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Handbook on Clinical Neurology and Neurosurgery Alekseenko YU.V. HANDBOOK ON CLINICAL NEUROLOGY AND NEUROSURGERY FOR STUDENTS OF MEDICAL FACULTY Vitebsk - 2005 УДК 616.8+616.8-089(042.3/;4) ~ А 47 Алексеенко Ю.В. А47 Пособие по неврологии и нейрохирургии для студентов факуль­ тета подготовки иностранных граждан: пособие / составитель Ю.В. Алексеенко. - Витебск: ВГМ У, 2005,- 495 с. ISBN 985-466-119-9 Учебное пособие по неврологии и нейрохирургии подготовлено в соответствии с типовой учебной программой по неврологии и нейрохирургии для студентов лечебного факультетов медицинских университетов, утвержденной Министерством здравоохра­ нения Республики Беларусь в 1998 году В учебном пособии представлены ключевые разделы общей и частной клиниче­ ской неврологии, а также нейрохирургии, которые имеют большое значение в работе врачей общей медицинской практики и системе неотложной медицинской помощи: за­ болевания периферической нервной системы, нарушения мозгового кровообращения, инфекционно-воспалительные поражения нервной системы, эпилепсия и судорожные синдромы, демиелинизирующие и дегенеративные поражения нервной системы, опу­ холи головного мозга и черепно-мозговые повреждения. Учебное пособие предназначено для студентов медицинского университета и врачей-стажеров, проходящих подготовку по неврологии и нейрохирургии. if' \ * /’ L ^ ' i L " / УДК 616.8+616.8-089(042.3/.4) ББК 56.1я7 б.:: удгритний I ISBN 985-466-119-9 2 CONTENTS Abbreviations 4 Motor System and Movement Disorders 5 Motor Deficit 12 Movement (Extrapyramidal) Disorders 25 Ataxia 36 Sensory System and Disorders of Sensation 46 Disorders of Cranial Nerves Functions 60 Cerebral Cortex and Neuropsychological Disorders 119 Dementia and Amnestic Syndromes 146 Coma 168 Intracranial Pressure, Cerebral Oedema, Hydrocepha­ 178 lus Headache and Facial Pain 198 Meningitis and Encephalitis 222 Peripheral Nerves Lesions 242 Stroke and Vascular Dementia 279 Epilepsy, Seizure and Syncope 328 Multiple Sclerosis and Demielinating Diseases 354 Amyotrophic Lateral Sclerosis 370 Spinal Cord Disorders 376 Movement Disorders 387 Myasthenia Gravis 412 Myopathic Disorders 417 Traumatic Brain Injury 421 Brain Tumours 447 Lumbar Disc Disease 463 Neurologic Examination 470 Lumbar Puncture 490 Literature 495 3 ABBREVIATIONS ADC Activated diffusion coefficients AIDS Immunodeficiency syndrome AVM Arteriovenous malformation BDNF Brain-derived neurotrophic factor CBF Cerebral blod flow CCF Carotid-cavernous fistulae CNS Central nervous system CSF Cerebrospinal fluid CT Computed tomography DWI Diffusion-weighted imaging EEG Electroencephalography EMG Electromyogram ESR Erythrocyte sedimentation rate GCS Glasgow coma scale HBO Hyperbaric oxygen HMSN Hereditary motor and sensory neuropathies ICH Intracerebral haemorrhage ICP Intracranial pressure MLF Medial longitudinal fasciculus MR1 Magnetic resonance imagine MRN Magnetic resonance neurography MS Multiple sclerosis NCS Nerve conduction studies NGF Nerve growth factor PCNSL Primary CNS lymphoma PNET Primitive neuroectodermal tumor SABP Systemic arterial blood pressure SAH Subarachnoid haemorrhage SIADH Syndrome of inappropriate secretion of antidiuretic hormone SLE Systemic lupus erythematosus SMA Supplementary motor area SSEP Somatosensory evoked potential STN Subthalamic nucleus TBI Traumatic brain injury 4 MOTOR SYSTEM AND MOTOR DISORDERS The spinal cord anterior horn cells are influenced by descending pathways from the cerebral cortex and from brainstem centres. These motor cortical and brainstem outflow areas are regulated by other cortical areas, the basal ganglia and cerebellum. The basal ganglia and the cerebellum are both characterized by parallel processing of inputs from cortical areas and subsequent projection back to cortex via thalamic relay nuclei. MOTOR CORTEX There are several motor cortical areas in the human; these are classified simply as the primary motor cortex, lateral pre-motor cortex, supplementary mo­ tor area (SMA), and motor regions of the cingulate cortex. The primary motor cortex (Brodmann's area 4) pyramidal cells are the principal source of the pyramidal tract but also project to other motor cortical areas and to sensory cortex, the thalamus, the basal ganglia (corpus striatum), the red nucleus, brainstem reticular nuclei, and the cerebellum (via the cortico­ pontine fibres and pontine nuclei). The primary motor cortex shows a soma- totopic organization but pyramidal cells may activate more than one muscle and a muscle may be affected by pyramidal cells spread over a wide cortical area. Primary motor cortex cells are activated prior to and during voluntary contralat­ eral movement, as shown by functional imaging and neurophysiological event- related recordings. Lesions of the primary motor cortex are associated princi­ pally with deficits of small accurate finger and hand movements. Such move­ ments require motor cortex outputs not only to agonist muscle spinal motor neu­ rons but also those needed to regulate the activity of antagonists and muscles needed to stabilize proximal joints. The lateral pre-motor cortex (the lateral part of Brodmann's area 6) is lo­ cated on the lateral aspect of the frontal lobe, anterior to the primary motor cor­ tex. There are two discreet motor areas (superior and inferior) within the lateral premotor cortex with separate motor cortical maps and corticospinal projections. There is a considerable output from the lateral pre-motor cortex to the medial brainstem tegmentum which projects to the spinal cord in the ventromedial de­ scending system (see below). The pre-motor cortex is important for the control of axial and proximal limb movements and also for the control of movements in response to external cues or instructions. The activation of the lateral pre-motor cortex begins prior to the execution of movement, suggesting an important role in preparation for movement, and may be bilateral. Lesions of the lateral pre­ 5 motor area produce proximal limb weakness and impairment of movements re­ quiring use of the whole arm and hand. There is also impaired learning of motor responses to external cues. The SMA (medial part of Brodmann's area 6) is on the inner aspect of the frontal lobe, anterior to area 4 and continuous with the lateral pre-motor cortex. The SMA receives considerable basal ganglia inputs and has outputs to the pri­ mary motor cortex, corticospinal tract, basal ganglia, cerebellum, red nucleus, and reticular formation. Like the lateral pre-motor cortex, the SMA seems to be important for the preparation of movements, particularly internally generated, learned, sequential, or bimanual movements. SMA lesions lead to difficulty ini­ tiating speech and movement, impaired bimanual co-ordination, and the 'alien limb' phenomenon where the arm moves spontaneously in response to external stimuli, grasping at objects spontaneously. This may represent a dissociation of externally (lateral pre-motor cortex) and internally (SMA) cued movement. Cingulate motor areas have been identified in humans and non-human primates. They have outputs to spinal cord and the basal ganglia and receive in­ puts from frontal pre-motor cortex. Cingulate motor neurons are active in inter­ nally generated movements and cingulate activation is seen mainly with com­ plex motor tasks. Stimulation of cingulate cortex produces complex motor activ­ ity. The descending pathways The descending pathways are grouped into two divisions within the spinal cord. A dorso-lateral group contains the lateral corticospinal tract along with the rubrospinal tract and the crossed reticulospinal tract (from the lateral pontine tegmentum). These dorso-lateral pathways are concerned with distal move­ ments. The ventro-lateral group is made up of the ventral corticospinal tract with the interstitiospinal, vestibulospinal, and reticulospinal (from medial pontine and medullary tegmentum) tracts and is involved in the control of proximal move­ ments. The pyramidal tract comprises the corticobulbar and corticospinal tracts and in the human, the latter component contains about one million fibres on each side. About 60 per cent of the fibres in the corticospinal tract originate in the frontal motor areas. The remainders are from parietal and somatosensory cortex. The corticospinal tract influences spinal afferent pathways, inhibitory interneu­ rons, and gamma efferent cells as well as the alpha motor neurons. There is con­ siderable convergence and divergence within the corticospinal tract; cortical py­ ramidal cells project to several muscles and each muscle can be activated by cells from a large cortical motor field. Direct synapses with alpha motor neurons are particularly dense on cells concerned with finger movements and there is a close association between the corticospinal tract and the execution of fine finger movements. Lesions of'the pyramidal tract tend to produce impaired manual dexterity with variable degrees of weakness. 6 Other descending pathways are poorly understood in man. The reticu­ lospinal pathway appears to be important in the startle reflex. Vestibulospinal pathways are concerned in part with postural control. THE CEREBELLUM AND BASAL GANGLIA Neither the cerebellum nor the basal ganglia have direct efferent connec­ tions to the spinal motor apparatus and yet both are clearly involved in the cor­ rect execution and control of movement. Profound disturbances of movement as their primary symptoms we can find in patients with lesions of these structures. Anatomically, both structures are characterized by extensive inputs from the cerebral cortex, parallel internal
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