讀書報告 小腦出血課件

1、小腦出血匯報人：李達(dá)導(dǎo)師：劉春風(fēng)教授病例分析患者，女 ，78歲，因頭痛、視物旋轉(zhuǎn)伴嘔吐2小時入院。發(fā)病后至我急診科就診。查體：脈搏70次/分呼吸24次/分，血壓 190/100mmHg，意識清楚，語言清晰，對答切題，頭顱五官無畸形，雙側(cè)瞳孔等大等圓，直徑3.0mm對光反射靈敏 .心肺腹未見異常。四肢活動自如，肌張力正常，肌力V級，腱反射對稱（+） ，Romberg征因未能站立而拒絕檢查感覺系統(tǒng)正常無錐體束征血常規(guī)：WBC 17.8xl06、N 91.6，肝功能、腎功能、電解質(zhì)、血脂檢查正常。病例分析診斷為：眩暈癥：高血壓危象。而給予甘露醇、腦復(fù)康、奧美拉唑、脫水、營養(yǎng)腦細(xì)胞、保護(hù)粘膜治療，入院

2、后有少量嘔血，加用止血藥物治療。治療3天后，血壓下降，但仍有明顯視物旋轉(zhuǎn)，轉(zhuǎn)頭或翻身即可出現(xiàn)，且伴嘔吐?？紤]存在顱內(nèi)病變，而行頭顱CT檢查示：右側(cè)小腦半球出血，出血量約為16.6ml。修正診斷為右側(cè)小腦半球出血。加強(qiáng)脫水、腦細(xì)胞營養(yǎng)等治療，1個月后，出血吸收，癥狀好轉(zhuǎn)治愈出院 。林忠如，小腦出血誤診為眩暈癥1例，中國誤診學(xué)雜志，2011年7月共濟(jì)失調(diào)分類深感覺性共濟(jì)失調(diào)：明亮的地方不明顯，黑暗環(huán)境或閉眼時明顯（軀干和四肢）；Romberg征陽性；步態(tài)異常；踩棉花感；步幅較大，腳間距寬，踵步（抬足較高，跨步大小不一，足跟用力著地，并產(chǎn)生拍擊地面的聲音）前庭性共濟(jì)失調(diào)：共濟(jì)失調(diào)以平衡障礙為主，表現(xiàn)

3、站立不穩(wěn)，行走時向病側(cè)傾倒，改變頭位癥狀加重，眩暈、眼球震顫明顯Romberg 征各類共濟(jì)失調(diào)臨床表現(xiàn)大腦性共濟(jì)失調(diào)：共濟(jì)失調(diào)比較輕；常伴有病理征陽性及其他定位體征小腦性共濟(jì)失調(diào)：四肢或軀干的共濟(jì)失調(diào)Romberg征陰性步態(tài)不穩(wěn)（醉漢步態(tài)）意向性震顫言語：吟詩樣，聲音時斷時續(xù)，爆發(fā)性等肌張力減低（鐘擺運動）、反擊征陽性小 腦 cerebellum* 后顱窩* 大腦后下* 腦干后* 借三對小腦腳與 腦干相連接 位置皮質(zhì) cortex髓體小腦核頂核 fastigal中間核齒狀核 dentate球狀核 globose栓狀核 emboliform 內(nèi)部結(jié)構(gòu)小腦的血液供應(yīng)：來自椎基底動脈三對動脈：小腦上

4、動脈 小腦前下動脈 小腦后下動脈小腦的血管供應(yīng)側(cè)面觀小腦血管供血區(qū)圖片來源：奈特神經(jīng)解剖圖譜小腦前下動脈 小腦后下動脈 小腦前下動脈 小腦后下動脈 小腦上動脈 Reviewed non-traumatic cerebellar haemorrhage between 1927 and 2011 including 1579 patients.Cerebellar haemorrhagesCerebellar haemorrhages constitute approximately 10% of all intracerebral haemorrhages (ICH), about 15% o

5、f cerebellar strokes. Caused by tumour, vascular malformation or aneurysm，trauma， but mostly，primary cerebellar haemorrhage (PCH) Requires timely diagnosis and prompt therapeutical decision-making.Flaherty ML, Woo D, Haverbusch M, Sekar P, Khoury J, Sauerbeck L, et al.Racial variations in location a

6、nd risk of intracerebral hemorrhage. Stroke 2005;36:9347患者，男，68歲因“頭暈伴惡心嘔吐6.5小時”入院。既往：高血壓病史10余年，未服藥控制。3年前有“腦出血”病史，遺留左肢拖步。查體：神志清，瞳孔等大光敏，雙眼右側(cè)凝視，可及水平眼震，左側(cè)中樞性面舌癱，四肢肌力尚可，左側(cè)指鼻試驗完成差，雙側(cè)巴氏征未引出。治療：甘露醇+速尿q4h交替，控制血壓。經(jīng)治療2周后，病情較平穩(wěn)，但出血未完全吸收，要求自動出院。Complicationsbrainstem compression 腦干壓迫upward or downward herniation

7、 腦疝Hydrocephalus 腦積水a(chǎn) 60 year old woman Blood is present in the 4th, 3rd and the lateral ventricles. The temporal horns of the lateral ventricles are dilated, indicating hydrocephalus. suboccipital osteoplastic craniotomy external ventricular drain placementConservative therapyDecrease of intracrani

8、al pressure（ICP）：elevation of the head by 15 to 30 degree，hyperventilation, osmotherapy, administration of barbiturates巴比妥類.Surgical therapyVentricular drainage腦室引流Suboccipital craniectomy枕骨下去骨瓣minimally invasive hematoma removal 微創(chuàng)血腫清除術(shù)outcome腦室切開引流Mortality in patients with primary cerebellar haem

9、orrhageKobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of hypertensive cerebellar hemorrhage surgical or conservative management? Neurosurgery 1994;34:24650, discussion 250241.Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar h

10、ematomas: a prospective treatment protocol. Neurosurgery 2001;49:137886, discussion 138677Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D. Neurosurgical management of cerebellar haematoma and infarct. Journal of Neurology, Neurosurgery and Psychiatry 1995;59:28792腦干反射存在BAEP/SEP正常腦干反射消失病理BAEP/SEPreco

11、mmendation1. For most patients with ICH, the usefulness of surgery is uncertain(Class IIb; Level of Evidence: C).(New recommendation) Specific exceptions to this recommendation follow2. Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compressionand/or h

12、ydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible(Class I; Level of Evidence: B).(Revised from the previous guideline) Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended(

13、Class III; Level of Evidence: C).(New recommendation)3. For patients presenting with lobar clots30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered(Class IIb; Level of Evidence: B).(Revised from the previous guideline)4. The effectiveness

14、 of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational (Class IIb; Level of Evidence: B).(New recommendation)5. Although theoretically attractive, no clear evidence at present ind

15、icates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding(Class III; Level of Evidence: B).(Revised from the previous guideline)腦出血選擇手術(shù)指證1.對于大多數(shù)ICH患者而言，手術(shù)的作用尚不確定。（b C）2.小腦出血伴神經(jīng)

16、功能惡化、腦干受壓和/或腦室梗阻致腦積水者應(yīng)盡快手術(shù)清除血腫。（ B）不推薦以腦室引流作為該組患者的初始治療。（ C）3.腦葉出血超過30ml且血腫距皮層表面1cm以內(nèi)者，可考慮開顱清除幕上血腫。（b B）4.把立體定向設(shè)備或內(nèi)鏡單用，或與溶栓藥物聯(lián)用，以微創(chuàng)的方式清除血腫，其效果尚不確定，目前正處于研究階段。（b B）5.盡管理論上來看有效，但是沒有明確的證據(jù)表明超早期清除幕上血腫可以改善臨床預(yù)后或降低死亡率。早期開顱清除血腫可能增加再出血的風(fēng)險，從而產(chǎn)生負(fù)面作用。（ B） 血壓控制收縮壓150-220mmHg的住院患者，快速降壓至140mmHg可能是安全的（a B）。高血壓的ICH患者降壓推薦意見（ C級推薦）1.SBP200mmHg或MAP150mmHg,建議持續(xù)靜脈應(yīng)用降壓藥物快速降壓，測血壓，5min/次。2.SBP180mmHg或MAP130mmHg，且可能存在顱內(nèi)高壓，可考慮監(jiān)測顱內(nèi)壓，并間斷或持續(xù)靜脈應(yīng)用降壓藥物以降壓，保持腦灌注壓不低于60mmHg。3.SBP180mmHg或MAP130mmHg,且沒有