神經(jīng)病學(xué)緒論課件

神經(jīng)病學(xué)緒論IntroductionofNeurology神經(jīng)病學(xué)緒論IntroductionofNeurolog1

是研究中樞神經(jīng)系統(tǒng)(centralnervoussystem,CNS)、周圍神經(jīng)系統(tǒng)(peripheralnervoussystem,PNS)及骨骼肌疾病(musculardiseases)的病因、發(fā)病機(jī)制、臨床表現(xiàn)、診斷、治療及預(yù)防的一門臨床醫(yī)學(xué)學(xué)科。神經(jīng)病學(xué)Neurology是研究中樞神經(jīng)系統(tǒng)(centralnervouss2神經(jīng)病學(xué):最具發(fā)展前景的學(xué)科解剖復(fù)雜、生理功能疑問(wèn)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(fèi)用居各項(xiàng)疾病前列,我國(guó)城市腦血管病居死亡原因首位,每年造成直接經(jīng)濟(jì)損失超過(guò)100億元.研究手段及方法日新月異相關(guān)基礎(chǔ)科學(xué)發(fā)展迅猛神經(jīng)病學(xué):最具發(fā)展前景的學(xué)科解剖復(fù)雜、生理功能疑問(wèn)眾多3神經(jīng)病學(xué)neurology

神經(jīng)眼科學(xué)神經(jīng)耳科學(xué)神經(jīng)心理學(xué)神經(jīng)內(nèi)分泌學(xué)神經(jīng)腫瘤學(xué)神經(jīng)影像學(xué)

神經(jīng)科學(xué)neuroscience

神經(jīng)病學(xué)神經(jīng)眼科學(xué)神經(jīng)科學(xué)4

神經(jīng)科學(xué)neuroscience

Anatomy解剖學(xué)Developmentalbiology發(fā)育生物學(xué)Biophysics生物物理學(xué)Pharmacology藥理學(xué)Cellbiology細(xì)胞生物學(xué)Molecularbiology分子生物學(xué)Computerscience計(jì)算機(jī)科學(xué)Psychology心理學(xué)神經(jīng)科學(xué)Anatomy解剖學(xué)5美國(guó)把20世紀(jì)九十年代定為“腦的十年”。1997年19個(gè)國(guó)家參與的“人類腦計(jì)劃”在美國(guó)正式啟動(dòng)。2001年9月，中國(guó)正式成為參與“人類腦計(jì)劃”的第20個(gè)國(guó)家。諾貝爾獎(jiǎng)多次授予神經(jīng)科學(xué)家。美國(guó)把20世紀(jì)九十年代定為“腦的十年”。1997年19個(gè)國(guó)家6NobelPrize2000ARVIDCARLSSON,PAULGREENGARDandERICKANDELfortheirdiscoveriesconcerningsignaltransduction

inthenervoussystem.HediscoveredthatdopamineisatransmitterinthebrainandthatithasgreatimportanceforourabilitytocontrolmovementsandcontributedtothedevelopmentofL-dopaasatreatmentforParkinson‘sdisease,totheunderstandingoftheactionofdrugsforschizophrenia(精神分裂癥),andthedevelopmentofselectiveserotoninreuptakeinhibitors(選擇性5-羥色胺再攝取抑制劑)asantidepressants(抗抑郁劑).NobelPrize2000ARVIDCARLSSON,71997STANLEYB.PRUSINERforhisdiscoveryofPrions-anewbiologicalprincipleofinfection-smallproteinaceousinfectiousparticleswhichresistinactivationbyproceduresthatmodifynucleicacidsandareresponsibleforCreutzfeldt-JacobDisease，Kuruandcertainotherdegenerativediseasesofthenervoussystem.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(kù)魯病及其它某些神經(jīng)系統(tǒng)變性病的病原體。NobelPrize1997STANLEYB.PRUSINERforhi81994ALFREDG.GILMANandMARTINRODBELLfortheirdiscoveryofG-proteinsandtheroleoftheseproteinsinsignaltransductionincells.Theystudiedthecomplexrelay(中繼)

ofcellcommunication.Gproteins,lyinginsidethecell,canrespondtosignalsfromoutsidethecell-light,smell,neurotransmittersandhormones-andtranslatethemintoafrenzyofcellularactioninside.NobelPrize1994ALFREDG.GILMANandMARTI91991ERWINNEHERandBERTSAKMANNfortheirdiscoveriesconcerningthefunctionofsingleionchannelsincells.Theydiscoveredawaytorecordandobservetheionchannelsortunnel-likepassagewaysfromtheinsidetotheoutsideofacell.Theirtechniquecanbeusedinthestudyofsuchdiseasesasneuromusculardisorders,epilepsyandanxiety,andtailor-makingadruginordertoachieveanoptimal

effect.NobelPrize1991ERWINNEHERandBERTSAKMA10神經(jīng)系統(tǒng)疾病診斷具有獨(dú)特的方法和體系,強(qiáng)調(diào)系統(tǒng)性和邏輯性全面的相關(guān)知識(shí)邏輯的思維方式規(guī)范的檢查手段嚴(yán)謹(jǐn)?shù)墓ぷ鲬B(tài)度全面的病史詢問(wèn)系統(tǒng)的體格檢查準(zhǔn)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)疾病診斷具有獨(dú)特的方法和體系,強(qiáng)調(diào)系統(tǒng)性和邏輯性全面11神經(jīng)系統(tǒng)疾病診斷神經(jīng)解剖學(xué)(neuroanatomy)、神經(jīng)生理學(xué)(neuro-physiology)神經(jīng)病理學(xué)(neuropathology)神經(jīng)系統(tǒng)體格檢查(neurologicalexamination)神經(jīng)系統(tǒng)疾病診斷神經(jīng)解剖學(xué)(neuroanatomy)、12神經(jīng)疾病的診斷方法共同點(diǎn)：詳細(xì)病史采集,詳細(xì)體格檢查特殊性：病史和體格檢查的客觀性：特殊思維方法：定位診斷定性診斷神經(jīng)疾病的診斷方法13Stepsinthediagnosisofneurologicaldisease診斷步驟采集病史Byhistory神經(jīng)系統(tǒng)體格檢查Byneurologicalexamination得到臨床資料ElicitationofclinicalfactsStepsinthediagnosisofneur14用解剖學(xué)和生理學(xué)術(shù)語(yǔ)解釋癥狀和體征Interpretationofsymptomsandsignsintermsofanatomyandphysiology得到臨床資料Elicitationofclinicalfacts診斷步驟用解剖學(xué)和生理學(xué)術(shù)語(yǔ)解釋癥狀和體征得到臨床資料診斷步驟15確定損害系統(tǒng)或部位Syndromicalformulationandlocalizationofthelesion(topicaldiagnosis定位診斷)用解剖學(xué)和生理學(xué)術(shù)語(yǔ)解釋癥狀和體征Interpretationofsymptomsandsignsintermsofanatomyandphysiology診斷步驟

16定位診斷定位診斷起病形式和演變過(guò)程Modesofonsetandcourse其它醫(yī)學(xué)資料Othermedicaldata適宜的實(shí)驗(yàn)室檢查Appropriatelabtest+++定性診斷

(Pathologicaloretiologicdiagnosis)診斷步驟定位診斷定位診斷起病形式和演變過(guò)程其它醫(yī)學(xué)資料適宜的實(shí)驗(yàn)室檢17DiagnosisAnatomicdiagnosis（定位診斷)Pathologicaloretiologicdiagnosis(定性診斷)Pathologicaloretiologicdiagnosis(病因診斷)CLINICALMETHODDiagnosisAnatomicdiagnosis（定位18大腦中動(dòng)脈主干閉塞綜合征三偏癥狀:病灶對(duì)側(cè)中樞性面舌癱中樞性偏癱偏身感覺(jué)障礙和偏盲不同程度的意識(shí)障礙失語(yǔ)或體象障礙

診斷:1.急性腦血管病定位診斷:右側(cè)大腦中動(dòng)脈;定性診斷:腦梗死2.原發(fā)性高血壓(三級(jí));頸動(dòng)脈狹窄大腦中動(dòng)脈主干閉塞綜合征三偏癥狀:診斷:1.急性腦血管病19采集病史TAKINGTHEHISTORY疾病發(fā)生的背景情況、起病與演變形式、病程；Thesettinginwhichtheillnessoccurred,itsmodeofonsetandevolution,anditscourseareofparamountimportance.明確每一個(gè)癥狀是如何發(fā)生和演變的Onemustattempttolearnpreciselyhoweachsymptombeganandprogressed.診斷步驟采集病史TAKINGTHEHISTORY診斷步驟20

神經(jīng)系統(tǒng)體檢應(yīng)總是按照一定的順序進(jìn)行操作與記錄，以避免遺漏和方便以后的病案分析。Theneurologicalexaminationisalwaysperformedandrecordedinasequentialanduniformmannerinordertoavoidomissionsandtofacilitatethesubsequentanalysisofcaserecords.

神經(jīng)系統(tǒng)體格檢查THENEUROLOGICALEXAMINATION神經(jīng)系統(tǒng)體檢應(yīng)總是按照一定的順序進(jìn)行操作與記錄，21神經(jīng)系統(tǒng)檢查順序：腦神經(jīng)(cranialnerves)、頸、軀干(trunk)及上下肢(theupperandlowerlimbs)的運(yùn)動(dòng)功能(motorfunctions)、反射(reflex)、感覺(jué)功能(sensoryfunctions)、共濟(jì)和步態(tài)(coordinationandgait)，再評(píng)估自主神經(jīng)系統(tǒng)(autonomicnervoussystem)和腦膜刺激征(meningealirritation)。

神經(jīng)系統(tǒng)體格檢查THENEUROLOGICALEXAMINATION神經(jīng)系統(tǒng)檢查順序：神經(jīng)系統(tǒng)體格檢查22綜合征與定位Syndromicalformulationandlocalizationofthelesion神經(jīng)科醫(yī)生常常能將一組癥狀和體征識(shí)別為一個(gè)綜合征。Oftentheneurologistcanrecognizesacharacteristicclusteringofsymptomsandsigns,constitutingasyndrome.綜合征與定位23癥狀眩暈(Vertigo)、惡心嘔吐(nauseaandvomiting)吞咽困難(dysphagia)體征：眼震(nystagmus)、構(gòu)音障礙(dysarthria)同側(cè)Horner征(ipsilateralHorner’ssyndrome

)、同側(cè)肢體共濟(jì)失調(diào)(ipsilaterallimbataxia)同側(cè)面部和對(duì)側(cè)軀干痛溫覺(jué)喪失(ipsilaterallossofpainandtemperaturesensationofthefaceandcontralaterallossofpainandtemperatureofthetrunkandextremities)

WallenbergSyndromeWallenbergSyndrome24定位：小腦后下動(dòng)脈支配的延髓背外側(cè)(thedorsallateralmedullaryplatesuppliedbytheposteriorinferiorcerebellarartery)定性：梗死性(infarction)WallenbergSyndrome定位：小腦后下動(dòng)脈支配的延髓背外側(cè)(thedorsalW25

神經(jīng)病理學(xué)知識(shí)有助于定性診斷，即諸如梗死、出血、脫髓鞘、外傷、壓迫、炎癥、新生物和感染等常見疾病性質(zhì)。Theneurologistisalsohelpedbyaknowledgeofneuropathology,i.e.,thechangesthatareproducedbydiseaseprocessessuchasinfarction,hemorrhage,demyelination,physicaltrauma,compres-sion,inflammation,neoplasm,andinfection,tonamethemorecommon.定性診斷Pathologicaloretiologicdiagnosis定性診斷26單獨(dú)的“病案分析”往往無(wú)法進(jìn)行定性。需求助于各種輔助檢查。Ithappensoftenthatthenatureofthediseaseisnotdiscernedby“casestudy”alone.So,theneurologistresortstotheancillaryexaminationsoutlinedinthenextslide.應(yīng)基于臨床信息來(lái)選擇適宜的實(shí)驗(yàn)室檢查。Laboratorystudycanbeplannedintelligentlyonlyonthebasisofclinicalinformation.定性診斷Pathologicaloretiologicdiagnosis單獨(dú)的“病案分析”往往無(wú)法進(jìn)行定性。需求助于各種輔助檢查。定27

各種輔助檢查(ancillaryexami-nations)，尤其是各種影像學(xué)檢查的出現(xiàn)，為神經(jīng)系統(tǒng)疾病的診斷帶來(lái)革命性的變化。定性診斷Pathologicaloretiologicdiagnosis各種輔助檢查(ancillaryexami-na28輔助檢查腰椎穿刺與腦脊液檢查(Lumbarpunctureandexaminationofcerebrospinalfluid)輔助檢查腰椎穿刺與腦脊液檢查(Lumbarpuncture29計(jì)算機(jī)斷層掃描(computedtomography,CT)磁共振成像(magneticresonanceimaging,MRI)血管造影(angiography)正電子發(fā)射斷層掃描(positronemissiontomography,PET)單光子發(fā)射計(jì)算機(jī)斷層掃描(singlephotonemissioncomputedtomography)SPECT頭顱和脊柱影像學(xué)檢查Radiographicexaminationofskullandspine輔助檢查計(jì)算機(jī)斷層掃描(computedtomography,C30CT輔助檢查CT輔助檢查31MRI、MRA輔助檢查MRI、MRA輔助檢查32MRI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MRI新技術(shù)缺血半暗帶界定33血管造影(angiography)輔助檢查血管造影(angiography)輔助檢查34PET(positronemissiontomography,PET）輔助檢查PET(positronemissiontomog35神經(jīng)病學(xué)緒論課件36SPECT

復(fù)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SPECT復(fù)雜部分性發(fā)作的癲癇病人發(fā)作期與發(fā)37(經(jīng)顱多普勒

transcranialDoppler,TCD)輔助檢查(經(jīng)顱多普勒輔助檢查38腦電圖(electroencephalography)輔助檢查腦電圖(electroencephalography)輔助39誘發(fā)電位(evokedpotentials)軀體感覺(jué)誘發(fā)電位(somatosensoryevokedpotentials,SEP)視覺(jué)誘發(fā)電位(visualevokedpotentials,VEP)腦干聽覺(jué)誘發(fā)電位(brainstemauditoryevokedpotentials,BAEP)運(yùn)動(dòng)誘發(fā)電位(motorevokedpotentials,MEP)事件相關(guān)電位(event-relatedpotential,ERP)輔助檢查誘發(fā)電位(evokedpotentials)輔助檢查40肌電圖(electromyography)與神經(jīng)傳導(dǎo)檢查

(nerveconductionstudies)

肌電圖神經(jīng)傳導(dǎo)檢查輔助檢查肌電圖(electromyography)與神經(jīng)傳導(dǎo)檢查41肌肉、神經(jīng)、皮膚、腦及其它組織的活檢(Biopsyofmuscle,nerve,skin,brain,andothertissue)心理測(cè)量(Psychometry)視野檢查(Perimetry)、測(cè)聽(audio-metry)輔助檢查肌肉、神經(jīng)、皮膚、腦及其它組織的活輔助檢查42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(dǎo)。Focustheclinicalanalysisontheprincipalsymptomsandsignsandavoidbeingdistractedbyminorsignsanduncertainclinicaldata.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43治療

THERAPEUTICS

在內(nèi)科領(lǐng)域，神經(jīng)病學(xué)傳統(tǒng)上被許多人視為不過(guò)是對(duì)無(wú)法治療的疾病下診斷的智力訓(xùn)練。Amongmedicalspecialties,neurologyhastraditionallybeenthoughtofbymanyaslittlemorethananintellectualexerciseconcernedwithmakingdiagnosesofuntreatablediseases.

治療THERAPEUTICS在內(nèi)科領(lǐng)域，神經(jīng)病學(xué)傳44例如：血管支架成形術(shù)(angioplastyandstenting)治療頸動(dòng)脈或顱內(nèi)動(dòng)脈狹窄(carotidstenosesorintracranialstenoses)。其中，頸動(dòng)脈支架成形術(shù)(CarotidAngioplastyandStenting,CAS)較為成熟。治療

THERAPEUTICS例如：治療THERAPEUTICS45治療

THERAPEUTICS治療THERAPEUTICS46治療

THERAPEUTICS

支架是一個(gè)小金屬網(wǎng)管，置入動(dòng)脈中提供支撐。Astentisasmallwiremeshtube,insertedandactsasascaffoldtoprovidesupportinsidetheartery.治療THERAPEUTICS支架是一個(gè)小金屬網(wǎng)管，置47治療

THERAPEUTICS

過(guò)濾裝置，與抗血小板藥物聯(lián)用，預(yù)防微栓子。Filterdevices,combinedwithantiplateletmedication,provideprotectionagainstmicroemboli.治療THERAPEUTICS過(guò)濾裝置，與抗血小板藥48治療

THERAPEUTICS

在操作結(jié)束時(shí)，過(guò)濾裝置帶著所俘獲的殘片移出動(dòng)脈。Attheendoftheprocedure,thefilterisremovedfromthearteryalongwithcaptureddebris.治療THERAPEUTICS在操作結(jié)束時(shí)，過(guò)濾裝置49治療

THERAPEUTICS手術(shù)前后比較（頸動(dòng)脈）治療THERAPEUTICS手術(shù)前后比較（頸動(dòng)脈50治療

THERAPEUTICS手術(shù)前后比較（大腦中動(dòng)脈）治療THERAPEUTICS手術(shù)前后比較（大51治療

THERAPEUTICS

因此，掌握神經(jīng)病學(xué)的診斷方法既有益于臨床醫(yī)生在診斷、預(yù)后和治療方面的解決實(shí)際問(wèn)題，也有益于臨床科研工作者對(duì)疾病機(jī)制與病因的探究。Theclinicalmethodofneurologythusservesboththephysicianinthepracticalmattersofdiagnosis,prognosis,andtreatmentandtheclinicalscientistinthesearchforthemechanismandcauseofthedisease.治療THERAPEUTICS因此，掌握神經(jīng)病學(xué)的診52神經(jīng)病學(xué)緒論IntroductionofNeurology神經(jīng)病學(xué)緒論IntroductionofNeurolog53

是研究中樞神經(jīng)系統(tǒng)(centralnervoussystem,CNS)、周圍神經(jīng)系統(tǒng)(peripheralnervoussystem,PNS)及骨骼肌疾病(musculardiseases)的病因、發(fā)病機(jī)制、臨床表現(xiàn)、診斷、治療及預(yù)防的一門臨床醫(yī)學(xué)學(xué)科。神經(jīng)病學(xué)Neurology是研究中樞神經(jīng)系統(tǒng)(centralnervouss54神經(jīng)病學(xué):最具發(fā)展前景的學(xué)科解剖復(fù)雜、生理功能疑問(wèn)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(fèi)用居各項(xiàng)疾病前列,我國(guó)城市腦血管病居死亡原因首位,每年造成直接經(jīng)濟(jì)損失超過(guò)100億元.研究手段及方法日新月異相關(guān)基礎(chǔ)科學(xué)發(fā)展迅猛神經(jīng)病學(xué):最具發(fā)展前景的學(xué)科解剖復(fù)雜、生理功能疑問(wèn)眾多55神經(jīng)病學(xué)neurology

神經(jīng)眼科學(xué)神經(jīng)耳科學(xué)神經(jīng)心理學(xué)神經(jīng)內(nèi)分泌學(xué)神經(jīng)腫瘤學(xué)神經(jīng)影像學(xué)

神經(jīng)科學(xué)neuroscience

神經(jīng)病學(xué)神經(jīng)眼科學(xué)神經(jīng)科學(xué)56

神經(jīng)科學(xué)neuroscience

Anatomy解剖學(xué)Developmentalbiology發(fā)育生物學(xué)Biophysics生物物理學(xué)Pharmacology藥理學(xué)Cellbiology細(xì)胞生物學(xué)Molecularbiology分子生物學(xué)Computerscience計(jì)算機(jī)科學(xué)Psychology心理學(xué)神經(jīng)科學(xué)Anatomy解剖學(xué)57美國(guó)把20世紀(jì)九十年代定為“腦的十年”。1997年19個(gè)國(guó)家參與的“人類腦計(jì)劃”在美國(guó)正式啟動(dòng)。2001年9月，中國(guó)正式成為參與“人類腦計(jì)劃”的第20個(gè)國(guó)家。諾貝爾獎(jiǎng)多次授予神經(jīng)科學(xué)家。美國(guó)把20世紀(jì)九十年代定為“腦的十年”。1997年19個(gè)國(guó)家58NobelPrize2000ARVIDCARLSSON,PAULGREENGARDandERICKANDELfortheirdiscoveriesconcerningsignaltransduction

inthenervoussystem.HediscoveredthatdopamineisatransmitterinthebrainandthatithasgreatimportanceforourabilitytocontrolmovementsandcontributedtothedevelopmentofL-dopaasatreatmentforParkinson‘sdisease,totheunderstandingoftheactionofdrugsforschizophrenia(精神分裂癥),andthedevelopmentofselectiveserotoninreuptakeinhibitors(選擇性5-羥色胺再攝取抑制劑)asantidepressants(抗抑郁劑).NobelPrize2000ARVIDCARLSSON,591997STANLEYB.PRUSINERforhisdiscoveryofPrions-anewbiologicalprincipleofinfection-smallproteinaceousinfectiousparticleswhichresistinactivationbyproceduresthatmodifynucleicacidsandareresponsibleforCreutzfeldt-JacobDisease，Kuruandcertainotherdegenerativediseasesofthenervoussystem.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(kù)魯病及其它某些神經(jīng)系統(tǒng)變性病的病原體。NobelPrize1997STANLEYB.PRUSINERforhi601994ALFREDG.GILMANandMARTINRODBELLfortheirdiscoveryofG-proteinsandtheroleoftheseproteinsinsignaltransductionincells.Theystudiedthecomplexrelay(中繼)

ofcellcommunication.Gproteins,lyinginsidethecell,canrespondtosignalsfromoutsidethecell-light,smell,neurotransmittersandhormones-andtranslatethemintoafrenzyofcellularactioninside.NobelPrize1994ALFREDG.GILMANandMARTI611991ERWINNEHERandBERTSAKMANNfortheirdiscoveriesconcerningthefunctionofsingleionchannelsincells.Theydiscoveredawaytorecordandobservetheionchannelsortunnel-likepassagewaysfromtheinsidetotheoutsideofacell.Theirtechniquecanbeusedinthestudyofsuchdiseasesasneuromusculardisorders,epilepsyandanxiety,andtailor-makingadruginordertoachieveanoptimal

effect.NobelPrize1991ERWINNEHERandBERTSAKMA62神經(jīng)系統(tǒng)疾病診斷具有獨(dú)特的方法和體系,強(qiáng)調(diào)系統(tǒng)性和邏輯性全面的相關(guān)知識(shí)邏輯的思維方式規(guī)范的檢查手段嚴(yán)謹(jǐn)?shù)墓ぷ鲬B(tài)度全面的病史詢問(wèn)系統(tǒng)的體格檢查準(zhǔn)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)疾病診斷具有獨(dú)特的方法和體系,強(qiáng)調(diào)系統(tǒng)性和邏輯性全面63神經(jīng)系統(tǒng)疾病診斷神經(jīng)解剖學(xué)(neuroanatomy)、神經(jīng)生理學(xué)(neuro-physiology)神經(jīng)病理學(xué)(neuropathology)神經(jīng)系統(tǒng)體格檢查(neurologicalexamination)神經(jīng)系統(tǒng)疾病診斷神經(jīng)解剖學(xué)(neuroanatomy)、64神經(jīng)疾病的診斷方法共同點(diǎn)：詳細(xì)病史采集,詳細(xì)體格檢查特殊性：病史和體格檢查的客觀性：特殊思維方法：定位診斷定性診斷神經(jīng)疾病的診斷方法65Stepsinthediagnosisofneurologicaldisease診斷步驟采集病史Byhistory神經(jīng)系統(tǒng)體格檢查Byneurologicalexamination得到臨床資料ElicitationofclinicalfactsStepsinthediagnosisofneur66用解剖學(xué)和生理學(xué)術(shù)語(yǔ)解釋癥狀和體征Interpretationofsymptomsandsignsintermsofanatomyandphysiology得到臨床資料Elicitationofclinicalfacts診斷步驟用解剖學(xué)和生理學(xué)術(shù)語(yǔ)解釋癥狀和體征得到臨床資料診斷步驟67確定損害系統(tǒng)或部位Syndromicalformulationandlocalizationofthelesion(topicaldiagnosis定位診斷)用解剖學(xué)和生理學(xué)術(shù)語(yǔ)解釋癥狀和體征Interpretationofsymptomsandsignsintermsofanatomyandphysiology診斷步驟

68定位診斷定位診斷起病形式和演變過(guò)程Modesofonsetandcourse其它醫(yī)學(xué)資料Othermedicaldata適宜的實(shí)驗(yàn)室檢查Appropriatelabtest+++定性診斷

(Pathologicaloretiologicdiagnosis)診斷步驟定位診斷定位診斷起病形式和演變過(guò)程其它醫(yī)學(xué)資料適宜的實(shí)驗(yàn)室檢69DiagnosisAnatomicdiagnosis（定位診斷)Pathologicaloretiologicdiagnosis(定性診斷)Pathologicaloretiologicdiagnosis(病因診斷)CLINICALMETHODDiagnosisAnatomicdiagnosis（定位70大腦中動(dòng)脈主干閉塞綜合征三偏癥狀:病灶對(duì)側(cè)中樞性面舌癱中樞性偏癱偏身感覺(jué)障礙和偏盲不同程度的意識(shí)障礙失語(yǔ)或體象障礙

診斷:1.急性腦血管病定位診斷:右側(cè)大腦中動(dòng)脈;定性診斷:腦梗死2.原發(fā)性高血壓(三級(jí));頸動(dòng)脈狹窄大腦中動(dòng)脈主干閉塞綜合征三偏癥狀:診斷:1.急性腦血管病71采集病史TAKINGTHEHISTORY疾病發(fā)生的背景情況、起病與演變形式、病程；Thesettinginwhichtheillnessoccurred,itsmodeofonsetandevolution,anditscourseareofparamountimportance.明確每一個(gè)癥狀是如何發(fā)生和演變的Onemustattempttolearnpreciselyhoweachsymptombeganandprogressed.診斷步驟采集病史TAKINGTHEHISTORY診斷步驟72

神經(jīng)系統(tǒng)體檢應(yīng)總是按照一定的順序進(jìn)行操作與記錄，以避免遺漏和方便以后的病案分析。Theneurologicalexaminationisalwaysperformedandrecordedinasequentialanduniformmannerinordertoavoidomissionsandtofacilitatethesubsequentanalysisofcaserecords.

神經(jīng)系統(tǒng)體格檢查THENEUROLOGICALEXAMINATION神經(jīng)系統(tǒng)體檢應(yīng)總是按照一定的順序進(jìn)行操作與記錄，73神經(jīng)系統(tǒng)檢查順序：腦神經(jīng)(cranialnerves)、頸、軀干(trunk)及上下肢(theupperandlowerlimbs)的運(yùn)動(dòng)功能(motorfunctions)、反射(reflex)、感覺(jué)功能(sensoryfunctions)、共濟(jì)和步態(tài)(coordinationandgait)，再評(píng)估自主神經(jīng)系統(tǒng)(autonomicnervoussystem)和腦膜刺激征(meningealirritation)。

神經(jīng)系統(tǒng)體格檢查THENEUROLOGICALEXAMINATION神經(jīng)系統(tǒng)檢查順序：神經(jīng)系統(tǒng)體格檢查74綜合征與定位Syndromicalformulationandlocalizationofthelesion神經(jīng)科醫(yī)生常常能將一組癥狀和體征識(shí)別為一個(gè)綜合征。Oftentheneurologistcanrecognizesacharacteristicclusteringofsymptomsandsigns,constitutingasyndrome.綜合征與定位75癥狀眩暈(Vertigo)、惡心嘔吐(nauseaandvomiting)吞咽困難(dysphagia)體征：眼震(nystagmus)、構(gòu)音障礙(dysarthria)同側(cè)Horner征(ipsilateralHorner’ssyndrome

)、同側(cè)肢體共濟(jì)失調(diào)(ipsilaterallimbataxia)同側(cè)面部和對(duì)側(cè)軀干痛溫覺(jué)喪失(ipsilaterallossofpainandtemperaturesensationofthefaceandcontralaterallossofpainandtemperatureofthetrunkandextremities)

WallenbergSyndromeWallenbergSyndrome76定位：小腦后下動(dòng)脈支配的延髓背外側(cè)(thedorsallateralmedullaryplatesuppliedbytheposteriorinferiorcerebellarartery)定性：梗死性(infarction)WallenbergSyndrome定位：小腦后下動(dòng)脈支配的延髓背外側(cè)(thedorsalW77

神經(jīng)病理學(xué)知識(shí)有助于定性診斷，即諸如梗死、出血、脫髓鞘、外傷、壓迫、炎癥、新生物和感染等常見疾病性質(zhì)。Theneurologistisalsohelpedbyaknowledgeofneuropathology,i.e.,thechangesthatareproducedbydiseaseprocessessuchasinfarction,hemorrhage,demyelination,physicaltrauma,compres-sion,inflammation,neoplasm,andinfection,tonamethemorecommon.定性診斷Pathologicaloretiologicdiagnosis定性診斷78單獨(dú)的“病案分析”往往無(wú)法進(jìn)行定性。需求助于各種輔助檢查。Ithappensoftenthatthenatureofthediseaseisnotdiscernedby“casestudy”alone.So,theneurologistresortstotheancillaryexaminationsoutlinedinthenextslide.應(yīng)基于臨床信息來(lái)選擇適宜的實(shí)驗(yàn)室檢查。Laboratorystudycanbeplannedintelligentlyonlyonthebasisofclinicalinformation.定性診斷Pathologicaloretiologicdiagnosis單獨(dú)的“病案分析”往往無(wú)法進(jìn)行定性。需求助于各種輔助檢查。定79

各種輔助檢查(ancillaryexami-nations)，尤其是各種影像學(xué)檢查的出現(xiàn)，為神經(jīng)系統(tǒng)疾病的診斷帶來(lái)革命性的變化。定性診斷Pathologicaloretiologicdiagnosis各種輔助檢查(ancillaryexami-na80輔助檢查腰椎穿刺與腦脊液檢查(Lumbarpunctureandexaminationofcerebrospinalfluid)輔助檢查腰椎穿刺與腦脊液檢查(Lumbarpuncture81計(jì)算機(jī)斷層掃描(computedtomography,CT)磁共振成像(magneticresonanceimaging,MRI)血管造影(angiography)正電子發(fā)射斷層掃描(positronemissiontomography,PET)單光子發(fā)射計(jì)算機(jī)斷層掃描(singlephotonemissioncomputedtomography)SPECT頭顱和脊柱影像學(xué)檢查Radiographicexaminationofskullandspine輔助檢查計(jì)算機(jī)斷層掃描(computedtomography,C82CT輔助檢查CT輔助檢查83MRI、MRA輔助檢查MRI、MRA輔助檢查84MRI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MRI新技術(shù)缺血半暗帶界定85血管造影(angiography)輔助檢查血管造影(angiography)輔助檢查86PET(positronemissiontomography,PET）輔助檢查PET(positronemissiontomog87神經(jīng)病學(xué)緒論課件88SPECT

復(fù)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SPECT復(fù)雜部分性發(fā)作的癲癇病人發(fā)作期與發(fā)89(經(jīng)顱多普勒

transcranialDoppler,TCD)輔助檢查(經(jīng)顱多普勒輔助檢查90腦電圖(electroencephalography)輔助檢查腦電圖(electroencephalography)輔助91誘發(fā)電位(evokedpotentials)軀體感覺(jué)誘發(fā)電位(somatosensoryevokedpotentials,SEP)視覺(jué)誘發(fā)電位(visualevokedpotentials,VEP)腦干聽覺(jué)誘發(fā)電位(brainstemauditoryevokedpotentials,BAEP)運(yùn)動(dòng)誘發(fā)電位(motorevokedpotentials,MEP)事件相關(guān)電位(event-re