医药卫生出血性脑卒中课件

出血性脑卒中 hemorrhagic apoplexy,中南大学湘雅医院神经内科 谷文萍 Wenping Gu,MD.PhD. Neurology Department, Xiangya Hospital, central south University,脑出血 cerebral hemorrhage,脑出血 cerebral hemorrhage,是指原发性非外伤性脑实质内出血 发病率高，占全部脑卒中2030 80%以上由高血压性脑内细小动脉病变引起,固又称高血压动脉硬化性脑出血 Hypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage,病因与发病机制 etiopathogenisis and pathogenesy,高血压性脑内细小动脉硬化 高血压性脑动脉硬化时可有脑内细小动脉透明变性、纤维素样坏死，病变管壁在血流冲击下形成微动脉瘤 hypertension appears to promote structural changes including lipohyalinosis, fibrinoid necrosis and microaneurysm formation in the walls of pinetrating arteries,predisposing them to intracerebral hemorrhage. 导致脑动脉管壁薄弱(cerebral arteries vessel wall weak )的其他疾病 血液系统疾病(hematological system disease ) 肿瘤卒中(tumor apoplexy) 原因不明(unknown aetiology ),病理 pathology,多为脑动脉深穿支破裂所致 豆纹动脉最为常见，次为丘脑穿通动脉 多发于大脑半球基底核区，次为脑叶、脑桥、小脑和脑室等 Most hypertensive hemorrhages originate in certain areas of predilection,corresponding to long,narrow,penetrating arterial branches.These include the caudate and putaminal branches of the middle cerebral arteies(42%);branches of the basilar artery supplying the pons(16%);thalamic branches of the posterior cerebral arteries(15%);branches of the superior cerebellar arteries supplying the dentate nuclei and the deep white matter of the cerbellum(12%);and some white matter branches of the cerebral arteries(10%). 出血可直接破坏脑组织(hemorrhage to destroy brain tissue ) 血肿挤压周围组织，引起脑组织水肿、颅内压增高，严重可引起脑疝(hematoma crushing surrounding tissue),临床表现 clinical manifestation,50岁 高血压患者(hypertensive patients) 突然发病,迅速达高峰(suddenly onset) 全脑症状(global symptom) 局灶症状(focal symptom),临床表现 clinical manifestation,基底节区出血(basal ganglia hemorrhage)：50%60% 壳核出血（putamen hemorrhage） 内囊外侧型出血，为高血压性脑出血最常见的类型 Internal capsule lateral bleeding is the most common type of hypertensive cerebral hemorrhage 丘脑出血（thalamic hemorrhage） 尾状核头出血(head of caudate nucleus hemorrhage ) 脑叶出血（lobe hemorrhage）：5%10%,临床表现 clinical manifestation,脑干出血（brain stem hemorrhage） 中脑出血（midbrain hemorrhage） 脑桥出血（pontine hemorrhage）：10% 延髓出血（medulla oblongata hemorrhage） 小脑出血（cerebellar hemorrhage）：10% 脑室出血（cerebroventricular haemorrhage）：3%5%,辅助检查 laboratory findings,头颅CT(CT scan) MIR 脑血管造影(cerebral arteriography) MRA、CTA 、 DSA 腰穿脑脊液检查(lumbar puncture) 血、尿常规、血糖、电解质等检查,诊断与鉴别诊断 diagnosis and differential diagnosis,大于50岁，多有长期高血压病史(old patients with hypertension) 活动中或情绪激动时突然发病(suddenly onset) 头痛、呕吐、意识障碍等全身症状(headache,vomitting, impairment of consciousness) 偏瘫、偏身感觉障碍、失语等局灶神经体征(hemiparesis,hemisensory deficit,hemianopia,aphasia) CT见脑内出血病灶(CT find hematomas) 与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病鉴别(identification),治疗 treatment,基本原则(basic principle) 脱水降颅内压(antiedema) 调控血压(contral blood pressure) 防止继续出血(to prevent continue hemorrhage) 减轻继发损害(to ease secondary lesion ) 防治并发症 (complication),治疗 treatment,内科治疗(medical treatment) 一般治疗(general treatment) 脱水降颅压(antiedema) 调控血压(contral blood pressure) 亚低温治疗(inferior hypothermy curatio ) 并发症处理(complication) 上消化道出血(upper gastrointestinal hemorrhage) 肺部感染(lung infection) 其他(other) 外科治疗(surgical measures) 康复治疗(convalescent care),预后 prognosis,与出血部位、量及是否有合并症有关，出血量大、全身情况差者，病死率高 脑干出血病死率高达70% 大脑半球出血约为20% 总病死率为30%40% 存活患者中，病残率达70% The prognosis is related to the bleeding site, volume and whether there are complications,蛛网膜下腔出血,subarachnoid hemorrhage,蛛网膜下腔出血 subarachnoid hemorrhage,SAH,蛛网膜下腔出血是多种病因所致脑底部或脑及脊髓表面血管破裂的急性出血性脑血管病，血液直接流入蛛网膜下腔，又称原发性SAH 。此外，临床还可见因脑实质内、脑室出血、硬膜外或硬膜下血管破裂等血液穿破脑组织流入蛛网膜下腔者，称为继发性SAH Subarachnoid hemorrhage, SAHthe primary subarachnoid hemorrhage .Many etiological factors make cerebral basal part ,cerebral and spinal cord surface blood vessels rupture . Following these ,blood enters subarachnoid space ,which is called SAH. In addition , succeeding SAH is that blood enters subarachnoid space which is caused by rupturing of blood vessel in cerebral parenchyma, epidural , infradura mater or ventricular hemorrhage.,病因 etiopathogenisis,颅内动脉瘤(cerebral arterial aneurysm)，好发于30岁以上成年人，占50%85% Occurs in adults over the age of 30,about 50%85% 脑动静脉畸形(intracranial AVMs)，多见于青少年和儿童 脑底异常血管网病（moyaya) 其他：高血压脑动脉硬化(hypertention)、血管炎(vasculitides)等,发病机制 pathogenesy,颅内容积增加 颅内压增高 脑疝 血液刺激脑膜 剧烈头痛及脑膜刺激征 刺激丘脑下部和脑干 高热、植物神经功能紊乱 急慢性梗阻性脑积水、交通性脑积水 脑动脉痉挛 脑梗死 Rupture of an intracranial artery elevates intracranial pressure and distorts pain-sensitive structures, producing headache and causing the loss of consciousness.,病理 pathology,绝大多数颅内动脉瘤位于前循环，尤其是Wills环的动脉分叉处 Most of intracranial aneurysms occur anterior circulation , specially artery crotch of Wills circulus,临床表现 clinical manifestation,青壮年多见 突然起病，可有剧烈运动等诱因，少数起病前有头痛、头晕、视物模糊或长期间歇慢性头痛史 主要症状 突然发生的头部剧烈胀痛，位于前额、枕部或全头部，常伴有恶心、喷射性呕吐，意识障碍 定位体征 脑膜刺激征(meningeal irritation) 眼底改变(subhyaloid retinal hemorrhagess) The classic presentation of subarachnoid hemorrhage is the sudden onset of an unusually severe generalized headache.Loss of consciousness is frequent,as are vomiting and necckstiffness.,临床表现 clinical manifestation,并发症（complication） 再出血(rehemorrhage)，4周内，第2周尤多见 脑血管痉挛(cerebrovascular spasm)，发病早期或1-2周出现 脑积水（hydrocephalus） 其他：癫痫发作(epileptic attack)、低钠血症(hyponatremia)、上消化道出血（upper gastrointestinal hemorrhage）、发热（fever）等,辅助检查 laboratory findings,头颅CT或MIR检查 CT是诊断蛛网膜下腔出血快速、安全的手段，作为诊断本病的首选检查 CT scan will usually confirm that hemorrhage has occurred and may help to identify a focal source. 腰穿脑脊液检查(lumbar puncture) 脑血管造影(cerebral arteriography) DSA、MRA、CTA 经颅超声多普勒（TCD）,诊断与鉴别诊断 diagnosis and differential diagnosis,诊断(diagnosis) 根据病史、临床表现、CT检查和CSF的检查结果，可进行确诊According to histery、 clinical manifestation 、CT、CSF 鉴别诊断(differential diagnosis) 各种原因引起的脑膜炎(meningitis) 其他类型脑卒中(stroke),治疗 treatment,急性期治疗原则上是制止继续出血、降低颅内压、去除病因、防治并发症（complication），降低病死率和致残率 一般治疗及对症治疗 避免继续出血或再出血诱因To prevent bleeding or bleeding incentives 对症处理Symptomatic treatment 降低颅内压Lower intracranial pressure 防治再出血prevent and cure rehaemorrhagia 安静休息，绝对卧床4-6周(Absolute bed rest, mild sedation and analgesics for headache) 调控血压regulation blood pressure 止血治疗hemostasis 外科手术oper