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,armandthelegononeorbothsidesofthebodyLossofspeech,ordifficultyspeakingorunderstandingspeechDimnessorlossofvision,particularlyinonlyoneeyeUnexplaineddizziness(especiallywhenassociatedwithotherneurologicsymptoms)unsteadiness,orsuddenfallsSuddensevereheadacheand/orlossofconsciousnessEVALUATIONVitalsignsConsciousnessCranialnerveMotorSensoryHighcorticalfunctionCranialnerveCN2:visualfield,lightreflexCN3,4,6:extra-ophthalmicmuscle,nystagmusCN5:facialsensation,massetermuscleCN7:facialexpressionCN8:audiotory/vestibularCN9,10:swallow,gagreflexCN11:sternocleidomastoideusCN12:tonguemovementMotorMusclepower/muscletoneDTR/pathologicreflexBarbinskin’ssignHolfmann’ssignInvoluntarymovementTremorClonus/MyoclonusChoreaCerebellarsign:Finger-nose-fingerRombergtestGaitSensorynumbnessParesthesiaPain/temperatureJointposition/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:JudgementOrientationMemoryAbstractthinkingCalculationLossofConsciousnessVitalsignLightreflex/TreatentestEyemovement/Doll’seyesignFacialnerveGagreflexExtremitiesmovement/stimulationDTR/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HemiplegiabrainparaplegiaspinalcordNIHSS1aLevelofCons.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/dl13.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),INR1.315.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