《神經(jīng)病學(xué)》（英文）課件1.Symptomatology of Neurological Diseases

1、 NeurologyDepartment of Neurology, The 2nd affiliated hospital, Harbin Medical UniversityChapter 1. Introduction神經(jīng)病學(xué) ( Neurology)The Objects of Neurology:CNS、PNS and muscular disordersThe contents of study: Etiology and Pathogenesis Pathology Clinical features Diagnosis and Differential diagnosis, T

2、reatment and Prevention Prognosis Nervous systemCentral nervous system: brain spinal cordPeripheral nervous system: cranial nerves spinal nervesNervous systemNeurology is a part of neuroscience, including: Neuroanatomy, Neurophysiology, Neurobiochemistry, Neuropathology, Neurogenetics, Neuroimmunolo

3、gy, Neuroepidemiology, Neuroiconography神經(jīng)影像學(xué), Neurophamacology, Neuropsychology, Experimental Neurology, Neurobiology, Molecular BiologyCatalogue of the neurological diseasesVascular diseasesInfectious diseasesTumorsTraumatic diseasesCatalogue of the neurological diseasesAutoimmune diseases(some of

4、them are demyelinative diseases脫髓鞘疾病)Hereditary and metabolic disordersCongenital dysplasia先天性發(fā)育障礙IntoxicationNutritional disturbancesSymptoms of Nervous System could divided to four classes:Deficit symptoms deficits or loss on the normal functions (hemiparalysis, aphasia)Irritative symptoms excessi

5、ve excitements that nervous structures appeared when they were stimulated (seizures, radical pain)Symptoms of Nervous System could divided to four classes:Liberated symptoms When the higher centers were impaired, the function of the lower center that normally controlled by the former was liberated(p

6、yramidal signs錐體束征).Symptoms of Nervous System could divided to four classes:Shock Symptoms CNS急性局部嚴(yán)重病變，引起與之功能相關(guān)的遠(yuǎn)隔部位神經(jīng)功能短暫缺失 Brain shock: cerebral hemorrhage Spinal shock: in the acute stage of total cord transverse, there is a flaccid paralysis with loss of tendon and other reflexes, accompanied b

7、y sensory loss below the level of the lesion and by urinary and fecal retention.Supplemented exam in neurological diseases1. Lumbar puncture and CSF analysis: Appearance, Pressure, DynamicsRoutine examBiochemical examinationsCSF-IgG index, OBCytologic examSpecific antibodies(MBP, AChR)Supplemented e

8、xam2. Imaging studies: plain X-rays of the skull and the spine, myelographyCT, MRI (magnetic resonance imaging), MRA DSA (digital subtraction angiography)Supplemented exam3. Electrophysiologic studies: EEG(electroencephalography)EMG (electromyography)NCV(nerve conduction velocity)VEP(visual evoked p

9、otentials)BAEP(brianstem auditory evoked potentials)SEP(somatosensory evoked potentials) 4. Transcranial doppler(TCD) Supplemented exam Radioisotope examinations(放射性同位素) SPECT(single photon computed tomography) PET(positron emission tomography)Immunologic and virologic detections(免疫學(xué)及病毒學(xué)檢測(cè))：such as

10、MBP、AChR and cysticercus antibodies, (HSV)PCRBiopsy: muscles, nerves and brainChapter 2. Symptomatology of the Neurological DiseasesSection 1. Disorders of ConsciousnessDisturbances of the Level of ConsciousnessConsciousness is awareness of the internal or external world.意識(shí)(awareness) 指大腦的覺(jué)醒(arousal

11、)程度，是機(jī)體對(duì)自身和周?chē)h(huán)境的感知和理解功能，并通過(guò)語(yǔ)言、軀體運(yùn)動(dòng)和行為表達(dá)出來(lái)；是CNS對(duì)內(nèi)、外環(huán)境刺激應(yīng)答反應(yīng)的能力。該能力減退或消失就意味著不同程度的意識(shí)障礙(disorders of consciousness)。意識(shí)(consciousness)-ConceptConsciousness describes that sets of neural processes that allow an individual to perceive, comprehend, and act upon the internal and external environments.It is u

12、sually envisioned in two parts: arousal and awareness. 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. Arousal requires the interplay of both

13、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.Awareness reflects the depth and content of the aroused state. Awareness is dependent on arousal,

14、 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). Attention depends on awareness and implies the ability to respond to particular types of

15、 stimuli (modality-specific).Stupor refers to a condition in which the patient is less alert than usual, but can be stimulated into responding.Obtundation (意識(shí)模糊) describes a patient who appears to be asleep much of the time when not being stimulated. This eyes-closed state is not electroencephalogra

16、phic sleep, however.Stuporous/obtunded patients will respond to noxious stimuli by attempting to deflect or avoid the stimulus.Patient with Coma lies with eyes closed and does not make an attempt to avoid noxious stimuli. Such a person may display various forms of reflex posturing, but does not acti

17、vely try to avoid the stimulus.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. However, the vegetative patient does not respond to auditory stimuli, and does not appear to sense pain, hunge

18、r, or other stimuli. This is a state in which there is arousal but no awareness.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. The disturbance develops over a short period o

19、f time, usually hours or days, and tends to fluctuate during the course of the day.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 medi

20、cation, or toxin exposure, or a combination of these factors.Disorders of ConsciousnessAnatomical basis of alerting system(維持意識(shí)清醒的重要結(jié)構(gòu)): 腦干上行性網(wǎng)狀激活系統(tǒng) (ascending reticular activating system) 廣泛的大腦皮質(zhì)神經(jīng)元的完整性 (Cerebral cortex and the afferent pathways) (中樞整合機(jī)構(gòu)) The maintenance of consciousness requires a

21、 fine balance of activity between the cerebral cortex and the reticular system.Disorders of consciousness -Clinical classification意識(shí)障礙：指意識(shí)水平下降嗜睡(somnolent): 患者處于睡眠狀態(tài)，喚醒后定向力基本完整，但注意力不集中，記憶稍差，如不繼續(xù)對(duì)答，又進(jìn)入睡眠。The early stage of consciousness disorder, it is often a feature of raised intracranial pressure.

22、 Disorders of consciousness -Clinical classification昏睡狀態(tài)(stupor)：處于較深睡眠狀態(tài)，較重的疼痛或言語(yǔ)刺激方可喚醒，作簡(jiǎn)單模糊的回答，旋即熟睡。The patient can be roused only briefly by pain stimulation or loud speech.Disorders of consciousness-Clinical classification昏迷(coma): the patient is unresponsive and unarousable) 意識(shí)喪失，對(duì)言語(yǔ)刺激 無(wú)應(yīng)答反應(yīng)，可

23、分為淺、中、深昏迷。Disorders of consciousness-Clinical classificationDisorders of consciousness affecting the contents of consciousness 意識(shí)模糊(confusion)或朦朧狀態(tài)(twilight state) 意識(shí)輕度障礙，表現(xiàn)意識(shí)范圍縮小，常有定向力障礙，突出表現(xiàn)是錯(cuò)覺(jué)，幻覺(jué)較少見(jiàn)，情感反應(yīng)與錯(cuò)覺(jué)相關(guān)，可見(jiàn)于癔癥。Disorders of consciousness-Clinical classificationDisorders of consciousness affec

24、ting the content of consciousness譫妄狀態(tài)(delirium state) 定向力(orientation)、自知力障礙，注意力渙散(attention)，不能與外界正常接觸。常有hallucinations、delusions，以錯(cuò)視為主，形象生動(dòng)逼真，可有恐懼、外逃或傷人行為。Acute: fever, intoxication such as Atropine Chronic: chronic alcoholismDisorders of consciousness-Clinical classification特殊類(lèi)型意識(shí)障礙-醒狀昏迷(coma vig

25、il)1. 去皮層綜合征(decorticate) 無(wú)意識(shí)睜眼閉眼，光、角膜反射(corneal reflex)存在，對(duì)外界刺激無(wú)反應(yīng)，去皮層強(qiáng)直狀態(tài)(decorticate rigidity)，病理征(+) 上行網(wǎng)狀激活系統(tǒng)未受損，保持覺(jué)醒-睡眠周期，無(wú)意識(shí)咀嚼和吞咽缺氧性腦病、大腦皮質(zhì)廣泛損害CVD及外傷等Disorders of consciousness -Clinical classification2. 無(wú)動(dòng)性緘默癥(akinetic mutism)：對(duì)外界刺激無(wú)意識(shí)反應(yīng)，四肢不能動(dòng)，不語(yǔ)。無(wú)目的睜眼或眼球運(yùn)動(dòng)，睡眠-醒覺(jué)周期可保留。伴自主神經(jīng)功能紊亂，體溫高、心跳或呼吸節(jié)律不規(guī)則

26、、多汗、尿便潴留或失禁，無(wú)錐體束征。腦干上部或丘腦網(wǎng)狀激活系統(tǒng)及前額葉-邊緣系統(tǒng)損害。Disorders of consciousness -Clinical classificationDifferential diagnosis(1) 意志缺乏癥 清醒狀態(tài)，但不講話，無(wú)自主活動(dòng)。對(duì)刺激無(wú)反應(yīng)、無(wú)欲望，嚴(yán)重淡漠狀態(tài)。雙側(cè)額葉病變。 閉鎖綜合征(locked-in syndrome)腦橋基底部病變，皮質(zhì)核束&皮質(zhì)脊髓束雙側(cè)受損(Lacunar infarct, Multiple sclerosis)表現(xiàn)幾乎全部運(yùn)動(dòng)功能喪失Quadriplegiccranial nerves palsy tha

27、t come from pons or below the pons閉鎖綜合征(locked-in syndrome)They are conscious by opening their eyes or moving their eyes vertically on command, but they are speechless, motionless and they cant swallow.Section 2. AphasiaAphasia-Concept 失語(yǔ)癥(aphasia)：腦損害所致的語(yǔ)言交流能力障礙，后天獲得性各種語(yǔ)言符號(hào)(口語(yǔ)、文字、手語(yǔ)等)表達(dá)及認(rèn)識(shí)能力受損或喪失。

28、Points for diagnosis：Alert, normal mental state, no severe intelligent disturbances No visual and auditory deficits, no palsy or ataxia on the muscles of vocal organs (mouth, pharynx and larynx)Aphasia-classification目前國(guó)內(nèi)常用的失語(yǔ)癥分類(lèi) 外側(cè)裂周?chē)дZ(yǔ)綜合征共同點(diǎn)：病灶都在外側(cè)裂周區(qū), 共同特點(diǎn)是均有復(fù)述障礙(repetition disorder)。-Broca 失語(yǔ)(Bro

29、ca aphasia, BA)-Wernicke失語(yǔ)(Wernicke aphasia, WA)-傳導(dǎo)性失語(yǔ) (conduction aphasia, CA）Aphasia-classification經(jīng)皮層性失語(yǔ)(transcortical aphasia)-分水嶺區(qū)失語(yǔ)綜合征 病灶位于分水嶺區(qū), 共同特點(diǎn)是復(fù)述相對(duì)保留。經(jīng)皮層運(yùn)動(dòng)性失語(yǔ)(transcortical motor aphasia, TCMA)經(jīng)皮層感覺(jué)性失語(yǔ)(transcortical sensory aphasia, TCSA)經(jīng)皮層混合性失語(yǔ)(mixed transcortical aphasia, MTA)Aphasia

30、-classification完全性失語(yǔ) (global aphasia, GA)命名性失語(yǔ) (anomic aphasia, AA)皮層下失語(yǔ)綜合征 (subcortical aphasia syndrome)丘腦性失語(yǔ) (thalamic aphasia, TA)底節(jié)性失語(yǔ) (basal ganglion aphasia, BaA)Broca Aphasia -Clinical features obvious expression disturbancetypically nonfluent, paucity of speech, difficult to talk, difficult

31、 to give words, telegraphic, loss of grammar, disorders of repetition, naming, reading and writing.Broca Aphasia -LesionsBroca aphasia累及優(yōu)勢(shì)半球Broca區(qū)(額下回后部)相應(yīng)皮層下白質(zhì)腦室周?chē)踪|(zhì)及頂葉島葉損害Wernicke Aphasia -Clinical featuresno comprehensionfluent，dash along，speech no difficultclear pronunciation，normal tunea lot se

32、mantic paraphasia(語(yǔ)義錯(cuò)語(yǔ)，如帽子襪子)neologism (新語(yǔ))，答非所問(wèn)與理解一致的復(fù)述、聽(tīng)寫(xiě)障礙(dictation disorder)Wernicke Aphasia -LesionsWernicke aphasia位于優(yōu)勢(shì)半球Wernicke區(qū) (顳上回后部)Conduction Aphasia-Clinical featuresrepetition lost n lost(不成比例地)preserved spontaneous speechnormal understanding不能講出自發(fā)講話時(shí)較易說(shuō)出的詞或句子，或以錯(cuò)語(yǔ)復(fù)述-語(yǔ)音錯(cuò)語(yǔ)(鉛筆“先北”)，找詞困

33、難、猶豫、停頓Conduction Aphasia-Lesions優(yōu)勢(shì)半球緣上回皮質(zhì)或深部白質(zhì)內(nèi)弓狀纖維Transcortical Aphasia -Clinical features復(fù)述較其它語(yǔ)言功能好，甚至是不成比例地好Transcortical Aphasia -Lesions因病變部位不同，臨床表現(xiàn)亦不同，臨 床特點(diǎn)及病變部位如表2-3Anomic Aphasia -Clinical features 以命名不能為主要特征呈選擇性命名障礙，找詞困難，贅語(yǔ)在所給的供選擇名稱(chēng)中能選出正確的名詞Anomic Aphasia -Lesions在優(yōu)勢(shì)半球顳中回后部或顳枕交界區(qū)Global Aph

34、asia -Clinical features所有語(yǔ)言功能口語(yǔ)、聽(tīng)理解、復(fù)述、命名、閱讀、書(shū)寫(xiě)均嚴(yán)重障礙表現(xiàn)為啞，刻板性語(yǔ)言（嗎、吧、噠等）Global Aphasia -Lesions優(yōu)勢(shì)半球大范圍病變，如大腦中動(dòng)脈區(qū)大病灶Subcortical Aphasia -Clinical features皮層下病變產(chǎn)生失語(yǔ)較皮質(zhì)病變少見(jiàn)，癥狀不典型，但仔細(xì)觀察仍可發(fā)現(xiàn)其特點(diǎn) Classification: -thalamic aphasia：表現(xiàn)為音量小、語(yǔ)調(diào)低、表情淡漠、不主動(dòng)講話，且有找詞困難，可伴錯(cuò)語(yǔ)。-basal ganglion aphasia：表現(xiàn)自發(fā)性言語(yǔ)受限、音量小、語(yǔ)調(diào)低Apra

35、xia-ConceptApraxia: inability to perform previously learned task企圖作有目的或細(xì)巧動(dòng)作時(shí)，不能準(zhǔn)確執(zhí)行所了解的隨意性動(dòng)作。如不能按要求做伸舌、吞咽、洗臉、刷牙、劃火柴和開(kāi)鎖等簡(jiǎn)單動(dòng)作但病人在不經(jīng)意時(shí)卻能自發(fā)地做這些動(dòng)作腦部疾患時(shí)，患者無(wú)癱瘓、共濟(jì)失調(diào)、肌張力障礙和感覺(jué)障礙，無(wú)意識(shí)及智能障礙病變部位多在左側(cè)緣上回 Agnosia -ConceptAgnosia：不能通過(guò)某種感覺(jué)辨認(rèn)以往熟悉的物體，卻能通過(guò)其它感覺(jué)通道識(shí)別如看到手表不知為何物，觸摸表外形或聽(tīng)表走動(dòng)聲音，可知是手表腦損害時(shí)，無(wú)視覺(jué)、聽(tīng)覺(jué)、觸覺(jué)、智能及意識(shí)障礙。是少見(jiàn)的神

36、經(jīng)心理學(xué)障礙Agnosia-classificationTactile Agnosia: cannot recognize a familiar objects placed in his hands if his eyes are closed.Visual Agnosia: there is impairment of recognition of familiar objects,symbols or personsAuditory Agnosia: cannot appreciate the significance of well known soundsDisturbances o

37、f Vision and Eye MovementsSection 3.Disturbances of Vision -Anatomy and PhysiologyVisual pathways：retinaoptic nerveoptic chiasm(a)optic tractlateral geniculate nucleioptic radiationscalcarine cortex(posterior poles of the occipital lobes)視神經(jīng)、視束及視放射纖維均按嚴(yán)格的排列順序與視網(wǎng)膜的每一點(diǎn)有精確的對(duì)應(yīng)關(guān)系。視交叉處視神經(jīng)纖維的重組則成為偏盲或象限盲的基礎(chǔ)

38、如圖2-2。Disturbances of Vision -Anatomy and Physiology Decreased visual acuity in one eye:Acute loss of vision: obstruction of the ophthalmic artery or the central retinal artery) Transient monocular blindness: TIA of internal carotid artery, ocular migraineProgressive loss of vision: several hours, d

39、ays (ON、MS)不規(guī)則視野缺損，之后視力障礙或失明compressive lesions on the optic nerves: tumors, aneurysm, Foster-Kennedy syndromeDisturbances of Vision -Anatomy and PhysiologyDecreased visual acuity in both eyes:Transient recurrent amaurosis:TIA of visual centers on bilateral occipital lobes, obstruction can led to co

40、rtical blindness (positive pupillary reaction to light )Progressive blindness：intoxicationoptic neuropathy caused by innutritionprimary optic atrophypapilledema (tumor, hemorrhages, inflammation, increased intracranial pressure) Disturbances of Vision -Anatomy and PhysiologyVisual field defects Anat

41、omical bases:圖2-2 雙顳側(cè)偏盲(Bitemporal hemianopia)垂體瘤、顱咽管瘤等使視交叉中部受損.Disturbances of Vision -Anatomy and Physiology對(duì)側(cè)同向性偏盲(homonymous hemianopia )Clinical features：雙眼病變對(duì)側(cè)視野的同向偏盲 Lesions：lateral geniculate bodies, whole damage of optic radiation and calcarine cortex 圖2-2Disturbances of Vision -Anatomy and

42、 Physiology對(duì)側(cè)視野同向象限盲(homonymous quadrantanopia) 雙眼同向上象限盲(homonymous superior quadrantanopia):見(jiàn)于顳葉后部病變使視輻射下部受損所致雙眼對(duì)側(cè)視野同向下象限盲(homonymous inferior quadrantanopia):見(jiàn)于頂葉病變(腫瘤或血管病)使視輻射上部受損引起Eye Movement Disorders- Clinical features 解剖生理基礎(chǔ):圖2-3 眼肌麻痹(ocular palsy) Peripheral ocular palsy 動(dòng)眼神經(jīng)麻痹(oculomotor n

43、erve palsy): ptosis, outward deviation, diplopia, 瞳孔散大、光反射消失，loss of reaction to accommodationEye Movement Disorders- Clinical features解剖生理基礎(chǔ):圖2-3 眼肌麻痹(ocular palsy) Peripheral ocular palsy trochlear nerve palsy：The superior oblique muscle palsy, diplopia is most pronounced when the patient looks do

44、wnwardabducens nerve palsy：inward deviation, failure of attempted abduction, diplopiaEye Movement Disorders- Clinical features Nuclear ophthalmoplegia合并鄰近神經(jīng)結(jié)構(gòu)損害：展神經(jīng)核受損常累及面神經(jīng)和錐體束等. 產(chǎn)生分離性眼肌麻痹：動(dòng)眼神經(jīng)核性損害更可選擇性損害個(gè)別眼肌,也可累及雙側(cè)眼肌。The lesions are usually vascular diseases of brain stem, inflammatory diseases, o

45、r tumors.Eye Movement Disorders- Clinical features核間性眼肌麻痹(internuclear ophthalmoplegia) 前核間性眼肌麻痹Lesions: lesions lie in the medial longitudinal fasciculus, an unilateral ascending pathway in the brain stem 圖2-4Clinical features: On lateral gaze, excursion of the abducting eye is full(with nystagmus

46、or not), but adduction of the contralateral eye is impaired. Convergence is preserved.Eye Movement Disorders- Clinical features后核間性眼肌麻痹一側(cè)內(nèi)側(cè)縱束下行纖維受損On lateral gaze, the adduction of the contralateral eye is full, but the abduction of the ipsilateral eye is impaired.Eye Movement Disorders- Clinical fe

47、atures一個(gè)半綜合征(one and a half syndrome)一側(cè)腦橋被蓋部病變引起該側(cè)副外展神經(jīng)核或PPRF受損，A symptom that combines internuclear ophthalmoplegia with an inability to gaze towards the side of the lesion.圖2-4Eye Movement Disorders- Clinical features中樞性-核上性眼肌麻痹(Supranuclear opthalmoplesia)Lesions：皮層眼球水平同向運(yùn)動(dòng)中樞(lateral gaze center)

48、 Clinical features：palsy of conjugate horizontal movement雙眼水平同向運(yùn)動(dòng)障礙即凝視麻痹(gaze palsy)，即雙眼向病灶側(cè)凝視刺激性病灶引起雙眼向病灶對(duì)側(cè)的同向偏斜 圖2-4Eye Movement Disorders- Clinical features帕里諾(Parinaud syndrome) Clinical features: up gaze paralysisLesions：上丘眼球垂直同向運(yùn)動(dòng)皮質(zhì)下中樞損害 Eye Movement Disorders- Clinical featuresPupillary abnor

49、malities anatomy and physiologyPupils size: In a brightly illuminated examining room, normal pupils are 24mm in diameter in adults.瞳孔調(diào)節(jié): 支配瞳孔括約肌的動(dòng)眼神經(jīng)副交感纖維支配瞳孔散大肌的來(lái)自superior cervical ganglion交感纖維共同調(diào)節(jié)Eye Movement Disorders- Clinical featuresPupillary light reflex: Pathway: retinaoptic nervesoptic chia

50、smaoptic tractpretectal area(中腦頂蓋前區(qū)) Edinger-Westphal nucleusoculomotor nervesciliary ganglion(睫狀神經(jīng)節(jié))postgangliar fiberspupillary constrictor muscles(瞳孔括約肌)光反射傳入纖維，外側(cè)膝狀體之前視覺(jué)徑路病變、中腦病變、傳出纖維即動(dòng)眼神經(jīng)損害均可使光反射減弱或消失Eye Movement Disorders- Clinical featuresReaction to accommodation(調(diào)節(jié)反射, 集合反射) When the eyes co

51、nverge to focus on a nearer object, the pupils normally constrict 縮瞳反應(yīng)和會(huì)聚動(dòng)作不一定同時(shí)受損，調(diào)節(jié)反射路徑尚不確切阿羅(Argyll-Robertson)瞳孔 negative pupillary light reflex, positive accommodation reflex 頂蓋前區(qū)光反射徑路受損所致 neurosyphilis is the usual cause.Eye Movement Disorders- Clinical features艾迪瞳孔 又稱(chēng)強(qiáng)直性瞳孔(tonic pupil)Clinical

52、 features: Unilateral larger pupil, reacts sluggishly and only to persistent bright light 光照停止后瞳孔緩慢散大。調(diào)節(jié)反射同樣緩慢出現(xiàn)，緩慢恢復(fù) Eye Movement Disorders- Clinical features霍納征(Horner sign) clinical features: unilateral small pupil(myosis), ptosis(眼裂變小: 瞼板肌麻痹)、 enophthalmus(眼球內(nèi)陷: 眼眶肌麻痹)， lack of sweating in the i

53、psilateral face.Lesions：見(jiàn)于頸上交感神經(jīng)徑路損害及腦干網(wǎng)狀結(jié)構(gòu)的交感纖維損害(圖2-5) 。Section 4. Vertigo and Auditory DisordersVertigo-concept眩暈(vertigo) is the illusion of movement of the body or the environment. 患者主觀感覺(jué)自身或外界物體呈旋轉(zhuǎn)感或升降、直線運(yùn)動(dòng)、傾斜、頭重腳輕等感覺(jué)。是對(duì)自身平衡覺(jué)和空間位象覺(jué)的自我體會(huì)錯(cuò)誤頭暈(dizziness) 常缺乏自身或外界物體的旋轉(zhuǎn)感，sensations of light-headedne

54、ss, faintness or giddinessVertigo-Clinical features and classification1. Systemic vertigo Etiology：caused by lesions on vestibule system, main cause of vertigo, accompanied by equilibrium disorder, 眼球震顫 and dysaudia。 (1) Peripheral vertigo (真性眩暈)病變見(jiàn)于前庭感受器及前庭神經(jīng)顱外段(未出內(nèi)聽(tīng)道)，如迷路炎、中耳炎、前庭神經(jīng)元炎、內(nèi)耳眩暈癥(Meniere

55、病)等。Vertigo-Clinical features and classification(2) Central vertigo (假性眩暈)病變?cè)谇巴ド窠?jīng)顱內(nèi)段、前庭核（vestibular nuclei）、核上纖維、內(nèi)側(cè)縱束及皮質(zhì)和小腦的前庭代表區(qū) 圖2-6Usually occur in transient ischaemia of vertibro-basal arteries; tumors in cerebellum, brain stem, and the fourth ventricle; increased intracranial pressure; auditory

56、 neuroma; epilepsy et al.系統(tǒng)性眩暈的鑒別Vertigo-Clinical features and classification2. Non-systemic vertigo etiology：caused by other somatic diseases, for instance eye diseases, anemia, hematonosis, heart failure, infection, intoxication and neurasthenia(神經(jīng)功能失調(diào)), and so on.features：是頭暈眼花或輕度站立不穩(wěn)，無(wú)眩暈感，seldom

57、 accompanying nausea、vomiting，no nystagmus.Vertigo-Clinical features and classification耳聾 (deafness) Conductive deafness (傳音性耳聾) 外耳道和中耳病變，如外耳道異物或耵聹、骨膜穿孔和中耳炎等。Perceptive deafness (感音性耳聾) 內(nèi)耳、聽(tīng)神經(jīng)、蝸神經(jīng)核核上聽(tīng)覺(jué)通路病變所致 Mixed hearing loss 傳導(dǎo)性及神經(jīng)性耳聾同時(shí)存在Auditory Disorders -Clinical features耳鳴(tinnitus) Concept: 無(wú)

58、外界聲音刺激，患者卻主觀聽(tīng)到持續(xù)性聲響。Lesions: 是由聽(tīng)感受器及其傳導(dǎo)徑路病理性刺激所致的主觀性耳鳴。Auditory Disorders -Clinical features聽(tīng)覺(jué)過(guò)敏(acoustic hyperesthesia, hyperacusis)Concept 聲音呈病理性增強(qiáng)，即患者感覺(jué)到的聲音較真正聽(tīng)到的強(qiáng)。Lesions 常見(jiàn)于面神經(jīng)麻痹時(shí)，因鐙骨肌癱瘓使微弱的聲波振動(dòng)即導(dǎo)致內(nèi)淋巴強(qiáng)烈震蕩而引起。 Section 5. Syncope and SeizureSyncope -Concept暈厥(syncope) Pathogenesis: The loss of co

59、nsciousness is due to reduced supply of blood to the cerebral hemispheres or brain stem, 并因姿勢(shì)性張力喪失而倒地，但可很快恢復(fù)。 Etiology: orthostatic hypotension, decreased cardiac output, acute global ischemia.Syncope-Classification反射性暈厥 調(diào)節(jié)血壓和心率的反射弧功能障礙，或自主神經(jīng)疾病所致。包括：血管減壓性暈厥(普通暈厥): 最常見(jiàn)(vasovagal syncope)直立性低血壓性暈厥(ort

60、hostatic hypotension)特發(fā)性直立性低血壓性暈厥(Shy-Drager)Syncope-ClassificationOthers: carotid sinus syncope micturition syncope (排尿性) swallow syncope(吞咽性) glossopharyngeal neuralgia, cough syncope, and so on.Syncope-ClassificationCardiovascular syncopeArrhythmiacardiac outflow obstruction (valve diseases, coro