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סיכום לורן מאוחד לקובץ אחד
סיכום לורן מאוחד לקובץ אחד
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
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-
).
18
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
: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- ).
.
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
:Parietal lobe
.
.
( )
.
( ,
)
, ...
:
25
, 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
30
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
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
Weber without
lateralization
Normal
Combined loss :
conductive and
sensorineural loss in left
: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
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
.
:
, ' .
, .
. 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
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
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%- . !!!
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
- .
" .
.
- ,
. ,
( .)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
.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
.
.
)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
/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
Hypertensive hemorrhage
ICH- .Hypertensive hemorrhage
ICH-:
/
.Amyloid aeteropathy
" ( ICH- "
-) . " -ICH ICH
" ( ) (
) .ICH-
ICH- " .
; penetrating
- :
92
:
, . 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 ".
. .
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
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%- . .
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
.
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.
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109
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) .
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. 30 .
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110
:
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111
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. 2.
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:
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. - ADEM " - ,
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113
:
MS TH1 .TH2
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, :
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.
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.
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.
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, ,40
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, .
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) , .MRI-
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114
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.
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,.
,.
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115
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117
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118
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119
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120
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. .
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MRI o :Diffusion ,FLAIR ,T2- - ,
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, .
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121
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.
122
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123
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,
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/
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124
, . "
MRI " . -
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.
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, .
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125
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.
126
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127
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128
; , .
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129
130
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;
.
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,
.
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C8 T1-
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.
131
, :
S1
L5
L4
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C7
C6
C5
>
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, .CIDP-
,
.
.2 ,
. ,,
.
.3 .
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.6 .
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.
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.
:
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.
. : ,,
133
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.
: , , , , , ,
( ) , , , .
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.
:
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. 4.5 () ,
, .
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)
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.
.
.
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, .
Mononeuropathy multiplex
, , ,
.patchy
.
.
,.
( )
.
( ) .
Polyneuropathy
( ) . "
( ,)Gloves & socks , ,
( ,)Axonal transport-
" .
.
(
) . , .
,
.Conversion disorder
:
.
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.
( ,
) .
134
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) . .
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.
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, , , ,
.
:
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o,
o .B12
o
o , , , .
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.)chronic inflammatory demyelinating polyneuropathy( CIDP o
.3
o () , ,
o.
o Cisplatin ,Taxol ,Vyncristin
Amiodarone o , ,
.
Isoniazid o B12
.4 ,AIDS - , , ,
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.6
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Freidrich ataxia o
Familial amyloidosis o
Paraneoplastic .7 ( ).
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,MM TB ,FMF .
.
:
Pure sensory o , ,B12 .
o ,Poephyria ,CIPD ,Gullain Barre syndrome .
o- CMT -
o
( )
o ( - (Myelinopathies ;
,CIDP ,GBS ,
( .)CMT 1 & 3
.
o ( - (Distal axonopathies ,
.
- Neuronopathies o
.CMT 2
135
o 4 .
o 4-8 .
o 8 .
:
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.
CBC o
o CRPEST-
o - , , ,
, .B12 ,
o ANA ,RF ,
o ( ) . .
o
o ( ,,
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"
:
- . -
, .Fiber type grouping
.
,
Superficial radial nerve- .
, ,.
Punch biopsy
. .
(,Small fibers
) .EMG
. ,
. , Mexiletine
; , TCA .
capsaicin .
, .
:
Diabetes mellitus polyneuropathy .1
( , ) 70%- .
. ,
( , ,[ ].
:
- ,
, , Drop foot .
"
.
136
( ) . ,
.
.
Acute painful axonal polyneuropathy
. ( ) ,
.
" , .
.
( )3,6,7 .
o 3- 6 , .
,Idiopathic occulomotor/abducense palsy
. . 3
, PCA- .
o ,Bell's palsy = 7
,
." .
, ,
, , , , .
( )Mononeuropathy simplex
.
o .CTS
Diabetic amyotrophy o ,
, ."
.2"
.
.
" 2-3 .
, .
,Iliosacral plexus- Lumbosacral
.radiculopathy ,
.
Mononeuritis multiplex "
. .
Thoraco-abdominal polyradiculopathy
. . T10-
12 (.)buldging
,
/ . ,
.
:
, (
) . " ,
" . Mononeuropathy simplex
. +
( ,) , ( ,
).
137
Guillain-Barre' syndrome .2
.Acute idiopathic polyneuropathy .
, .
. .
- , -
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, ( GI - Campylobacter jejuni )HP
( - ) . ,
. .
:
ascending paralysis ( 9%-
) . " , .
. / , . -
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o .
o - ,
.
.
.
.
- ,
. .acute flaccid paralysis -
, .
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-.
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() , .
, , gag.
, .
:
.1 - , ," ,
, , ( ) ,
DVT . .PE GBS-
.
.2 .
:
:" , ,B12 ,HBA1C , DD
- LP CSF- 2
( ) 4-5 . ( 10- ")
. CSF- CIDP-
.
-EMG . -
. 10
- [ .
, -
].
:
anti-GM1, anti- GD1 - , .
-.
138
/ : HP .
( .
).
: Guillain-Barre'-
.1 ;
/ .
.2 4; ; ;
( ;)VII 4 ;
; ; CSF- ;10-
(.)EMG
.3 ; /; -
CSF ( 50 PMN ;)0 .
.4 ; .
:- , ,
.
:Guillain-Barre'-
!!! .
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(
) , .
Arrest .
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,
. . -.
400 IVIG .2"// 5 ,
." : , ,-
.3 . ",
".
,CIDP- .
:
4- ;
,Self limiting .
( ).
70%- 25% , , 5%- (
) 7% . relapse , -
.
:
)1
)2 ( )
)3
)4
)5
)6
:
-AIDP- Acute inflammatory demyelinating polyneuropathy
( GBS ) - .
139
140
, 2-3
. ;
.
CSF- . ,
.
- , /
( ) . ,
.
.5:
;
( ) . ,
, ( )
.
, , . ,
. ,
. , " .
.
Charcot-Marie-Tooth .6
Hereditary motor and sensory
neuropathies .
, .
:
, drop foot .
.
, hammer toe ,Pes cavus -
, .
-
:
CMT 1 .1 . ,
, .
. .
" X-linked .
CMT 2 .2 () , , -
.Progressive spinal muscular atrophy
Freidrich ataxia .7
" , (
anticipation ).
clumsiness ,ataxic gait - .
.
.
.8 AIDS-
GBS Like GBS- .
. "
.
- Painful sensor neuropathy .
, .
.
141
:
Neuromuscular junction
Myasthenia gravis
, - .
.
: 20-30 3 , .F=M 60
.
:
- .
, . :
- , , , (!!! ) . .
Facial - . . ( !( ( drop head )MG- Myasthenia crisis . . . - ,
Superimposed"
.
GBS- , .
:
.
-)85%( Seropositive
.
-)20-30%( Seronegative ,
() anti MuSK
ACH ( NMJ-
).
: , ( 1/3,
1/3 1/3, ) 3 , . ( ,,
, , , , ,
.)MG
MG :
MG .Thymoma .MG
().SLE ,RA , :
o .
, , CNS.
o 90% - ,
. .
o 2 ,
(
).
o , .
142
o GBS- ,
.
:
o
o - ( 2 3)
;
single fiber EMG . "
(
.)decrement
Tensilon (Edrophonium) test o ,NMJ
.Double blind IV ACH esterase inhibitor 10"
2" ( ) 8-" 30
. ,MG , 5-.
, 1.5-" ,IM .
o " CT .
:
MG :
)Pyridostegmine( Cholineesterase inhibitors .1
. " 30-180" (
)60 4 , .
" .
Cholinergic crisis -
( MG )Edrophonium IV
, , , , , .
Thymectomy .2 ,60 ,60
- .
, , .
.3 2- .
, .
, .
)Imuran( Azathioprine .4
. ,
.
Mycophenolate mofetil .5 B T-
, " , , , , .
MG ( steroid
,)sparing " .
.6
.a -
,Myasthenic crisis
.
IVIG .b ." AVN ,MI ,stroke
.
: " .
.Aspiration pneumonia -
143
o , . ,MG-
- , .
o , MG- .-
EMG single fiber EMG
.increment
o , .
:
o " ( )EMG
.
o - P/Q
, .
( ) IVIG/
. Guanidine hydrochloride ( "
" ) . MG
.
.
Botulism
" - Clostridium botulinium ACHNMJ-
," .
12-72 ,
, , , , . .
, paralytic ileus , .
.
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-.
!!! MG MG
144
( ):
(
, ) , , .
:
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.
Myotonia . .
.
. " .
Muscular dystrophies .1
.
. , ,
, . ,
. ;
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. .dystrophine ,5
, .
, .
,
.
(.)Gower sign
- ( ) .
, .
- CK- . ,
3.
Becker dystrophy - .X linked
. .Duchene -
( 11) ( 42) .
, CK .
.
Emery-Dreifuss Muscular Dystrophy - X linked
. ,
, (
, ,
) , , . CK- .
Limb girdle dystrophy -
; ,
.
Facioscapulohumeral dystrophy - '
" , , ,
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Distal myopathy - ' ,40
, ,
. .
145
146
,
. ( )
( ).
Periodic paralysis syndromes ,
" .
. .
, ,
. ,
.
, .
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:
/ ,/ , , ( ) ,
.
:
() , (.)pompe
148
( )
, .
.
:
.1
. ,
, ,,
,.
.2
;
.
-
.
,Globus pallidus ,Putamen ,Caudate
Subthalamic nucleusSubstantia -
.negra GB-
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.Corpus striatum
:
Corticocortical loop .1
, ,
.
.Nigrostriatal loop .2
.Striatopallidal loop .3
( )
"; ( )essential tremor .
:
Tremor .1
, ,
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. :
Static/rest tremor . .
( ) . " ",
, ,
.
Postural tremor . ( ) .
, .
:
( Physiologic tremor o " )
o ()Benign essential tremor
o
o .
, , ,
. . ,
/ . ,
149
.
( ) . ,
" .
asteriaxis ,Postural tremor -
.
" .
,
,"
( ) ,
. .
Intention tremor . . ( Postural
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. .
Chorea .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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.)PEG- -
( Uptake GABA) ,
' . .
Hemiballismus .3
150
, .
( )
, . 90%-
( ) - ,
. . ,
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Athetosis & dystonia .4
- ( ).
,
Dystonia .
( )Generalized ( ,Segmental dystonia
.)Focal dystonia
- , " ()
. -" ,
( , ).
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o " -
. ,
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.
. ( ).
.
, . 90-
95% . ,
.
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.11-12
5 .
.debilitating state
o :
. - , .
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.
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. .
. .
Myoclonus .5
"
Generalized myoclonus , Focal/segmental
myoclonus . ,
, (.)Action myoclonus
( ) ,
. ,
.
151
Segmental myoclonus ,
, .
,
.
Tics .6 ;
. 80%- ( )OCD, ADHD .
- .
- Dyskinesia .7 , ,
, . Tardive
,
D1 ,D2- ( Metoclopramide
).
DD -
- Primary .1
Parkinson o
.CBD ,PSP ,MSA - Parkinson + o
Lewy bodies disease o
Huntingtons disease o
Wilson disease o
Secondary .2
SOL o
o
o
,
, , .
( ) ,
,Drug/toxin induced ,Encephalitis lethargica .
" ' , ,
, ;
( ) . ,
" " . "
( ,)1919 . 1979-
, - ( L-DOPA .)1963
- Thalamotomy
" . .
:
1-2% .65
. 2-3 5
. 25%- .
:
. - 65 . 85
10% ( 2 ).
152
. - .
,
.
. : ,
. ()
. : , .
: ,.
:
Substantia niegra -
, Globus pallidum- .Putamen-
.
.
( )Lewy bodies Alpha-sinuclein
, , . ,
; -
; -
( ).
- Diffused Lewy Bodies Disease
-
, ;
( ).
12 -" .
- .
.
2002 Braak Staging- "
- ,
.
; , - -
Dorsal vagal nucleus - Olfactory bulb - - .
- Reticular formation ;
.
, - .
- .
:
( ) ,
, - . Output GABA
( )Caudate + putamen ACH Output .
, GABAnergic output - .
4 :
Rest tremor . .
5- : , , - -
. ,Pill rolling[ .
, ,Titibation
( )].
( ) -
,Re emergent tremor .
" ,
, . ,
.
153
-:
15-20 .35%-
.
( )hyponosmia/anosmia (
) , ( ) .
.olfactory bulb
- 15-20%-.
, .
, , ,
- " -
- +
. .
- REM sleep behavioral disorders ,
, " , ".
Fatigue .
: executive functions- ,/ ,
( ) .
, " " .
.
. ( , ,).
.
- . Emotional incontinence , . - - .Lewy body disease-
154
:
.1 - .
.2 / 2 .
.3 .
.4 L-DOPA - .
.5 L-DOPA- On and off
;phenomenon
.
.6 .
:
- " ACH
" .
:
Resagaline/selegiline( MAO B inhibitors .1 ) -
. .
( ) . levo
. , "
".
Amantadine .2 NMDA , .
.
- . -
Amantadine .
, ( , , ,,
disease
) . ,
modifyinf effect
. ( IV
BDNF( brain
derived neurotripic
, ) acute -
)factor
.parkinsonean crisis
.3 , ,
. : , , ,
.
Dopa .4
Levodopa ,
.
,
" "Honey moon
- On/Off .
!!! ,
.Levodopa
" "honey moon
.
-Carbidopa Levodopa - )Sinement( Carbidopa
, Levodopa; -
Levodopa ( CNS- ,)BBB -
Levodopa .
( COMT Inhibitors )
, Levodopa .
+ Levodopa + .Stalevo COMT
" , , " , () ,
. . .
Levodopa - Wearing-off effect
( ) ( On-off phenomenon
155
,
).
:
Wearing off Honey moon On/Off Response fluctuations
( Delayed on ,
) ( No on ,
).
.5 Levodopa - ,
On/off phenomenon - ."
( Sinement - L-DOPA) " :dysinhibition
, , , . .
(:)On/Off
Continuous delivery
. :
Apomorphine .Short acting ,
:
- Off
.
.
Dua-Dopa . .
'' .
,
( On/off- ).
.
-)DBS( Deep Brain Stimulation o (
) (
, ) .DOPA-
. (
) . ,
.
, .
On/Off- .
- ( ) .
, STN-
( 50%-) . DBS .
" . ,
.
:
, , . . o " ( Thalamotomy )
( Pallidotomy )
" .
. ( ,)20%
( )5%- .
, ,
.
156
:
- .
, . , ,
" , . - , " , ,
. .
. ,Memorit , .
, , .
. .
" .
o ,
. , ( ,
' " ) , (
, ) .
.
o " Supine hypertension
. "
45- ( ) .
" . :
. -
10-15" " . .
, .
2:
Florinef .
. , .
psychotic
depression . .
vivid dreams :
( )
.
:
o
o )Clozapine( Leponex" !!!
Seroquel
.?
REM REM .
?
, () , , .
.
157
:parkinson plus /
(,
, , )
.
,CBD ,MSA, PSP : . 2:
synucleinopathies .tauopathies :
, ).olivopontocerebellar atrophy(OPCA - ataxia and dysarthria,
.
- DBS
, + . " (MSA-
PSP- ).
DAT ( DAT
, ) . +
, ( ) . IBZM
. DAT +
.
)PSP (Progressive supra nuclear palsy
(
) . " (+
).
Vertical gaze- ( .)Downward gaze
,
( - = ) .
.Upward gaze-
Pseudo-bulbar palsy ( ) .
, .
, .
.
)MSA (Multisystem atrophy
.50-60
: , .
Supine
,HTN , , , (
).
.Shy-Drager syndrome
- REM Behavior Disorder , .
P , , ( ,)Jaw jerk ,
, , (
).
C , , ,
.
158
.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 .
- ( );
, .
, ,
( . ).
.2 - ,Caudate -
, .
, , , , ,,
, . .
.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
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
. .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
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
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 , , .
. - , ,' -
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257