神經(jīng)病學緒論華中同濟課件

1、神經(jīng)病學緒論Introduction of Neurology同濟醫(yī)學院附屬同濟醫(yī)院 王 偉 是研究中樞神經(jīng)系統(tǒng)(central nervous system, CNS)、周圍神經(jīng)系統(tǒng)(peripheral nervous system, PNS)及骨骼肌疾病(muscular diseases)的病因、發(fā)病機制、臨床表現(xiàn)、診斷、治療及預防的一門臨床醫(yī)學學科。神經(jīng)病學 Neurology神經(jīng)病學:最具發(fā)展前景的學科解剖復雜、生理功能疑問眾多神經(jīng)系統(tǒng)疾病發(fā)病率、 死亡率、致殘率高 僅腦血管病發(fā)病率、 死亡率、致殘率以及住院費用居各項疾病前列,我國城市腦血管病居死亡原因首位,每年造成直接經(jīng)濟損失超

2、過100億元.研究手段及方法日新月異相關(guān)基礎(chǔ)科學發(fā)展迅猛神經(jīng)病學 neurology 神經(jīng)眼科學神經(jīng)耳科學神經(jīng)心理學 神經(jīng)內(nèi)分泌學神經(jīng)腫瘤學神經(jīng)影像學 神經(jīng)科學 neuroscience 神經(jīng)科學 neuroscience Anatomy 解剖學Developmental biology 發(fā)育生物學Biophysics 生物物理學Pharmacology 藥理學Cell biology 細胞生物學Molecular biology 分子生物學Computer science 計算機科學Psychology 心理學Nobel Prize2000ARVID CARLSSON, PAUL GREEN

3、GARD and ERIC KANDEL for their discoveries concerning signal transduction in the nervous system. He discovered that dopamine is a transmitter in the brain and that it has great importance for our ability to control movements and contributed to the development of L-dopa as a treatment for Parkinsons

4、disease, to the understanding of the action of drugs for schizophrenia(精神分裂癥), and the development of selective serotonin reuptake inhibitors (選擇性5-羥色胺再攝取抑制劑) as antidepressants(抗抑郁劑). 1997STANLEY B. PRUSINER for his discovery of Prions - a new biological principle of infection - small proteinaceous

5、 infectious particles which resist inactivation by procedures that modify nucleic acids and are responsible for Creutzfeldt-Jacob Disease，Kuru and certain other degenerative diseases of the nervous system. 朊蛋白：阻止修飾核酸的程序失活的蛋白質(zhì)性質(zhì)的感染顆粒，是克雅氏病、庫魯病及其它某些神經(jīng)系統(tǒng)變性病的病原體。Nobel Prize1991ERWIN NEHER and BERT SAKMA

6、NN for their discoveries concerning the function of single ion channels in cells. They discovered a way to record and observe the ion channels or tunnel-like passageways from the inside to the outside of a cell. Their technique can be used in the study of such diseases as neuromuscular disorders, ep

7、ilepsy and anxiety, and tailor-making a drug in order to achieve an optimal effect .Nobel Prize神經(jīng)系統(tǒng)疾病診斷具有獨特的方法和體系,強調(diào)系統(tǒng)性和邏輯性全面的相關(guān)知識邏輯的思維方式規(guī)范的檢查手段嚴謹?shù)墓ぷ鲬B(tài)度全面的病史詢問系統(tǒng)的體格檢查準確的輔助診斷綜合的分層診斷神經(jīng)系統(tǒng)疾病診斷神經(jīng)系統(tǒng)疾病診斷神經(jīng)解剖學(neuroanatomy)、神經(jīng)生理學(neuro-physiology)神經(jīng)病理學(neuropathology)神經(jīng)系統(tǒng)體格檢查(neurological examination)Steps i

8、n the diagnosis of neurological disease診斷步驟采集病史By history神經(jīng)系統(tǒng)體格檢查By neurological examination得到臨床資料Elicitation of clinical facts用解剖學和生理學術(shù)語解釋癥狀和體征Interpretation of symptoms and signs in terms of anatomy and physiology得到臨床資料Elicitation of clinical facts診斷步驟定位診斷定位診斷起病形式和演變過程Modes of onset and course其它醫(yī)學

9、資料Other medical data適宜的實驗室檢查Appropriate lab test+定性診斷 (Pathological or etiologic diagnosis)診斷步驟DiagnosisAnatomic diagnosis（定位診斷)Pathological or etiologic diagnosis(定性診斷)Pathological or etiologic diagnosis(病因診斷)CLINICAL METHOD大腦中動脈主干閉塞綜合征三偏癥狀: 病灶對側(cè)中樞性面舌癱 中樞性偏癱 偏身感覺障礙和偏盲不同程度的意識障礙 失語或體象障礙 診斷:1.急性腦血管病 定

10、位診斷:右側(cè)大腦中動脈;定性診斷:腦梗死 2.原發(fā)性高血壓(三級);頸動脈狹窄采集病史 TAKING THE HISTORY疾病發(fā)生的背景情況、起病與演變形式、病程； The setting in which the illness occurred, its mode of onset and evolution, and its course are of paramount importance. 明確每一個癥狀是如何發(fā)生和演變的 One must attempt to learn precisely how each symptom began and progressed. 診斷步驟

11、 神經(jīng)系統(tǒng)體檢應(yīng)總是按照一定的順序進行操作與記錄，以避免遺漏和方便以后的病案分析。 The neurological examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records. 神經(jīng)系統(tǒng)體格檢查THE NEUROLOGICAL EXAMINATION 神經(jīng)系統(tǒng)檢查順序： 腦神經(jīng)(cranial nerves)、頸、軀干 (t

12、runk) 及上下肢(the upper and lower limbs)的運動功能(motor functions)、反射(reflex)、感覺功能(sensory functions)、共濟和步態(tài)(coordination and gait)，再評估自主神經(jīng)系統(tǒng)(autonomic nervous system)和腦膜刺激征 (meningeal irritation)。 神經(jīng)系統(tǒng)體格檢查THE NEUROLOGICAL EXAMINATION癥狀 眩暈(Vertigo)、 惡心嘔吐(nausea and vomiting) 吞咽困難(dysphagia)體征：眼震(nystagmus)

13、、構(gòu)音障礙 (dysarthria) 同側(cè)Horner征(ipsilateral Horners syndrome ) 、 同側(cè)肢體共濟失調(diào)(ipsilateral limb ataxia) 同側(cè)面部和對側(cè)軀干痛溫覺喪失(ipsilateral loss of pain and temperature sensation of the face and contralateral loss of pain and temperature of the trunk and extremities) Wallenberg Syndrome定位：小腦后下動脈支配的延髓背外側(cè)(the dorsal l

14、ateral medullary plate supplied by the posterior inferior cerebellar artery)定性：梗死性(infarction) Wallenberg Syndrome單獨的“病案分析”往往無法進行定性。需求助于各種輔助檢查。 It happens often that the nature of the disease is not discerned by “case study” alone. So, the neurologist resorts to the ancillary examinations outlined i

15、n the next slide.應(yīng)基于臨床信息來選擇適宜的實驗室檢查。 Laboratory study can be planned intelligently only on the basis of clinical information.定性診斷Pathological or etiologic diagnosis 各種輔助檢查(ancillary exami-nations)，尤其是各種影像學檢查的出現(xiàn)，為神經(jīng)系統(tǒng)疾病的診斷帶來革命性的變化。定性診斷Pathological or etiologic diagnosis輔助檢查腰椎穿刺與腦脊液檢查(Lumbar puncture

16、and examination of cerebrospinal fluid)計算機斷層掃描(computed tomography, CT) 磁共振成像(magnetic resonance imaging, MRI)血管造影 (angiography)正電子發(fā)射斷層掃描(positron emission tomography, PET)單光子發(fā)射計算機斷層掃描(single photon emission computed tomography)SPECT頭顱和脊柱影像學檢查Radiographic examination of skull and spine輔助檢查CT輔助檢查 MRI

17、、MRA輔助檢查MRI新技術(shù)彌散（DWI）和灌注（PWI）成像技術(shù)超早期診斷腦梗死缺血半暗帶界定血管造影 (angiography)輔助檢查 PET (positron emission tomography, PET）輔助檢查SPECT 復雜部分性發(fā)作的癲癇病人發(fā)作期與發(fā)作間期SPECT差值與MRI疊加輔助檢查(經(jīng)顱多普勒 transcranial Doppler , TCD)輔助檢查腦電圖 (electroencephalography)輔助檢查誘發(fā)電位(evoked potentials)軀體感覺誘發(fā)電位(somatosensory evoked potentials, SEP)視覺誘發(fā)

18、電位(visual evoked potentials, VEP)腦干聽覺誘發(fā)電位(brainstem auditory evoked potentials, BAEP)運動誘發(fā)電位(motor evoked potentials, MEP)事件相關(guān)電位(event-related potential, ERP)輔助檢查肌電圖 (electromyography)與神經(jīng)傳導檢查 (nerve conduction studies ) 肌電圖神經(jīng)傳導檢查輔助檢查肌肉、神經(jīng)、皮膚、腦及其它組織的活檢(Biopsy of muscle, nerve, skin, brain, and other t

19、issue)心理測量(Psychometry) 視野檢查(Perimetry)、測聽(audio-metry) 輔助檢查診斷技巧臨床分析應(yīng)關(guān)注主要的癥狀和體征，避免被次要體征和不確定的臨床資料誤導。Focus the clinical analysis on the principal symptoms and signs and avoid being distracted by minor signs and uncertain clinical data.治療 THERAPEUTICS 在內(nèi)科領(lǐng)域，神經(jīng)病學傳統(tǒng)上被許多人視為不過是對無法治療的疾病下診斷的智力訓練。Among medica

20、l specialties, neurology has traditionally been thought of by many as little more than an intellectual exercise concerned with making diagnoses of untreatable diseases. 例如：血管支架成形術(shù)(angioplasty and stenting)治療頸動脈或顱內(nèi)動脈狹窄(carotid stenoses or intracranial stenoses) 。其中，頸動脈支架成形術(shù)(Carotid Angioplasty and Stenting, CAS) 較為成熟。治療 THERAPEUTICS治療 THERAPEUTICS治療 THERAPEUTICS 支架是一個小金屬網(wǎng)管，置入動脈中提供支撐。A stent is a small wire mesh tube, insert