Neurologie
Embryologie ................................................................................................................................16
Neurulatie ..................................................................................................................................... 16
Anencefalie ............................................................................................................................ 16
Spina bifida ............................................................................................................................ 16
Encephalocele ....................................................................................................................... 17
Verdere embryologische ontwikkeling ............................................................................................. 17
Spinale zenuwen .................................................................................................................... 18
Verdere embryologische ontwikkeling ............................................................................................. 18
Lissencephalie ....................................................................................................................... 19
Neuroanatomie: cerebrale topografie...........................................................................................20
Oppervlakte anatomie .................................................................................................................... 20
Basisbegrippen ...................................................................................................................... 20
Componenten van het zenuwstelsel ........................................................................................ 20
Anatomische vlakken ............................................................................................................. 20
Cerebrum .............................................................................................................................. 21
Gyri en sulci ....................................................................................................................... 21
Insula ................................................................................................................................ 21
Hersenkwabben (lobben) .................................................................................................... 22
Functionele anatomie ..................................................................................................... 22
Frontale kwab ................................................................................................................. 22
Pariëtale kwab ................................................................................................................ 23
Hemispatieel neglect .................................................................................................. 23
Occipitale kwab .............................................................................................................. 23
Hemianopsie .............................................................................................................. 24
Temporale kwab ............................................................................................................. 24
Prosopagnosie ............................................................................................................ 24
Limbische kwab of limbisch systeem ............................................................................... 24
Cerebellum ............................................................................................................................ 24
Cerebellaire pedunkels ....................................................................................................... 25
Functie .............................................................................................................................. 26
Hersenvliezen ........................................................................................................................ 26
Dura mater ......................................................................................................................... 26
Arachnoïdea....................................................................................................................... 27
Pia mater ........................................................................................................................... 27
Interne anatomie cerebrum ............................................................................................................ 27
Thalamus ............................................................................................................................... 27
Hypothalamus ....................................................................................................................... 28
Basale ganglia ........................................................................................................................ 28
Capsula interna ...................................................................................................................... 29
Hippocampus ........................................................................................................................ 30
Fornix .................................................................................................................................... 30
1
, Associatie en commissurale vezels ......................................................................................... 31
Lange associatievezels ....................................................................................................... 31
Commissurale vezels ......................................................................................................... 31
Corpus callosum ............................................................................................................ 32
Anterieure commissuur ................................................................................................... 32
Ventrikelsysteem ................................................................................................................... 32
Cerebrospinaal vocht ......................................................................................................... 33
Hydrocephalus ............................................................................................................... 33
Neuroanatomie: hersenstam & medulla spinalis...........................................................................34
Hersenstam ................................................................................................................................... 34
Mesencephalon ..................................................................................................................... 34
Cerebrale pedunkels .......................................................................................................... 34
Tegmentum............................................................................................................................ 35
Pons ...................................................................................................................................... 35
Colliculus facialis ............................................................................................................... 35
Medulla oblongata.................................................................................................................. 35
Cerebellaire pedunkels ........................................................................................................... 36
Nucleus dentatus ................................................................................................................... 36
Medulla spinalis ............................................................................................................................. 37
Functies................................................................................................................................. 38
Stijgende en dalende banen ............................................................................................................ 38
Dalende motorische banen ..................................................................................................... 38
Corticospinale baan ........................................................................................................... 38
Corona radiata ............................................................................................................... 39
Spinomedullaire junctie .................................................................................................. 39
Transversale coupes: tractus corticospinalis .................................................................... 39
Medulla spinalis – motorische voorhoorncel ........................................................................ 40
Stijgende sensorische banen .................................................................................................. 40
Bewuste (corticaal) ............................................................................................................. 41
Spinothalamische banen ................................................................................................ 41
Lemniscaal systeem ....................................................................................................... 41
Transversale coupes: lemniscus medialis (onder naar boven) ....................................... 41
Overeenkomsten spinothalamische baan en lemniscaal systeem ..................................... 42
Incomplete dwarslaesie ‘Brown-Séquard syndroom’ ............................................................ 43
Tetraplegie vs. paraplegie.................................................................................................... 43
Onbewuste (cerebellair)...................................................................................................... 43
Dorsale/posterieure spinocerebellaire tractus ................................................................. 43
Cuneocerebellaire tractus............................................................................................... 44
Cerebellaire banen ................................................................................................................. 44
Integratie van sensorische input – motorische output ............................................................... 45
Sensorische input: spinothalaam en lemniscaal systeem ..................................................... 45
Cerebellaire controle: spinocerebellair systeem .................................................................. 45
Motorische output: corticospinale baan .............................................................................. 45
Cerebellaire respons .......................................................................................................... 46
Neuroanatomie: craniale zenuwen ...............................................................................................47
2
, Hersenstam ................................................................................................................................... 47
N. I – olfactorius ............................................................................................................................. 48
N. II – opticus ................................................................................................................................. 48
Letsels visuele banen ............................................................................................................. 49
N. III – oculomotorius ..................................................................................................................... 49
Parasympathische vezels ....................................................................................................... 50
N. III parese ............................................................................................................................ 50
Pupillaire lichtreflex (N. II & III)................................................................................................. 50
N. IV – trochlearis ........................................................................................................................... 51
N. VI – abducens ............................................................................................................................ 51
N. VI parese ........................................................................................................................... 51
Sympathische innervatie oog .......................................................................................................... 52
Pupillaire constrictie en dilatatie ..................................................................................................... 52
N. V – trigeminus ............................................................................................................................ 52
N. VII – facialis ............................................................................................................................... 53
N. facialis pars intermedius .................................................................................................... 54
N. VIII – vestibulocochlearis ............................................................................................................ 54
Auditieve tractus .................................................................................................................... 55
Vestibulo-oculaire reflex ......................................................................................................... 55
N. IX – glossopharyngeus ................................................................................................................ 56
N. X – vagus ................................................................................................................................... 56
N. XI – accessorius ......................................................................................................................... 57
N. XII – hypoglossus ....................................................................................................................... 58
Neuroanatomie: bloedvoorziening hersenen & ruggenmerg ...........................................................59
Arteriële bloedvoorziening van de hersenen ..................................................................................... 59
Anteriorcirculatie ................................................................................................................... 59
Posteriorcirculatie .................................................................................................................. 59
Cirkel van Willis ...................................................................................................................... 60
Centrale perforerende takken ................................................................................................. 60
Arteria cerebri anterior ............................................................................................................ 61
Centrale takken .................................................................................................................. 62
Arterie cerebri media .............................................................................................................. 62
Centrale takken .................................................................................................................. 62
Bloedvoorziening capsula interna ............................................................................................ 63
Arteria cerebri posterior .......................................................................................................... 63
Centrale takken .................................................................................................................. 64
Bloedvoorziening plexus choroïdeus laterale ventrikels ............................................................ 64
Arteria vertebralis ................................................................................................................... 65
Arteria basilaris ...................................................................................................................... 65
Arteriële territoria ................................................................................................................... 66
Cerebrum .......................................................................................................................... 66
3
, Hersenstam en cerebellum ................................................................................................. 66
Waterscheidingsgebieden ...................................................................................................... 67
Collateralen ........................................................................................................................... 67
Veneuze drainage van de hersenen ................................................................................................. 68
Oppervlakkige drainerende venen ........................................................................................... 68
Diepe drainerende venen ........................................................................................................ 68
Collateralen ........................................................................................................................... 69
Sinus cavernosus ................................................................................................................... 69
Bloedvaten van het ruggenmerg ...................................................................................................... 70
Arteriën.................................................................................................................................. 70
Venen .................................................................................................................................... 70
Casussen neuroanatomie ............................................................................................................71
Casus 1 ......................................................................................................................................... 71
Casus 2 ......................................................................................................................................... 71
Casus 3 ......................................................................................................................................... 71
Casus 4 ......................................................................................................................................... 72
Casus 5 ......................................................................................................................................... 72
Casus 6 ......................................................................................................................................... 72
Casus 7 ......................................................................................................................................... 72
Casus 8 ......................................................................................................................................... 73
Innervatie van de huid ..................................................................................................................74
De huid.......................................................................................................................................... 74
Bezenuwing ........................................................................................................................... 74
Sensorische eenheden ................................................................................................................... 74
Receptoren – opgedeeld in functie .................................................................................................. 75
Receptoren – opgedeeld volgens morfologie .................................................................................... 75
Behaarde vs onbehaarde huid ........................................................................................................ 75
Innervatie van de behaarde huid .............................................................................................. 76
Innervatie van de onbehaarde (naakte) huid ............................................................................. 76
Vrij zenuwuiteinden ........................................................................................................................ 76
Axon reflex ............................................................................................................................. 77
Merkel-cell neurite complexen........................................................................................................ 77
Folliculaire zenuwuiteinden (behaarde huid) .................................................................................... 77
Meissner lichaampjes .................................................................................................................... 77
Ruffini uiteinden ............................................................................................................................. 78
Pacini lichaampjes ......................................................................................................................... 78
Sensorische integratie .................................................................................................................... 78
4
, Lepra ..................................................................................................................................... 78
Take home ..................................................................................................................................... 79
Transmitters en receptoren..........................................................................................................80
Synapsen ...................................................................................................................................... 80
Elektrische synapsen .............................................................................................................. 80
Chemische synapsen ............................................................................................................. 80
Eiwitten betrokken in transmitter transport en vesikel recyclage ............................................ 81
Auto- en heteroreceptoren ............................................................................................................. 81
Ionotrope receptoren .............................................................................................................. 81
Metabotrope receptoren ......................................................................................................... 81
Second messenger-systemen ............................................................................................. 82
Sensibilisatie en de-sensibilisatie ........................................................................................ 82
Neurotransmitters .................................................................................................................. 82
Wat is een transmitter? .................................................................................................................. 82
Aminozuur neurotransmitters ................................................................................................. 83
AMPA (kortwerkend) – NMDA (langwerkend) ......................................................................... 83
NMDA receptor................................................................................................................... 84
Glutamaat .......................................................................................................................... 84
GABA ................................................................................................................................. 84
GABA agonisten .............................................................................................................. 84
Glycine .............................................................................................................................. 85
Biogene amines ...................................................................................................................... 85
Acetylcholine ..................................................................................................................... 85
Muscarine receptoren ..................................................................................................... 86
Acetylcholine ................................................................................................................. 86
Monoamines ...................................................................................................................... 86
Dopamine ...................................................................................................................... 86
Dopamine receptoren ................................................................................................. 86
Dopamine en norepinefrine ............................................................................................. 87
Dopamine .................................................................................................................. 87
Norepinefrine ................................................................................................................. 87
Epinefrine ....................................................................................................................... 88
Serotonine ..................................................................................................................... 88
Histamine .............................................................................................................................. 89
Transmitters en receptoren ............................................................................................................ 89
Elektrische fenomenen ................................................................................................................90
Elektrochemische communicatie in het zenuwstelsel ...................................................................... 90
Isolerende celmembraan – ionenkanalen ........................................................................................ 90
Types ionen kanalen ............................................................................................................... 90
Evenwichtspotentiaal – rust membraan potentiaal ........................................................................... 90
Synaptische transmissie zorgt voor ontstaan postsynaptische potentialen ........................................ 91
Temporele summatie.............................................................................................................. 91
5
, Spatiële summatie ................................................................................................................. 91
Locatie van trigger point.................................................................................................................. 92
Kenmerken van de actiepotentiaal .................................................................................................. 92
AP gegenereerd door veranderingen in Na+ en K+ conductantie .................................................. 92
Absolute en relatieve refractaire periode ......................................................................................... 93
Propagatie van de actie potentiaal ........................................................................................... 93
Saltatoire geleiding in gemyelineerde zenuwen ........................................................................ 93
Voorbeelden van klinische relevantie .............................................................................................. 93
Bewustzijn ..................................................................................................................................94
Wat is bewustzijn? ......................................................................................................................... 94
Formatio reticularis ........................................................................................................................ 94
Het ascenderende reticulaire activerende systeem (ARAS) ............................................................... 94
Arousal circuits .............................................................................................................................. 94
Ascending arousal system ...................................................................................................... 95
Arousal system: neuromodulatoir systeem .............................................................................. 95
Nog systemen van belang voor waakzaamheid? ............................................................................... 95
Inhoud van bewustzijn: cortex ......................................................................................................... 96
Bewustzijnsstoornis ....................................................................................................................... 96
Verlaagd bewustzijn ............................................................................................................... 96
Glasgow coma scale = EMV score........................................................................................ 97
FOUR = Full Outline of UnResponsiveness score .................................................................. 97
Locked-in-syndroom: géén coma ........................................................................................ 98
Veranderd bewustzijn ............................................................................................................. 98
Neuromusculaire transmissie .................................................................................................... 100
Beweging ..................................................................................................................................... 100
Myasthenia Gravis ........................................................................................................................ 100
Pathofysiologie .................................................................................................................... 100
Neuromusculaire junctie (motorische eindplaat) ................................................................ 100
Klinisch beeld ...................................................................................................................... 100
Dysfagie + moeite kauwen ................................................................................................. 101
Dysartrie .......................................................................................................................... 101
Vermoeibaarheid .............................................................................................................. 101
Krachtverlies .................................................................................................................... 101
Ademhalingsinsufficiëntie ................................................................................................. 102
Myasthene crisis .............................................................................................................. 102
Diagnose ............................................................................................................................. 102
Behandeling ......................................................................................................................... 103
Lambert-Eaton syndroom ............................................................................................................. 103
Klinisch beeld ...................................................................................................................... 104
Diagnose ............................................................................................................................. 104
6
, Behandeling ......................................................................................................................... 104
Botulisme .................................................................................................................................... 104
Symptomen ......................................................................................................................... 104
Behandeling ......................................................................................................................... 105
Congenitale myasthenia ............................................................................................................... 105
Neuronen en glia ....................................................................................................................... 106
Inleiding ...................................................................................................................................... 106
Neuronen .................................................................................................................................... 106
Synapsen ............................................................................................................................. 107
Neurotransmitter vrijstelling .............................................................................................. 107
Receptor activatie ................................................................................................................ 107
Exciterende versus inhiberende neurotransmitters ............................................................. 107
Volume transmissie .............................................................................................................. 108
Inhibitie vs disinhibitie .......................................................................................................... 108
Zeldzamere vormen van transmissie...................................................................................... 108
Neuroglia..................................................................................................................................... 109
Astrocyten ........................................................................................................................... 109
Gliale tumoren ................................................................................................................. 109
Oligodendrocyten ................................................................................................................. 110
Myelinevorming ................................................................................................................ 110
Demyelinisatie ................................................................................................................. 110
Ependymcellen .................................................................................................................... 111
Andere epdenym-geassocieerde celtypes .......................................................................... 111
Take home messages ................................................................................................................... 111
Perifere zenuwen en innervatie van spieren en gewrichten .......................................................... 112
Waarom relevant voor de kliniek?.................................................................................................. 112
Perifere zenuwen ......................................................................................................................... 112
Waar begint het perifeer zenuwstelsel? ................................................................................. 112
Zenuwwortels ...................................................................................................................... 112
Microscopische structuur ..................................................................................................... 113
Myelinevorming .................................................................................................................... 113
Conductie van axonen .......................................................................................................... 113
CNS-PNS transitiezone ......................................................................................................... 114
Degeneratie – regeneratie PNS .............................................................................................. 114
Regeneratie ...................................................................................................................... 114
Degeneratie – regeneratie CNS .............................................................................................. 114
Het perifere zenuwstelsel omvat: .......................................................................................... 114
Innervatie van spieren en gewrichten ............................................................................................. 115
Opbouw spier....................................................................................................................... 115
Skeletspier ........................................................................................................................... 115
Motore innervatie ............................................................................................................. 115
Opbouw spiervezels ......................................................................................................... 115
7
, Motorische eindplaat ............................................................................................................ 116
Skeletspier ........................................................................................................................... 116
Excitatie-contractie coupling............................................................................................. 116
Vezeltypes ....................................................................................................................... 116
Skeletspier en motor units: ageing ..................................................................................... 116
Sensore informatie uit skeletspier ..................................................................................... 116
Spierspoeltjes ...................................................................................................................... 117
Golgi-peeslichaampjes ......................................................................................................... 117
Innervatie van gewrichten ............................................................................................................. 118
Het autonoom zenuwstelsel ...................................................................................................... 119
Functionele organisatie van het AZS .............................................................................................. 119
Orthosympathisch zenuwstelsel ................................................................................................... 120
Fight-or-flight ....................................................................................................................... 120
Klinische relevantie .............................................................................................................. 121
Parasympathisch zenuwstelsel ..................................................................................................... 121
Preganglionaire neuronen ..................................................................................................... 121
Postganglionaire neuronen ................................................................................................... 121
Rest-and-digest.................................................................................................................... 122
Neurotransmissie in autonoom zenuwstelsel ................................................................................ 122
Neurotransmitters in postganglionaire neuronen ................................................................... 122
Effect van AZS in respons organen ................................................................................................. 123
Autonoom zenuwstelsel – agonisten en antagonisten ..................................................................... 124
Medicatie en het PS zenuwstelsel .......................................................................................... 124
Enterisch zenuwstelsel ................................................................................................................. 124
Controle van blaaswerking – autonoom zenuwstelsel..................................................................... 125
Autonome innervatie van mannelijke genitale tractus ..................................................................... 125
Overzicht autonome zenuwstelsel ................................................................................................ 125
Orthosympathisch vs. parasympathisch zenuwstelsel ................................................................... 126
Basale ganglia ........................................................................................................................... 127
Neuro-anatomie .......................................................................................................................... 127
Controle van motoriek in CZS........................................................................................................ 127
Basale ganglia – verschillende circuits .......................................................................................... 128
Motorische loop ................................................................................................................... 128
Directe en indirecte route.................................................................................................. 129
Motorisch circuit bij de ziekte van Parkinson ...................................................................... 129
Limbische loop..................................................................................................................... 129
Klinisch belang ............................................................................................................................ 130
Ziekte van Parkinson ............................................................................................................. 130
Symptomen ..................................................................................................................... 130
8
, Behandeling ..................................................................................................................... 130
Hyperkinetische aandoeningen ......................................................................................... 130
Ziekte van Huntington ........................................................................................................... 131
Pathogenese .................................................................................................................... 131
Hemiballisme .............................................................................................................................. 131
Take home messages ................................................................................................................... 132
Neuroimmunologie: inflammatie en auto-immuniteit .................................................................. 133
Inleiding in de neuroimmunologie ................................................................................................. 133
Mogelijke mechanismen die leiden tot neuroinflammatie ....................................................... 133
Cellen van het CZS parenchym.............................................................................................. 133
Functies cellen in het CZS ................................................................................................. 133
Wat is neuro-immunologie? .................................................................................................. 134
Neuroimmunologische aandoeningen ............................................................................... 134
Immuunsysteem: 3 niveaus van verdediging .......................................................................... 134
Bloed-hersen-barrière ...................................................................................................... 134
Regio’s zonder functionele BHB ..................................................................................... 134
Transport mechanismen over de BHB ............................................................................ 135
Lokalisatie van de meningeale lymfevaten ............................................................................. 135
Communicatie tussen CZS en perifere immuunsysteem ......................................................... 135
Auto-immuniteit ................................................................................................................... 135
Paroxysmale koude hemoglobinurie .................................................................................. 136
Mechanismen van tolerantie en (auto-)immuniteit .............................................................. 136
Definitie van autoimmuunziekte ........................................................................................ 136
Kruisreacties waardoor auto-immuniteit ontstaat: molecular mimicry ................................. 136
Toepassingen – neuropathofysiologie ............................................................................................ 137
Multipele sclerose ................................................................................................................ 137
Immuun respons bij MS .................................................................................................... 137
Pathofysiologie van progressieve MS ................................................................................. 137
NMO(SD).......................................................................................................................... 137
Paraneoplastische syndromen .............................................................................................. 137
Anti-Hu ............................................................................................................................ 138
Anti-NMDAR encephalitis .................................................................................................. 138
Geheugen en gedrag .................................................................................................................. 139
Geheugen .................................................................................................................................... 139
Semiologie ........................................................................................................................... 139
Functionele neuroanatomie .................................................................................................. 139
Consolidatie ........................................................................................................................ 140
Functionele anatomie ........................................................................................................... 140
Klinische en experimentele observaties ................................................................................. 140
Stoornissen van het geheugen ............................................................................................... 141
Dementie ......................................................................................................................... 142
Criteria ......................................................................................................................... 142
Cognitief continuum ..................................................................................................... 142
Onderliggende aandoeningen ........................................................................................ 143
9
, Gedrag ........................................................................................................................................ 143
Gestuurd door frontale kwabben ........................................................................................... 143
Frontale kwab dysfunctie / frontale psychosyndroom ............................................................. 143
Stoornissen gedrag: frontotemporale dementie ..................................................................... 144
Gedragsvariant van frontotemporale dementie (bvFTD) ...................................................... 144
Onderzoek geheugen en gedrag ............................................................................................ 145
Anamnese bij verdenking op cognitieve stoornis ................................................................. 145
Speciële (hetero)anamnese ........................................................................................... 145
Algemene anamnese (andere oorzaken nagaan) ............................................................. 145
Cognitieve screeningstesten ............................................................................................. 145
Elektrodiagnostisch onderzoek .................................................................................................. 146
Opbouw van het zenuwstelsel en de spieren .................................................................................. 146
Zenuw.................................................................................................................................. 146
Het actiepotentiaal ........................................................................................................... 146
Saltatoire geleiding over de knopen van Ranvier ................................................................. 146
Spiervezel en spierspoel ....................................................................................................... 147
Skeletspier ........................................................................................................................... 147
Neuromusculaire overgang ............................................................................................... 147
Motor unit ........................................................................................................................ 147
Neurofysiologische evaluatie van het PZS ...................................................................................... 148
Elektromyogram (EMG) – zenuwgeleiding ............................................................................... 148
Zenuwgeleiding ................................................................................................................ 148
Elektromyogram (EMG) – naaldonderzoek .............................................................................. 149
Myogene versus neurogene afwijking ................................................................................. 149
Spontane spier- of zenuwactiviteit ..................................................................................... 150
Neuromusculaire overgang ............................................................................................... 150
Neurofysiologische evaluatie van het CZS ..................................................................................... 151
Geëvokeerde potentialen (EP) ............................................................................................... 151
Visueel EP = VEP ............................................................................................................... 151
Brain auditory evoked EP = BAEP ....................................................................................... 152
SSEP bovenste ledematen ................................................................................................ 152
SSEP onderste ledematen ................................................................................................. 153
Motorisch EP = MEP .......................................................................................................... 154
Intra-operatieve neuromonitoring .......................................................................................... 154
Hemisferische asymmetrie ........................................................................................................ 155
Neuroanatomische asymmetrie .................................................................................................... 155
Functionele asymmetrie ............................................................................................................... 155
Taalnetwerk ......................................................................................................................... 155
Neuroanatomie ................................................................................................................ 155
Theoretisch ...................................................................................................................... 156
Lezen ............................................................................................................................... 156
Rechterhemisfeer ............................................................................................................. 157
Pathologie ........................................................................................................................ 157
Lexicon ........................................................................................................................ 157
10
Embryologie ................................................................................................................................16
Neurulatie ..................................................................................................................................... 16
Anencefalie ............................................................................................................................ 16
Spina bifida ............................................................................................................................ 16
Encephalocele ....................................................................................................................... 17
Verdere embryologische ontwikkeling ............................................................................................. 17
Spinale zenuwen .................................................................................................................... 18
Verdere embryologische ontwikkeling ............................................................................................. 18
Lissencephalie ....................................................................................................................... 19
Neuroanatomie: cerebrale topografie...........................................................................................20
Oppervlakte anatomie .................................................................................................................... 20
Basisbegrippen ...................................................................................................................... 20
Componenten van het zenuwstelsel ........................................................................................ 20
Anatomische vlakken ............................................................................................................. 20
Cerebrum .............................................................................................................................. 21
Gyri en sulci ....................................................................................................................... 21
Insula ................................................................................................................................ 21
Hersenkwabben (lobben) .................................................................................................... 22
Functionele anatomie ..................................................................................................... 22
Frontale kwab ................................................................................................................. 22
Pariëtale kwab ................................................................................................................ 23
Hemispatieel neglect .................................................................................................. 23
Occipitale kwab .............................................................................................................. 23
Hemianopsie .............................................................................................................. 24
Temporale kwab ............................................................................................................. 24
Prosopagnosie ............................................................................................................ 24
Limbische kwab of limbisch systeem ............................................................................... 24
Cerebellum ............................................................................................................................ 24
Cerebellaire pedunkels ....................................................................................................... 25
Functie .............................................................................................................................. 26
Hersenvliezen ........................................................................................................................ 26
Dura mater ......................................................................................................................... 26
Arachnoïdea....................................................................................................................... 27
Pia mater ........................................................................................................................... 27
Interne anatomie cerebrum ............................................................................................................ 27
Thalamus ............................................................................................................................... 27
Hypothalamus ....................................................................................................................... 28
Basale ganglia ........................................................................................................................ 28
Capsula interna ...................................................................................................................... 29
Hippocampus ........................................................................................................................ 30
Fornix .................................................................................................................................... 30
1
, Associatie en commissurale vezels ......................................................................................... 31
Lange associatievezels ....................................................................................................... 31
Commissurale vezels ......................................................................................................... 31
Corpus callosum ............................................................................................................ 32
Anterieure commissuur ................................................................................................... 32
Ventrikelsysteem ................................................................................................................... 32
Cerebrospinaal vocht ......................................................................................................... 33
Hydrocephalus ............................................................................................................... 33
Neuroanatomie: hersenstam & medulla spinalis...........................................................................34
Hersenstam ................................................................................................................................... 34
Mesencephalon ..................................................................................................................... 34
Cerebrale pedunkels .......................................................................................................... 34
Tegmentum............................................................................................................................ 35
Pons ...................................................................................................................................... 35
Colliculus facialis ............................................................................................................... 35
Medulla oblongata.................................................................................................................. 35
Cerebellaire pedunkels ........................................................................................................... 36
Nucleus dentatus ................................................................................................................... 36
Medulla spinalis ............................................................................................................................. 37
Functies................................................................................................................................. 38
Stijgende en dalende banen ............................................................................................................ 38
Dalende motorische banen ..................................................................................................... 38
Corticospinale baan ........................................................................................................... 38
Corona radiata ............................................................................................................... 39
Spinomedullaire junctie .................................................................................................. 39
Transversale coupes: tractus corticospinalis .................................................................... 39
Medulla spinalis – motorische voorhoorncel ........................................................................ 40
Stijgende sensorische banen .................................................................................................. 40
Bewuste (corticaal) ............................................................................................................. 41
Spinothalamische banen ................................................................................................ 41
Lemniscaal systeem ....................................................................................................... 41
Transversale coupes: lemniscus medialis (onder naar boven) ....................................... 41
Overeenkomsten spinothalamische baan en lemniscaal systeem ..................................... 42
Incomplete dwarslaesie ‘Brown-Séquard syndroom’ ............................................................ 43
Tetraplegie vs. paraplegie.................................................................................................... 43
Onbewuste (cerebellair)...................................................................................................... 43
Dorsale/posterieure spinocerebellaire tractus ................................................................. 43
Cuneocerebellaire tractus............................................................................................... 44
Cerebellaire banen ................................................................................................................. 44
Integratie van sensorische input – motorische output ............................................................... 45
Sensorische input: spinothalaam en lemniscaal systeem ..................................................... 45
Cerebellaire controle: spinocerebellair systeem .................................................................. 45
Motorische output: corticospinale baan .............................................................................. 45
Cerebellaire respons .......................................................................................................... 46
Neuroanatomie: craniale zenuwen ...............................................................................................47
2
, Hersenstam ................................................................................................................................... 47
N. I – olfactorius ............................................................................................................................. 48
N. II – opticus ................................................................................................................................. 48
Letsels visuele banen ............................................................................................................. 49
N. III – oculomotorius ..................................................................................................................... 49
Parasympathische vezels ....................................................................................................... 50
N. III parese ............................................................................................................................ 50
Pupillaire lichtreflex (N. II & III)................................................................................................. 50
N. IV – trochlearis ........................................................................................................................... 51
N. VI – abducens ............................................................................................................................ 51
N. VI parese ........................................................................................................................... 51
Sympathische innervatie oog .......................................................................................................... 52
Pupillaire constrictie en dilatatie ..................................................................................................... 52
N. V – trigeminus ............................................................................................................................ 52
N. VII – facialis ............................................................................................................................... 53
N. facialis pars intermedius .................................................................................................... 54
N. VIII – vestibulocochlearis ............................................................................................................ 54
Auditieve tractus .................................................................................................................... 55
Vestibulo-oculaire reflex ......................................................................................................... 55
N. IX – glossopharyngeus ................................................................................................................ 56
N. X – vagus ................................................................................................................................... 56
N. XI – accessorius ......................................................................................................................... 57
N. XII – hypoglossus ....................................................................................................................... 58
Neuroanatomie: bloedvoorziening hersenen & ruggenmerg ...........................................................59
Arteriële bloedvoorziening van de hersenen ..................................................................................... 59
Anteriorcirculatie ................................................................................................................... 59
Posteriorcirculatie .................................................................................................................. 59
Cirkel van Willis ...................................................................................................................... 60
Centrale perforerende takken ................................................................................................. 60
Arteria cerebri anterior ............................................................................................................ 61
Centrale takken .................................................................................................................. 62
Arterie cerebri media .............................................................................................................. 62
Centrale takken .................................................................................................................. 62
Bloedvoorziening capsula interna ............................................................................................ 63
Arteria cerebri posterior .......................................................................................................... 63
Centrale takken .................................................................................................................. 64
Bloedvoorziening plexus choroïdeus laterale ventrikels ............................................................ 64
Arteria vertebralis ................................................................................................................... 65
Arteria basilaris ...................................................................................................................... 65
Arteriële territoria ................................................................................................................... 66
Cerebrum .......................................................................................................................... 66
3
, Hersenstam en cerebellum ................................................................................................. 66
Waterscheidingsgebieden ...................................................................................................... 67
Collateralen ........................................................................................................................... 67
Veneuze drainage van de hersenen ................................................................................................. 68
Oppervlakkige drainerende venen ........................................................................................... 68
Diepe drainerende venen ........................................................................................................ 68
Collateralen ........................................................................................................................... 69
Sinus cavernosus ................................................................................................................... 69
Bloedvaten van het ruggenmerg ...................................................................................................... 70
Arteriën.................................................................................................................................. 70
Venen .................................................................................................................................... 70
Casussen neuroanatomie ............................................................................................................71
Casus 1 ......................................................................................................................................... 71
Casus 2 ......................................................................................................................................... 71
Casus 3 ......................................................................................................................................... 71
Casus 4 ......................................................................................................................................... 72
Casus 5 ......................................................................................................................................... 72
Casus 6 ......................................................................................................................................... 72
Casus 7 ......................................................................................................................................... 72
Casus 8 ......................................................................................................................................... 73
Innervatie van de huid ..................................................................................................................74
De huid.......................................................................................................................................... 74
Bezenuwing ........................................................................................................................... 74
Sensorische eenheden ................................................................................................................... 74
Receptoren – opgedeeld in functie .................................................................................................. 75
Receptoren – opgedeeld volgens morfologie .................................................................................... 75
Behaarde vs onbehaarde huid ........................................................................................................ 75
Innervatie van de behaarde huid .............................................................................................. 76
Innervatie van de onbehaarde (naakte) huid ............................................................................. 76
Vrij zenuwuiteinden ........................................................................................................................ 76
Axon reflex ............................................................................................................................. 77
Merkel-cell neurite complexen........................................................................................................ 77
Folliculaire zenuwuiteinden (behaarde huid) .................................................................................... 77
Meissner lichaampjes .................................................................................................................... 77
Ruffini uiteinden ............................................................................................................................. 78
Pacini lichaampjes ......................................................................................................................... 78
Sensorische integratie .................................................................................................................... 78
4
, Lepra ..................................................................................................................................... 78
Take home ..................................................................................................................................... 79
Transmitters en receptoren..........................................................................................................80
Synapsen ...................................................................................................................................... 80
Elektrische synapsen .............................................................................................................. 80
Chemische synapsen ............................................................................................................. 80
Eiwitten betrokken in transmitter transport en vesikel recyclage ............................................ 81
Auto- en heteroreceptoren ............................................................................................................. 81
Ionotrope receptoren .............................................................................................................. 81
Metabotrope receptoren ......................................................................................................... 81
Second messenger-systemen ............................................................................................. 82
Sensibilisatie en de-sensibilisatie ........................................................................................ 82
Neurotransmitters .................................................................................................................. 82
Wat is een transmitter? .................................................................................................................. 82
Aminozuur neurotransmitters ................................................................................................. 83
AMPA (kortwerkend) – NMDA (langwerkend) ......................................................................... 83
NMDA receptor................................................................................................................... 84
Glutamaat .......................................................................................................................... 84
GABA ................................................................................................................................. 84
GABA agonisten .............................................................................................................. 84
Glycine .............................................................................................................................. 85
Biogene amines ...................................................................................................................... 85
Acetylcholine ..................................................................................................................... 85
Muscarine receptoren ..................................................................................................... 86
Acetylcholine ................................................................................................................. 86
Monoamines ...................................................................................................................... 86
Dopamine ...................................................................................................................... 86
Dopamine receptoren ................................................................................................. 86
Dopamine en norepinefrine ............................................................................................. 87
Dopamine .................................................................................................................. 87
Norepinefrine ................................................................................................................. 87
Epinefrine ....................................................................................................................... 88
Serotonine ..................................................................................................................... 88
Histamine .............................................................................................................................. 89
Transmitters en receptoren ............................................................................................................ 89
Elektrische fenomenen ................................................................................................................90
Elektrochemische communicatie in het zenuwstelsel ...................................................................... 90
Isolerende celmembraan – ionenkanalen ........................................................................................ 90
Types ionen kanalen ............................................................................................................... 90
Evenwichtspotentiaal – rust membraan potentiaal ........................................................................... 90
Synaptische transmissie zorgt voor ontstaan postsynaptische potentialen ........................................ 91
Temporele summatie.............................................................................................................. 91
5
, Spatiële summatie ................................................................................................................. 91
Locatie van trigger point.................................................................................................................. 92
Kenmerken van de actiepotentiaal .................................................................................................. 92
AP gegenereerd door veranderingen in Na+ en K+ conductantie .................................................. 92
Absolute en relatieve refractaire periode ......................................................................................... 93
Propagatie van de actie potentiaal ........................................................................................... 93
Saltatoire geleiding in gemyelineerde zenuwen ........................................................................ 93
Voorbeelden van klinische relevantie .............................................................................................. 93
Bewustzijn ..................................................................................................................................94
Wat is bewustzijn? ......................................................................................................................... 94
Formatio reticularis ........................................................................................................................ 94
Het ascenderende reticulaire activerende systeem (ARAS) ............................................................... 94
Arousal circuits .............................................................................................................................. 94
Ascending arousal system ...................................................................................................... 95
Arousal system: neuromodulatoir systeem .............................................................................. 95
Nog systemen van belang voor waakzaamheid? ............................................................................... 95
Inhoud van bewustzijn: cortex ......................................................................................................... 96
Bewustzijnsstoornis ....................................................................................................................... 96
Verlaagd bewustzijn ............................................................................................................... 96
Glasgow coma scale = EMV score........................................................................................ 97
FOUR = Full Outline of UnResponsiveness score .................................................................. 97
Locked-in-syndroom: géén coma ........................................................................................ 98
Veranderd bewustzijn ............................................................................................................. 98
Neuromusculaire transmissie .................................................................................................... 100
Beweging ..................................................................................................................................... 100
Myasthenia Gravis ........................................................................................................................ 100
Pathofysiologie .................................................................................................................... 100
Neuromusculaire junctie (motorische eindplaat) ................................................................ 100
Klinisch beeld ...................................................................................................................... 100
Dysfagie + moeite kauwen ................................................................................................. 101
Dysartrie .......................................................................................................................... 101
Vermoeibaarheid .............................................................................................................. 101
Krachtverlies .................................................................................................................... 101
Ademhalingsinsufficiëntie ................................................................................................. 102
Myasthene crisis .............................................................................................................. 102
Diagnose ............................................................................................................................. 102
Behandeling ......................................................................................................................... 103
Lambert-Eaton syndroom ............................................................................................................. 103
Klinisch beeld ...................................................................................................................... 104
Diagnose ............................................................................................................................. 104
6
, Behandeling ......................................................................................................................... 104
Botulisme .................................................................................................................................... 104
Symptomen ......................................................................................................................... 104
Behandeling ......................................................................................................................... 105
Congenitale myasthenia ............................................................................................................... 105
Neuronen en glia ....................................................................................................................... 106
Inleiding ...................................................................................................................................... 106
Neuronen .................................................................................................................................... 106
Synapsen ............................................................................................................................. 107
Neurotransmitter vrijstelling .............................................................................................. 107
Receptor activatie ................................................................................................................ 107
Exciterende versus inhiberende neurotransmitters ............................................................. 107
Volume transmissie .............................................................................................................. 108
Inhibitie vs disinhibitie .......................................................................................................... 108
Zeldzamere vormen van transmissie...................................................................................... 108
Neuroglia..................................................................................................................................... 109
Astrocyten ........................................................................................................................... 109
Gliale tumoren ................................................................................................................. 109
Oligodendrocyten ................................................................................................................. 110
Myelinevorming ................................................................................................................ 110
Demyelinisatie ................................................................................................................. 110
Ependymcellen .................................................................................................................... 111
Andere epdenym-geassocieerde celtypes .......................................................................... 111
Take home messages ................................................................................................................... 111
Perifere zenuwen en innervatie van spieren en gewrichten .......................................................... 112
Waarom relevant voor de kliniek?.................................................................................................. 112
Perifere zenuwen ......................................................................................................................... 112
Waar begint het perifeer zenuwstelsel? ................................................................................. 112
Zenuwwortels ...................................................................................................................... 112
Microscopische structuur ..................................................................................................... 113
Myelinevorming .................................................................................................................... 113
Conductie van axonen .......................................................................................................... 113
CNS-PNS transitiezone ......................................................................................................... 114
Degeneratie – regeneratie PNS .............................................................................................. 114
Regeneratie ...................................................................................................................... 114
Degeneratie – regeneratie CNS .............................................................................................. 114
Het perifere zenuwstelsel omvat: .......................................................................................... 114
Innervatie van spieren en gewrichten ............................................................................................. 115
Opbouw spier....................................................................................................................... 115
Skeletspier ........................................................................................................................... 115
Motore innervatie ............................................................................................................. 115
Opbouw spiervezels ......................................................................................................... 115
7
, Motorische eindplaat ............................................................................................................ 116
Skeletspier ........................................................................................................................... 116
Excitatie-contractie coupling............................................................................................. 116
Vezeltypes ....................................................................................................................... 116
Skeletspier en motor units: ageing ..................................................................................... 116
Sensore informatie uit skeletspier ..................................................................................... 116
Spierspoeltjes ...................................................................................................................... 117
Golgi-peeslichaampjes ......................................................................................................... 117
Innervatie van gewrichten ............................................................................................................. 118
Het autonoom zenuwstelsel ...................................................................................................... 119
Functionele organisatie van het AZS .............................................................................................. 119
Orthosympathisch zenuwstelsel ................................................................................................... 120
Fight-or-flight ....................................................................................................................... 120
Klinische relevantie .............................................................................................................. 121
Parasympathisch zenuwstelsel ..................................................................................................... 121
Preganglionaire neuronen ..................................................................................................... 121
Postganglionaire neuronen ................................................................................................... 121
Rest-and-digest.................................................................................................................... 122
Neurotransmissie in autonoom zenuwstelsel ................................................................................ 122
Neurotransmitters in postganglionaire neuronen ................................................................... 122
Effect van AZS in respons organen ................................................................................................. 123
Autonoom zenuwstelsel – agonisten en antagonisten ..................................................................... 124
Medicatie en het PS zenuwstelsel .......................................................................................... 124
Enterisch zenuwstelsel ................................................................................................................. 124
Controle van blaaswerking – autonoom zenuwstelsel..................................................................... 125
Autonome innervatie van mannelijke genitale tractus ..................................................................... 125
Overzicht autonome zenuwstelsel ................................................................................................ 125
Orthosympathisch vs. parasympathisch zenuwstelsel ................................................................... 126
Basale ganglia ........................................................................................................................... 127
Neuro-anatomie .......................................................................................................................... 127
Controle van motoriek in CZS........................................................................................................ 127
Basale ganglia – verschillende circuits .......................................................................................... 128
Motorische loop ................................................................................................................... 128
Directe en indirecte route.................................................................................................. 129
Motorisch circuit bij de ziekte van Parkinson ...................................................................... 129
Limbische loop..................................................................................................................... 129
Klinisch belang ............................................................................................................................ 130
Ziekte van Parkinson ............................................................................................................. 130
Symptomen ..................................................................................................................... 130
8
, Behandeling ..................................................................................................................... 130
Hyperkinetische aandoeningen ......................................................................................... 130
Ziekte van Huntington ........................................................................................................... 131
Pathogenese .................................................................................................................... 131
Hemiballisme .............................................................................................................................. 131
Take home messages ................................................................................................................... 132
Neuroimmunologie: inflammatie en auto-immuniteit .................................................................. 133
Inleiding in de neuroimmunologie ................................................................................................. 133
Mogelijke mechanismen die leiden tot neuroinflammatie ....................................................... 133
Cellen van het CZS parenchym.............................................................................................. 133
Functies cellen in het CZS ................................................................................................. 133
Wat is neuro-immunologie? .................................................................................................. 134
Neuroimmunologische aandoeningen ............................................................................... 134
Immuunsysteem: 3 niveaus van verdediging .......................................................................... 134
Bloed-hersen-barrière ...................................................................................................... 134
Regio’s zonder functionele BHB ..................................................................................... 134
Transport mechanismen over de BHB ............................................................................ 135
Lokalisatie van de meningeale lymfevaten ............................................................................. 135
Communicatie tussen CZS en perifere immuunsysteem ......................................................... 135
Auto-immuniteit ................................................................................................................... 135
Paroxysmale koude hemoglobinurie .................................................................................. 136
Mechanismen van tolerantie en (auto-)immuniteit .............................................................. 136
Definitie van autoimmuunziekte ........................................................................................ 136
Kruisreacties waardoor auto-immuniteit ontstaat: molecular mimicry ................................. 136
Toepassingen – neuropathofysiologie ............................................................................................ 137
Multipele sclerose ................................................................................................................ 137
Immuun respons bij MS .................................................................................................... 137
Pathofysiologie van progressieve MS ................................................................................. 137
NMO(SD).......................................................................................................................... 137
Paraneoplastische syndromen .............................................................................................. 137
Anti-Hu ............................................................................................................................ 138
Anti-NMDAR encephalitis .................................................................................................. 138
Geheugen en gedrag .................................................................................................................. 139
Geheugen .................................................................................................................................... 139
Semiologie ........................................................................................................................... 139
Functionele neuroanatomie .................................................................................................. 139
Consolidatie ........................................................................................................................ 140
Functionele anatomie ........................................................................................................... 140
Klinische en experimentele observaties ................................................................................. 140
Stoornissen van het geheugen ............................................................................................... 141
Dementie ......................................................................................................................... 142
Criteria ......................................................................................................................... 142
Cognitief continuum ..................................................................................................... 142
Onderliggende aandoeningen ........................................................................................ 143
9
, Gedrag ........................................................................................................................................ 143
Gestuurd door frontale kwabben ........................................................................................... 143
Frontale kwab dysfunctie / frontale psychosyndroom ............................................................. 143
Stoornissen gedrag: frontotemporale dementie ..................................................................... 144
Gedragsvariant van frontotemporale dementie (bvFTD) ...................................................... 144
Onderzoek geheugen en gedrag ............................................................................................ 145
Anamnese bij verdenking op cognitieve stoornis ................................................................. 145
Speciële (hetero)anamnese ........................................................................................... 145
Algemene anamnese (andere oorzaken nagaan) ............................................................. 145
Cognitieve screeningstesten ............................................................................................. 145
Elektrodiagnostisch onderzoek .................................................................................................. 146
Opbouw van het zenuwstelsel en de spieren .................................................................................. 146
Zenuw.................................................................................................................................. 146
Het actiepotentiaal ........................................................................................................... 146
Saltatoire geleiding over de knopen van Ranvier ................................................................. 146
Spiervezel en spierspoel ....................................................................................................... 147
Skeletspier ........................................................................................................................... 147
Neuromusculaire overgang ............................................................................................... 147
Motor unit ........................................................................................................................ 147
Neurofysiologische evaluatie van het PZS ...................................................................................... 148
Elektromyogram (EMG) – zenuwgeleiding ............................................................................... 148
Zenuwgeleiding ................................................................................................................ 148
Elektromyogram (EMG) – naaldonderzoek .............................................................................. 149
Myogene versus neurogene afwijking ................................................................................. 149
Spontane spier- of zenuwactiviteit ..................................................................................... 150
Neuromusculaire overgang ............................................................................................... 150
Neurofysiologische evaluatie van het CZS ..................................................................................... 151
Geëvokeerde potentialen (EP) ............................................................................................... 151
Visueel EP = VEP ............................................................................................................... 151
Brain auditory evoked EP = BAEP ....................................................................................... 152
SSEP bovenste ledematen ................................................................................................ 152
SSEP onderste ledematen ................................................................................................. 153
Motorisch EP = MEP .......................................................................................................... 154
Intra-operatieve neuromonitoring .......................................................................................... 154
Hemisferische asymmetrie ........................................................................................................ 155
Neuroanatomische asymmetrie .................................................................................................... 155
Functionele asymmetrie ............................................................................................................... 155
Taalnetwerk ......................................................................................................................... 155
Neuroanatomie ................................................................................................................ 155
Theoretisch ...................................................................................................................... 156
Lezen ............................................................................................................................... 156
Rechterhemisfeer ............................................................................................................. 157
Pathologie ........................................................................................................................ 157
Lexicon ........................................................................................................................ 157
10
