外科学教学课件：Cerebrovascular Disorders

Chapter4.CerebrovascularDisordersNeurosurgeryNeurosurgeryDepartment,2ndHospital,CQMUNeurosurgeryDepartment,2ndHospital,CQMUCase1.Sep.30.2009,Mr.赵本山因“suddenheadacheandvomiting1h”被紧急送往上海华山医院抢救。之后,神经外科专家为赵本山施行手术，手术非常成功。NeurosurgeryDepartment,2ndHospital,CQMUSubarachnoidHemorrhageandIntracranialAneurysmNeurosurgeryDepartment,2ndHospital,CQMUGeneralintroduction1Clinicalaspects2EpidemiologicalAspects3Outcome4CauseofSAH5Investigations6Management7contentNeurosurgeryDepartment,2ndHospital,CQMU1.Generalintroduction

＃Subarachnoidhemorrhage(SAH)isnotadisorder,thatoccurswhensomediseasescauseavesselruptureintothissubarachnoidlayer.

SAHoccursattherelativelyyoungagewiththepooroutcome.NeurosurgeryDepartment,2ndHospital,CQMU＃

2.Clinicalaspects2.1Symptomandsignofthehaemorrhage

sudden,unusuallysevereheadache---clinicalhallmark

nauseaandvomitingbackandradicularpain(rare)consciousnessdisorders,comahydrocephalus

meningealirritationsign:neckstiffnessandpositiveKernig’ssign

NeurosurgeryDepartment,2ndHospital,CQMU2.2Focalneurologicaldeficit2.3Epilepsythethirdnerve(oculomotornerve)palsyhemiplegia2.4Others:Fever,hypertensionandleucocytosisNeurosurgeryDepartment,2ndHospital,CQMU3.EpidemiologicalAspects3.1AnnualincidenceofSAH:variedwithdifferentcountries,from2.0casesper100,000populationinChinato22.5per100,000inFinland.3.2Averageage:issubstantiallylowerthanforothertypesofstroke,40-60yearsold.3.3Factorsaffectingtheincidence:Gender,race,andregion3.4Geneticfactors:apositivefamilyhistory

Womenhavea1.6timeshigherriskthanmen

Blackpeoplea2.1timeshigherriskthanwhites.NeurosurgeryDepartment,2ndHospital,CQMU4.OutcomeofSAH4.1CasefatalityofSAHrangesbetween32and67%.

4.2One-thirdofSAHsurvivorsremaindependent.4.3Thethreebaselinevariablesmostcloselyrelatedtopooroutcome

theneurologicalconditionofthepatientonadmission---thelevelofconsciousness

age

theamountofsubarachnoidbloodontheininitialCTscanNeurosurgeryDepartment,2ndHospital,CQMUHunt-hessscaleNeurosurgeryDepartment,2ndHospital,CQMU＃

5.CauseofSAH5.1Intracranialaneurysms(accountfor70~85%)5.2Vascularmalformations

5.3Moyamoyadisease5.4rareconditions:microbialaneurysm,traumaticbraininjury,etcNeurosurgeryDepartment,2ndHospital,CQMUNeurosurgeryDepartment,2ndHospital,CQMUUnruptureaneurysmRuptureaneurysmNeurosurgeryDepartment,2ndHospital,CQMU＃6.Investigations6.1BrainScanning(CT,MRI)

CTscanning---first-lineinvestigationforSAHdiagnosisCTshowthecharacteristicallyhyperdenseappearanceofextravasatedbloodinthebasalcisterns.NeurosurgeryDepartment,2ndHospital,CQMU

MRI:isimpracticableintheacutephaseHowever,MRIisincreasinglysuperiortoCTindetectingextravasatedblood,upto40dayslater.TheprobabilityofCTdetectingahemorrhageisproportionaltotheclinicalgradeandthetimefromhemorrhage.Inthefirst12hoursafterSAH,thesensitivityofCTforSAHis98%to100%,decliningto93%at24hoursandto57%to85%6daysafterSAHNeurosurgeryDepartment,2ndHospital,CQMU6.2LumbarPunctureLumbarpunctureisstillanindispensablestepintheexclusionofSAHinpatientswithaconvincinghistoryandnegativebrainimaging.NeurosurgeryDepartment,2ndHospital,CQMU6.3CTAandMRA

MRAissafebutlesssuitableintheacutestage

CTAhassensitivitiesapproachingequivalencetoDSAforlargeraneurysms.NeurosurgeryDepartment,2ndHospital,CQMU6.4Digitalsubtractionangiography(DSA)DSAisthegoldstandardfordiagnosinganeurysmsasthecauseofSAH

~showthepresenceandanatomicfeaturesofaneurysms2D-DSA3D-DSANeurosurgeryDepartment,2ndHospital,CQMUDiagnosisofSAH:Summary

1.SAHisamedicalemergencythatisfrequentlymisdiagnosed.AhighlevelofsuspicionforSAHshouldexistinpatientswithacuteonsetofsuddensevereheadache.2.CTforsuspectedSAHisthefirst-lineinvestigation,andlumbarpunctureforanalysisofCSFisstronglyrecommendedwhentheCTscanisnegative.3.DSAisthegoldstandardfordiagnosinganeurysms.4.MRAandCTAmaybeconsideredwhenconventionalangiographycannotbeperformedinatimelyfashion.NeurosurgeryDepartment,2ndHospital,CQMU7.Management＃ComplicationsofaSAHrebleedingdelayedischaemicneurologicaldeficit(DIND)cerebralvasospasm(CVS)Theriskofrebleedingis4%inthefirst24hoursand19%inthefirst2weeks,andcarriesamortalityandmorbidityof60%CVSisseenin30%to70%ofpatients,withatypicalonset3to5daysafterthehemorrhage,maximalnarrowingat5to14daysNeurosurgeryDepartment,2ndHospital,CQMU7.1Treatmentstrategyforpreventrebleeding

Controlbloodpressure

AbsoluteBedrest

Antifibrinolytictherapy:6-EACA

SurgicalclippingorendovascularcoilingNeurosurgeryDepartment,2ndHospital,CQMUNeurosurgeryDepartment,2ndHospital,CQMUSurgicalclippingNeurosurgeryDepartment,2ndHospital,CQMUCase3.PComAneurysmØ3cmNeurosurgeryDepartment,2ndHospital,CQMUNeurosurgeryDepartment,2ndHospital,CQMUCase4.MCAAneurysmandHematomaPre-NeurosurgeryDepartment,2ndHospital,CQMUPost-NeurosurgeryDepartment,2ndHospital,CQMUendovascularcoilingNeurosurgeryDepartment,2ndHo