颅内压

1,颅内压增高与脑疝,2,颅内压增高,intracranial pressure (ICP)Elevated ICP Increased ICPIntracranial Hypertension,3,颅内压增高,颅内压增高概述 ：生理，原因，病理，分类，临床表现，处理急性颅内压增高,4,颅内压增高-概述 ：生理 (1),Intracranial Compartment ：total 1500ml Brain Parenchyma 80 % Cerebrospinal Fluid 120140 ml Cerebral Blood Volume 150 mlIntracranial Pressure (ICP) 成人：0.72.0 kPa (70200mmH2O) 儿童：0.51.0 kPa (50100mmH2O),5,颅内压增高-概述 ：生理 (2),正常生理情况下 ICP 可以有小范围的波动主要通过血液及脑脊液来调节 ICPICP持续超过2.0kPa(200mmH2O),生理调节已无能为力，这时称 颅内压增高,6,7,颅内压增高-概述 ：颅内压增高的原因（ 1 ）,颅腔内原有成分体积增加脑实质(由于炎症、外伤等原因引起的水肿等)脑脊液（脑积水）血流（血管功能障碍或 PaCO2 及 PaO2的变化或血管性疾病如AVM 等）,8,Diffuse swelling of one cerebral hemisphere in a patient who died 5 days after head injury,9,Hydrocephalus.,10,9岁男孩,左侧颞枕 AVM,11,12,手术中,13,切除的标本,14,术后10天,15,颅内压增高-概述 ：颅内压增高的原因（2）,颅内占位性病变（space occupying lesion）： 肿瘤、血肿、脓肿、寄生虫等,颅内巨大肿瘤,16,70岁男性左侧巨大脑膜瘤,17,70岁男性左侧巨大脑膜瘤,18,男性，72岁 肺癌、颅内广泛转移,19,男性，72岁 肺癌、颅内广泛转移,20,颅内压增高-概述 ：颅内压增高的原因（3）,space occupying lesion: Epidural Hematoma,21,颅腔狭小,颅内压增高-概述 ： 颅内压增高的原因,(4),22,颅内压增高-概述 ：Pathophysiology,年龄病变扩张速度 Langfitt （1965）体积/压力关系曲线 volume-pressure response curve 病变部位伴发脑水肿的程度全身情况,(一)影响颅内压增高的因素：,23,颅内压增高-概述 ：Pathophysiology,（二）颅内压增高的后果： 对脑血流的影响,CBF = ( mSAP - ICP ) / CVR,CBF=CPP / CVR,脑灌注压 Cerebral Perfusion Pressure CPP normal: 9.312kPa (7090mmHg)自我调节机理 Autoregulatory Mechanisms,24,颅内压增高-概述 ：Pathophysiology,（二）颅内压增高的后果脑疝,25,颅内压增高-概述 ：Pathophysiology,脑水肿：血管源性、细胞毒性胃肠功能紊乱： 下丘脑植物神经中枢功能紊乱神经性肺水肿：510%，年轻人柯兴反应 ：BP ， HR,（二）颅内压增高的后果：,26,颅内压增高-概述 ：category of increased ICP,弥漫性颅内压增高： 无明显的压力差，脑组织移位不明显，耐受力好,局灶性颅内压增高： 多为局灶性扩张性病变，存在压力差，造成脑组织移位，耐受力好,27,颅内压增高-概述 ：category of increased ICP,急性颅内压力增高：颅脑损伤、急性颅内出血，病情发展快、重亚急性颅内压力增高：介于急性、慢性之间慢性颅内压力增高：颅内良性肿瘤，长期存在，缓慢发展，病情时好量坏,28,三主征：头痛、呕吐、视神经乳头水肿,The majority of writers and teachers concurred that the increased ICP produces its general and vital effect through the medullary centers and that these symptoms are: bradycardia, hypertension, irregular slow respiratory rate, vomiting and headache that progress to stupor and coma.,颅内压增高-概述 ：Clinical Manifestation,29,Papilledema:19-year-old obese woman with idiopathic intracranial hypertension, MR was normal , LP showed an open presure of 380mmH2O.,瞳孔改变,去皮层,去大脑,33,病史,颅内压增高-概述 ：Diagnosis,症状,体征,初步分析,初步诊断,进一步检查,分析,最后诊断,辅助性检查：,Lumbar Punctureplain film of head Computer Tomography CTMagnetic Resonance Imaging MRDigital Subtraction Angiography DSA,34,颅内压增高-概述 ：Management,Acute elevation of ICP is a medical emergency that should be controlled before any irreversible neurological damage develops. 一般处理General Supportive Therapy :注意生命体征的改变，尤其是意识的变化；注意内环境的稳定，尤其是电解质的稳定；强调保持大便通畅。,35,颅内压增高-概述 ：Management,去除病因： 开颅术Craniotomy（肿瘤、血肿、 脓肿、肉芽肿、AVM等） 药物控制炎症、水肿、血压 脑室腹腔分流术 V-P shunt,36,颅内压增高-概述 ：Management,药物降颅内压治疗 indication:原因不明或无法立即去除病因的颅内压增高的患者Osmotic Therapy Urea 1920s Mannitol 1960sNonosmotic Diuretics Loop diuretics such as furosemide,37,颅内压增高-概述 ：Management,激素的应用：DXM 甲基强的松龙 corticosteroid亚低温hypothermia巴比妥barbiturates过度换气hyperventilation脑室外引流：直接降低颅内压 ventricular CSF drainage抗生素：不主张滥用控制症状：禁用吗啡类,增加氧供减少氧耗,38,脑室穿刺管,39,脑室穿刺(侧脑室前角),40,脑室外引流术,穿刺,41,连接,42,脑室外引流术后在ICU,自发性颅内出血破入脑室、急性脑积水,43,亚低温疗法：认为有确定疗效，目前有一定争议,44,颅内压增高-急性脑疝 herniation,颅腔内存在压力差脑组织移位(高压低压)=脑疝形成小脑幕切迹疝-颞叶疝枕骨大孔疝-小脑扁桃体疝,45,颅内压增高-急性脑疝 解剖,46,颅内压增高-急性脑疝 解剖,47,颅内压增高-急性脑疝 解剖及原因,48,颅内压增高-急性脑疝 解剖及原因,49,颅内压增高-急性脑疝 解剖及原因,50,颅内压增高-急性脑疝,Subfalcine herniation,Cingulate gyrus,大脑镰下疝,51,颅内压增高-急性脑疝,小脑幕切迹疝,颞叶疝,Herniation of uncus of the temporal lobe against midbrain,P.a.,52,颅内压增高-急性脑疝 manifestation,颅内压增高：明显加重意识改变：逐渐加重瞳孔变化：同侧，先小后大运动障碍：多为对侧偏瘫，角弓 反张生命体征紊乱：,小脑幕切迹疝,53,颅内压增高-急性脑疝,Herniation of the cerebellar to