第一部分-神經(jīng)病學(xué)總論課件

1、Neurology General Introduction Neurology is the branch of medicine dealing with diseases of the central, peripheral, and autonomic nervous systems, including the skeletal musculature.ConceptionsNeurologynervous systemsCentral Nervous System Brain Spinal cordPeripheral Nervous Systemskeletal musculat

2、ure學(xué)習(xí)目標(biāo)掌握腦神經(jīng)的解剖、生理功能、損害表現(xiàn)及定位掌握運(yùn)動(dòng)系統(tǒng)的定位診斷及癱瘓的類型掌握感覺系統(tǒng)的定位診斷及感覺障礙類型掌握深淺反射及病理反射的臨床意義熟悉神經(jīng)系統(tǒng)常見的診斷方法和原則ContentsIntroductionAnatomy、 Physiology、Neuroanatomy of LocalizationSome Neurological Signs of Interest Neurological History and ExaminationNeurodiagnostic Tests and ProceduresMental Status Examination Dia

3、gnostic Procedures1. Central nervus system 2. Vessels of brain and spinal cord3. Cranial nerve 4. Peripheral nervous system5. Muscle6. Motor system 7. Sensory system8. Reflex Anatomy、 Physiology、Neuroanatomy of LocalizationCentral nervous system第一節(jié)1、Cerebral hemispheres 2、 internal capsule 3、Basal N

4、uclei 4、Diencephalon 6、Cerebellum Central nervus system 7、Spinal Cord 5、Brainstem Cerebral Hemisphere 大腦半球 Frontal lobe-motor control of the opposite side of the body, insight and control of emotions,in the dominant hemisphere, output of speech.Temporal lobe- memory and emotions, in the dominant hem

5、isphere, comprehension of speech.Parietal lobe-sensation of the opposite side of the body andappreciation of spaceOccipital lobe-appreciation of vision.Insular lobeLimbic lobeFrontal Lobe 額葉Frontal Lobe 額葉Parietal lobe 頂葉Temporal lobe 顳葉Anterior part of claw olfactory, tasting sensation centerseizur

6、e, epileptic attack, epileptic seizure:claw attackAnterior part of superior temporal gyrus sensory aphasiaamnesic aphasia Anterior part of claw olfactory, tasting sensation centerseizure, epileptic attack, epileptic seizure:claw attackAnterior part of superior temporal gyrus sensory aphasiaamnesic a

7、phasia Temporal lobe 顳葉claw attackseizure 、 amnesiaOccipital lobe 枕葉 Vision, visual sense or opticum centerLesion of one side: hemianopiaOccipital lobe 枕葉 Vision, visual sense or opticum centerLesion of one side: hemianopia主要引起視覺障礙。中樞性偏盲、幻視、視覺認(rèn)識(shí)不能、視物變形。又稱腦島（insula），與內(nèi)臟感覺和運(yùn)動(dòng)有關(guān) insular lobe 島葉 包括隔區(qū)、扣帶

8、回、海馬回、海馬旁回和鉤回，參與高級(jí)神經(jīng)、精神（情緒和記憶等）和內(nèi)臟的活動(dòng)limbic lobe 邊緣葉隔 區(qū)鉤 回行經(jīng)內(nèi)囊的纖維束 white matter fibers among lenticular nucleus thalamus and caudate nucleuspyramidal tract, thalamocortic tract and optic radiationAnatomycontralateral hemiplegiacontralateral hemiparesthesiacontralateral hemianopialesioninternal capsu

9、le 內(nèi)囊Anatomycontralateral hemiplegiacontralateral hemiparesthesiacontralateral hemianopialesioninternal capsule 內(nèi)囊 丘腦前輻射額橋束皮質(zhì)核束皮質(zhì)脊髓束皮質(zhì)紅核束頂枕顳橋束丘腦中央輻射視輻射聽輻射white matter fibers among lenticular nucleus thalamus and caudate nucleuspyramidal tract, thalamocortic tract and optic radiationinternal capsule

10、內(nèi)囊 Central facial and lingual paralysiscontralateral hemiparesthesiacontralateral hemiplegiacontralateral hemianopia basal ganglia 基底神經(jīng)節(jié) Caudate nucleus、Lentiform nucleus、Amygdaloid body、Claustrum basal ganglia 基底神經(jīng)節(jié) basal ganglia 基底神經(jīng)節(jié) basal ganglia 基底神經(jīng)節(jié) A lack of movementElimination of inhibition

11、DystoniaRigidity caudate and putamenElimination of inhibition、hypotoniaClinical symptoms and signs of basal ganglia diseaseglobus pallidus and substantia nigraA lack of movement、hypertonia basal ganglia 基底神經(jīng)節(jié) Diencephalon 間腦Thalamusepithalamus hypothalamussubthalamusthalamus 丘腦 丘腦 解剖結(jié)構(gòu)及生理功能前核群內(nèi)側(cè)核群外側(cè)

12、核群丘腦外側(cè)膝狀體內(nèi)側(cè)膝狀體 腹前核 腹外側(cè)核 腹后外側(cè)核 腹后內(nèi)側(cè)核 thalamus 丘腦 thalamus 丘腦 Anterior Nuclei Limbic功能：丘腦前核與下丘腦及邊緣系統(tǒng)的聯(lián)系受損：情感與記憶障礙thalamus 丘腦 Midline Nuclei Nonspecific Associational功能：是聯(lián)合軀體、內(nèi)臟、感覺沖動(dòng)的整合中樞Thalamus 丘腦 a. Ventral anterior from basal gangliab. Ventral lateral from cerebellum and red nucleusc. Ventral ventr

13、al from basal ganglia and cerebellumd. Ventral posterior:(1) Posterolateral from posterior columns upper postcentral gyrus(2) Posteromedial from trigeminal system lower postcentral gyrusHypothalamus 下丘腦Hypothalamus 下丘腦Hypothalamus 下丘腦下丘腦的纖維聯(lián)系：視上核視上垂體束垂體后葉抗利尿激素視旁核室旁垂體束垂體后葉催產(chǎn)素弓狀核結(jié)節(jié)垂體束垂體前葉Hypothalamus

14、下丘腦部位核團(tuán)功能視前區(qū)視前核體溫調(diào)節(jié)視上區(qū)視上核水代謝室旁核糖代謝結(jié)節(jié)區(qū)腹內(nèi)側(cè)核性功能背內(nèi)側(cè)核脂肪代謝乳頭體區(qū)下丘腦后核產(chǎn)熱保溫乳頭體核下丘腦的核團(tuán)分區(qū)epithalamus 上丘腦 丘腦髓紋韁連合松果體韁三角后連合Epithalamus 上丘腦 松果體分泌抗雄性激素，抑制兒童性成熟；分泌松果體激素，有降低血糖作用1. 瞳孔對(duì)光反射消失（上丘受損） 2. 眼球垂直同向運(yùn)動(dòng)障礙，特別是向上的凝視麻痹（上丘受損） （Parinaud syndrome）3. 動(dòng)眼危象Subthalamus 底丘腦 是中腦和間腦的移行區(qū)錐體外系的組成部分丘腦底核蒼白球和額葉運(yùn)動(dòng)前區(qū)出現(xiàn)對(duì)側(cè)以上肢為重的舞蹈運(yùn)動(dòng)，表現(xiàn)

15、為連續(xù)的不能控制的投擲運(yùn)動(dòng)蒼白球黑質(zhì) 紅核 中腦被蓋偏身投擲運(yùn)動(dòng)（hemiballismus）損害Subthalamus 底丘腦 Brain Stem 腦干 Brain Stem 腦干 、腦干內(nèi)腦神經(jīng)核團(tuán)（背面） Brain Stem 腦干 腦干傳導(dǎo)束為腦干內(nèi)的白質(zhì)，包括深淺感覺傳導(dǎo)束、錐體束、錐體外通路及內(nèi)側(cè)縱束等腦干網(wǎng)狀結(jié)構(gòu) 網(wǎng)狀結(jié)構(gòu)（reticular formation）：腦干中軸內(nèi)呈彌散分布的胞體和纖維交錯(cuò)排列的“網(wǎng)狀”區(qū)域，腦干網(wǎng)狀結(jié)構(gòu)中有許多神經(jīng)調(diào)節(jié)中樞，同時(shí)還可以接受各種信息傳至大腦皮層，可以維持軀體的正常的生理活動(dòng)和意識(shí)清醒Brain Stem 腦干 1) 延髓上段的背外側(cè)區(qū)

16、病變：延髓背外側(cè)綜合征 （Wallenberg syndrome）1. 延髓（medulla oblongata） 病損表現(xiàn)及定位診斷前庭神經(jīng)核損害：眩暈、惡心、嘔吐及眼震疑核及舌咽、迷走神經(jīng)損害：病灶側(cè)軟腭、咽喉肌癱瘓繩狀體及脊髓小腦束、部分小腦半球損害：病灶側(cè)共濟(jì)失調(diào)交感神經(jīng)下行纖維損害：Horner綜合征三叉神經(jīng)脊束核和脊髓丘腦側(cè)束損害：交叉性感覺障礙 延髓綜合征損傷部位及表現(xiàn) Brain Stem 腦干 2) 延髓中腹側(cè)損害：延髓內(nèi)側(cè)綜合征（Dejerine syndrome） 舌下神經(jīng)損害：病灶側(cè)舌肌癱瘓及肌肉萎縮錐體束損害：對(duì)側(cè)肢體中樞性癱瘓內(nèi)側(cè)丘系損害：對(duì)側(cè)上下肢觸覺、位置覺、振

17、動(dòng) 覺減退或喪失延髓綜合征損傷部位及表現(xiàn) Brain Stem 腦干 病損表現(xiàn)及定位診斷1) 腦橋腹外側(cè)綜合征（Millard-Gubler syndrome） 2. 腦橋（pons） 腦橋綜合征損傷部位及表現(xiàn) 展神經(jīng)麻痹： 病灶側(cè)眼球不能外展面神經(jīng)核損害：周圍性面神經(jīng)麻痹錐體束損害：對(duì)側(cè)中樞性偏癱內(nèi)側(cè)丘系和脊髓丘腦束損害：對(duì)側(cè)偏身感覺障礙 多見于小腦下前動(dòng)脈阻塞病損表現(xiàn)及定位診斷Brain Stem 腦干 2) 腦橋背外側(cè)部損害： 腦橋被蓋下部綜合征（Raymond-Cestan syndrome） 前庭神經(jīng)核損害：眩暈、惡心、嘔吐、眼球震顫展神經(jīng)損害：病側(cè)眼球不能外展面神經(jīng)核損害：病側(cè)面肌

18、麻痹腦橋側(cè)視中樞及內(nèi)側(cè)縱束損害：雙眼患側(cè)注視不能三叉神經(jīng)脊束損害：交叉性感覺障礙內(nèi)側(cè)丘系損害：對(duì)側(cè)偏身觸覺、位置覺、振動(dòng)覺減退或喪失交感神經(jīng)下行纖維損害：病側(cè)Horner征小腦中腳、小腦下腳和脊髓小腦前束損害：病側(cè)偏身共濟(jì)失調(diào)病損表現(xiàn)及定位診斷Brain Stem 腦干 3) 腦橋腹內(nèi)側(cè)綜合征，又稱福維爾綜合征（Foville syndrome） 病灶側(cè)眼球不能外展（展神經(jīng)麻痹）及周圍性面神經(jīng)麻痹（面神經(jīng)核損害）兩眼向病灶對(duì)側(cè)凝視（腦橋側(cè)視中樞及內(nèi)側(cè)縱束損害）對(duì)側(cè)中樞性偏癱（錐體束損害），多見于腦橋旁正中動(dòng)脈阻塞4) 閉鎖綜合征（locked-in syndrome），又稱去傳出狀態(tài)，主要見于

19、基底動(dòng)脈腦橋分支雙側(cè)閉塞 出現(xiàn)雙側(cè)中樞性癱瘓（雙側(cè)皮質(zhì)脊髓束和支配三叉神經(jīng)以下的皮質(zhì)腦干束受損）只能以眼球上下運(yùn)動(dòng)示意（動(dòng)眼神經(jīng)與滑車神經(jīng)功能保留），眼球水平運(yùn)動(dòng)障礙，不能講話，雙側(cè)面癱，舌、咽及構(gòu)音吞咽運(yùn)動(dòng)均障礙，不能轉(zhuǎn)頸聳肩，四肢全癱，可有雙側(cè)病理反射，常被誤認(rèn)為昏迷 病損表現(xiàn)及定位診斷Brain Stem 腦干 3. 中腦（mesencephalon） 1) 大腦腳綜合征（Weber syndrome） 多由于小腦幕裂孔疝引起表現(xiàn)為動(dòng)眼神經(jīng)麻痹：病側(cè)除外直肌和上斜肌外的所有眼肌麻痹，瞳孔散大錐體束損害：對(duì)側(cè)中樞性面舌癱和上下肢癱瘓中腦綜合征損傷部位及表現(xiàn)病損表現(xiàn)及定位診斷Brain St

20、em 腦干 動(dòng)眼神經(jīng)麻痹：病側(cè)除外直肌和上斜肌外的所有眼肌麻痹，瞳孔散大黑質(zhì)損害：對(duì)側(cè)肢體震顫、強(qiáng)直紅核損害： 舞蹈、手足徐動(dòng)及共濟(jì)失調(diào)內(nèi)側(cè)丘系損害：對(duì)側(cè)肢體深感覺和精細(xì)觸覺障礙2) 紅核綜合征（Benedikt syndrome）,中腦被蓋腹內(nèi)側(cè)部損害病損表現(xiàn)及定位診斷Brain Stem 腦干 Cerebellum 小腦Cerebellum 小腦Cerebellum 小腦解剖結(jié)構(gòu)及生理功能（一）小腦的結(jié)構(gòu) 絨球小結(jié)葉三個(gè)主葉前葉后葉（二）小腦的功能解剖結(jié)構(gòu)及生理功能cerebellum小腦絨球小結(jié)葉（古小腦）前庭器小腦蚓部大部分、蚓旁區(qū)（舊小腦）脊髓小腦半球（新小腦）大腦皮質(zhì) Functi

21、onCerebellar hemisphere impairment:dysmetria poor finger-to-nose test, heel-knee-shin test Cerebellar vermis impairment:standing lability, drunken gait or ataxic gaitLesionCerebellum 小腦（一）脊髓外部結(jié)構(gòu)解剖結(jié)構(gòu)及生理功能頸膨大C5T1 支配上肢 腰膨大L2S3 支配下肢脊髓圓錐S35 馬尾L2C0共10對(duì)神經(jīng)根組成Spinal Cord 脊髓 8 cervical12 thoracic5 lumbar 5 sa

22、cral1 coccygeal spinal nerve Spinal Cord 脊髓 1. 脊髓的灰質(zhì)： 前角、后角和側(cè)角脊髓橫斷面感覺運(yùn)動(dòng)傳導(dǎo)束的排列（二）脊髓內(nèi)部結(jié)構(gòu)2. 脊髓的白質(zhì)上行纖維束 薄束和楔束 脊髓小腦束 脊髓丘腦束 皮質(zhì)脊髓束 紅核脊髓束 前庭脊髓束 網(wǎng)狀脊髓束 頂蓋脊髓束 內(nèi)側(cè)縱束下行纖維束 解剖結(jié)構(gòu)及生理功能Spinal Cord 脊髓 （一）不完全性脊髓損害 1. 前角損害 6. 后索損害2. 后角損害 7. 側(cè)索損害3. 中央管附近的損害 8. 脊髓束性損害4. 側(cè)角損害 9. 脊髓半側(cè)損害5. 前索損害 病損表現(xiàn)及定位診斷1. 高頸髓（頸14）2. 頸膨大（頸5胸

23、2）3. 胸髓（胸312）4. 腰膨大（腰1骶2）5. 脊髓圓錐（骶35和尾節(jié)）6. 馬尾神經(jīng)根（二）脊髓橫貫性損害Spinal Cord 脊髓 （一）不完全性脊髓損害 前角損害 節(jié)段性下運(yùn)動(dòng)神經(jīng)元性癱瘓進(jìn)行性脊髓性肌萎縮癥 脊髓前角灰質(zhì)炎 損害部位臨床表現(xiàn)常見疾病病損表現(xiàn)及定位診斷Spinal Cord 脊髓 （一）不完全性脊髓損害 1. 前角損害 節(jié)段性下運(yùn)動(dòng)神經(jīng)元性癱瘓后角損害 進(jìn)行性脊髓性肌萎縮癥 脊髓前角灰質(zhì)炎 損害部位臨床表現(xiàn)常見疾病常見脊髓空洞癥、出血、髓內(nèi)膠質(zhì)瘤早期 節(jié)段性分離性感覺障礙：病灶側(cè)相應(yīng)皮節(jié)出現(xiàn)痛溫覺缺失、觸覺保留病損表現(xiàn)及定位診斷Spinal Cord 脊髓 損害

24、部位臨床表現(xiàn)常見疾病中央管附近的損害雙側(cè)對(duì)稱的分離性感覺障礙、痙攣性癱瘓或遲緩性癱瘓 脊髓空洞癥脊髓中央管積水或出血 Spinal Cord 脊髓 脊髓半側(cè)損害 脊髓半切綜合征（Brown-Sequard syndrome）：病變節(jié)段以下同側(cè)上運(yùn)動(dòng)神經(jīng)元性癱、深感覺障礙、精細(xì)觸覺障礙及血管舒縮功能障礙，對(duì)側(cè)痛溫覺障礙 Spinal Cord 脊髓 后索和皮質(zhì)脊髓束亞急性聯(lián)合變性Spinal Cord 脊髓 前角和皮質(zhì)脊髓側(cè)束肌萎縮側(cè)索硬化Spinal Cord 脊髓 皮質(zhì)脊髓束原發(fā)性側(cè)索硬化Spinal Cord 脊髓 Blood Vessels of Brain and Spinal Cor

25、dArteries to Brainanterior circulation ofthe braininternal carotid middle cerebralanterior cerebral posterior circulation of the brainVertebralBasilarposterior cerebralArteries to Brain 腦動(dòng)脈Arteries to BrainArteries to Brain 腦動(dòng)脈Arteries to Brain 腦動(dòng)脈Arteries to Brain 腦動(dòng)脈Arteries to Brain 腦動(dòng)脈Arteries t

26、o Brain 腦動(dòng)脈Arteries to Brain 腦動(dòng)脈大腦后動(dòng)脈終末支大腦后動(dòng)脈終末支Arteries to Brain 腦動(dòng)脈Arteries to Brain 腦動(dòng)脈Venous Circulation of the Brain 腦靜脈Venous Circulation of the Brain 腦靜脈Venous Circulation of the Brain 腦靜脈 Spinal Circulation 脊髓血管Cranial NervesCranial Nerves嗅神經(jīng)（olfactory N.）視神經(jīng)（optic N.）動(dòng)眼神經(jīng)（oculomotor N.）滑車神經(jīng)

27、（trochlear N.）三叉神經(jīng)（trigeminal N.）展神經(jīng)（abduct N.）面神經(jīng)（facial N.）前庭蝸神經(jīng)（vestibulocochlear N.）舌咽神經(jīng)（glossopharyngeal N.）迷走神經(jīng)（vagus N.）副神經(jīng)（accessory N.）舌下神經(jīng)（hypoglossal N.）I Olfactory N 嗅神經(jīng)Anatomybipolar olfactory neurons olfactory bulb olfactory tract olfactory centerI Olfactory N 嗅神經(jīng)Lesion:Bilateral hypos

28、mia: nasal mucosa lesionUnilateral hyposmia: lesion of anterior cranium fossaII Optic Nerve 視神經(jīng) Anatomy:optic ganglion cell optic N optic chiasma optic tract lateralgeniculate body optic radiation occipital lobe vision centerII Optic Nerve 視神經(jīng)Lesion visual deteriorationeye disease and/or optic neuro

29、pathy papilledema in fundus oculi increased intracranial pressure optic atrophyII Optic Nerve 嗅神經(jīng)Lesion optic neuropathy total blindness of one sidelesion of optic chiasma bitemporal hemianopsialesion of optic tract contralaterally hemianopialesion of optic radiationtotal- contralaterally hemianopia

30、 partialcontralaterally quadrant hemianopiacortical lesionhemianopia, sparing of maculaIII、IV、VI nervesAnatomy Oculomotor N. cavernous sinus superior orbital fissureTrochlearN.AbducentN.III、IV、VI nervesMotor fiberIII: levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, inf

31、erior oblique muscleIV: superior oblique muscle: Lateral rectus muscleParasympathetic fiberIII、IV、VI nervesIII、IV、VI nervesophthalmoplegiaIII、IV、VI N. impairmentdrooping eyelid, abduction position of eye, unable to make upper, down & internal movements, pupil dilation, diplopiaIII、IV、VI nerves（1）雙側(cè)眼

32、球運(yùn)動(dòng)障礙動(dòng)眼神經(jīng)核緊靠中線，病變時(shí)常為雙側(cè)動(dòng)眼神經(jīng)的部分受累，引起雙側(cè)眼球運(yùn)動(dòng)障礙（2）腦干內(nèi)鄰近結(jié)構(gòu)的損害展神經(jīng)核病變可累及面神經(jīng)纖維，同時(shí)累及三叉神經(jīng)和錐體束（3）分離性眼肌麻痹 病變時(shí)可僅累及其中部分核團(tuán)而引起某一眼肌受累，其他眼肌不受影響 核性眼肌麻痹（nuclear ophthalmoplegia）III、IV、VI nerves（1）前核間性眼肌麻痹（2）后核間性眼肌麻痹（3）一個(gè)半綜合征（one and a half syndrome） 核間性眼肌麻痹（internuclear ophthalmoplegia） III、IV、VI nerves雙眼向?qū)?cè)注視時(shí)，患側(cè)眼球不能內(nèi)收

33、，對(duì)側(cè)眼球可外展，伴單眼眼震 兩眼同側(cè)注視時(shí)，患側(cè)眼球不能外展，對(duì)側(cè)眼球內(nèi)收正常 患側(cè)眼球水平注視時(shí)既不能內(nèi)收又不能外展；對(duì)側(cè)眼球水平注視時(shí)不能內(nèi)收，可以外展，但有水平眼震 核間性眼肌麻痹（internuclear ophthalmoplegia） III、IV、VI nerves核上性眼肌麻痹（uppernuclear ophthalmoplegia）側(cè)視麻痹示意圖核上性眼肌麻痹臨床上有三個(gè)特點(diǎn)： （1） 雙眼同時(shí)受累 （2） 無復(fù)視 （3） 反射性運(yùn)動(dòng)仍保存 III、IV、VI nerves light reflexlight retina optic N midbrain E-W nuc

34、leusoculomotor N ciliary ganglion sphincter muscle of pupil Trigeminal nerve 三叉神經(jīng)-Anatomy1. Sensation trigeminal ganglion ：ophthalmic, maxillary, mandibular nucleus of spinal tract of trigeminal N.pain sensation & thalposisprincipal sensory nucleustactile sensationmesencephalic nucleusdeep sensation

35、 Trigeminal nerve 三叉神經(jīng)2. Motormotor nucleus of trigeminal N. asticatory muscles3. Reflectiontcorneal reflextcornea ophthalmic branch of Trigeminal N principal sensorynucleus nucleus of facial N.facial N. orbicularis oculiLesionsensory disorder:peripheral lesion, central lesionmotor disordertAbsent c

36、orneal reflexLower jaw hyperreflexia Facial N 面神經(jīng)AnatomyMotor:Nucleus of facial N.superior part: bilateral corticobulbar tractemotional expression M. of facial superior partBottom part: contralateralcorticobulbar tract basifacial emotional expression muscleSensory: tasting on anterior 2/3tongue Para

37、sympathetic N.: submandibular gland,Sublingual gland, lacrimal gland Facial N 面神經(jīng) Facial N 面神經(jīng) Facial N 面神經(jīng) Lesion1. Peripheral facial paralysis:paralysis of unilateral emotional expression M.reduced tasting on 2/3anterior tonguehyperacusis2. Central facial paralysis:paralysis of contralateralbasifa

38、cial expression M Vestibulocochlear N Anatomy 1.Cochlear N. 2.Vestibular N. Lesion1. Cochlear N. tinnitus、deafness2.Vestibular Nvertigo、balance impairment、nystagmus Vestibulocochlear N 前庭蝸神經(jīng) Glosopharyngeal N. 舌咽神經(jīng) Anatomy Motorambiguous nucleus stylopharyngeus Sensationpharynx、soft palate、tonsil、 t

39、ympan、mucosa of posterior 3rd tongue、carotid sinus、bulbus of carotid artery Parasympathetic N. parotid gland Vagus N. 迷走神經(jīng) Anatomy Motor: soft palate、throat & larynx M. Sensation: external auditory canal 、skin of pinna Parasympathetic N. visceral parasympathetic N Vagus N.迷走神經(jīng) Lesion Glosopharyngeal

40、 & vagus N. Two types of symptoms:Bulbar paralysis nerve or neuron injuryvoice hoarseness, swallowing disturbance, pharyngeal areflexiaPseudobulbarpalsybilateral corticobulbar tract involvement pharyngeal reflex, unable to control crying or laughing or pyramidal sign真性和假性球麻痹的鑒別 Accessorius N. 副神經(jīng)Ana

41、tomysternocleidomastoid muscle: turning head trapezius muscle: shrugging shouldersLesion: inable to turn head inable to raise shoulders Hypoglossal N 舌下神經(jīng)Anatomygenioglossal M: extension of the tongue hyoglossus M: withdrawal of the tongue Hypoglossal N 舌下神經(jīng)Lesion Paralysis of hypoglossal Non protru

42、sion deviates to the affected side, on retraction deviates to the intact side, myotrophy of tongue and fibrillation of tongue M.Central paralysis of hypoglossal N. on protrusion deviates contralaterally to the affected side, accompanied with hemiplegia contralaterally to the lesionperipheral nervepe

43、ripheral nerve 周圍神經(jīng)The peripheral nervous system is divided into a somatic and a visceral division. The somatic division innervates the skin and skeletal muscles in the body. The visceral, or autonomic division, innervates the cardiac muscles of the heart and the smooth muscles and receptors in the

44、blood vessels and gastrointestinal, respiratory, urogenital, and endocrine organs.peripheral nerve 周圍神經(jīng)somaticvisceralperipheral nerve 周圍神經(jīng)spinal nervesCranial Nervesperipheral nerve 周圍神經(jīng) Polyneuropathies： distal, symmetric sensory deficits and weakness usually affect the lower more than the upper l

45、imbs associated with areflexiaMusclesMusclesThe approximately 240 muscles in the body three different functional and histological entities: skeletal, smooth, and cardiac.MusclesMyopathies (disorders of muscle) produce proximal weakness, which may affect the face and trunk as well as the limbs,withou

46、t sensory loss.Motor systemLower motor neuronspinal cord anterior horn cellsmotor nuclei of cranial nerves and associated nervesUpper motor neuroncorticospinal tract precentral gyrus of cortex cerebral pyramidal cells internal capsule brain stem (pyramidal crossing) spinal cord anterior horncorticob

47、ulbar tractprecentral gyrus of cerebral cortex pyramid cells brainstem crossingcontralateral cranial N.Motor systemDifferential Diagnosisof Upper and Lower Motor Neuron InjurySignUpper Motor NeuronLower Motor Neuron muscle tone個(gè)tendon reflex個(gè)pathologic reflex+-muscle atrophy-+Motor systemMotor syste

48、mIdentification of paralysis of UMNCortex contralateral monoplegiaInternal capsule contralateral hemiplegiaBrainstem crossing paralysisSpinal cord :chest/lumber regionparaplegiacervical regiontetraplegia or quadriplegiaMotor systemExtrapyramidal Systembasal gangliaLesion1.Abnormal involuntary moveme

49、ntstremor, choreic movement, athetosis, torsion spasm, hemiballismus, tics2.Muscle tonehypertonia lead-pipe rigidity, cogwheel rigidityhypotonia choreaSensory systemSensory systemSensory systemsuperficial sensation:algesi-, thermo-, tactile sensation spinothalamic tractdeep sensationtjoint position、

50、vibration spinal posterior cordcomplicated sensationtsensation of structure, localization, pattern senseSensory systemLocation of sensational disturbanceMononeuropathyPolyneuropathy stocking and-glove sensory lossPosterior root segmental typeSpinal cord conduction tract type Brainstem crossing typeI

51、nternal capsulehemisensory dysfunctionCortex complicated typeFunctional type distribution unrelated to anatomyReflexReflexReflex arc :receptor afferent N center efferent N. effectorTendon Reflex （ deep reflexes ） biceps reflex: C5-6 radioperiosteal:C5-6 triceps reflex: C6-7patellar reflex or knee jerk: L2-4 ankle jerk: S1-2ReflexTendon Reflex biceps reflex: C5-