指非外傷性腦實(shí)質(zhì)內(nèi)出血

(CerebralHemorrhage)定義(dìngyì)：指非外傷性腦實(shí)質(zhì)內(nèi)出血腦出血DepartmentofNeurology,The2ndaffiliatedhospital,KunmingMedicalcollege第一頁，共六十頁。精選課件ConceptionItmeansprimaryandnontraumaticintracerebralhemorrhage.Countfor20%~30%instrokeHypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage.第二頁，共六十頁。精選課件EtiologyHalfofthepatientssufferfromhypertensioncombinedwitharteriolaratherosclerosis,itisthemostcommoncauseofthedisease.Others：cerebralatherosclerosis,hematopathy,

cerebralamyloidangiopathyCAA,aneurysm,AVM第三頁，共六十頁。精選課件Pathophysiology高血壓——小動脈：纖維素樣壞死(huàisǐ)fibrinoidnecrosis、脂質(zhì)透明變性hyalinefattychange、microaneurysm小動脈瘤、微夾層動脈瘤——滲出exudation、破裂rupture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(diǎn)狀出血、腦水腫brainedema——融合成片(子癇)第四頁，共六十頁。精選課件Pathophysiology腦內(nèi)動脈：壁薄、中層(zhōngcéng)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penetratingarteries豆紋動脈lenticulostriateartery：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bleedingartery第五頁，共六十頁。精選課件Pathophysiology一次出血(chūxiě)常在30min內(nèi)停止頭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activehemorrhage或早期再出血earlyrebleeding多發(fā)性腦出血常繼發(fā)于：hematopathy,cerebralamyloidangiopathy,neoplasm,vasculitis第六頁，共六十頁。精選課件PathologyHypertensiveICH：基底節(jié)的內(nèi)囊(nèinánɡ)區(qū)intercapsule、殼核putamen占70%，腦葉lobe、腦干brainstem、小腦齒狀核區(qū)各占10%LocationofICH：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subarachnoidspace、第四腦室forthventricle第七頁，共六十頁。精選課件PathologyHypertensiveICH：cerebralpenetratingarterymiliaryaneurysmNonHypertensiveICH：occurinsubcorticalwhitematterwithoutarteriosclerosis第八頁，共六十頁。精選課件PathologySwellingandcongestionofhemisphere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(bānhén)或中風(fēng)囊）第九頁，共六十頁。精選課件Clinicalfeaturesage：50~70yearsoldsex：moremalepatientsseason：winterorspringpasthistory：hypertensioninducement：activity、excitementonset：acuteonset第十頁，共六十頁。精選課件臨床表現(xiàn)一般癥狀：中年以上發(fā)病。起病突然，動態(tài)起病，病勢兇險(xiǎn)。高顱壓征intracranialhypertensionsign

頭痛，嘔吐，血壓升高，脈搏減慢，視乳頭水腫(shuǐzhǒng)，意識障礙易形成腦疝cerebralherniation神經(jīng)系統(tǒng)定位體征：取決于血腫的部位、體積

第十一頁，共六十頁。精選課件局灶性神經(jīng)功能缺損基底節(jié)區(qū)：內(nèi)囊(nèinánɡ)“三偏征”偏癱hemiplegia

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hemiplegiaalternate小腦

眩暈vertigo

共濟(jì)失調(diào)ataxia第十二頁，共六十頁。精選課件基底節(jié)區(qū)的血液(xuèyè)供應(yīng)豆紋動脈的破裂(pòl(fā)iè)成因第十三頁，共六十頁。精選課件Clinicalfeatures

basalganglionhemorrhageThetwomostcommonsitesofhypertensivehemorrhagearetheputamen(figure1)andthalamus(figure2),whichareseparatedbytheposteriorlimboftheinternalcapsule.Ingeneral,putaminalhemorrhageleadstoamoreseveremotordeficit(hemiplegia)andthalamichemorrhagetoamoremarkedsensorydisturbance(hemianesthesia).第十四頁，共六十頁。精選課件Clinicalfeatures

basalganglionhemorrhage

Homonymoushemianopiamayoccurasatransientphenomenonafterthalamichemorrhageandisoftenapersistentfindinginputaminalhemorrhage.Inlargethalamichemorrhages,theeyesmaydeviatedownward,asinstaringatthetipofthenose,becauseofimpingementonthemidbraincenterforupwardgaze.第十五頁，共六十頁。精選課件Clinicalfeatures

basalganglionhemorrhageAphasiamayoccurifhemorrhageateithersiteexertspressureonthecorticallanguageareas.Largehemorrhagesmayleadtoconsciousnessdisturbance,whileminorhemorrhagesleadtolacunarsyndrome.第十六頁，共六十頁。精選課件Clinicalfeatures

basalganglionhemorrhage丘腦(qiūnǎo)出血thalamushemorrhage:

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caputnucleicaudati

hemorrhage:

少見，僅見腦膜刺激征第十七頁，共六十頁。精選課件Clinicalfeatures

pontinehemorrhage

Withbleedingintothepons(figure3),coma

occurswithinsecondstominutesandusuallyleadstodeathwithin48hours.Ocularfindingstypicallyincludepinpointpupils.Horizontaleyesmovementsareabsentorimpaired,butverticaleyemovementsmaybepreserved.Insomepatients,theremaybeocularbobbing.第十八頁，共六十頁。精選課件Clinicalfeatures

pontinehemorrhagePatientsarecommonlyquadripareticorhemiplegiaalternateandexhibitdecerebrateposturing.Hyperthermia,respirationdisorderissometimespresent.Thehemorrhageusuallyrupturesintotheforthventricle,androstralextensionofthehemorrhageintothemidbrainwithresultantmidpositionfixedpupilsiscommon.第十九頁，共六十頁。精選課件Clinicalfeatures

midbrainhemorrhageMidbrainhemorrhageisrarelyseeninclinic.ThepatientsoftenmanifestWebersyndrome.Largehemorrhagesmayleadtocomaandflaccidparalysis.第二十頁，共六十頁。精選課件Clinicalfeatures

cerebellarhemorrhage小腦(xiǎonǎo)齒狀核動脈破裂Thedistinctivesymptomsofcerebellarhemorrhage(figure4)aresevereheadache,dizziness,vomiting,andtheinabilitytostandorwalk,butstrengthinthelimbsisnormal.Largehemorrhagesleadtocomawithin12hoursin75%ofpatientsandwithin24hoursin90%.Theymayleadtocompressionofthebrainstem.第二十一頁，共六十頁。精選課件Clinicalfeatures

lobarhemorrhageEtiology：AVM、Moyamoyadisease、cerebralamyloidangiopathy、tumorHypertensivehemorrhagesalsooccurinsubcorticalwhitematterunderlyingthefrontal,parietal,temporal,andoccipitallobes(figure5).Symptomsandsignsvaryaccordingtothelocation;theycanincludeheadache,vomiting,hemiparesis,hemisensorydeficits,aphasia,andvisualfieldabnormalities.Seizuresaremorefrequentthanwithhemorrhagesinotherlocations,whilecomaislessso.第二十二頁，共六十頁。精選課件Clinicalfeatures

cerebralventriculushemorrhage脈絡(luò)叢plexuschorioideus動脈(dòngmài)或室管膜下動脈(dòngmài)破裂(figure6)Globalsymptomsareobvious，butlocalsymptomsarenot.Thepatientsmayhaveafullrecoveryandagoodoutcome.Largehemorrhagesmayleadtocoma,vomiting,pinpointpupils,impliesapooroutcome.第二十三頁，共六十頁。精選課件SupplementaryfindingsCTcomputerizedtomographyischosenfirstLesion:highdensity(hematoma)surrondedbylowdensity(edema)（figure7）MasseffectisoftenseeninCT第二十四頁，共六十頁。精選課件SupplementaryfindingsMRImagneticresonanceimage急性期對幕上及小腦出血顯示不如(bùrú)CT，對腦干出血顯示優(yōu)于CTICHandcerebralinfarctioncanbedistinguishedbyMRI4~5weeks,butCTcannotdistinguishthemEasytodetectAVM、aneurysmComplexstages第二十五頁，共六十頁。精選課件SupplementaryfindingsDSA：todiagnoseAVM、Moyamoyadisease、arteritisCSF：elevatedpressure,consistentlybloody,butnottheroutineexamination其他：血、尿、便常規(guī)(chángguī)，肝功，腎功，凝血功能，心電圖等第二十六頁，共六十頁。精選課件診斷依據(jù)病史高顱壓征：頭痛，嘔吐，血壓高早期意識障礙(zhàngài)局灶性定位體征頭顱CT：腦實(shí)質(zhì)內(nèi)局灶性高密度病灶第二十七頁，共六十頁。精選課件DiagnosisSenilepatientsafter50yearsofagePasthistoryofhypertensionOnsetduringactivitySuddenonsetCTscan第二十八頁，共六十頁。精選課件DifferentialdiagnosisCerebralinfarction:situationandspeedofonset,bloodpressure,lesionshowedbyCTComaduetoothercauses:presentillnesshistoryInjury:historyofinjuryNonhypertensivehemorrhage:withouthistoryofhypertension第二十九頁，共六十頁。精選課件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(bìngqíng)選擇手術(shù)第三十頁，共六十頁。精選課件Treatment

medicaltreatment保持安靜keepquiet、臥床(wòchuánɡ)休息restinbed、減少探視avoidmeeting水電解質(zhì)平衡keepwater_electrolytebalance和營養(yǎng)nutrition控制腦水腫controlbrainedema，降低顱內(nèi)壓decreaseICP:antiedemaagents,e.g.mannitol控制高血壓controlbloodpressure:antihypertensiveagentsordiureticsuchasfurosemide防治并發(fā)癥preventcomplications:rebleeding,herniation,infection第三十一頁，共六十頁。精選課件Treatment

surgicaltreatment時機(jī)：超早期(zǎoqī)6-24小時IndicationContraindications術(shù)式第三十二頁，共六十頁。精選課件Rehabilitation盡早(jìnzǎo)進(jìn)行assoonaspossible抗抑郁antidepression第三十三頁，共六十頁。精選課件SpecifictreatmentNonhypertensivehemorrhagePoly-cerebralhemorrhageRebleedingUnstablecerebralhemorrhage第三十四頁，共六十頁。精選課件PrognosisThemortalityin30daysis35%~52%,halfofthepatientsdiewithin2days,duetocerebralherniation.Largehemorrhagesofbrainstem、thalamus、ventricleimpliesapoorprognosis.第三十五頁，共六十頁。精選課件（SubarachnoidHemorrhage）定義各種(ɡèzhǒnɡ)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(chūxiě)第三十六頁，共六十頁。精選課件

ConceptionItisanacutehemorrhagiccerebralvasculardiseaseinwhichvesselsonsurfaceofbrainandspinalcordrupturesuddenlyduetomanycauses,bloodflowintothesubarachnoidspace,calledprimarySAHSecondarySAH：hemorrhagesinbrain、ventricleorepidural(subdural)spaceruptureintosubarachnoidspaceTraumaticSAHCountfor10%instroke，for20%inhemorrhagicstroke第三十七頁，共六十頁。精選課件EtiologyCongenitalaneurysmismostcommonetiologyAVM

isalessfrequentcauseofSAHHypertensivearteriosclerosisaneurysmisthethirdcauseofSAHMoyamoyadiseaseistheforthcauseOthersincludetumor,arteritis第三十八頁，共六十頁。精選課件病因和發(fā)病(fābìng)機(jī)制第三十九頁，共六十頁。精選課件PathophysiologyCerebralarteryaneurysmaremostcommonlycongenital“berry”aneurysms,whichresultfromdevelopmentalweaknessofthevesselwall,especiallyatthesitesofbranching.AVMaremostcommoninthemiddlecerebralarterydistribution.Arteritiscanalsoplayanimportantroleinthedisease.Tumorinvasivethevesselwallcannotbeoverlooked.第四十頁，共六十頁。精選課件Pathophysiology顱內(nèi)壓增高increasedICP阻塞性腦積水obstructivehydrocephalus化學(xué)性腦膜炎asepticmeningitis下丘腦功能紊亂自主神經(jīng)功能紊亂dysautonimia交通性腦積水communicatinghydrocephalus血管活性物質(zhì)致血管痙攣(jìnɡluán)vascularspasm、蛛網(wǎng)膜顆粒粘連、甚至腦梗死、正常顱壓腦積水第四十一頁，共六十頁。精選課件Pathology85%~90%ofintracranialaneurysmslocateanteriorinthecircleofWillis,theyaremainlysingle,theyaremultipleinabout10%—20%ofcases,locatingintheoppositesiteofthesamevessel,calledmirroraneurysm.好發(fā)于Willis環(huán)動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(nǎoshì)致腦積水蛛網(wǎng)膜無菌性炎癥反應(yīng)第四十二頁，共六十頁。精選課件ClinicalfeaturesAnyageofpersonmaysufferfromSAH.Theclassic(butnotinvariable)presentationofSAHisthesuddenonsetofanunusuallyseveregeneralizedheadache,patientsoftendescribeitas“theworstheadacheIeverhadinmylife”.Theabsenceoftheheadacheessentiallyprecludesthediagnosis.

Lossofconsciousnessisfrequent,asarevomitingandneckstiffness.Symptomsmaybeginatanytimeofdayandduringeitherrestorexertion.第四十三頁，共六十頁。精選課件ClinicalfeaturesThemostsignificantfeatureoftheheadacheisthatitis

new.

Milderbutotherwisesimilarheadachesmayhaveoccurredintheweekspriortotheacuteevent.Theseearlierheadachesareprobablytheresultofsmallprodromalhemorrhages(sentinel,orwarning,hemorrhages)oraneurysmalstretch.第四十四頁，共六十頁。精選課件ClinicalfeaturesTheheadacheisnotalwayssevere,buttheintensityoftheheadachemayremainunchangedforseveraldaysandsubsideonlyslowlyoverthenext2weeks.Arecrudescentheadacheusuallysignifiesrecurrentbleeding.Thereisfrequentlyconfusion,stupor,orcoma.Nuchalrigidityandotherevidenceofmeningealirritationarecommon.Meningealirritationmayinducetemperatureelevationstoashighas39℃duringthefirst2weeks.Preretinalglobularsubhyaloidhemorrhages(foundin20%ofcases)aremostsuggestiveofthediagnosis.第四十五頁，共六十頁。精選課件ClinicalfeaturesBecausebleedingoccursmainlyinthesubarachnoidspaceinpatientswithaneurysmalrupture,prominentfocalsignsareuncommononneurologicexamination.Whenpresent,theymaybearnorelationshiptothesiteoftheaneurysm.Anexceptionisoculomotornervepalsyoccurringipsilateraltoaposteriorcommunicatingarteryaneurysm.Bilateralextensorplantarresponsesandⅵnervepalsiesarefrequentinsuchcases.RupturedAVMsmayproducefocalsigns,suchashemiparesis,aphasia,oradefectofthevisualfields.第四十六頁，共六十頁。精選課件

ClinicalfeaturesInducementandaura：inducementincludeintensiveactivity、exhaustion、excitement,auracanbe“warningleak”andlocalizedsign.SymptomsofSAHpatientsabove60yearoldarenottypical：slowlyonset,headacheandmeningealirritationarenotobvious,withsevereconsciousnessdisturbance,oftenaccomplishedwithcardiacdamageandothercomplications第四十七頁，共六十頁。精選課件ComplicationsRecurrenceofhemorrhage:Recurrenceofaneurysmalhemorrhage(20%over10-14days)isthemajoracutecomplicationandroughlydoublesthemortalityrate.RecurrenceofhemorrhagefromAVMislesscommonintheacuteperiod.Arterialvasospasm:Delayedarterialnarrowing,termedvasospasm,occursinvesselssurroundedbysubarachnoidbloodandcanleadtoparenchymalischemiainmorethanone-thirdofcases.第四十八頁，共六十頁。精選課件ComplicationsAcuteorsubacutehydrocephalus:Acuteorsubacutehydrocephalusmaydevelopduringthefirstday-orafterseveralweeks-asaresultofimpairedCSFabsorptioninthesubarachnoidspace.Progressivesomnolence,nonfocalfindings,andimpairedupgazeshouldsuggestthediagnosis.第四十九頁，共六十頁。精選課件ComplicationsSeizures:Seizuresoccurinfewerthan10%ofcasesandonlyfollowingdamagetothecerebralhemisphere.Others:Althoughinappropriatesecretionofantidiuretichormoneandresultantdiabetesinsidiouscanoccur,theyareuncommon.第五十頁，共六十頁。精選課件

SupplementaryfindingsCT：patientspresentingwithSAHaregenerallyinvestigatedfirstbyCTscan(figure8)，whichwillusuallyconfirmthathemorrhagehasoccurredandmayhelptoidentifyafocalsource.約15%患者CT僅顯示(xiǎnshì)腳間池少量出血，向中腦環(huán)池、外側(cè)裂池基底擴(kuò)散，稱非動脈瘤性SAHnA-SAHCSF:ifCTscanfailstoconfirmtheclinicaldiagnosis,lumberpunctureisperformed.Thefluidisgrosslybloody,thesupernatantofthecentrifugedCSFbecomesyellow(xanthochromic),thechemicalmeningitismayproducepleocytosis.第五十一頁，共六十頁。精選課件SupplementaryfindingsDSA:todetectaneurysmorAVM,itisaprerequisitetotherationalplanningofsurgicaltreatment.MRIandMRA:MRIisespeciallyusefulindetectingsmallAVMslocalizedtothebrainstem(anareapoorlyseenonCTscan).TCD：todetermineCVS實(shí)驗(yàn)室檢查(jiǎnchá)：血常規(guī)、凝血功能、肝功、免疫學(xué)第五十二頁，共六十頁。精選課件DiagnosisSymptom：thehistoryofasuddensevereheadachewithconfusionorobtundationSign：nuchalrigidity,anonfocalneurologicexaminationCSF：bloodyspinalfluidFundusoculi：preretinalglobularsubhyaloidhemorrhagesCTfindings第五十三頁，共六十頁。精選課件鑒別診斷腦出血顱內(nèi)感染(gǎnrǎn)第五十四頁，共六十頁。精選課件DifferentialdiagnosisHypertensiveintracranialhemorrhage：thereareprominentfocalfindings.Intracranialinfection:it