神經(jīng)精神病學(xué)課件：腦出血

腦出血

Intracerebralhemorrhage(ICH)IntroductionOverage65years(2/3)HigherinmanthaninwomenRisk:systolicordiastolichypertension,hypercholesterolemia（高膽固醇血癥）,smoking,heavyalcoholconsumption,oralcontraceptiveuseHypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage,aslocalledhypertensivehemorrhage（高血壓腦出血）.CharacteristicsofICHOnetypeofstrokeresultsfromcerebralvasculardisturbanceAcuteonsetofneurologicdeficitDurationofdeficits:persisitsatleast24hoursFocalinvolvementoftheCNSFocalinvolvement-Circleof

willisFocalinvolvementCorrelatewiththeareaofthebrainsuppliedbytheaffectedbloodvessel.Anteriorcirculationstrokesarecommonlyassociatedwithsymptomsandsignsthatindicatehemisphericdysfunction,suchasaphasia,apraxia,oragnosia,hemiparesis,hemisensorydisturbancesetc.Posteriorcirculationstrokesproducesymptomsandsignsofbrainstemdysfunction,includingcoma,vertigo,nauseaandvomiting,cranialnervepalsy,ataxia,andcrosssensorimotordeficits.FocalinvolvementComplicationssuchasincreasedintracranialpressure,cerebraledma,compressionofbraintissueandbloodvessels,ordispersionventriclescanimpairbrainfunctionatsitesremotefromthehemorrhage.Themoreextensivetheareaofbrainaffected,themorefunctionthatarelikelytobelost.ClinicalfindingsAcuteonset,nowarningProcedure:activebleeding(brief)->edmasurroundingthehemorrhagearea(overaperoidminutestodays)Headache(50%patients),sometimessevereVomitingImpairmentofconsciousnessElevatedbloodpressureHerniation（腦疝）(fataloutcome->duetothecombinedmasseffectofthehematomaandedma)ClinialfeaturesvarywiththesiteofhemorrhageClinicalfindings-

deepcerebralhemorrhagePutamen（殼核）andthalamus（丘腦）(mostcommonsites)Descendingmotorfiberandascendingsensorfiber,includingtheopticradiationsClinicalfindings-

deepcerebralhemorrhagePutamen（殼核）Thalamus（丘腦）Clinicalfindings-

deepcerebralhemorrhageContralateralsensorimotordefictHomonymoushemianopia（偏盲）Deviateddownwardeyes(impingementonthemidbraincenterforupwardgaze)Aphasia（失語(yǔ)）(exertspressureonthecorticallanguageareas)Clinicalfindings-

lobarhemorrhage（腦葉出血）Subcorticalwhitematterunderlyingthefrontal,temporal,parietal,andoccipitallobes.Clinicalfindings-

lobarhemorrhageSymptomsandsignsvaryaccordingtothelocation.Headache,hemiparesis,hemisensorydeficits,aphasia,seizures,etc.Clinicalfindings-

pontinehemorrhage（橋腦出血）Clinicalfindings-

pontinehemorrhage（橋腦出血）Coma,occurswithinsecondstominutesandusuallyleadstodeathwithin48hours.Ocularfindings:pinpointpupils（針尖樣瞳孔）,horizontaleyemovementsabscent,ocularbobbingQuadriparetic（四肢癱）Decebrebrateposturing（去腦強(qiáng)直）Hyperthermia（高熱）Clinicalfindings-

cerebellarhemorrhage（小腦出血）Clinicalfindings-

cerebellarhemorrhage（小腦出血）Distinctivesymptoms:headache,dizziness,vomiting,andtheinabilitytostankorwalkComa(largehemorrhage,affectingtheascendingreticularactivatingsysteminbrainstem)Ocularfindings:skewdeviationClinicalfindings-

ventricularhemorrhage（腦室出血）ableedingintotheventricularsystem,wherecerebrospinalfluidisproducedandcirculatesthroughtowardsthesubarachnoidspace.Clinicalfindings-

ventricularhemorrhage（腦室出血）Clinicalfindings-

ventricularhemorrhage（腦室出血）Headache,vomitingStiffneck（頸強(qiáng)）AnonfocalneurologicexaminationCTscanHydrocephalus（腦積水）iscommonDiagnosisAcuteonsetatlaterageHistory:HypertensionDistinctivesymptoms:headache,dizziness,vomiting,hemiparesis,gaitataxia,impairmentofconsciousness,seizureSigns:correlatewiththeareaofthebrainsuppliedbytheaffectedbloodvesselCTscan:high-densitysignalatthesiteofhemorrhageHerniation（腦疝）DiffernetialdiagnosisCerebralinfarctionsCTscanorMRITreatment-medicalmeasuresAbsolutebedrestwiththeheadofthebedelevated15-20degreesMildsedationPreventingelevationofintracranialpressure(mannital,lasix,)Treatment-medicalmeasuresControlhypertensiontoareasonablelevelDiastolicleveltoapproximately100mmHgNeuroprotectionComplicationsmanagementsRehabilitationTreatment–surgicalmeasuresCerebraldecompressionCerebellardecompression蛛網(wǎng)膜下腔出血

SubarachnoidHemorrhage(SAH)DefinitionSpontaneoussubarachnoidhemorrhage(SAH)isbleedingintothesubarachnoidspace,usuallyresultingfromarupturedcerebralarterialaneurysm（動(dòng)脈瘤）orarterio-venousmalformation（動(dòng)靜脈畸形）(AVM)IntroductionIncidence:6/100,000Age:50-60,equalsexdistributionPathology:ruptureofcerebralarterialaneurysm(75%,50-60y)orAVM(10%,20-40y)Inducedreason:acuteelevatedofbloodpressurePathologyAneurysm,resultingfromthedevelopmentalweaknessofthevesselwall,especiallyatsitesofbranching.AVM,consistingofabnormalvascularcommunicationsthatpermitarterialbloodtoenterthevenoussystemwithoutpassingthroughacapillarybed.SymptomsandsignsSuddenonsetofsevereheadache(``theworstheadacheIeverhadinmylife``)Theintensityofheadachemayremianunchangedforseveraldaysandmaysubsideonlyslowlyoverthenext2weeks.LossofconsciousnessisfrequentVomittingNeckstiffnessSympotomsmaybeginatanytimeandduringeitherrestorexertion.Symptomsandsignsbloodpressurefrequentlyrisesmeningealirritations（腦膜刺激征）(nuchalrigidity)arecommonPeretinalglobularsubhyaloidhemorrhage(20%ofcases)temperatureelevationtoashighas39.c(inducedbymeningealirritation)SymptomsandsignsProminentfocalsignsareuncommon,except:oculomotornervepalsyORVInerveplasy(ipsilateraltoaposteriorcommunicatingarteryaneurysm)aneurysmsintheMCAregionRupturedAVM(hemiparesis,aphasiaetc)pathophysiologyHeadache(elevatedintracranialpressureanddistortspain-sentitivestructures)Lossofconsciousness(acutelydecreasecerebralbloodflow,togetherwiththeconcussiveeffectoftherupture)about50%attheonsetSubhyaloidretinalhemorrhage(rapidelevationofintracranialpressure)Nofocalcerebrallesion(SAHconfinedtothesubarachnoidspace)exceptaneurysmsintheMCAregionRupturedAVMsproducedfocalabnormalitiesthatcorrespondtotheirparenchymallocationLaboratoryfindings-CTscan(SAH)Laboratoryfindings-MRI(AVM)CTMRILaboratoryfindings-CSFIftheCTscanfailstoconfirmtheclinicaldiagnosisoftheSAH,lumbarpunctureisperformed.ElevatedpressureGrosslybloody,containing100,000tomorethan1millionredcells/mm3In12hours,supernatantofthecentrifugedCSFwillbeyellow,asaresultofthebreakdownofthehemoglobinfromredcellsWhitecellsareinitiallypresentintheCSFinthesameproportiontoredcellsasintheperiphralbloodLaboratoryfindings-DSAOncethediagnosisisconfirmed,fourvesselscerebralarteriographyisundertaken.(carotidandvertibralarteries)Timing:attheearliesttimeAprerequisitetotherationalplanningofsurgicaltreatmentLaboratoryfindings-DAS(aneurysm)

apartiallycoiledaneurysm(indicatedbyyellowarrows)oftheposteriorcerebralarterywitharesidualaneurysmalsac.Laboratoryfindings-DAS(AVM)Diagnosis(keypoints)AsuddensevereheadacheConfusionorortundationNuchalrigidity(stiffneck)AnonfocalneurologicexaminationCTscanBloodyspinalfluidHighlyspecificforsubarachnoidhemorrhage!!!ComplicationsandSequelaeRecurrenceofhemorrhage(aneurysmal)Intraparenchymalextensionofhemorrhage(AVM)ArterialvasospasmAcuteandsubacutehydrocephalusSeizureshydrocephalusDifferentialDiagnosisHypertensiveintracerebralhemorrhageBaterialmeningitisMigraineSeizureconfusion&hyperglycermia&hepaticencephalopathy&UremiaTreatment–medicaltreatmentPreventingelevationofarterialorintracranialpressure(mannital,lasix,)Absolutebedrestwiththeheadofthebedelevated15-20degreesMildsedationNeuroprotectionTreatment–medicaltre