2014 -

3 ................................................................................................ :
7 ................................................................................................ :
10 ....................................................................................................... :Spinal Cord
13 ............................................................................................................ :
17 .............................................................................................................
20 ............................................................................................................... :
24 ........................................................................ :
29 .................................................................................................. :
32 ..............................................................................................
49 ......................................................
52 .........................................................................
62 .............................................................................................
75 ............................................................................. stroke-
92 ..................................................................... Intracerebral hemorrhage- ICH
94 .............................................................................. Global Cerebral Ischemia
96 ..............................................................................................
97 ..............................................................................................
107 ......................................................................................................... Syncope
/ 108 ..................................................................
112 .......................................................................................................
115 .....................................................................
117 ........................................................................................................
1

 119 ..........................................................................
127 ................................ Anterior horn cell disorders/ Motor neuron disease
131 ................................................................... Nerve root and plexus lesions:
133 ..............................................................................................
142 ............................................................................................... :
( )145 ..................................................................................... :
149 .....................................................................................................
152 ...................................................................................................
158 ..........................................................................:parkinson plus /
163 ....................................................................................................... CNS
172 ..................................................................................................... :CNS
183 ................................................. :
188 ..................................................................................... :
191 ............................................................................................... :
195 ............................................................................................................. :
202 ........................................................................................... :
208 .............................................................................................. :
212 ................................................................................................
223 ...............................................................................CSF-
225 .......................................................................................
231 ..................................................................................................... :
-236 .........................................................................................:
- 253 ...................................................................... :

 :
( ) ,
/ .
.
:

,
.
.
Dorsal root ganglion- .

( Primary sensory
.)cortex Post central gyrus- Central sulcus-
.
.1-3
.

. ,
.
/ ,
. -
-
(
) , / .
( )Falx Falx-
// .
Superior sagital sinus- .
:
:
(?).
. 3
2.

( ),
.2
,

.

.

( ) .
( ).

.
.
- , ,
.
3

 :
(:)dorsal column /Posterior tract

, .
, , .
:

( ) .
.

.
-
.
. ,
.
/ = .
.
:
,
, .


.
.

.

, (
).
:
= .
() ,
.
L5 .
:
C3-4 .
T5 .
T10 .
L3 .
- L5 5
L4
- S1
.
:
" -.
- ,
" . " -

 Internal capsule- (
).
,
.
:
Light touch .
Dorsal column medial ( DCML-
.)lemniscus

.

. .
256 .
"
.
' ( ).

.
3 :
Two point discrimination o
. "
. "
.
Streognosis o
. , - (5 ,
') . -.
o ( )Graphesthesia
. -.
,TPD-- -
.
.

,Conversion . .Malingering

.
:
- , ,
. :
o ,CTS- .
3.5 .
o ( ) .
. .
o ,
.
Lateral femoral cutaneus nerve o
, ' ( ).
,
( , ,) .
:
o
5

o
o

o
o
o

HIV
MM ,
.
TB ,IBD ,FMF-
.
-
. .

.

, (
).
( Fabry ).

* - ,- , ,
2 .
.
. : , ,,
, ,RA ,PAN , .

.
, (
,)MM . .
,
.
, T6
T3- .T7
()
.
.
, PICA-
( )Posterior Inferior Cerebral A .
- ,
.
.
" .

:
.
:3-
V1
V2
V3 + .
!
' . ,
.
:
,60 ,
V2-.
,42 ,
.
6

.

, .

:
.
.
(=):
.
.

.
.



.
Cerebral peduncle-
.

. ( )
.
(= )
.
() ( laterla
,)corticospinal tract .

.
:
( )UMN
( )LMN ( ).
"
:
,
.
:
5- .
, ,

. " .
UMN :LMN
( )
( ).
UMN CNS LMN .PNS
7

 :UMN
.
( ).
( Clasp knife )
, .UMN-
.UMN
- . UMN
.
= "
,
UMN .
UMN- ,
.
:LMN
UMN
,Disuse-
.
LMN
.
.
, .
, .
.
.
( ).
(= ) ,
.
:
LMN
Yes
Yes
Yes

()

UMN
Yes
No
No

()

Weakness
Atrophy
Fasciculation
Reflexes
Tone
Plantar Responses

-
" , ,
. ,
, , , .
( UMN) , MS ,.
LMN , , .
UMN:LMN-
- ALS UMN.LMN-
( ,
,).
Drop foot
8

.

, .ALS

.
- .ALS- LMN
UMN.

?
- , ().
LMN UMN- .-
ALS .
:
:



:

( NT ) . ACH- -

.
T tubule- ( SR )
. T- SR-
.

>- >- .
- , Z line- .
I , A- ,
H- .
H-
.
Re uptake SR- .
:
:



,
.
:
Type 1 , .ATP-
,
.
Type 2 , .
= . ,
. LMN
.
9

 :
ACH
ACH- .
.
,
.
=
.Myastenic crisis
LMN-.Neuro muscular junction-

:Spinal Cord
-:
8 7- ,
C2-3 .C3.S1-S5 ,L1-L5 ,T1-T12 ,C1-C7 :
" T3 .T3-4
:Spine


.
:
( )
" ( )Vertebral canal
(.)Anterior X 1 & posterior spinal A X 2

" ( .)T8-10-
,
, AF ,.
:
( :Anterior spinal artery syndrome )
Anterior spinal A-
(
.)Posterior spinal A

( )
, Sparing.
= Hemi cord lesion ( :Brown Sequard )
,
,MS ,.
:
-
, .
10

( ')
.

.

Spine ' .
.Spine-
spine
, .
( :Central cord syndrome )
.
() CSF
. Arnold
,Chiari ( Tonsils- )
.
.


.

LMN- ( ),
.

() ( UMN
, ,).
:Sub acute combined degeneration
B12 , ( ,)IBD .IF
+ .

+ .
B12


B12 .
,IF () , "
B12 .
:Tabes dorsalis
" .
( ) .-
Tabes dorsalis ,
. .
:
(=)General paresis
-
- (=)
:
11

, LMN ,
,.
ALS
MS . ,
, .
HTLV1 , ,UMN Tropical para
.paresis

:
3-:
, .
, , .MS

. .
.
Spinal cord compression ,
.

, , ,.
:
L4-5 ,L3-4 .
:


( , CT
)
.
:
1
2 ?
D ( )DCML -
.
2 ' ,
. .T10-
D , '
,
.
3 ' .
.
, "
( ,)T4-5 (
).
B .
.

12

 :
:
.
:
= Mid brain
Pons
Bulb
, .
:
- ()

.
Pyramidal tract- .
-
Lateral .Anterior- Light
,touch . 15%-
. .
( Posterior tract- ) Posterior -
column , .Medial lemniscus
)Reticular activating system( RAS + Aqueduct- -
.
-
, .
- Cerebellar peduncles
,Peduncles .
,Superior cerebellar peduncle
Pons- ,Medial cerebellar peduncle Inferior -
.cerebellar peduncle
:
:
1 o ( )S , .
)S( Optic 2 o >- >- >-
>- Lateral geniculate bode-( LGB- )
,
.
/ .
( Midbrain-):
)M+PS( Oculomotor 3 o (
) , ( -
Superior oblique.)Lateral rectus-
, ()
( ).
-)M( Trochlear 4 o ,Superior oblique-
.
, .
- .
:Pons-
13

5 o ( -)M+S + .
, .
/ /
(// ) .

.
.
5
, .C2
5 .C2
-)M( Abdusence 6 o .Lateral rectus-
.
)M+S+PS( Facial 7 o .
8 o- " .
Pons- Pons-
( ).
,
. .
.
:
9 o .
- 10 o ,Reccurent laryngeal ,
.
12 o ( )M .
-)M( Spinal Accessory 11 SCM .
,
9-10- , .

:
( )Bulbar pulsy 12 ,10 ,9 ,
( ) .
- 3D- , ,.
3,4,6-
, . 6
.
" " .
11 12- .
:
.
( )
( )Pons-
( PCA .)Midbrain-
:
Medial & Para median branches
Circumflex branches
o .PICA-
o Pons- .AICA-
o Superior
.cerebelar A

14

 :
,
" - .
3,4,6 12- .
7 6 .
Weber syndrome :Anterior Midbrain
.SCA :
3 , .
( )
( , )
UMN 7
( .)7 .
:Millard Gobler Syndrome = Medial syndrome of pons
:
/ 5
6
, LMN 7
( ) ( )
-Wallenberg Syndrome :
,PICA .
:
- 3D , ,
( , ,)
.8-

.
'
, checkerboard sensory loss
.
Peducle-
().
:Lateral Pons Cerebellar pontine angle-
.
:
( ,)tinnitus
8 .

7
,5 -
.spino-thalamic tract
UMN- = .
:
=8( 3,6,8
' ).

15

 3 6- )MLF( Medial longitudinal fasciculus

6- ,3- 6 .3-
.Inter-nuclear pathway
( PPRF-
) ,
( .)6 MLF- ( )
.
MLF )Intra-nuclear ophtalmoplegia( INO:
( )
( )
. " .
" .
MLF
. ( ) .
.MS
- :


o
o
. ( 3
) , , .


( )RAS , ( Drop attacks
).
INO 6 .3
:Evoked potential
"
. ( ,)VEP ( ,)SSEP
AEP=BERA .

16


WHO ( )
24- (
).
: , , , ().
24- .TIA

- .10% , .
.10%
( 80% ).

o () ( internal carotid-
brachiocephalic- ) , ,ophthalmic artery
MCA- .ACA- , 3/4
() Acom . ACA- .
o (-) 6- , -
.formamen magnum .
MCA - .
- ( .)broca motor -
.aphasia
- ( .)vernicke sensory -
.aphasia MCA- .
, , .
( .)penetrating -
capsula interna " .)M1( MCA-
ACA
.
A1 internal capsule-.caudate-
PCA
,)primary visual cortex( calcarine ' .
P1 .

, basilar- pons-
.midbrain-
.
:basilar-
PICA .vertebral-
)SCA( Superior cerebellar artery ,basilar- 2/3.
AICA .basilar-
- P1 PCA .
Pcom ' ( internal carotid artery
.)MCA-

17

" ( "
,Acom- . , interal -
carotid ).
)CT angiography( CTA
.MRA
- Doppler .
, ( spectral broadening )
. (external -
carotid ).
- Trans-cranial doppler - -
MCA( PCA- ) ACA- vertebral artery-( foramen magnum-
) . 3 ,
. - ( ).
: ( ) ,- ( SAH
TCD ) ,AVM , ( ICP-
) , ( ,)TCD
.
PET / DWI . Diffusion / .
perusion mismatch ( 4-
).

800 - )cerebral blood flow( CBF" 52 ," . 80%-

.
' " 100-' . = .50
)cerebral metabolic rate( CMR 3.5" 100-' ,5-
" 100-' . 33% 10%- ( ).
4 .
CBF = CPP / CVR
= CVR
CPP = ABP VBP
VBP = ICP
CPP = ABP ICP
:" - . , ,.
: ,'.Hct ,
CPP ( 50-150") .
" , " " ,
.
20-" 100 /' .
" 60- CBF- (
,)CBV ( )OEF ( ,)CMRO2
.
,
.
20 , CBF
- = .time is brain

18

 : ( CBV CBV / CBF ,) ,

OEF- CMRO2 ,GEF- , CMRO2 ,
pH , , , ,
.
:
CBF -.
.
.
.
90-180 ( 3) . ,tPA ,
, .
- .
,
.
, ( ) . Pcom--
Acom , ophthalmic artery- external -
carotid artery .
posterior cervical arteries- .
Subclavian steal syndrome ,subclavian-
.
' -.

Auto-depletion - .
.
.

19

:
:
3 :
Vestibular = Archi cerebelar .1
,36 . .
.)FNL( Flocullar nodular lobe-
Tone & Posture = Paleo cerebelum .2 ,
, , ' . .Anterior lobe-
Coordination = Neo cerebelum .3 . -
.Posterior Lobe
(:)VANISH DDT
= V:
( ,)Sensational motion .
( Lightheadedness- ) ( Postural instability-
).
, :
" .
- BPPV o
.
.
o , .
o , ,
.
Vestibular neuronitis o
8 ()Wallenberg syndrome
.
/.
A:
+ (.)Broad uncoordinated gait
N:
:
- ,Delayed onset .
- ( ,)Fatigue ,
.
- , .
- , , ,
.
:Intentional tremor I
.
( - )Action tremor Postural .Intentional
Postural tremor o , .
:
, ,
()

20

Essential (Age related) ,

. .
Intentional tremor o ,
, .
.
( - )Resting tremor
, (.)Pill rolling

:Speech S
, (:)S3
Slurred .
Staccato (Jerky) ,
.
Sing song .
H:
.
:Dysdiadochkinesia D
, .
.
D:
, Overshooting .
:Titibation T
, ( ) .
":
,Pendular reflex- .
Overshooting
. .
Finger nose test :
o
o
o .Over shooting
Heel-sheen test . .
:
:
o
o
o ()S3

o UMN () . Clasp knife-
.
o , , .Led pipe
Led pipe Cogwheel" + Led pipe
.
o .LMN
NMJ .
.
21

.

. ,-
.Posterior column ( )Position sense
, .
Posterior column-
.

. .

:
FNL

FNL
Intension

-
-
-

-Anterior lobe , ,.
-Posterior lobe , ,DDK , , ,.
-FNL ( ).
:
:
() ,
, .
, .
,
.
, .
,
.
: , ,,
.
FNL ( )
.
.
:
( Anterior vermis- )
. ,
.
( FNL-).
, , . >-
ICP , .
( Posterior lobe- , )
.
22

 :
:

Developmental
Aplasia / Hypoplasia of cerebellum (Dandy Walker) o

Hereditary

. .
o CSF .
Arnold Chiari Malformation o posterior
fossa ( +) , ( basilar
)invagination ( .)platybasia
,foramen magnum- tonsilar
.herniation ( ,
) . Colloid cyst
.
aquaduct (syringobulbia)-
( .)syringomyelia
,syrinx , .central spine syndrome
Spino-thalamic tract
( )ant. white commisure- ' "
.
constrictive hydrocephalus ICP:
.
.
.
CN6" ( ).
pulse pressure- (
, ).
- drowsiness-( stupor-
) ( coma- ).
.

Spino-cerebellar atrohpy o .friedrich ataxia

Acquired

23

 :
:
- +.
.
( )
.
.
( )sylvian fissure- ,
, , + + (
)medio-temporal orbito-frontal
:
o
o -
:

= , = , =.
,
"" ,
"" , ,.

:
- Expressive aphasia .
= = = .
, .
Non fluent , ,
( ).
.
(
).
- Receptive aphasia .
= = .
, .
( Fluent) , ( ),
() , ,.
.
Conduction aphasia .

//
.Repetition .
Anomic aphasia Naming- .
.
.
Trans cortical aphasia .
, .Repetition
:
:Frontal lobe
.
, .
:
24

Motor Strip = Primary motor cortex

, .
Partial seizure . -
Motor strip .Global seizure-
Jacksonian march
.
Pre motor area . .
Micturition control ( ).
.Incontinence
.
, .Incontinence with indifference
Voluntary (Conjugate) gaze ,
, ,3 -Frontal eye field .MLF ,6
.
.

.
( )pursuit

.
:
o - , .
.
, ,
, , .
o -
, (-) >- Coma
,vigilance , , .
Palmar-mental ,Rooting ,Grasp
.reflex (
) ,
.
.
. '.

:
o = 1 - .
o - Foster kenedy syndrome = 2
, Optic atrophy- .

:Parietal lobe
.
.
( )
.
( ,
)
, ...

:
25

Primary sensory cortex

. .
Associative sensory cortex Discrimination sensation:
Stereo gnosis o , , , .
-.
Graphestesia o . ,
.
Two point discrimination o
,
.
Exact localization o .
Triangular gyrus
. (
).

, 100%-
85%-.
( ) :
.1 Cortical sensation-
Construction apraxia .2 .
3 :
Geometric apraxia o "
Dress apraxia o ,
Topographic apraxia o ,
.
- Neglect/denial/inattention .3
. , .
. ( ) ,
, ( ) .
, .
() :
.1 Cortical sensation-
= Gertsaman's syndrome .2 , , ,
.
.3 .
( ) :
.1 a- ,Astereognosis - Cortical discrimination-
,graphasthesia ,2-point- .
Inferior quadratic hemianopia .2 :Primary visual pathway-
>- >- 2 ( optic tract >- ( LGB >- )diencephalon-
) >- internal capsule >- +
.
.
Optokinetic reflex .3
, .pursuit-
.
:Occipital lobe
26

 .Vision ,
:
Primary visual cortex = calcarine cortex
o Primary visual cortex >-
Homonimous hemianopsia .
o ,
.
o ( CVA- )PCA-
,Macular sparing
PCA- MCA- PCA
.
o
,Denial .Anton syndrome
,
.
Associative visual cortex ,Visual agnosia
.
.
( - )Prosopagnosia ,
, '.
, Unformed
.visual hallucination
:Temporal lobe
.
, , .
:


, . /
.

( Wernicke aphasia )
' ( ) , Superior quadratic
.hemianopia
-
,Tornado epilepsy .
(
) , 'Formed ,
.visual hallucination ( ).
Kluver Bucy syndrome ,
( )( bizarre sexuality , ).

:
27

 -.
- :
, , unformed
.visual hallucinations
,Formed visual .
.
(
) ,Tonato epilepsy - .
= ,deja vu
= .jamais vu

28

 :
' ( )UMN .
:

. ,
Overshooting , .

.
:
:
o ()Clasp Knife
o
o
:
o ( Led pipe )Cogwheel
o
.
:

.

.
:
.

.
-
Globus palidum GPI -
() ( GPE-) .
( ).
.Caudate-
+ = ,

.
+ Caudate- =
,Striatum . ( = )Caudate +
.Corpus striatum
Intra cerebral hemorrhage
" . .
, , .
".
:
.

29

 >- >- L dopa >- ,

L-dopa- . -
.Midbrain
,BBB L-DOPA BBB
. ,BBB L-DOPA
.CNS-
" :

,
.
( ) .
,GABA
.
:
,
70% .
Lewy bodies.
( )
:
D1 , ,
.
D2 , .
+
, .
( = )
.
.SNPR+GPI
:D1

(.)D1
( )GABA -
.GPI+SNPR .
= .
VA VL- >- .

.
(
,).
D1 ,
.
:D2
.D2
( )GABA
( !) "
= .

30

 ( )GPE .Sub thalamic nucleus--

Sub thalamic nucleus GPI+SNPR-
>- GABA VL VA- >- .
GPI+SNPR-
( )...
:
:
>- ( )D2 >- >-
-.
:
, .
= .
Sub thalamic nucleus- .
=
.
Dopa .
( 10%).

31


- 1
. :
.
.
( ) ,
, .
. )1( :
( ) posturing )2( ,
- )3( ,withdrawal .
. ()
.
mini mental MOCA :
.1 , ,.
.2/ ( , , ).
.3 (.)100-7
.4 ( ) - 4 5.
.5 - .
.6
.7 ( , ).
.:
.1 ( ).
.2
.3
.4
.5
.6 (.)naming
2 :
,
. (
) . .
.
. .
- Kerning 90- ,
Cross Kerning .
.
-Bruzinsky
.
.
3 :
:



32

nasolabial

( Mask face-) . ,
.Stare
Tardive dyskinesia ,
. .
Occulogyric crisis ,
. .
, ( 0.5" 2").
- -.

:
:Olfactory nerve 1
. "
. " 40 -
DD . (=):
.ENT - , 10-15 , .
," . .
, . :Optic nerve 2
( ) , .
:
.
BS , .
( 30")
. .
.
.
- ( CF -
.)COUNTING FINGERS -
. - ,
. - ( NLP ) NO LIGHT -
.PERCEPTION
( optic neuritis- ,Red disaturation )MS-
.
.
. ,
( ) .
. 4:
o
( ).
o
( ) . (
)
. 160 135-.
33


:
,
, "

2 ," (

) .

.
:

- .

( - )optic neuritis- pre-chiasmic Central
- scotoma -
.
- (
).
- ;
.
Bitemporal hemianopsia
.chiasmic .
Homonimous hemoanopsia post-chiasmic
( )
, ,
.
- Right upper quadrant anopsia
. ,
.
Homonymous hemianopsia with macular sparing
.PCA
** - ( )
. : - , , -
.
. -
o - ,
( -
CONES ).
o -
. MS
.
.
; .
, (
) .
.
:
afferent pretecal nucleus midbrain optic radiation 2
- accessory oculmotor 3
34

 (Edinger-Westphal) nucleus Efferent

Cilliary ganglion 3 .
o )Relative afferent pupil defect( RAPD
Marcus Gunn pupil ( optic neuritis 2
) . (
) ,
2 afferent-
(
) .
. .
o LIGHT SWINGING
TEST .

. -
.
o - 3 III
. EFFERENT- .
, , 2 .3-
o , ,"
' - PUPILLARY PLAY
( , , ).
-PERLA -
( )P ( ,)E ( ,)R ( )L (.)A
. ()
. " .
, - ,
( , ) . :
Papilledema ICP .
ICP ,
, . ,
.
Papillitis ICP ,
. ,
. RETRO
BULBAR NEURITIS .
, - . RAPD
( ).
OPTIC -
.ATROPHY ,
( ) . , ,
.
-
; -
,COLLAPSE . 85%-
. ICP- , -
.

35

 - 4 ,3 :6
Occulomotor 3
:
.1 4 .6- 3 ,,
Elevation .
.2 Levator palpebra Muller- (
) .
3 .
.3 .
.4 ,
3 ().
3 .
Trochlear 4
-Superior oblique , .Intorsion- 4
, superior oblique-
.
Abducens - 6
.Lateral rectus- 6 -
PONTINE GAZE CENTER ( )MLF 3
- 2 . - ( )INO

INO . ( INO") ,
. - .
:
. ( ).
. :
- Smooth persuit o .
H .
( ) . ,
SCLERA . , . -
tempo-parieto-occipital area smooth persuit-.
Saccade o . "
- - . " Frontal ( FEF
)visual field [ . ].
( Convergence .) .
.
:
Hypometric (broken) saccades , . Square waves jerks , . .
. :
o . .
o ?
o ?
2 : 6
3 .

36

 .
() .
:Trigeminal 5
3 ( ,)V1 ( ,)V2 ( .)V3 +
( , ) . 5
C2-3 ( 5 -
).
:5
.
:
o (
" )C2 .
o - ,
.
o - // , ,
( " .)C3 " C2-3
" .5
, .

( .)Pin prick
.
-
, ,5
.
. .

. . ,
.
Jaw jerk reflex . .
,UMN -
, ALS- LMN
.UMN
. " .
Corneal reflex . ( 5 AFF ) 7-
( ) . "
( ) .
.
. . "
.
Trigeminal neuralgia 5 ,
. !!!MS-
:Facial 7
:
14- ( .)17
,
(-).
- 2/3- " .

.

37

 :7
. 7 ,
,nasolabial , ( ).
Sparing
" .
,
. sparing.
. , .
. .
? Bells phenomena
.
. ,
. .
Corneal refex . .5
- BELLS PALSY 7 ,
,
.' ( ) ,
-Hemifacial spasm post Bells palsy .
, .
:Vestibulocochlear 8
.
.1 , , , .
:
, .3,4,6 Dix-Hallpike maneuver . , , (
) , , ,
.
.

=

3-:
-1 end point- .
-2 . .
-3 -
.
.2 .
( -
500-2000 .)128
.

, - .
o Weber .
.
38

 ( )Conductive hearing loss (

"" -
) . .
o Rine
.
.
, .
Weber lateralizes right

Weber lateralizes left

Weber without
lateralization

Sensorineural loss in left

Sensorineural loss in right

Normal

Combined loss :
conductive and
sensorineural loss in left

Conductive loss in left

Rinne left BC>AC

Conductive loss in right

Combined loss : conductive

and sensorineural loss in
right

Rinne right BC>AC

Rinne both ears

AC>BC

:Glossopharyngeal 9
.1 1/3- .
.2 , , .
.3 .
.4 .
:
-
.
,AAA .
GAG 9- .10- 9 AFF- 10- ( EFF-
, , ) .
( ) . -
GAG .
, .
,GAG .GAG
9 - . - .
, .
:Vagus 10
- . " Recurrent
laryngeal
.
( )Posterior oricular nerve .
9- .10- 9 10 - . 10
-.
:Spinall accessory 11
C1-3-
' . SCM- .
- ( ,
) ." - .
39

 - SCM . - -
SCM .
. ( -)C2-C4
:Hypoglossal 12
.
- . ,
. "
.
:

. - = ".
(
) . ( )
, :
7 o "
( 11 o 12- )
.
- 4 :
, , ,.
: UMN-
; ."
. - .
-:
- .
o -/.
o - , , , , ,.
o/
o - .
( ) . -
( )LMN .
o
o ,
o - .
-:
. .
: -/ .
,rolling , .
Noika . -.
:
o () .LMN -
( UMN ).
o
.a ,UMN ,Clasp knife
( ).
.b , =
.Led pipe Cogwheel .
.
40

 .c ,
.
,
.
- :
, ,-
.
- . UMN
.LMN
. :
.
= .Pronation drift
( .)Digiti minimi sign
, , .
Barre 90-
, .
90- .
. - :
:0-5-
0 o .
1 o .
2 o ( )
3 o
4 o .
. +4-.-4-
5 o (
) . .
** .C5-T1

() 15-
Deltoid
. "
supraspinatus
Biceps
supinatopn-
Brachioradialis midpronation

Triceps
Hand extensors
(extensor carpi
& radialis longus
brevis) &ext. carpi
ulnaris

Hand flexors
& (flx carpi radialis
)ulnaris

Finger extensors

( ).

Axillary

C5,6

Musculocutaneous
Radial
Radial
Radial

C5,6
C5,6
C7,8
C7,8

))C6,7

Median

( )

Radial

()extensor digitorum

41

C7,8
C7,8

(via its dev. Post

)interosseus n

Finger flexors
(flexor digitorum
& suoerficialis
)profundus

Abductor pollicis
brevis
Interossei
Iliopsoas
Gluteus max.

Quadriceps
Hamstrings
Adductors
Gluteus med.
Tibialis ant.
Gastrocnemius
soleus-
Ext. Hall. Long
Tibialis post.

Peroneous

Median Ulnar

C7,8, T1

.2,3 .4,5

( )DIP

(
)

Median

C7,8

Ulnar

C8,T1

Femoral

L1-3

Inf. gluteal

L5,S1-2

Femoral
Sciatic
Obturator

L2-4
L5,S1-2
L2-4

Sup. gluteal

L5

dorsiflexion
-

Deep peroneal
Tibial

L4,5
S1-2

( )
!
deep peroneal-
( L4,5
)
( )

Deep peroneal
Tibial

L4,5,S1
L4,5

Peroneal

L5,S1

( )

:
.1 ,

.
.2
.
()
( )
()
( - ,
).
(
).

3:
.1 ( grip ) - ,
.
.2 . 2-3
.
.3 - 2 O .
:

.
, (L2-
.)L4 (
, ).
-)deep peroneal ,L4-5( tibalis anterior ,L5
( )sup. gluteal L5 -

42

deep peroneal . )tibial, L4-5( tibalis posterior

.peroneal
:
.
, .

.
:
, ' .
, .
. LMN .UMN- UMN
, (=
UMN ).
0 : ,1 , 2 , 3 , 4 , ( non
)<3 sustained ;>3 sustained
C5-6( Biceps o) - .
.Cubital fossa-
( ).
C7-8( Triceps o) -
. ( )
C5-6( Brachioradialis o) - .
, " ( "
) , .
C7-8( Finger flexors o) -
.
L3-4( Patellar o) - ,
.
.
) -Cross adduction (Rosenthal
+ .
S1-2( Achilles o)
/ ,
- .
:
.UMN-
-Abdomenal reflex o
. .
- Plantar reflex o ( ).
( ) .

, ().
- Cremasteric reflex o
.
:
-Troemners sign o
,
.
- )C7-8( Hoffman o ,
, .

43

o
o
o

2 " - .
- ,
- .
" . - .,
.UMN
Babinski reflex "
.
() . .UMN
.
Chaddocks reflex ,
. .
Oppnheims sign ,
.
Gordons sign , .

:
, "
.
o .
, .
Snout o , ,Snout
.
Rooting o
Palmo-mental reflex o .
.
Grasp o .
5 :
2 -
( Spinothalamic .1 )
' .
(
) 2




( ) .
(
)

44

 .2 ( )
.
dorsal root gangelion

( )
( Nucleus gracillis-) Nucleus
( cuneatus)
VPL
.
.
( ) ,
'
.
:
,
, , .
. .
.
o C5
o .C8 ,T1 ,C6
o .C8 ,C7 ,C6
o .L2 ,L4
o L3( .L4 ,L5-S1 )
o .S1 ,L5 ,L4
. " .

,C .
.
(" ).
.
.

45

 : ,C4 ,T4
,T6 ,T10 ,L1 ,L3-4
,S1 .S2 -
D3 C4 - ;

:
.
" " . '
,
.
.
(
) .

.

C2
C3

.
- . - (.)Occiput
46

C4
C5
C6
C7
C8
D1
D2-D12
L1
L2
L3
L4
L5
S1
S2
S3
S4
S5

( ) . .
- , . .
, ,Thenar - .
. , .
, . ".
- . .
D4 . D10 . .
.Inguinal .
.
, .
, Medial maleolus .
, .
, . - .
- ( .)S3 - .
( .)S2 .
.
-.

:
. - ,
. .
60 . .
./ . ,
. 36 .24-
.
.
, . /
. .
, .
, .
( ).
o (
) . .
. .
o = sensory ataxia
o
. - ()
.Two point discrimination o . 4" ,
1".
Graphesthesia o
Stereognosis o .
.
- 6 :Cerebellum-
.
" . (
).
:
o

47

 o
.
o
o .
:
.titubation -
: Pursuit-
,Saccadic pursuit .
.
- Overshot .
- , , .Scanning speech
- . - .
;
:
Intention tremor o " .
,
. .
.
o Overshooting , .
.
o " (
).
Rapid alternating movements/Dyadochkinesia
. .
,
-.
-
. .
- .
. ,
.
: , , ,
( ).
tandem ,
.
( Holmes) = arm pulling test .
.
.
.
.

" . .
.
() -
,
, .
.

48


():
.
ext rotation (
).
.
o ( ).
- Jaw jerk o ( )UMN ,
V afferent .efferent- (
LMN- ).
o - " . UMN
".
- ( )UMN .
Pronation drift- ( Digiti
)minimi sign . .
-.
( . 4 ) Spreading .
().
.
:
o (=) .96%
( ,' ).
o - .35%

49

o Spreading
() - .
.
( ).
- (
) , .

-:
4 : , , .
.1 ,/ , , (,)stare
" , ( Air pillow
).
.2 MMT .MoCa
o .
o .
.3 :
.
.
Smooth persuit .1 () ,
( )PSP ( .)MSA .
.
square waves jerk Saccades .2 ( -
, )broken .
.(hypometric) saccades
( Glabellar reflex .) , .
.70%
. palmo-mental ,snout
.4 - .Cogwheel/led pipe
.)Noika( . , PSP- .
- ,CBD- MSA- .
.5 .MSA
.6 - .
.
.7 - ( ) ,- ,-
.8 - , , ()
( ,)freezing , -Gower sign .
.
.9 .
.
:
titubation
- ,Stuttering\scaning speech.
.tower of saigon -
( Saccadic pursuit ) .
- Overshot ( ).
.
, ,Intentional tremor :
Overshooting - Holmes test
50

, .Tandem .
() - .

:
:
.
( ) .
. : .
.
.
.
.
() - , ( ) ,
( - ) . "
.
: ,-
, - .
:

( motor strip .)pre motor area
.Incontinence with indufference
. .
: ( )FEF .conjugate gaze
:
o , .
o , , .
o .
:
Palmomental . . .
Snout .
.
- Grasping . .
- Rooting ,Boxer sign . .
" - ,
.
-Gate apraxia - Fastination .
" " . -NPH :
, .
:

Inferior quadratic hemianopsia
- ( ).
( )
"
- ,
. :
Astereognosis .1 " .
51

.2
.3
.4
.5
.6

.7

Agraphestesia .
.
-Two point discrimination
. .
.
Allesthesia " .
Extinction ,
.
Unilateral neglect and Anosognosia
"
- , ( ,)Anosognosia
.
,Constructional apraxia
/ Neglect of external space -
. Constructional apraxia -
, .

()
)angular gyrus( Gerstmann syndrome 4 :,
, .finger agnosia -
( ) ( . ').
, .
()
.
(::)construction apraxia
- geometric apraxia o / .
-Dress apraxia o .
- topotgraphic disorientation\apraxia o
.
.
Unilateral neglect and Anosognosia ( )denial
-)neglect( . Extinction
.

:
, " "
. ,
. ,Fovea - .
, ( )Rods and Cones ,
( CN II- ).
, () ,
() , . ,
52

 Optic tract . ,
prechiasmal , Retrochiasmal
2.
Optic tracts - ,Lateral geniculate nuclei -
Optic radiation
( ,)Calcarine cortex .
()
,
,Calcarine fissure -.
:
. " Central
,retinal artery Ophtalmic artery .Internal carotid -
,Superior and Inferior retinal branches -
.Altitudinal
Ophtalmic.a - . Optic radiations - " .MCA
,PCA-
( .)MCA-
:
" 6 . 6
( Primary position - ) .
,
( )Ophtalmoplegia . ,
, ,
(.)Diplopia
" VI ,III .VI-

.
, " .
)Oculomotor( III ,Superior rectus ,Medial rectus
Inferior rectus Inferior oblique - Levator palpebrae -
( ) . .
III , ,
; () .
-)Trochlear( IV .Superior oblique
.
-)Abducens( VI () .
,Lateral rectus .
III IV- , of ( Cerebral aqueduct -
.)sylvius VI .Pons-
:
III , Superior rectus -
III , levator palpebrae

Superior rectus ,
Superior rectus III .
,IV .IV

53

VI ( VI ) , Lateral rectus
, Conjugate gaze ,
. VI,Facial nerve fasciculus -
PPRF.Ascending RAS -

- :
-
, )Conjugate gaze( Version
.Vergence
( )Brainstem gaze centers
Pons--
Pretectal region , ,
.
,Lateral gaze center Paramedian pontine -
)PPRF( reticular formation ,VI
VI
III . PPRF-
( , ).
PPRF- Input ,
() , -
,
( .)Persuits ,

( ) . , (,
)
.

:
.
.
. MS ,.MG-
. .
. , ,MS
," , , ( ) ,
, , , .
:
.1
" , , (
20/40 ,20/20 .)20/200 ,
( ,)CF ( )HM . ,
.NLP - (
).

54

 .2
160
135-
. ,
180 .
, 5
.Optic disc -

( )Confrontation .
:
Central scotoma .
.
)Optic neuritis( Optic disk -
(.)Retrobulbar neuritis
.
.
.
" .
Right nasal hemianopsia . -
(
).
. - ( ,Optic tract
.)Optic radiation
. Optic
radiation .
. - Optic
radiation .
. Macular sparing .PCA
.3
:

( Pretectal nucleus -).
, , .Iris - 20%-
( Anisocoria) , 1".
() ()
.
, .
:
.
( Iris - ,Iritis ,) , ( III" ,
) (.)MS ,Optic neuritis
Light-near dissociation .
; " , - ,,
, .
. Argyll Robertson , ,
, . Light-
.near dissociation -.
Tonic pupil .
. ,
, (.)Holmes adie syndrome
55

 Horner syndrome .


(
) ,
(
,)III
( ).
- :

3
(
,)T1 -
(

) -
( Internal carotid
.)V1
"
. ,
" 1-" . (
) ,
, .CNS- ,
. , .
( RAPD . -) ,
. "
( Afferent - ).
.4 ()
, Optic disk- ICP -
. , (" )
.
Optic disk - ,
. ( Optic disk swelling) ICP,
Swelling ICP-
() .Ischemic optic neuropathy -
" ,
( ) .
"
, ICP (
) . ,
. ,
. .
, .
.5
( )Ocular palsies ( )Gaze palsies "
" 6- .
( ) , " :
( ; )
( ) ,
;
56

 ,
. ,
, (
) .
:
Ocular palsy . ,
- ( NMJ , ) .
, .
III .
, .
.
superior oblique( IV )
;

.
.
( VI )
.
.
Gaze palsy .
(
2 ) .
" - ,Gaze palsy .
,Ocular palsy - 2 "
. Upgaze - .
Internuclear ophthalmoplegia .
( MLF- VI
.)III , 2
( ) ,
. INO ;
III" . INO-
" .
One and a half syndrome .
Pons- MLF- PPRF-
INO
, ( )
. ,
( ) .
MS ,pons- .pons-

57

:

,
, 6- . ,
.
,

( ).
:
. ,
. ,
( ) , ( )
( ) . :Jerk nystagmus
Gaze-evoked nystagmus .
. . "
Residual ocular palsy - . "
,
.
Vestibular nystagmus .
" " .
,
, . ,
, ; " .
( )Positional " ,
.
/ ( )
/ ( ).
.6 :
Optokinetic nystagmus .
; .
. Levator palpebrae,
III , .
,III NMJ
, .
( )Lid retraction -
( Parinaud syndrome .)Pineal -

58

 Exophthalmus . " .
, ,
( Cavernous sinus
" ).

:Monocular disorders .1
Transient monocular blindness . ,Amaurosis fugax
,
1-5 10-20 .
, .
( .)TIA-
TIA-.
Optic neuritis . . .
" -
. ( ,) , ,
.B12 ,
. ,
90%; " .
,Central scotoma
( Retrobulbar neuritis - ).
.RAPD ,
2-3 .
.
)AION( Anterior ischemic optic neuropathy .
. .50 , ,
" . ,
( Altitudinal ) . .
, .
, .Optic atrophy
Giant cell (temporal) arteritis .
.
, , ,
. . ,
. .
, .70-80
( ESR )50 CRP-.
:Binocular disorders .2
Papilledema . -
ICP (
CSF- -) .
, ICH
SAH . 2-3
.ICP-
ICP , , (
.)VI ,
( ) ,
.Pseudotumor cerebri

59

 Chiasmal lesions . ,
. MS , ,
.Berry ,
" .
Retrochiasmal lesions . :
Optic tract & lateral geniculate body o
.
Optic radiations o ,
. , ("
) .
.
Occipital cortex o "
, 90% .
.PCA AVM-
. " ;
, (.)Tunnel vision

Gaze palsy .1 III
, :
Hemispheric lesions . , 2
( ) .
, .
.
Midbrain lesions . Upward -
gaze , .
, ( ) , Midposition pupils ,
.Light-near dissociation -
Pontine lesions . PPRF- .
, ( ),
" .
.VI
INO .2 INO- " III . -
,INO " .MS
, " 2 . 80%.
INO ( MG ).
Oculomotor nerve lesions .3 III ,
( ) , , , ( ,
,Cavernous sinus ) , .
:
. - . "
.
. " P. -
( connecting. A III
).
Cavernous sinus . III V1 ,VI ,IV .V2-
III .
Orbit . III ,
CT MRI Cavernous
.sinus

60

.4
.5

.6

.7
.8
.9

Trochlear nerve palsy , ,

32%( IV-) .
( ,)21% (.)29%
Abducens nerve palsy VI .
VI- ,ICP-
. , VI-
.
Diabetic ophthalmoplegias IV ,III- .VI
III ( Pupillary sparing -
, ) . ,
(" )
Cavernous sinus ,Paranasal sinus "
.Mucormycosis
Painful ophthalmoplegias
.
CT MRI , , .
90%-.
; , .
Ocular myopathies "
" . .
Progressive external ophthalmoplegias
, . ,
.

61


Acute
Subarahnoid hemorrhage (SAH)
Meningitis or encephalitis
Ocular disorders (glaucoma, acute iritis)
Seizures
Lumbar puncture (positional headache)
Hypertensive encelopathy
Carotid/vertebral artery dissection
Sinus vein thrombosis
Pituitary apoplexy
Coitus (?)
Subacute
Intracranial mass (tumor, subdural hematoma, abscess)
Giant cell (temporal) arteritis
Pseudotumor cerebri
Trigeminal neuralgia (tic douloureux)
Glossopharyngeal neuralgia
Postherpetic neuralgia
Atypical facial pain
Hypertension (pheochromocytoma or MAO inhibitors+tyramine)
Chronic
Migrane
Cluster headache
Tension headache
Sinusitis
Cervical spine disease
Dental disease

) (,)- (- , .1
.1-10 ) / , , ,/ (.2
.3
,cluster -
tension
optic , , (Ocular or retroocular
.retroorbital inflammation ,cluster , ,)neuritis
Paranasal
, ()
.ICP bioccipital bifrontal-
, (, ,tension Bandlike or occipital
.) ,
.postherpetic neuralgia- trigeminal V1
.tic douloureux trigeminal V2,3
.glossopharyngeal neuralgia Pharynx and ext.auditory canal

62

.4
.5

.6
.7

.8
.9
.10

, ( ,)SOL
( ,)cluster ( ,)tension .

()
() -
cluster
, ,
giant cell arteritis ,tic douloureux ,glossopharyngeal neuralgia
(.)jaw claudication
/ tension
)post LP( postural
-
, -
)post LP( postural
SOL
,scotoma , aura
.
-
,giant cell arteritis ,

,ocular disorder ,
/optic tract/optic .
,-.SOL ,
.SOL
,.SAH ,
() ( )lacrimation .cluster
,tension .Giant cell ,
,
, .
, ,.

( )CT
.1 [ 2 weeks 6 months , ]
.2
.3
.4
.5 , , .
()
.1 ( , ) ," ( HTN
, ,Hypertensive encelopathy
).
.2

- , () ,
,caf au latte , ( AVM ) ,
.herpes zoster
.

63

 .3 ( ,)giant cell (,Paget

,Myeloma) , ().
.4 (!) .
.5 : , (!
) , .

SAH - Subarachnoid hemorrhage
:SAH-
.1 ( -)75% 6 100,000-,
, .
, ."
, ( )
.

.
AVM .2 ( -)10% - 2 ,
.
.3 ,
.
:
,berry
, .
, 20% .
( )Internal carotid ,MCA :
( vertebral A. ,PICA ,ACA ,Basilar A. ,AICA ,)ICA.PCA -
PKDaortic -
.coarctation
SBE Mycotic ameurism
( 2-3% - ) .
.
AVM
; MCA.
:
ICP ( ").
ICP ,
50% -.
ICP .Subhyaloid retinal hemorrhage-
,
, .MCA - ,AVM
.
:

(" ") .
64

 , . .

. .
,AVM
. .
:
o . - .
o - 39'
. .
o .
.
o ( preretinal globular subhyaloid hemorrhage)20% -
. .
o ,
III Post communicating artery- .
" VI .Non localizing
AVM
, .
:
CT o - . 90-95%
. .
= . ( supracellar cistern-
.)sella-
.
.
CT o - CT- CT-.
MRI o AVM ( MRI-
. )AVM
- LP o ( 180" ) ( 100,000
" ) . CSF
( )xanthochromic .
4-8
.
o - .15,000 -
o - "
T , PR U ,.

.
:
ICH .1 .
.2 " .CSF-
.3 ( ) " .
.4 " ( CSF ).
:
- Rebleeding . 20% 10-14- (
) . AVM .
. , AVM ACA - .MCA -
.transtentorial herniation
65

.
.
.
.

- Vasospasm . .
3 .
.
- Hydrocephalus CSF
.
- 10% - .
.SIADH

/:
ICP ( ) -
o , .
o .
o .
o IV .
o " NaCl 3% NS.
o () .
.
o .
o - , SAH- .
.
:
: -
.
.
, .
,
.
:AVM .
. AVM
.
:
20% - " ,25% -
20% -
65%( . ) .
.
. AVM - 90% -.
Meningitis encephalitis
.
, .
. , , '
ICP . .
.
. " CSF
.
LP :
"

- . 5 .
.PMN

( ).
66

 : 2-4 ,2 X ,
. ()
750" .3 X
LP
, ,
. 24-48 .
Traction-
. "
.
. ( )Blood patch "
.
Carotid or vertebral artery dissection
, .
stroke (.)<40
:
() , () , ,Marfan
.Fibromuscular dysplasia ,Takayasu vasculitis
:
+
.
.
:
.stroke stroke-
TIA ( amaurosis fugax
).
: , Horner
( , ,) .
, Superior cervical ganglion- .
, -
.
( :vertebrobasilar ) , ,
.
:
- )CT angio( CTA .flame shaped
:
+ ( ).
Sinus vein thrombosis

, , ( APLA , ) .
, ,.
stroke . stroke - .
: , , ( ,)presenting sign
.
: ICP ( ) ,Swollen disk
, , .
:
CT venography o
CT o
MRI o , .
LP o , .Pleocytosis
67

 . .

Intracranial mass
, - . 30%
, 80%-
. - .
" , ,
. , ( ) ,
( , ,).
.
,
, .
;drop attacs
. SOL " CT
MRI ( ).
)Tic douloureux( Trigeminal neuralgia
.
( V 5%-
) , .
. .
. - .
.
, , ,
. (.)CT/MRI
MS .
basilar a .
" , ( )Trgretol( Carbamzepine -
24); ( Phenytoin ; IV
) . .
.Posterior fossa microvascular decompressive surgery -
Giant cell (Temporal) Arteritis
,External carotid - superficial temporal -
artery .vertebral artery- .
. " ( 2) .50
:
, .
.
. ( )jaw claudication
giant cell arthritis .
, , , =
.Polymyalgia rheumatica
ophthalmic artery- 50%-
( ") .
, .
.)Anterior ischemic optic neuropathy( AION -
Posterior ciliary artery- .
:

68

 " .
. ESR- ,100 .
:
PO , IV .
.ESR- ,
. .
.
)Pseudotumor Cerebri (Idiopathic intracranial hypertension
.ICP , " ,
. , ,A
.Tetracycline
!
:
( .)presenting symptome- :
, .
( Abducens nerve palsy- )6
:
( , )
, ,A
, , , ,
.
: ( ) .
,
.
( DD) : " : ( sinus
,vein thrombosis) ,SOL , , ,A ,
, , .
:
CT-V - MRI-V empty sella - 70%- .
II .
( LP CT ) . ( 200
" , ,)180 CSF- . ml 20-40 CSFLP-

Self limiting ' CSF-
; 10%- . !!!

-)Diamox) Acetazolamide , .CSF

.
Topamax - . .
,
.
. .
VP shunt .2
.
69

Postherpetic neuralgia
herpes zoster ,
( ,).
:
, , .dysestetis ," " V1
' .
:
.
- pin-prick .
,
.
:
, herpetic
.
( TCA ) .
-,
6-12 , 50%- 70 .
()primary headaches
Tension headache
.
Cluster
.headache ;
, , .
.
.
: .20
( ) . ,( , lange ( " , , .
, Tension headache
; Tension headaches -
, , . , Tension
headaches . Tension -
headaches .
:
o ( NSAIDS , ,(,
( Ergotamine) .Dihydroergotamine
o .imipramine ,amitriptyline .
SSRI ( ).
o ,
.
o , .
Migrane
" ;
, , , . 15%- Aura

70

 ( ,)Classical migrane aura

.Common migrane
:
3 . 25%- ,
55% ,20 90%- .40 .
;18% .25-45
, -
. ,28-52%
.
aura ,Familial hemiplegic migraine
; Loci
19p13 .1q
:
,aura .
Ergotamine
, Amyl nitrate .Aura -

, , .Aura -
.
Aura - ,
Aura - . ,
,)Headache phase( ,
( )Cingulate, Auditory, Visual - ( Raphe -
Nucleus ceruleus) . ( )Ergotamine ,Sumatriptan
, .
CBF
. Periaquaductal gray - Raphe
.
,
. ,
. " Reserpine ; -
.
:
.1 ( :)Classic migraine 15% .
2 .
Aura o 4-
( 30 ,TIA - ) . ,
( ),
" , " , ;
,
, .
o ( ) ,
, - .
72.
o , ( ),
, , , .
o , 50%-
. 2-4 .
,
, , .
; , ,
71

 - .
" .
.
- ,
. ,
( .)Tension headache -
.
, .
.2 ( :)Common migraine
," - , .
.
, . ,
. .
, "
superficial tempotal a. .
:
( , , )
.
. ( ). - , , . :
o - , , . pramin
.
.serotonin agonists Triptanes o .
( ) . ;
" . -
.
- Ergotamine o , . "
.

- 5
; (
) - , (,
Substance P') .

: ( 4) -
. :
( Beta-blockers o).
( TCA - Trycyclic antidepressants o).
o ( ,.)topomax/
Ca channel blockers (CCBs) o
- ( ) .
TCA - - Topamax( Valporate ).
-
.
Staus migrenosus ( 72) , ,
" ( ).

72

Cluster headache
.
: . ,
.25 .
:
, 45-90 ( lange ).
- ," .( - )
.
" , , ( ) , .
, .
: , ( Horner , ) .
.
:
100% ,Sumatriptan (
) ,Dihtdroergotamine 40-80"
,cluster- ( .)1.2meq/L
,
( Cluster headache Ergotamine .)Dihydroergotamine
( ) .Indomethacin -
, , .
:
Sinusitis

. ,
. " " .
.
" , .
, .
;
.Tension headaches
Dental disease
TMJ - - - , ,
"" .
, .
, , .NSAIDS
, ,- .
,
. .
:Analgesic withdrawal headache
( ) .,
, ( .)OTC-
, , . ,
Superimposed .
.

73

 .
Sumatriptan - .Dihydroergotamine
:Cervical spine disease

. .C2

, . .
.

74

 stroke-
DD - Acute neurologic deficit
Vascular .1
Ischemic or hemorrhagic (ICH) Stroke (TIA )DD
Subdural/Epidural hematoma
SAH
.2 - , Todds palsy .
Aura .3 ,
,
/ ( Hemiplegic migrane ).
SOL .4 , (/).
Syncope .5
.6/ , , ,
.
MS .7 .MS
Acute disseminated encephalomyelitis (ADEM) .8
:
.1

, ,IHD : , ,
,PVD ,.
.tPA
,
- onset .2 ?
Witnessed time Wake up ,
(
).Last seen normal ,
- , 20-30 - , TIA ,
" 30
.3 ? ?
, TIA
.
.
.4 ( , )
( 25%- ).
.5 ? ?
?
.6 ?
.7 .tPA
:
" .140-180
/:
o ,,
o - ,
o ,
o ( , , ),
75

o .SAH ,
.
stroke
/
.
:
.1
.2 ( apraxia ).agraphastesia ,
.3 ( optic radiation ).
.4 .Palmomental ,snout
Neglect .5 .
.6 rightway gaze deviation
( ).

.1
.2 -
.3 , intra nuclear ( INO ,
,)ophtalmoplegia . wrongway gaze
deviation .
Vertigo .4
.5 ( dantato-rubrothalamic tract
) .
Alternating signs .6 -
(/).

.
:
. CT
!!! CT MRI
, ( ,) ." CT
,
.
. C/I tPA- ,
:
CBC PLT , , ,
.

( CRP ) ( ESR ).
- (
) , ( ).


." (?) MI AF
.
:

76

.
.
.
.

MRI " CT ,
.
LP SAH .
.
.

Stroke
, .
20,000- . ,
.65 .
:
.1
.2" .
.3.
.4 .
.5.
.6.
.7 ,.
,
.
, , -
,AF , ,,
, , , ,
. , .
, 24,
,CNS- .
:
.1
; (
) ( )
.
( ) Stroke in evolution .Progressive stroke
( ) ,
, .
.2
, 24 .
(" 30) ,
.)TIA( Transient ischemic attack
TIA ,
.
TIA ,
.
77

 ,TIA TIA 5 "

.
, 24-
Minor stroke Reversible
TIA .)RIND( ischemic neurological deficit ,RIND- ,
.
.3
.
, , ,
ICP : , , ,

.

, ;stroke
( Global cerebral ischemia" ) Subarachnoid -
.hemorrhage
;Stroke CVA .
( )20% ( .)80% ( ICH- )
( SAH- ).
( -)Hemorrhagic transformation
- ;
- . 3-5
. ( ).
CT-" 24-48; .
- CT- , CT
.

:
( ,)40% ( ,)15-20% ( ,)15-20% (.)5%
- .
Vascular .1
- Atherosclerosis .a ,"
. - MCA, ACA, PCA -
( , , ) .
- ( ) - Perforating arteries ,
.
Fibromuscular dysplasia .b
. .
, ,vertebral-
.TIA/Stroke .string of beads
antipletlet drugs.intraluminal dilatation-
- Inflammatory disorders .c
temporal artritis o
-SLE o .Libman sacks endocarditis-
-Polyarteritis nodosa o ,
.
-Granulomatous angiitis o ,CNS-
.CSF-
Syphilitic arteritis o
78

.d
.e

.f

.g
.h

.i

.AIDS o
- Carotid or vertebtal artery dissection
.stroke stroke- TIA
.
- Lacunar infarcts
( , );
1.5" .
" " .
- Sinus vein thrombosis , , (
,)presenting sign . stroke -.
stroke .
, ( ),
. IV .embolic stroke
)Moyamoya( Multiple progressive intracranial arterial occlusion
- distal internal carotid arteries MCA
trunks + " .
, ,
.
.

( Cardiac disorders .2 )
Mural thrombus .a .MI
Rheumatic heart disease .b /. AF
.c )Bradicardia-tachycardia syn( sick sinus syndrome ,AF
. -
,dimming of vision ,light-headednes , ,
.
( Infective Endocarditis .d )
mycotic aneurisms Non bacterial (marantic) ..
Paradoxic emboli .e ASD ,VSD .
.f ,atrial myxoma ,mitral valve prolapse
( Hematologic disorders .3 )
Thrombocytosis .a , ,,
. PLT .1,000,000
:
Polycythemia .b
.1 Granulomatous ,PAN ,SLE
Sickle cell disease .c
.AIDS ,Syphilitic arteritis ,angiitis
Fibromuscular dysplasia .2
.d.
.3
,
postpartum
,

.e
.4 , ,.
.Venous or Sinus thrombosis .5
, ( ,APLA C).
.6
.7

79

,
( ,)AF , (.)ASD
,,
, ,
( .)APLA

 .
.

Anterior (Carotid) cerebral

circulation:
- Ophthalmic a.
- ACA
- Ant. communicating a.
- MCA
- Post communicating a.
- Leticulostriate as.

)Posterior (Vertebro-basilar
cerebral circulation:
- PCA
- Superior cerebellar a.
- Pontine as.
- AICA
- PICA

( -
)Carotid

-Internal carotid-
PCA- ,
Ophtalmic artery . CT- MCA - ACA
( , ') . Internal carotid -
. ,
( ).
:
./ .
. -.
( Homonymous hemianopsia . .)Optic radiation-
( Global aphasia . ).
. .
15% TIA (
.)retinal a
: (
, >-) .
.

. " ,
.
80

 . , (
) , .
MCA
MCA- ;
:
)( Rolandi -.Broca ,Precental & Postcentral Gyri
() ,Parietal & temporal ,Optic radiation
.Wernike
- Leticulostriate
trunk- MCA- .
2-3 MCA- 10
.
MCA ( ,):
. ( " .)ACA
. .
. () - .
. ( .)SMA
Lange
. .
MCA- ():
Homonymous hemianopsia .- - optic radiation-
.
. .
(" ) Gerstmann
4 )angular gyrus( syndrome :
Agraphia .1
.2
.3
( finger agnosia .4 ).
alexia( sensory aphasia) - .
.
() ,
:
- geometric apraxia .1 / .
- topotgraphic disorientation .2 .
.3 .
Neglect .4

81

 - ,
(
)
:Lenticulostriate
Perforating
( MCA ) ,
, (
.)Internal capsule - ,
:
. (!)
..
..
MCA- (
) , - MCA-
Lenticulostriate .
- ( )
. , ,
. - , .
MCA -
( ) .
( ) .supplementary ( SMA-
)motor area - , "" ,
- , - 2
. ,
.
SMA- - -
-;
3- , .
:
.
.

() , (),
() -
. "

.
- ,
,
(
).
- Astereogenesis .

;
.
- 2 point discrimination -

.
82

 Denial . - Neglect , ,
.
- Denial -
( - ,
).
- Neglect , ,
Esteem - - .
,
- (
, ') - .Alien hand
ACA
ACA- ( MCA ) ACA .
- (
) - ACA - .
, MCA
. ACA- :
Contralateral monoparesis . ;
- ( -).
- Urine incontinence . -
.
. .
-
, '.

- - .
-
, ' . -
( ,
- ).
,
; - ,
.
**( - Normopressure hydrocephalus (NPH
- CSF , , ' . ,
- .
, - ,
- .Normopressure hydrocephalus
.
- " :
- gait apraxia -1 (" " - ,
)
-2 -
-3 .
- ACA
, (
) . -
50" LP- (
) ." ,
. .
- Gait ataxia .

83

 ACA : ACA-
- 30%- - ACA
, .ACA-
( - )ACA :
. ( ).
. , - ,Abulia
-
.
. .
( )
- , -
. - ,UMN
, CT - " .
- ,
.
- ()

"

Paramedian -
.branches
Pontine arteries -
.pons
, 3 Circumferential -
.PICA, AICA, SCA
- PICA

.
PICA- , - PICA-
.
4 Perforating , Choroid -. ,
( , ') . -
. :
. ( - .)VPL, VPM-
. - ( -
).
- Dejarine Russy " VPL-
. , .
.5 PCA - .
:
-1 ( Reticular formation , ')
Paramedian core - .
-2 - .
84

 -3 - ( ,)Afferent
; ( )
.medial lemniscus-
-4 " - Peduncles 3
. -.
-5 :
.a 1,2
.b Midbrain- 3,4
.c Pons- 5,6,7
.d pons-medulla ( 8 ,
)
.e Medulla- .9,10,12
3,4,6 12
, .
:
.1 .
3,4,6; .
.
- 5 , .
- 7 .
- 8 ,/ ( ) -
.
- 9,10,12 :D , , ().
.2 ( - )Reticular formation -
.
.3 () - ( UMN )
-.
.4 -.
- (
).
.5 : ( ) .
- , ,.
( ) -
.Alternating (crossing) symptoms
- .:
. ( 5 ) -
( ) .
. -
( UMN- ) , ( 3,
, ) . 4
.
. , 6,7- .
. - " , (
/ ).
- ,
.
:
PCA
85

 PCA- , ,
. PCA
. PCA:
Homonymous hemianopsia
.
- ,Macular sparing
.

( .)MCA
.
(
mesencephalic vertical
-
, )gaze center INO ,III
PCA- .
. - ( Anomic
,)aphasia
. Visual agnosia-

.
PCA , ( ) ,
( ,)Prosopagnosia ( ).

2 ,
.PCA ,
, , .
:
. "
( .)AICA ,
. 2 .
" , .Pons-
() :
o / .6
o ( PRPF-
= .)horizontal gaze center
o ( ).
o , .
, Ventral-
( Locked in syndrome
) ,
" .
EEG .
. " " ,
.PCA- :
( Reticular -
,)formation
/ .III
(
) Uncal
.herniation
86

 :
.1 .Weber syndrome :
.1 - III (
) .
.2 - - ' .
.
** ""
;III , , :
- - () .
( - ) - -
().
- 90% .
, -
; - "
Posterior communicating " .
?
o - - ,
(
).
o - III
, .
o III -
,
.
.2 Millard-Gubler:
.1 - ( ).
.2 .6-
.3 7 -LMN ,
( Bells palsy -) - Bells palsy DD-
-
VII- ,
.
.3 - Wallenberg syndrome
( -)PICA syndrome:
- ( )
8 .
- 3D 10 ,9 , ,( .
.)10
( )inferior Peducle.
- .
, 5- -
, ,.
,
V (
)5- .
** - - D .
; .

87

 Lacunar infarction
" , , .
" . 15".
-
4- . 12- (
) . :
- Pure motor hemiparesis . ( )
. . 50% ,
.
- Pure sensory syndrome . .
.
Disarthria clumsy hand . .
+ .
- Hemiparesis hemiataxia syndrome . -
. 3 - () ,
(-) -- () .
Peduncles - . -
-; , -
.

Internal
carotid
MCA
()

/
.

-.

-.

MCA

(
Perforating
MCA

)
( ACA30%-
ACA


")
PCA

-
.

-.

(
)

-
.

Weber
syndrome

MillardGubler
Wallenberg

//

( ).
.
( ).

( ;)SMA
.
.

.
(
.)Abulia

Macular
.sparing

.
3 .4
III-
,
.

-
.

-9,10,12 :-
,
, .
88

.
( ).
.

,,
.Visual agnosia

.
.

 -5

(
).

().

** "

Stroke:
6 ( CT - MRI
) . stroke :
Hyperdensic artery sign o .
Loss if insular ribbon sign o -
lentiform
12 .
3-5 , .
6 . ()\ .

89

 3-6
Penumbra
.
, TPA .
CTA .MRA
( IA ).
.

Time is brain .1
.2 " 160-180"
.3 24
.4 4-5 C/I tPA tPA- 0.9
mg/kg 90" , 10% .
:TPA-
" 180/105
21- .
MI
() INR 1.5
100-

/ (
)CI
TPA .Todd's
CI-.
" .TIA-

90 ,
. CI-
( +
).
:TPA
6% . , ,
( ) , ,
" .
, FFP . "
.
,
.
.
.
.5 8 , C/I-
( tPA ) , ( -
MCA ( M2 ) .
.tPA
.0.6mg/kg bridging tPA
:lange-
Asymptomatic carotid bruit or stenosis .1
90

 ( " ) .
,
. ( ) ,
(.)Endarterectomy
TIA .2
, :
. TIA - ( );
, ,.
. TIA ;
( ,AF ) .
, - ( INR
.)2-3
Carotid endarterectomy .
TIA . -

Endarterectomy . TIA- -
- . ,
.
.
.
Stroke in evolution .3
.
, . TPA-
. " .
-Completed stroke .4
:
. TPA IV ,
. TPA 4.5
. 0.9"
90" 10% . , .
. C/I-
, (
3- ) , ," ,
( )TIA .
,TPA ,
( , ,CVP , ).
. ( Prourokinase
) IV ,
MCA 3-6 .
. - 48' , ,TIA- .
. ,
. ,
.
. .
, "
.
.
stroke

" ,the lower the better ACEI ARB

LDL , .70-

91

/TIA
Antiaggregants .1
.20%" , .GFR
. PG
.
)Plavix( Clopidrogrel . " .
. ? , (TIA
).
Aggrenox +slow release dipyridamole .
." .
, 2 / .
!!!
.2 ( )70-90% (/TIA).
, .
( radiation vasculopathy ) restenosis , ,endarterectomy
.
)Coumadin( Warfarin - Anticoagulation .3:
AF

Patent foramen ovale shunt
APLA ,
6-12.
Sinus vein thrombosis

Intracerebral hemorrhage- ICH

Hypertensive hemorrhage
ICH- .Hypertensive hemorrhage
ICH-:


/


.Amyloid aeteropathy
" ( ICH- "
-) . " -ICH ICH
" ( ) (
) .ICH-
ICH- " .
; penetrating
- :
92

 Caudate and putaminal branches ,)42%( MCA

( ,)16% , )15%( PCA SCA Dentate
nuclei (.)12%

:
, . 50%-
, . " .
, ICH .
, .
, . , .
, ,
.
, CSF-.
ICH " .
:
Deep cerebral hemorrhage .1
, " (
, .)Optic radiation
- . ,
, .
,
. , ,
.Upward gaze- " ,
.
Lobar hemorrhage .2 .
, , , ,,
. ,
.
Pontine hemorrhage .3 , "
48 . ,
, , ( ,
) . . " ,
RAS- .
Cerebellar hemorrhage .4 , ,,
, .
,
12-24 . -
. LMN .
, .
:ICH
.1 , .Lobar
, CT . .
.2 / . "
, " .
.3 , , gait -
.ataxia , ," .
:
.1 :
93

 Cerebellar decompression . ,
.
. , .
Cerebral decompression .
.
.
C/I Pontine .

.
.2 :
. ( ).
. Volume overload ".
. .

Global Cerebral Ischemia

.
.
, .
, Border zones -
.Watershed region -
:
.1 ; 12.
, .
, .
.2 :
Focal cerebral dysfunction . 12,
, .
, .
(
) , 2 ,.
Persistent vegetative state . , -
( .)Neocortical death , .
Spinal cord syndromes . ,
.
, ( border
zone ) . ( Spinal stroke anterior -
- spinal shock').
Global Cerebral Ischemia - , ,
. ," ,
.
DD
Hypertenssive .1
.2
.3
Amyloid angiopathy .4 " .!!!
.
94

Vascular malformation .5
Aneurisms .6
:)sinus vein thrombosis( Cerebral venous sinus thrombosis CVST

. : , , .
ICP ) , (optic disc swelling -> visual obscurations
, " , , . "
CT MRI.

95


2 , Reticular -
activating system . ,
. 2 :
.1 .
.2 .
.
, :
. , ,
. .
. " /
, .

. , .
. = , partial seizure - ,
, , , . . visual aura

vision- .
Ictus . . .
() " ,
Jerking (
.)Convulsion syncope 15-
.
, .
( -) . -
( ) .
( - ) . EEG
().
. "
. .
. " (,AS
,HOCM ) ( ).
. - , , ."
- . () .
( )Prolonged postictal state ,
( , ,
) . , .

96


:
=
. ,EEG
( ) .
. .8-10%
= 2 .
. .0.5%-
.3%-
=
, .
, .
.60
60 .Stroke
20-40 .
40 .Partial seizures
2 (
) - ( -).
:
( )75% ;
.
. :

:
-
,,

SOL 20-40
-

.2 :
Febrile seizures () 2-4% 3 5 . 10-15-
2/3 . 10%- 3 .
18 .
" , 15 .Diazepam
2-6%
, .
.
/ 2/3 ." .5-25 . .
10% 2%- . .
5-15% AVM . .
- SOL . . HSV. HIV encephalopathy " AIDS dementia -.c.
- Mesial temporal sclerosis ,
.Complex partial seizures -
97

 .3 :
20-30"/" . 120 . ( ,) .330 . . . . - Drug overdose , , , ,TCA , , ,.
Withdrawal ( )sedatives.
. ( ).
. . . :
:Remote symptomatic = Localization related
: ,Cerebrovascular disease ,
, , ,
,.isoniazide overdose , ,.
Withdrawal ,BZD ,.
.
.
, .5-25 75%-
.18 :
.1
.2 ( ,
,).
.3
. (),
.
.)Juvenile myoclonic epilepsy( JME-
, .

( ) . Absence
( .)15% EEG- .Poly spike & wave
:
Partial
Simple o .
.Simple partial-
Complex o
( !) . .Complex-
o
.
Generalized ,
.complex
Absence o , . .Complex partial
? Complex , 90
98

 , .
.
:
2-:
.1 ( )Generalized :
Absence / Petit mal .
.
( 5-10) .
, . ,
. ,
(
) . EEG- 3 per second spike and
wave .
Generalized Tonic-Clonic / Grand mal .
," . 2
:
.i 10-30 , ,
, ( );
. ,
.
.ii ,jerking-
. 30-60 . ,
. . , Jerking -
, .

.iii - ,
. ,
. 10-30- .
( )Todd paralysis
.
. :
Tonic . Clonic . Myoclonic jerking . , Juvenile myoclonic epilepsy .
;
, .Juvenile myoclonic epilepsy -
- .
Atonic ( )drop attaks .Lennox-Gastaut
.2 ( )Partial
. Simple .Complex -
Simple Complex - -
:
Simple Partial . . 30 .
, ( ) , , (
)jame vu ,dj vu ,' .

99

 , .
, , , , ,
, .
jacksonian march
.
.
Complex partial . , ,responssiveness-.
.
, - (
) . , ( Video EEG
) - -
().
CPS 1-3 .
( )Automatism 75%- ,Orobuccolingual
( ,
) - .
, , , ,
( ) - .
- . .
; ,
. .
) (partial :
:
( 100).
.
=

EEG .

() .

Jacksonian march (
// ' =

).
( ,) =

() =

() :
= Literal aphasia o
= Verbal aphasia o .
Non-fluent o
.
.
Supplementary motor area-
, , ,
.
-
( Simple partial- )
.
( Complex partial )
( .)Complex partial- EEG
.
:
( )
.
( )
100

o ( ,)wernike
.
o () = ,

. ,
.
:
,
,
( ),

.

( Complex/Simple partial ,
, ' , = .)Complex
,Formed vision , .
,
( )Unformed vision .
( de ja vu ) ( je ma vu
).

' ,
, , .
Complex partial
() () .
.
' , .
:Acute Transient neurological deficit
CVA ,TIA

.
:
, EEG- 60%
. , , -
.10%-
EEG- - ( 8-13
) ; ( ) -
() . ( ) , (
) . EEG- Abnormal , polyspike discharges
spikes( spike-wave complexes - .)Absence-
( ) ," .
,EEG
( ) .
25 " .MRI
:
:
:

101

o ( , ')
.
.
o ( ,) Self
limiting .
o ( 24- )
.
o
(
).
. Absence
.
,JME (
).
.
.

2 70%- ; ( 50% 20%
) 30% -
( ) ,
( ) .
2:
.1 " .
.2 - . Mesial
,Temporal Sclerosis .

/ .
, , NT-.
( GABA ) .
; " :
o ( )
o GI
o - , , .
CBC
, ( , 6, 3 ,1 ).
:
()Partial
)lamotrigine( Lamictal
.
:
o .
(
,
).
o , ( JME-
.)15-20%-
o (
).

102

":
o , )1%( Steven Johnson
.
o . .
Simple
,partial
.
-(Carbamzapine) Tegretol

.
" : , ,GI , , ( SJS) , ,
, P450
, ( , ,),
SIADH .
(Oxcarbazapine) Trileptal
,
. .
, .
. .
) Kepra (Levitiracetam
, .
( NT ) .
. ,
. .

, .
. .

(Phenytoin) Dentoin
, SOS
( )
" .":
o - , , ,,
, , ,.
o , , , ,
.
o IV AV block- (
) .
,
. .
)Valproic acid = Valporate) Depalept
, , .

,
. IV .
( ) , ,
, ,,
, .
)topiramate( Topamax
. . .
, , GABA ,
.
103

" ( , ) ,
( ) ( ) . .
. .
.
:
Topomax ,Lamictal ,Depalept :
Phenytoin ,Tegretol JME
, , , , ,
(Phenobarbital) luminal
, . -
.GABA .P450 . "
.
. : , , , , , .SJS ,
.

P,G,S

" .Valproate

Phenytoin
)Dentoin

300-400

P,G,S

Carbamezapine
)Tegreto

400-1600
3- 4

P,S

Valproic acid
)Depalept

750-3000
2- 3

G,M,A,P,
S

Topiramate
)Topamax
Lamotrigine
)Lamicta

100-4002-

200-500
2-

G,P,S

"
Topiramate.BD-
" ,
.
" .Valproate
" ,
.Oxcarbazapine ,
" ,
,Lamotrigine ,
.
" ,
.Valproate ,
" .Valproate
" ,
.

.
.

Oxcarbazapine
)Trilpetal
Levetiracetam
)Keppra

600-24002-

1000-3000-
2

Phenobarbita
)Luminal

(")
90-180

G,P,S

()partial
!!! !!! (
).

partial-

P,S
.

G,P

A absebce, G generalized tonic clonic, M myoclonic, P-partial, S

secondary generalized
:
. ,
.
. MRI-
EEG-
:
Stroke o
o , ,
o
Sinus vein thrombosis o
,

104

 :
( ) 2-5
. ,
.25%- Spikes .EEG- ,
," 6 . -
20% 40%- , .
:
.
:
(
) . ,EEG ,MRI .Wada
,
.
.
? " .
:
( = )intractable
2.


,
.
:
, ,
MRI

/EEG o EEG
Intracranial (invasive) EEG o
ECOG Electrocorticography o
( ) ,

.Lange -
PET " ( ) . - PET .
SPECT ,
.
.
MEG ," .
Functional MRI
. (
, ) .
)ISAP( intracarotid sodium amobarbital procedure Wada test
.
. .
(
, ) .
.
, (
) .
:

105

( )corpus callosus
.Drop attacks
Multiple subpial transaction
Vagal nerve stimulation
. .

( , ) , .
, . 50% 30%-
, 50%- . .

)Mesial temporal sclerosis( MTS

70-80% .30%-

:
60% ,
= ( .)75%-
. -
. ,
, .
.
( ):
Pseudoseizures
( )
,Conversion disorder ,Factitious , .Malingering
, .
,Factitious ,
. ,Malingering .
:
- 2 (
) . .
DD .
"
- ,
.
. .
. -
" .
. .
EEG (
) ,
.EEG-

106

 Syncope
.
.
:
( Vasovagal syncope .1 ) - .
, , , , ,
. "
. :
o " . .
, .
o ( 10-15)
o ( )Pre-presyncope -
, , , , , , .
. ,
.
o - convulsive syncope ,
, .
, - (
) . .
o .
o ( ) ,
, , , , , .
, ( ).
" .Tilt test" .
- Cardiovascular syncope .2
, , .
CO - :
. .
. - , ( SVT
200) ,VT, MVP, Long QT syndrome ,.
Cardiac inflow obstruction . ,MS ,
, .tension pneumothorax ,
,HOCM ,PS ,AS Cardiac outflow obstruction .
. .
PE ..
. .
.3 " , - (
) . , (
) ( ).
-
-" ( "!!!( ,
CNS .:
-Idiopathic Orthostatic Hypotension o
-
-Shy Drager Syndrome o -;
, , .LMN
, 30" " 10" "
. .Tilt test

107

 - Micturition syncope .4 ,
. , .
()
." .
:
, , ," .
Cataplexy & narcolepsy
, .
- ,
, " .SSRI
. : , , , ,
, , .
sleep ,sleep attacks ,Excessive Daytime Sleepiness -
.paralysis .

!!!
.1 ( , ,)
( ,)withdrawal !
.2 ?
.3 // , ?
.4 ?
.a aura - ,
, ( ?).
.b , , , ,,
.
.5 ?
.6 :
.a
.b ?
.c
.d
.e , .
.f - ?
.g/
.7 " 30 2 , 10-15.
.8 ? ( "
) . , , , , ()todds paralysis
.9
.a
.b
.c , ,
.d ?

108

 .e ) (febrile convulsions . ,
, . , ,
= .
.f
.g
.10 -
, ,CNS .SAH Sinus vein thrombosis
ICP.
.1
.3 ( + / )HSV
.4
SAH /
.5 , , ,

.6 (
.)todds () , , (),
() , .
.7
!!! .8 ( axillary ,
,freckling ,Disuse atrophy , Lisch nodules ,),
Periungual ,ash leaf spots ,adenoma sebaceum( Tuberous sclerosis
,fibromas' ).

CBC
, , , ,,
.TSH ,Mg ,Ca
Toxic screen
- CPK , baseline
.
.LP
, .LP
, CT LP-
.
!!! LP ,
.CT

:
CT .1
MRI .2
- EEG .3 :EEG-
= .
.
3 X ,.
.4 , .
.5 :
109

:PET MRI EEG- .PET PET

- , , .
:SPECT ,
.

False normalization .
. (
) .

Status epilepticus
:
30 () 30
. 30 .
.
:
Convulsive ,
( , ).
Non-convulsive
, .Non convulsive status epilepticus
, .
EEG ,
. , .EEG-
EEG () .
.
.
:
- . ().
-
- , , ( ,) ,) .
.
- , ,.

- , ,.

:
ABC . .
.
: , ,
.
- / ()50%
- .
- 2 - :
5-10 IV Diazepam (Valium) -1" 2 .
. .
(=) . 10" .
:
-2 IV:

110

20 mg/kg Penytoin o - 50"

( ") . AV Block ,
C/I !!!
,20-30 mg/kg - )Valproic acid( Orfenil o
-
5-10" .
20mg/kg Phenobarbital
100" . !
Pentothal (batbiturate) -
Coma " . "
, ( . ).

:
: () , () , , ,
( CBC ) , , CPK .
( CPK 24 CPK ) ,
( , , ,).
-LP LP--

.ECG
SE
( 42-43),
( PH )7- ( .)60k
, .
.Curare

EEG .
. ,
, ( ).
*** - SUDEP . ,
.

111


Multiple sclerosis " .
, .
. , ( ).
.1:1000 - ( .)20-40
.50 .
. DD- .
:
. ;
. ;
.
, . ,
.
HLA DR2 . , .
1 3-4% , .30-40%
:
- " " ,
. BBB- , ,BBB-"
( " " ) .
, . - , .
, , .
, , .
" MS T2 Flair-.MRI-
T1-" " - CSF
; , -
.T1
MS CSF( T2-) .
( .)Periventricular -
,CNS- -
.
,
- -.
:
.
:
, , .
-Optic neuritis
, ,RAPD (,)Red desaturation
, . -
.MS MRI- 20% ,MS-
MRI- 65% .MS-
- INO ( MS- ).
- "
- , .
: , , (
- "
; MS "
).
112

 : , ,.
, -
.
" , ,
.
( ) , .
,
( , ).
( :)Relapse , 3 ,
- " ( ).
, ,
, , , , ,
.
, 4 :
Relapsing and remitting .1 ( )85% . ,
.
- Secondary progressive MS
. 25 .
, : ,; ,
, , . -
,Secondary progressive- .
Primary progressive MS .2 ( .)10% ,
.
Progressive relapsing MS .3 ,
. .
- Benign MS .4 .
15 MS .
:
,MS . MS
2 . MRI
(( .)2T
2 ) .
. 2.
MS ( ) -
:
o CSF ( CSF- IgG
90%- .)100%
o - MS-
EDSS . 0 , 4
" , - 7 .
o ( Evoked potentials ) . ,VEP
. .P100
:MS-
DD- :
. ( ,APLA ,).
. .
.Optic neuropathy .
. - ADEM " - ,
, .MS .
113

:
MS TH1 .TH2
TH1-.TH2-
, :
.1
, Optic neuritis
IV-" .PO - IV (
); , -
.
BBB- . .
.2 --
. .
:
. - . TH1--
.TH2 -
( )
. E.coli-
. ; 30%-
.MRI- " -
" , , ,
.
. ( )Glatiramer acetate , "
.
." .
30%- ,
.
.
- Natalizumab . ;
( T ) .
IV . "
PML .1:1000
.MRI
. - () , MS-
. , .
.
.
:MS
- .
,MS- (.)secondery progressive
, ,40
( ) , ( Relapsing and
remitting ) , ,
, .
- ( ) ,
, ( Primary progressive MS
) , .MRI-
10 50% , .

114

( )
Onset .1 ?
( ,) ,
.
( subacute -) , ,.
(-) , ,.
.2 -
,.
,.
( )
.
.3 - .
:
.i .
.ii ( ) ,neglect
,astereognosis ,agraphasthesia two point -
.discrimination
.iii
.iv gloves and socks .
.v NMJ ,)motor neuron( anterior horn cells
.
!!! .vi
.vii , , , ,
.
, , ,.
: . .
.4 ? ?

.
, , .
, , .
.5 , ,
.6
.7
.8 , , .
.9
- ,
.

UMN
- Pyramidal corticobulbar : cortico-spinal , .
)1( : )2( , () )3( ,
)4( , ( ) )5( , ,
( difused atrophy )7 .
:
115

parasaggital intracranial lesion

:
o Contralateral limb
o contralateral
(.)pseudobulbar
Internal capsule .contralateral
ipsilateralcontralateral -
.hemiparesis
quadriplegia paraplegia .
- (Brown Sequard( hemicord/ ,
, .

LMN
)1( : )2( , )3( ,
)4( , / )5( , (
)6( , .
:
Anterior horns / .
( ) ,"
, .
- .
.
Neuromuscular junction
o
o
o
o " ,Patchy
(.)MG
o .

o "
o muscle wasting
o

:

( ,CIPD ,GBS .)B12

().
-
( foramen magnum ).
:
. ,
.
DD :
/ / +
Myelopathies .1

116

NMO ,ADEM ,Multiple sclerosis

,Epidural abscess ,AIDS ,TB ,

o , " ant. Spinal a
o ()hematimyelia
o
cord compression
Syrinx

Motor neuron Anterior horn .2

ALS
- SMA
west nile virus ,poliovirus
Nerve root and plexus lesions .3
Peripheral neuropathy .4
Mononeuripathy .anerve entrapment ,
Mononeuropathy multiplex .b "
Polyneuripathy .c
CIDP ,Miller-Fischer syndrome GBS
, ,B12 ,

o
o , , ,
/ , ,
() SLE ,RA ,PAN
freidrich ataxia ,CMT
Paraneoplastic
, ,MM- ,TB ,FME
Neuro-mucsular junction .5
Myasthenia gravis
Lambert Eaton syndrome
Botullism
.6
( Muscular dystrophies ,),Myotonic dystrophy ,
( Congenital myopathies)
/ Inclusion body ,Polymyositis ,Dermatomyositis
myositis
,
- Drug induced ,
K
/ ,/ , ,
( ,)Gaucher ()Pompe

117

 :
- (
) .
.
.
(
.)9, 8 -
- ,
" . L2-4 -
( ).
- ,
( ) - .
:
.
( ) -
.
, ;

;C5-T1 L1 - ( ).
o
, .
, , .
1-3; -
.
( VPL VPM- ).
,
,
.
.
o
(,
,) -
, - ;
, (
- ) .
( ).
:
( T5- ) -
, , (
) . ( UMN
,- , ()
.
T5 -
-
, , - .
-
( ) ,
.

118

 4-:
, , . , . , , . ,
.
, C5
.
C5-
T1- .
,UMN
. ,
.
, ,
.
, ,
.
-Central cord syndrome
.
.

. S-
C- ( )C-Th-L-S .
CCS
.

".
:Traumatic myelopathy .1
-
( , ,
) , .
.
() :Spinal shock
- LMN , ,
( ; = ) .
, . .
.
, .
( ) ,
. - LMN UMN-
. -
. ; .Overflow incontinence
- - Mass reflexes
, , .

119

- . Spastic
.paraplegia/quadriplegia
(
) " ,
.UTI ,
( ).
.
,
, .
.Urgency incontinence -

:
,
( ) . " .
( 8) ( ) ,
( , , ).
, , (
,)GABA , ( 2) . ,
.
- (
, ).
-Central cord syndrome
.

.
.
S- C- ( )C-Th-L-S
. CCS
.
-Cauda Equina syndrome
,L1-L2
L1-5 and S1-5 .
: , LMN (- ) , ,,
.fecal incontinence ,saddle-anaesthesia MRI .CT
: , , , .
-Whiplash
" " - -,
. -
, , -"
. .
.
-Brown Sequard

120

 . ,
, . , , '.
( ) ,
( ) ,
( ) 2- .
.
,
.
" ( LMN ).

.2

:Demyelinating myelopathies

Multiple sclerosis
. .
, , -
.CNS ,2-4 .30
relapsing remitting 3 (
) .F=M
,
.
/
.
:
)!( Optic neuritis o , .
, .central scotoma
.
o
Trigeminal neuralgia o
o INO .INO 1.5 syndrome .MS
o
o .
o " Lermitt .
o "
( , )
:
MRI o :Diffusion ,FLAIR ,T2- - ,
periventricular . corpus callosus
o Oligoclonal bands CSF 90% MS 2
,bands .
, DD-MS-
.
3 Evoked potentials o )visual( VEP
)sensory( SEP , BERRA ,
. , .
o .central scotoma
:
o Corticosteroids :
, .
o Disease modifying

121

 Interferons )1 .
2-3 IM " : (
NSAIDS ) ,.
- Copaxon )2 . SC
." : .
)Natalizumab( TISABRI )3
.60%- Progressive multifocal ( PML-
)leukoencephalopathy ,
, " .JC virus
.
Gilenia )4 .PO
. .
o ( ) ,
( ,)SSRI ( Lyrica .)]SNRI[ Simbalta- ,
.

-)NMO( Neuromyelitis optica

, " IgGAquaporines 4-
. .relapsing remitting
(.optic neuritis + )myelitis
:
MRI o ( " )MS- 3".
o .aquaporine 4
: ,Imuran ,.IVIg ,

Acute disseminated encephalomyelitis ADEM

.
,"
, .molecular minnicry
.
-
.
:" , . .
: , - UMN
.
, .
, , .
o CSF- , .
o MRI- .
:
IVIG , ( ) .
( ,)5-30%
.

122

.3

Metabolic myelopathies

:Sub acute combined degeneration of cord

.B12 B12
( , ) .
B12-
() ,
. ( Lhermitte sign
).
-
- " () .

( ,) .
,Optic atrophy
() . "
. , ,
.
B12 . B12 IM ,"
, .
.4 :
Epidural abscess
! , OM ,,
,IVDU , .LP AIDS
( ) . ' ,
, ,- . : ,
, , ;
, .
MRI .
" . .

- ,
( ) -Tabes dorsalis .
" .
TB
, ,-
() , " .Tuberculoma
AIDS
( Vacuolar myelopathy 20%-
) ,
. ,
( " ,HIV ) .
,B12 ,
. " ,,
. ,
, , ,.

" . ,
(
, ) .
.

123

 , NT , GABA-
. .
3 , (
) , ,
( .)Risus sardonicus
( -) .
.
, EMG- CK ,
. " . 5-10
. ( ) ,
.Tetanus IG
: " , IG ( IM -
) , ' .
; - . ;10-60%
95% , .
.5 :
( Infarction of the spinal cord ')
.Anterior spinal artery
,
" ,
"
. ,
, ,PAN , .
,
(" .)T10-T11
,
,
( UMN -) .
, .
. - ,
.
Hematomyelia
; " , ,
- .
.CSF- .

, , / , , .LP
. (" ) LP
. LP
- . 20k-
.LP

; ./ ,
/
CT/MRI .
AVM or Fistula
SAH .
.
. . ,
LMN ,UMN . "
. , .
124

 , . "
MRI " . -
; " , ,
. , .
Cord compression .6
.
- 90% .
( ) 10% , .
,
.
( ) . " ().

.7

:Cervical Spondylosis
" ( ) :
o
o
o UMN.
" . ,
, , .
,
, .
:
" .
, ;
.
.
, .
C5-C6
: LMN
( ,/ ,,
) ,
(.)C5-C6
( ) ,
UMN , , .
.
, MRI/CT-
.
DD- ,MS , ,B12 , , .
, .

Congenital myelopathies
:Syringomyelia

125

 () ;
( Communicating
Central canal -

)CSF-
Non
( communicating
-
.)CSF
central
-spine +
.
:
o
,
.
LMN o -
.
UMN o -
,
.
o ( ,)LMN
(.)UMN
o .

/ , ,
. T1 .
( )Syringobulbia
, , ,
, .
Communicating
( 1
;
) . Non communicating , -
, . - ,
, ;
. , .
:Spinocerebellar ataxia

.
, ( Anticipation
) .
.
,
. .

. GAA
.Frataxin ( ) ,
. ,
, , .
( )4 " , , ,
.
126

 , , ,
. ,
; .40 .

Anterior horn cell disorders/ Motor neuron disease

30 ,60- .
,
, /.
" , - 5-10%-
.)SOD( Superoxide dismutase .
, " ,ROS
SOD , " .
5 , :
Progressive Bulbar Palsy .1 ,
( )LMN .
Pseudobulbar palsy .2 , UMN
" - Pseudobulbar palsy .
" , .
Progressive spinal muscular atrophy .3 LMN
, . .ALS
primary lateral sclerosis .4 , UMN
() . .ALS
Amyotrophic lateral sclerosis .5 UMN LMN-;
UMN .LMN
- .
Amyotropic lateral sclerosis - ALS .1
. ," ( 10%-) ,
, .
.Superoxide dismutase - ALS
" .

127

 UMN LMN-" , ,"

, . common pathway-
.
:
40% -
. .
. ,,
, , , ;
.
, -
.
-
.
20% . bulbar muscle
weakness , , , , .
, ,gag reflex Progressive bulbar .
.palsy UMN ( LMN ) , .
.ALS
5%
:
" .EMG
(.)MRI
ALS-
UMN LMN- 2 (,
) , . ,
- . CSF-.
DD : .
:

( Riluzose ) 100" .
, (
).
.
, .
, - , .PEG
, ,
.

, 3-5 .
. ,
- .
.
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, , LMN ( .)ALS

128

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129

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130

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.

131

:Neuralgic Amyotrophy (Idiopathic Brachial Plexopathy) .3

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:
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5

, ,

132


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.
. : ,,

133

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134

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.

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135

o 4 .
o 4-8 .
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136

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137

Guillain-Barre' syndrome .2
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:
anti-GM1, anti- GD1 - , .
-.

138

 / : HP .
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).
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139

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.3.
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- ,
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: , ,
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,
. ,
.
.
, , , ,.
. " ' .

140

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anticipation ).
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.
.
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. "
.
- Painful sensor neuropathy .
, .
.

141

 :
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.
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.
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- .
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).
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142

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.
:
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.
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.Aspiration pneumonia -

143

)Myasthenic syndrome (Lambert-Eaton syndrome

- -
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50% Small lung cell carcinoma
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. - ,
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144

 ( ):
(
, ) , , .
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.
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.
. " .

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.
. , ,

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; ,
.
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, ,
. .

145

 Ocular dystrophy - ' ,

. " ;30 ,
. .
.
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.
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.

146

 (T cell mediated) Polymyositis o

.
, , . ,
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. .
.

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( CK 500) ,
CK .
:
147

 ,
. ( )
( ).
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. .
, ,
. ,
.
, .
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:
/ ,/ , , ( ) ,
.
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148


( )
, .
.
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, ,,
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.2
;
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.
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:
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, ,
.
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, ,
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, ,
.
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, .
:
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o ()Benign essential tremor
o
o .
, , ,
. . ,
/ . ,
149

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( ) . ,
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.
" .
,

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( ) ,
. .
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. " .
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, , ,
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' . .
Hemiballismus .3
150

 , .
( )
, . 90%-
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. . ,
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.debilitating state
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.
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. .
. .
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, (.)Action myoclonus
( ) ,
. ,
.

151

 Segmental myoclonus ,
, .
,
.
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. 80%- ( )OCD, ADHD .
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,
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).
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o
o

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, , .
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. 2-3 5
. 25%- .
:
. - 65 . 85
10% ( 2 ).
152

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,
.
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:
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153

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, " , ".
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: executive functions- ,/ ,
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, " " .
.

. ( , ,).
.
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154

 :
.1 - .
.2 / 2 .
.3 .
.4 L-DOPA - .
.5 L-DOPA- On and off
;phenomenon
.
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:
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, ( , , ,,
disease
) . ,
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, Levodopa; -
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( COMT Inhibitors )
, Levodopa .
+ Levodopa + .Stalevo COMT
" , , " , () ,
. . .
Levodopa - Wearing-off effect
( ) ( On-off phenomenon
155

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).
:
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) ( No on ,
).
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, ,
.
156

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?
, () , , .
.

157

:parkinson plus /
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: , .

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).
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158

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, , ' ".
o .Lewy-
.
.
o .MSA
o - .CBD - -
, , -.
:
:
.1
, ( ) ( ) , ( -MPTP ). - () , , , , .
159

.2
.3

.4
.5
.6

- , ,. () , , ,
( , , ,) .
.MSA

.
o , " -.
o - , , ,
, , .
o , , ,,
. .
o , ,
o
o , . , ,
( ) .
PSP .
( ) , ,
,.
, , . 30%-
, .
.Lewy
" . , , .
,.
, , ( )
DD .Lewy- ( ) . ,On/Off
- wearing off .
( ,) = Dopamine disregulation
,syndrome ( ) . ,,
, .

:
- , , , .
.1 , , , ,stare ,Seborrheic dermatitis
. , " ,.
.2 MMT MoCa .
.a
- Executive function .b 5 , .
.c 3
.d ,100-7 .
.e ( )1 )2( , - )3( , ,)4( ,
)5( ,.
.f .
.3 :
.a
- , PSP-
(" ).
Smooth persuit .i () , ()PSP
Broken (hypometric) saccades Saccades .ii.
Glabellar reflex .b .
- . " repetitive tapping on the forehead

160

 (A 'E , facial
).
.c ( palmo-mental ,snout .)NPH
.d - .
.4 - .Cogwheel/led pipe
( .)Noika (
) . . -PSP
.
.5 MSA -
.6 - . .
. . ,
.
.7 - ,- ,-,
.8 -freezing , ,
Freezing ( ).
, , , ,
.
.9 ..
:
,
-
:
, ,
- -
( .)PSP
- , , .
.

- NPH - "SOL" CSF "
" , , . " 50" LP-
. .
: .
()Huntington disease
.
, 5 .100,000-" (
)30-50 .
Huntingtin ;4
, 50% .
, ( CAG 40 , 11-34
) . ( Anticipation ) .Paternal descent -
.
:
" ,
15 . :
.1 , ,
, ,
.
.2 ,
.
161

 .3
, , , impaired ,
.glucose tolerance
.4 ;
,
,Westphal variant " .
( ).
:
" CT . MRI- .Caudate -
; Benign
hereditary chorea , ,
.
, 10-20 .
, " ( D2 /
) SSRI .
.
Wilson disease
, .
" .13 ,
,
, ,.
. 11
, 19- ,
( ).
.
, , , .
:
.1 .
- ( );
, .
, ,
( . ).
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, .
, , , , ,,
, . .
.3 - , ,
;
.4 - , ;
.
, 20
; , , .
, , "
.
:
" , 24-.
" .
- .
:
" ( ) .
, .
162

" , ,MG , , ,
.SLE , .
, .
,
. , .
" , ,
.
Gilles de la Tourette syndrome
" ( ).
- . ,21
. , (
) . . ,
.Cortico-striato-thalamo-cortical
, " .
:
" .12-21 80%-
( 20%- ); .
, , , ,
'; .
;
" , , , ;
( ) , , ( ),
( ) . .
50%- ( ,
, ') . .
, OCD ADHD- .
" .
.
, , .
( ,)50%- ,Pimozide ,.
Restless legs syndrome

, . ,
, .
( ) .
. , .

.
.

CNS
163

 :MRI/CT-
/
Multiple lesions/
,
( )Enhancing - ".
BBB .
. / Ring
enhancement ,High grade glioma-
, . -.
.
, .
.
.
.RCC ,
(
, Stroke Anoxic brain
,damage - CSF ) .
. T2- .FLAIR
.
:
o .
o
.
.

.
CT , .
.MRI
, . ()
. .Micro vascular proliferation Hallmarks .
:
CNS : 10-17 100,000 -
. 400-500 ( 1-2 ).
50% ; .
( 70% ) .
/ .
( .)Shunt ,
( ) . .
, .
50% .
25% , . .
,
.

164


( .)1926
. .
- ( - ,
) . .
o .
o ( )
o Choroid plexus
o .




:

. Grade-.
:- , , ,
. grading .
3:
. .
Pilocytic astrocytoma =Grade 1 ,
; " ,
().
Diffuse astrocytoma =Grade 2 ,-
. .Loose , .
Anaplastic astrocytoma =Grade 3 - +
. 3 .
GBM =Grade 4 . 3 -
, , , .
2 . 4
.)Common pathway( GBM
II IV . Grade - ,
Grade - . 2
( ) .
GBM (
) , .
. ,
Oligodendroglioma.Anaplastic Oligodendroglioma -
. - , .
.
,Ependymoma( Anaplastic Ependymoma -
) . , ' .

165

 :
:
.1 , , .
:
o , .
o ,
.
( , ) .
Diffuse brain stem glioma-,
.
o - tumor burden
. ,
.
,
.
( ,
).
,
"
( .)f-MRI DTI
. " .

" .
.2 4-6 .
.3-4 2.
,Focal 3D conformal radiation
. ,
.

" 6-8 .
, .
.3
, . 14 ( GBM- .)4
.
( BCNU ,Alkylating agent
).
2000- Alkylating agent( Temodal = Temozolomide
) , . BBB
.
BCNU- , .
.
+ ( ,
) . 12- 14-
. 10%-.26%-
- Local drug delivery
( )BCNU ( .)Gliadel
.
. " ,FDA
.Recurrence
:
166

 Progression free survival 9 GBM .:

( )
:
o .
.10-15%
o , .

Avastin o .VEGF
Irinotecn
( (57% , .
, .
2 4- 9-.
( )
. . Ganglion cell
tumor ," .
( ) . 5%- .
/ (
) . ( / / ).
.
- Medulloblastoma ; .PNET
. ,
. ; ( CSF-
).
; .
. , .
.
.
.
Pia .Arachnoid -
, . .
.
(
) . ,
.
. .
() ;Non Hodgkin's lymphoma -
B cell ( T cell) . ( )95% EBV
( ,) . , EBV
.

; EBV- ;
, .
50% , .
Border zone - , .
, ( ) .
.
:

167

 ICP-
. , ,
( ).
, '
. , .
:

Malignant Low
grade
glioma
glioma
50
40

15-25
65-95

30-50
5-15

40-60
10

Meningioma
)(benign
36
40
22
21

.
.
CNS- (.)56%
:
.1
, .
;CNS-
, , CXR , .
- . ,
.
.2
" ,2-20 .
. ICP ,
, .
, .
.3
. .
, .
, .CNS-
, .
, , , .
, .
,Gait ataxia , , .
, .
. .
Acoustic neuroma .4
. , Cerebello-pontine
angle , ,
.
.
,1 .2
Hemangioblastoma .5
" ; ,
.Von Hippel-Lindau " ,
, . .
.6
168

 9% . ,
" .
,Petrous - ,,Cerebellar convexities ,Clivus -
. ," .
, .
.7
. ,
" .
; " .
, , CSF- ,
.
:
, ( ICP) .
, , , ,.
:
,
.
, , ,
.
, CT MRI ,
.
. .

-Foster Kennedy syndrome :
( central scotoma- )
,II ,
,I .
Cerebellopontine angle
Cerebellopontine angle - " ,
.Petrous ridge - ,Acoustic neuroma
( )
.
,.)Epidermoid cysts( primary cholesteatomas -
, ,
.CSF- , V VII- .
,30-60
1 .2
:Cerebellopontine angle-
" . ,
, ,gait ataxia , , , , .
20-30%- ,
. ,Meniere
. , .
.
" .

169

 . CSF- 70%- ,
.50-200 MRI -.
DD- .
. ,
.

. :
.1- ( )10% ,
.
.2- ( )90% - .
; ,
. ( ,,
) / " -.
:
" ,
, ( -).
, ( ).
" -
; "
.
, , .
.
.
" , LMN/UMN
( ) .
, - .Central cord syndrome
-:
()%
()%
/
96
96

76
2

51
0

57
0

, :
CSF- , ,
CXR . , /MRI/CT
.
:
-
, , , ;
.
- (-) ( ).
- " , ()
.
. "
- , ,
. .

170

Neurofibromatosis
nerve tissue tumors (i.e.,neurofibromas) that may be benign or may cause
serious damage by compressing nerves and other tissues. The disorder affects
all neural crest cells (Schwann cells,melanocytes and endoneurial fibroblasts).
melanocytes also function abnormally in this disease, resulting in "cafe-aulait" spots.
Neurofibromatosis is an autosomal dominant disorder.The severity in affected
individuals can vary, this may be due to variable expressivity. Approximately
half of cases are due to de novo mutations. It affects males and females equally.
Neurofibromatosis type 1 ("von Recklinghausen disease") is the most
common form of NF, accounting for up to 90% of the cases. NF 1 has a
disorder frequency of 1 in 4,000 making. It occurs following the mutation
of the tumor suppressor neurofibromin who inhibit the ras oncoprotein,
therfore, increases the risk of tumor development,
particularly: meningiomas, gliomas and pheochromocytomas. The diagnosis
of NF1 is made if any two of the following seven criteria are met:
neurofibromas(Two or more), Freckling(groin or axilla (arm pit), Caf au lait
spots (Six or more), Skeletal abnormalities( such as sphenoid dysplasia), Lisch
nodules (hamartomas of iris), Tumors on the optic nerve(optic glioma),
Macrocephaly ,Epilepsy , Juvenile posterior lenticular opacity.
Neurofibromatosis type 2 ("central neurofibromatosis"[) is the result of
mutation in a tumor suppressor gene NF2("merlin"). It accounts for only 10%
of all cases of NF, and its frequency is lower than NF1. It is also caused by a
mutation in a tumor suppressor gene (NF2 or merlin). NF2 disorder manifests
in the following fashion: bilateral acoustic neuromas, headaches (due to a
tummor), facial weakness/paralysis(CN VII involvement/compression),brain
tumors and spinal tumors, meningiomas and ependymomas. The
bilateral acoustic neuromas is a schwannoma thata causes
deafness and tinnitus, infact, the hallmark of NF 2 is hearing loss due
to acoustic neuromas around the age of twenty. The schwannoma and
involvement of the inner ear also causee balance problems and
peripheral vertigo.

171

 :CNS
:
!
. ,
.

IVIg ,MTX ,NSAIDs

DD


SAH
Epidural abscess
( aseptic ,)
Leptomeningeal spread

Bacterial meningitis
,
. ( ) ,
, , , ,,
.
, :
/
3 -
3 8
50 18
50



CSF

S agalactiae
E coli
L monocytogenes
N meningitides
S pneumoniae
H influenzae
S pneumoniae
N meningitides
S pneumoniae
L monocytogenes
Gram-Negative Bacilli
L monocytogenes
Gram-Negative Bacilli
Staphylococci
Gram-Negative Bacilli
S pneumoniae

,50 , , ,
, , .
Staph. , , .
TB . ,
, ( .)6/3
.Non communicating
; , ,,
; ( ,-
, ,- ).

:
CNS-" " ,
, - .
- :
- .
,
; -
172

 . , IL1 ,IL6 - TNF

,BBB- , CBF -
.
, "
PMN . S pneumoniae
( HI - ) , . ,
, .
:
1-7 :
.1 - -
( ).
.2 - . ,
, .
.3 .
.4 - 80%- ,
, .
, ' (
90- ,
).
.5 - 50%- " .N meningitides
:
( )PMN ,
. 40-90%- . .CRP
( , ) .
CT MRI , .
EEG " , ,
.
:LP -
:
. 90%-
. .

1000-10,000 - WBC . ( PMN

).

. .100-500 mg/dL -

. - 40 mg/dL- 80%-.
. 80%-.
. CSF 80%- ,
".
PCR . .herpes encephalitis DD ( HI
) , .

- mmHg 180
,5 < WBC .
= .
> 2/3- .
( .)60
< 60" "
RBC ,
1000-
WBC1 1- -.

:LP
( )Partially treated meningitis
.CSF- ?
.
LP-
.PMN -
CSF .
173

CSF:

 :
SAH .1 , CSF .
.2 PMN
, LP- 6-12
.
:Management
, C/I : ( ),
CSF- ".
,
CT CT- C/I .
" ," . /
" . LP 24 -
CSF , 3 WBC- .PMN-
:
Rocephin - 3 Vancomycin ( ). Ampicillin , , . Doxylin ()lyme ,q-fever , () " 4 6 ,
.
- , ".
.
2-4 ( ,).

, , ,SIADH ,
( VIII ) ,.
" "
( -).
20% ,
( , )- ( ,HI).
, , ,
Stupor , .
:
:TB meningitis .1
, TB
, . TB"
" , .CNS-
. "
" . .
, .
:
,/ , . , , ,
, , .
,
.
:
o PPD .
o :LP- " , " 50- WBC ,
500 , PMN
174

 . CSF- ,100 .500

( .)20
o " CSF
.CSF .PCR-
o Acid fast .
:DD-

, , .
:
( CSF-
) - ! . ,
, " PO .
,Spinal subarachnoid block ICP
( -
).
, .
.
:Syphilitic meningitis .2
. ,
, .
Treponema palidum - ,CNS-
" (= ).
, , , , ,
, , , , ( ).
, , , .
( ) VI ,V ,III ,VIII ,VII
.II-" .
" CSF .
( )100-1000 . ( )200-
VDRL . CSF- FTA- MHA-TP " .
" ,self limiting . " G IV
10 . CSF .
:Lyme disease .3
" " Borrelia
.burgdorferi . (
) " , . , ,
, , , , .
10- ,
/ . , .
Lyme meningitis" , " ,
, , . , "
, , /.
CSF-" 100-200 , , .
.IgG "
, " Elisa western blot .PCR-
,Lyme CNS IV
2-4 . 10 .
,
.

175

Viral meningitis/encephalitis
, .
,Enteric viruses ,HSV
( , , ,) " .
CNS :
.1 ( " )
.2 ( ,)
.3 ( ,).
, " .
, Microglia
; .
:
:
o
o
o
o
:
, , .
, , , ,,
, , .
, ,
. , -
.
( ) ,"
LP , . .
.
- LP
,
( 1,000- ) . PMN
, .
( .)80-200 " ( , ) .
, . PCR- '.
:
o : , .
;
, .
o EEG- .
o CT- MRI .
. .
:
.1 .TB , , ,.
Immune mediated encephalomyelitis .2
, , .
:
" , .
- .

176

 ,
.REYE
." IV 8 , 14-21 .
,
.
" .
- .
:
,
.
,
.
:Herpes simplex Encephalitis
.40 ( )1
( .)2 ,
. ,HSV1 Encephalitis ,
. ,
HSV2 ( ) . HSV2 ,"
.
HSV1 , ,
," .
, , , , ,,
, , .
, .
, .
CSF- 50-100 , ( ,)PMN
, . ,RBC .
" .PCR
EEG-
CT- MRI .
.
DD- , 2 " .
CNS .HSV Encephalitis
" , " .
" IV 8 , 14-21 .
, .
30 .
, 25% 18-.

CSF/:

TB meningitis

CSF

180

1000-10,000
PMN
50-500
'

100-500
100
500

40-
80%-
,

-
20

80%-

177

-
80%

Syphilitic
meningitis

Lyme
meningitis
Viral
meningitis/
encephaitis
HSV1
Encephalitis

100-1000

( -
)200

100-200

80-200 1000-

50-100'

PMN

"
.

VDRL-
CSF

.

"
.PCR

" PCR
.

.RBC
PCR
.

:AIDS-
AIDS , , , .
, CNS-
" ,HIV- .
:
HIV1 meningitis .1
" , , ,
( , )VII . " Seroconversion
.HIV1 CSF- 200 .
" .
Cryptococcal meningitis .2
5-10%- . , , ,,
/ , . -
CSF 20%- , "
.CSF- .
HSV & VZ Encephalitis .3
, HS1 HS2 ( " .)HS1
CSF- ,
. VZ ( ).
CMV encephalitis .4
. -
CSF ." ,
. .
Cerebral Toxoplasmosis .5
.
PCP .
. .
( ,)30% , (
,) , , , .
MRI .
, , , .
.
Primary CNS Lymphoma .6
178

 . , ,,
, . .-
CSF , .
.
MRI ,CT- ,
- 3 ,
. CNS .
JC virus (PML) .7
.
. .
, . PML
.MS-
:AIDS Dementia Complex
;
, .
HIV1 ,
,
HIV . , ,
,AIDS Dementia Complex
(" ).
:
, , ,
" , , .
, ,
, .
, , ,,
, , .
:
CSF- , .
CT MRI- - ,
.
HIV- "
. ,
" . " 1-9
.
)carcinomatous meningitis( Leptomeningeal metastases
- ,ALL
,Non Hodgkin lymphoma ,AML , ,Hodgkin lymphoma , ,
,GI .
CNS .
" 3 5 ,
, .
:
, , .
, , .
: ( ,)46% ( ,)38% ,
,)78%( LMN ( ,)60% ( ,)50%
( ,)50% (.)50%
:LP
179

 ( ,)50% ( ,)57% ( ,)81%

( .)31% " CSF-.
, CSF- HCG ,CEA.AFP-
, , ,
.
, . / "
, Small cell .
, Leptomeningeal metastases -
, .

, 2% - . ,"
,:
.1 ( )
.2 - ( OM , ,)
.3
.4
.5 .
, - ,Bacteroides
Fusobacterium .Prevotella -' , -
.
, " .
.
( ,)55% ( ,)58% ,.
CT- MRI . CSF- 200
75%- , 25-500 , ( )45-500 60%-.
CSF " . , LP
.
" (
) .
, . G .IV
DD + :


SBE . DD-

180

.1 / ,SAH , ,
, .ICP
.2 / .
.3 - .
.4 ( CSF).
:
.1 SOL- .
.2 , .
.3 , .20k-
.4 SOL- LP ,
.
:
, .
, .
.
.
L3-4 ,L4-5 (
) L1-2 . L3-4
.Posterior iliac crests , ""
.Ligamentum flavum - ,CSF
( ) . ," 1-2
" 5- , ,VDRL , .
.
, ( 10") . CSF- ,
.
:
. ,
. /
Spinal cord compression
.
. , .
, . "
,
. NSAIDS .
:
.1 CSF- . 200
. ,50 .
() , () ().
.2 180-200" .
, SAH ,.PTC-
.3 .
CSF . 5 (
) , ,PMN ( RBC ) .
.
181

 CSF .4 .CNS
, RBC
Supernatant , ( , ,
.)CNS ,SAH CSF- 6 . -
,CSF 1000 WBC 1mg/dL.

182

 :
,
:
.1 , RAS-
. (
) . () ,
, , .
, ,
( , ," , , ,) , (,
).
.2 "
. ,
()
.
, 2
.
, . ,
,
.
, ( )Mini mental
, , ( ,) .
Mini mental - .
, ,
() , .
, .

!
Pre-morbid functioning )1 ,.
)2 / , / ,
.
)3 ( , ,
).
)4 ? , ,
)5
)6
)7 :- ,BZD ,
)8 ,
ADL )9
)10 , ()
)11

.
MoCA .
.1:
, ,
. .
, ;
. ,
.
183

( ) ,
, .
.

.2
. .
.
.3 :
.
.
," ( .
=/).
. 20 -0
. 1- 10
.
. 7 100- 3 20- () ,
.
. .
( Digit span . ) - 5
. -working memory
() .
,
. .
. .
. ""
. -
.
.4 :
2:

."
. : ,
, / ,
.
/ ( ).
3 : ,/ :
,

.
/Working memory

, .
( ).
/ - ().
,
" .
Mini mental - , .
-
, .
184

 , ,
.
, " ,"
( ).
,
.
, . (
)
.
( )
( ).
:
. 3 5 registration ,
(= . ) .
, . 3 (=
. ) - .
.episodic memory

.
.
.
.
" MS
.
. ( )ray figure 3 , , .
. - , ,' -
.
.5 :
. . ()anomia
. .
( ):
o - ( ) .
.
o - -
.
, .

. ,
, (.)alexia
. - " "" , "" , " .
- conceptual comprehension ?

( ) .
. , , . " ,
, , "
. " . "
. gertsmann

.
.6 / ( )
185

 , , , ,
, , .
, .
, ( .)MS ,ALS
( Fluency .( -
o ' ,
.
. 11 .
o
( ).
-
. .
Impulsivity . .
inputs .outputs-
.
o go no go .
(
) , ( ) .
.
.
Anti saccades o (
) ,
.
3 step Luria test . .fist edje palm .

, ).
.
. . echolalia
.
. .
. .
.
( Apraxia .7 )
.=
. ,
.
- / ,
.
( ).
"
?" .
(
) .
' . .
Dressing apraxia
. ,
. .
( ).
-Gate apraxia . .
fastination .

(.)NPH

186

 () gait apraxia-
.dressing apraxia corticobasal
.degeneration .
" " - pre motor -
. , ,Gait apraxia
.
:
. ( ) ,thumb up ,
.
. ( ) ,
, .
.
. orobuccal , ..
-Ideational apraxia . ().
/Visuospatial function .8
Visuospatial ability .

"" "" . nglect- ,
, ' .
.constuctional apraxia
. (
, ).
.

. .
( ).
.9 ( ):
"
- ,
.
. :
Astereognosis . " .
Agraphestesia . .
. .Two point discrimination
Allesthesia . " .
Extinction . ,
.
Unilateral neglect and Anosognosia . "

- , ( ,)Anosognosia
.
. ,Constructional apraxia
/ Neglect of external space -
. Constructional apraxia -
, .

187

 .1 , ,- ( ,
, , ) . ,
, , .
. , , .
.2 .
, ()
.

:
- , ' .
- , , / / , , (
) , , ( )
.

() :
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-
.
-2 - ,
. ,
.
:
Dysarthria
( ) .
( ).
:
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- . ,
() - (
, ).
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; .
.
.3 - )Bulbar( LMN
() . ( )hot potato .
,GBS - , '.
, -
.
() - -
.
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. , ,
.
. - .
188

 - Repetition .
.
- )Broka( Motor Aphasia
/ .Non fluent /
Broka major: Minor -
, - .
' - -
( 60-100
; 10 - ) . , .
, . -
; .
- , .
.
" ? ,
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189

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192

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193

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194

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195

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196

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197

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198

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199

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200

Creutzfeldt-Jacob disease
CNS
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201

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202

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203

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204

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205

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o ,- ,,
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:
206

o
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207

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208

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209

 :
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o .
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cerebellar abscess o
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210

Chronic
- Alcoholic cerebellar degeneration -



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.
..
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.

211


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.
212

 " ,,
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, " "
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) .Cold-opposite, warm-same COWS

213


( ).
afferent-
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214


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.
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Ataxic .)Grasping - -
,
.

:Diffuse encephalopathies
( )
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SAH , .
( , ) ,
( SAH).
.
. ,

215

 . ,
. .
,
.
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.
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( 7")

.

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).

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.

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.

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,
.

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- ).
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, ).
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, , CT- .
. ,
( ) . ,
- , . .
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.MMA
( ) , Lucid interval
( , , ) ,"

216

 . " ,
.III
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. .
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, , . , . -
,
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( , ) .
.
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Cerebral infarction (stroke) .8
, .

. 48-72 .
, Stupor- .
.
Brain tumor .9 CNS-
, .
217

 , ,
, , . 25%-
. " CT ,MRI .
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, .
, .
, , , .
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, CT- . "
.
:
.1/ ,
. , .
,
( ).

218

 SAH .2
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.
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219

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220

:Persistent vegetative state

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. (.)perla
. () , ,.
- 4 ,3 :6
. ( ).
. :
H - Smooth persuit o . - . " -
-.
Saccade o - Frontal visual field . .
( Convergence .)
. - .
:Trigeminal 5
. , .
. . .
Jaw jerk reflex .
Corneal reflex .
:Facial 7
. .
. - , , ,
. .
Corneal refex . .5
:Vestibulocochlear 8
.3 , , , .
o ( ,//).
.Dix-Hallpike maneuver o
.4 .
o Weber
255

 o Rine
:Glossopharyngeal 9
,( .)
,AAA .
GAG ,.
:Vagus 10
- , -.
:Spinall accessory 11
- .
- SCM .
. -
:Hypoglossal 12
- . .
- 4 :
, , ,.
.: , ,/,
, , , ().
. : .
. : , ,-
. .UMN
. ,pronator drift : Barre
. - ( :)0-5 , , , ,
, , , , ,
, , , , ,
, , .
( grip : ) , 2 O
( ).
: .
.
o )0-4( : .UMN , ,,
, , ( UMN ).
o : .UMN- , ,.
o ( :)UMN , , ,' , ,.
o ( : ) : ,snout , ,,
.palmomental
5 :
, .
. , , ,
, , .
. " .
. - " .
.
. - .
./ .
.
o . .
o - .
. - ()
Two point discrimination o 4".
256

Graphesthesia o
Stereognosis o
Allesthesia o .
- 6 :Cerebellum-
" , , , .
.titubation -
Saccadic pursuit : .
- Overshot ( ).
.Scanning speech -
.
.
Intention tremor o
o Overshooting .
Rapid alternating movements/Dyadochkinesia
.
- .
- ( ). :
, , ( ).
tandem
( Holmes) .
.
() - .

257