k5 - disorders of autonomic nervous system.ppt
TRANSCRIPT
DISORDERS OF AUTONOMIC NERVOUS
SYSTEMBY
Dr. Puji Pinta O. Sinurat, Sp S.
Neurology Departement/ Medical Faculty Sumatera Utara University
MEDAN
THE AUTONOMIC NERVOUS SYSTEM
The Autonomic (visceral) Nervous System (ANS)
Control the target tissue involuntarily
- cardiac muscle - visceral smooth muscle - glands - maintain a constant internal body
environment (homeostasis)
Contrasting the Somatic and Autonomic Nervous System
Peripheral Nervous System: 1. Sensory neuron: act pot: periphery
CNS2. Motor neuron: act pot: CNS periphery. a.Somatic motor neuron innerv skeletal
m b. Autonomic motor neuron
innvervate smooth m, cardiac m and glands.
Somatic motor neuron - cell bodies : in the CNS - axon : extend from CNS to skeletal m.- innerv : skeletal muscle
Autonomic motor neuron has 2 neurons: 1. Preganglionic neuron - cell body : in the CNS (within brainstem or spinalcord) axon extend to autonomic ganglia (located outside the CNS)2. Postganglionic neuron - cell body : in the autonomic ganglia axon extend to effector organ--- innerv : smooth m, cardiac muscle and glands.
AUTONOMIC NERVOUS SYSTEM Anatomically : 2 major division:
1.Sympathetic (Thoracolumbar) division
2.Parasympathetic (Craniosacral) division
Central & Peripheral Component
Central component: Hypothalamus Cerebral Cortex Hypophyse Mesencephalon and Brain stem Spinal cord Peripheral component : N III, VII, IX dan X Preganglion, ganglion,postganglion S2 –
S4 Preganglion, ganglion,postganglion T1 –
L2
Neurotransmitter SSO Cholinergic Neuron Acetylcholine at all pregangl endings (Sympathetic &
Parasympathetic preganglionic neuron) parasympathetic postganglionic neuron Sympathetic postgagl that project to sweat
gld or mediate vasodilation Adrenergic Neuron Norepinephrine is the chemical transmitter at most
sympathetic postganglionic endings.
Sympathetic N S Pathway The cell bodies of sympathetic
preganglionic neuron: in the lateral horns of sp cord graymatter between T1-L2 segment (Thoracolumbar division)
Axon pregl ventral root T1-L2 course thrgh spinal nerve (white ramus communicans autonomic ganglia (sympathetic chain ganglia = paravertebral gangl= sympathetic trunk gang) postgangl (gray ramus communicans) --> visceral organ
Sympathetic Nervous System Pregang T1 Trunkus gang
Superior symp ganglion Postgang Pupillary dilator m, Lacrimal gld & nasal gld, Submaxill & subling gld, Parotid gld.
Pregang T1-5 Trunkus gang post gang Heart and Lungs
Pregang T5-9 Trunkus Gang Celiac ganglion postgang innerv: stomach,liver,pancreas,spleen
Pregang T9-10 postgang innerv adrenal medulla.
Pregang T10-12 Trunkus gang sup mesenteric gang Postgang innerv small intestine, colon.
Pregang L1-2 Trunkus gang inf mesenteric ganglion postgang, innerv : colon,kidney and bladder
Pregang L2 Trunkus gang postgang innerv sex organ
Peripheral Sympathetic Nervous System Dysfunction
Horner’s Syndrome damage of: Pregang T 1 nerve fibres Superior cervicalis ganglion sympathetic postgang fibres Clinically: Unilateral Enophthalmos Ptosis Myosis Anhydrosis (loss of sweating) ------
over the ipsilateral half of the face or forehead.
Disturbances of sweat gld secretion
Hypo/anhydrosis perspiration test Hyperhidrosis (excessive sweating) caused
by exagregated symph innerv of the sweat gld
Orthostatic Hypotension is a drop in BP from sitting/lying down suddenly stands up. - failure of the vessels of lower extremity to constrict venous return & CO decreased BP ↓ CBF ↓ fainting
Causalgia : painful cond of the hands or feet, caused by irritation of median/ sciatic n thrgh injurycharact : severe burning pain, glossi skin, swelling, redness, sweating and tropic nail changes.th/ sympathetic block or sympathectomy
Parasympathetic Nervous System The cell bodies of parasympathetic
preganglionic neuron : within cranial nerve nuclei (III, VII, IX, X) in the brainstem or within the lateral part of the graymatter of sp cord (region S2-4). (Craniosacral division)
The Cranial Component Pregang N III Ciliary Gangl Postgang
innervate: m.constrictor pupillae & m. ciliaris Pregang N VII Sphenoplatine Gang &
submaxillar gang Postgang innervates: lacrimal gld, nasal gld, submaxill & subling gld.
Pregang N IX Otic Gang Postgang innervate: parotis gld
Pregang N X Postgang innervate: cardiac muscle, lung, stomach, liver, pancreas, spleen, intestine and colon
The Sacral Component Preganglion ; arises from Sacral cord
segment 2,3,4 Post Ganglion innervate : descending colon
rectum baldder anal prostat and sexual organ
Peripheral Parasympathetic Nervous System dysfunction
Pupillary light reflex ( - ), mydriasis Hirschprung’s disease (megacolon) : is caused by a
functional obstruct in the lower colon & rectum.Ineffective parasympathetic stimulation & predominance sympathetic stimulation of the colon inhibit peristaltic contraction feces accumulate obove the inhibited area.It is associated with congenital lack of parasymp gang & the existence of abnormal nerve fibrils in an apparently normal segment of large bowel
Incotinentia urin & alvii Ejaculatio dysfunction
INFLUENCE OF HIGHER PARTS OF THE BRAIN ON AUTONOMIC FUNCTION
Sudden BP↑ initiates parasympathetic reflex inhibits cardiac muscle cells & HR ↓ BP normal.
Sudden BP ↓ sympathetic reflex stimulates heart to increase HR & force contraction BP to normal
Regulates body temperature Thought & emotion Regulating defecation,urination,
penile & clitoral erection, and ejaculation
Central A N S disturbances Cerebral Lesion Respiration type :Cheyne stokes Urinary & Alvii Incotinentia hemiplegic region: edema,
Cyanosis, Temp >> Temp<< , Vasodilation vasoconstriction
Diencephalon Hypothalamic disfunction: failure of body temperature, respiratory & Cardio Vascular regulation.
disorders of basal metabolic GIT disorders, sleep disorder, etc Mesencephalon Central Neurogenic Hyperventilation Horner’s Syndrome disturbances of pupillary size & reflex
Pontine Lesion Apneustic respiration Horner’s Syndrome disfunction of N VII Medulla oblongata Ataxic Respiration disfunction of N IX dan X disturbances of Cardiac center & vasomotor center
Spinal Cord Lesion TH 1 – 4 Lesion Horner’s Syndrome (Th 1) Sympathetic Dysfuntion Face &
Visceral organ thoracal visceral organ
L 1 – 2 Lesion disorders of micturition, defecation erection & ejaculation dysfunction Anhydrosis of Trunk & Leg
Innervation of the urinary bladderParasympathetic innervation: Control of bladder m is predominantly
parasympath. The pelvic splanchnic n originating in the sacral
cord (S2-4) terminate at ganglia in the wall of bladder & in internal spinchter m.
Bladder dilated sensory impulses by parasympathetic neurons Excite detrusor m & inhibit urinary spinchter Emptying the bladder.
Paralysis of the parasympathetic fibres Atonic Bladder.
Sympathetic Innervation: originate in the Intermediolat nucl of
lateral horn of Th 12, L1 and L2 pass through caudal segment of the trunks inf mesenteric gang by way of inf splanchnic n. Inf hypogastric plexus transmits the impulses to internal spinchter m.
Stimulation of int spinch m relaxation of the wall of bladder filling the bladder
Voluntary urinary bladder innervation
The external spinchter m is striated musc. ( is under voluntary control) but : the muscle opens by reflex when urine passes through internal spinchter and stays open until the bladder is empty.
External spinchter m, perinealis, levator ani, penial corpus cavernosus, urogenital diaphragm innervate by n,pudendalis: S 2 – 4 voluntarily
supra segmental innervation of bladder cerebral paracentral lobe inisiative :urination or suppression
Micturition mechanismFull Bladder
detrusor m. dilation
Parasympathetic afferent
Ascending pathway (spinothal tract)
Cerebral cortex :voluntary : urination or
Retard urination
Efferent innervationSYMPATHETIC PARA SYMPATHETIC
T 12T 11
L 1L 2
S 2
S 3
S 4
SOMATIC EFFERENTOrigin : ant horn cell S 2,3,4
CORTICAL CONTROL
BLADDER
Function :Detrusor mus relaxInternal sphinc contrac
Function :Detrusor mus contracInternal sphinc relax
Detrusor muscel
Pudendal nerves
Hypogastric plexus
Inferior hypogasganglion
AUTONOMIC BLADDER INNERVATIONAUTONOMIC BLADDER INNERVATION
Micturition disturbances Uninhibited neurogenic
bladder Infant :cerebral cortex inhibition (-), control of volume (-), tone & sensation normal emptying the bladder cerebral diffuse lesion
th/ : Atropin, tofranil
NEUROGENIC BLADDER Reflex interrupt of ascendens & descenden tract upper medulary conus (arch reflex) cortical ( - )
initiation & suppression micturition (-)
AUTONOMOUS NEUROGENIK BLADDER
innervation of bladder (-) bladder emptying (-) caused by
failure of detrusor m contraction Bladder capacity <<, urinary residu
>>> - full bladder overflow emptying abdominal pressure etiology : lesion of medulary conus,
cauda equine, motor / sensory root of S2-S4
SENSORIC PARALYTIC BLADDER
sensory impulses signaling that the bladder is dilated (-)
inisiative for urination (-) contraction ( - ) atonic neurogenic
bladder bladder capacity & urinary residu : >>
urinary overflow Emptying abdominal pressure Lesion : dorsal root S2 – S4, post column
of spinal cord
MOTOR PARALYTIC BLADDER
Bladder dilation & decompensation detrusor m contraction (-) Sensasion (normal) pain
sensation (+) but urination (-)
cause : polio, polyradiculoneuritis, trauma, neoplasm, congenital
Spastic neurogenic bladder : caused by a more or less complete
transection of the spinal cord above S2.
Flaccid Neurogenic bladdercaused by a lesion of either the sacral portion of the spinal cord or the cauda equina