1、CN: Olfactory Nerve (嗅神经)Foster-Kennedy syndrome: Frontal lobe tumors cause optic atrophy on the side of the tumor, papilledema reflex movement exist 麻痹性眼肌的反射性运动仍保存(不能随意向一侧运动,但声响可产生转向该侧的反射活动)Horners syndromeThe descending sympathetic tract 由颈上交感神经径路损害所致Lesions result in ipsilateral 病变同侧: 1.miosis /
2、Small pupil 瞳孔缩小2.mild ptosis 眼睑下垂3.hemi-anhidrosis / loss of sweating in lesion side 损面无汗4.apparent enophthalmos 眼球内陷Trigeminal Nerve 三叉神经周围分布 VS 中枢分布Peripheral：眼支 ophthalmic nerve 4.对侧面部表情运动障碍5.丘脑痴呆，有强迫性哭笑倾向、记忆下降、人格改变、情感障碍；6.丘脑语言，言语缓慢、重复、发音困难、复述差；7.精神障碍，如情绪不稳、情感淡漠、情绪低落等 hypothalamus 下丘脑（神经内分泌 吞咽、构
3、音障碍，病变同侧软腭咽喉肌及声带瘫痪，咽反射消失(舌咽迷走神经及疑核) ；共济失调(绳状体及部分小脑)，Horner 综合征( 交感神经下行纤维) 。vertigo, anarthria 构音障碍 and dysphagia 吞咽困难, crossed palsy 交叉性感觉障碍, cerebellar ataxia;cerebellar posterior and inferior artery had obstructed.小脑后下 A 闭塞Affected structures and resultant deficits include: The vestibular nuclei 前
4、庭核. Lesions results in nystagmus 眼球震颤, nausea, vomiting, and vertigo 眩晕. The inferior cerebellar peduncle 小脑下脚. Lesions result in ipsilateral cerebellar ataxia 同侧小脑征损害即cerebellar ataxia. The nucleus ambigus 疑核损害 of CN, CNand CN, Lesions result in ipsilateral laryngeal, pharyngeal, and palatal hemipa
5、ralysis 同侧软腭麻痹, loss of the gag reflex , dysarthria, dysphagia, dysphonia 咽反射消失,构音障碍,吞咽困难, 声音嘶哑 The spinothalamic tracts (脊丘系 spinal lemniscus). Lesions result in contralateral loss of pain and temperature sensation from the trunk and extremities.对侧半身痛温觉损害 The spinal trigeminal nucleus and tract 三叉脊
6、束核. Lesions result in ipsilateral loss of pain and temperature sensation from the face (facial hemianesthesia 同侧半面麻木). The descending sympathetic tract 交感 N 降支损害. Lesions result in ipsilateral(同侧) Horners syndrome (i.e., ptosis, miosis, hemianhidrosis, and apparent enophthalmos)眼睑下垂,眼球内陷,半面无汗,瞳孔小(4)
7、Dejerine syndrome 延髓旁正中综合征，病变位于延髓中腹侧，出现舌下神经交叉瘫，表现为：病灶侧舌肌瘫痪和萎缩（舌下神经损害） 、对侧肢体中枢性瘫痪（锥体束损害） 、对侧肢体深感觉障碍（内侧丘系损害）(5)Jackson syndrome,延髓橄榄核损害，一侧舌下神经受损和对侧锥体束征，X 及 XI 对脑神经麻痹，无内侧丘系受损所导致的深感觉障碍；decorticated syndrome:去皮质综合征对外界刺激无反应、无自发性言语和目的性动作，可无意识睁眼闭眼，光反射、角膜反射存在，上肢屈曲和下肢伸直姿势，病理征（）；保存觉醒-睡眠周期，无意识咀嚼和吞咽（脑干上行网状激活系统未受
8、损）。见于缺氧性脑病、脑卒中及脑外伤导致大脑皮质广泛损害。 typically regain spontaneous eye-opening, sleep-wake cycles, brainstem Manifestation: Manifestation extradural extramedullary IntramedullaryRoot pains Occur early early Less frequentSymptoms develop Bilateral, symmetricalUnilateral to bilateralBilateral, symmetricalMoto
9、r symptoms Appear first earlier EarlierSensory changes late early EarlySphincter disturbances later later EarlyProtein content of CSF Slightly increased high lower1.急性脊髓压迫症发作 acute onset，多出现脊髓休克；2.慢性脊髓压迫症发作 chronic onset，分 3 期：根痛期、部分受压期和完全受压期；3.髓外病变时，感觉障碍自下肢远端向上发展至受压节段；髓内病变累及脊髓丘脑束时，导致分离性感觉障碍，自病变节段向下
10、发展，鞍区（S35）感觉保留至最后受累，称“鞍区回避”sacral sparing；可用于鉴别髓内外病变；4.椎管严重梗阻时脑脊液蛋白-细胞分离，细胞数正常，蛋白含量超过 10g/L 时，黄色脑脊液流出后自动凝结，称弗洛因综合征 Froin syndrome；周围神经脱髓鞘疾病 GBS , Guillain-Barr Syndrome: acute inflammatory demyelinating polyneuropathy characterized by acute onset of peripheral 脑神经损伤以双侧面神经损伤最常见，其次为舌咽感觉障碍一般比运动障碍轻或无感觉障
11、碍，表现为肢体远端深感觉异常和手套、袜套样感觉减退，特殊感觉多保留； Autonomic dysfunction is commonly associated 自主神经症状损害明显, e.g. orthostatic hypotension 直立性低血压, unstable BP, tachyarrhythmia, bradyarrhythmia, resting tachycardia, disturbed sweating is frequent in severe cases, and easy to die 病情进展迅速，4 周内可停止进展， 12 个月后开始恢复；Froin sign
12、/“phenomenon of protein-cell dissociation” 蛋白细胞分离现象Cell count is usually normal. Protein content is elevated in most patients but may be normal in the first few days after onset, it may increase from 2 weeks after onset. Protein(0.8-8g/L).【变异型】 Miller-Fisher Syndromecharacterized by gait ataxia, are
13、flexia, and ophthalmoparesis, papillary abnormalities are sometimes present; 三大特点是共济失调、腱反射消失、眼外肌麻痹；有时可见瞳孔改变；多由呼吸道感染诱发，持续数周后好转，脑脊液蛋白含量升高，没有肢体瘫痪，血清中抗神经节苷脂 GQ16 抗体滴度升高，NCV 多正常，H 反射多延迟； Acute motor axonal neuropathy (AMAN)急性轴索性运动神经病多 caused by infection with campylobacter jejuni or paraenteral injection
14、 of gangliosides 神经节苷脂；急性发作，2448 小时内即出现四肢无力的迟缓性瘫痪，少感觉障碍，病情严重，多累及呼吸机，需气管切开；2030%患者血清有 GM1 or GD1 神经节苷脂抗体；【诊断】1.病前 1-3 周有感染史2.急性或亚急性起病，4 周内进展的对称性四肢弛缓性瘫痪和脑神经损害，轻微感觉异常3.脑脊液蛋白-细胞分离现象4.肌电图检查，早期见 F 波或 H 反射延迟或消失，神经传导速度减慢，远端潜伏期延长，动作电位波幅正常或下降5.排除其他疾病【鉴别诊断】1. Acute poliomyelitis 急性脊髓灰质炎: acute, generalized dis
15、ease caused by destruction of motor neurons in the spinal cord It is distinguished by asymmetry of flaccid paralysis, signs of meningeal irritation, fever, and CSF pleocytosis no dysfunction of sense( anaesthesia; hyperaesthesia)2. Acute myelitis 急性脊髓炎: a transverse myelitis interrupting both motor
16、and sensory tracts at one level, usually thoracic. It usually begins with localized back or radicular pain followed by abrupt onset of bilateral paresthesia in the legs, an ascending sensory level Urinary bladder and bowel involvement occurs early and is prominent Both cell count and Protein content
17、 in CSF are mildly elevated or normal3. Myasthenia Gravis 重症肌无力： characterized by fluctuating weakness affected muscles involve: ocular, facial, oropharyngeal muscles. Limb frequent Sudden; more frequentCommon manifestationcontralateral Monoplegia/hemiplegia 对侧单瘫/偏瘫contralateral facial paresis 对侧面瘫c
18、ontralateral sensory impairment 对侧偏身感觉障碍Vertigo, nausea, vomiting;balance disorder;with or without tinnitus; Special manifestationCrossed paralysis 眼动脉交叉瘫 Drop attack(跌倒发作，网状结构缺血 ); transient global amnesia/TGA(短暂性全面遗忘症，一过性，颞叶/海马缺血); aphasia 失语症 (dominant hemisphere) astereognosis 体像障碍(non-dominant
19、hemisphere)visual impairment or visual field defect(双眼视力障碍发作，枕叶视皮质受损)Probable manifestationContralateral homonymous hemianopia 对侧同向性偏盲(大脑中后动脉皮质分支分水岭缺血)三偏综合征 Internal capsule lesion：对侧偏瘫、偏身感觉障碍、同向性偏盲Dysarthria 构音障碍 ,dysphagia 吞咽障碍 ,crossed palsy 交叉性感觉障碍,crossed paralysis 交叉性瘫痪,bulbar palsy 球麻痹,nystag
20、mus 眼震,ataxia 共济失调,unconsciousness; Diplopia 复视;大脑后动脉深穿支Weber syndrome（中脑大脑脚）Parinaud syndrome（四叠体）Benedikt syndrome（中脑红核）椎动脉Millard-Gubler syndrome（脑桥腹外侧）小脑前下 aFoville syndrome（脑桥腹外侧+内侧纵束） same基底动脉Locked-in syndrome（脑桥基底部）Wallenberg syndrome（延髓外侧）小脑后下 a Top of the basilar artery syndrome, TOBS 基底动脉
21、尖综合征：基底动脉尖端分出的两支动脉堵塞（大脑后动脉&小脑上动脉） ，影响中脑、丘脑、小脑上部、颞叶内侧和枕叶，出现眼球运动障碍，瞳孔异常，觉醒和行为障碍可伴记忆力丧失，病灶对侧偏盲或皮质盲，少数幻觉脑血管疾病2,5,8,3Arterothrombotic infarcts脑梗死Cerebral embolism脑栓塞Lacunar infarcts腔隙性梗死intracerebral hemorrhage脑出血subarachnoid hemorrhage蛛网膜下腔出血1.Age 较大，60 小，Adult 青壮年 大，65 中，50-70 years 较小，40-70 years 2.TI
22、A history Yes no no no no3.Main cause 病因 Artherosclerosis大动脉粥样硬化Atrial fibrillation各种心脏病（房颤为主）Hypertensive arteriosclerosis高血压引起小动脉硬化Hypertensive arteriosclerosis高血压& 动脉硬化1.Saccular/berry aneurysm囊/梭动脉瘤2.Arteriovenous malformation 血管畸形4.Inducing factors 诱因 Quiet time, blood flowor BPstrong mood,up a
23、nd activeQuiet time, strong mood,up and activestrong mood,up and active5.Onset 起病缓急 H - d 慢 S - m/acute onset 最急 M - h/sudden onset 急 M h/Sudden onset m/Sudden onset 6.BP at the onset Low or normal Usually normal High or normal much higher High or normal7.Involving cerebral arteries major branches颈内
24、& 大脑中最多middle cerebral artery Penetrating arteries Most common sites of hypertensive hemorrhageLenticulostriate a 豆纹动脉arterioles and small arteries on brain surface8.Unconsciousness No Transient or mild confusion No Yes No or transient 9.Headache no Less No Yes Yes, severe10.Vomit Less Less No yes Y
25、es, severe11.Meningeal stimulus signs stiffness neck kernig sign brudzinski signNo No No Yes Yes, severe12.Convulsion Less or no More or yes No Yes yes13.hemiplegia Yes Yes Yes Yes Mild, delayed 14.Pupil Normal normal Normal Pontine and ventricular hemorrhage: may tiny pupilsMost normalMay dilated p
26、upil (3rd n palsy) 15.visual fundus artherosclerosis Sometimes embolus arteriosclerosis Arteriosclerosis, retinal hemorrhage动脉硬化&出血Sub-vitreous membrane hemorrhage玻璃体下出血16.Brain CT/MRI local ischemic lesion 局部低密度病灶local ischemic lesion with or without hemorrhage局部低密度灶Local ischemic lesion1.5cm, loca
27、lly or diffusely blood site 脑内高密度灶blood in the subarachnoid space locally or diffusely蛛网膜下腔高密度灶17.CSF normal normal Normal High pressure, bloody Bloody CSF, high pressure18.Brain DSA large a. Stenosis&occlusion large a. Stenosis&occlusion Seems normal Abnormal: aneurysm/AVM an aneurysm or AVMArterot
28、hrombotic cerebral infarction 脑梗死【Treatment】Acute period (stroke unit)I. General management:II. Management to restore the circulation and arrest the pathologic processThrombolytic therapy:溶栓治疗Time widow: 3h, 4.5h, 6hThrombolytic agents: rt-PA, urokinase超早期溶栓治疗的应用、适应证选择及并发症？（1 ）应在发病 6 小时内洽疗时间窗进行溶栓，恢复
29、梗死区血流灌注，减轻神经元损伤。常用药物：尿激酶 urokinase：25-100 万 U 加糖或盐水中静脉滴注；重组的组织型纤溶酶原激活剂（rt-PA）：选择性纤维蛋自溶解剂，0.9mg/Kg/次，总量90mg。（2）适应证：年龄75 岁 ，血压200/120mmHg无意识障碍，椎-基底动脉系统脑梗死预后极差，昏迷也可考虑；发病 6 小时内，进展性卒中 12 小时内；CT 未显示梗死灶，并排除颅内出血和 TIA；无出血性疾病及出血素质，无禁忌；患者和家属同意。（3）并发症：梗死灶继发出血 ：应监测出凝血时间及凝血酶原时间；再灌注损伤Antiplatelet therapy 抗血小板治疗Hem
30、odilution Treatment for cerebral edema and high intracranial pressure: iv mannitol, furosemideAcute surgical revascularization and decompression Cerebral protection Traditional Chinese medicineIII. secondary preventionASA-抗高血压+他汀+ 抗血小板 Antiplatelet therapy Statin 他汀类 Treatment for the primary diseasesPost-acute periodI. RehabilitationII. Preventive III. lifestyle
