ICH自发性脑出血的诊断与治疗

Intracranial Hemorrhage,1,introduction,Intracranial hemorrhage (ie, the pathological accumulation of blood within the cranial vault) may occur within brain parenchyma.Intracerebral hemorrhage accounts for 8-13% of all strokes.Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction.,2,INCIDENCE & MORTALITY:,Each year, approximately 37,000 to 52,400 people in the United States.The case-fatality rate 34.6% at 7 days.50.3% at 30 days.59.0% at 1 year.,(Stroke. 2009;40:00-00),3,RISK FACTORS:,Hypertension- 60-70 %.Cerebral Amyloid Angiopathy- 15 %.Heavy alcohol consumption.Hypercholesterolemia.Anemia.Smoking/anti-platelet agents merging evidence.,4,LOCATIONS,Subcortical/lobar:20 %,Putamen40-50 %,Thalamus15 %,Pons8 %,Cerebellum8 %,5,6,Clinical Manifestion,Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with progressive (ie, minutes to hours) development of the following:Alteration in level of consciousness (approximately 50%)Nausea and vomiting (approximately 40-50%)Headache (approximately 40%)Seizures (approximately 6-7%) Focal neurological deficitsLobar hemorrhage due to cerebral amyloid angiopathy may be preceded by prodromal symptoms of focal numbness, tingling, or weakness.,7,Herniation Syndromes,Displacement of structures with resulting compression of tissue and blood flow1. Uncal2. Central3. Cingulate4. Transcalvarial5. Upward6. TonsillarSmith, Julian; Joe J. Tjandra; Gordon J. A. Clunie; Kaye, Andrew H. (2006).,8,Potential Secondary Brain Injury,Intracranial EffectsSecondary impactEdemaDelayed ICHHyperemiaVasospasmSeizures,Systemic EffectsHypoxia HypercarbiaHypotensionElectrolyte imbalanceAnemia/old bloodHyperthermia,9,Laboratory Studies,Complete blood count (CBC) with plateletsProthrombin time (PT)/activated partial thromboplastin time (aPTT): Identify a coagulopathy.Serum chemistries including electrolytes and osmolarity: Assess for metabolic derangements, such as hyponatremia, and monitor osmolarity for guidance of osmotic diuresis.Toxicology screen and serum alcohol level if illicit drug use or excessive alcohol intake is suspected,10,Imaging Studies,CT scan CT scan readily demonstrates acute hemorrhage as hyperdense signal intensity.Hematoma volume in cubic centimeters can be approximated by a modified ellipsoid equation: (A x B x C)/2, where A, B, and C represent the longest linear dimensions in centimeters of the hematoma in each orthogonal plane.,11,MRIThe MRI appearance of hemorrhage on conventional T1 and T2 sequences evolves over time because of chemical and physical changes within and around the hematoma.,12,MRI Appearance of Intracerebral Hemorrhage,13,MANAGEMENT:,Medical: Supportive care. BP control. Prevention of Hematoma growth. ICP Surgical options.,14,Acute Management,ICP, CPP TherapyVolume ResuscitationVasopressorsSedation/ParalyticsDraining CSFPerfusionTemperature RegulationBrain Tissue Oxygen Monitoring,15,Medication treatment,Antihypertensive agents reduce blood pressure to prevent exacerbation of intracerebral hemorrhage. Osmotic diuretics, such as mannitol, may be used to decrease intracranial pressure.As hyperthermia may exacerbate neurological injury, acetaminophen may be given to reduce fever and to relieve headache.,16,Anticonvulsants are used routinely to avoid seizures that may be induced by cortical damage. Levetiracetam has shown efficacy in children for prophylaxis of early posthemorrhagic seizures.Vitamin K and protamine may be used to restore normal coagulation parameters. Antacids are used to prevent gastric ulcers associated with intracerebral hemorrhage.,17,Surgical care,Consider surgery for patients with cerebellar hemorrhage greater than 3 cm, for patients with intracerebral hemorrhage associated with a structural vascular lesion, and for young patients with lobar hemorrhage. Other surgical considerations include the following: Clinical course and timing Patients age and comorbid conditions Etiology Location of the hematoma Mass effect and drainage patterns,18,Goals of ICP Monitoring,Avoid herniation syndromesPrevent secondary injuryEarly detection of increasing ICPMaintenance of ICP within normal limitsEvaluation of interventionsEvaluation of pathology resolution,19,ICP Monitoring Guidelines,Patients at risk for intracranial hypertensionPatients in comaCT demonstrates Mass lesion; Midline shift; Loss of third ventricleDilatation of contralateral ventricleObliteration of perimesencephalic cisternsNormal CT with 40y/o, GCSm 3, hypotensionGCS 8,20,ICP Monitor Placement,21,ICP Waveform examples,Compliant brainNon-compliant brainMalignant HypertensionDampened waveform,22,Brain,Blood,CSF,Increasing ICP,23,Stepwise Approach to ICP Management颅内压循序管理的步骤,治疗步骤,循证等级,治疗方法,无报告,L-3,L-3,L-3,L-2,L-3,无报告,无报告,去骨辦减压,代谢抑制（苯巴比妥盐）,降低体温,诱导高碳酸血症,高渗性治疗，高渗氯化钠,脑室脑脊液引流,增加镇静,插管，正常二氧化碳分压通气,风险,咳嗽，人机不同步 呼吸机相关性肺炎,低血压,感染,