脑 出 血ppt课件

脑出血 1 脑出血Intracerebralhemorrhage DepartmentofNeurology The2ndaffiliatedhospital HarbinMedicalUniversity 脑出血 2 Conception Itmeansprimaryandnontraumaticintracerebralhemorrhage Countfor20 30 instrokeHypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage 脑出血 3 Etiology Halfofthepatientssufferfromhypertensioncombinedwitharteriolaratherosclerosis itisthemostcommoncauseofthedisease Others cerebralatherosclerosis hematopathy cerebralamyloidangiopathyCAA aneurysm AVM 脑出血 4 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 脑出血 5 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 脑出血 6 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 脑出血 7 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 脑出血 8 Pathology HypertensiveICH cerebralpenetratingarterymiliaryaneurysmNonHypertensiveICH occurinsubcorticalwhitematterwithoutarteriosclerosis 脑出血 9 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 脑出血 10 Clinicalfeatures age 50 70yearsoldsex moremalepatientsseason winterorspringpasthistory hypertensioninducement activity excitementonset acuteonset 脑出血 11 Clinicalfeatures Hypertensivehemorrhageoccurswithoutwarning mostcommonlywhilethepatientisawake Headacheispresentin50 ofpatientsandmaybesevere vomitingiscommon Bloodpressureiselevatedafterthehemorrhagehasoccurred Thus normalorlowbloodpressureinapatientwithstrokemakesthediagnosisofhypertensivehemorrhageunlikely asdoesonsetbefore50yearsofage 脑出血 12 Clinicalfeaturesbasalganglionhemorrhage Thetwomostcommonsitesofhypertensivehemorrhagearetheputamen figure1 andthalamus figure2 whichareseparatedbytheposteriorlimboftheinternalcapsule Ingeneral putaminalhemorrhageleadstoamoreseveremotordeficit hemiplegia andthalamichemorrhagetoamoremarkedsensorydisturbance hemianesthesia 脑出血 13 Clinicalfeaturesbasalganglionhemorrhage Homonymoushemianopiamayoccurasatransientphenomenonafterthalamichemorrhageandisoftenapersistentfindinginputaminalhemorrhage Inlargethalamichemorrhages theeyesmaydeviatedownward asinstaringatthetipofthenose becauseofimpingementonthemidbraincenterforupwardgaze 脑出血 14 Clinicalfeaturesbasalganglionhemorrhage Aphasiamayoccurifhemorrhageateithersiteexertspressureonthecorticallanguageareas Largehemorrhagesmayleadtoconsciousnessdisturbance whileminorhemorrhagesleadtolacunarsyndrome 脑出血 15 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 脑出血 16 Clinicalfeaturespontinehemorrhage Withbleedingintothepons figure3 comaoccurswithinsecondstominutesandusuallyleadstodeathwithin48hours Ocularfindingstypicallyincludepinpointpupils Horizontaleyesmovementsareabsentorimpaired butverticaleyemovementsmaybepreserved Insomepatients theremaybeocularbobbing 脑出血 17 Clinicalfeaturespontinehemorrhage Patientsarecommonlyquadripareticorhemiplegiaalternateandexhibitdecerebrateposturing Hyperthermia respirationdisorderissometimespresent Thehemorrhageusuallyrupturesintotheforthventricle androstralextensionofthehemorrhageintothemidbrainwithresultantmidpositionfixedpupilsiscommon 脑出血 18 Clinicalfeaturesmidbrainhemorrhage Midbrainhemorrhageisrarelyseeninclinic ThepatientsoftenmanifestWebersyndrome Largehemorrhagesmayleadtocomaandflaccidparalysis 脑出血 19 Clinicalfeaturescerebellarhemorrhage 小脑齿状核动脉破裂Thedistinctivesymptomsofcerebellarhemorrhage figure4 aresevereheadache dizziness vomiting andtheinabilitytostandorwalk butstrengthinthelimbsisnormal Largehemorrhagesleadtocomawithin12hoursin75 ofpatientsandwithin24hoursin90 Theymayleadtocompressionofthebrainstem 脑出血 20 Clinicalfeatureslobarhemorrhage Etiology AVM Moyamoyadisease cerebralamyloidangiopathy tumorHypertensivehemorrhagesalsooccurinsubcorticalwhitematterunderlyingthefrontal parietal temporal andoccipitallobes figure5 Symptomsandsignsvaryaccordingtothelocation theycanincludeheadache vomiting hemiparesis hemisensorydeficits aphasia andvisualfieldabnormalities Seizuresaremorefrequentthanwithhemorrhagesinotherlocations whilecomaislessso 脑出血 21 Clinicalfeaturescerebralventriculushemorrhage 脉络丛plexuschorioideus动脉或室管膜下动脉破裂 figure6 Globalsymptomsareobvious butlocalsymptomsarenot Thepatientsmayhaveafullrecoveryandagoodoutcome Largehemorrhagesmayleadtocoma vomiting pinpointpupils impliesapooroutcome 脑出血 22 Supplementaryfindings CTcomputerizedtomographyischosenfirstLesion highdensity hematoma surrondedbylowdensity edema figure7 MasseffectisoftenseeninCT 脑出血 23 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 脑出血 24 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 脑出血 25 Diagnosis Senilepatientsafter50yearsofagePasthistoryofhypertensionOnsetduringactivitySuddenonsetCTscan 脑出血 26 Differentialdiagnosis Cerebralinfarction situationandspeedofonset bloodpressure lesionshowedbyCTComaduetoothercauses presentillnesshistoryInjury historyofinjuryNonhypertensivehemorrhage withouthistoryofhypertension 脑出血 27 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 脑出血 28 Treatmentsurgicaltreatment 时机 超早期6 24小时IndicationContraindications术式 脑出血 29 Rehabilitation 尽早进行assoonaspossible抗抑郁antidepression 脑出血 30 Specifictreatment NonhypertensivehemorrhagePoly cerebralhemorrhageRebleedingUnstablecerebralhemorrhage 脑出血 31 Prognosis Themortalityin30daysis35 52 halfofthepatientsdiewithin2days duetocerebralherniation Largehemorrhagesofbrainstem thalamus ventricleimpliesapoorprognosis 脑出血 32 蛛网膜下腔出血Subarachnoidhemorrhage SAH DepartmentofNeurology The2ndaffiliatedhospital HarbinMedicalUniversity 脑出血 33 Conception Itisanacutehemorrhagiccerebralvasculardiseaseinwhichvesselsonsurfaceofbrainandspinalcordrupturesuddenlyduetomanycauses bloodflowintothesubarachnoidspace calledprimarySAHSecondarySAH hemorrhagesinbrain ventricleorepidural subdural spaceruptureintosubarachnoidspaceTraumaticSAHCountfor10 instroke for20 inhemorrhagicstroke 脑出血 34 Etiology CongenitalaneurysmismostcommonetiologyAVMisalessfrequentcauseofSAHHypertensivearteriosclerosisaneurysmisthethirdcauseofSAHMoyamoyadiseaseistheforthcauseOthersincludetumor arteritis 脑出血 35 Pathophysiology Cerebralarteryaneurysmaremostcommonlycongenital berry aneurysms whichresultfromdevelopmentalweaknessofthevesselwall especiallyatthesitesofbranching AVMaremostcommoninthemiddlecerebralarterydistribution Arteritiscanalsoplayanimportantroleinthedisease Tumorinvasivethevesselwallcannotbeoverlooked 脑出血 36 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 脑出血 37 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 脑出血 38 Clinicalfeatures AnyageofpersonmaysufferfromSAH Theclassic butnotinvariable presentationofSAHisthesuddenonsetofanunusuallyseveregeneralizedheadache patientsoftendescribeitas theworstheadacheIeverhadinmylife Theabsenceoftheheadacheessentiallyprecludesthediagnosis Lossofconsciousnessisfrequent asarevomitingandneckstiffness Symptomsmaybeginatanytimeofdayandduringeitherrestorexertion 脑出血 39 Clinicalfeatures Themostsignificantfeatureoftheheadacheisthatitisnew Milderbutotherwisesimilarheadachesmayhaveoccurredintheweekspriortotheacuteevent Theseearlierheadachesareprobablytheresultofsmallprodromalhemorrhages sentinel orwarning hemorrhages oraneurysmalstretch 脑出血 40 Clinicalfeatures Theheadacheisnotalwayssevere buttheintensityoftheheadachemayremainunchangedforseveraldaysandsubsideonlyslowlyoverthenext2weeks Arecrudescentheadacheusuallysignifiesrecurrentbleeding Thereisfrequentlyconfusion stupor orcoma Nuchalrigidityandotherevidenceofmeningealirritationarecommon Meningealirritationmayinducetemperatureelevationstoashighas39 duringthefirst2weeks Preretinalglobularsubhyaloidhemorrhages foundin20 ofcases aremostsuggestiveofthediagnosis 脑出血 41 Clinicalfeatures Becausebleedingoccursmainlyinthesubarachnoidspaceinpatientswithaneurysmalrupture prominentfocalsignsareuncommononneurologicexamination Whenpresent theymaybearnorelationshiptothesiteoftheaneurysm Anexceptionisoculomotornervepalsyoccurringipsilateraltoaposteriorcommunicatingarteryaneurysm Bilateralextensorplantarresponsesand nervepalsiesarefrequentinsuchcases RupturedAVMsmayproducefocalsigns suchashemiparesis aphasia oradefectofthevisualfields 脑出血 42 Clinicalfeatures Inducementandaura inducementincludeintensiveactivity exhaustion excitement auracanbe warningleak andlocalizedsign SymptomsofSAHpatientsabove60yearoldarenottypical slowlyonset headacheandmeningealirritationarenotobvious withsevereconsciousnessdisturbance oftenaccomplishedwithcardiacdamageandothercomplications 脑出血 43 Complications Recurrenceofhemorrhage Recurrenceofaneurysmalhemorrhage 20 over10 14days isthemajoracutecomplicationandroughlydoublesthemortalityrate RecurrenceofhemorrhagefromAVMislesscommonintheacuteperiod Arterialvasospasm Delayedarterialnarrowing termedvasospasm occursinvesselssurroundedbysubarachnoidbloodandcanleadtoparenchymalischemiainmorethanone thirdofcases 脑出血 44 Complications Acuteorsubacutehydrocephalus Acuteorsubacutehydrocephalusmaydevelopduringthefirstday orafterseveralweeks asaresultofimpairedCSFabsorptioninthesubarachnoidspace Progressivesomnolence nonfocalfindings andimpairedupgazeshouldsuggestthediagnosis 脑出血 45 Complications Seizures Seizuresoccurinfewerthan10 ofcasesandonlyfollowingdamagetothecerebralhemisphere Others Althoughinappropriatesecretionofantidiuretichormoneandresultantdiabetesinsidiouscanoccur theyareuncommon 脑出血 46 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 脑出血 47 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 脑出血 48 Diagnosis Symptom thehistoryofasuddensevereheadachewithconfusionorobtundationSign nuchalrigidity anonfocalneurologicexaminationCSF bloodyspinalfluidFundusoculi preretinalglobulars