小脑出血ppt课件.ppt

小脑出血,1,病例分析,患者，女，78岁，因头痛、视物旋转伴呕吐2小时入院。发病后至我急诊科就诊。查体：脉搏70次/分呼吸24次/分，血压190/100mmHg，意识清楚，语言清晰，对答切题，头颅五官无畸形，双侧瞳孔等大等圆，直径3.0mm对光反射灵敏.心肺腹未见异常。四肢活动自如，肌张力正常，肌力V级，腱反射对称（+），Romberg征因未能站立而拒绝检查感觉系统正常无锥体束征血常规：WBC17.8xl06、N91.6，肝功能、肾功能、电解质、血脂检查正常。,2,病例分析,诊断为：眩晕症：高血压危象。而给予甘露醇、脑复康、奥美拉唑、脱水、营养脑细胞、保护粘膜治疗，入院后有少量呕血，加用止血药物治疗。治疗3天后，血压下降，但仍有明显视物旋转，转头或翻身即可出现，且伴呕吐。考虑存在颅内病变，而行头颅CT检查示：右侧小脑半球出血，出血量约为16.6ml。修正诊断为右侧小脑半球出血。加强脱水、脑细胞营养等治疗，1个月后，出血吸收，症状好转治愈出院。,林忠如，小脑出血误诊为眩晕症1例，中国误诊学杂志，2011年7月,3,非典型小脑出血鉴别,1、椎基底动脉供血不足：头晕、呕吐、眼震等症状，部分患者反复发作。2、原发性蛛网膜下腔出血：小脑半球靠近表面出血破入蛛网膜下腔，故以头痛、呕吐、脑膜刺激征为首发症状，血肿扩大后方出现小脑症状；伴有意识障碍，患者不能配合共济运动检查。3、脑干卒中或脑室出血：部分患者血肿向前压迫脑干至昏迷，眼位异常，或破入脑室。,4,共济失调分类,深感觉性共济失调：明亮的地方不明显，黑暗环境或闭眼时明显（躯干和四肢）；Romberg征阳性；步态异常；踩棉花感；步幅较大，脚间距宽，踵步（抬足较高，跨步大小不一，足跟用力着地，并产生拍击地面的声音）前庭性共济失调：共济失调以平衡障碍为主，表现站立不稳，行走时向病侧倾倒，改变头位症状加重，眩晕、眼球震颤明显Romberg征,5,各类共济失调临床表现,大脑性共济失调：共济失调比较轻；常伴有病理征阳性及其他定位体征小脑性共济失调：四肢或躯干的共济失调Romberg征阴性步态不稳（醉汉步态）意向性震颤言语：吟诗样，声音时断时续，爆发性等肌张力减低（钟摆运动）、反击征阳性,6,7,小脑cerebellum,*后颅窝*大脑后下*脑干后*借三对小脑脚与脑干相连接,位置,8,原裂,蚓部,小脑半球,小脑中脚,绒球,小结,小脑扁桃体tonsilofc.,上面观,下面观,蚓部vermis半球,：小脑上脚小脑中脚小脑下脚小脑扁桃体,外形,前叶后叶绒球小结叶flocculonodularlobe,分叶分部,后外侧裂,小脑体,蚓部中间部外侧部,9,皮质cortex髓体小脑核,顶核fastigal中间核齿状核dentate,球状核globose栓状核emboliform,内部结构,10,小脑的主要纤维联系和功能,机能分区主要传入自相关小脑核主要传至功能前庭小脑前庭感受器前庭N核维持前庭N核平衡,脊髓小脑脊髓小脑束顶核前庭N核调节肌网状结构张力和,大脑小脑大脑皮质齿状核丘脑调节随脑桥核大脑皮质意运动、运动起始,中间核红核丘脑协调运动,11,小脑的血液供应：来自椎基底动脉三对动脉：小脑上动脉小脑前下动脉小脑后下动脉,小脑的血管供应,12,小脑血管,13,侧面观,14,15,小脑血管供血区,图片来源：奈特神经解剖图谱,16,小脑前下动脉,小脑后下动脉,17,小脑前下动脉,小脑后下动脉,小脑上动脉,18,小脑后下动脉,小脑上动脉,基底动脉-大脑后动脉,19,Reviewednon-traumaticcerebellarhaemorrhagebetween1927and2011including1579patients.,20,Cerebellarhaemorrhages,Cerebellarhaemorrhagesconstituteapproximately10%ofallintracerebralhaemorrhages(ICH),about15%ofcerebellarstrokes.Causedbytumour,vascularmalformationoraneurysm，trauma，butmostly，primarycerebellarhaemorrhage(PCH)Requirestimelydiagnosisandprompttherapeuticaldecision-making.,FlahertyML,WooD,HaverbuschM,SekarP,KhouryJ,SauerbeckL,etal.Racialvariationsinlocationandriskofintracerebralhemorrhage.Stroke2005;36:9347,21,CTscanofarighthemisphericcerebellarhaematomaina51yearoldwomenwithahistoryofheadache30minbeforeadmission.Onadmissionshewasdrowsybutorientated(GCS13).,CTscanofa78-yearoldpatientwhowaslastseenhealthy2hbeforeadmission.20minbeforeadmissionhewasfoundcomatose(GCS3),brainstemreflexeswereabsent,andBabinski-signswerepositiveonbothsides.CTscanshowsamassivecerebellarhaematomainvolvingbothhemispheres,22,患者，男，68岁因“头晕伴恶心呕吐6.5小时”入院。既往：高血压病史10余年，未服药控制。3年前有“脑出血”病史，遗留左肢拖步。查体：神志清，瞳孔等大光敏，双眼右侧凝视，可及水平眼震，左侧中枢性面舌瘫，四肢肌力尚可，左侧指鼻试验完成差，双侧巴氏征未引出。治疗：甘露醇+速尿q4h交替，控制血压。经治疗2周后，病情较平稳，但出血未完全吸收，要求自动出院。,23,Complications,brainstemcompression脑干压迫upwardordownwardherniation脑疝Hydrocephalus脑积水,a60yearoldwomanBloodispresentinthe4th,3rdandthelateralventricles.Thetemporalhornsofthelateralventriclesaredilated,indicatinghydrocephalus.suboccipitalosteoplasticcraniotomyexternalventriculardrainplacement,24,四叠体池消失对脑积水出现有强烈的提示作用,25,Conservativetherapy,Decreaseofintracranialpressure（ICP）：elevationoftheheadby15to30degree，hyperventilation,osmotherapy,administrationofbarbiturates巴比妥类.,26,Surgicaltherapy,Ventriculardrainage脑室引流Suboccipitalcraniectomy枕骨下去骨瓣minimallyinvasivehematomaremoval微创血肿清除术,27,outcome,脑室切开引流,Mortalityinpatientswithprimarycerebellarhaemorrhage,28,Clinicaloutcomeinsurvivorsofprimarycerebellarhaemorrhage,Glasgowoutcomescale(GOS)：5，4，2-3modifiedRankinscale(mRS):0-2，3，4-5,29,KobayashiS,SatoA,KageyamaY,NakamuraH,WatanabeY,YamauraA.Treatmentofhypertensivecerebellarhemorrhagesurgicalorconservativemanagement?Neurosurgery1994;34:24650,discussion250241.KirollosRW,TyagiAK,RossSA,vanHillePT,MarksPV.Managementofspontaneouscerebellarhematomas:aprospectivetreatmentprotocol.Neurosurgery2001;49:137886,discussion138677MathewP,TeasdaleG,BannanA,Oluoch-OlunyaD.Neurosurgicalmanagementofcerebellarhaematomaandinfarct.JournalofNeurology,NeurosurgeryandPsychiatry1995;59:28792,脑干反射存在BAEP/SEP正常,脑干反射消失病理BAEP/SEP,30,31,recommendation,1.FormostpatientswithICH,theusefulnessofsurgeryisuncertain(ClassIIb;LevelofEvidence:C).(Newrecommendation)Specificexceptionstothisrecommendationfollow2.Patientswithcerebellarhemorrhagewhoaredeterioratingneurologicallyorwhohavebrainstemcompressionand/orhydrocephalusfromventricularobstructionshouldundergosurgicalremovalofthehemorrhageassoonaspossible(ClassI;LevelofEvidence:B).(Revisedfromthepreviousguideline)Initialtreatmentofthesepatientswithventriculardrainagealoneratherthansurgicalevacuationisnotrecommended(ClassIII;LevelofEvidence:C).(Newrecommendation)3.Forpatientspresentingwithlobarclots30mLandwithin1cmofthesurface,evacuationofsupratentorialICHbystandardcraniotomymightbeconsidered(ClassIIb;LevelofEvidence:B).(Revisedfromthepreviousguideline)4.Theeffectivenessofminimallyinvasiveclotevacuationutilizingeitherstereotacticorendoscopicaspirationwithorwithoutthrombolyticusageisuncertainandisconsideredinvestigational(ClassIIb;LevelofEvidence:B).(Newrecommendation)5.Althoughtheoreticallyattractive,noclearevidenceatpresentindicatesthatultra-earlyremovalofsupratentorialICHimprovesfunctionaloutcomeormortalityrate.Veryearlycraniotomymaybeharmfulduetoincreasedriskofrecurrentbleeding(ClassIII;LevelofEvidence:B).(Revisedfromthepreviousguideline),32,脑出血选择手术指证,1.对于大多数ICH患者而言，手术的作用尚不确定。（bC）2.小脑出血伴神经功能恶化、脑干受压和/或脑室梗阻致脑积水者应尽快手术清除血肿。（B）不推荐以脑室引流作为该组患者的初始治疗。（C）3.脑叶出血超过30ml且血肿距皮层表面1cm以内者，可考虑开颅清除幕上血肿。（bB）4.把立体定向设备或内镜单用，或与溶栓药物联用，以微创的方式清除血肿，其效果尚不确定，目前正处于研究阶段。（bB）5.尽管理论上来看有效，但是没有明确的证据表明超早期清除幕上血肿可以改善临床预后或降低死亡率。早期开颅清除血肿可能增加再出血的风险，从而产生负面作用。（B）,33,34,血压控制,收缩压150-220mmHg的住院患者，快速降压至140mmHg可能是安全的（aB）。高血压的ICH患者降压推荐意见（C级推荐）1.SBP200mmHg或MAP150mmHg,建议持续静脉应用降压药物快速降压，测血压，5min/次。2.SBP180mmHg或MAP130mmHg，且可能存在颅内高压，可考虑监测颅内压，并间断或持续静脉应用降压药物以降压，保持脑灌注压不低于60mmHg。3.SBP180mmHg