脑储蓄英文课件

Cerebrovascular

Diseases第一节

outline（概述）

key conceptsCerebrovasculardiseases:

thefocalordiffusedfunctiondisordersofthebrain,onthebasicdisorderofthecerebralvascularwallorofthebloodflowType:Accute:TIA(transientischemicattack)StrokeChronic:CerebrovasculardementiaStroke（apoplexy/cerebrovascularaccident）:asyndromecharacterizedbytheacuteonsetofaneurologicdeficitthatpersistsforatleast24hours,reflectsfocalinvolvementofthecentralnervoussystem,andistheresultofadisturbanceofthecerebralcirculation.Types:ischemia:localthrombosisorembolizationfromadistantsitehemorrhage：Strokeischemia:Cerebralischemicstroke(cerebralinfarction)arterothromboticinfarctionCerebralembolismLacunarinfarctionhemorrhage：

CerebralhemorrhageSubarachnoidhemorrhageTerritoriesoftheprincipalcerebralarteriesAnteriorcirculationInternalcarotidarteryOphthalmicarteryposteriorcommunicatingarteryAnteriorchoroidalartery(hippocampus,globuspallidus,lowerinternalcapsule)Anteriorcerebralartery(medialfrontal额叶andparietal顶叶cortexandsubjacentwhitematter,anteriorcorpuscallosum胼胝体)Middlecerebralartery(lateralfrontal,parietal,occipital,andtemporal颞叶cortexandsubjacentwhitematter)

Lenticulostriatebranches(caudatenucleus尾状核,putamen壳核,upperinternalcapsule)TerritoriesoftheprincipalcerebralarteriesPosteriorcirculationVertebralartery

Posteriorinferiorcerebellar

(medulla,lowercerebellium)Basilarartery

Anteriorinferiorcerebllar(lowerandmidpons,midcerebellium)

Superiorcerebellar

(upperpons,lowermidcerebellum)

Posteriorcereballar

(medialoccipitalandtemporalcortexandsubjacentwhitematter,posterriorcorpuscallosum胼胝体,uppermidbrain)Thalamoperforatebranches丘脑穿通动脉(thalamus)Thalamogeniculatebranches丘脑膝状体动脉

(thalamus)Pathology,physiologyandbloodcirculationregulationWeightofbrainis1.5kg,about2~3%ofbodyweightCBF750~1000ml/min

(CBF∞CPP/CVR)Cerebralbloodflow∞cerebralperfusionpressure/cerebralvascularresistanceCBF=(MAC-ICP)πr4/(8η*L)

MAC(平均动脉压)，ICP（颅内压),r(caliber管径)，

η（bloodviscosity血黏度），L（血管长度）

第二节Epidemiologyandprevention(流行病学和预防)EtiologicfactorsRiskfactorsHypertensionDiabetesmellitusCardiacdisorderHyperhomocysteinemiaTIAorstrokehistorySmokingoralcoholabuseHyperlipemiaOthers:obesity,age,contraceptive（避孕）,highfibrinogen…Primaryprevention(一级预防)HypertensionCardiacdisorderDiabetesmellitusHyperlipemiaSmokingoralcoholabuseWeightcontrolCarotidarterystenosisHyperhomocysteinemia(>16umol/l)highfibrinogenExercise,dietSecondaryprevention(二级预防)Hypertension,Cardiacdisorder,Diabetesmellitus,Hyperlipemia,Smokingoralcoholabuse,Weightcontrol,Carotidarterystenosis,Hyperhomocysteinemia(>16umol/l),highfibrinogen,Exercise,diet…Anti-plateletaggregationpost-strokecognitivehandicapinterventionpost-strokedepressionintervention

第三节transientischemicattack

（短暂性脑缺血发作）transientischemicattack(TIA)Transient,repeatedly,episode（发作性）,Lastafewminutes~1hour,oftencompletelyrecoverwithin30min,neverlastover24hours,leavenosymptom,physicalsignorsequela（后遗症）EtiologicalfactorsandpathogenesisMini-embolismCerebralvascularspasmBloodconstituentandhemodynamic（血液动力学）alterationOthers:vasculitis,cervicalsyndrome（颈椎病）ClinicalsituationMiddle-ageorsenium,male>female,Companywithhypertension,diabetes,cardiacdisease,hyperlipemiaAcuteonset,usuallyreachtothepeakwithin5min,recoverwithin30min,neverlastover24hours,leavenosymptom,physicalsignorsequelaRelativefixedsymptom,relapseClinicalsituationInternalcarotidarteryTIAOphthalmicarterycrossingparalysisHornersigncrossingparalysisAphasia失语(dominanthemisphere)Vertebral-BasilararteryTIADropattack:reticularformationofbrainstem(脑干网状结构)TransientglobalamnesiaBinocularvisiondisorderattack（双眼视力障碍）vertigo(眩晕),nausea(恶心),vomiting(呕吐),diplopia(复视),dysequilibrium(平衡失调),dysphagia(吞咽困难)DiagnosisCasehistoryPlateletcountingandaggregationrateBloodsugarandbloodlipidonanemptystomachProthrombintimeandpartialthromboplastintimeErythrocytesedimentation（血沉）EEG,TCDCT,MRA,CTA,DSA

differentialdiagnosisPartialepilepsiaMeniere’sdiseaseCardiacdisorderRIND(reversibleischemicneurologicdeficit)Migraineheadache(偏头痛)TumortreatmentEtiologicaltreatmentProphylacticdrugs(预防用药)Anti-plateletaggregationdrugsAnticoagulantdrugsBrainconservancySurgery

prognosis

第四节

cerebralinfarction

（脑梗死）

cerebralinfarctionProlongedinterruptionofbloodflowleadstoirreversibleinjuryandpersistentneurologicdeficitscliniccategoryRIND(reversibleischemicneurologicdeficit):<3wProgressiveischemicstroke:6h~2wCompletedischemicstroke:6hPathologiccategoryAtherothromboticcerebralinfarction(arterytoarteryembolism/thromboembolism&cerebralthrombosis)CerebralembolismLacunarinfarctionCerebralwatershedinfarction

Partone

Atherothrombotic

cerebralinfarctionArterothromboticcerebralinfarctionThrombusformsinthearterybasingonthecerebralatherosclerosisorotherdisorderofthevascularwall,leadstotheprolongedinterruptionofbloodflow,irreversibleinjuryandpersistentneurologicaldeficits.etiologicfactorCerebralatherosclerosisPathogenesisEndothelialinjuryadherenceofmonocyto/macrophages/T-lymphocytemigrationandsubendotheliallocalizationofthecellsformationofplateletthrombusproliferativelesion(fibrousplaque)Energy,excitatoryaminoacid,calciumoverload,ischemiccerebraledema,nitricoxide,immediateearlygenes,neurotrophicfactors,heatshockprotein,CK,apoptosisIschemicpenumbra(缺血半暗带)CBF~20ml/100g.minelectricfailurethresholdCBF~10ml/100g.minmembranefailurethresholdReperfusiondamage,hemorrhagicinfarctionTTW(therapeutictimewindow),RTW(reperfusiontimewindow),CTW(cytoprotectivetimewindow)PathologyClinicalfindingselderpersonwithatherosclerosis,hypertension,diabetes,cardiacdisorderStepwiseincrementalneurologicdeficitsAssociatedsymptoms(oftenwithoutseizures,headache,vomiting,dementia)InquietstatusInternalcarotidarterySyndromeTransientmonocularblindness(retinalarteryischemia)theseverityishighlyvariableSymptomaticsimilartotheMCAocclusionorasymptomaticMiddlecereberalartery

occlusionAnatomy:

suppliesmostofthecerebralhemisphereanddeepsubcorticalstructuressuperiordivision:theentiremotorandsensorycorticalrepresentationoftheface,hand,andarm;andtheexpressivelanguageareaofthedominanthemisphere;

inferiordivision:

thevisualradiations,theregionofvisualcortexrelatedtomacularvision;thereceptivelanguageareaofthedominanthemispherelenticulostriatebranches:thebasalgangliaandtheposteriorlimboftheinternalcapsule(themotorfibersrelatedtotheface,hand,arm,andleg)Middlecereberalartery

occlusionSyndrome:superiordivisionstroke:

contralateralhemiparesisthataffectstheface,hand,andarmbutsparesthelegContralateralhemisensorydeficitinthesamedistributionNohomonymosehemianopia(偏盲）Brocar’saphasia(thedominanthemisphereisinvolved),whichischaracterizedbyimpairmentoflanguageexpressionwithintactcomprehensionMiddlecereberalartery

occlusionSyndrome:Inferiordivisionstroke:Contralateralhomonymosehemianopia,maybedenserinferiorlyImpairmentofcorticalsensoryfunctionsDisordersofspatialthoughtWernicke’saphasia(dominanthemisphere),manifestedbyimpairedcomprehensionandfluentbutoftennonsensasiacalspeechAcuteconfusionalstate(nondomonanthemisphere)Middlecereberalartery

occlusionSyndrome:thebifurcationortrifurcationofMCAContalateralhemiparesisandhemisensorydeficitinvolvingthefaceandarmfarmorethanthelegHomonymoushemianopiaGlobal(dominanthemisphere)aphasia,characterizedbycombinedexpressiveandreceptiveMiddlecerebralartery

occlusionSyndrome:thestemofMCAContalateralhemiparesisandhemisensorydeficitinvolvingtheface,hand,armandthelegHomonymoushemianopiaGlobal(dominanthemisphere)aphasiaanteriorcerebralarteryocclusionAnatomy:suppliestheparasagittal

矢状旁cerebralcortex—includesportionsofmotorandsensorycortexrelatedtothelegandmicturition排尿centerSyndrome:Contralateralparalysisandsensorylossaffectingleg,voluntarycontrolofmicturitionmaybeimpairedBasilarArterysystemAnatomy:branchesofBAsupplytheoccipitalandmedialtemporal，medialthalamus,theposteriorlimboftheinternalcapsule,andtheentirebrainstemandcerebellumClinicalsyndromes:aseriouseventthatisoftenincompatiblewithsurvival,producesbilateralneurologicsignsreferabletoinvolvementofbothvertebralartery(VA)orofaloneunpairedVAIpsilateralcerebellarataxia共济失调,vertigo,nausea,vomiting,dysphagia吞咽困难,dysarthria构音障碍

coma,constrictedpupils,hightemperature,lockedinsyndrome,hemiplegiaorquadriplegia四肢瘫,evendeathBasilarArterysystemLockedinsyndrome:withbasilarocclusion,theventralportionofthepons(basispontis)isinfarctedandthetegmentumisspared,suchpatientsremainconsciousbutquadriplegic.Theymayopentheireyesormovetheireyesverticallyoncommand.Webersyndrome:ipsilateral

IIInervepalsy,contralateralhemiparesisParinaudsyndrome:unabletomoveeyesverticallyBenediktsyndrome:ipsilateralIIInervepalsy,involuntarymovement不自主运动onthecontralateralBasilarArterysystemMillard-Gublersyndrome:ipsilateralfacialnerve,abducentnerveparalysis,contralateralhemiplagiaFovillesyndrome:syntropygazeparalysistothefocus,ipsilateralfacialnerve,abducentnerveparalysis,contralateralhemiplagiaWallenbergsyndrome:ipsilateralcerebellarataxia,Horner’ssyndrome,facialsensorydeficit;contrlateralimpairedpainandtemperaturesensation;nystagus(眼震),vertigo，nausea,vomiting,dysphagia,dysarthria,andhiccupTopofthebasilararterysyndrome:abnormaleyemovement,pupil,consciousnessandbehavior,loseofrememberance,contralateralhemiablepsiaorcortexablepsia

PosteriorarteryAnatomy:supplytheoccipitalcerebralcortex,medialtemporallob,thalamus,androstralmidbrain(中脑脚)Clinicalsyndrome:homonymoushemianopiaaffectingcontralateralvisualfield,verticalgazepalsy;oculomotornervepalsy,internuclearophthalmoplegia,verticalskewdeviationoftheeyes;anomicaphasia,visualagnosia(失认)；corticalblindness,memoryimpairment,inabilitytorecognizefamiliarthings,exotonicvisualandbehavioralsyndrome.InvestigativestudiesInvestigativestudiesElectrocardiaogram(todetectunrecognizedmyocardialinfarctionorcardiacarythmias,suchasfibrillation)CT:lowdensityMRI:T1-weightedMRIscanshowsdecreasessignal,T2-weightedMRIscanshowsincreasessignalLumbarpuncture(腰穿)CerebralangiographyUltrasonography/transcranialdoppler/Echocardiography(心超)ElectroencephalogramSPECT，PETDiagnosisanddifferentialdiagnosisOnsetandcourse:

neurologicdeficitsprogressoversecondstohours/occasionallydays,happenedinquietstatusorinsleepDurationofdeficits:

persistforatleast24hrRIND(almostcompletelyresolveinafewdays,<3weeks)History:

artherosclerosis,hypertension,diabetesmellitus,coronaryarterydisease,TIAs,Associatedsymptoms:withoutheadache,vomiting,seizures,orcoma.CTscanandMRI:T1short,T2longTreatmentTreatmentprognosisMortality10%Multilationrate50%about40%patientswhosurvivedtheacuteperiodwouldrecidivismParttwoCerebralembolism

（脑栓塞）CerebralembolismAllkindsofembolienterthecerebralvascular,breakdownbloodflow,inducethedistrictbrainnecrosis,andturnuprelevantneurologicaldeficiency.EtiologicalfactorsandpathogenesisCardiacgenesis(70%)Muralthrombus(附壁血栓)/rheumaticheartdisease/arrhythmias（心律失常）/endocarditis…NoncardiacgenesisFracture,cancer,airRedinfarction(hemorrhagicinfarction)ClinicfindingOnset:beginabruptly,usuallywithinafewsecondsorminutes,neurologicdeficitsmaybemaximalatonset,happenedinquietorinactivestatusAge:youngaswellasoldHistory:TIAs,Muralthrombus/rheumaticheartdisease/arrhythmias/endocarditis/fractureAssociatedsymptoms:headache,vomiting,seizures,ordisordersofconsciousnesscanbefoundinsomepatients.SymptomsrelatewiththeembolioriginaldiseasesorembolisignsinothertissuesSyndromes:Internalcarotidarterysystem:ContralateralhemiparesisandhemisensorylossContralateralhomonymoushemianopiaaphasia(dominanthemisphere),characterizedbycombinedexpressiveandreceptivevertebral-basilararterysystem:Ipsilateralcerebellarataxia,vertigo,nausea,vomiting,dysphagia,dysarthria

coma,constrictedpupils,hightemperature,lockedinsyndrom,hemiplegiaorqudriplegia(四肢瘫),evendeathInvestigativestudiesCTscanandMRI:T1short,T2longElectrocardiaogram：(todetectunrecognizedmyocardialinfarctionorcardiacarrhythmias(心律失常),suchasatrialfibrillation(心房颤动)Lumbarpuncture(腰穿)Cerebralangiography（DSA）transcranialdoppler,Echocardiography(心超)DiagnosisanddifferentialdiagnosisAbruptdisplayoftheocclusionofthecerebralartery,withtheevidenceofemboli,CTscan,MRIorDSAshowcharacteristicappearancetreatmentThetreatmentforcerebralembolismAlmostsametoArterothromboticcerebralinfarctionTrytothrombolysiswithinthewindowtime,butshouldbemorecarefully,becauseofthehighriskofbleedingtreatmentfororiginaldiseaseprognosisMortality15%Dieofcerebralhernia(脑疝)，heartfailure,lunginflammationAbout10~20%patientswhosurvivedtheacuteperiodwouldrecidivismwithin2weeksOver60%patientswhosurvivedtheacuteperiodwouldrecidivismwithin1year

Partthree

Lacunarinfarction

(腔隙性脑梗死)Etiologyandpathology

Smallpenetratingarterieslocateddeepinthebrainmaybecomeoccludedasaresultofchangesinthevesselwallinducedbychronichypertension.Theinfarcttissueiscleanedandleavesanlacune

腔隙.Theresultinglacunarinfarctsaremorecommonindeepnucleiofthebrain.Putamen壳核(37%),thalamus(14%),caudatenucleus尾状核(10%),thepons(16%)，theposteriorlimboftheinternalcapsule(10%)Mostdiameteroflacunarinfarctionisbetween0.2~15mm,neverlargerthan20mm.Becauseoftheirsmallsizeandtheirfrequentlocationinrelativelysilentareasofthebrain,manyLIarenotrecognizedclinically.ClinicfindingsHistory:hypertensionAge:usually>65yearsoldOnset:gradual,developoverhoursordays,usuallyinquietstatus

Associatedsymptoms:withoutheadache,vomiting,seizures,ordisordersofconsciousnessPrognosis:goodLacunarsyndromesPuremotorhemiparesis:withoutanassociateddisturbancetosensation,vision,orlanguage;usuallyduetothecontralateralinternalcapsuleorpons.Puresensorystroke:mayassociatedwithparesthesia(感觉异常)；usuallyduetothecontralateralthalamus.LacunarsyndromesAtaxichemiparesis:characterizedbypuremotorhemiparesiscombinedwithataxiaofthehemipareticside,andpredominantlyaffectsleg;resultingfromthecontralateralpons,internalcapsule,orsubcorticalwhitematter.Dysarthria-clumsyhandsyndrome:dysarthia,facialweakness,dysphagia,andmildweaknessandclumsinessofthehandonthesideoffacialinvolvement;causedbythelesionofcontralateralponsorinternalcapsuleInvestigativestudiesDiagnosisanddifferentialdiagnosis

HypertensionAcuteonsetshowinglocalneurologicdeficienciesCTscanorMRIshowslacunarinfarctsDistinguishbetweensmallintracerebralhemorrhage,subduralhematoma(硬膜下血肿),orintracerebralmasslesions.TreatmentandprognosisSametothearterothromboticcerebralinfarction,butneednotthrombolysis,anticoagulation,decreasethebloodpressure,dehydrate.Prognosisisnotsobad,

mostpatientscanrecoversoon.Butitmayhappenagainandagain,thenpseudobulbarpalsy(假性球麻痹)andvasculardementiamaybeinduced.

Partfour

cerebralwatershedinfarction

(脑分水岭梗死)EtiologyandpathologyBorderzoneinfarction:theinfarctionzonelocatedbetweentheterritoriessuppliedbytwoarteriesclosetogether.Narrowofthecerebralartery+abnormalofhaemodynamics

(decreaseofbloodvolume,lowbloodpressure)stroke,overdoseofnarcotic(麻醉药)，hypotensive(降压药),severeanhydrationThemostcommonsiteofCWSIisthezoonbetweenMCAandPCA,thenextcommonsiteisthezoonbetweenACAandMCA.ClinicfindingsAge:>50y,History:hypertension,artherosclerosis,coronaryarterydisease,diabetes,hypotension,TIAhistoryOnset:withlowbloodpressure,lowbloodvolumeClinicfindingsPre-cortex:mainlyeffectupperlimb,hemiparalysis,hemi-sensorydisturbance,withorwithoutfrontallobesymptoms,suchaspsychiatricsymptom,forcedgraspingreflex;trans-cortexataxicaphasia(运动性失语),whenthesitelocatedinthedominanthemisphere.(ACA&MCA)Post-cortex:hemiablepsiaisthemostcommonphysicalsign，withorwithoutsensorydisturbance,hemiparesis;trans-cortexreceptiveaphasia(MCA&PCA)Sub-cortex:hemiparalysis,hemi-sensorydisturbance(basalganglia,internalcapsule,bodyoflateralcerebralventrical)posteriorcirculation:cerebellarataxia,consciousdisturbance,contractedpupil,gazingatthecontralateralofthesite(anteriorcerebellarartery&superiorcerebellar,brainstem

)InvestigativestudyCT&MRITCDDSADiagnosisandtreatment>50y,lowbloodpressureorlowbloodvolume,focalneuralfunctiondefection,CT&MRIshowsinfarctioninbendiformis.Correctlowbloodvolume&lowbloodpressure&hypercoagulabalestate.Treattheetiologyfactor.Sectionfour

第四节Hemorrhagestroke

出血性卒中

PartoneCerebralhemorrhageCerebralhemorrhageNotraumatic非外伤性IntracerebralPrimaryEtiologyHypertensivehemorrhageisthemostcommoncauseofintracerebralhemorrhage,account20~30%ofstroke.hypertension,

atherosclerosis/inflamatorydisorder…Hematologicdisorders(bloodconsistuentandhemorheologydisorders)Hypocoagulablestate/leukemia/thrombolysis/antiplateletTumorpathophysiologychronichypertensionpromotestructuralchangesinthewallsofpenetratingarteries,lipohyalinosisorfibrinoidnecrosis,inducetoformmicroaneurysms,suddenincreaseinbloodpressuremaycausetheruptureofeitheramicroaneurysmalorlipohyalinoticsegmentofasmallresistancearteryleadtointracerebralhemorrhage.ClinicfindingsOnset:

withoutwarning,usuallywithinafewsecondsorminutes,neurologicdeficitsmaybemaximalwithinafewminutesorhours,happenedinactivestatusAge:usually>50yearsHistory:hypertensionAssociatedsymptoms:headache,vomiting,seizures,ordisordersofconsciousnesscanbefoundinmanypatients,andthebloodpressureiselevated.neurologicdeficits

symptomsDeepcerebralhemorrhagePutamen壳核andthalamushemorrhagearethetwomostcommonsitesofhypertensivehemorrhageThissegmentoftheinternalcapsuleistraversedbydescendingmotorfibersandsensoryfibers,includingtheopticradiations.PutamenhemorrhageleastoamoreseveremotordeficitThalamushemorrhageleadstoamoremarkedsensorydisturbance,theeyesmaydeviatedownward.Homonymoushemianopia(同向偏盲)mayoccur.AphasiamayoccurifhemorrhageattheeithersideexertspressureonthecorticallanguageareaLobarhemorrhage(脑叶出血)Subcorticalwhitematterunderlyingthefrontal,parietal,temporal,andoccipitallobs.Symptomsandsignsvaryaccordingtothelocation,theycanincludevomiting,headache,hemiparesis,hemisensorydeficits,aphasia,andvisualfieldabnormalities.Seizuresaremorefrequentthanwithhemorrhagesinotherlocations,whilecomaislessso.Pontinehemorrhage(脑桥出血)Comaoccurswithinsecondstominutesandusuallyleadstodeathwithin48hours.Pinpointpupils（针尖样瞳孔）Horizontal(水平)eyemovementsareabsentorimpaired,butvertical（垂直）eyemovementsmaybepresent.Ocularbobbing(眼球浮动)Quadriparetic,decerebrateposturing(去脑强直)SmallhemorrhagesareassociatedwithlessseveredeficitsandexcellentrecoveryPontinehemorrhage(脑桥出血)Ocularfindings:impairmentofgazetothesideofthelesionorforceddeviationawayfromthelesion;skewdeviation(反侧偏斜)mayalsooccur；thepupilsaresmallandreactiveIpsilateralfacialweaknessoflowermotorneurontype,butstrengthinthelimbsisnormalPlantarresponses+Impairmentofvoluntaryorreflexupgazeindicatestranstentorialherniation(小脑幕切迹疝)CerebellarhemorrhageHeadache,dizziness,vomiting,andinabilitytostandorwalkdeviationLargehemorrhageleadtocomawithin12hoursin75%patientscerebralventriclehemorrhageHeadache,nausea,vomiting,Kernigsign+,withorwithoutdisordersofconsciousness.Pinpointpupils（针尖样瞳孔）HighfeverDeepbreathDecerebrateposturing(去脑强直)DeathInvestigativestudiesCT:highdensityMRI:T1-weightedMRIscanshowsequalsignal,T2-weightedMRIscanshowsincreasessignalLumbarpuncture(腰穿):bloodcerebrospinalfluid脑脊液CerebralangiographyDiagnosisanddifferentialdiagnosisOthertypeofstrokeCerebraltrauma(脑外伤)othermorbusinternus(内科病)脑梗死与脑出血的鉴别要点treatmentHerniationisthemaincauseofofdeathinacuteperiodofCH，socontroltheintracranialpressureisthemainpointtodecreasethemotality.Generaltreatment(keepinbed,decreasethetemperaturebyphysicalways)Antiedemaagents(mannitol甘露醇,furosemide速尿)whenSBp>200mmHg,orDBp>110mmHg,lowerbloodpressuretoabout100mmHgDeuto-lowtemperaturetreatment:within6h,keepfor48-72hpreventandcurethecomplication,suchasinflammation,gastrichemorrhageSurgicaltreatmentprognosisMortalityBrainstemhemorrhage70%Hemicerebralhemorrhage20%Disabilityrate30~40%ParttwoSubarachnoidhemorrhage(蛛网膜下腔出血)SubarachnoidhemorrhageIntracranialhemorrhagebecauseoftraumaorvascularmalformations,bloodbleedingintosubarachnoidPrimary:theruptureofthesurfacebrainvascularcausebleedingintosubarachnoiddirectlySecondary:intracerebralhemorrhageleadtothebleedingintosubarachnoidindirectlyEtiologyAneurysmsisthemostcommoncauseofSAH,whichareusuallyontheinternalcarotid.Vascularmalformationsarethesecondlycommoncau