1、神经病学绪论,Introduction of Neurology,同济医学院附属同济医院 王 伟,是研究中枢神经系统(central nervous system, CNS)、周围神经系统(peripheral nervous system, PNS)及骨骼肌疾病(muscular diseases)的病因、发病机制、临床表现、诊断、治疗及预防的一门临床医学学科。,神经病学 Neurology,神经病学:最具发展前景的学科,解剖复杂、生理功能疑问众多神经系统疾病发病率、 死亡率、致残率高 仅脑血管病发病率、 死亡率、致残率以及住院费用居各项疾病前列,我国城市脑血管病居死亡原因首位,每年造成直接
2、经济损失超过100亿元.研究手段及方法日新月异相关基础科学发展迅猛,神经病学 neurology,神经眼科学神经耳科学神经心理学 神经内分泌学神经肿瘤学神经影像学,神经科学 neuroscience,神经科学 neuroscience,Anatomy 解剖学Developmental biology 发育生物学Biophysics 生物物理学Pharmacology 药理学Cell biology 细胞生物学Molecular biology 分子生物学Computer science 计算机科学Psychology 心理学,美国把20世纪九十年代定为“脑的十年”。1997年19个国家参与的“
3、人类脑计划”在美国正式启动。2001年9月，中国正式成为参与“人类脑计划”的第20个国家。诺贝尔奖多次授予神经科学家。,Nobel Prize,Nobel Prize,Nobel Prize,Nobel Prize,神经系统疾病诊断具有独特的方法和体系,强调系统性和逻辑性,全面的相关知识逻辑的思维方式规范的检查手段严谨的工作态度,全面的病史询问系统的体格检查准确的辅助诊断综合的分层诊断,神经系统疾病诊断,神经系统疾病诊断,神经解剖学(neuroanatomy)、神经生理学(neuro-physiology)神经病理学(neuropathology)神经系统体格检查(neurological e
4、xamination),神经疾病的诊断方法,共同点：详细病史采集,详细体格检查特殊性：病史和体格检查的客观性： 特殊思维方法：定位诊断 定性诊断,Steps in the diagnosis of neurological disease,诊断步骤,采集病史By history,神经系统体格检查By neurological examination,得到临床资料Elicitation of clinical facts,用解剖学和生理学术语解释症状和体征Interpretation of symptoms and signs in terms of anatomy and physiology
5、,得到临床资料Elicitation of clinical facts,诊断步骤,确定损害系统或部位Syndromical formulation and localization of the lesion (topical diagnosis定位诊断),用解剖学和生理学术语解释症状和体征Interpretation of symptoms and signs in terms of anatomy and physiology,诊断步骤,定位诊断,定位诊断,起病形式和演变过程Modes of onset and course,其它医学资料Other medical data,适宜的实验室
6、检查Appropriate lab test,+,+,+,定性诊断 (Pathological or etiologic diagnosis),诊断步骤,Diagnosis,Anatomic diagnosis（定位诊断)Pathological or etiologic diagnosis(定性诊断)Pathological or etiologic diagnosis(病因诊断),CLINICAL METHOD,大脑中动脉主干闭塞综合征,三偏症状: 病灶对侧中枢性面舌瘫 中枢性偏瘫 偏身感觉障碍和偏盲不同程度的意识障碍 失语或体象障碍,诊断:1.急性脑血管病 定位诊断:右侧大脑中动脉;定性
7、诊断:脑梗死 2.原发性高血压(三级);颈动脉狭窄,采集病史 TAKING THE HISTORY疾病发生的背景情况、起病与演变形式、病程； The setting in which the illness occurred, its mode of onset and evolution, and its course are of paramount importance. 明确每一个症状是如何发生和演变的 One must attempt to learn precisely how each symptom began and progressed.,诊断步骤,神经系统体检应总是按照一
8、定的顺序进行操作与记录，以避免遗漏和方便以后的病案分析。 The neurological examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records.,神经系统体格检查THE NEUROLOGICAL EXAMINATION,神经系统检查顺序： 脑神经(cranial nerves)、颈、躯干 (trunk) 及上下肢(th
9、e upper and lower limbs)的运动功能(motor functions)、反射(reflex)、感觉功能(sensory functions)、共济和步态(coordination and gait)，再评估自主神经系统(autonomic nervous system)和脑膜刺激征 (meningeal irritation)。,神经系统体格检查THE NEUROLOGICAL EXAMINATION,综合征与定位Syndromical formulation and localization of the lesion神经科医生常常能将一组症状和体征识别为一个综合征。O
10、ften the neurologist can recognizes a characteristic clustering of symptoms and signs, constituting a syndrome.,症状 眩晕(Vertigo)、 恶心呕吐(nausea and vomiting) 吞咽困难(dysphagia)体征：眼震(nystagmus) 、构音障碍 (dysarthria) 同侧Horner征(ipsilateral Horners syndrome ) 、 同侧肢体共济失调(ipsilateral limb ataxia) 同侧面部和对侧躯干痛温觉丧失(ips
11、ilateral loss of pain and temperature sensation of the face and contralateral loss of pain and temperature of the trunk and extremities),Wallenberg Syndrome,定位：小脑后下动脉支配的延髓背外侧(the dorsal lateral medullary plate supplied by the posterior inferior cerebellar artery)定性：梗死性(infarction),Wallenberg Syndrom
12、e,神经病理学知识有助于定性诊断，即诸如梗死、出血、脱髓鞘、外伤、压迫、炎症、新生物和感染等常见疾病性质。 The neurologist is also helped by 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
13、 the more common.,定性诊断Pathological or etiologic diagnosis,单独的“病案分析”往往无法进行定性。需求助于各种辅助检查。 It happens often that the nature of the disease is not discerned by “case study” alone. So, the neurologist resorts to the ancillary examinations outlined in the next slide.应基于临床信息来选择适宜的实验室检查。 Laboratory study ca
14、n be planned intelligently only on the basis of clinical information.,定性诊断Pathological or etiologic diagnosis,各种辅助检查(ancillary exami-nations)，尤其是各种影像学检查的出现，为神经系统疾病的诊断带来革命性的变化。,定性诊断Pathological or etiologic diagnosis,辅助检查,腰椎穿刺与脑脊液检查(Lumbar puncture and examination of cerebrospinal fluid),计算机断层扫描(comp
15、uted tomography, CT) 磁共振成像(magnetic resonance imaging, MRI)血管造影 (angiography)正电子发射断层扫描(positron emission tomography, PET)单光子发射计算机断层扫描(single photon emission computed tomography)SPECT,头颅和脊柱影像学检查Radiographic examination of skull and spine,辅助检查,CT,辅助检查,MRI、MRA,辅助检查,MRI新技术弥散（DWI）和灌注（PWI）成像技术超早期诊断脑梗死,缺血半
16、暗带界定,血管造影 (angiography),辅助检查,PET (positron emission tomography, PET）,辅助检查,SPECT,复杂部分性发作的癫痫病人发作期与发作间期SPECT差值与MRI叠加,辅助检查,(经颅多普勒 transcranial Doppler , TCD),辅助检查,脑电图 (electroencephalography),辅助检查,诱发电位(evoked potentials)躯体感觉诱发电位(somatosensory evoked potentials, SEP)视觉诱发电位(visual evoked potentials, VEP)脑
17、干听觉诱发电位(brainstem auditory evoked potentials, BAEP)运动诱发电位(motor evoked potentials, MEP)事件相关电位(event-related potential, ERP),辅助检查,肌电图 (electromyography)与神经传导检查 (nerve conduction studies ),肌电图,神经传导检查,辅助检查,肌肉、神经、皮肤、脑及其它组织的活检(Biopsy of muscle, nerve, skin, brain, and other tissue)心理测量(Psychometry) 视野检查(
18、Perimetry)、测听(audio-metry),辅助检查,诊断技巧,临床分析应关注主要的症状和体征，避免被次要体征和不确定的临床资料误导。Focus the clinical analysis on the principal symptoms and signs and avoid being distracted by minor signs and uncertain clinical data.,治疗 THERAPEUTICS,在内科领域，神经病学传统上被许多人视为不过是对无法治疗的疾病下诊断的智力训练。Among medical specialties, neurology h
19、as traditionally been thought of by many as little more than an intellectual exercise concerned with making diagnoses of untreatable diseases.,例如：血管支架成形术(angioplasty and stenting)治疗颈动脉或颅内动脉狭窄(carotid stenoses or intracranial stenoses) 。其中，颈动脉支架成形术(Carotid Angioplasty and Stenting, CAS) 较为成熟。,治疗 THER
20、APEUTICS,治疗 THERAPEUTICS,治疗 THERAPEUTICS,支架是一个小金属网管，置入动脉中提供支撑。A stent is a small wire mesh tube, inserted and acts as a scaffold to provide support inside the artery.,治疗 THERAPEUTICS,过滤装置，与抗血小板药物联用，预防微栓子。Filter devices, combined with antiplatelet medication, provide protection against microemboli.,治
21、疗 THERAPEUTICS,在操作结束时，过滤装置带着所俘获的残片移出动脉。At the end of the procedure, the filter is removed from the artery along with captured debris.,治疗 THERAPEUTICS,手术前后比较（颈动脉）,治疗 THERAPEUTICS,手术前后比较（大脑中动脉）,治疗 THERAPEUTICS,因此，掌握神经病学的诊断方法既有益于临床医生在诊断、预后和治疗方面的解决实际问题，也有益于临床科研工作者对疾病机制与病因的探究。The clinical method of neurology thus serves both the physician in the practical matters of diagnosis, prognosis, and treatment and the clinical scientist in the search for the mechanism and cause of the disease.,
