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 musculature
2、掌握脑神经的解剖、生理功能、损害表现及定位掌握运动系统的定位诊断及瘫痪的类型掌握感觉系统的定位诊断及感觉障碍类型掌握深浅反射及病理反射的临床意义熟悉神经系统常见的诊断方法和原则ContentsIntroductionAnatomy、Physiology、Neuroanatomy of LocalizationSome Neurological Signs of Interest Neurological History and ExaminationNeurodiagnostic Tests and ProceduresMental Status Examination Diagnostic
3、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第一节1、Cerebral hemispheres 2、internal capsule 3、Basal Nuclei 4、Diencephal
4、on 6、Cerebellum 7、Spinal Cord 5、Brainstem Cerebral Hemisphere 大脑半球 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 hemisphere,comprehension of speech.Parietal lob
5、e-sensation of the opposite side of the body andappreciation of spaceOccipital lobe-appreciation of vision.Insular lobe Limbic lobeFrontal Lobe 额叶Frontal Lobe 额叶Parietal lobe 顶叶Temporal lobe 颞叶 Anterior part of claw olfactory,tasting sensation center seizure,epileptic attack,epileptic seizure:claw a
6、ttackAnterior part of superior temporal gyrus sensory aphasia amnesic aphasia Anterior part of claw olfactory,tasting sensation center seizure,epileptic attack,epileptic seizure:claw attackAnterior part of superior temporal gyrus sensory aphasia amnesic aphasia Temporal lobe 颞叶claw attackseizure、amn
7、esiaOccipital lobe 枕叶v Vision,visual sense or opticum centerv Lesion of one side:hemianopiaOccipital lobe 枕叶v Vision,visual sense or opticum centerv Lesion of one side:hemianopia主要引起视觉障碍。中枢性偏盲、幻视、视觉认识不能、视物变形。又称脑岛（insula），与内脏感觉和运动有关 insular lobe 岛叶 包括隔区、扣带回、海马回、海马旁回和钩回，参与高级神经、精神（情绪和记忆等）和内脏的活动limbic l
8、obe 边缘叶隔隔 区区钩钩 回回行经内囊的纤维束 white matter fibers among lenticular nucleus thalamus and caudate nucleus pyramidal tract,thalamocortic tract and optic radiationAnatomy contralateral hemiplegia contralateral hemiparesthesia contralateral hemianopialesioninternal capsule 内囊Anatomy contralateral hemiplegia
9、contralateral hemiparesthesia contralateral hemianopialesioninternal capsule 内囊 丘脑前辐射丘脑前辐射额桥束额桥束皮质核束皮质核束皮质脊髓束皮质脊髓束皮质红核束皮质红核束顶枕颞桥束顶枕颞桥束丘脑中央丘脑中央辐射辐射视辐射视辐射听辐射听辐射 white matter fibers among lenticular nucleus thalamus and caudate nucleus pyramidal tract,thalamocortic tract and optic radiationinternal cap
10、sule 内囊 Central facial and lingual paralysisCentral facial and lingual paralysiscontralateral contralateral hemiparesthesiahemiparesthesiacontralateral hemiplegiacontralateral hemiplegiacontralateral hemianopiacontralateral hemianopia basal ganglia 基底神经节 Caudate nucleus、Lentiform nucleus、Amygdaloid
11、body、Claustrum basal ganglia 基底神经节 basal ganglia 基底神经节 basal ganglia 基底神经节 A lack of movementElimination of inhibitionDystoniaRigidity caudate and putamenElimination of inhibition、hypotoniaClinical symptoms and signs of basal ganglia diseaseglobus pallidus and substantia nigraA lack of movement、hype
12、rtonia basal ganglia 基底神经节 Diencephalon 间脑 Thalamus epithalamus hypothalamus subthalamusthalamus 丘脑 丘脑 解剖结构及生理功能前核群内侧核群外侧核群丘脑外侧膝状体内侧膝状体 腹前核 腹外侧核 腹后外侧核 腹后内侧核 thalamus 丘脑 thalamus 丘脑 Anterior Nuclei Limbic功能：丘脑前核与下丘脑及边缘系统的联系受损：情感与记忆障碍thalamus 丘脑 Midline Nuclei Nonspecific Associational功能：是联合躯体、内脏、感觉冲动
13、的整合中枢Thalamus 丘脑 a.Ventral anterior from basal gangliab.Ventral lateral from cerebellum and red nucleusc.Ventral ventral from basal ganglia and cerebellumd.Ventral posterior:(1)Posterolateral from posterior columns upper postcentral gyrus(2)Posteromedial from trigeminal system lower postcentral gyru
14、sHypothalamus 下丘脑Hypothalamus 下丘脑Hypothalamus 下丘脑下丘脑的纤维联系：视上核视上垂体束垂体后叶抗利尿激素视旁核室旁垂体束垂体后叶催产素弓状核结节垂体束垂体前叶Hypothalamus 下丘脑部位核团功能视前区视前核体温调节视上区视上核水代谢室旁核糖代谢结节区腹内侧核性功能背内侧核脂肪代谢乳头体区下丘脑后核产热保温乳头体核下丘脑的核团分区epithalamus 上丘脑 丘脑髓纹缰连合松果体缰三角后连合Epithalamus 上丘脑 松果体分泌抗雄性激素，抑制儿童性成熟；分泌松果体激素，有降低血糖作用1.瞳孔对光反射消失（上丘受损）2.眼球垂直同向运动
15、障碍，特别是向上的凝视麻痹（上丘受损）（Parinaud syndrome）3.动眼危象Subthalamus 底丘脑 是中脑和间脑的移行区锥体外系的组成部分丘脑底核苍白球和额叶运动前区出现对侧以上肢为重的舞蹈运动，表现为连续的不能控制的投掷运动苍白球黑质 红核 中脑被盖偏身投掷运动（hemiballismus）损害Subthalamus 底丘脑 Brain Stem 脑干 Brain Stem 脑干、脑干内脑神经核团（背面）Brain Stem 脑干 脑干传导束为脑干内的白质，包括深浅感觉传导束、锥体束、锥体外通路及内侧纵束等脑干网状结构 网状结构（reticular formation）：
16、脑干中轴内呈弥散分布的胞体和纤维交错排列的“网状”区域，脑干网状结构中有许多神经调节中枢，同时还可以接受各种信息传至大脑皮层，可以维持躯体的正常的生理活动和意识清醒Brain Stem 脑干 1)延髓上段的背外侧区病变：延髓背外侧综合征 （Wallenberg syndrome）1.延髓（medulla oblongata）病损表现及定位诊断前庭神经核损害：眩晕、恶心、呕吐及眼震疑核及舌咽、迷走神经损害：病灶侧软腭、咽喉肌瘫痪绳状体及脊髓小脑束、部分小脑半球损害：病灶侧共济失调交感神经下行纤维损害：Horner综合征三叉神经脊束核和脊髓丘脑侧束损害：交叉性感觉障碍 延髓综合征损伤部位及表现 B
17、rain Stem 脑干 2)延髓中腹侧损害：延髓内侧综合征（Dejerine syndrome）舌下神经损害：病灶侧舌肌瘫痪及肌肉萎缩锥体束损害：对侧肢体中枢性瘫痪内侧丘系损害：对侧上下肢触觉、位置觉、振动 觉减退或丧失延髓综合征损伤部位及表现 Brain Stem 脑干 病损表现及定位诊断1)脑桥腹外侧综合征（Millard-Gubler syndrome）2.脑桥（pons）脑桥综合征损伤部位及表现 展神经麻痹：病灶侧眼球不能外展面神经核损害：周围性面神经麻痹锥体束损害：对侧中枢性偏瘫内侧丘系和脊髓丘脑束损害：对侧偏身感觉障碍 多见于小脑下前动脉阻塞病损表现及定位诊断Brain Stem
18、 脑干 2)脑桥背外侧部损害：脑桥被盖下部综合征（Raymond-Cestan syndrome）前庭神经核损害：眩晕、恶心、呕吐、眼球震颤展神经损害：病侧眼球不能外展面神经核损害：病侧面肌麻痹脑桥侧视中枢及内侧纵束损害：双眼患侧注视不能三叉神经脊束损害：交叉性感觉障碍内侧丘系损害：对侧偏身触觉、位置觉、振动觉减退或丧失交感神经下行纤维损害：病侧Horner征小脑中脚、小脑下脚和脊髓小脑前束损害：病侧偏身共济失调病损表现及定位诊断Brain Stem 脑干 3)脑桥腹内侧综合征，又称福维尔综合征（Foville syndrome）病灶侧眼球不能外展（展神经麻痹）及周围性面神经麻痹（面神经核损害
19、）两眼向病灶对侧凝视（脑桥侧视中枢及内侧纵束损害）对侧中枢性偏瘫（锥体束损害），多见于脑桥旁正中动脉阻塞4)闭锁综合征（locked-in syndrome），又称去传出状态，主要见于基底动脉脑桥分支双侧闭塞 出现双侧中枢性瘫痪（双侧皮质脊髓束和支配三叉神经以下的皮质脑干束受损）只能以眼球上下运动示意（动眼神经与滑车神经功能保留），眼球水平运动障碍，不能讲话，双侧面瘫，舌、咽及构音吞咽运动均障碍，不能转颈耸肩，四肢全瘫，可有双侧病理反射，常被误认为昏迷 病损表现及定位诊断Brain Stem 脑干 3.中脑（mesencephalon）1)大脑脚综合征（Weber syndrome）多由于小脑
20、幕裂孔疝引起表现为动眼神经麻痹：病侧除外直肌和上斜肌外的所有眼肌麻痹，瞳孔散大锥体束损害：对侧中枢性面舌瘫和上下肢瘫痪中脑综合征损伤部位及表现病损表现及定位诊断Brain Stem 脑干 动眼神经麻痹：病侧除外直肌和上斜肌外的所有眼肌麻痹，瞳孔散大黑质损害：对侧肢体震颤、强直红核损害：舞蹈、手足徐动及共济失调内侧丘系损害：对侧肢体深感觉和精细触觉障碍2)红核综合征（Benedikt syndrome）,中脑被盖腹内侧部损害病损表现及定位诊断Brain Stem 脑干 Cerebellum 小脑Cerebellum 小脑Cerebellum 小脑解剖结构及生理功能解剖结构及生理功能（一）小脑的结
21、构（一）小脑的结构 绒球小结叶绒球小结叶三个主叶三个主叶前叶前叶后叶后叶（二）小脑的功能解剖结构及生理功能cerebellum小脑绒球小结叶（古小脑）前庭器小脑蚓部大部分、蚓旁区（旧小脑）脊髓小脑半球（新小脑）大脑皮质 FunctionCerebellar hemisphere impairment:dysmetria poor finger-to-nose test,heel-knee-shin test Cerebellar vermis impairment:standing lability,drunken gait or ataxic gaitLesionCerebellum 小脑（
22、一）脊髓外部结构解剖结构及生理功能颈膨大C5T1 支配上肢 腰膨大L2S3 支配下肢脊髓圆锥S35 马尾L2C0共10对神经根组成Spinal Cord 脊髓 8 cervical12 thoracic5 lumbar 5 sacral1 coccygeal spinal nerve Spinal Cord 脊髓 1.脊髓的灰质：前角、后角和侧角脊髓横断面感觉运动传导束的排列（二）脊髓内部结构2.脊髓的白质上行纤维束 薄束和楔束 脊髓小脑束 脊髓丘脑束 皮质脊髓束 红核脊髓束 前庭脊髓束 网状脊髓束 顶盖脊髓束 内侧纵束下行纤维束 解剖结构及生理功能Spinal Cord 脊髓 （一）不完全性
23、脊髓损害 1.前角损害 6.后索损害2.后角损害 7.侧索损害3.中央管附近的损害 8.脊髓束性损害4.侧角损害 9.脊髓半侧损害5.前索损害 病损表现及定位诊断1.高颈髓（颈14）2.颈膨大（颈5胸2）3.胸髓（胸312）4.腰膨大（腰1骶2）5.脊髓圆锥（骶35和尾节）6.马尾神经根（二）脊髓横贯性损害Spinal Cord 脊髓 （一）不完全性脊髓损害（一）不完全性脊髓损害 前角损害前角损害 节段性下运动节段性下运动神经元性瘫痪神经元性瘫痪进行性脊髓性肌萎缩症进行性脊髓性肌萎缩症 脊髓前角灰质炎脊髓前角灰质炎 损害部位损害部位临床表现临床表现常见疾病常见疾病病损表现及定位诊断病损表现及定
24、位诊断Spinal Cord 脊髓 （一）不完全性脊髓损害（一）不完全性脊髓损害 1.前角损害前角损害 节段性下运动节段性下运动神经元性瘫痪神经元性瘫痪后角损害后角损害 进行性脊髓性肌萎缩症进行性脊髓性肌萎缩症 脊髓前角灰质炎脊髓前角灰质炎 损害部位损害部位临床表现临床表现常见疾病常见疾病常见脊髓空洞症、出常见脊髓空洞症、出血、髓内胶质瘤早期血、髓内胶质瘤早期 节段性分离性感觉节段性分离性感觉障碍：病灶侧相应障碍：病灶侧相应皮节出现痛温觉缺皮节出现痛温觉缺失、触觉保留失、触觉保留病损表现及定位诊断病损表现及定位诊断Spinal Cord 脊髓 损害部位损害部位临床表现临床表现常见疾病常见疾病中
25、央管附近的损中央管附近的损害害双侧对称的分离性感觉双侧对称的分离性感觉障碍、痉挛性瘫痪或迟障碍、痉挛性瘫痪或迟缓性瘫痪缓性瘫痪 脊髓空洞症脊髓空洞症脊髓中央管积水或出血脊髓中央管积水或出血 Spinal Cord 脊髓 脊髓半侧损害 脊髓半切综合征（Brown-Sequard syndrome）：病变节段以下同侧上运动神经元性瘫、深感觉障碍、精细触觉障碍及血管舒缩功能障碍，对侧痛温觉障碍 Spinal Cord 脊髓 后索和皮质脊髓束亚急性联合变性Spinal Cord 脊髓 前角和皮质脊髓侧束肌萎缩侧索硬化Spinal Cord 脊髓 皮质脊髓束原发性侧索硬化Spinal Cord 脊髓 B
26、lood Vessels of Brain and Spinal CordBlood Vessels of Brain and Spinal CordArteries to Brainanterior circulation ofthe braininternal carotid middle cerebralanterior cerebral posterior circulation of the brainVertebralBasilarposterior cerebralArteries to Brain 脑动脉Arteries to BrainArteries to Brain 脑动
27、脉Arteries to Brain 脑动脉Arteries to Brain 脑动脉Arteries to Brain 脑动脉Arteries to Brain 脑动脉Arteries to Brain 脑动脉大脑后动脉终末支大脑后动脉终末支Arteries to Brain 脑动脉Arteries to Brain 脑动脉Venous Circulation of the Brain 脑静脉Venous Circulation of the Brain 脑静脉Venous Circulation of the Brain 脑静脉 Spinal Circulation 脊髓血管Cranial
28、 NervesCranial Nerves嗅神经（olfactory N.）视神经（optic N.）动眼神经（oculomotor N.）滑车神经（trochlear N.）三叉神经（trigeminal N.）展神经（abduct N.）面神经（facial N.）前庭蜗神经（vestibulocochlear N.）舌咽神经（glossopharyngeal N.）迷走神经（vagus N.）副神经（accessory N.）舌下神经（hypoglossal N.）I Olfactory N 嗅神经Anatomybipolar olfactory neurons olfactory bu
29、lb olfactory tract olfactory centerI Olfactory N 嗅神经Lesion:Bilateral hyposmia:nasal mucosa lesionUnilateral hyposmia:lesion of anterior cranium fossaII Optic Nerve 视神经 Anatomy:optic ganglion cell optic N optic chiasma optic tract lateral geniculate body optic radiation occipital lobe vision centerII
30、 Optic Nerve 视神经Lesion visual deteriorationeye disease and/or optic neuropathy papilledema in fundus oculi increased intracranial pressure optic atrophyII Optic Nerve 嗅神经Lesion optic neuropathy total blindness of one side lesion of optic chiasma bitemporal hemianopsia lesion of optic tract contralat
31、erally hemianopia lesion of optic radiation total-contralaterally hemianopia partialcontralaterally quadrant hemianopia cortical lesionhemianopia,sparing of maculaIII、IV、VI nervesvAnatomy Oculomotor N.cavernous sinus superior orbital fissureTrochlearN.AbducentN.III、IV、VI nervesMotor fiberIII:levator
32、 palpebrae superioris,superior rectus,medial rectus,inferior rectus,inferior oblique muscleIV:superior oblique muscle:Lateral rectus muscle Parasympathetic fiberIII、IV、VI nervesIII、IV、VI nervesophthalmoplegiaIII、IV、VI N.impairmentdrooping eyelid,abduction position of eye,unable to make upper,down&in
33、ternal movements,pupil dilation,diplopiaIII、IV、VI nerves（1）双侧眼球运动障碍动眼神经核紧靠中线，病变时常为双侧动眼神经的部分受累，引起双侧眼球运动障碍（2）脑干内邻近结构的损害展神经核病变可累及面神经纤维，同时累及三叉神经和锥体束（3）分离性眼肌麻痹 病变时可仅累及其中部分核团而引起某一眼肌受累，其他眼肌不受影响 核性眼肌麻痹（nuclear ophthalmoplegia）III、IV、VI nerves（1）前核间性眼肌麻痹（2）后核间性眼肌麻痹（3）一个半综合征（one and a half syndrome）核间性眼肌麻痹（in
34、ternuclear ophthalmoplegia）III、IV、VI nerves双眼向对侧注视时，患侧眼球不能内收，对侧眼球可外展，伴单眼眼震 两眼同侧注视时，患侧眼球不能外展，对侧眼球内收正常 患侧眼球水平注视时既不能内收又不能外展；对侧眼球水平注视时不能内收，可以外展，但有水平眼震 核间性眼肌麻痹（internuclear ophthalmoplegia）III、IV、VI nerves核上性眼肌麻痹（uppernuclear ophthalmoplegia）侧视麻痹示意图核上性眼肌麻痹临床上有三个特点：（1）双眼同时受累（2）无复视（3）反射性运动仍保存 III、IV、VI ner
35、ves light reflexlight retina optic N midbrain E-W nucleusoculomotor N ciliary ganglion sphincter muscle of pupil Trigeminal nerve 三叉神经-Anatomy1.Sensation trigeminal ganglion：ophthalmic,maxillary,mandibular nucleus of spinal tract of trigeminal N.pain sensation&thalposisprincipal sensory nucleustacti
36、le sensationmesencephalic nucleusdeep sensation Trigeminal nerve 三叉神经2.Motormotor nucleus of trigeminal N.asticatory muscles3.Reflectiontcorneal reflextcornea ophthalmic branch of Trigeminal N principal sensorynucleus nucleus of facial N.facial N.orbicularis oculi Lesionsensory disorder:peripheral l
37、esion,central lesionmotor disordertAbsent corneal reflexLower jaw hyperreflexia Facial N 面神经 AnatomyMotor:Nucleus of facial N.superior part:bilateral corticobulbar tractemotional expression M.of facial superior partBottom part:contralateral corticobulbar tract basifacial emotional expression muscleS
38、ensory:tasting on anterior 2/3tongue Parasympathetic N.:submandibular gland,Sublingual gland,lacrimal gland Facial N 面神经 Facial N 面神经 Facial N 面神经 Lesion1.Peripheral facial paralysis:paralysis of unilateral emotional expression M.reduced tasting on 2/3 anterior tonguehyperacusis2.Central facial para
39、lysis:paralysis of contralateralbasifacial expression M Vestibulocochlear N Anatomy 1.Cochlear N.2.Vestibular N.Lesion1.Cochlear N.tinnitus、deafness2.Vestibular Nvertigo、balance impairment、nystagmus Vestibulocochlear N 前庭蜗神经 Glosopharyngeal N.舌咽神经 Anatomy Motor ambiguous nucleus stylopharyngeus Sens
40、ationpharynx、soft palate、tonsil、tympan、mucosa of posterior 3rd tongue、carotid sinus、bulbus of carotid artery Parasympathetic N.parotid gland Vagus N.迷走神经 Anatomy Motor:soft palate、throat&larynx M.Sensation:external auditory canal、skin of pinna Parasympathetic N.visceral parasympathetic N Vagus N.迷走神
41、经 Lesion Glosopharyngeal&vagus N.Two types of symptoms:1.Bulbar paralysis nerve or neuron injuryvoice hoarseness,swallowing disturbance,pharyngeal areflexia2.Pseudobulbarpalsy bilateral corticobulbar tract involvement pharyngeal reflex,unable to control crying or laughing or pyramidal sign真性和假性球麻痹的鉴
42、别 Accessorius N.副神经Anatomysternocleidomastoid muscle:turning head trapezius muscle:shrugging shouldersLesion:inable to turn head inable to raise shoulders Hypoglossal N 舌下神经Anatomygenioglossal M:extension of the tongue hyoglossus M:withdrawal of the tongue Hypoglossal N 舌下神经Lesion Paralysis of hypog
43、lossal Non protrusion 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 lesionperip
44、heral nerveperipheral nerve 周围神经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 receptor
45、s in the blood vessels and gastrointestinal,respiratory,urogenital,and endocrine organs.peripheral nerve 周围神经somaticvisceralperipheral nerve 周围神经spinal nervesCranial Nervesperipheral nerve 周围神经u Polyneuropathies：distal,symmetric sensory deficits and weakness usually affect the lower more than the up
46、per limbs associated with areflexiaMusclesMuscles The approximately 240 muscles in the body three different functional and histological entities:skeletal,smooth,and cardiac.Muscles Myopathies(disorders of muscle)produce proximal weakness,which may affect the face and trunk as well as the limbs,witho
47、ut sensory loss.Motor systemvLower motor neuronspinal cord anterior horn cellsmotor nuclei of cranial nerves and associated nervesvUpper motor neuronvcorticospinal tract precentral gyrus of cortex cerebral pyramidal cells internal capsule brain stem(pyramidal crossing)spinal cord anterior horncortic
48、obulbar 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个个tendon reflex个个pathologic reflex+-muscle atrophy-+Motor systemMotor s
49、ystemIdentification of paralysis of UMN Cortex contralateral monoplegia Internal capsule contralateral hemiplegia Brainstem crossing paralysis Spinal cord:chest/lumber regionparaplegia cervical regiontetraplegia or quadriplegiaMotor systemu Extrapyramidal Systemp basal ganglia Lesion1.Abnormal invol
50、untary movements tremor,choreic movement,athetosis,torsion spasm,hemiballismus,tics2.Muscle tone hypertonia lead-pipe rigidity,cogwheel rigidity hypotonia choreaSensory systemSensory systemSensory systemsuperficial sensation:algesi-,thermo-,tactile sensation spinothalamic tractdeep sensationtjoint p
