高血壓小動脈纖維素樣壞死fibrinoid

1、腦 出 血intracerebral hemorrhage department of neurology, the 2nd affiliated hospital, harbin medical universityconceptionnit means primary and nontraumatic intracerebral hemorrhage.ncount for 20%30% in strokenhypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.eti

2、ologynhalf of the patients suffer from hypertension combined with arteriolar atherosclerosis, it is the most common cause of the disease.nothers：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy caa , aneurysm, avm pathophysiologyn高血壓小動脈：纖維素樣壞死fibrinoid necrosis、脂質(zhì)透明變性hyaline fatty

3、change、microaneurysm小動脈瘤、微夾層動脈瘤滲出exudation、破裂rupturen高血壓遠(yuǎn)端血管痙攣vasospasm缺氧anoxia、壞死angio-necrosis、血栓形成thrombosis斑點狀出血、腦水腫brain edema融合成片(子癇)pathophysiology n腦內(nèi)動脈：壁薄、中層肌細(xì)胞及外膜結(jié)締組織少、缺乏外彈力層隨年齡增長彎曲呈螺旋狀出血主要部位：深穿支penetrating arteriesn豆紋動脈lenticulostriate artery：大腦中動脈呈直角分出，易發(fā)生粟粒狀動脈瘤，為腦出血最好發(fā)部位，其外側(cè)支稱為出血動脈bleed

4、ing artery pathophysiology n一次出血常在30min內(nèi)停止n頭ct動態(tài)觀察：20%-40%患者24小時內(nèi)血腫仍繼續(xù)擴(kuò)大，為活動性出血active hemorrhage或早期再出血early rebleedingn多發(fā)性腦出血常繼發(fā)于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis pathologynhypertensive ich：基底節(jié)的內(nèi)囊區(qū)inter capsule、殼核putamen占70%，腦葉lobe、腦干brainstem、小腦齒狀核區(qū)各占10%nlocation of ich：殼

5、核（內(nèi)囊、側(cè)腦室），丘腦thalamus（第三腦室、內(nèi)囊、側(cè)腦室），腦橋pons、小腦cerebellum、蛛網(wǎng)膜下腔subarachnoid space、第四腦室forth ventriclepathologynhypertensive ich：cerebral penetrating artery miliary aneurysmnnon hypertensive ich：occur in subcortical white matter without arteriosclerosispathologynswelling and congestion of hemispheren出血灶：

6、充滿血液的空腔，周圍是壞死腦組織及淤點狀出血性軟化帶、腦水腫n血塊溶解吞噬細(xì)胞清除含鐵血黃素和壞死腦組織膠質(zhì)增生（膠質(zhì)瘢痕或中風(fēng)囊）clinical featuresnage：5070 years oldnsex：more male patientsnseason：winter or springnpast history：hypertensionninducement：activity、excitementnonset：acute onsetclinical featuresnhypertensive hemorrhage occurs without warning, most commo

7、nly while the patient is awake. nheadache is present in 50% of patients and may be severe, vomiting is common.nblood 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 does on

8、set before 50 years of age. clinical featuresbasal ganglion hemorrhagenthe 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. n in general, putaminal hemorrhage leads to a more severe m

9、otor deficit (hemiplegia) and thalamic hemorrhage to a more marked sensory disturbance (hemianesthesia). clinical featuresbasal ganglion hemorrhage nhomonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage.n 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 hemorrhagenaphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas. nlarge

11、 hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.clinical featuresbasal ganglion hemorrhagen丘腦出血thalamus hemorrhage: 丘腦膝狀動脈、穿通動脈破裂，表現(xiàn)為三偏癥狀，不同于殼核之處為均等癱、深淺感覺障礙、特征性眼征、意識障礙重、中線癥狀等尾狀核頭出血caput nuclei caudati hemorrhage: 少見，僅見腦膜刺激征clinical featurespontine

12、 hemorrhage nwith bleeding into the pons(figure 3), coma occurs within seconds to minutes and usually leads to death within 48 hours. nocular 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 hemorrhagenpatients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing. hyperthermia, respiration disorder is sometimes present. nthe 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 hemorrhagenmidbrain hemorrhage is rarely seen in clinic.nthe patients often manifest weber syndrome.nlarge hemorrhages may lead to coma and flaccid paralysis.clinical featurescerebellar hemor

15、rhagen小腦齒狀核動脈破裂nthe 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.nlarge hemorrhages lead to coma within 12 hours in 75% of patients and within 24 hours in 90%.they may lead to

16、 compression of the brainstem.clinical featureslobar hemorrhagenetiology：avm、moyamoya disease、cerebral amyloid angiopathy、tumornhypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal, temporal, and occipital lobes(figure 5).nsymptoms and signs vary according

17、to the location; they can include headache, vomiting, hemiparesis, hemisensory deficits, aphasia, and visual field abnormalities.nseizures are more frequent than with hemorrhages in other locations, while coma is less so.clinical featurescerebral ventriculus hemorrhagen脈絡(luò)叢plexus chorioideus動脈或室管膜下動脈

18、破裂(figure 6)nglobal symptoms are obvious，but local symptoms are not.nthe patients may have a full recovery and a good outcome.nlarge hemorrhages may lead to coma, vomiting, pinpoint pupils,implies a poor outcome.supplementary findingsnct computerized tomography is chosen firstnlesion:high density(he

19、matoma) surronded by low density(edema)（figure 7）nmass effect is often seen in ctsupplementary findingsnmri magnetic resonance image 急性期對幕上及小腦出血顯示不如ct，對腦干出血顯示優(yōu)于ctnich and cerebral infarction can be distinguished by mri 45 weeks,but ct can not distinguish themneasy to detect avm、aneurysmncomplex stag

20、essupplementary findingsndsa：to diagnose avm、moyamoya disease、arteritisncsf：elevated pressure,consistently bloody,but not the routine examinationn其他：血、尿、便常規(guī)，肝功，腎功，凝血功能，心電圖等diagnosisnsenile patients after 50 years of agenpast history of hypertensionnonset during activitynsudden onset nct scandifferen

21、tial diagnosisncerebral infarction:situation and speed of onset,blood pressure,lesion showed by ctncoma due to other causes:present illness historyninjury:history of injurynnonhypertensive hemorrhage:without history of hypertensiontreatmentmedical treatmentn保持安靜keep quiet、臥床休息rest in bed、減少探視avoid m

22、eetingn水電解質(zhì)平衡keep water_electrolyte balance 和營養(yǎng)nutritionn控制腦水腫control brain edema，降低顱內(nèi)壓decrease icp:antiedema agents,e.g.mannitoln控制高血壓control blood pressure: antihypertensive agents or diuretic such as furosemiden防治并發(fā)癥prevent complications:rebleeding, herniation, infectiontreatmentsurgical treatmen

23、tn時機(jī)：超早期 6-24小時nindication ncontraindicationsn術(shù)式rehabilitation n盡早進(jìn)行as soon as possiblen抗抑郁antidepressionspecific treatmentnnonhypertensive hemorrhagenpoly-cerebral hemorrhage nrebleedingnunstable cerebral hemorrhageprognosisnthe mortality in 30 days is 35%52%,half of the patients die within 2 days,

24、due to cerebral herniation.nlarge hemorrhages of brainstem、thalamus 、ventricle implies a poor prognosis.蛛網(wǎng)膜下腔出血subarachnoid hemorrhage, sahdepartment of neurology, the 2nd affiliated hospital, harbin medical university conceptionnit is an acute hemorrhagic cerebral vascular disease in which vessels

25、on surface of brain and spinal cord rupture suddenly due to many causes,blood flow into the subarachnoid space,called primary sahnsecondary sah：hemorrhages in brain、ventricle or epidural (subdural) space rupture into subarachnoid spacentraumatic sahncount for 10% in stroke，for 20% in hemorrhagic str

26、okeetiologyncongenital aneurysm is most common etiologynavm is a less frequent cause of sahnhypertensive arteriosclerosis aneurysm is the third cause of sahnmoyamoya disease is the forth causenothers include tumor, arteritis pathophysiologyncerebral artery aneurysm are most commonly congenital “berr

27、y” aneurysms, which result from developmental weakness of the vessel wall, especially at the sites of branching.navm are most common in the middle cerebral artery distribution.narteritis can also play an important role in the disease.ntumor invasive the vessel wall can not be overlooked.pathophysiol

28、ogyn顱內(nèi)壓增高increased icpn阻塞性腦積水obstructive hydrocephalusn化學(xué)性腦膜炎aseptic meningitis下丘腦功能紊亂n自主神經(jīng)功能紊亂dysautonimian交通性腦積水communicating hydrocephalusn血管活性物質(zhì)致血管痙攣vascular spasm、蛛網(wǎng)膜顆粒粘連、甚至腦梗死、正常顱壓腦積水 pathologyn85%90% of intracranial aneurysms locate anterior in the circle of willis,they are mainly single,they

29、 are multiple in about 10%20% of cases,locating in the opposite site of the same vessel,called mirror aneurysm.n好發(fā)于willis環(huán)動脈分叉處n破裂頻度n血液主要沉積在腦底部、腦池n可破入腦室致腦積水n蛛網(wǎng)膜無菌性炎癥反應(yīng)clinical featuresnany age of person may suffer from sah.n the classic (but not invariable) presentation of sah is the sudden onset of

30、 an unusually severe generalized headache, patients often describe it as “the worst headache i ever had in my life”.n the absence of the headache essentially precludes the diagnosis.n loss of consciousness is frequent, as are vomiting and neck stiffness.n symptoms may begin at any time of day and du

31、ring either rest or exertion. clinical featuresnthe most significant feature of the headache is that it is new. nmilder but otherwise similar headaches may have occurred in the weeks prior to the acute event. nthese earlier headaches are probably the result of small prodromal hemorrhages (sentinel,o

32、r warning, hemorrhages) or aneurysmal stretch.clinical featuresnthe 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.nthere is frequently

33、confusion, stupor, or coma. nnuchal 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. npreretinal globular subhyaloid hemorrhages (found in 20% of cases) are most suggestive of the diagnos

34、is. clinical featuresnbecause 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. nan exception is oculomotor nerve palsy occurring

35、 ipsilateral to a posterior communicating artery aneurysm. bilateral extensor plantar responses and nerve palsies are frequent in such cases. nruptured avms may produce focal signs, such as hemiparesis, aphasia, or a defect of the visual fields. clinical featuresninducement and aura：inducement inclu

36、de intensive activity、exhaustion、excitement,aura can be “warning leak” and localized sign.nsymptoms 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 other

37、complicationscomplicationsnrecurrence 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.narterial vasospasm:delayed arterial narrowing, t

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

39、f absorption in the subarachnoid space. progressive somnolence, nonfocal findings, and impaired upgaze should suggest the diagnosis.complicationsnseizures: seizures occur in fewer than 10% of cases and only following damage to the cerebral hemisphere. nothers:although inappropriate secretion of anti

40、diuretic hormone and resultant diabetes insidious can occur, they are uncommon. supplementary findingsnct：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. 約15%患者ct僅顯示腳間池

41、少量出血，向中腦環(huán)池、外側(cè)裂池基底擴(kuò)散，稱非動脈瘤性sah na-sahncsf: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 findingsndsa:to

42、 detect aneurysm or avm, it is a prerequisite to the rational planning of surgical treatment.nmri and mra:mri is especially useful in detecting small avms localized to the brainstem (an area poorly seen on ct scan).ntcd：to determine cvsn實驗室檢查：血常規(guī)、凝血功能、肝功、免疫學(xué) diagnosisnsymptom：the history of a sudden severe headache with confusion or obtundationnsign：nuchal rigidity, a nonfocal neurologic examinationncsf：bloody spinal fluidnfundus oculi：preretina