98年?？谱o理師訓(xùn)練

神經(jīng)系統(tǒng)常見問題之評估(一)頭痛Headache頭暈Dizziness成大醫(yī)院神經(jīng)科黃涵薇醫(yī)師98年?？谱o理師訓(xùn)練

神經(jīng)系統(tǒng)常見問題之評估(一)頭痛H1頭痛Headache頭痛Headache2Pain-sensitivecranialstructures顱外Skin,subcutaneoustissues,musclesextracranialarteries,periosteumofskullEye,earnasalcavitiesperinasalsinuses顱內(nèi)血管Intracranialvenoussinusesandtheirlargetributaries,esp.pericavernousstructuresArterieswithintheduraandpia-subarachnoid,particularytheproximalpartsoftheACA,MCAandtheintracranialsegmentofICAThemiddlemeningealandsuperficialtemporalarteries腦膜Partsoftheduraatthebaseofthebrain顱神經(jīng)Theoptic,oculomotor,trigeminal,glossopharyngeal,vagus,(andthefirstthreecervicalnerves)Pain-sensitivecranialstructu3FromsupratentorialstructuresAnterior2/3ofhead(V1,V2dermatones)FrominfratenotrialstructuresVertex,posteriorheadandneckFromVII,IX,XcranialnervesNaso-orbitalregion,ear,throatPainfromextracrainalpartofbodyNOTrefertohead,EXCEPTCervicalportionofICAEyebrow,supraorbitalregionUppercervicalspineocciputAnginapectoris(rare)Jaw,vertexAreasofreferpainfromintracranialstructuresFromsupratentorialstructures4?國際頭痛疾病分類?ICHD

(InternationalClassificationofHeadacheDisorders)第一版在1988年公布，第二版於2004年刊登於Cephalalgia雜誌。不論是中文版或英文版的?國際頭痛疾病分類?都長達一百五十頁以上!在英文版第二版中，作者建議－?這份內(nèi)容龐大的分類文件不是用來背的，這是一份須要一次又一次不斷查看的文件。??國際頭痛疾病分類?ICHD

(Internationa5原發(fā)性(Primary)次發(fā)性(Secondary)以決定頭痛的原因及訂定適切的治療計畫頭痛Headache原發(fā)性(Primary)頭痛Headache6原發(fā)性頭痛(primaryheadache)意謂頭痛本身即為痛的成因。超過百分之九十的頭痛患者屬於此類。重點就是排除次發(fā)性的可能。原發(fā)性頭痛(primaryheadache)意謂頭痛本身7無預(yù)兆偏頭痛

Migrainewithoutaura

A.至少有5次能符合基準B-D的發(fā)作B.

頭痛發(fā)作持續(xù)4-72小時(未經(jīng)治療或治療無效)C.頭痛至少具下列二項特徵：1.單側(cè)2.搏動性3.疼痛程度中或重度4.日?；顒訒诡^痛加劇或避免此類活動（如走路或爬樓梯）D.當(dāng)頭痛發(fā)作時至少有下列一項：1.噁心及/或嘔吐2.畏光及怕吵E.非歸因於其他疾患無預(yù)兆偏頭痛

Migrainewithoutaura8典型預(yù)兆偏頭痛性頭痛

Typicalaurawithmigraineheadache

A.至少有2次符合基準B-D的發(fā)作B.預(yù)兆至少包括下列一項，但無肢體無力：1.完全可逆視覺癥狀，包括正向特徵(如：閃爍的光、點或線)及/或負向特徵(即視力喪失)2.完全可逆感覺癥狀，包括正向特徵(即針刺感)及/或負向特徵(即麻木感)3.完全可逆失語性語言障礙C.至少具下列2項：1.單側(cè)的視覺癥狀及/或單側(cè)感覺癥狀2.至少一種預(yù)兆癥狀在≧5分鐘逐漸產(chǎn)生，及/或不同預(yù)兆癥狀，在≧5分鐘相繼發(fā)生3.每一種癥狀持續(xù)≧5及≦60分鐘D.符合無預(yù)兆偏頭痛基準B-D的頭痛，在預(yù)兆同時或預(yù)兆之後的60分鐘內(nèi)發(fā)生E.非歸因於其他疾患典型預(yù)兆偏頭痛性頭痛

Typicalaurawith9緊縮型頭痛

Tension-typeheadache

A.Frequent:至少有十次能符合基準B-D之發(fā)作，且發(fā)作平均每月≧1日但＜15日，已至少三個月（每年≧12日且＜180日,頭痛持續(xù)30分鐘至7日

Chronic:頭痛平均發(fā)作每月≧15日，已＞3個月（每年≧180日）且符合基準B-D,頭痛持續(xù)數(shù)小時或可能持續(xù)不斷B.

頭痛至少具下列二項特徵：1.雙側(cè)2.壓迫/緊縮性（非搏動性）3.程度輕或中度4.不因日?；顒尤缱呗坊蚺罉翘荻觿.下列兩項皆符合：1.無噁心或嘔吐（可能有食慾不振）2.最多只有畏光或怕吵其中一項癥狀D.非歸因於其他疾患緊縮型頭痛

Tension-typeheadacheA10叢發(fā)性頭痛

Clusterheadache

A.至少有5次符合基準B-D之發(fā)作B.位於單側(cè)眼眶、上眼眶及/或顳部重度或極重度疼痛，如不治療可持續(xù)15至180分鐘C.

頭痛時至少伴隨下列一項：1.同側(cè)結(jié)膜充血及/或流淚2.同側(cè)鼻腔充血及/或流鼻水3.同側(cè)眼皮水腫4.同側(cè)前額及臉部出汗5.同側(cè)瞳孔縮小及/或眼皮下垂6.不安的感覺或躁動D.發(fā)作頻率為每二日一次至每日八次E.非歸因於其他疾患叢發(fā)性頭痛

ClusterheadacheA.至少有11典型三叉神經(jīng)痛

Classicaltrigeminalneuralgia

A.發(fā)作性(paroxysmal)疼痛發(fā)作，持續(xù)由不到一秒到兩分鐘，影響三叉神經(jīng)一支或一支以上分支的支配區(qū)，且符合基準B及CB.疼痛至少具下列一項特徵：1.劇烈、尖銳、表淺或刺戳痛2.於誘發(fā)區(qū)引發(fā)或由誘因引發(fā)C.就個別病人而言，疼痛的發(fā)作型態(tài)是固定(stereotyped)的D.沒有神經(jīng)功能缺損的臨床證據(jù)E.非歸因於其他疾患典型三叉神經(jīng)痛

Classicaltrigeminal12次發(fā)性頭痛(Secondaryheadache)意謂頭痛由其他原因所引起頭部與頸部外傷顱部或頸部血管疾患非血管性顱內(nèi)疾患物質(zhì)或物質(zhì)戒斷感染體內(nèi)恆定疾患頭顱,頸,眼,鼻,耳,口,鼻竇,牙或其他面部或顱部結(jié)構(gòu)疾患精神疾患?國際頭痛疾病分類?ICHDII需治療引起頭痛之原因。次發(fā)性頭痛(Secondaryheadache)意謂頭痛13與腦瘤相關(guān)的頭痛Thepainhasnospecificfeaturestendtobedeep-seated,usuallynon-throbbingLastsafewminutestoanhourormoreOccuronceormanytimesduringadayPhysicalactivityandchangesinpositionoftheheadmayprovokepain,whereasrestdiminishesitsfrequencyIfunilateral,thepainisnearlyalwaysonthesamesideoftumorSupratentorial/infratentorialtumor的頭痛以interauricularcircumference為分界Latestage,IICPleadstoUnilateraltobioccipitalorbifrontalheadache,nocturnalawakening,projectilevomiting與腦瘤相關(guān)的頭痛Thepainhasnospecif14與中風(fēng)相關(guān)的頭痛25%strokewithheadachearoundtheonset50%headacheonsetpriortotheneurologicaldeficitspressingorthrobbingIfunilateral,painisusuallyipsilateraltothesideofstrokeMoreinlargestrokeposteriorcirculationwithahistoryofprimaryheadache與中風(fēng)相關(guān)的頭痛25%strokewithheadac15老年人的特殊頭痛Temporalarteritis(Giantcellarteritis)肇因於頭部動脈的發(fā)炎,多是外頸動脈的分支頭皮動脈腫脹壓痛併ESR或CRP上升可能伴隨polymyalgiarheumatica及jawclaudication變異性大,故凡是60歲以上新發(fā)的持續(xù)性頭痛均需懷疑此診斷,進行適當(dāng)?shù)脑\察易併發(fā)前側(cè)缺血性視神經(jīng)病變(anteriorischemicopticneuropathy)導(dǎo)致失明,由一側(cè)失明進展至另一側(cè)的時間小於一週需積極用高劑量類固醇預(yù)防治療,治療三天內(nèi)顯著緩解頭痛通常也有腦部缺血及失智的危險Hypnicheadache鈍痛,只在睡眠中發(fā)生,使病人醒來三項中具其二首次發(fā)作在50歲以後,醒來後頭痛持續(xù)15分鐘以上,一個月發(fā)生15次以上無自主神經(jīng)系統(tǒng)癥狀,且噁心,畏光,怕吵不超過一項老年人的特殊頭痛Temporalarteritis(Gi16”雷擊般頭痛”ThunderclapheadacheSubarachnoidhemorrhageSentinelleakAcutehypertensivecrisisCervicalarterydissectionPituitaryhypoplexyCerebralspasmPrimarythunderclapheadachePrimarycoughheadachePrimaryheadacheassociatedwithsexualactivityCerebralvenousthrombosis”雷擊般頭痛”ThunderclapheadacheSu17需懷疑顱內(nèi)高壓之頭痛IICPHeadacheSymptoms廣泛性脹痛,平躺更易頭痛Valsalvamaneuver會更痛半夜痛醒(nocturnalawakening)噴射性嘔吐(projectilevomiting)IICPSigns視乳頭水腫(papilloedema)盲點擴大視野缺損第六對腦神經(jīng)痲痺臥姿經(jīng)腰椎穿刺測量出腦脊髓液壓力增加(在非肥胖者＞200mmH2O；在肥胖者＞250mmH2O)CushingresponseHypertension,bradycardia,slowandirregularbreathing需懷疑顱內(nèi)高壓之頭痛IICPHeadacheSympt18腦脊髓液低壓之頭痛

IntracranialhypotensionA.整個頭(diffuse)及/或鈍痛，在坐起或站立後15分鐘內(nèi)惡化，至少具下列一項，且符合基準D：1.頸部僵硬2.耳鳴3.聽力障礙4.畏光5.噁心B.至少具下列一項：1.MRI有腦脊髓液低壓的證據(jù)（如：硬腦膜對比增強）2.傳統(tǒng)脊髓攝影、CT脊髓攝影、或腦池攝影術(shù)證實有腦脊髓液滲漏3.在坐姿，腦脊髓液起始壓力＜60mmH2OC.有/無硬腦膜穿刺或?qū)е履X脊髓液瘻管病因等病史D.頭痛在硬腦膜外血液貼片後72小時內(nèi)緩解腦脊髓液低壓之頭痛

Intracranialhypote19原發(fā)性頭痛和次發(fā)性頭痛可以並存!原發(fā)性頭痛和次發(fā)性頭痛可以並存!20ApproachpatientswithheadacheApproachpatientswithheadach21LocationQualityTightness,pressure,throbbing,stabbing…IntensityModeofonset,time-intensitycurve,anddurationPrecipitating,aggravatingandrelievingfactorsAssociativesymptomsHeadAche…

有關(guān)頭痛需要獲得的病史LocationHeadAche…

有關(guān)頭22評估頭痛的嚴重程度目測類比量表(Visualanaloguescale,VAS)區(qū)分頭痛為十級，即1至10分?！?」代表沒有頭痛、「10」代表這一輩子最嚴重的疼痛。概括而言1到3分表示「輕度」，4到6分表「中度」，7到9分表「重度」，而10分表示「極重度」。評估頭痛的嚴重程度目測類比量表(Visualanalogu23SNOOP

Maria-CarmanB.Wilson,MD.Symptoms（癥狀）如發(fā)燒，倦怠，體重減輕Neurological（神經(jīng)學(xué)）癥狀或徵象Onset（發(fā)生）突然，快速惡化Older（年紀大的病患）出現(xiàn)新發(fā)生或逐漸惡化之頭痛Previous（原先）頭痛的頻率、強度、時程、特色改變

SNOOP

24焦點病史病人這種頭痛有多久了？長時間持續(xù)多年且未曾改變的頭痛常為原發(fā)性頭痛，如偏頭痛。新頭痛的發(fā)生，特別是超過50歲，則是個警訊。若病人已有多年頭痛，它改變了嗎？了解原本頭痛的改變，包括頻率、強度、時程等不同的特徵。焦點病史病人這種頭痛有多久了？25何時頭痛發(fā)生？夜間頭痛可能是次發(fā)性，導(dǎo)因於某些引起顱內(nèi)壓上昇的情形。有些時候，剛睡醒時也會有次發(fā)性頭痛。因為這些相似性，頭痛發(fā)生的時間需進一步探討來決定原發(fā)或次發(fā)。睡眠時發(fā)生的頭痛可以是原發(fā)的。叢發(fā)性頭痛及偏頭痛都可在睡眠時發(fā)生或?qū)⑷送葱?。何時頭痛發(fā)生？26頭痛是突發(fā)或慢慢發(fā)生？對於數(shù)秒或數(shù)分鐘即痛到最痛者，可能會評估是否有潛在疾患如腦出血、栓塞、顱內(nèi)壓上昇等情形。原發(fā)性頭痛，包括不明原因（idiopathic）、刺戳性(stabbing)頭痛、咳嗽或用力(exertion)引起的、和性交有關(guān)的、叢發(fā)性及叢發(fā)類(variant)，都可以快速發(fā)生。頭痛是突發(fā)或慢慢發(fā)生？27是否曾注意到下列神經(jīng)學(xué)癥狀：意識混亂、意識不清、麻木、無力、言語視力或平衡因難、或其他神經(jīng)學(xué)不正常的癥狀及徵象？若在偏頭痛發(fā)生前產(chǎn)生這些癥狀，病人可能符合預(yù)兆偏頭痛。然而，必須區(qū)分不符合典型預(yù)兆偏頭痛的癥狀及徵象，因此會仔細的詢問相關(guān)病史看看是否這些癥狀指向其他問題。是否曾注意到下列神經(jīng)學(xué)癥狀：意識混亂、意識不清、麻木、無力、28若病人曾經(jīng)歷過預(yù)兆，它是如何發(fā)生又持續(xù)多久？偏頭痛預(yù)兆通常在數(shù)分鐘內(nèi)逐漸產(chǎn)生，約在15至20分鐘達到頂峰後，約25分鐘消失。依定義，偏頭痛預(yù)兆小於一小時。若預(yù)兆超過一小時，需小心是否為migraineousinfarct。是否曾經(jīng)歷發(fā)燒、倦怠、體重減輕或全身不適？這些癥狀可能和潛在的感染、發(fā)炎或惡性腫瘤有關(guān)，可能有進一步檢查的必要若病人曾經(jīng)歷過預(yù)兆，它是如何發(fā)生又持續(xù)多久？29焦點身體檢查PhysicalexaminationT/P/RandBPHeadandneckLocalheat/swelling/erythemaLocaltenderness/knockingpainEyesinjection/bruitNeckbruitNeckstiffness焦點身體檢查Physicalexamination30NeurologicalexaminationConsciousnesslevel/contentCranialnervesPupilsize,lightreflex,(eyefundus)EOMlimitationFacialpalsy,gagreflex,tonguedeviationMotorsystemMusclepowerDTRSensorysystemPinprick,lighttouchCoordinationsystemF-N-F/H-K-StestGaitNeurologicalexamination31III,IV,VI眼動神經(jīng)眼皮下垂ptosispartial/complete眼動是否對稱,有無雙影

X000000X0000000正常~-4不動III,IV,VI眼動神經(jīng)X000000X00000032肌力MusclePower5分:正常4分:抗阻力3分:抗重力2分:平移1分:肌肉收縮0分:不動555555555555肌力MusclePower55555555555533肌腱反射DTR(deeptendonreflex)Hypo0~1LowmotorneuronlesionNormal2Hyper3~clonusUppermotorneuronlesion++++++++++↓↑肌腱反射DTR(deeptendonreflex)+34實驗室與診斷檢查血液檢查影像學(xué)檢查CTorMRI?CTA/MRAorconventionalangiography?腦脊髓液檢查Open/closepressureCSFappearanceWBC,RBC,totalprotein,lacticacid,glucoseCulture/antigenidentification/PCR實驗室與診斷檢查血液檢查3598年專科護理師訓(xùn)練神經(jīng)系統(tǒng)常見問題之評估(一)課件36HeadacheHygieneTips(1)GetRegularSleepGotobedandwakeupatregulartimeseachdayDonotsleepexcessivelyontheweekendsandtoolittleontheweekdaysMostadultsneedapproximately6-8hoursofsleeppernightEatRegularMealsLowbloodsugarcantriggeraheadacheEatregularmealsthreetimeseachdayincludingprotein,fruits,vegetablesandcarbohydratesToomuchsugarmayleadtoarapidincreaseinbloodsugarfollowedbyarapiddeclineinbloodsugar,whichcantriggeraheadacheGetModerateAmountsofRoutineExerciseModerateexercisethreetofivetimeseachweekwillhelpreducestressandkeepyouphysicallyfitToomuchexerciseorinconsistentpatternsofexercisemaytriggerheadacheHeadacheHygieneTips(1)GetR37HeadacheHygieneTips(2)DrinkPlentyofWaterAnormaladultshoulddrinkplentyofwaterthroughoutthedayDehydrationmaycauseheadachesLimitCaffeine,AlcoholandotherDrugsCaffeineisastimulantandcaffeinewithdrawalmaycauseheadacheswhenbloodlevelsofcaffeinetaperAlcoholmaybeatriggerforheadachesandalcoholinmoderationmayreducethenumberofheadachesReduceStress

StressmayleadtoanincreaseinheadacheRelaxationandstressmanagementmayhelpreduceheadachesHeadacheHygieneTips(2)Drink38Headache-CasesdiscussionHeadache-Casesdiscussion39CASE128歲女性主訴:頭痛三個月現(xiàn)在病史：似乎三個月前就開始會頭痛，然後發(fā)現(xiàn)次數(shù)愈來愈頻繁，也愈痛，尤其最近這兩週較嚴重，甚至胃口不好，吃不下飯。頭痛的部位是整個頭，緊緊脹脹的痛、好像是整圈緊紮的痛，早上睡醒或者好好去睡一覺後，會覺得好一點，經(jīng)常是越到下午越容易頭痛。但是不曾有半夜痛醒來的經(jīng)驗。頭痛起來時，並沒有眼前出現(xiàn)閃光，眼睛周圍沒有痛，不會怕光，沒有伴隨嘔吐或噁心，最近視力正常，記憶力也還好。最近沒有感冒、發(fā)燒、鼻塞、濃鼻涕，也沒有過敏性鼻炎、鼻竇炎。耳朵也不會痛。手腳活動正常，不會常跌倒最近半年換新工作，因工作還未完全熟悉，且業(yè)務(wù)量大，常常加班，自覺很辛苦。身體檢查：血壓136/88mmHg心跳96/min意識清醒、記憶正常，神經(jīng)學(xué)檢查一切正常CASE128歲女性40CASE225year-oldfemale,nounderlyingdiseaseSubacuteprogressiveheadachefor2monthsDiffuse,swellingsensationCoughanddefecationworsetheheadacheMidnightheadache,awakingherfromsleepnausea/vomitingwhileheadacheBlurredvision(+)Bodyweightloss(+)Fever(-)CASE225year-oldfemale,nou41SummaryofN.E.&labConsciousclearNecksuppleNEallnormal,exceptpapilloedema(OU)CSFopenpressure310mmH2O,nocellSummaryofN.E.&labConscious42LupusleukoencephalopathywithIICPLupusleukoencephalopathywith43頭暈Dizziness頭暈Dizziness44病人主訴Dizziness”頭暈”的意思是….?Vertigo眩暈anillusionofmotion“spinningsensation”,”whirling”,”tilting”likelytoindicateanabnormalityofthesemicircularcanalsorthecentralnervoussystemstructuresthatprocesssignalsfromthesemicircularcanalsNonspecific“dizziness”“giddy”or“l(fā)ightheaded”DisequilibriumPresyncope病人主訴Dizziness”頭暈”的意思是….?Vert4540%haveperipheralvestibulardysfunction25%haveotherproblems,suchaspresyncopeanddisequilibrium15%haveapsychiatricdisorder10%haveacentralbrainstemvestibularlesion10%remainsuncertaininapproximately當(dāng)病人主訴”頭暈”….40%haveperipheralvestibular46區(qū)分vertigo和dizziness(1)TimecourseVertigoisnevercontinuousEvenwhenthevestibularlesionispermanent,thecentralnervoussystemadaptstothedefectsothatvertigosubsidesoverseveralweeksProvokingfactorsSomeareprecipitatedbymaneuversthatchangeheadpositionormiddleearpressuremaneuversthatchangeheadpositionwithoutloweringbloodpressureordecreasingcerebralbloodflowisdiagnosticAggravatingfactorsAllvertigoismadeworsebymovingthehead.Ifheadmotiondoesnotworsenthefeeling,itisprobablyanothertypeofdizziness.區(qū)分vertigo和dizziness(1)Timeco47Associatedsignsandsymptoms

Nystagmusisnotalwaysreadilyvisible,althoughitoftencanbeelicitedbyprovocativemaneuversorwithelectronystagmography.Posturalinstabilityitiscommonforpatientswithvertigotohavedifficultymaintainingsteadyuprightposturewhenwalking,standing,andevensittingunsupported,particularlywhenthesymptomsareacute.Hearinglossverysuggestiveofaperipheralcauseofvertigo,althoughtheirabsencedoesnotexcludethediagnosisBrainstemsignsThepresenceofadditionalneurologicsignsstronglysuggeststhepresenceofacentralvestibularlesion.區(qū)分vertigo和dizziness(2)Associatedsignsandsymptoms

4898年?？谱o理師訓(xùn)練神經(jīng)系統(tǒng)常見問題之評估(一)課件49PeripheralvertigoPeripheralvertigo50BenignparoxysmalpositionalvertigoThemostcommonformofpositionalvertigo,accountingfornearly1/2ofpatientswithperipheralvestibulardysfunctionMostcommonlyattributedtocalciumdebriswithintheposteriorsemicircularcanal,knownascanalithiasisposteriorcanalBPPVmoreoftenthantheanterior(superior)andhorizontalsemicircularcanalsSymptomsrecurrentepisodesofvertigolastingoneminuteorlessprovokedbyspecifictypesofheadmovementstypicallyrecurperiodicallyforweekstomonthswithouttherapymaybeassociatedwithnauseaandvomitinghavenootherneurologiccomplaintsBenignparoxysmalpositionalv51Dix-HallpikemaneuverWiththepatientsitting,theneckisextendedandturnedtooneside.Thep’tisthenplacedsupinerapidly,sothattheheadhangsovertheedgeofthebed.Thepatientiskeptinthispositionandobservedfornystagmusfor30seconds.Nystagmususuallyappearswithalatencyofafewsecondsandlastslessthan30seconds.Ithasatypicaltrajectory,beatingupwardandtorsionally,withtheupperpolesoftheeyesbeatingtowardtheground.Afteritstopsandthepatientsitsup,thenystagmuswillrecurbutintheoppositedirection.Therefore,thepatientisreturnedtouprightandagainobservedfornystagmusfor30seconds.Ifnystagmusisnotprovoked,themaneuverisrepeatedwiththeheadturnedtotheotherside.Ifnystagmusisprovoked,thepatientshouldhavethemaneuverrepeatedtothesame(provoked)side;witheachrepetition,theintensityanddurationofnystagmuswilldiminish.Dix-HallpikemaneuverWiththe52VestibularneuritisViralorpostviralinflammatorydisorderaffectingthevestibularportionoftheeighthcranialnerveSymptomsSapidonsetofseverevertigonausea,vomitinggaitinstability.preservedabilitytoambulate.towardtheaffectedsidehavenootherneurologiccomplaintsSignsSpontaneousvestibularnystagmusunilateral,horizontal,orhorizontal-torsionalsuppressedwithvisualfixationdoesnotchangedirectionwithgazefastphaseofnystagmusbeatsawayfromtheaffectedside.VestibularneuritisViralorp53Meniere'sdiseaseArisefromabnormalfluidandionhomeostasisintheinnerearendolymphatichydropswithdistortionanddistentionofthemembranous,endolymph-containingportionsofthelabyrinthinesystemSyndromeepisodicvertigoassociatedwithnauseaandvomiting,andpersistsfrom20minutesto24hoursdurationSgressesovertime,andoftenresultsinpermanenthearinglossatallfrequenciesintheaffectedearoveran8to10yearperiodtypicallyassociatedwithintenseauralfullnessorpressureintheearorthesideoftheheadTinnituscharacteristicallylowpitchmaybeassociatedwithauditorydistortionMeniere'sdiseaseArisefroma54CentralvertigoCentralvertigo55Lateralmedullaryinfarction

WallenbergsyndromeIpsilateralHorner'ssyndromeDissociatedsensoryloss(lossofpainandtemperaturesensationontheipsilateralfaceandcontralaterallimbsandtrunk)AbnormaleyemovementsIpsilaterallossofcornealreflexHoarsenessanddysphagiaIpsilaterallimbataxiaLateralmedullaryinfarction

56CerebellarstrokeVertigo,maywithnausea/vomitingLimbdysmetria,dysarthria,orheadacheUsuallyunabletostandorwalkunsupportedThedirectionoffallingisnotnecessarilyoppositetothedirectionofthenystagmusNystagmusotherthanhorizontalorhorizontal-torsional,maychangedirectionwithgazenotsuppressedwithvisualfixationPatientswithavasculareventaretypicallyolderand/orhaveatherosclerosisriskfactors(hypertension,diabetes,smoking).CerebellarstrokeVertigo,may57Vestibularschwannoma(acousticneuroma)

Symptomscanbeduetocranialnerveinvolvement,cerebellarcompression,ortumorprogression.Cochlearnerve(95%)ThetwomajorsymptomswerehearinglossusuallychronicTinnituswaspresentin63percent.Vestibularnerve(61%)Unsteadinesswhilewalking,whichwastypicallymildtomoderateinnatureandfrequentlyfluctuatedinseverityTruespinningvertigowasuncommon.ThemostnondescriptvertiginoussensationsTrigeminalnerve(17%)facialnumbness(paresthesia),hypesthesia,andpain.Facialnerve(6%)facialparesisand,lessoften,tastedisturbances.Tumorprogressionpressonthecerebellumorbrainstemandresultinataxia.lowercranialnerves(nervesIX,X,andXI,leadingtodysarthria,dysphagia,aspiration,andhoarsenessBrainstemcompression,cerebellartonsilherniation,hydrocephalusanddeathcanoccurinuntreatedcases.Vestibularschwannoma(acousti58Peripheralvs.CentralvertigoNystagmusLatency2-20secondsUsually<1minFatiguability(+)Unidirectional,fastphasetowardthenormalear;neverreversesdirectionHorizontalwithatorsionalcomponent,neverpurelytorsionalorverticalvisualfixationSuppressedUnidirectionalinstability,walkingpreservedDeafnessortinnitusmaybepresentNystagmusNolatencyUsually>1minNofatiguabilitySometimesreversesdirectionwhenpatientlooksinthedirectionofslowphaseCanbeanydirectionvisualfixationNOTSuppressedSevereinstability,patientoftenfallswhenwalkingOtherneurologicsignsoftenpresentUsuallylessseverevertigoPeripheralvs.Ce59Other“dizziness”O(jiān)ther“dizziness”60PresyncopeTheprodromalsymptomoffaintingoranearfaint.SymptomsLastsforsecondstominutesandisoftenrecognizedbythepatientas"nearlyblackingout","nearlyfainting.",lightheadedness,afeelingofwarmth,diaphoresis,nausea,andvisualblurringoccasionallyproceedingtoblindnessusuallyoccurswhenthepatientisstandingorseateduprightandnotwhensupineSignsAnobservationofpallorbyonlookersAhistoryofcardiacdisease,includingcardiacdysrhythmias(tachycardiasorbradyarrhythmias),coronaryheartdisease,congestiveheartfailure,isrelevantTheetiologyOrthostatichypotension,cardiacarrhythmias,andvasovagalattacks..PresyncopeTheprodromalsympto61DisequilibriumAsenseofimbalancethatoccursprimarilywhenwalkingEtiologyperipheralneuropathyamusculoskeletaldisorderinterferingwithgaitvestibulardisordercervicalspondylosisParkinsonismvisualimpairment.DisequilibriumAsenseofimbal62Nonspecificdizziness精神科疾病Oftenbuildsupgradually,waxesandwanesoveraperiodof20minutesorlonger,andgraduallyresolves1/4majordepression1/4generalizedanxietyorpanicdisorder1/2somatizationdisorder,alcoholdependence,and/orpersonalitydisorderinoneseriesCommonlyrelatedtohyperventilation;maybenosensationof"airhunger"sincethesepatientsarehyperventilatingonlytoaslightdegree頭部外傷、貧血、慢性阻塞性肺病、睡眠不足、營養(yǎng)不良、血糖過低過高、電解質(zhì)不平衡、長期在密閉的空間工作，疲倦加上工作場所的不良氣體（二氧化碳、油漆、塗料、麥克筆、修正液、印表機的碳粉油墨…）藥物(例降血壓藥、鎮(zhèn)定劑、酒精、帕金森氏癥藥物、精神用藥、抗生素..)Nonspecificdizziness精神科疾病63ApproachpatientswithdizzinessApproachpatientswithdizzine64焦點病史Dizziness?Vertigo?Onset(posture),duration,course,aggravatingfactor,relievingfactorAssociatedSymptomsVomiting?Headache?Visualloss(black-orwhite-out)?Hearingloss?Palpitations?Chestdiscomfort?Dyspnea?Staggeringorataxicgait?Doublevision?Slurredspeech?Numbness/weaknessofthefaceorbody?Clumsiness,orincoordination?Medications/Substance焦點病史Dizziness?Vertigo?65焦點身體檢查PhysicalexaminationPulserateandBPHeadandneckEyes:conjunctivapaleornot,visualacuityEar:tenderness/dischargeNeck:pain/ROMlimitationExtremitiesJointspain/deformity焦點身體檢查Physicalexamination66NeurologicalexaminationConsciousnesslevel/contentCranialnervesEOMlimitationFacialsensation,cornealreflexNystagmus,hearingFacialpalsy,gagreflex,tonguedeviationMotorsystemMusclepowerDTRSensorysystemPinprick,lighttouchCoordinationsystemF-N-F/H-K-StestGaitNeurologicalexamination67VIII聽平衡神經(jīng)聽力Rinnetest:AC>BCWebertest:中央或偏向眼振00000←←←線條越粗代表幅度越大箭頭越多代表速度越快小腦,腦幹或平衡神經(jīng)問題皆有可能出現(xiàn)眼振區(qū)分中耳問題或聽神經(jīng)問題VIII聽平衡神經(jīng)00000←←←線條越粗代表幅度越大小6898年?？谱o理師訓(xùn)練神經(jīng)系統(tǒng)常見問題之評估(一)課件69血液檢查CalorictestTheheadofthepatientshouldbetiltedat30oWhenwarmwaterat44oCisinfusedintoanear,thenormalresponseisnystagmuswiththefastcomponenttowardtheinfusedear.Whencoldwaterat30oCisinfused;thenormalresponseisnystagmuswiththefastcomponentawayfromthecoldwater-infusedear.Audiometry

聽力檢查Brainstemauditoryevokedpotentials

腦幹聽覺誘發(fā)電位Electronystagmography

眼振圖檢查影像學(xué)檢查對於後顱窩的病灶MRI優(yōu)於CT實驗室與診斷檢查血液檢查實驗室與診斷檢查70Short-latencycomponentsofBAEPShort-latencycomponentsofBA71Dizziness-CasesdiscussionDizziness-Casesdiscussion72CASE165y/omale,DMandH/Tpoorcontrol

Acutevertigoandunsteadinesssinceyesterdaymorning(notedwhilegettingup)TendtodeviatetorightsidewhilewalkingCan’tusechopstickeswellwhileeatingRightoccipitaldullheadache(+),nausea(+)Novomiting,notinnitusNolimbsweaknessornumbness,nosphincterproblemNoottohrea,earpain,drugusageorsignificantinfectionepisodeLMDMxineffective,thusvisitourERCASE165y/omale,DMandH/T73SummaryofN.E.HearingnormalGaze-evokednystagmus,fastphasetoleftsideNormalmusclepowerandsensationRightlimbsdysmetriaanddysdiadochokinesiaTendsdeviatetorightsidewhilestandingandwalkingSummaryofN.E.Hearingnormal74Rightcerebellarhemisphereinfarct

Rightcerebellarhemispherei75CASE220y/ofemale,nosignificantpasthistory

ProgressiveR’thearingimpairmentsinceabout4yearsagoIntermittentvertigo,R’ttinnitusassociatedwithunsteadinesswhilechangingpositioninrecent1year,withincreasingfrequencyMouthangledeviatetoL’t,mildslurredspeechandoccasionalchokinginrecent1monthDeniedfacialnumbnessanddoublevisionNolimbsweaknessornumbness,nosphincterproblemNoottohrea,earpain,drugusageorsignificantinfectionepisodeCASE220y/ofemale,nosignif76SummaryofN.E.Cranialnervesinvolvement R’tFacial(VII)nervepalsy R’tVestibulocochlear(VIII)nerveSuspiciousCrNIX,Xinvolvement(accordingtohistory)Noobviouspyramidalsysteminvolvement00SummaryofN.E.Cranialnerves77Hugerightacousticneuroma

withbrainstemandcerebellarcompressionHugerightacousticneuroma

78ThanksForYourAttention~ThanksForYourAttention~79需要立刻求醫(yī)的頭痛警訊任何突發(fā)性嚴重的頭痛。頭痛伴隨抽筋的現(xiàn)象。頭痛伴隨有發(fā)燒的現(xiàn)象。頭痛伴隨神智不清。頭痛伴隨昏迷。頭部外傷以後的疼痛。以前不頭痛，現(xiàn)在突然發(fā)生的頭痛。以前有頭痛，但現(xiàn)在的型態(tài)改變?？人浴⒂昧驈澭臅r候，其頭痛增加。頭痛導(dǎo)致半夜醒來。頭痛伴隨著眼睛或耳朵的疼痛。頭痛伴隨著頸部僵硬。需要立刻求醫(yī)的頭痛警訊任何突發(fā)性嚴重的頭痛。8098年專科護理師訓(xùn)練神經(jīng)系統(tǒng)常見問題之評估(一)課件8198年?？谱o理師訓(xùn)練神經(jīng)系統(tǒng)常見問題之評估(一)課件8298年?？谱o理師訓(xùn)練

神經(jīng)系統(tǒng)常見問題之評估(一)頭痛Headache頭暈Dizziness成大醫(yī)院神經(jīng)科黃涵薇醫(yī)師98年?？谱o理師訓(xùn)練

神經(jīng)系統(tǒng)常見問題之評估(一)頭痛H83頭痛Headache頭痛Headache84Pain-sensitivecranialstructures顱外Skin,subcutaneoustissues,musclesextracranialarteries,periosteumofskullEye,earnasalcavitiesperinasalsinuses顱內(nèi)血管Intracranialvenoussinusesandtheirlargetributaries,esp.pericavernousstructuresArterieswithintheduraandpia-subarachnoid,particularytheproximalpartsoftheACA,MCAandtheintracranialsegmentofICAThemiddlemeningealandsuperficialtemporalarteries腦膜Partsoftheduraatthebaseofthebrain顱神經(jīng)Theoptic,oculomotor,trigeminal,glossopharyngeal,vagus,(andthefirstthreecervicalnerves)Pain-sensitivecranialstructu85FromsupratentorialstructuresAnterior2/3ofhead(V1,V2dermatones)FrominfratenotrialstructuresVertex,posteriorheadandneckFromVII,IX,XcranialnervesNaso-orbitalregion,ear,throatPainfromextracrainalpartofbodyNOTrefertohead,EXCEPTCervicalportionofICAEyebrow,supraorbitalregionUppercervicalspineocciputAnginapectoris(rare)Jaw,vertexAreasofreferpainfromintracranialstructuresFromsupratentorialstructures86?國際頭痛疾病分類?ICHD

(InternationalClassificationofHeadacheDisorders)第一版在1988年公布，第二版於2004年刊登於Cephalalgia雜誌。不論是中文版或英文版的?國際頭痛疾病分類?都長達一百五十頁以上!在英文版第二版中，作者建議－?這份內(nèi)容龐大的分類文件不是用來背的，這是一份須要一次又一次不斷查看的文件。??國際頭痛疾病分類?ICHD

(Internationa87原發(fā)性(Primary)次發(fā)性(Secondary)以決定頭痛的原因及訂定適切的治療計畫頭痛Headache原發(fā)性(Primary)頭痛Headache88原發(fā)性頭痛(primaryheadache)意謂頭痛本身即為痛的成因。超過百分之九十的頭痛患者屬於此類。重點就是排除次發(fā)性的可能。原發(fā)性頭痛(primaryheadache)意謂頭痛本身89無預(yù)兆偏頭痛

Migrainewithoutaura

A.至少有5次能符合基準B-D的發(fā)作B.

頭痛發(fā)作持續(xù)4-72小時(未經(jīng)治療或治療無效)C.頭痛至少具下列二項特徵：1.單側(cè)2.搏動性3.疼痛程度中或重度4.日?；顒訒诡^痛加劇或避免此類活動（如走路或爬樓梯）D.當(dāng)頭痛發(fā)作時至少有下列一項：1.噁心及/或嘔吐2.畏光及怕吵E.非歸因於其他疾患無預(yù)兆偏頭痛

Migrainewithoutaura90典型預(yù)兆偏頭痛性頭痛

Typicalaurawithmigraineheadache

A.至少有2次符合基準B-D的發(fā)作B.預(yù)兆至少包括下列一項，但無肢體無力：1.完全可逆視覺癥狀，包括正向特徵(如：閃爍的光、點或線)及/或負向特徵(即視力喪失)2.完全可逆感覺癥狀，包括正向特徵(即針刺感)及/或負向特徵(即麻木感)3.完全可逆失語性語言障礙C.至少具下列2項：1.單側(cè)的視覺癥狀及/或單側(cè)感覺癥狀2.至少一種預(yù)兆癥狀在≧5分鐘逐漸產(chǎn)生，及/或不同預(yù)兆癥狀，在≧5分鐘相繼發(fā)生3.每一種癥狀持續(xù)≧5及≦60分鐘D.符合無預(yù)兆偏頭痛基準B-D的頭痛，在預(yù)兆同時或預(yù)兆之後的60分鐘內(nèi)發(fā)生E.非歸因於其他疾患典型預(yù)兆偏頭痛性頭痛

Typicalaurawith91緊縮型頭痛

Tension-typeheadache

A.Frequent:至少有十次能符合基準B-D之發(fā)作，且發(fā)作平均每月≧1日但＜15日，已至少三個月（每年≧12日且＜180日,頭痛持續(xù)30分鐘至7日

Chronic:頭痛平均發(fā)作每月≧15日，已＞3個月（每年≧180日）且符合基準B-D,頭痛持續(xù)數(shù)小時或可能持續(xù)不斷B.

頭痛至少具下列二項特徵：1.雙側(cè)2.壓迫/緊縮性（非搏動性）3.程度輕或中度4.不因日?；顒尤缱呗坊蚺罉翘荻觿.下列兩項皆符合：1.無噁心或嘔吐（可能有食慾不振）2.最多只有畏光或怕吵其中一項癥狀D.非歸因於其他疾患緊縮型頭痛

Tension-typeheadacheA92叢發(fā)性頭痛

Clusterheadache

A.至少有5次符合基準B-D之發(fā)作B.位於單側(cè)眼眶、上眼眶及/或顳部重度或極重度疼痛，如不治療可持續(xù)15至180分鐘C.

頭痛時至少伴隨下列一項：1.同側(cè)結(jié)膜充血及/或流淚2.同側(cè)鼻腔充血及/或流鼻水3.同側(cè)眼皮水腫4.同側(cè)前額及臉部出汗5.同側(cè)瞳孔縮小及/或眼皮下垂6.不安的感覺或躁動D.發(fā)作頻率為每二日一次至每日八次E.非歸因於其他疾患叢發(fā)性頭痛

ClusterheadacheA.至少有93典型三叉神經(jīng)痛

Classicaltrigeminalneuralgia

A.發(fā)作性(paroxysmal)疼痛發(fā)作，持續(xù)由不到一秒到兩分鐘，影響三叉神經(jīng)一支或一支以上分支的支配區(qū)，且符合基準B及CB.疼痛至少具下列一項特徵：1.劇烈、尖銳、表淺或刺戳痛2.於誘發(fā)區(qū)引發(fā)或由誘因引發(fā)C.就個別病人而言，疼痛的發(fā)作型態(tài)是固定(stereotyped)的D.沒有神經(jīng)功能缺損的臨床證據(jù)E.非歸因於其他疾患典型三叉神經(jīng)痛

Classicaltrigeminal94次發(fā)性頭痛(Secondaryheadache)意謂頭痛由其他原因所引起頭部與頸部外傷顱部或頸部血管疾患非血管性顱內(nèi)疾患物質(zhì)或物質(zhì)戒斷感染體內(nèi)恆定疾患頭顱,頸,眼,鼻,耳,口,鼻竇,牙或其他面部或顱部結(jié)構(gòu)疾患精神疾患?國際頭痛疾病分類?ICHDII需治療引起頭痛之原因。次發(fā)性頭痛(Secondaryheadache)意謂頭痛95與腦瘤相關(guān)的頭痛Thepainhasnospecificfeaturestendtobedeep-seated,u