Transcript 腦中風的神經學檢查及評估

腦中風的神經學檢查及評估
NEUROLOGY R1 陳安芝
2008/08/05
檢查的原則
 原有功能喪失
 額外的症狀
 運動/感覺
 Sudden weakness, paralysis, or numbness of the face,
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arm and the leg on one or both sides of the body
Loss of speech, or difficulty speaking or understanding
speech
Dimness or loss of vision, particularly in only one eye
Unexplained dizziness (especially when associated with
other neurologic symptoms) unsteadiness, or sudden
falls
Sudden severe headache and/or loss of consciousness
EVALUATION
 Vital signs
 Consciousness
 Cranial nerve
 Motor
 Sensory
 High cortical function
Cranial nerve
 CN 2: visual field, light reflex
 CN 3, 4, 6: extra-ophthalmic muscle, nystagmus
 CN 5: facial sensation, masseter muscle
 CN 7: facial expression
 CN 8: audiotory/vestibular
 CN 9, 10: swallow, gag reflex
 CN 11: sternocleidomastoideus
 CN 12: tongue movement
Motor
 Muscle power/muscle tone
 DTR/ pathologic reflex
 Barbinskin’s sign
 Holfmann’s sign
 Involuntary movement
 Tremor
 Clonus/Myoclonus
 Chorea
 Cerebellar sign:
 Finger-nose-finger
 Romberg test
 Gait
Sensory
 numbness
 Paresthesia
 Pain/temperature
 Joint position/vibration
High cortical function
 左腦(優勢半球): 語言
 右腦:視覺、立體感覺半邊忽略
 失語症
 失用症
 人格異常
 JOMAC:
Judgement
Orientation
Memory
Abstract thinking
Calculation
Loss of Consciousness
 Vital sign
 Light reflex/ Treaten test
 Eye movement/Doll’s eye sign
 Facial nerve
 Gag reflex
 Extremities movement/ stimulation
 DTR/ pathologic reflex
衛教
 微笑測試：
叫病人微笑或秀出牙齒，看嘴角有無歪斜。
 舉手測試：
叫病人雙眼閉合，雙手手心朝上，向前平舉約10秒，
看患側有無垂下。
 言語測試：
叫病人說話或唸報紙，看是否流暢。
腦中風發作的徵兆
1. 臉部或一側肢體突然感到無力或麻木。
2. 突然視力模糊、多重影像
或是一隻眼睛一邊視野看不到。
3. 突然出現不明原因的頭痛、頸部僵硬。
4. 突然講話字句不清或聽不懂他人所說的話。
5.無緣無故覺得暈眩、失去平衡或跌倒。
6.突發吞嚥困難、臉部發麻、聽力減退
Stroke in hospital
 身體約束時，注意四肢動作
 Hemiplegia  brain
paraplegia  spinal cord
NIHSS
1b
LOC questions
(月/年齡)
Alert
Drowsy
Stuporous
Comatous
Answers both correctly
Answers one correctly
Both incorrect
1c
LOC commands
(睜閉眼/握放拳)
Obeys both correctly
Obeys one correctly
Both incorrect
1a
Level of Cons.
2
Best gaze
3
Visual field
4
Facial paresis
Normal
Partial gaze palsy
Forced deviation
No visual loss
Partial hemianopsia
Complete hemianopsia
Bilateral hemianopsia
Normal movement
Minor paresis
Partial paresis
Complete paresis
No drift
Drift
Some effort against gravity
No effort against gravity
No movement
Amputation, joint fusion..
No drift
Drift
0 5b
Some effort against gravity
1 Motor arm right No effort against gravity
2
No movement
Amputation, joint fusion
0
No drift
1
Drift
2
6a
Some effort against gravity
0
Motor leg left
No effort against gravity
1
No movement
2
Amputation, joint fusion
3
No drift
0
Drift
1 6b
Some effort against gravity
2 Motor leg right No effort against gravity
3
No movement
Amputation, joint fusion
0
1
2 5a
3 Motor arm left
0
1
2
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
-
7
Limb ataxia
8
Sensory
Absent
Present in one limb
Present in 2 or more limbs
Amputation, joint fusion..
0
1
2
-
Partial loss
Dense loss
0
1
2
No aphasia
9
Mild to moderate aphasia
Best language Severe aphasia
Mute, global aphasia
10
Dysarthria
Normal articulation
Mild to moderate
dysarthria
Severe/Mute
Ventilator/Endo..
11
No abnormal
Extinction and Partial neglect
inattention
Complete neglect
0
1
2
3
0
1
2
0
1
2
A. 收案條件 (必須均為“是”)
是否
  1. 臨床懷疑是急性缺血性腦中風，中風時間明確在3小時內
  2. 腦部電腦斷層沒有顱內出血
  3. 年齡在18歲到80歲之間
B. 排除條件 (必須均為“否”)
是否
  1. 輸注本藥前，缺血性發作的時間已超過3小時或症狀發作時間不明
  2. 輸注本藥前，急性缺血性中風的症狀已迅速改善或症狀輕微（例如NIHSS < 6分）。
  3. 臨床(例如NIHSS>25分)及/或適當之影像術評估為嚴重之中風(電腦斷層大於1/3中大
腦動脈灌流區之低密度變化)。
  4. 中風發作時病發癲癇
  5. 最近3個月內有中風病史或有嚴重性頭部創傷
  6. 過去曾中風且合併糖尿病
  7. 中風發作前48小時內使用heparin, 目前病人活化部份凝血酶原時間(aPTT)之值過高
  8. 血小板 < 10萬
  9. 活動性內出血
  10.顱內腫瘤、動靜脈畸形或血管瘤
  11.收縮壓>185或舒張壓>110mmHg,或需要積極的治療(靜脈給藥)以降低血壓至前述界
限以下
  12.血糖 < 50或> 400mg/dl
  13.目前或過去6個月內有顯著的出血障礙、易出血體質
  14.病人正接受抗凝血劑(如warfarin), INR>1.3
  15.中樞神經系統損害之病史(腫瘤、血管瘤、顱內或脊柱的手術)
  16.懷疑或經證實包括SAH之顱內出血或其病史
  17.嚴重且未被控制的動脈高血壓
  18.過去10天內曾動過大手術或有嚴重創傷(包括最近之急性心肌梗塞所伴隨的任何創
傷)，最近頭部或顱部曾發生創傷
  19.過久的或創傷性的心肺甦醒術(超過2分鐘)、分娩、過去10天內曾對無法壓制之部
位施行血管穿刺(如鎖骨下靜脈或頸靜脈穿刺)
  20.嚴重肝病，包括肝衰竭、肝硬化、肝門脈高壓(食道靜脈
曲張)及急性肝炎
  21.出血性視網膜病變，如糖尿病性(視覺障礙可能為出血性視網膜病變的指標)或其他
出血性眼疾
  22.細菌性心內膜炎，心包炎
  23.急性胰臟炎
  24最近3個月內曾患胃腸道潰瘍
  25.動脈瘤動靜脈型畸形
  26.易出血之腫瘤
  27.對本藥之主成分Actilyse或賦型劑過敏者
  28.其他(例如在排除條件未提到但會增加出血危險的狀況，如洗腎患者、嚴重心衰竭
或身體太衰弱者
The End
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