神经内科疾病临床诊治 2018年版

神经内科疾病临床诊治主编

庞

啸

虎

包

华

李

艾

帆前

言,,,,,,》。,,,,,,,,,,201811

目录CONTENTS 126102237414346576478 81C 90C(T)931(MRI)96SPECT

101 107 112120

135142143151241541561601621641651671701731761781822第一章

脑血管病的病因及危险因素第一节

脑血管病的病因,,,,(),,,,,1.,,,,,,

,,,,,,,2.,,,,,,,,,,,,,,,,,,,,B,,(inswanger),B,1,()-,(),()(),,,血液动力学因素,,,,第二节

脑血管病的危险因素,,,1.,,,(≥,90mmHg),10mmHg,49%,5mmHg,215μmolL15μmolL,≥16μmolL546%(),51.

,,,4,58%,(),,2.,,,,,55 853%5%,50%55 85,0591.%,08923.%5,,68%7,9.5,7

, P45.4(0.05)。 P420%

,40% 6820.%,

10% 6823.,,

2,,,L4.,,L(DL),5.,,,B12,B12(),

5//405926%,≥6035%405921%,≥6037%6.20%,31%15%,,57.,,,2Jdi di11di45Jdi di11di,2“rnk”(

“rnk”1114g),4,50ml(

,30g),640ml,200ml()5“rnk”,a8.aMil,20%,10,2.Bl

,(MI)BlWaker40752864323,231.9,/2.39 97

B9

B39 97

B9

B3BMI2728.

1.5,MI2931.1.0,MI322.718,BMI69.,,6,,45,5%14%3.%,10.,35,,411.

,,,,,,5第二章

脑血管病的解剖学基础第一节

(2-1)。,,(),1.,1(),()1,,,,图2-1脑解剖示意图62(),23B()(roca)：3B,,,4(),,4,2.,12(),,12(),,3(),3,,,,,,3.,,,,1(),,,1,,23(),23(),,,4.,,,,,,5.,,,,,,(),,()1.,,,7,,,,,2.,,,,,,,,()(),,,,,,,1.,,,,,,,1()()：1HE,40%,,,,,,,10%,,,,(),(),850%,,,,2()()：,2,,(),,,,,,,,2.,,,3.,,,,,(),,,()。,,,,,(),,,,,,,,,,,,,,,,,,,,,,(),9,,,,,,,,,,,,,,,,,第二节

脑神经,12,,,1.2.3.4.,,5.6.7.,,,,,,,,,,,,24,10(),,,,,,,,,脑神经损伤的解剖学基础(),,20,,

,,,,,,,,,,,,,,,1.1(),123(),23,CT

()()：,,CTMRI4(),,4C,,XT

C2.12(),,12,,(),,(),52.3cm,,5112,11.cm,,,2,,,,,(),,,,,,,,(),,,,,,,,,,,1,,610,,,,,1/3,30°,,,,(),,,,,,,,,(),,,,,3,,,,12(),,,,,,123,1.,,,,1(),,,123,,,2,,2(),,,,,,3(),3,,,,,2.,,,1,,,1(),,,,2(),,,,2,33(),33,,

,4(),23,,,4(),,,,3.,,,,13,,2/3,12(),12,,,,,,(),3(),3,2/3,,,2/3,2/3,,,4(),,,,4,,,,5(),,54,,,,,(),,,,,,,,(),,,,,,,2/3,,,,,,,,,,,,,141.1(),,1,,,2/3,,,2(),,,2,,,,,,,3()32.,,,,,12()3,12()34,3()34,,34(),45(),5,,,,,,,,,,,,,,,,,2/3()(),,151.,,,,,,2.(),,,,,,,,11,,,,,,,()2()()、2(),,,,,,,1/3,,,,,1/3,,,,,,,,,,1.,1/3,2.34,,,3.,,,,,,,,,,4.12,,16,,,,,,,,,,,1/3,(,),(),,,,,,,(),,,,,,,,,,,,,,,,,,,,,1.12(),,12,,,,,(),,,,,3(),,34(),,417,5(),52.12()12,,,,,,,,,,,,,,,,,(),,,,3.()1(),46,1,“”2(),,,23(),,3,4(),,,4,,,,(),,,,,,,,,,,,,18,,,1/3,1/3,,,,,,,1/31/3

,,,(),,,,,,,,,,,,眼的神经解剖学基础以及临床联系()1.1()123()23()4(),42.12()()：12()()：3.,,610,,,,,,,,,,,,6,19,,,1,,,,,,()1.,1,,1,,,,,,(),(),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Gurm,,,,,2,,,,,,2(),2,,,,,,,,,,,,,,,-,20,,(),,,,,,,,,,,,,2,,,,3(),3,,,,,,,,,,,,,,1,(

2),,14,(),,4(),,,,,,,,135,()5(),,,,1/31/4li,,li,,,,,,,,,,,

Wils6(),6,,,,,21,,,,,,7(),,7,,,,,,,,,(),,,,,,,,(),,,,,,,,5,30°40°,5,(°10°)第三节

脑血管2%,20%,,1.,,2.,3.,4.,5.()(),,,226.7.8.()9.-,,,--,10.11.,-,,2/3,1/3-,-,,,(),,,,,,,,,,,, CC3CC332 CC3CC332(5)：,(4)：,(C

)：,C(2),(1)：C

C

C

1.,,,,,,,,,,,,,2-323图2-2颈内动脉造影图图2-3大脑半球内侧面、脑干和小脑动脉的分支与分布(2-4)：1(),12(),,,2,3(),,,3,,,,1/4,244(),,4,,2/3,,,,,图2-4大脑半球外侧面和小脑动脉的分支与分布,,,1/4,,,,,,()。()。,,,2.,,,,,,,,,60%,,40%58,,,25,,,,(2-5)。,,,,,,,,,,,,,1(),,,1,,

Broca()2(),,,2323/4(46)。,,33, 24(),33, 24,3/4(4,

1

,340)。,图2-5大脑中动脉的皮质支与中央支424(),424,,3/4(1

07)。,26,,4,3,,3,54(),,54,,(0)6(),,67(),,72

2(122

282

249 2

24()82

249 2

24,(12412)。(),,,,,(412,1237)。1(0),13,,,,3(9),,,,3/4,,,,,,,,,,()()3.()-,61,,,,,,,,,1.1(),12(),,,2,1/3()273(),3,,,,4(),,4,,,2.,(2-6)。1()1/3,1,2(),,,,2,80%3()10,,34(),,4()、图2-6脑底面的动脉分支5(),,,528,,,-,,,,,,,,,(2-7)：,,,,,23,,,,,,,,,,,,,,,1/3,()。,,,,,图2-7大脑后动脉的分支与分布()lilili-Willilili,

WilsWils,,,2935048%,(27%)；14%,7%(2-8)。,,,,,图2-8大脑动脉环左侧发育不良(左侧大脑后动脉发自颈内动脉代替部分后交通动脉)(),,,,,,,,(2-9)。1.1()34,,1,2()23,,2,3(),,3,,,(),15,30图2-9大脑动脉环中央支的分群2.,,,,,,,,,3.,,,,,1cm,13,,1cm,14,,,,,,,

S,,(2-10,2-11)。4.16,34,,31图2-10丘脑和低丘脑的动脉供应图2-11基底核和丘脑的动脉供应,,,,,,,,,,,,32,(),,(2-12,2-13)。图2-12大脑半球背外侧面的静脉图2-13大脑半球内侧面的静脉1.()1015,79,,,,67,,,,,,,,33,,,,,,,,1cm,,,5,11.cm,,52.13,,,,,,,3.,,,(),(2-14),,图2-14大脑大静脉及其属支341.,,,1(),,,12()2cm,2,,,,,,,3(),,3

,,2.,,,,,,(2-15)。图2-15基底静脉的形成与属支351(),(1)2(),2,,3.,,,,脑各部的血液供应1.,(2-16)。,,3/42.,,(2-17)。3.,图2-16大脑半球背外侧面的动脉分布区36图2-17大脑半球内侧面的动脉分布区第四节

脑脊液140180ml,150ml,(3040ml

2530ml

5565ml

1015ml2030ml)。,7 7582420.81.6kPa(.513.mmHg),3.7 758242,,,,,600700ml,4580%85%,,,,,()。,,,,,,,(,,

TrypanBlue,(,),,37,,-,6nm,,,,,,,,,,,,,,,,,,,,,,,,(2-18)。41,1.7kPa41(1mmHg),,,,,,6μm(2-19)。,,,,,,,,,,,,38图2-18脑脊液循环图2-19蛛网膜粒与上矢状窦的关系39脑脊液的化学成分和功能00/ /

4/5,,00/ /

4/5,,-,液中蛋白,200

L(65%),60%70%,2.4.mmolL(575mg100ml),,,,,,,,,,,,,,,,

Ca2+K+Mg2+,,40第三章

脑血液循环的病理生理学,,,,,68,,(1020)345,,30,68,48/3208822 2 /C///3208822 2 /C//241100L,1.8ml,1.0ml,1.5ml,1.3ml,0.7ml0.ml,0.00.3ml,2%3%,15%20%(),100g(MRO

)3mlmin,45ml2465L,25%,48gh,24115g2.mmolL,第一节

生理条件下脑血流量的调节 /g0 /g565

/g10 /g0 /g565

/gmin)。,25,0.40.2ml(·min)。50,0.ml(·min)。20%,40%41 /g60.5ml(·min), /g6,,,,,脑血流量的调节,,,-(),,,,,,i(,Baylss(MABP)i(70

Adams-Stokes)、60mmHg,60%,,30%,,(),,,,,,()31.-,[5kPa(7.5mmHg)]3,,,,,2.-,,,42//g770g

L,,0.9ml(·min//g7,,3.,1()1, P22()(aO

)： P22

,85%100%13%15%,35%,,,,,,,51P2 /g911%15%2.kPa(51P2 /g9,pH,(aCO

)：()5%7%0.3ml(·min)。,,,pHpH,,,3,pH,3,pHpH,

HCO

H+,,第二节

脑血管病变时脑血流量的调节(=-),,,43,40%(50mmHg),,,,,,,,,,,,,1.,30%40%,,,,2.,23,,,,223.,,22,PaCO

,

PaCO

,,,,,,,,()。,,,()。124.,,,5.,,,6.5%,,,,,,,44,,60%,,,,,,,,45第四章

神经系统损害的定位诊断,,,第一节

脑神经(),,,,,,,()(),,,,,,,,,()(4-1)：(4-1a)。()(4-1b)。,,(4-1c),,(4-1d),(4-1e)。,,,,,(4-1fh)。46,,,(4-1i)。图4-1视通路损害的定位症状()、()、()(),,(4-1),表4-1眼球运动神经支配与功能47()1.,,,,,,,,,it

l(4-2)。Ednger-Wespha

(E-Wit

l(),图4-2眼球运动的神经支配2.,,,,,,()3.,,,(),,,,,()1.1(),,1,,(4-3)。48图4-3动眼神经麻痹图4-4展神经麻痹2(),,23(),(4-4)。32.1()1,,,(

laeF

i-

Milrd-Gubl(

laeF

i,(ovlesyndrome)。2c(),2c,,,,(Wernike)3.(4-5)束综合征,P,P(PRF),,P

,,,,,P

(PRF),,

,,ol(neandha)ol

可出现一,

,

,

49图4-5核间性眼肌麻痹4.,,,1()1(),,,,,,,,,,(),,,,(4-6)。50图4-6两眼同向凝视的神经支配 P

i2()(ar P

i2 o

a o

aii,

(culrcrss),()、5.,,,,,,,,,,,,56.(,)5(,)1. 553.,2., 551 ( (1 ( (

)

(

)

,

6mm)

,

2(),2(

),()、((),(4-74-8)。,,51图4-7眼交感神经通路图4-8瞳孔光反射通路3(),3E-W,()、,,(),,4P

ia(tl4P

ia(tl,,(eri

),,,E-W,,-

Argyl-Robersonpupi),,,(

il,

Ad(

il()(),1,

,：(4-9)1(),,2(),,,3(),52,,,2,,,(2),(3),,,3,,,图4-9三叉神经解剖(),,

,,

,

()()53,,,2/3,,,,,(),(),,2/3,,,()Bl(1.,Bl(,(el)

(4-10)：,2/3,2/3,,

Huntsyn-),图4-10面神经损害的定位2.,,,,,54()()C

t1.,,(C

t),,,,,2.,,,,(4-11)。图4-11前庭神经的纤维连路()1.1 i t

i 1 i t

i ((

)。

,

)、

)、

55 h

rn

e

tod

f2()

h

rn

e

tod

f2,,

,,

( ,

,

病变引起,,,

,,(

)、

)和动脉硬化所致的内

(

),v

t in

tii2.(erigo)、v

t in

tiiton),,,,-,,()、()()1.,,1/3,1/3,,,,,,2.,

,

,

,

,

(),,,,,,,()()56()()16,,,,,,,,,,,,,,,,第二节

感觉系统()()。()2

2

1,

()()感觉的神经传导通路,(),,,,(,,),,,,,,,,,,57(),(4-12)。,,,(),()。()1/3,,(),(),,,,(),,()。,,(4-13)。,,127,,12723,,(3

),,(4-14)。(5

)图4-12感觉通路58图4-13脊髓传导束的纤维排列(示意图)图4-14躯体各部位在大脑半球感觉代表区的分布()(),,,(),()(),(),,()。(),(4-13),4(),4()(),(t

i1.

hypereshesa)(t

i(2.

hyperpathi),(,,,,,59“”, t

ip3.(areshesa), t

ippi4.(an),pi,,(l

l

ir

i

i i),l

l

ir

i

i i(adatngpan)：,,,siiricli,siiricli

,,

(e-ferredpan)：,,,,(ausaga)：,, li ip li ip

C,,

C,(hantomlmbpan)：(ighte-ningpan)：,,,,,5.(),(),(),,(),(),()(),,1.,,,,(4-15)。60图4-15末梢型感觉障碍2.,,,45,781(4-16)。(),3.,(4-17),,()4.1(),1

(),,(4-18a)。,,2(),2(4-18b)。61图4-16神经干型感觉障碍bca.神经根、干、丛；.上干型感觉分布；bcb图4-17第5～6颈髓神经根损害图4-18脊髓型感觉障碍a.后角型；.前连合型b3()3,(),,62,,,,,()。,B,(rown-Sfequard)B(4-19)。,(4-20),图4-19Brown-Sequard综合征图4-20脊髓横贯性损伤5.,,,,,,,,(4-21)。,,6.,()(4-22),,7.1/3,,(4-22)；,,()。63图4-21延髓外侧综合征图4-22右侧内囊或丘脑损伤8.,(4-14),,,,,,,第三节

运动系统-----()、()1.(),,,64,,,(),,,,5(14)、(51)、(14)、(54)(5),,,(4-23),()图4-23肌肉节段型神经支配、周围神经及神经根676 567Ⅰ、Ⅱ、Ⅲ三个节段发出5、、

三个神经根。5、

神经根组成3号神经支配肌肉2,、、

676 5679 1神经支配肌肉1。8、

为前角细胞群,0为脊髓9 12.,,,14(),,3145f

i

aifif

i

aifi,,(ascculton),,(ibrlaton)。2(),2,,,3(),36544(),,,())1.

(

)

,

criilrt rilrrcriilrt rilrrtcotbatac)。110,

B6127(4B6127

,(3

)(5

)z,

Bet

(120μm)4zz2

Bet

3%,,(z2)40%4,0%,(6)(4-24)。4-24大脑皮质功能代表区；a.外侧面

b.内侧面；J(4),J,4,,,(4-25)。,4(ackson),

4,66,,图4-25躯体各部位在大脑皮质的运动代表区

图4-26内囊与放射冠,()2/3()(4-26)。3/5,,,, l ip85%,(yramida l ip523,523,,,(4-27)。(),0%,0%,0%,,,5

,,,(), feγarlγ(-relxloop) feγarlγ,(nnu-lospiareceptor),,α,,,67(4-28)。(),,,,,()γ,,,,α,,,,α,,,γ,7,,,,,图4-27锥体束的传导通路图4-28牵张反射弧与肌张力增高b.a.牵张反射弧；

7b.682.(),,cafds,“”(lsp-knie),cafds,(omi),,(),,,,,,,,,,,,,,,,,,,,,,,,,,4-2表4-2中枢性与周围性瘫痪的鉴别 () () ,() ,(),,(

,,)3.,691(),,1,()。,,(4-29a)。,,,

2(),2(4-29b)。,,,“”(),,,,图4-29椎体束损害定位模式图解3la ei(),3la ei,,(4-29C)。,

,,

Milrd-Gublr,,

Fovle,,704(),4,,,,(4-29d)。,,,,,,,,B,,,(rown-SSquard)B(4-19)。1.,,,sll(ubthaamicnuceus,Luys)、sll,(4)(6)。cn

titipe

ti(orpussratum)cn

titipe

tilosratum)。,pli,,,,pli,,,,,,(al)。4-30图4-30纹状体结构的隶属关系,,,1()(),

1,718(4)(6)8(4ss),5-((γ-

GABA),

P2()(),2ae

i

aif

ie

i

aiae

i

aif

ie

i

ai,--(),(4)(6)(4-31)。图4-31纹状体-苍白球系统与锥体外系统的练习,,,,,,,,,,72lKinnerWison,l,,4s()8s,,(46),,,,()；()()；,,2.,,,,,,,1riliics

tcliii()1riliics

tcliii,,,(ead-piper-gdty)。,,(rgdty),-(pasi-tiy),,t2s

i

rpl3c2s

i

rpl3ci,,48,“(ilroling)”,()(horecmovement)：,,,4 ai()(thetoss)：4 ai,,“”,(l

mobiespasm)。(l)5t

id

tf()(ors)5t

id

tf,,,6hli()(emibalsmus)：6hli737 tc,,,7 tc()(i)：,,,dt

ifilia(a)dt

ifilia(ardvedyskinesa),(aca/oro-fac

ldyskinesa),,,i(le

Mege

GilsdelaTouretei(le

(4-3)。表4-3锥体系和锥体外系综合征的临床鉴别要点

() ()()；, (), ,,S,,S,,,,(7)-(Npr),1.(),,,,()、()(),,,,,74fa,,fa,,,(rlobe)。,V,V,“

”,,(4-32,4-33)。图4-32小脑半球上面观图4-33小脑半球下面观,,Pe(urkinj,)Pe,

,ci(i(lmbingfbres),ci(i

mossyfbres),,bsla ll,bsla ll,(asketcel)(teltecel),

,,,,(),(4-34)。75图4-34小脑传入纤维与传出纤维Ca,Ca()()(lrke,),,,,,,,,(),,--,,(),,(),,--,,[F

l(ore)],,,F

l76--,,46F

l,F

l,,,3()(ore)a la l,,,,(rchierebelum),,pllpll,(alum),,nl(),nl(lum),,,,2.,,(),,,,,,,,,,,,,,,ve(on-Hippl-Lindau)ve1()1aainito(txainain)：aainito小脑病变时,,Rr

(g)；

Rr,

,,,,

,,,“”。d ra(ysmeti)：d ra,,t(remor)：t77,si

i(kewdevaton),si

i,,,

,2()(),,2,,,,,,,,,,3(),3,,,,--,4(),,4,第四节

反射,()、()()。,(),,(),,,,()、()、,,,,,4-478表4-4浅反射定位

7891 1112

12()12()

,

1

45,(1)(),1

,,,4-5表4-5深反射定位

3

56

叩击鹰嘴上方

56

68

58

24/ 1279(),,,,,,,,,,,,,,B1.(abinskisgn),,B,,,,

,,

(4-6)。1表4-6锥体束受损后的足部病理反射 B

nCiO i

iGiSiG iRlB

nCiO i

iGiSiG iRl(haddocksgn)

(msgn)

(ordonsgn)(chafersgn)(ondasgn),,(ossoimosgn) (i2.

Hofmannsgn)(i,,,,,fe3.(Massrelx),fe,(,),,,()80,3,,,,,,,4.,(),,,,,(fe5.

Grasprelx),(feL6.(),L,第五节

脑功能定位,,,,()()、(),()。,,,,,,,(4-24)。()1/3,,2z1.I

2z,6,,30%4,8%6,

Bet

3%,,,,,,,,81B(rodmman8),B,,,,BB42.BB4(roca),(5)。()a,,a,

,

(-graphi)。3.,()；,()。4.(),1.,,,,,,(()；(),,代表区分,,aiati i2.能相关区aiati i40(nomicaphasa),,,(caphasn)。,,,,()、()、()(),(),,1.,8240,c,,,c,

,,,

Wernike,,,22.,2,422,,,,3.,,4.,,,,(),,,(,)；,,()l(t

imbicsysem)l(t,Papezs,,,,5-,,,,,,,,,,,,,()(4-35)。,,,,383,,,,,,(),“”图4-35右侧内囊的组成,,(4-36),()5,4cm,1.cm,305,(,,)、()()。()、()、(--)、()()。()84图4-36脑干失状切面(示间脑)(

ji,(

ji,()-

Deerne,),(,),,,(),,,(),4g,,,,0//1.-0//(1.06),290mmolL,8hL,2.“”,85“”,3.,,,,28℃4.,,,i(,Frohlchsyndrome,)。i,,5.-,,,,(),,,,()1.,,()()2.(

,,)3.

,,,,

,,,

,

()1.1le()(Wal),1le4-37),(,()；,()；()；(

)()；((86Dji)。(eerne)：Dji,ll图4-37瓦伦贝格(Wa

nberg)综合征ll la e2()-(Mi la e2)(4-38)：()、()()。()。()：(),(),87(),(),(l),()。(ocked-inl)：,,,lae图4-38米亚尔-居布勒(Milrd-Gubllae3,P

i()(),3,P

i

,(4-39)。(ar),88,,,,aii

ataii

atvit(scendngretculraciatngsysem)。o,,o,,

Bit图4-39韦伯综合征89第五章

神经系统疾病的常用诊疗技术第一节

脑脊液检查cllC(fuid,SF)cllCbii

B,bii

B,,,-(lood-branbarrer,BB)。,,,lt(ure)、lt,1.1()12(),23,3()2.12(),,12(),3456(),3456()()(),3.,,9028d,,,,,10ml46h,,4.1

,2

3

,34,,23,,,,,,,,,,2%12ml,,46cm(23cm),“”,,,,,46h,,,脑脊液常规检查1.()()。,802O,2O,2O),,4,,20mmHg0mmHg460mmHg,,1002O,,,(),(),,,,,,2.1(),1,,,,,2(),,2,,,,/(10g

L),/91i,

Froni36(),300×10/L

36060663.(5)×10/L06066×10/L10×10/L,,,P4.andy()P,,Pandy,,, /

55/ /

4/1. /

55/ /

4/75mgdl),50%70%,2.5mmolL(5mgdl),,//72.120L,(00//7,,,1//4112

////1153.1//4112

////1150.5g

L(025mgdl),0.50.5g

L(15mgdl)。,-1.,,,,,(2.,,(

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(2WI)(5-1)。()

GRE),,(i rai12(3.(i rai12(

Gadolninumdethylne-ticacd,Gd-DTPA),,XCT

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MRI,T

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T1Gd-DTPA, /121

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WI,Gd-DTPA,,()1.,,,,

MR,,,,CT,,,,,2.,,磁共振特殊成像技术()(i,i1.

cresonanceang

MRA(i,iMKA,97(il,

(ilfowimagng)。

MRI

MR()、()。1()1(),90°180°,,,90°,,,180°,

MR,,,,,,,,,2()2,,90°,,,,“”,180°,,,

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at

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at

PFMRI,

MRA,

MRAMRAMRA,,MRA,(ercuta-neousintaumina

angoplsy,TA),MRA

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WIT

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MR

BOLD

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SPECTC,C,,,,TMRI,79,,79,,,,,CTMRI,6%,6%,96%,()li-li———3/5-2/5,,

Wils()750850ml,,20%34,1500g,24h1100L2%3%,15%20%()；25%24h115g,,,“”“”,,()1.10501012.1()12(r(),

CBF)2(r(CBF),3.,,脑显像与血流灌注断层显像()1.(-)()(-)。SPECT()

PET(),PET

SPECT2.CT,(),(),,,,CTMRI,,3.SPECT

,,1cm4.,,,()1.99mTc-ECD(),,,,SPECT

,102,,,,,04T1n22.99mTc-HMPAO

99mTc-ECD04T1n2,,94%,6h,,.min,10min3.,4.

c-ECD,555(525mCi),,

,

20mi

4hSPECT5.,

CO

常见神经疾病及其显像特点r(CBF)rrCBFCVDCVD,(),ls(12d)、TIA,ls,,HelmanTikofkySPECT

CVDSPECTrCBFCVD,,,,90d()1.sr,sr,

,(toke)。

,,,,24h,S,,2.SPECT

,,CTS,,1cm,,PECT,

CTSPECT

,,

CTMRISPECT103SPECT,CTMRI,,CT

MRI,8,,,

31.

%

854%,,,()1.TIA,-riesifctRriesifctR,24h,24h(eversblichemicncdeii,IND)。1TIA,,1/3,/31,1/3TIA2.TIA(),,CT

MRI,()rCBF,,/,18.%,CBFrCBF,,,((

a Daa

Acetazolmide.ACZ),

((

a DaarCBF20%,,rCBF,DimoxrCBF,imox,()1.,50%2.CT

MRI,1224h,rCBF()1.,55,,0.%104S2.,,,SEEG,,SPECTrCBFEEG,,PECTPET,6%,SPECT

,,,rCBF,()1.1(Pcz

i()

Al1(Pcz

i)、2 ( i()

2 ( i3()3,,,2.1)(z

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AD,,(),,,2((

tti,3

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MRI()ik,4560,,SPECT,AD

MID4()4PP(arkingscmdsease,D)：PP,5060,,,(i’

i

HuntngtonsD(i’

i105,2050,15rCBF

PD,5(),520%,2,,CTMKI,,,rCBF,6(),6,2040,,rCBFrCHF,rCBF7()CTMRI,SPECT7,rCBF,,rCBF,8rr()8rr,,CBF,CBF9()9rCBF,,rCBFCBF,rCBF,rCBF,

1.,,,2.1(),1106,

PET

PET,

PET

PET

11C3N5O8F,11C3N5OCNO,l8F

H,(1C20min3N10min,5O2min8F110min),7.

11C8F

2448h2448h2()2第五节

正电子发射断层扫描成像p

irsi P(osp

irsi P,

PET

PET11 111,,y,PETl l11Ccc1.Ccc,,(MR-gl

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PET

1D, (((AT),

DAT

5-

D, ((HTT)

NET)P,ET

P107i,,,8F-FDG

l8F-(8i,,,8F-FDG

l8F-(8F-FDG)

18F-(8F-FDOPA)

15-(H52O)

15-(5o2)

11-(1C-MET)

11-(1C-NMSP) D2

11-(1C-Cocane) ,

PET

,5-2表5-2常用PET脑造影药 l11C15

-

(15O)C1111,18F-FDGPET

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6-,6-,,

PET

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CT(l,l8F-FDG,20,,90%PET,2.,γ,1,,E,60%90%E,,PET,11C-METPET,PETEEG

MRI,(CoG)PET,

EEG

,EcoG,PET

,z

i(3.,z

i(Alhemer

AD)18F-FDGPET

ADAD,CT

MRI,18F-FDGPET

,(5-1)。109,(A)PET

PD,(A)PET

PD8FD-dopa,D,DA8F-FDOPAP

F-FPCIT

,D,Pz

iBA.晚期AD见双侧顶叶,联叶,额叶葡萄糖代谢明显减低；.早期AD仅见双侧顶叶代谢减低Bz

iPikli Pc,z

iPikli Pc,PET

Alhemer,AD,ADPET

c

Wison

Huntngton

(DD),,rCMRgl

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PDPD,PDCMRgl

l8l

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,rCBFrCMRO

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/165μmol(00g·min),/12 P( (25 (()2 P( (25 (,,,

ACZ)PETCBF

OEF

TT),()H1O

AVM),6.PET

P,,PCT

MRI,ET

,

PET,,CTMRI,PET

,18PET

,

MRI,CT

MRI,,,,,18F-FDGPET,,PET,,,,,PETAIDS,,111,CT

MRI第六节

脑血管造影检查,,,dlr

to,ie(igtadlr

to,ie

,,,,X16031.

X500mA,50kV,3/X1603,0.,.,,,(5-2)。 152., 156.F,04F,HSH,‘’,3.,,,,,,Conrav,,图5-2GE双C形臂数字减影血管造彩机器11212()12()3(),312()12()3(),3,,X,1.,1(),,1,,,,,25055()1.2.cm1%250554ml,,0.cm,,45°60°,,,,,,,,,20,,,,,,,,,,,,,,,,,1∶100020ml,,1015min,1h15min1,30min1,1,6h,,12h2.,,,,113(),,6s,,,,2h3.,,,,,4.,,,,,,1cm,20min,6h1.,,2.,正常脑血管造影表现图5-3正常脑血管造影图像B； ；A.主动脉弓上血管造影；.颈总动脉造影

C.颈内动脉造影侧位像

B； ；1.1(),,1,,,,,,,,2311429()0%,2

23,,292cm3()1

,,,3,4(),2,4,,,,,5(),5,,,,,,,,,,,6(),,,6,,,,,,,,,,X,,,,“”,,,2.1(),,1

,,,U,,,U,,,,,,,

,,34cm,5cm,,,,,,(5-4)。115图5-4正常椎动脉造影图像BA.椎动脉造影侧位像；.椎动脉造影正位像B2(),2,,,,,3.-,1(),,1,,23(),,,23,,(),,,4.1()1a()：,612,aTrolrd,,iL(Sylvan)：,iL()：,(abbe),2(),,2,,,,,116,,,,,,,,3l,,l,1cm,,

,,,,,“”,5,11.cm,5lGaen,,,l,,,3(),3,,,,,510,34,,5,6.,234()4,,,,,,,,,,,,,S,,,异常脑血管造影表现1.1 1D()931,ot

1 1D,,,,,2(,S

iel1()

AVM)：tenl2(,S

iel1117AVM,,,,,,3(),3,,,4()()：4,,,,5(),5,,2.,,1(),,1,,,,,,2(),2

,,,,3(),,,3,,,,,,4(),4,,,,,5(),,5,,,,,6()6,118,,,,,,,3.,,CTMRI,1(),1,,,,,,,,,,,,,2(),2,,,,,,,,,,,,,,,,3(),,3,13cm,,,,,,,4()4,,,,,,,3,,119第七节

超声检查,ce

l t,iece

l t,ieagng,CDFI)(ranscranilDopplrTCD)1l1201l12090CraVEN(990)

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TCDVAVA,VA,VA4()CCAICAECA4,()ICA2.1(),1

S1,,,,,S2,,,1221,D,10.0±0.2(,1996)。2()2,,,1,,1,,,0.2s,,

PIRI,,P,,,P,IRI,,,,,TCD,,,,,,,,,,,,,,,,,3.i,,i,,,“”(MuscMurmurs)。,,123T4.CDTCD,T,1P()1P,OA,VAICABA2,()

TCD2,3,(),3,,,ACA,,,

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20%30%-MCAACAPCA≧

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MCA≧ICA

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MCA,ICA1

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PCA,

PCA()1.T,,T,CD1()TCD,,1,,,,,,124,,2(),2,,,,,,,T(9s(B

ssST(9s(B

ssS,

Vm)0/,30%()。

MCAA

VAICA),50%69%,70%,

Vm

120/,Vm/,/,,,,P,l2T29 ,2P5s ,sP,l2T29 ,2P5s ,sP , sP7P,(002)TCD,50%

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MFV/,100%,96.%,PV84%

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MFV/,100%,97.%,PV88.%

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NPV94.%ICA,,2∶1,,,,,,a 2PP,a 2PP

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BA,,,3.AVM,,,1()

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MCA,AVMCCA20%30%,AVM

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l1P()

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MCAICA,,ACACA(,),

MCA,,ICA,

MCAICA,,,

MCA,,3ST()AHCD3ST,SAH412dSAH1993199546,,7,3/,,0%

SAH48d7,3/,,

12,4,

1d

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PIMCAICA),20%30%

MCA∶ICA3∶1,,C5.CICP,(CP),,,ICP,,ICP,129li

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l1CCPKlngehSer(991)TCD,IP1 I,P113,IP1 I,P1,CPRI1992Chan

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,ll1l6.1991AasidNewel,ll1l

1994Joanna995Va,13TCDTCD1996TCD,1998,160,1( sB919c9.()1( sB919c9.DMCV58(.±2.)m/(VR)：BVR419(

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DMCVVRTCD,,T7.CDTCD,T,,,1301 15,

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TCD

2),,,,t

2Csst

2CssDrose(002)TCD33,58d,/s,325/h,T

MRI

,/

/,≧/s,颈动脉超声检查IE()(IE)、CCACACAVASA05,68001.CCAIMT05,68001.1.cm-

,CCA,0.0.cm,,1.cm1.cm,3.,CCA,CCA1.000 542.ICA4.6.000 541.1.cmICAIMT,ICA0.56 00.5cmIMT1.6 03.ECACCA,131E E,ICA,CA,CAE E334.,330.0.5cm43%,,,(),,,,,,ICA,ICA5.,-,,,,,(),,,,123f1Irzo51.,123f1Irzo5IMTBond(989)IMT1.,IMT1.,Toshiumi(997),MT1.

Patii

,1.IMT1.,IMT,,1(),,12()IMT

,-,25,IMT1.,552.51.,,,,IMT

t1t1,Sizer(995),TCD,,,,,1321()1,,,,,,“”,2()2,,,,,,,3.,,1I()CCACAECACCAICA1I50%,70%,50%,,(50%69%),,,,5(70%99%),1.,,5E,,E,ECA,CCA,CCA,ICACA

,,,,2(),,2,,II,IICCA,CAECA,ECAICA,CCACAECAa0,a0.,1.cm,133bcde.,,bcde.,.,.,(),4.,,1(),-,12(),2,,3(),3“”,5.1(),161.cm62()-,23(),,3,6.,“”,,-,,,,7.,,,,,,,,,,,,8.,1341()1()。,,2()2,,,,,CCA,3(),3,第八节

神经心理学检查,,,,,,,,,,76,,76,0.5%4.9%,,,,,,1.,,,2.,3.,4.,135,5.,,,,6.,rlalt,(eirlalt,,

,vl(aidty),vl,,,,,,,,,,,,,,,,,,,,,1.,2.,,,,,,,136ltlilllltlilllintelgencescae,WAIS)、(ermemoryscae,WMS),,,,,,,,,,,,,,()100%,,,,,,,,,AD(MID),Hachinski,,,,,,,常用量表及其检查方法s (,s (,,,(MMSE)、Mati

DRS)、(CADAS)(ERAD)(C1.1()(MMSE)：MMSE1,30,137899 0510min0.00.9,0.5899 080%90%,70%80%,,,,,,,,MMSE,,2IeI()--(MCT)：MCT19682IeI,,,,IMCT

,,,,36,1994,3EsE,,3EsE()(SD)：SD

Hersch1979

Mati

1 2 29674,1 2 296748,,823,250,154920817ESD0.,0.90.8,ESDESD,85.%,,4(1()

HDS)：HDS1974,4(1,

MMSE,3,3,30,,,,HDS,,,,,

MMSE

HDS5()(WAIS)(WMS)：(WAIS)5198211,,,1381,1(WMS).,7,987673,,,WMS6CCC()(

AMCOG),(6CCCRoth1986,,8,(AMCOG)CAMCOG

MMSE,CAMCOG,,,AD,CAMCOG

MMSE

,,7S()7S,997min42s,“”。,9996%,0.1,0.2

,,8C()(ASI)：,8C9,20,1520minCASI100,

MMSE

HDS,,8988,

Kappa0.6,89880.7,0.9CASI,

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)、(

)(

)2 FF()(AQ)：AQ2 FF,,FAQ,,,,,,,,ADL,02,303.1 CiC()(DR)：DR1982

1 CiC,,,CDR-,,,,05123,,05123,,,0.

,CDR,CDR,2(,,GG()

GDS)：2(,,GG,,1,7GDSMMSE,GDS4

MMSE1623DS,

MMSE,DS3)si(

Mati

(MatsDRS)：3)si537,1530min,144,,,15min,5,,,“”,,-

MCI4.1(()

NPI)：,,1(,NPI10,,1402BB,2BB,AD4(X)144(4×3×12)。,4()(AHAVE-AD)：AHAVE-ADAD,,,,20min1)(55.1)(5,,

ADVD,(

Hachinski

HIS)：HIS

Hachinski1975,AD,≧7,6,≦4ADRosen,70%,2II5512()(2II55121986,AD,AD,,IDCF-DAT10,

,

,0

AD,AD14,100%AD94%AD,,AD,141第六章

脑电图检查第一节

脑电图E(EG)E,,,,(,)、,1875,Caton1924HansBerger,19361947“”,1(,

,1(

,958,

TEEOVR)()、()8128(),()102010%20%,,142()(),第二节

脑电图的分析()(

6-1),,

ms( 图6-1脑电波周期波()C,/(/S)(6-2)。C图6-2()()(6-3)。图6-32725μV()27575μV5100μV100μV()143(),(6-4)。图6-4()β,αβ()(),Alpha,,(),(),,()(6-5)图6-5脑电图各成分示意图1442.6.

2.6.

α1.

α/

1813cs,0100μVα,/

1()。β/

5β1430cs,20μVβ,,50μV/

5βα,

β,βθ3.θ/47cs,10200μV,θ/,,θ10%δ4.

δ5 /0.3cs,10200μV5 /γ5.

γ/3345cs,25μV,,/μ/,711cs,50μV,μ,/,λ7.

λ/35cs,1040μVλ/κ8.

κ/610cs,/9.1

/80200ms,100μV,2cs1

/,10.80ms,2060ms100150μV,/,,1/3614cs/,,11.12./,23cs,/14513.,αβ14.,300μV,δ15.

δ/(,κδ14cs,

/(,κ16.-1/κ-1/(216cs)

,17.,30%,()。18.,,()()1 3(

3)、(

1 3)、(10)、(,,,)、()、,,,,()(),25μV27575μV275100μV146100μV(),,(,,,)。儿童正常脑电图/3/δ3/4//3/δ3/4/α2,,(5cs),,35,

,5cs,()。611,7cs,θ()。/1,58cs,/,δ //35,

,,θ,810csδ //,46csθ,δ3(6-6)。3图6-6正常儿,男,

岁,清醒。正常范围脑电图3 8 /θ68,,12csα(),α 8 /θβ,6βα//δ910,

,αα//δ

78cs,θ,

1210α,150μV1117,,,θδ儿童异常脑电图1(),1147()

()

2()23()344/ //()

6cs,64cs,44/ //9 / /,

8cs,1049 / /5()5成人正常脑电图α()

α5/αα,,,1.cs,5/θβ,()(79%,6-7)。θβββ,2030μV,50μVββ(4%)。()βα,20μV,,θβα(7%)。4图6-7女,2岁,觉醒。正常α型脑电图4()α,α,β(10%)。成人异常脑电图()1αα()

,α,,

1αα148/■1cs/5/

22.c5/5/■0.c5/α150μV,50%2 β()β,50μ2 β3θ4()(1015%),3θ4(),--5()α5()1θ(),θ1θ23(),23(),-,-45(),1045()δ1δ()1δ()

2()23(),34()(10μV)。4,,,,,,,()α,θ,,,(),,δ()3/δ(cs),,κ-3/1/(216c1/()δ,300600μV,/47csθ,/149()(),α,βα,,

,αα,,,(()

HV)(2 2CO

,CO

,pH2 2,,,,,,()30%,80%,2/3,,()--,,-,,,(),,,,--,,,-,90%-,-()22,O

-150第三节

脑电图的临床应用(),,δθ(6-8)。//；/；B； F/A.发作前：为11cs广泛性α波；.先兆期：为5cs之θ节律

C.完全强直//；/；B； F/完全强直期：棘节律频率较前减慢

E.阵挛期：阵发性节律性慢波和多棘波；.恢复期：开始为平坦坡,后为中等波幅慢波并14cs之睡眠纺锤波。2图6-8某女,8岁,癫痫大发作(发作期)脑电图2()/ /3cs-,2c/ /-(),,

,,()//6cs14cs,,//151()/ /46cs3csS,/ /(),(,)。5090%,,,,θδθ,,,,,,,,,,,,,(6-9)。1图6-9某男,6岁,病毒性脑膜炎继发癫痫1/觉醒以5～6cs节律为基本节律,伴有阵发性高波幅(最高350μV)// /δ2～3cs及4～6cs

和θ节律、棘波和尖波发放,偶见棘-慢波/ /δα,,,α,

,,152,,,θααθθδ,

ααθδθ,

(δ),,ααα,,,αα

,α,,,20%60%,30%,,α()

αα,α,α(),(),2/6cs/()20%25%()64%-1531.α,θδα,2.αα,θ3.α,θ(脑功能轻度障碍)

24(2424

AEEG)。(,24,,,1

2248,6,41

224

,,动态脑电图的适应证,,,

,,异常动态脑电图表现1()12()2154345(),345(),-()6()67()7动态脑电图的优势与不足()1()12(()X

CT)、(MRI2(345()345()()6(),,6()1234()1234(),()()动态脑电图检查的临床意义1.,,2.,1%5%3.,,4.,25,20,11,5,1555.5,,5,0%10,,,,10,,,906.,12,,,,,,1030,,,34,7.,,,,2,34,,--C,,C,,,T

MRI,,,,,,,CTMRI,第五节

视频脑电图1936,,,,156a215,a215Video-EEG)20,,,Kolr66-,3,7,3,,,,,,,,,(,,,视频脑电图分析,,()()-,,-,,,,,,,,,视频脑电图对癫痫诊断和(),,3030%,,,50%,95%

OldAni23,52.%87%(6-10)。157图6-10视频脑电图6某女,

岁,临床诊断：原发性癫痫6注：视频脑电图检查见临床发作伴尖波发放()5%20%,“”。,(),,,,,,,,,,1.,,,Hamer76

296,,24%,20%,17%,20%,5119,37%45106,218,32,3,3,52.,,,,-3.,1584.,(),,,()(),,,,,10,,159第七章

神经系统疾病症状学,,第一节

意识障碍c i(onsc),c i

,,,,

(),(7-1)。■嗜睡■嗜睡()

ss昏睡状态(opor)s意识水平下降的意识障碍■

■浅昏迷伴意识内容改变的意识障碍

意识模糊(伴意识内容改变的意识障碍

意识模糊(onfuson){■c)■ ■深昏迷意识障碍■c idlru t tctdlru t tctd去皮层综合征(ecoriaed)aki

i i特殊类型的意识障碍■无动性缄默症aki

i i■

l■(醒状昏迷comavigi)l图7-1意识障碍分类160,,1.,,,,,,,2.,,,3.,,12()()