“ЗАТВЕРДЖЕНО” на методичній нараді кафедри нервових хвороб, психіатрії та медичної психології
“______” _______________ 2008 р.
Протокол № _____
Зав. кафедри нервових хвороб, психіатрії та медичної психології професор В.М. Пашковський
.
.
METHODOLOGICAL INSTRUCTION 18
THEME: DISEASES OF AUTONOMIC NERVOUS SYSTEM
Modul 2. Special neurology
Сontents modul 3. Cerebrovascular diseases. Paroxysmal diseases. Cephalargy. Sleep disorders. Neurointoxications. Traumatic lesions of nervous system.
Subject:
Nervous deseases
Year 4
Medical faculty
Hours 2
Author of methodological instructions
MD Filipets O.O.
Chernivtsy 2008

1.
Scientific and methodological substantiation of the theme.
The autonomic nervous system is a purely efferent system of nerve fibers with ganglia and plexuses outside the central nervous system innervating the blood vessels, heart, viscera, glands, and smooth muscles throughout the body. The vegetative disturbance have own specific clinical signs.
2. Aim: students should be able to determine independently signs of lesion of
Autonomic nervous system, to localize the pathological process (focus) on different topical levels. Students should be able to formulate and to explain the topical diagnosis.
Students must know:
1.
Anatomical structures and function of the Autonomic nervous system.
2.
Specific methods of examination of Autonomic nervous system.
3.
The signs of lesion of sympathetic part of vegetative nervous system.
4.
The signs of lesion of parasympathetic part of vegetative nervous system.
5.
Hypothalamic syndromes.
6.
Lesion of limbic-reticular complex.
7.
The paroxysmal and permanent disturbances of vegetative function.
Students should be able to:
1.
Examine patient status: a.
activity of inner organs (attacks of tachy- and bradycardia, breath, b.
c.
dyspeptic disturbance after meals, abdominal spastic pain, diarrhea, frequent and abundant urination) activity of cardiovascular system (attacks of a skin pallor and hyperemia, high and low of blood pressure) activity of the sweating, sebaceous glands and lacrimal organs d.
e.
(salivation, hyperhidrosis, dry skin, eyewatering) etc activity of pelvic (urogenital) organs (ischuria/retention of urine/, incontinence of urine and feces) trophic disturbance (hyperkeratosis, skin lesion, peeling of the skin, fissures of skin, pustules, skin edema, hyperpigmentation, alopecia, hemiatrophia) f.
disturbance of the height and substances exchange (low and high height, increasing of weight, cachexia, acromegalia) g.
disturbance of sleep, thermoregulation, memory, emotions and tendencies
2.
Localize the pathological processes on different levels of somatic nervous system.
3.
To put topical diagnosis and to explain it.

Student should gain practical skills:
1.
To examine pupillary reaction, eye-heart reflex, solar reflex, vascular responses of the skin (local and reflex).
2.
To find the difference in blood pressure levels on hands and legs.
3.
To diagnose the pathological processes on different levels of somatic nervous system.
4.
To examine temperature and activity of sweating (apirine test).
5.
To provide pharmacological tests (atropine, adrenaline, pylocarpine).
4. Integration (basic level) .
Subjects Gained skills
Anatomy
Histology
Physiology
Knowledge of anatomy of sympathetic and parasympathetic divisions of autonomic nervous system
Hystological structure of the sympathetic and parasympathetic divisions of autonomic nervous system
Knowledge of function of vegetative reflex arch .
Subject
Table 1 compares the sympathetic and parasympathetic divisions.
Table 1.
Comparison of Sympathetic and Parasympathetic Divisions
Component Sympathetic Parasympathetic
CNS segments of origin Thoracic-lumbar region of the spinal cord Cranial-sacral regions of the spinal cord
Location of ganglia
Preganglionic neuron
Paravertebral ganglion chain
Short, myelinated
Preganglionic neurotransmitter substance
Acetylcholine
Postganglionic neuron Long, unmyelinated
Postganglionic neurotransmitter substance
Norepinephrine
Divergence ratio 1:10
On or near effector organ
Long, myelinated
Acetylcholine
Short, unmyelinated
Acetylcholine
1:3

Outflow specificity Can be widespread
Can be specific
"Fight or flight"
Specific
Behavior produced with stimulation
Effect on energy stores Energy mobilization
Energy utilization
Inhibition of digestion
Sedentary activities
Voiding
Energy conservation
Energy restoration
Stimulation of digestion
The autonomic nervous system is a purely efferent system of nerve fibers with ganglia and plexuses outside the central nervous system innervating the blood vessels, heart, viscera, glands, and smooth muscles throughout the body. The vegetative disturbance have own specific clinical signs.
Aim: students should be able to determine independently signs of lesion
Vegetative nervous system, to localize the pathological process (focus) on different topical levels. Students should be able to formulate and to explain the topical and clinical diagnosis.
Basic level:
1.
History talking.
2.
To carry outexaminations of somatic and neurologic state.
3.
Estimate additional methods of examination: laboratory, roentgenologic, electrophysiological, radiopaque methods.
4.
Knowledge of anatomical structures, physiology and function of the
Autonomic nervous system.
Students must know:
1. Etiology and pathogenesis of different diseases of Vegetative nervous system.
2. Clinical features of different diseases of Vegetative nervous system.
3. Differential diagnosis of sympatho-adrenal and vago-insular paroxysms.
Students should be able to:
1.
Examine the patient with different diseases of Vegetative nervous system.
2.
Administer additional methods examination.
3.
Make a correct topical diagnosis.
4.
Make a correct clinical diagnosis.
5.
Administer treatment of different diseases of Vegetative nervous system.
Students should gain practical skills:
1.
To take anamnesis.

2.
To make neurological examination of the patient.
3.
To formulate the diagnosis.
4.
To administer treatment .
The scheme of diagnostic search of vegetative disorders
The aim is to determine presence of sings of vegetative system lesion. For this purpose it is necessary:
I. To gather an anamnesis and to examine patient's status.
II.
At the analysis of the complaints of the patient to find out presence of attributes of a lesion of a vegetative system: a. activity of inner organs (attacks of tachy- and bradycardia, breath, dyspeptic disturbance after meals, abdominal spastic pain, diarrhea, frequent and abundant urination), b. activity of cardiovascular system (attacks of a skin pallor and hyperemia, high and low of blood pressure), c. activity of the sweating, sebaceous glands and lacrimal organs (salivation, hyperhidrosis, dry skin, eyewatering, xeroftalmia), d. activity of pelvic (urogenital) organs (ischuria /retention of urine/, incontinence of urine and feces), e. trophic disturbance (hyperkeratosis, skin lesion, peeling of the skin, fissures of skin, pustules, skin edema, hyperpigmentation, alopecia, hemiatrophia, osteoarthropathia), f. disturbance of height and substances exchange (low and high height, increasing of weight, cachexia, acromegalia), g. disturbance of sleep, thermoregulation/memory, emotions .
The disturbance of vegetative function
The paroxysmal signs
The disturbance of vegetative functions :
1. The paroxysmal signs
Sympathy-adrenal attacks: a) skin pail
Vagoinsular attacks: a) hyperemia b) c) xerostomia dryness of hair and skin d) tachycardia e) high blood pressure f) midriasis and widing of Eye-slit g) exophthalmia b) hyperhidrosis c) oily skin and hair d) bradycardia e) low blood pressure f) miosis g) angina pectoris h) tremor i) gooseflesh h) salivation i) breathlessness j)abdominal spastic pain k) diarrhea l)frequent and abundant urination

a) periarthritis b) epicondilitis c) miositis d) hyperkeratosis e) fissures of skin f) arthropatias g) tropic ulcer h) alopecia i) hyperpigmentation j) Horner’s sign (ptosis, miosis, enophthalmia)
2.The lesion (permanent) signs: a) incontinence of urine and feces b) ischuria/retention of urine
c) eye accommodation paralysis
d) midriasis
e) dyspnea f) apnea g) cardiac arrhythmia
h) asystolia i) collapse
III. To determine level of vegetative system lesion.
For this purpose it is necessary to use the following criteria:
1. Peripheral vegetative nerves (in structure of peripheral nerves, plexus and radiculus): b) vegetative pains, c) trophic and vascular disturbances, d) other specific vegetative disturbances:
• peripheral type of pelvic (urogenital) organs pathology (ischuria /retention of urine/ vera or paradoxical)
• Horner's sign (ptosis, miosis, enophthalmia)
2. Sympathetic nerve of vertebral artery: a) cervical pains and pains at the back of the head b) temporo-fronto-parietal headache type c) attack of pains with extension into the arms, chest and neck d) photopsias e) attacks of dizziness, unsteadiness and noise in the ears
3. Lesion of Celiac ganglion: a) abdominal (burning, dull, sharp pain, clicky) pains in areas of umbilicus, back and abdomen, b) sensation of pulsation aorta c) unstable blood pressure d) retention of feces e) diarrhea f) frequent and abundant urination g) glycosuria
4. Lesion of sympathetic (thoraco-lumbar) outflow: a) causalgia b) parethesia c) hypoesthesia

d) trophic, secretory and vascular disturbances
• superior cervical ganplion - the signs are localized in head and neck , Horner's sign
•
Stellate ganglion - the signs are localized in arms and chest
•
Superior mesenteric ganglion - all named disturbances and taxicardia, cardialgia,
•
Inferior mesenteric ganglion - the signs are localized in lower part of abdomen and legs. There are viscerovegetative disturbances of inner organs
5. S3-S5 segments of spinal cord: a) ischuria (retention of urine) vera b) ischuria paradoxical c) imperative incontinence of urine and feces
6. Lateral horn of spinal cord: a) .vascular disturbances (pail and cyanotic skin) b) trophic (skin edema, fissures, arthropatias) c) secretory (dry skin, hyperhidrosis) in such segments;
• C8-D3 - head and neck
• D4-D7 - chest and arms
• D8-D9 - trunk,
•
D10-L3 - pelvic and legs-
7. The superior and inferior salivatory nucleus of medulla oblongata.
a) salivation and lacrimation b) xerostomia c) xerophtalmia d) dyspnea, irregular respiration e) Biota's respiration f) Kussmaul, Cheyne-Stokes respiration g) Apnea h) Tachycardia, bradycardia, arrhythmia i) High or low blood pressure, vascular collapse
8. The Edinger-Westphal nuclei of midbrain: a) spasms and paralysis of accommodation b) miosis or midriasis c) the Argyll Robertson sign
9. Hypothalamic lesion: a) viscera-vegetative-vascular attacks
• sympathoadrenal
• vagoinsular
• mixed b) diencephalic epilepsy c) temperature disturbances

d) disturbance of sleep end vivacity e) endocrinal disturbances
• Iizenko-Cushing's disease f) neuro-myogenic disturbances g) trophic disturbances h) h) pseudoneurastenic signs
10. Lesion of limbic-reticular complex; a) emotional disturbances b) anorexia c) bulimia d) sexual disturbances e) -loss of memory (Korsakov's sign) f) endocrinal disturbances g) illusions,
11. hallucinations h) consciousness pathology i) temporal epilepsy
Frontal lobe: a) edema b) cyanosis hyperkeratosis of paretic extremities
Tests for self-assessment:
1.
Clinical features of sympathy-adrenal attack.
2.
Clinical features of vago-insular attack.
3.
Enumerate hypothalamic syndromes.
4.
Name the symptoms of lesion of limbic-reticular complex.
5.
Describe vegetative-trophic disorders in case of lateral horns of spinal cord lesion.
6.
Describe the irritation symptoms of sympathetic nerve of vertebral artery.
7.
Enumerate hypothalamic realizing-factors.
8.
Enumerate hypothalamic inhibits factors.
9.
Clinical features of sympathy-adrenal attack.
10.
Clinical features of vago-insular attack.
11.
Enumerate hypothalamic syndromes.
12.
Name the symptoms of lesion of limbic-reticular complex.
13.
Describe vegetative-trophic disorders in case of lateral horns of spinal cord lesion.
14.
Describe the irritation symptoms of sympathetic nerve of vertebral artery.
15.
Enumerate hypothalamic realizing-factors.
16.
Enumerate hypothalamic inhibits factors.

1.
What makes a part of suprasegmental division of autonomic nervous system
 a) truncus simpaticus; b) Nucleus ruber; c) hypothalamus; d) septum pellucidum; e) substantia nigra.
2.
Sympathetic fibers from the cerebrospinal center innervate: a) M. ciliaris; b) M. Sphincter pupillae; c) M. Dilatator pupillae; d) M. Rectus medialis; e) M. Obliquus superior.
3. In what time after skin irritation red vessel reaction appears
 a) 1-5 seconds; b) 5-11 seconds; c) 20-30 seconds; d) 25-35 seconds; e) 30-40 seconds.
Real-life situations:
1.
Patient has prosoplegia, xerophtalmia, ageysia of anterior 2/3 of tongue.
What vegetative structures are damaged?
2.
Patient with spastic paraplegia of lower extremities has centrally uninhibited bladder. What part of nervous system is damaged

References:
1.
A textbook of Neurology. – H. Houston Merrit. – 6-th Edition. – P.556-597.
2.
Basic Neurology. Second Edition. John Gilroy, M.D. Pergamon press.
McGraw Hill international editions, medical series. – 1990.
3.
Clinical examinations in neurology /Mayo clinic and Mayo foundation. – 4 th edition. –W. B. Saunders Company, Philadelphia, London, Toronto. – 1976.
4.
McKeough, D. Michael. The coloring review of neuroscience /D. Michael
McKeough/ - 2 nd ed. – 1995.
5.
Meret’s Textbook of Neurology. – 7-th Edition. – Edited by p.Roland. – P.556-
597.
6.
Neurology for the house officer. – 3 th edition. – Howard L. Weiner, MD and
Lawrence P. Levitt, MD, - Williams&Wilkins. – Baltimore. – London. – 1980.

7.
Neurology in lectures. Textbook. Edited by the head of Neurology Department
–prof. S.I. Shkrobot. – 2005.