?？谱o(hù)理師訓(xùn)練神經(jīng)系統(tǒng)常見問題之評(píng)估一

1、,頭痛 Headache,Pain-sensitive cranial structures,顱外Skin, subcutaneous tissues, muscles extracranial arteries, periosteum of skullEye, ear nasal cavities perinasal sinuses顱內(nèi)血管Intracranial venous sinuses and their large

2、 tributaries, esp. pericavernous structuresArteries within the dura and pia-subarachnoid, particulary the proximal parts of the ACA, MCA and the intracranial segment of ICAThe middle meningeal and superficial temporal

3、arteries腦膜Parts of the dura at the base of the brain顱神經(jīng)The optic, oculomotor, trigeminal, glossopharyngeal, vagus, (and the first three cervical nerves),From supratentorial structuresAnterior 2/3 of head (V1, V2 der

4、matones)From infratenotrial structuresVertex, posterior head and neck From VII, IX, X cranial nervesNaso-orbital region, ear, throatPain from extracrainal part of body NOT refer to head, EXCEPTCervical portion of I

5、CAEyebrow, supraorbital regionUpper cervical spineocciputAngina pectoris (rare)Jaw, vertex,Areas of refer pain from intracranial structures,?國際頭痛疾病分類? ICHD (International Classification of Headache Disorders),第一版在1

6、988年公布，第二版於2004年刊登於Cephalalgia雜誌。 不論是中文版或英文版的?國際頭痛疾病分類?都長達(dá)一百五十頁以上 ! 在英文版第二版中，作者建議－?這份內(nèi)容龐大的分類文件不是用來背的，這是一份須要一次又一次不斷查看的文件。?,原發(fā)性 (Primary)次發(fā)性 (Secondary)以決定頭痛的原因及訂定適切的治療計(jì)畫,頭痛 Headache,原發(fā)性頭痛 (primary headache),意謂頭痛本身即為痛

7、的成因。超過百分之九十的頭痛患者屬於此類。重點(diǎn)就是排除次發(fā)性的可能。,無預(yù)兆偏頭痛 Migraine without aura,A. 至少有5次能符合基準(zhǔn)B-D的發(fā)作B. 頭痛發(fā)作持續(xù)4-72小時(shí) (未經(jīng)治療或治療無效)C. 頭痛至少具下列二項(xiàng)特徵：1. 單側(cè)2. 搏動(dòng)性 3. 疼痛程度中或重度4. 日?；顒?dòng)會(huì)使頭痛加劇或避免此類活動(dòng)（如走路或爬樓梯）D. 當(dāng)頭痛發(fā)作時(shí)至少有下列一項(xiàng)：1. 噁心及/或嘔吐2

8、. 畏光及怕吵E. 非歸因於其他疾患,典型預(yù)兆偏頭痛性頭痛 Typical aura with migraine headache,A. 至少有2次符合基準(zhǔn)B-D的發(fā)作B. 預(yù)兆至少包括下列一項(xiàng)，但無肢體無力：1. 完全可逆視覺癥狀，包括正向特徵 (如：閃爍的光、點(diǎn)或線) 及/或負(fù)向特徵 (即視力喪失)2. 完全可逆感覺癥狀，包括正向特徵 (即針刺感)及/或負(fù)向特徵 (即麻木感)3. 完全可逆失語性語言障礙C. 至少

9、具下列2項(xiàng)：1.單側(cè)的視覺癥狀及/或單側(cè)感覺癥狀2. 至少一種預(yù)兆癥狀在≧5分鐘逐漸產(chǎn)生，及/或不同預(yù)兆癥狀，在≧5分鐘相繼發(fā)生3. 每一種癥狀持續(xù)≧5及≦60分鐘D. 符合無預(yù)兆偏頭痛 基準(zhǔn)B-D的頭痛，在預(yù)兆同時(shí)或預(yù)兆之後的60分鐘內(nèi)發(fā)生E. 非歸因於其他疾患,緊縮型頭痛 Tension-type headache,A. Frequent: 至少有十次能符合基準(zhǔn)B-D之發(fā)作，且發(fā)作平均每月≧1日但＜15日，已至少三個(gè)

10、月（每年≧12日且＜180日, 頭痛持續(xù)30分鐘至7日 Chronic: 頭痛平均發(fā)作每月≧15日，已＞3個(gè)月（每年≧180日）且符合基準(zhǔn)B-D, 頭痛持續(xù)數(shù)小時(shí)或可能持續(xù)不斷B. 頭痛至少具下列二項(xiàng)特徵：1. 雙側(cè)2. 壓迫/緊縮性（非搏動(dòng)性）3.程度輕或中度4.不因日?；顒?dòng)如走路或爬樓梯而加劇C.下列兩項(xiàng)皆符合：1. 無噁心或嘔吐（可能有食慾不振）2. 最多只有畏光或怕吵其中一項(xiàng)癥狀D. 非歸因於其

11、他疾患,叢發(fā)性頭痛 Cluster headache,A. 至少有5次符合基準(zhǔn)B-D之發(fā)作B. 位於單側(cè)眼眶、上眼眶及/或顳部重度或極重度疼痛，如不治療可持續(xù)15至180分鐘 C. 頭痛時(shí)至少伴隨下列一項(xiàng)：1. 同側(cè)結(jié)膜充血及/或流淚2. 同側(cè)鼻腔充血及/或流鼻水3. 同側(cè)眼皮水腫4. 同側(cè)前額及臉部出汗5. 同側(cè)瞳孔縮小及/或眼皮下垂6. 不安的感覺或躁動(dòng)D. 發(fā)作頻率為每二日一次至每日八次 E. 非歸因

12、於其他疾患,典型三叉神經(jīng)痛 Classical trigeminal neuralgia,A. 發(fā)作性 (paroxysmal) 疼痛發(fā)作，持續(xù)由不到一秒到兩分鐘，影響三叉神經(jīng)一支或一支以上分支的支配區(qū)，且符合基準(zhǔn)B及CB. 疼痛至少具下列一項(xiàng)特徵：1. 劇烈、尖銳、表淺或刺戳痛2. 於誘發(fā)區(qū)引發(fā)或由誘因引發(fā)C. 就個(gè)別病人而言，疼痛的發(fā)作型態(tài)是固定 (stereotyped) 的D. 沒有神經(jīng)功能缺損的臨床證據(jù)E

13、. 非歸因於其他疾患,次發(fā)性頭痛 (Secondary headache),意謂頭痛由其他原因所引起頭部與頸部外傷顱部或頸部血管疾患非血管性顱內(nèi)疾患物質(zhì)或物質(zhì)戒斷感染體內(nèi)恆定疾患頭顱,頸,眼,鼻,耳,口,鼻竇,牙或其他面部或顱部結(jié)構(gòu)疾患精神疾患 ?國際頭痛疾病分類? ICHD II需治療引起頭痛之原因。,與腦瘤相關(guān)的頭痛

14、,The pain has no specific featurestend to be deep-seated, usually non-throbbingLasts a few minutes to an hour or moreOccur once or many times during a dayPhysical activity and changes in position of the head may prov

15、oke pain, whereas rest diminishes its frequency If unilateral , the pain is nearly always on the same side of tumorSupratentorial/infratentorial tumor 的頭痛以interauricular circumference為分界Late stage, IICP leads to Unil

16、ateral to bioccipital or bifrontal headache, nocturnal awakening, projectile vomiting,與中風(fēng)相關(guān)的頭痛,25% stroke with headache around the onset 50% headache onset prior to the neurological deficitspressing or throbbingIf uni

17、lateral, pain is usually ipsilateral to the side of stroke More in large strokeposterior circulationwith a history of primary headache,,老年人的特殊頭痛,Temporal arteritis (Giant cell arteritis)肇因於頭部動(dòng)脈的發(fā)炎, 多是外頸動(dòng)脈的分支頭皮動(dòng)脈腫脹壓

18、痛併ESR或CRP上升可能伴隨polymyalgia rheumatica及jaw claudication變異性大, 故凡是60歲以上新發(fā)的持續(xù)性頭痛均需懷疑此診斷, 進(jìn)行適當(dāng)?shù)脑\察易併發(fā)前側(cè)缺血性視神經(jīng)病變(anterior ischemic optic neuropathy)導(dǎo)致失明, 由一側(cè)失明進(jìn)展至另一側(cè)的時(shí)間小於一週需積極用高劑量類固醇預(yù)防治療, 治療三天內(nèi)顯著緩解頭痛通常也有腦部缺血及失智的危險(xiǎn)Hypnic

19、headache鈍痛, 只在睡眠中發(fā)生, 使病人醒來三項(xiàng)中具其二首次發(fā)作在50歲以後, 醒來後頭痛持續(xù)15分鐘以上, 一個(gè)月發(fā)生15次以上無自主神經(jīng)系統(tǒng)癥狀, 且噁心, 畏光, 怕吵不超過一項(xiàng),”雷擊般頭痛” Thunderclap headache,Subarachnoid hemorrhageSentinel leakAcute hypertensive crisisCervical artery dissection

20、Pituitary hypoplexyCerebral spasmPrimary thunderclap headachePrimary cough headachePrimary headache associated with sexual activityCerebral venous thrombosis,需懷疑顱內(nèi)高壓之頭痛 IICP Headache,Symptoms廣泛性脹痛, 平躺更易頭痛Valsalv

21、a maneuver會(huì)更痛 半夜痛醒 (nocturnal awakening)噴射性嘔吐 (projectile vomiting)IICP Signs視乳頭水腫 (papilloedema)盲點(diǎn)擴(kuò)大視野缺損 第六對(duì)腦神經(jīng)痲痺 臥姿經(jīng)腰椎穿刺測(cè)量出腦脊髓液壓力增加 (在非肥胖者＞200mm H2O；在肥胖者＞250mm H2O)Cushing responseHypertension, bradycardia, s

22、low and irregular breathing,腦脊髓液低壓之頭痛 Intracranial hypotension,A. 整個(gè)頭(diffuse)及/或鈍痛，在坐起或站立後15分鐘內(nèi)惡化，至少具下列一項(xiàng)，且符合基準(zhǔn)D：1. 頸部僵硬2. 耳鳴3. 聽力障礙4. 畏光5. 噁心B. 至少具下列一項(xiàng)：1. MRI有腦脊髓液低壓的證據(jù)（如：硬腦膜對(duì)比增強(qiáng)）2. 傳統(tǒng)脊髓攝影、CT脊髓攝影、或腦池?cái)z影術(shù)證實(shí)有腦脊髓

23、液滲漏3. 在坐姿，腦脊髓液起始?jí)毫Γ?0mm H2OC. 有/無硬腦膜穿刺或?qū)е履X脊髓液瘻管病因等病史D. 頭痛在硬腦膜外血液貼片後72小時(shí)內(nèi)緩解,原發(fā)性頭痛和次發(fā)性頭痛可以並存 !,Approach patients with headache,,Location QualityTightness, pressure, throbbing, stabbing…IntensityMode of onset, time

24、-intensity curve, and durationPrecipitating, aggravating and relieving factorsAssociative symptoms,Head Ache … 有關(guān)頭痛需要獲得的病史,評(píng)估頭痛的嚴(yán)重程度,目測(cè)類比量表(Visual analogue scale ,VAS)區(qū)分頭痛為十級(jí)，即1至10分。 「0」代表沒有頭痛、「10」代表這一輩子最嚴(yán)重的疼痛。

25、 概括而言1到3分表示「輕度」，4到6分表「中度」，7到9分表「重度」，而10分表示「極重度」。,SNOOP Maria-Carman B. Wilson, MD.,Symptoms（癥狀）如發(fā)燒，倦怠，體重減輕Neurological（神經(jīng)學(xué)）癥狀或徵象Onset（發(fā)生）突然，快速惡化Older（年紀(jì)大的病患）出現(xiàn)新發(fā)生或逐漸惡化之頭痛Previou

26、s（原先）頭痛的頻率、強(qiáng)度、時(shí)程、特色改變,焦點(diǎn)病史,病人這種頭痛有多久了？長時(shí)間持續(xù)多年且未曾改變的頭痛常為原發(fā)性頭痛，如偏頭痛。新頭痛的發(fā)生，特別是超過50歲，則是個(gè)警訊。若病人已有多年頭痛，它改變了嗎？了解原本頭痛的改變，包括頻率、強(qiáng)度、時(shí)程等不同的特徵。,,何時(shí)頭痛發(fā)生？夜間頭痛可能是次發(fā)性，導(dǎo)因於某些引起顱內(nèi)壓上昇的情形。有些時(shí)候，剛睡醒時(shí)也會(huì)有次發(fā)性頭痛。因?yàn)檫@些相似性，頭痛發(fā)生的時(shí)間需進(jìn)一步探討來決定原發(fā)或次發(fā)

27、。睡眠時(shí)發(fā)生的頭痛可以是原發(fā)的。叢發(fā)性頭痛及偏頭痛都可在睡眠時(shí)發(fā)生或?qū)⑷送葱选?,頭痛是突發(fā)或慢慢發(fā)生？對(duì)於數(shù)秒或數(shù)分鐘即痛到最痛者，可能會(huì)評(píng)估是否有潛在疾患如腦出血、栓塞、顱內(nèi)壓上昇等情形。原發(fā)性頭痛，包括不明原因（idiopathic）、刺戳性(stabbing)頭痛、咳嗽或用力(exertion)引起的、和性交有關(guān)的、叢發(fā)性及叢發(fā)類(variant)，都可以快速發(fā)生。,,是否曾注意到下列神經(jīng)學(xué)癥狀：意識(shí)混亂、意識(shí)不清、麻木、

28、無力、言語視力或平衡因難、或其他神經(jīng)學(xué)不正常的癥狀及徵象？若在偏頭痛發(fā)生前產(chǎn)生這些癥狀，病人可能符合預(yù)兆偏頭痛。然而，必須區(qū)分不符合典型預(yù)兆偏頭痛的癥狀及徵象，因此會(huì)仔細(xì)的詢問相關(guān)病史看看是否這些癥狀指向其他問題。,,若病人曾經(jīng)歷過預(yù)兆，它是如何發(fā)生又持續(xù)多久？偏頭痛預(yù)兆通常在數(shù)分鐘內(nèi)逐漸產(chǎn)生，約在15至20分鐘達(dá)到頂峰後，約25分鐘消失。依定義，偏頭痛預(yù)兆小於一小時(shí)。若預(yù)兆超過一小時(shí)，需小心是否為migraineous infa

29、rct。是否曾經(jīng)歷發(fā)燒、倦怠、體重減輕或全身不適？這些癥狀可能和潛在的感染、發(fā)炎或惡性腫瘤有關(guān)，可能有進(jìn)一步檢查的必要,焦點(diǎn)身體檢查,Physical examinationT/P/R and BPHead and neckLocal heat/swelling/erythemaLocal tenderness / knocking painEyes injection/ bruitNeck bruitNeck st

30、iffness,Neurological examinationConsciousness level / contentCranial nervesPupil size, light reflex, (eye fundus)EOM limitationFacial palsy, gag reflex, tongue deviationMotor systemMuscle powerDTRSensory system

31、Pinprick, light touchCoordination systemF-N-F / H-K-S testGait,III, IV, VI 眼動(dòng)神經(jīng)眼皮下垂 ptosispartial / complete眼動(dòng)是否對(duì)稱, 有無雙影,,,,X,0,0,0,0,0,0,,,,X,0,0,0,0,0,0,0正常~ -4不動(dòng),肌力 Muscle Power5分: 正常4分: 抗阻力3分: 抗重力2分: 平移1分:

32、 肌肉收縮0分: 不動(dòng),5,5,5,5,5,5,5,5,5,5,5,5,,,,肌腱反射 DTR (deep tendon reflex)Hypo0~1Low motor neuron lesionNormal2Hyper3~clonusUpper motor neuron lesion,++,++,++,++,++,↓,↑,,實(shí)驗(yàn)室與診斷檢查,血液檢查影像學(xué)檢查CT or MRI ?CTA/MRA or conv

33、entional angiography ?腦脊髓液檢查Open / close pressureCSF appearanceWBC, RBC, total protein, lactic acid, glucoseCulture / antigen identification / PCR,Headache Hygiene Tips (1),Get Regular SleepGo to bed and wake up at

34、 regular times each day Do not sleep excessively on the weekends and too little on the weekdays Most adults need approximately 6-8 hours of sleep per night Eat Regular MealsLow blood sugar can trigger a headache Eat

35、 regular meals three times each day including protein, fruits, vegetables and carbohydrates Too much sugar may lead to a rapid increase in blood sugar followed by a rapid decline in blood sugar, which can trigger a head

36、ache Get Moderate Amounts of Routine ExerciseModerate exercise three to five times each week will help reduce stress and keep you physically fit Too much exercise or inconsistent patterns of exercise may trigger heada

37、che,Headache Hygiene Tips (2),Drink Plenty of WaterA normal adult should drink plenty of water throughout the day Dehydration may cause headaches Limit Caffeine, Alcohol and other DrugsCaffeine is a stimulant and caf

38、feine withdrawal may cause headaches when blood levels of caffeine taper Alcohol may be a trigger for headaches and alcohol in moderation may reduce the number of headaches Reduce Stress  Stress may lead to

39、an increase in headache Relaxation and stress management may help reduce headaches,Headache - Cases discussion,,CASE 1,28歲女性主訴: 頭痛三個(gè)月現(xiàn)在病史：似乎三個(gè)月前就開始會(huì)頭痛，然後發(fā)現(xiàn)次數(shù)愈來愈頻繁，也愈痛，尤其最近這兩週較嚴(yán)重，甚至胃口不好，吃不下飯。頭痛的部位是整個(gè)頭，緊緊脹脹的痛、好像是整圈緊紮的

40、痛，早上睡醒或者好好去睡一覺後，會(huì)覺得好一點(diǎn)，經(jīng)常是越到下午越容易頭痛。但是不曾有半夜痛醒來的經(jīng)驗(yàn)。頭痛起來時(shí)，並沒有眼前出現(xiàn)閃光，眼睛周圍沒有痛，不會(huì)怕光，沒有伴隨嘔吐或噁心，最近視力正常，記憶力也還好。最近沒有感冒、發(fā)燒、鼻塞、濃鼻涕，也沒有過敏性鼻炎、鼻竇炎。耳朵也不會(huì)痛。手腳活動(dòng)正常，不會(huì)常跌倒最近半年換新工作，因工作還未完全熟悉，且業(yè)務(wù)量大，常常加班，自覺很辛苦 。身體檢查：血壓 136/88 mmHg 心跳 96/

41、min意識(shí)清醒、記憶正常，神經(jīng)學(xué)檢查一切正常,CASE 2,25 year-old female, no underlying diseaseSubacute progressive headache for 2 monthsDiffuse, swelling sensation Cough and defecation worse the headacheMidnight headache, awaking her from

42、 sleepnausea/vomiting while headacheBlurred vision (+)Body weight loss (+)Fever (-),Summary of N.E. & lab,Conscious clearNeck suppleNE all normal, except papilloedema (OU)CSF open pressure 310 mmH2O, no cell,

43、Lupus leukoencephalopathy with IICP,,,頭暈 Dizziness,病人主訴Dizziness”頭暈”的意思是…. ?,Vertigo 眩暈an illusion of motion“spinning sensation”, ”whirling” , ”tilting”likely to indicate an abnormality of the semicircular canals or t

44、he central nervous system structures that process signals from the semicircular canals Nonspecific “dizziness” “giddy” or “l(fā)ightheaded” DisequilibriumPresyncope,40% have peripheral vestibular dysfunction25% have oth

45、er problems, such as presyncope and disequilibrium 15% have a psychiatric disorder 10% have a central brainstem vestibular lesion10 % remains uncertain in approximately,當(dāng)病人主訴”頭暈”….,區(qū)分vertigo和dizziness (1),Time course

46、Vertigo is never continuousEven when the vestibular lesion is permanent, the central nervous system adapts to the defect so that vertigo subsides over several weeksProvoking factors Some are precipitated by maneuvers

47、 that change head position or middle ear pressure maneuvers that change head position without lowering blood pressure or decreasing cerebral blood flow is diagnostic Aggravating factors All vertigo is made worse by mo

48、ving the head. If head motion does not worsen the feeling, it is probably another type of dizziness.,Associated signs and symptoms  Nystagmus is not always readily visible, although it often can be elicited by pr

49、ovocative maneuvers or with electronystagmography. Postural instability it is common for patients with vertigo to have difficulty maintaining steady upright posture when walking, standing, and even sitting unsupported,

50、 particularly when the symptoms are acute. Hearing loss very suggestive of a peripheral cause of vertigo, although their absence does not exclude the diagnosisBrainstem signs The presence of additional neurologic sig

51、ns strongly suggests the presence of a central vestibular lesion.,區(qū)分vertigo和dizziness (2),Peripheral vertigo,,Benign paroxysmal positional vertigo,The most common form of positional vertigo, accounting for nearly 1/2 of

52、patients with peripheral vestibular dysfunction Most commonly attributed to calcium debris within the posterior semicircular canal, known as canalithiasis posterior canal BPPV more often than the anterior (superior) a

53、nd horizontal semicircular canalsSymptomsrecurrent episodes of vertigo lasting one minute or less provoked by specific types of head movementstypically recur periodically for weeks to months without therapy may be a

54、ssociated with nausea and vomitinghave no other neurologic complaints,Dix-Hallpike maneuver,With the patient sitting, the neck is extended and turned to one side. The p’t is then placed supine rapidly, so that the head

55、hangs over the edge of the bed. The patient is kept in this position and observed for nystagmus for 30 seconds. Nystagmus usually appears with a latency of a few seconds and lasts less than 30 seconds. It has a typical t

56、rajectory, beating upward and torsionally, with the upper poles of the eyes beating toward the ground. After it stops and the patient sits up, the nystagmus will recur but in the opposite direction. Therefore, the patien

57、t is returned to upright and again observed for nystagmus for 30 seconds. If nystagmus is not provoked, the maneuver is repeated with the head turned to the other side. If nystagmus is provoked, the patient should have t

58、he maneuver repeated to the same (provoked) side; with each repetition, the intensity and duration of nystagmus will diminish.,Vestibular neuritis,Viral or postviral inflammatory disorder affecting the vestibular portion

59、 of the eighth cranial nerveSymptomsSapid onset of severe vertigo nausea, vomitinggait instability. preserved ability to ambulate. toward the affected sidehave no other neurologic complaintsSignsSpontaneous vesti

60、bular nystagmus unilateral, horizontal, or horizontal-torsionalsuppressed with visual fixationdoes not change direction with gazefast phase of nystagmus beats away from the affected side.,Meniere's disease,Arise

61、from abnormal fluid and ion homeostasis in the inner ear endolymphatic hydrops with distortion and distention of the membranous, endolymph-containing portions of the labyrinthine system Syndrome episodic vertigo asso

62、ciated with nausea and vomiting, and persists from 20 minutes to 24 hours duration Sensorineural hearing loss often initially affects the lower frequencies. progresses over time, and often results in permanent hearing

63、 loss at all frequencies in the affected ear over an 8 to 10 year period typically associated with intense aural fullness or pressure in the ear or the side of the head Tinnitus characteristically low pitch may be as

64、sociated with auditory distortion,Central vertigo,,Lateral medullary infarction,Wallenberg syndromeIpsilateral Horner's syndrome Dissociated sensory loss (loss of pain and temperature sensation on the ipsilateral f

65、ace and contralateral limbs and trunk) Abnormal eye movements Ipsilateral loss of corneal reflex Hoarseness and dysphagia Ipsilateral limb ataxia,,Cerebellar stroke,Vertigo, may with nausea/vomitingLimb dysmetria, d

66、ysarthria, or headacheUsually unable to stand or walk unsupported The direction of falling is not necessarily opposite to the direction of the nystagmusNystagmus other than horizontal or horizontal-torsional,may cha

67、nge direction with gazenot suppressed with visual fixation Patients with a vascular event are typically older and/or have atherosclerosis risk factors (hypertension, diabetes, smoking).,Vestibular schwannoma (acoustic

68、neuroma),Symptoms can be due to cranial nerve involvement, cerebellar compression, or tumor progression.Cochlear nerve (95%)The two major symptoms were hearing loss usually chronic Tinnitus was present in 63 percent.

69、Vestibular nerve (61%)Unsteadiness while walking, which was typically mild to moderate in nature and frequently fluctuated in severity True spinning vertigo was uncommon. The most nondescript vertiginous sensationsTr

70、igeminal nerve (17%)facial numbness (paresthesia), hypesthesia, and pain. Facial nerve (6%)facial paresis and, less often, taste disturbances. Tumor progression press on the cerebellum or brainstem and result in at

71、axia. lower cranial nerves (nerves IX, X, and XI, leading to dysarthria, dysphagia, aspiration, and hoarseness Brainstem compression, cerebellar tonsil herniation, hydrocephalus and death can occur in untreated cases.,