(CerebralHemorrhage)腦出血定義和鑒別診斷

1、(Cerebral Hemorrhage)腦 出 血定義和鑒別診斷ConceptionIt means primary and nontraumatic intracerebral hemorrhage.Count for 20%30% in strokeHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.EtiologyHalf of the patients suffer from hypertension combined with arteriolar ath

2、erosclerosis, it is the most common cause of the disease.Others：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy CAA , aneurysm, AVM Pathophysiology高血壓小動(dòng)脈：纖維素樣壞死fibrinoid necrosis、脂質(zhì)透明變性hyaline fatty change、microaneurysm小動(dòng)脈瘤、微夾層動(dòng)脈瘤滲出exudation、破裂rupture高血壓遠(yuǎn)端血管痙攣vasospasm缺氧anoxia、壞死a

3、ngio-necrosis、血栓形成thrombosis斑點(diǎn)狀出血、腦水腫brain edema融合成片(子癇)Pathophysiology 腦內(nèi)動(dòng)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 arteries豆紋動(dòng)脈lenticulostriate artery：大腦中動(dòng)脈呈直角分出，易發(fā)生粟粒狀動(dòng)脈瘤，為腦出血最好發(fā)部位，其外側(cè)支稱為出血?jiǎng)用}bleeding artery Pathophysiology 一次出血常在30min內(nèi)停止頭CT動(dòng)態(tài)觀察：20%-40%患者24小時(shí)內(nèi)血腫仍繼續(xù)擴(kuò)大，為活動(dòng)性出血active h

4、emorrhage或早期再出血early rebleeding多發(fā)性腦出血常繼發(fā)于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis PathologyHypertensive 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%Location of ICH：殼核（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 ve

5、ntriclePathologyHypertensive ICH：cerebral penetrating artery miliary aneurysmNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosisPathologySwelling and congestion of hemisphere出血灶：充滿血液的空腔，周圍是壞死腦組織及淤點(diǎn)狀出血性軟化帶、腦水腫血塊溶解吞噬細(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 featuresage：5070 yea

6、rs oldsex：more male patientsseason：winter or springpast history：hypertensioninducement：activity、excitementonset：acute onset臨 床 表 現(xiàn)一般癥狀：中年以上發(fā)病。起病突然， 動(dòng)態(tài)起病，病勢兇險(xiǎn)。高顱壓征 intracranial hypertension sign 頭痛，嘔吐，血壓升高，脈搏減慢， 視乳頭水腫，意識障礙 易形成腦疝 cerebral herniation神經(jīng)系統(tǒng)定位體征： 取決于血腫的部位、體積 局灶性神經(jīng)功能缺損基底節(jié)區(qū)：內(nèi)囊“三偏征” 偏癱 hemipl

7、egia 偏盲 hemiscotosis 偏身感覺障礙 hemihypesthesia腦葉 額葉 顳葉 頂葉 枕葉 各具不同缺損腦干 交叉性癱瘓 hemiplegia alternate小腦 眩暈 vertigo 共濟(jì)失調(diào) ataxia基底節(jié)區(qū)的血液供應(yīng)豆紋動(dòng)脈的破裂成因Clinical featuresbasal ganglion hemorrhageThe two most common sites of hypertensive hemorrhage are the putamen(figure 1) and thalamus(figure 2), which are separated

8、 by the posterior limb of the internal capsule. In general, putaminal hemorrhage leads to a more severe motor deficit (hemiplegia) and thalamic hemorrhage to a more marked sensory disturbance (hemianesthesia). Clinical featuresbasal ganglion hemorrhage Homonymous hemianopia may occur as a transient

9、phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage. In large 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 hemorrhag

10、eAphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas. Large hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.Clinical featuresbasal ganglion hemorrhage丘腦出血thalamus hemorrhage: 丘腦膝狀動(dòng)脈、穿通動(dòng)脈破裂，表現(xiàn)為三偏癥狀，不同于殼核之處為均

11、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 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

12、movements are absent or impaired, but vertical eye movements may be preserved. In some patients, there may be ocular bobbing.Clinical featurespontine hemorrhagePatients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometim

13、es present. The hemorrhage usually ruptures into the forth ventricle, and rostral extension of the hemorrhage into the midbrain with resultant midposition fixed pupils is common. Clinical featuresmidbrain hemorrhageMidbrain hemorrhage is rarely seen in clinic.The patients often manifest Weber syndro

14、me.Large hemorrhages may lead to coma and flaccid paralysis.Clinical featurescerebellar hemorrhage小腦齒狀核動(dòng)脈破裂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 l

15、ead to coma within 12 hours in 75% of patients and within 24 hours in 90%.They may lead to compression of the brainstem.Clinical featureslobar hemorrhageEtiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumorHypertensive hemorrhages also occur in subcortical white matter underlying the front

16、al,parietal, temporal, and occipital lobes(figure 5).Symptoms and signs vary according 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 l

17、ess so.Clinical featurescerebral ventriculus hemorrhage脈絡(luò)叢plexus chorioideus動(dòng)脈或室管膜下動(dòng)脈破裂(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.Supple

18、mentary findingsCT computerized tomography is chosen firstLesion:high density(hematoma) surronded by low density(edema)（figure 7）Mass effect is often seen in CTSupplementary findingsMRI 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CTICH and cerebral infarction can be distinguished by MRI 45 w

19、eeks,but CT can not distinguish themEasy to detect AVM、aneurysmComplex stagesSupplementary findingsDSA：to diagnose AVM、Moyamoya disease、arteritisCSF：elevated pressure,consistently bloody,but not the routine examination其他：血、尿、便常規(guī)，肝功，腎功，凝血功能，心電圖等診 斷 依 據(jù)病史高顱壓征：頭痛，嘔吐，血壓高 早期意識障礙局灶性定位體征頭顱CT：腦實(shí)質(zhì)內(nèi)局灶性高密度病灶Di

20、agnosisSenile patients after 50 years of agePast history of hypertensionOnset during activitySudden onset CT scanDifferential diagnosisCerebral infarction:situation and speed of onset,blood pressure,lesion showed by CTComa due to other causes:present illness historyInjury:history of injuryNonhyperte

21、nsive hemorrhage:without history of hypertension治 療 原 則防止再出血降顱壓控制血壓防止并發(fā)癥根據(jù)病情選擇手術(shù)Treatmentmedical treatment保持安靜keep quiet、臥床休息rest in bed、減少探視avoid meeting水電解質(zhì)平衡keep water_electrolyte balance 和營養(yǎng)nutrition控制腦水腫control brain edema，降低顱內(nèi)壓控制高血壓control blood pressure: antihypertensive agents or diuretic su

22、ch as furosemide防治并發(fā)癥prevent complications:rebleeding, herniation, infectionTreatmentsurgical treatment時(shí)機(jī)：超早期 6-24小時(shí)Indication Contraindications術(shù)式Rehabilitation 盡早進(jìn)行as soon as possible抗抑郁antidepressionSpecific treatmentNonhypertensive hemorrhagePoly-cerebral hemorrhage RebleedingUnstable cerebral he

23、morrhagePrognosisThe mortality in 30 days is 35%52%,half of the patients die within 2 days,due to cerebral herniation.Large hemorrhages of brainstem、thalamus 、ventricle implies a poor prognosis.（Subarachnoid Hemorrhage）定義 各種原因引起的軟腦膜血管破裂，血液流入蛛網(wǎng)膜下腔。蛛網(wǎng)膜下腔出血 ConceptionIt is an acute hemorrhagic cerebral

24、 vascular disease in which vessels on surface of brain and spinal cord rupture suddenly due to many causes,blood flow into the subarachnoid space,called primary SAHSecondary SAH：hemorrhages in brain、ventricle or epidural (subdural) space rupture into subarachnoid spaceTraumatic SAHCount for 10% in s

25、troke，for 20% in hemorrhagic strokeEtiologyCongenital aneurysm is most common etiologyAVM is a less frequent cause of SAHHypertensive arteriosclerosis aneurysm is the third cause of SAHMoyamoya disease is the forth causeOthers include tumor, arteritis 病因和發(fā)病機(jī)制 PathophysiologyCerebral artery aneurysm

26、are most commonly congenital “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

27、 not be overlooked.Pathophysiology顱內(nèi)壓增高increased ICP阻塞性腦積水obstructive hydrocephalus化學(xué)性腦膜炎aseptic meningitis下丘腦功能紊亂自主神經(jīng)功能紊亂dysautonimia交通性腦積水communicating hydrocephalus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 Pathology85%90% of intracranial aneurysms locate anterior in the circle of Willis,the

28、y are mainly single,they are multiple in about 10%20% of cases,locating in the opposite site of the same vessel,called mirror aneurysm.好發(fā)于Willis環(huán)動(dòng)脈分叉處破裂頻度血液主要沉積在腦底部、腦池可破入腦室致腦積水蛛網(wǎng)膜無菌性炎癥反應(yīng)Clinical featuresAny age of person may suffer from SAH. The classic (but not invariable) presentation of SAH is th

29、e sudden 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

30、 of day and during either rest or exertion. Clinical featuresThe 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

31、(sentinel,or warning, hemorrhages) or aneurysmal stretch.Clinical featuresThe 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

32、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

33、diagnosis. Clinical featuresBecause 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 occu

34、rring 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 featuresInducement and aura：inducement in

35、clude 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 othe

36、r complicationsComplicationsRecurrence 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 narrowing, t

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

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

39、retic hormone and resultant diabetes insidious can occur, they are uncommon. Supplementary findingsCT：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僅顯示腳間池少量出血

40、，向中腦環(huán)池、外側(cè)裂池基底擴(kuò)散，稱非動(dòng)脈瘤性SAH nA-SAHCSF: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 findingsDSA:to detect aneurysm or AVM, it is a prerequisite to the rational planning of surgical treatment.MRI and MRA:MRI is especially useful in detectin