神經(jīng)病學(xué)緒論華中同濟(jì)

1、神經(jīng)病學(xué)緒論,Introduction of Neurology,,同濟(jì)醫(yī)學(xué)院附屬同濟(jì)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(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,,神經(jīng)病學(xué):最具發(fā)展前景的學(xué)科,,解剖復(fù)

2、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) 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)科學(xué) neurosci

3、ence,,Anatomy 解剖學(xué)Developmental biology 發(fā)育生物學(xué)Biophysics 生物物理學(xué)Pharmacology 藥理學(xué)Cell biology 細(xì)胞生物學(xué)Molecular biology 分子生物學(xué)Computer science 計(jì)算機(jī)科學(xué)Psychology 心理學(xué),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

4、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。,Nobel Prize,Nobel Prize,Nobel Prize,Nobel Prize,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,,神經(jīng)解剖學(xué)(neuroanatomy)、神經(jīng)

5、生理學(xué)(neuro-physiology)神經(jīng)病理學(xué)(neuropathology)神經(jīng)系統(tǒng)體格檢查(neurological examination),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,,Steps in the diagnosis of neurologic

6、al 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(xué)和生理學(xué)術(shù)語(yǔ)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

7、of clinical facts,診斷步驟,確定損害系統(tǒng)或部位Syndromical formulation and localization of the lesion (topical diagnosis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Interpretation of symptoms and signs in terms of anatomy and physiology,診斷步驟,,定位診斷,,定位診

8、斷,起病形式和演變過(guò)程Modes of onset and course,其它醫(yī)學(xué)資料Other medical data,適宜的實(shí)驗(yàn)室檢查Appropriate lab test,+,+,+,,,定性診斷 (Pathological or etiologic diagnosis),診斷步驟,Diagnosis,Anatomic diagnosis（定位診斷)Pathological or etiologic diagnosis

9、(定性診斷)Pathological or etiologic diagnosis(病因診斷),CLINICAL METHOD,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

10、 2.原發(fā)性高血壓(三級(jí));頸動(dòng)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(gè)癥狀是如何發(fā)生和演變的 O

11、ne must attempt to learn precisely how each symptom began and progressed.,診斷步驟,,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。 The neurological examination is always performed and recorded in a sequential and uniform man

12、ner 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 (trunk) 及上下肢(the upper and lower limbs)的運(yùn)動(dòng)功能(mot

13、or functions)、反射(reflex)、感覺(jué)功能(sensory functions)、共濟(jì)和步態(tài)(coordination and gait)，再評(píng)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,,綜合征與定位Syndromical formulation and lo

14、calization of the lesion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。Often the neurologist can recognizes a characteristic clustering of symptoms and signs, constituting a syndrome.,,癥狀 眩暈(Vertigo)、 惡心嘔吐(nausea and vomitin

15、g) 吞咽困難(dysphagia)體征：眼震(nystagmus) 、構(gòu)音障礙 (dysarthria) 同側(cè)Horner征(ipsilateral Horner’s syndrome ) 、 同側(cè)肢體共濟(jì)失調(diào)(ipsilateral limb ataxia) 同側(cè)面部和對(duì)側(cè)軀干痛溫覺(jué)喪失(ipsilateral loss

16、 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(dòng)脈支配的延髓背外側(cè)(the dorsal lat

17、eral medullary plate supplied by the posterior inferior cerebellar artery)定性：梗死性(infarction),,Wallenberg Syndrome,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(jiàn)疾病性質(zhì)。 The neurologist is also helped by

18、a knowledge of neuropathology, i.e., the changes that are produced by disease processes such as infarction, hemorrhage, demyelination, physical trauma, compres-sion, inflammation, neoplasm, and infection, to name the mor

19、e common.,定性診斷Pathological or etiologic diagnosis,,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。 It happens often that the nature of the disease is not discerned by “case study” alone. So, the neurologist resorts to the ancillary

20、 examinations outlined in the next slide.應(yīng)基于臨床信息來(lái)選擇適宜的實(shí)驗(yàn)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 exa

21、mi-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Pathological or etiologic diagnosis,,輔助檢查,腰椎穿刺與腦脊液檢查(Lumbar puncture and examination of cerebrospinal fluid),,計(jì)算機(jī)斷層掃描(computed tomography, CT) 磁共振成像(magnetic resonance

22、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(jì)算機(jī)斷層掃描(single photon emission computed tomography)SPECT,頭顱和脊柱影像學(xué)檢查Radiographic examination of skull and spine,輔助檢查,,CT,輔助檢查,,MRI、MRA,輔助

23、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(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,,(經(jīng)顱多普勒 transcranial Doppler , TCD),輔助檢查,,腦電圖 (electro

24、encephalography),輔助檢查,,誘發(fā)電位(evoked potentials)軀體感覺(jué)誘發(fā)電位(somatosensory evoked potentials, SEP)視覺(jué)誘發(fā)電位(visual evoked potentials, VEP)腦干聽(tīng)覺(jué)誘發(fā)電位(brainstem auditory evoked potentials, BAEP)運(yùn)動(dòng)誘發(fā)電位(motor evoked potenti

25、als, 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(dǎo)檢查 (nerve conduction studies ),肌電圖,神經(jīng)傳導(dǎo)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 tissue)心理測(cè)量(Psychome

26、try) 視野檢查(Perimetry)、測(cè)聽(tīng)(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(dǎo)。Focus the clinical analysis on the principal symptoms and signs and avoid being distracted by minor signs and uncertain clinical data.,治

27、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。Among medical specialties, neurology has traditionally been thought of by many as little more than an intellectual exercise concerned with making diagnoses of untrea

28、table diseases.,,例如：血管支架成形術(shù)(angioplasty and stenting)治療頸動(dòng)脈或顱內(nèi)動(dòng)脈狹窄(carotid stenoses or intracranial stenoses) 。其中，頸動(dòng)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

29、是一個(gè)小金屬網(wǎng)管，置入動(dòng)脈中提供支撐。A stent is a small wire mesh tube, inserted and acts as a scaffold to provide support inside the artery.,治療 THERAPEUTICS,,過(guò)濾裝置，與抗血小板藥物聯(lián)用，預(yù)防微栓子。Filter devices, combined with antiplatelet medication, p

30、rovide protection against microemboli.,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。At the end of the procedure, the filter is removed from the artery along with captured debris.,治療 THERAPEUTICS,,手術(shù)前后比較（頸動(dòng)脈）,,治療 THERAPEUTIC

31、S,,手術(shù)前后比較（大腦中動(dòng)脈）,,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。The clinical method of neurology thus serves both the physician in the practical matters of diagnosis, prognosis, and tre