccompanyingnausea、vomiting，nonystagmus.Vertigo-Clinicalfeatures

andclassification耳聋(deafness)Conductivedeafness(传音性耳聋)

外耳道和中耳病变，如外耳道异物或耵聍、骨膜穿孔和中耳炎等。Perceptivedeafness(感音性耳聋)

内耳、听神经、蜗神经核核上听觉通路病变所致Mixedhearingloss传导性及神经性耳聋同时存在AuditoryDisorders

-Clinicalfeatures耳鸣(tinnitus)

Concept:无外界声音刺激，患者却主观听到持续性声响。Lesions:是由听感受器及其传导径路病理性刺激所致的主观性耳鸣。AuditoryDisorders

-Clinicalfeatures听觉过敏(acoustichyperesthesia,hyperacusis)Concept

声音呈病理性增强，即患者感觉到的声音较真正听到的强。Lesions

常见于面神经麻痹时，因镫骨肌瘫痪使微弱的声波振动即导致内淋巴强烈震荡而引起。

Section5.

SyncopeandSeizureSyncope-Concept晕厥(syncope)

Pathogenesis:Thelossofconsciousnessisduetoreducedsupplyofbloodtothecerebralhemispheresorbrainstem,并因姿势性张力丧失而倒地，但可很快恢复。

Etiology:

orthostatichypotension,decreasedcardiacoutput,acuteglobalischemia.Syncope-Classification反射性晕厥调节血压和心率的反射弧功能障碍，或自主神经疾病所致。包括：血管减压性晕厥(普通晕厥):最常见(vasovagalsyncope)直立性低血压性晕厥(orthostatichypotension)特发性直立性低血压性晕厥(Shy-Drager)Syncope-ClassificationOthers:carotidsinussyncopemicturitionsyncope(排尿性)swallowsyncope(吞咽性)glossopharyngealneuralgia,coughsyncope,andsoon.Syncope-ClassificationCardiovascularsyncopeArrhythmiacardiacoutflowobstruction(valvediseases,coronaryheartdisease)pulmonarybloodflowobstruction

Syncope-Classification脑源性晕厥：各种严重脑血管闭塞性疾病引起全脑供血不足

transientcerebralischemia

hypertensiveencephalopathy

aorticarchsyndrome

basilarmigraine

lesionsinbrainstem:tumors,inflammation,angiosis,injury,medullaryvasomotorcenterdiseases,andsoon.Others:哭泣性晕厥、低血糖性晕厥、严重贫血性晕厥

Syncope-Clinicalfeatures

发作前期(aura)出现短暂而明显的自主神经症状，头晕、苍白、出汗、恶心、恍惚、无力、打哈欠。先兆期持续数秒至数十秒。发作期(spell)患者感觉眼前发黑、站立不稳，出现短暂的意识丧失而倒地。意识丧失数秒至数十秒。神经系统检查无阳性体征。恢复期(recoveryphase)意识转清，仍面色苍白、恶心、出汗、周身无力等，经数分或数十分钟休息可缓解，不遗留任何后遗症。Seizure-Concept

癎性发作(seizure)Theseizureisatransientdisturbanceofcerebralfunctioncausedbyanabnormalneuronaldischarge。痫性发作的临床表现形式多种多样。Pathogenesis引起脑部结构或代谢异常的各种局限性或广泛性病因，或目前尚不明确的原因均可导致癎性发作。表2-5癎性发作与晕厥的临床特点比较

Section6.

Disordersof

somaticsensationDisordersofsensation-concept感觉(sensation)

是作用于各感受器的各种形式刺激在人脑中的反映。包括：Specialsenses:vision,taste,smellandhearingSomaticsensesSomaticsensesSuperficialsense(pain,temperature,touch):fromskinandmucosaDeepsense(movement,position,vibration)，frommuscles,muscletendon,periosteum(骨膜)andjointsComplexsense(corticalsensibility:

stereognosis(实体觉)、图形觉、two-pointdiscrimination,graphesthesia(皮肤书写觉),location(定位觉),barognosis(重量觉)Disordersofsensation

-Anatomy&PhysiologySensorypathway图2-8共同特点：Threeneurons第二个神经元后发出的纤维交叉到对侧Disordersofsensation

-Anatomy&PhysiologyConductivepathway:Thefibersfromtheneuronsintheposteriorhornsmediatepain,temperatureandtouchcrossthemidlineandtravelinthelateralspinothalamictract。深感觉、精细触觉的纤维自后根神经节发出后，在同侧后索上行至薄束核、楔束核。Differentpathwaysarethebasisofdissociatedsensoryloss(impairmentofpainandtemperaturewithpreservationoftouch).Disordersofsensation

-Anatomy&Physiology髓内感觉传导束的排列图2-9Spinalthalamictract

fromexternaltointernal,laminationofsensorypathwaysrangeinsacral,lumbar,thoracic,cervical(SLTC)Gracilefasciculus,cuneatefasciculus

rangeincervical,thoracic,lumbar,sacralfromoutsidetoinside(CTLS)对髓内及髓外脊髓病变鉴别诊断有重要意义Disordersofsensation

-Anatomy&Physiology节段性感觉支配(segmentaldistribution)(图2-10)皮节(dermatomere)

每个感觉根或脊髓节段支配一片皮肤的感觉。31个皮节。每个皮节均由3个后根重叠支配--三根定律,图2-11。脊髓损伤上界比查体平面高1(–1)节段性支配关系有助于定位诊断Anteriorramiofcervical,lumbarandsacralformcervicalplexus,lumbarplexusandsciaticplexus,

respectively

peripheralnerve(体表分布与脊髓的节段性分布不同)图2-12,2-13Disordersofsensation

-Symptoms

抑制症状完全性感觉缺失(completesensoryloss)

polyneuropathy分离性感觉障碍(dissociatedsensoryloss)

syringomyelia刺激症状感觉过敏(hyperesthesia)感觉倒错(noseresthesia)感觉过度(hyperpathia)感觉异常(paresthesia)疼痛(pain)局部性、放射性、扩散性、牵涉性Disordersofsensation–Clinicalfeatures感觉障碍的临床表现多种多样，病变部位不同其临床表现各异，图2-14

1.末梢型(terminal)2.周围神经型(peripheralnerves)图6-33.节段型(segmental)单侧节段性完全性感觉障碍(dorsalrootinvolvement)unilateralsegmentaldissociatedsensoryloss(dorsalhorn)Bilateralsymmetricsegmentaldissociatedsensoryloss(anteriorcommissura)Disordersofsensation–Clinicalfeatures4.传导束型脊髓半切综合征(Brown-Sequardsyndrome)

belowthelesion,thereisanipsilateralpyramidaldeficitanddisturbedappreciationofvibrationandjointpositionsense,withcontralaterallossofpainandtemperaturethatbeginstwoorthreesegmentsbelowthelesion

图2-19Disordersofsensation–Clinicalfeatures4.传导束型脊髓横贯性损害(cordsection)Lossofallsensesblowthelesion,withparaplegiaandtetraplegia,andurination/defecationdisorders.Occurinacutemyelitisandcompressivemyelopathy.Disordersofsensation–Clinicalfeatures

5.交叉型

impairedpainandtemperaturesensationonthesamesideofthefaceasthelesion,andsensorylossontheoppositesideofthebody，accompanyingothersymptomsandsignscausedbyotherimpairment如小脑后下动脉闭塞所致延髓背外侧

(Wallenberg综合征)

involvethespinaltractoftrigeminalnerve,nucleiandlateralspinalthalamictractthathadcrossedmidlinefromthecontralateralside.WhatisWallenberg'sSyndrome?Wallenberg’ssyndromeisaneurologicalconditioncausedbyastrokeinthevertebralorposteriorinferiorcerebellararteryofthebrainstem.Symptomsincludedifficultieswithswallowing,hoarseness,dizziness,nauseaandvomiting,rapidinvoluntarymovementsoftheeyes(nystagmus),Continueandproblemswithbalanceandgaitcoordination.Someindividualswillexperiencealackofpainandtemperaturesensationononlyonesideoftheface,orapatternofsymptomsonoppositesidesofthebody–suchasparalysisornumbnessintherightsideoftheface,withweakornumblimbsontheleftside.ContinueUncontrollablehiccupsmayalsooccur,andsomeindividualswilllosetheirsenseoftasteononesideofthetongue,whilepreservingtastesensationsontheotherside.SomepeoplewithWallenberg’ssyndromereportthattheworldseemstobetiltedinanunsettlingway,whichmakesitdifficulttokeeptheirbalancewhentheywalk.Disordersofsensation–Clinicalfeatures6.偏身型

lesionsinpons,midbrain,thalamusandcapsulainterna,皮质感觉区分布较广，一般病变仅损及部分区域7.单肢型(singlelimb)

lesionofthesensorycortexSection7.

ParalysisParalysis-anatomyandphysiologyLowermotorneuron

Anteriorhorncell,motornucleusofcranialnervesanditsneuralaxis.

Thefinaljointpathwaythatacceptstheimpulsefrompyramidaltract,extrapyramidalsystemandcerebellasystem,itistheonlywaythatimpulsewastransferredtomuscles.Paralysis-anatomyandphysiologyUppermotorneurons大脑额叶中央前回(anteriorcentralconvolution)运动区第V层的锥体细胞

thefibersdescendfromthecortexmakeup

pyramidaltract(includecorticospinaltractandcorticonucleartract).MotorPathway(图2-15)特点：经两级神经元传导Paralysis-

Clinicalfeatures&classification弛缓性瘫痪(flaccidparalysis)

下运动神经元瘫痪或周围性瘫痪

causedbylowermotorneuronlesions

痉挛性瘫痪(spasticparalysis)

上运动神经元瘫痪(uppermotorneuronparalysis)因其瘫痪肢体肌张力增高而得名。痉挛性瘫痪和弛缓性瘫痪比较表2-6Central&PeripheralFacialPalsy中枢性面瘫(centralfacialnervepalsy)Lesions:impairmentonunilateralcorticonucleartractClinicalfeatures:paralysisoflowerpartoftheface,thelesionisontheoppositeside.

图2-16Central&PeripheralFacialPalsy周围性面瘫(peripheralfacialnervepalsy)Lesions:facialnerveimpairmentClinicalfeatures:thesmoothingofthefurrowsontheparalyzedside,thecornerofthemouthdroops,thenasolabialfoldissmoothedout皱额、闭目、鼓颊、露齿动作均不能真性球麻痹(Bulbarpalsy)

-假性球麻痹(Pseudobulbarpalsy)

Commonappearance:dysarthria,hoarsevoice(声音嘶哑),difficultyinswallowing(饮水发呛),dysphagia,andsoon.Bulbarpalsy&