高血压小动脉纤维素样坏死fib

1、脑 出 血Intracerebral hemorrhage,Department of Neurology, The 2nd affiliated hospital, Harbin Medical University,Conception,It means primary and nontraumatic intracerebral hemorrhage. Count for 20%30% in stroke Hypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.,E

2、tiology,Half of the patients suffer from hypertension combined with arteriolar atherosclerosis, it is the most common cause of the disease. Others：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy CAA , aneurysm, AVM,Pathophysiology,高血压小动脉：纤维素样坏死fibrinoid necrosis、脂质透明变性hyaline fatt

3、y change、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brain edema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penetrating arteries 豆纹动脉lenticulostriate artery：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ble

4、eding artery,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active hemorrhage或早期再出血early rebleeding 多发性脑出血常继发于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis,Pathology,Hypertensive ICH：基底节的内囊区inter capsule、壳核putamen占70%，脑叶lobe、脑干brainstem、小脑齿状核区各占10% Location of ICH：

5、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subarachnoid space、第四脑室forth ventricle,Pathology,Hypertensive ICH：cerebral penetrating artery miliary aneurysm Non Hypertensive ICH：occur in subcortical white matter without arteriosclerosis,Pathology,Swelling and congestion of hemisphere 出

6、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）,Clinical features,age：5070 years old sex：more male patients season：winter or spring past history：hypertension inducement：activity、excitement onset：acute onset,Clinical features,Hypertensive hemorrhage occurs without warning, most

7、commonly while the patient is awake. Headache is present in 50% of patients and may be severe, vomiting is common. Blood pressure is elevated after the hemorrhage has occurred. Thus, normal or low blood pressure in a patient with stroke makes the diagnosis of hypertensive hemorrhage unlikely, as doe

8、s onset before 50 years of age.,Clinical featuresbasal ganglion hemorrhage,The two most common sites of hypertensive hemorrhage are the putamen(figure 1) and thalamus(figure 2), which are separated by the posterior limb of the internal capsule. In general, putaminal hemorrhage leads to a more severe

9、 motor deficit (hemiplegia) and thalamic hemorrhage to a more marked sensory disturbance (hemianesthesia).,Clinical featuresbasal ganglion hemorrhage,Homonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage. In larg

10、e thalamic hemorrhages, the eyes may deviate downward, as in staring at the tip of the nose, because of impingement on the midbrain center for upward gaze.,Clinical featuresbasal ganglion hemorrhage,Aphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas. Large

11、hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.,Clinical featuresbasal ganglion hemorrhage,丘脑出血thalamus hemorrhage: 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caput nuclei caudati hemorrhage: 少见，仅见脑膜刺激征,Clinical featuresponti

12、ne hemorrhage,With bleeding into the pons(figure 3), coma occurs within seconds to minutes and usually leads to death within 48 hours. Ocular findings typically include pinpoint pupils. Horizontal eyes movements are absent or impaired, but vertical eye movements may be preserved. In some patients, t

13、here may be ocular bobbing.,Clinical featurespontine hemorrhage,Patients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometimes present. The hemorrhage usually ruptures into the forth ventricle, and rostral extension of t

14、he hemorrhage into the midbrain with resultant midposition fixed pupils is common.,Clinical featuresmidbrain hemorrhage,Midbrain hemorrhage is rarely seen in clinic. The patients often manifest Weber syndrome. Large hemorrhages may lead to coma and flaccid paralysis.,Clinical featurescerebellar hemo

15、rrhage,小脑齿状核动脉破裂 The distinctive symptoms of cerebellar hemorrhage(figure 4) are severe headache, dizziness, vomiting, and the inability to stand or walk, but strength in the limbs is normal. Large hemorrhages lead to coma within 12 hours in 75% of patients and within 24 hours in 90%.They may lead t

16、o compression of the brainstem.,Clinical featureslobar hemorrhage,Etiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumor Hypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal, temporal, and occipital lobes(figure 5). Symptoms and signs vary accordin

17、g to the location; they can include headache, vomiting, hemiparesis, hemisensory deficits, aphasia, and visual field abnormalities. Seizures are more frequent than with hemorrhages in other locations, while coma is less so.,Clinical featurescerebral ventriculus hemorrhage,脉络丛plexus chorioideus动脉或室管膜

18、下动脉破裂(figure 6) Global symptoms are obvious，but local symptoms are not. The patients may have a full recovery and a good outcome. Large hemorrhages may lead to coma, vomiting, pinpoint pupils,implies a poor outcome.,Supplementary findings,CT computerized tomography is chosen first Lesion:high densit

19、y(hematoma) surronded by low density(edema)（figure 7） Mass effect is often seen in CT,Supplementary findings,MRI magnetic resonance image 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CT ICH and cerebral infarction can be distinguished by MRI 45 weeks,but CT can not distinguish them Easy to detect AVM、aneurysm Complex

20、 stages,Supplementary findings,DSA：to diagnose AVM、Moyamoya disease、arteritis CSF：elevated pressure,consistently bloody,but not the routine examination 其他：血、尿、便常规，肝功，肾功，凝血功能，心电图等,Diagnosis,Senile patients after 50 years of age Past history of hypertension Onset during activity Sudden onset CT scan,D

21、ifferential diagnosis,Cerebral infarction:situation and speed of onset,blood pressure,lesion showed by CT Coma due to other causes:present illness history Injury:history of injury Nonhypertensive hemorrhage:without history of hypertension,Treatmentmedical treatment,保持安静keep quiet、卧床休息rest in bed、减少探

22、视avoid meeting 水电解质平衡keep water_electrolyte balance 和营养nutrition 控制脑水肿control brain edema，降低颅内压decrease ICP:antiedema agents,e.g.mannitol 控制高血压control blood pressure: antihypertensive agents or diuretic such as furosemide 防治并发症prevent complications:rebleeding, herniation, infection,Treatmentsurgical

23、 treatment,时机：超早期 6-24小时 Indication Contraindications 术式,Rehabilitation,尽早进行as soon as possible 抗抑郁antidepression,Specific treatment,Nonhypertensive hemorrhage Poly-cerebral hemorrhage Rebleeding Unstable cerebral hemorrhage,Prognosis,The mortality in 30 days is 35%52%,half of the patients die withi

24、n 2 days,due to cerebral herniation. Large hemorrhages of brainstem、thalamus 、ventricle implies a poor prognosis.,蛛网膜下腔出血Subarachnoid hemorrhage, SAH,Department of Neurology, The 2nd affiliated hospital, Harbin Medical University,Conception,It is an acute hemorrhagic cerebral vascular disease in whi

25、ch vessels on surface of brain and spinal cord rupture suddenly due to many causes,blood flow into the subarachnoid space,called primary SAH Secondary SAH：hemorrhages in brain、ventricle or epidural (subdural) space rupture into subarachnoid space Traumatic SAH Count for 10% in stroke，for 20% in hemo

26、rrhagic stroke,Etiology,Congenital aneurysm is most common etiology AVM is a less frequent cause of SAH Hypertensive arteriosclerosis aneurysm is the third cause of SAH Moyamoya disease is the forth cause Others include tumor, arteritis,Pathophysiology,Cerebral artery aneurysm are most commonly cong

27、enital “berry” aneurysms, which result from developmental weakness of the vessel wall, especially at the sites of branching. AVM are most common in the middle cerebral artery distribution. Arteritis can also play an important role in the disease. Tumor invasive the vessel wall can not be overlooked.

28、,Pathophysiology,颅内压增高increased ICP 阻塞性脑积水obstructive hydrocephalus 化学性脑膜炎aseptic meningitis下丘脑功能紊乱 自主神经功能紊乱dysautonimia 交通性脑积水communicating hydrocephalus 血管活性物质致血管痉挛vascular spasm、蛛网膜颗粒粘连、甚至脑梗死、正常颅压脑积水,Pathology,85%90% of intracranial aneurysms locate anterior in the circle of Willis,they are mainl

29、y single,they are multiple in about 10%20% of cases,locating in the opposite site of the same vessel,called mirror aneurysm. 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,Clinical features,Any age of person may suffer from SAH. The classic (but not invariable) presentation of SAH is the su

30、dden onset of an unusually severe generalized headache, patients often describe it as “the worst headache I ever had in my life”. The absence of the headache essentially precludes the diagnosis. Loss of consciousness is frequent, as are vomiting and neck stiffness. Symptoms may begin at any time of

31、day and during either rest or exertion.,Clinical features,The most significant feature of the headache is that it is new. Milder but otherwise similar headaches may have occurred in the weeks prior to the acute event. These earlier headaches are probably the result of small prodromal hemorrhages (se

32、ntinel,or warning, hemorrhages) or aneurysmal stretch.,Clinical features,The headache is not always severe, but the intensity of the headache may remain unchanged for several days and subside only slowly over the next 2 weeks. A recrudescent headache usually signifies recurrent bleeding. There is fr

33、equently confusion, stupor, or coma. Nuchal rigidity and other evidence of meningeal irritation are common. Meningeal irritation may induce temperature elevations to as high as 39 during the first 2 weeks. Preretinal globular subhyaloid hemorrhages (found in 20% of cases) are most suggestive of the

34、diagnosis.,Clinical features,Because bleeding occurs mainly in the subarachnoid space in patients with aneurysmal rupture, prominent focal signs are uncommon on neurologic examination. When present, they may bear no relationship to the site of the aneurysm. An exception is oculomotor nerve palsy occ

35、urring ipsilateral to a posterior communicating artery aneurysm. Bilateral extensor plantar responses and nerve palsies are frequent in such cases. Ruptured AVMs may produce focal signs, such as hemiparesis, aphasia, or a defect of the visual fields.,Clinical features,Inducement and aura：inducement

36、include intensive activity、exhaustion、excitement,aura can be “warning leak” and localized sign. Symptoms of SAH patients above 60 year old are not typical：slowly onset,headache and meningeal irritation are not obvious,with severe consciousness disturbance,often accomplished with cardiac damage and o

37、ther complications,Complications,Recurrence of hemorrhage:Recurrence of aneurysmal hemorrhage (20% over 10-14 days) is the major acute complication and roughly doubles the mortality rate. Recurrence of hemorrhage from AVM is less common in the acute period. Arterial vasospasm:Delayed arterial narrow

38、ing, termed vasospasm, occurs in vessels surrounded by subarachnoid blood and can lead to parenchymal ischemia in more than one- third of cases.,Complications,Acute or subacute hydrocephalus:Acute or subacute hydrocephalus may develop during the first day- or after several weeks-as a result of impai

39、red CSF absorption in the subarachnoid space. Progressive somnolence, nonfocal findings, and impaired upgaze should suggest the diagnosis.,Complications,Seizures: Seizures occur in fewer than 10% of cases and only following damage to the cerebral hemisphere. Others:Although inappropriate secretion o

40、f antidiuretic hormone and resultant diabetes insidious can occur, they are uncommon.,Supplementary findings,CT：patients presenting with SAH are generally investigated first by CT scan(figure 8)，which will usually confirm that hemorrhage has occurred and may help to identify a focal source. 约15%患者CT

41、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SAH nA-SAH CSF:if CT scan fails to confirm the clinical diagnosis, lumber puncture is performed. The fluid is grossly bloody, the supernatant of the centrifuged CSF becomes yellow (xanthochromic), the chemical meningitis may produce pleocytosis.,Supplementary findings

42、,DSA:to detect aneurysm or AVM, it is a prerequisite to the rational planning of surgical treatment. MRI and MRA:MRI is especially useful in detecting small AVMs localized to the brainstem (an area poorly seen on CT scan). TCD：to determine CVS 实验室检查：血常规、凝血功能、肝功、免疫学,Diagnosis,Symptom：the history of a sudden severe headache with confusion or obtundation Sign：nuchal rigidity, a nonfocal neurologic examination CSF：bloody spinal fluid Fundus oculi：preretinal gl