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  1. 1. Neurology Department of Neurology, The 2nd affiliated hospital, kunming Medical colleg
  2. 2. Introduction
  3. 3. 神经病学 ( Neurology) <ul><li>The Objects of Neurology: </li></ul><ul><ul><ul><li>CNS 、 PNS and muscular disorders </li></ul></ul></ul><ul><li>The contents of study: </li></ul><ul><li>Etiology and Pathogenesis </li></ul><ul><li>Pathology </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis and Differential diagnosis, </li></ul><ul><li>Treatment and Prevention </li></ul><ul><li>Prognosis </li></ul>
  4. 4. Nervous system <ul><li>Central nervous system: </li></ul><ul><li>brain </li></ul><ul><li>spinal cord </li></ul><ul><li>Peripheral nervous system: </li></ul><ul><li>cranial nerves </li></ul><ul><li>spinal nerves </li></ul>
  5. 5. Nervous system <ul><li>Neurology is a part of neuroscience, including: </li></ul><ul><li>Neuroanatomy, Neurophysiology, </li></ul><ul><li>Neurobiochemistry, Neuropathology, </li></ul><ul><li>Neurogenetics, Neuroimmunology, </li></ul><ul><li>Neuroepidemiology, Neuroiconography, </li></ul><ul><li>Neurophamacology, Neuropsychology, </li></ul><ul><li>Experimental Neurology, Neurobiology, </li></ul><ul><li>Molecular Biology </li></ul>
  6. 6. Catalogue of the neurological diseases <ul><li>Vascular diseases </li></ul><ul><li>Infectious diseases </li></ul><ul><li>Tumors </li></ul><ul><li>Traumatic diseases </li></ul>
  7. 7. Catalogue of the neurological diseases <ul><li>Autoimmune diseases(some of them are demyelinating diseases) </li></ul><ul><li>Hereditary and metabolic disorders </li></ul><ul><li>Congenital dysplasia </li></ul><ul><li>Intoxication </li></ul><ul><li>Nutritional disturbances </li></ul>
  8. 8. Symptoms of Nervous System could divided to four classes: <ul><li>Deficit symptoms deficits or loss on the normal functions (hemiparalysis, aphasia) </li></ul><ul><li>Irritative symptoms excessive excitements that nervous structures appeared when they were stimulated (seizures, radical pain) </li></ul>
  9. 9. Symptoms of Nervous System could divided to four classes: <ul><li>Liberated symptoms When the higher centers were impaired, the function of the lower center that normally controlled by the former was liberated(pyramidal signs). </li></ul>
  10. 10. Symptoms of Nervous System could divided to four classes: <ul><li>Shock Symptoms 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 </li></ul><ul><li>Brain shock: cerebral hemorrhage </li></ul><ul><li>Spinal shock: in the acute stage of total cord transverse, there is a flaccid paralysis with loss of tendon and other reflexes, accompanied by sensory loss below the level of the lesion and by urinary and fecal retention. </li></ul>
  11. 11. Supplemented exam in neurological diseases <ul><ul><li>1. Lumbar puncture and CSF analysis: </li></ul></ul><ul><li>Appearance, Pressure, Dynamics </li></ul><ul><li>Routine exam </li></ul><ul><li>Biochemical examinations </li></ul><ul><li>CSF-IgG index, OB </li></ul><ul><li>Cytologic exam </li></ul><ul><li>Specific antibodies(MBP, AChR) </li></ul>
  12. 12. Supplemented exam <ul><li>2. Imaging studies: </li></ul><ul><li>plain X-rays of the skull and the spine, </li></ul><ul><li>myelography </li></ul><ul><li>CT, MRI (magnetic resonance imaging), MRA </li></ul><ul><li>DSA (digital subtraction angiography) </li></ul>
  13. 13. Supplemented exam <ul><ul><li>3. Electrophysiologic studies: </li></ul></ul><ul><li>EEG(electroencephalography) </li></ul><ul><li>EMG (electromyography) </li></ul><ul><li>NCV(nerve conduction velocity) </li></ul><ul><li>VEP(visual evoked potentials) </li></ul><ul><li>BAEP(brianstem auditory evoked potentials) </li></ul><ul><li>SEP(somatosensory evoked potentials) </li></ul><ul><ul><li>4. Transcranial doppler(TCD) </li></ul></ul>
  14. 14. Supplemented exam <ul><ul><li>Radioisotope examinations( 放射性同位素 ) </li></ul></ul><ul><ul><li>SPECT(single photon computed tomography) </li></ul></ul><ul><ul><li>PET(positron emission tomography) </li></ul></ul><ul><ul><li>Immunologic and virologic detections( 免疫学及病毒学检测 ) : such as MBP 、 AChR and cysticercus antibodies, (HSV)PCR </li></ul></ul><ul><ul><li>Biopsy: muscles, nerves and brain </li></ul></ul>
  15. 15. Chapter 2. Symptomatology of the Neurological Diseases
  16. 16. Section 1. Disorders of Consciousness Disturbances of the Level of Consciousness
  17. 17. <ul><li>Consciousness is awareness of the internal or external world. </li></ul><ul><li>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。 </li></ul><ul><li>该能力减退或消失就意味着不同程度的意识障碍 (disorders of consciousness) 。 </li></ul>意识 (consciousness)- Concept
  18. 18. <ul><li>Consciousness describes that sets of neural processes that allow an individual to perceive, comprehend, and act upon the internal and external environments. </li></ul><ul><li>It is usually envisioned in two parts: arousal and awareness. </li></ul>
  19. 19. <ul><li>Arousal describes the degree to which the individual appears to be able to interact with these environments; the contrast between waking and sleeping is a common example of two different states of arousal. </li></ul>
  20. 20. <ul><li>Arousal requires the interplay of both the reticular formation and the cerebral hemispheres. The reticular components necessary for arousal reside in the midbrain and diencephalon; the pontine reticular formation is not necessary for arousal. </li></ul>
  21. 21. <ul><li>Awareness reflects the depth and content of the aroused state. </li></ul><ul><li>Awareness is dependent on arousal, since one who cannot be aroused appears to lack awareness. Awareness does not imply any specificity for the modality of stimulation. This stimulation may be external (e.g., auditory) or internal (e.g., thirst). </li></ul>
  22. 22. <ul><li>Attention depends on awareness and implies the ability to respond to particular types of stimuli (modality-specific). </li></ul>
  23. 23. Stupor refers to a condition in which the patient is less alert than usual, but can be stimulated into responding.
  24. 24. Obtundation ( 意识模糊 ) describes a patient who appears to be asleep much of the time when not being stimulated. This eyes-closed state is not electroencephalographic sleep, however.
  25. 25. <ul><li>Stuporous/obtunded patients will respond to noxious stimuli by attempting to deflect or avoid the stimulus. </li></ul>
  26. 26. <ul><li>Patient with Coma lies with eyes closed and does not make an attempt to avoid noxious stimuli. </li></ul><ul><li>Such a person may display various forms of reflex posturing, but does not actively try to avoid the stimulus. </li></ul>
  27. 27. <ul><li>Vegetative state, in which the eyes open and close, the patient may appear to track objects about the room, and may chew and swallow food placed in the mouth. </li></ul>
  28. 28. <ul><li>However, the vegetative patient does not respond to auditory stimuli, and does not appear to sense pain, hunger, or other stimuli. This is a state in which there is arousal but no awareness. </li></ul>
  29. 29. Delirium is defined as a disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a preexisting or evolving dementia.
  30. 30. The disturbance develops over a short period of time, usually hours or days, and tends to fluctuate during the course of the day.
  31. 31. There is evidence from the history, physical examination, or laboratory tests that the delirium is a direct physiological consequence of a general medical condition, substance intoxication or withdrawal, use of a medication, or toxin exposure, or a combination of these factors.
  32. 32. Disorders of Consciousness <ul><li>Anatomical basis of alerting system 脑干上行性网状激活系统 </li></ul><ul><li>(ascending reticular activating system) </li></ul><ul><li>广泛的大脑皮质神经元的完整性 </li></ul><ul><li>(Cerebral cortex and the afferent pathways) </li></ul><ul><li>( 中枢整合机构 ) </li></ul><ul><li>The maintenance of consciousness requires a fine balance of activity between the cerebral cortex and the reticular system. </li></ul>
  33. 33. Disorders of consciousness -Clinical classification <ul><li>意识障碍: 指意识水平下降 </li></ul><ul><li>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。 </li></ul><ul><li>The early stage of consciousness disorder, it is often a feature of raised intracranial pressure. </li></ul>
  34. 34. Disorders of consciousness -Clinical classification <ul><li>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。 </li></ul><ul><li>The patient can be roused only briefly by pain stimulation or loud speech. </li></ul>
  35. 35. Disorders of consciousness- Clinical classification <ul><li>昏迷 (coma): the patient is unresponsive and unarousable) 意识丧失,对言语刺激 无应答反应, 可分为浅、中、深昏迷。 </li></ul>
  36. 36. Disorders of consciousness -Clinical classification <ul><li>Disorders of consciousness affecting the contents of consciousness </li></ul><ul><li>意识模糊 (confusion) 或朦胧状态 (twilight state) </li></ul><ul><li>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。 </li></ul>
  37. 37. Disorders of consciousness -Clinical classification <ul><li>Disorders of consciousness affecting the content of consciousness </li></ul><ul><li>谵妄状态 (delirium state) </li></ul><ul><li>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。 </li></ul><ul><li>Acute: fever, intoxication such as Atropine Chronic: chronic alcoholism </li></ul>
  38. 38. Disorders of consciousness -Clinical classification <ul><li>特殊类型意识障碍 -- 醒状昏迷 (coma vigil) </li></ul><ul><li>1. 去皮层综合征 (decorticate) </li></ul><ul><li>无意识睁眼闭眼,光、角膜反射 (corneal reflex) 存在,对外界刺激无反应,去皮层强直状态 (decorticate rigidity) ,病理征 (+) </li></ul><ul><li>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 </li></ul><ul><li>缺氧性脑病、大脑皮质广泛损害 CVD 及外伤等 </li></ul>
  39. 39. Disorders of consciousness -Clinical classification <ul><li>2. 无动性缄默症 (akinetic mutism) : 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。 </li></ul><ul><li>脑干上部或丘脑网状激活系统及前额叶 - 边缘系统损害。 </li></ul>
  40. 40. Disorders of consciousness -Clinical classification <ul><li>Differential diagnosis </li></ul><ul><li>(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。 </li></ul>
  41. 41. 闭锁综合征 (locked-in syndrome) <ul><li>脑桥基底部病变,皮质核束 & 皮质脊髓束双侧受损 (Lacunar infarct, Multiple sclerosis) </li></ul><ul><li>表现几乎全部运动功能丧失 </li></ul><ul><li>Quadriplegic </li></ul><ul><li>cranial nerves palsy that come from pons or below the pons </li></ul>
  42. 42. 闭锁综合征 (locked-in syndrome) <ul><li>They are conscious by opening their eyes or moving their eyes vertically on command, </li></ul><ul><li>but they are speechless, motionless and they can’t swallow. </li></ul>
  43. 43. 神经系统疾病:定位诊断和定性诊断 (Topical and Etiologic Diagnosis) <ul><li>神经疾病诊断概括为三个步骤: </li></ul><ul><li>① 全面地搜集、占有 临床资料 ,采集详尽的病史、细致的神经系统检查,必要的辅助检查。 </li></ul><ul><li>② 用神经解剖学及生理学知识对临床及相关资料进行分析,确定病变的部位 -- 定位诊断 。 </li></ul><ul><li>③ 根据起病方式、疾病进展过程、既往史、个人史、家族史及临床资料,分析筛选可能病因,确定病变的性质 -- 病因诊断 或 定性诊断 。 </li></ul>
  44. 44. 神经系统疾病定位诊断的准则 (The Principles for Topical Diagnosis) <ul><li>1. 首先,明确神经系统病损的水平 </li></ul><ul><li>中枢性 ( 脑、脊髓 ) </li></ul><ul><li>周围性 ( 周围神经或肌肉 ) </li></ul><ul><li>其他系统疾病并发症。 </li></ul><ul><li>2. 其次,明确病变空间分布 是局灶性、多灶性、播散性、系统性。 </li></ul><ul><li>① Local : 如脑梗死、脑肿瘤、横贯性脊髓炎、桡神经麻痹、面神经麻痹等。 </li></ul>
  45. 45. The Principles for Topical Diagnosis) <ul><li>② Multifocus : 病变分布于神经系统两个或以上部位,如麻风多数周围神经受累,视神经脊髓炎,多发性脑梗死的多数梗死灶等,多灶性病变通常具有不对称性。 </li></ul><ul><li>③ Disseminated : 侵犯脑、周围神经或肌肉等两侧对称的结构,如代谢性及中毒性脑病、多发性神经病、周期性瘫痪等。 </li></ul><ul><li>④ Systemic : 病变选择性损害某些功能系统或传导束,如运动神经元病、亚急性联合变性。 </li></ul>
  46. 46. The Principles for Topical Diagnosis) <ul><li>3. 定位诊断通常要遵循一元论原则 (monophyletism) </li></ul><ul><li>尽量用一个局限性病灶来解释患者的全部临床表现,如果不合理而无法解释,再考虑多灶性或弥散性病变的可能。 </li></ul>
  47. 47. The Principles for Topical Diagnosis) <ul><li>4. 病人的首发症状常具有定位价值 </li></ul><ul><li>(initial symptoms usually can provide the clue for the topical diagnosis) ,可提示病变的主要部位,有时也可指示病变的性质。 </li></ul>