脑中风的神经学检查及评估

NEUROLOGYR1陳安芝2008/08/05腦中風的神經學檢查及評估檢查的原則原有功能喪失額外的症狀運動/感覺Suddenweakness,paralysis,ornumbnessoftheface,armandthelegononeorbothsidesofthebodyLossofspeech,ordifficultyspeakingorunderstandingspeechDimnessorlossofvision,particularlyinonlyoneeyeUnexplaineddizziness(especiallywhenassociatedwithotherneurologicsymptoms)unsteadiness,orsuddenfallsSuddensevereheadacheand/orlossofconsciousnessEVALUATIONVitalsignsConsciousnessCranialnerveMotorSensoryHighcorticalfunctionCranialnerveCN2:visualfield,lightreflexCN3,4,6:extra-ophthalmicmuscle,nystagmusCN5:facialsensation,massetermuscleCN7:facialexpressionCN8:audiotory/vestibularCN9,10:swallow,gagreflexCN11:sternocleidomastoideusCN12:tonguemovementMotorMusclepower/muscletoneDTR/pathologicreflexBarbinskin’ssignHolfmann’ssignInvoluntarymovementTremorClonus/MyoclonusChoreaCerebellarsign:Finger-nose-fingerRombergtestGaitSensorynumbnessParesthesiaPain/temperatureJointposition/vibrationHighcorticalfunction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:JudgementOrientationMemoryAbstractthinkingCalculationLossofConsciousnessVitalsignLightreflex/TreatentestEyemovement/Doll’seyesignFacialnerveGagreflexExtremitiesmovement/stimulationDTR/pathologicreflex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Strokeinhospital身體約束時，注意四肢動作HemiplegiabrainparaplegiaspinalcordNIHSS1aLevelofCons.AlertDrowsyStuporousComatous01231bLOCquestions(月/年齡)AnswersbothcorrectlyAnswersonecorrectlyBothincorrect0121cLOCcommands(睜閉眼/握放拳)ObeysbothcorrectlyObeysonecorrectlyBothincorrect0122BestgazeNormalPartialgazepalsyForceddeviation0123VisualfieldNovisuallossPartialhemianopsiaCompletehemianopsiaBilateralhemianopsia01234FacialparesisNormalmovementMinorparesisPartialparesisCompleteparesis01235aMotorarmleftNodriftDriftSomeeffortagainstgravityNoeffortagainstgravityNomovementAmputation,jointfusion..01234-5bMotorarmrightNodriftDriftSomeeffortagainstgravityNoeffortagainstgravityNomovementAmputation,jointfusion01234-6aMotorlegleftNodriftDriftSomeeffortagainstgravityNoeffortagainstgravityNomovementAmputation,jointfusion01234-6bMotorlegrightNodriftDriftSomeeffortagainstgravityNoeffortagainstgravityNomovementAmputation,jointfusion01234-7LimbataxiaAbsentPresentinonelimbPresentin2ormorelimbsAmputation,jointfusion..012-8SensoryPartiallossDenseloss0129BestlanguageNoaphasiaMildtomoderateaphasiaSevereaphasiaMute,globalaphasia012310DysarthriaNormalarticulationMildtomoderatedysarthriaSevere/MuteVentilator/Endo..012-11ExtinctionandinattentionNoabnormalPartialneglectCompleteneglect012A.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NIHSS6分）。3.臨床(例如NIHSS25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),INR1.3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THANKYOU!!TheEnd