脑出血 Intracerebral hemorrhage .ppt

脑出血Intracerebralhemorrhage DepartmentofNeurology The2ndaffiliatedhospital HarbinMedicalUniversity Conception Itmeansprimaryandnontraumaticintracerebralhemorrhage Countfor20 30 instrokeHypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage Etiology Halfofthepatientssufferfromhypertensioncombinedwitharteriolaratherosclerosis itisthemostcommoncauseofthedisease Others cerebralatherosclerosis hematopathy cerebralamyloidangiopathyCAA aneurysm AVM Pathophysiology 高血压 小动脉 纤维素样坏死fibrinoidnecrosis 脂质透明变性hyalinefattychange microaneurysm小动脉瘤 微夹层动脉瘤 渗出exudation 破裂rupture高血压 远端血管痉挛vasospasm 缺氧anoxia 坏死angio necrosis 血栓形成thrombosis 斑点状出血 脑水肿brainedema 融合成片 子痫 Pathophysiology 脑内动脉 壁薄 中层肌细胞及外膜结缔组织少 缺乏外弹力层 随年龄增长弯曲呈螺旋状 出血主要部位 深穿支penetratingarteries豆纹动脉lenticulostriateartery 大脑中动脉呈直角分出 易发生粟粒状动脉瘤 为脑出血最好发部位 其外侧支称为出血动脉bleedingartery Pathophysiology 一次出血常在30min内停止头CT动态观察 20 40 患者24小时内血肿仍继续扩大 为活动性出血activehemorrhage或早期再出血earlyrebleeding多发性脑出血常继发于 hematopathy cerebralamyloidangiopathy neoplasm vasculitis Pathology HypertensiveICH 基底节的内囊区intercapsule 壳核putamen占70 脑叶lobe 脑干brainstem 小脑齿状核区各占10 LocationofICH 壳核 内囊 侧脑室 丘脑thalamus 第三脑室 内囊 侧脑室 脑桥pons 小脑cerebellum 蛛网膜下腔subarachnoidspace 第四脑室forthventricle Pathology HypertensiveICH cerebralpenetratingarterymiliaryaneurysmNonHypertensiveICH occurinsubcorticalwhitematterwithoutarteriosclerosis Pathology Swellingandcongestionofhemisphere出血灶 充满血液的空腔 周围是坏死脑组织及淤点状出血性软化带 脑水肿血块溶解 吞噬细胞清除含铁血黄素和坏死脑组织 胶质增生 胶质瘢痕或中风囊 Clinicalfeatures age 50 70yearsoldsex moremalepatientsseason winterorspringpasthistory hypertensioninducement activity excitementonset acuteonset Clinicalfeatures Hypertensivehemorrhageoccurswithoutwarning mostcommonlywhilethepatientisawake Headacheispresentin50 ofpatientsandmaybesevere vomitingiscommon Bloodpressureiselevatedafterthehemorrhagehasoccurred Thus normalorlowbloodpressureinapatientwithstrokemakesthediagnosisofhypertensivehemorrhageunlikely asdoesonsetbefore50yearsofage Clinicalfeaturesbasalganglionhemorrhage Thetwomostcommonsitesofhypertensivehemorrhagearetheputamen figure1 andthalamus figure2 whichareseparatedbytheposteriorlimboftheinternalcapsule Ingeneral putaminalhemorrhageleadstoamoreseveremotordeficit hemiplegia andthalamichemorrhagetoamoremarkedsensorydisturbance hemianesthesia Clinicalfeaturesbasalganglionhemorrhage Homonymoushemianopiamayoccurasatransientphenomenonafterthalamichemorrhageandisoftenapersistentfindinginputaminalhemorrhage Inlargethalamichemorrhages theeyesmaydeviatedownward asinstaringatthetipofthenose becauseofimpingementonthemidbraincenterforupwardgaze Clinicalfeaturesbasalganglionhemorrhage Aphasiamayoccurifhemorrhageateithersiteexertspressureonthecorticallanguageareas Largehemorrhagesmayleadtoconsciousnessdisturbance whileminorhemorrhagesleadtolacunarsyndrome Clinicalfeaturesbasalganglionhemorrhage 丘脑出血thalamushemorrhage 丘脑膝状动脉 穿通动脉破裂 表现为三偏症状 不同于壳核之处为均等瘫 深浅感觉障碍 特征性眼征 意识障碍重 中线症状等尾状核头出血caputnucleicaudatihemorrhage 少见 仅见脑膜刺激征 Clinicalfeaturespontinehemorrhage Withbleedingintothepons figure3 comaoccurswithinsecondstominutesandusuallyleadstodeathwithin48hours Ocularfindingstypicallyincludepinpointpupils Horizontaleyesmovementsareabsentorimpaired butverticaleyemovementsmaybepreserved Insomepatients theremaybeocularbobbing Clinicalfeaturespontinehemorrhage Patientsarecommonlyquadripareticorhemiplegiaalternateandexhibitdecerebrateposturing Hyperthermia respirationdisorderissometimespresent Thehemorrhageusuallyrupturesintotheforthventricle androstralextensionofthehemorrhageintothemidbrainwithresultantmidpositionfixedpupilsiscommon Clinicalfeaturesmidbrainhemorrhage Midbrainhemorrhageisrarelyseeninclinic ThepatientsoftenmanifestWebersyndrome Largehemorrhagesmayleadtocomaandflaccidparalysis Clinicalfeaturescerebellarhemorrhage 小脑齿状核动脉破裂Thedistinctivesymptomsofcerebellarhemorrhage figure4 aresevereheadache dizziness vomiting andtheinabilitytostandorwalk butstrengthinthelimbsisnormal Largehemorrhagesleadtocomawithin12hoursin75 ofpatientsandwithin24hoursin90 Theymayleadtocompressionofthebrainstem Clinicalfeatureslobarhemorrhage Etiology AVM Moyamoyadisease cerebralamyloidangiopathy tumorHypertensivehemorrhagesalsooccurinsubcorticalwhitematterunderlyingthefrontal parietal temporal andoccipitallobes figure5 Symptomsandsignsvaryaccordingtothelocation theycanincludeheadache vomiting hemiparesis hemisensorydeficits aphasia andvisualfieldabnormalities Seizuresaremorefrequentthanwithhemorrhagesinotherlocations whilecomaislessso Clinicalfeaturescerebralventriculushemorrhage 脉络丛plexuschorioideus动脉或室管膜下动脉破裂 figure6 Globalsymptomsareobvious butlocalsymptomsarenot Thepatientsmayhaveafullrecoveryandagoodoutcome Largehemorrhagesmayleadtocoma vomiting pinpointpupils impliesapooroutcome Supplementaryfindings CTcomputerizedtomographyischosenfirstLesion highdensity hematoma surrondedbylowdensity edema figure7 MasseffectisoftenseeninCT Supplementaryfindings MRImagneticresonanceimage急性期对幕上及小脑出血显示不如CT 对脑干出血显示优于CTICHandcerebralinfarctioncanbedistinguishedbyMRI4 5weeks butCTcannotdistinguishthemEasytodetectAVM aneurysmComplexstages Supplementaryfindings DSA todiagnoseAVM Moyamoyadisease arteritisCSF elevatedpressure consistentlybloody butnottheroutineexamination其他 血 尿 便常规 肝功 肾功 凝血功能 心电图等 Diagnosis Senilepatientsafter50yearsofagePasthistoryofhypertensionOnsetduringactivitySuddenonsetCTscan Differentialdiagnosis Cerebralinfarction situationandspeedofonset bloodpressure lesionshowedbyCTComaduetoothercauses presentillnesshistoryInjury historyofinjuryNonhypertensivehemorrhage withouthistoryofhypertension Treatmentmedicaltreatment 保持安静keepquiet 卧床休息restinbed 减少探视avoidmeeting水电解质平衡keepwater electrolytebalance和营养nutrition控制脑水肿controlbrainedema 降低颅内压decreaseICP antiedemaagents e g mannitol控制高血压controlbloodpressure antihypertensiveagentsordiureticsuchasfurosemide防治并发症preventcomplications rebleeding herniation infection Treatmentsurgicaltreatment 时机 超早期6 24小时IndicationContraindications术式 Rehabilitation 尽早进行assoonaspossible抗抑郁antidepression Specifictreatment NonhypertensivehemorrhagePoly cerebralhemorrhageRebleedingUnstablecerebralhemorrhage Prognosis Themortalityin30daysis35 52 halfofthepatientsdiewithin2days duetocerebralherniation Largehemorrhagesofbrainstem thalamus ventricleimpliesapoorprognosis 蛛网膜下腔出血Subarachnoidhemorrhage SAH DepartmentofNeurology The2ndaffiliatedhospital HarbinMedicalUniversity Conception Itisanacutehemorrhagiccerebralvasculardiseaseinwhichvesselsonsurfaceofbrainandspinalcordrupturesuddenlyduetomanycauses bloodflowintothesubarachnoidspace calledprimarySAHSecondarySAH hemorrhagesinbrain ventricleorepidural subdural spaceruptureintosubarachnoidspaceTraumaticSAHCountfor10 instroke for20 inhemorrhagicstroke Etiology CongenitalaneurysmismostcommonetiologyAVMisalessfrequentcauseofSAHHypertensivearteriosclerosisaneurysmisthethirdcauseofSAHMoyamoyadiseaseistheforthcauseOthersincludetumor arteritis Pathophysiology Cerebralarteryaneurysmaremostcommonlycongenital berry aneurysms whichresultfromdevelopmentalweaknessofthevesselwall especiallyatthesitesofbranching AVMaremostcommoninthemiddlecerebralarterydistribution Arteritiscanalsoplayanimportantroleinthedisease Tumorinvasivethevesselwallcannotbeoverlooked Pathophysiology 颅内压增高increasedICP阻塞性脑积水obstructivehydrocephalus化学性脑膜炎asepticmeningitis下丘脑功能紊乱自主神经功能紊乱dysautonimia交通性脑积水communicatinghydrocephalus血管活性物质致血管痉挛vascularspasm 蛛网膜颗粒粘连 甚至脑梗死 正常颅压脑积水 Pathology 85 90 ofintracranialaneurysmslocateanteriorinthecircleofWillis theyaremainlysingle theyaremultipleinabout10 20 ofcases locatingintheoppositesiteofthesamevessel calledmirroraneurysm 好发于Willis环动脉分叉处破裂频度血液主要沉积在脑底部 脑池可破入脑室致脑积水蛛网膜无菌性炎症反应 Clinicalfeatures AnyageofpersonmaysufferfromSAH Theclassic butnotinvariable presentationofSAHisthesuddenonsetofanunusuallyseveregeneralizedheadache patientsoftendescribeitas theworstheadacheIeverhadinmylife Theabsenceoftheheadacheessentiallyprecludesthediagnosis Lossofconsciousnessisfrequent asarevomitingandneckstiffness Symptomsmaybeginatanytimeofdayandduringeitherrestorexertion Clinicalfeatures Themostsignificantfeatureoftheheadacheisthatitisnew Milderbutotherwisesimilarheadachesmayhaveoccurredintheweekspriortotheacuteevent Theseearlierheadachesareprobablytheresultofsmallprodromalhemorrhages sentinel orwarning hemorrhages oraneurysmalstretch Clinicalfeatures Theheadacheisnotalwayssevere buttheintensityoftheheadachemayremainunchangedforseveraldaysandsubsideonlyslowlyoverthenext2weeks Arecrudescentheadacheusuallysignifiesrecurrentbleeding Thereisfrequentlyconfusion stupor orcoma Nuchalrigidityandotherevidenceofmeningealirritationarecommon Meningealirritationmayinducetemperatureelevationstoashighas39 duringthefirst2weeks Preretinalglobularsubhyaloidhemorrhages foundin20 ofcases aremostsuggestiveofthediagnosis Clinicalfeatures Becausebleedingoccursmainlyinthesubarachnoidspaceinpatientswithaneurysmalrupture prominentfocalsignsareuncommononneurologicexamination Whenpresent theymaybearnorelationshiptothesiteoftheaneurysm Anexceptionisoculomotornervepalsyoccurringipsilateraltoaposteriorcommunicatingarteryaneurysm Bilateralextensorplantarresponsesand nervepalsiesarefrequentinsuchcases RupturedAVMsmayproducefocalsigns suchashemiparesis aphasia oradefectofthevisualfields Clinicalfeatures Inducementandaura inducementincludeintensiveactivity exhaustion excitement auracanbe warningleak andlocalizedsign SymptomsofSAHpatientsabove60yearoldarenottypical slowlyonset headacheandmeningealirritationarenotobvious withsevereconsciousnessdisturbance oftenaccomplishedwithcardiacdamageandothercomplications Complications Recurrenceofhemorrhage Recurrenceofaneurysmalhemorrhage 20 over10 14days isthemajoracutecomplicationandroughlydoublesthemortalityrate RecurrenceofhemorrhagefromAVMislesscommonintheacuteperiod Arterialvasospasm Delayedarterialnarrowing termedvasospasm occursinvesselssurroundedbysubarachnoidbloodandcanleadtoparenchymalischemiainmorethanone thirdofcases Complications Acuteorsubacutehydrocephalus Acuteorsubacutehydrocephalusmaydevelopduringthefirstday orafterseveralweeks asaresultofimpairedCSFabsorptioninthesubarachnoidspace Progressivesomnolence nonfocalfindings andimpairedupgazeshouldsuggestthediagnosis Complications Seizures Seizuresoccurinfewerthan10 ofcasesandonlyfollowingdamagetothecerebralhemisphere Others Althoughinappropriatesecretionofantidiuretichormoneandresultantdiabetesinsidiouscanoccur theyareuncommon Supplementaryfindings CT patientspresentingwithSAHaregenerallyinvestigatedfirstbyCTscan figure8 whichwillusuallyconfirmthathemorrhagehasoccurredandmayhelptoidentifyafocalsource 约15 患者CT仅显示脚间池少量出血 向中脑环池 外侧裂池基底扩散 称非动脉瘤性SAHnA SAHCSF ifCTscanfailstoconfirmtheclinicaldiagnosis lumberpunctureisperformed Thefluidisgrosslybloody thesupernatantofthecentrifugedCSFbecomesyellow xanthochromic thechemicalmeningitismayproducepleocytosis Supplementaryfindings DSA todetectaneurysmorAVM itisaprerequisitetotherationalplanningofsurgicaltreatment MRIandMRA MRIisespeciallyusefulindetectingsmallAVMslocalizedtothebrainstem anareapoorlyseenonCTscan TCD todetermineCVS实验室检查 血常规 凝血功能 肝功 免疫学 Diagnosis Symptom thehistoryofasuddensevereheadachewithconfusionorobtundationSign nuchalrigidity anonfocalneurologicexaminationCSF bloodyspinalfluidFundusoculi preretinalglobularsu