颅内血肿英文.ppt

INTRACEREBRALHEMORRHAGE DEFINITIONOFTERMSpontaneousbleedinginthebrain Primaryintracerebralhemorrhage Althoughmanycausesofintracranialhemorrhagehavebeenfound hypertensive spontaneous intracerebralhemorrhageaccountsformostofthehemorrhages ETIOLOGY 1 Hypertensivearteriosclerosis Hyalinosis fibrinoidnecrosisandformationofmicroaneurysmsofintracerebralarteriolesandsmallarteries ETIOLOGY 2 Congenitaldefectsofvascularwall Saccularaneurysmorberryaneurysm arteriovenousmalformation AVM ETIOLOGY 3 Hemorrhagicdisorders Leukemia aplasticanemia liverdisease complicationofanticoagulantorthrombolytictherapy ect ETIOLOGY 4 Others Arteritis vascularamylosis Moyamoyadisease Moyamoya ETIOLOGY 5 Undeterminedcause normalbloodpressure noaneurysmorAVMandnohemorrhagicandotherdisordersabove PATHOGENESISANDPATHOLOGY 1 Pathogenesis HypertensionFibrinoidnecrosis RuptureHyalinosis Formationofmicroaneurysmsofarteriolesandsmallarteries Rupture PATHOGENESISANDPATHOLOGY Penetratingbranchesofmiddlecerebralartery Laterallenticulostriatearteries Heubnerarteryandmediallenticulostriatearteries PATHOGENESISANDPATHOLOGY 2 PathologyMostcommonsitesofhypertensivehemorrhage 1 Basalganglia Putamen externalcapsule thalamus internalcapsule andmixed Variouspartsofthecentralwhitematter frontal temporalandotherlobes PATHOGENESISANDPATHOLOGY 2 PathologyMostcommonsitesofhypertensivehemorrhage 2 Cerebellarhemisphere Pons Ventricles PATHOGENESISANDPATHOLOGY 2 PathologyHematomainthebrain displaceandcompressadjacentbraintissue Brainedemaandischemia Intracranialhypertension Herniaofbrain Ischemiaandnecrosisofbrainstem Death PATHOGENESISANDPATHOLOGY 2 PathologyHematomaisobsorbedoveraperiodofweeksandmonths CLINICALPICTURE 1 Commonoccurrenceageis50 70years yongerthaninthromboticinfarction BloodpressureismuchhigherinmostcasesOnsetwhilethepatientisupandactive onsetduringsleepisararity CLINICALPICTURE 2 Symptomsofextensivebrainlesions Headache vomitinganddisturbanceofconsciousnessetc CLINICALPICTURE 3 LocalneurologicalsymptomsPutaminal basalganglia hemorrhage Paralysisofthecontralateralface armandleg sensoryimpairmentovercontralateralface armandleghomonymousdefectofvisualfield aphasiamaybepresentwithlesionsofthedominantside CLINICALPICTURE 3 LocalneurologicalsymptomsCerebrallobehemorrhage symptomsandsignsvarywiththesiteandsizeofthehemorrhage CLINICALPICTURE Pontinehemorrhage deepcomausuallyensuesinafewminutes totalparalysistinypupilshighfeverdeathusuallyoccurswithinafewhours CLINICALPICTURE Cerebellarhemorrhage occipitalheadache repeatedvomiting vertigo aasaresultofbrainstemcompression thenirregularrespiration death CLINICALPICTURE Ventricularhemorrhage Secondary bleedingfromthebraintissue Primary bleedingoriginallyinventricleoraroundventricle 1 5cm headache vomiting Kernigsign deepcoma totalparalysis highfever tinypupils thendeep orirregularrespiration death LABORATORYFINDINGS 1 Whitebloodcellcountintheperipheralbloodoftenrisesto15 20 x1012 2 CTscan reliableinthedetectionofhemorrhage1 5cmormorediametersituatedincerebralorcerebellarhemosphere butnotsmallpontinehemorrhage MRI LABORATORYFINDINGS 3 CSF BloodyCSF bloodcellsinside 4 Cerebralangiography demonstratesananeurysmorAVM DIAGNOSTICPROBLEMS 1 Diagnosis Symptoms signs CTscanorMRI DIAGNOSTICPROBLEMS 2 DifferentialdiagnosisDiseasesthatcausecoma diabetic hepatic uremicandalcoholicetc Diseasesthatcausebrainlesions tumor trauma encephalitisetc Othertypesofstroke cerebralinfarction subarachnoidhemorrhage TREATMENT 1 Acutestagesavelife preventcomplication inprinciple Generalmedicalmanagements TreatmentmuststartatnearesthospitalEstablishmentofaclearairwayanddeliveryofoxygenifnecessary Lateralpositiontopreventsecretionsandvomitusenterthetracheobronchialtree Endotrachealtubemustbeinsertedifnecessary Generalmedicalmanagement Intravenouslineshouldbeestablishedandbloodsamplesmustbetakenforthemeasurementofthebloodelementsaswellasglucose electrolytesandfortestsofliverandkidneyfunction Therapyforcerebraledema Inthefirstfewdaysfollowinghemorrhage cerebraledemamaythreatenlife Mannitol0 5 1 g kgbodyweightivdrips fast furosamide Lasix 40mgivGlycerol250ml ivgtt slow Humanalbumincanalsobeusedtoincreaseosmoticpressureofcolloid Managementofbloodpressure Itisofgreatimportancetomaintainbloodpressure Ifthebloodpressureisnothigherthan180 100mmHg antihypertensivedrugsisnotnecessarytouse Surgicaloperation Removalofthehematomabyevacuationoraspiration Hematomaincerebellumornearthecorticalsurface Hemostasis Hemostatictherapyisnotrecommendedexceptforotherhemorrhagicdisorders Cerebralprotectives GABA Nicholine latestage etc Preventionandtreatmentofcomplications Gastricerosion gastrointestinalhemorrhage pneumonia TREATMENT 2 Latestage 1 Rehabilitation 2 Controlofhypertension 3 Preventionofrecurrence PROGNOSIS Theimmediateprognosisisgrave some70to75percentofpatientsdiein1to30days PREVENTION 1 ManagementofHypertension2 Avoidanceofinducement Q Whichsiteofbrainhemorrhagehasnotparalysis A BasalgangliaB Lobes temporalandotherlobes C CerebellarhemisphereD PonsE Ventricles 02 SUBARACHNOIDHEMORRHAGE DEFINITIONOFTERMSpontaneousbleedinginthesubarachnoidspace SUBARACHNOIDHEMORRHAGE Traumatic Spontaneous Secondary Bloodinsubarachnoidspaceisfromthehematomainbraintissue Primary Bloodinsubarachnoidspaceoriginatesfromrupturedbloodvesselsinsubarachnoidspace onsurfaceofbrain ETIOLOGY Causesofsubarachnoidhemorrhage 1 Saccularaneurysmorberryaneurysm2 Arteriovenousmalformation AVM ETIOLOGY 3 Hypertensivearteriosclerosis Hyalinosis fibrinoidnecrosisandformationofmicroaneurysmsofarteriolesandsmallarteriesonbrainsurface ETIOLOGY 3 Others Arteritis Moyamoyadisease Hemorrhagicdisorders etc 4 Undeterminedcause normalbloodpressure noaneurysmorAVMandnohemorrhagicandotherdisordersabove PATHOGENESISANDPATHOLOGY 1 Rupturedbloodvessels bleedinginsubarachnoidspace brainedema Intracranialhypertension Herniaofbrain Ischemiaandnecrosisofbrainstem Death2 Activematerialsinblood vascularspasm cerebralischemiaandinfarction CLINICALPICTURE 1 Generally commonoccurrenceageis40 70years lowerthanincerebralhemorrhage Suddenonsetwhilethepatientisupandactive CLINICALPICTURE 2 Headache nausea vomiting3 Symdromeofmeningealirritation Stiffneck Brudzinskisign Kernigsign CLINICALPICTURE 4 Disturbanceofconsciousness seizure5 Inmostcase thereisnolocalneurologicdeficitexceptforthirdnervepalsy occularmovementdisturbance CLINICALPICTURE 6 Adelayedhemiplegiamayoccur4 10daysafteronset attributedtovascularspasm 7 Examinationoffundirevealspreretinalorsubhyaloidhemorrhage LABORATORYFINDINGS 1 CSF BloodyCSF bloodcellsinside 2 CTscan detectbloodinthesubarachnoidspacelocallyordiffusely MRI3 Cerebralangiography demonstratesananeurysmorAVM DIAGNOSIS Diagnosis Headache vomiting Meningiticsymdrome BloodyCSF DifferentialDiagnosis MeningitisSecondarysubarachnoidhemorrhageOthertypesofstroke TREATMENT Stopbleeding preventvascularspasm removecauseandpreventre occurrence inprinciple TREATMENT 1 Absolutebedrestfor4 6weeks relieveandstoppain avoidmakingtoostrenuousefforts 2 Therapyforintracranialhypertension TREATMENT 3 Stopbleeding EACA PAMBAfor7 10days 4 Preventionandtreatmentforvascularspasm Nimodipine TREATMENT 5 SurgicaloperationRemovaloftheaneurysmorAVM Intravascularapproachisagoodway TREATMENT 6 Preventionofrecurrence treatmentforthecause avoidanceofinducement PROGNOSIS 1 Theprognosisofrupturedaneurysmisgrave 30percentofpatientsdieatacutestage 30percentreoccurrence PROGNOSIS 2 TheprognosisofrupturedAVM3 CommunicatinghydrocephalusduetothedisturbanceofCSFabsorptionmayappearafter2 4weeks decreasedintelligencedisordersofgaitincontinenceofurine SUMMARYOFACUTECEREBROVASCULARDISEASE 1 Theprinciplesofdiagnosis 1 suddenonset stroke 2 extensivebrainlesions hemorrhagic 3 localneurologicdeficit siteoflesion 4 CTorMRI definitediagnosis SUMMARY 2 Theprinciplesoftreatment 1 generalmanagement 2 dehydranttherapy 3 brainprotective 4 hemorrhagicandischemicstrokeacutestage differentlatestage similar Whichsubtypeofstrokehasnotparalysisatacutestage CerebralhemorrhageCerebralinfarctionSubrachnoidhemorrhage HEADACHEandMIGRAINE GENERALCONSIDERATIONS1 Thetermheadacheencompasstheachesandpainslocatedinthehead butinpracticeitsapplicationisrestrictedtodiscomfortintheregionofcranialvault Facialpainsareputasideassomethingdifferent 2 Headacheisasyndromeinducedbydifferentcauses Whenthepainreceptorsinsensitivestructurearestimulated itoccurs Thecausesofheadache intracranialdiseasesextracranialdiseasessystemicdiseasespsychogenicdiseases MIGRAINE MIGRAINEisadisordercharacterizedbyperiodic commonlyunilateralorbilateral throbbingheadaches ETIOLOGYANDMECHANISMS Thespecificcauseisunknown Keyfactorsinclude 1 Hereditaryfactors familialhistory60 2 EEGdepression 3 DecreaseofCBF 5 HT1breceptor 4 Increaseofplateletaggregation KEYFACTORS 5 Dieteticfactors chocolate fattyfoods oranges tomatoes onionsandalcohol etc 6 Endocriticfactors Theincidenceofmigraineinfemalesisabouttwicethanthatinmales andtheheadachestendtooccurduringperiodofpremenstrualtension 7 Inducement overwork hunger climate sleeplessness CLINICALPICTURE 1 Migrainewithaura classic typical usheredinbyadisturbanceofneurologicfunction photopsia centralblindness etc followedin