神經(jīng)病學(xué) 腦血管病英文學(xué)習(xí)課件

重慶醫(yī)科大學(xué)臨床學(xué)院教案講稿PAGEPAGE1制表時(shí)間：2013年8月重慶醫(yī)科大學(xué)臨床學(xué)院教案及講稿（教案）課程名稱(chēng)神經(jīng)病學(xué)年級(jí)授課專(zhuān)業(yè)教師陳國(guó)俊職稱(chēng)教授授課方式大課學(xué)時(shí)5題目章節(jié)腦血管病教材名稱(chēng)神經(jīng)病學(xué)作者吳江出版社人民衛(wèi)生出版社版次第二版教學(xué)目的要求掌握腦血管病的病因與危險(xiǎn)因素掌握TIA、不同類(lèi)型腦梗死的診斷、鑒別診斷、預(yù)防和治療原則掌握常見(jiàn)部位腦出血的臨床表現(xiàn)、診斷和治療掌握蛛網(wǎng)膜下腔出血的臨床表現(xiàn)、診斷及治療教學(xué)難點(diǎn)腦血循環(huán)的解剖與生理是教學(xué)難點(diǎn)。TIA、腦梗死的病因及發(fā)病機(jī)制是教學(xué)難點(diǎn)腦出血的發(fā)病機(jī)理、病理是教學(xué)難點(diǎn)。蛛網(wǎng)膜下腔出血的病因、發(fā)病機(jī)理與并發(fā)癥的診治教學(xué)重點(diǎn)腦血管病的病因與危險(xiǎn)因素及臨床表現(xiàn)重點(diǎn)講授短暫性腦缺血發(fā)作(TIA)的定義、腦梗死的主要類(lèi)型臨床表現(xiàn)、診斷與治療。常見(jiàn)部位腦出血的臨床表現(xiàn)、診斷與治療是教學(xué)重點(diǎn)，蛛網(wǎng)膜下腔出血的臨床表現(xiàn)、診斷及治療。外語(yǔ)要求通過(guò)課堂教學(xué)讓學(xué)生了解一些有關(guān)的名詞。教學(xué)方法手段多媒體教學(xué)參考資料Harrison’sNeurologyinClinicalMedicine教研室意見(jiàn)同意教學(xué)組長(zhǎng)：王學(xué)峰教研室主任：王學(xué)峰2013年8月15日重慶醫(yī)科大學(xué)臨床學(xué)院教案講稿PAGEPAGE2制表時(shí)間：2012年8月（講稿）教學(xué)內(nèi)容輔助手段時(shí)間分配Lesionone:CerebrovascularDiseaseIntroduction(40mins)Definition（2mins）Cerebrovasculardisease:agroupofbraindysfunctionsrelatedtodiseaseofthebloodvesselssupplyingthebrain.Stroke:suddenlossofbloodcirculationtoanareaofthebrain,withcorrespondinglossofneurologicfunction..Thirdleadingcauseofdeath,approximately2,000,000newstrokeseachyearinchinaII.Bloodsupplyinthebrain（8mins）1.InternalcarotidarteryAnteriorcerebralartery（大腦前動(dòng)脈）Middlecerebralartery（大腦中動(dòng)脈）2.VertebralbasillaarteryVertebralartery（椎動(dòng)脈）Posteriorinferiorcerebellarartery（小腦后下動(dòng)脈）Basillarartery（基底動(dòng)脈）Anteriorinferiorcerebellarartery（小腦前下動(dòng)脈）Superiorcerebellarartery（小腦上動(dòng)脈）Posteriorcerebralartery（大腦后動(dòng)脈）3.CircleofWillisThecircleofWilliscomprisesthefollowingarteries:Anteriorcerebralartery(leftandright)大腦前動(dòng)脈Anteriorcommunicatingartery前交通動(dòng)脈Internalcarotidartery(leftandright)頸內(nèi)動(dòng)脈Posteriorcerebralartery(leftandright)大腦后動(dòng)脈Posteriorcommunicatingartery(leftandright)后交通動(dòng)脈Physiologicsignificance:arrangementofthebrain'sarteriesintothecircleofWilliscreatesredundanciesinthecerebralcirculation.III.Regulationofcerebralbloodflow(CBF)-Averagebrainweightis1500g,accountsfor2%~3%ofbodyweight.However,thebrainutilizes20%~25%ofglucoseandenergyofwholebody(almost10timeofproportionalCBF).-Thebraindoesnotstoreglycogenandrequires60-70mL/100gtissueperminutefornormalfunction.RegulationofCBFBloodpressure:CBFisautomaticallyregulatedwhenmeanarterialpressure(MAP)isbetween60-160mmHg,whichmaintainsCBFatrelativestablelevel(Baylisseffect).AutonomicregulationwillnotbeeffectivewhenMAPisbelow60mmHgorabove160mmHg(hypertension).Meanarterialpressure(MAP)=diastolicpressure+1/3pulsepressure(systolicpressure-diastolicpressure).1mmHg=7.5×kPa(kilopascal)Chemicals:O2,CO2andpHinbloodandCSF.Classificationofstroke（1min）1.Hemorrhagic（出血性,10~15%）-Intercranialcerebralhemorrhage（腦出血）-Subarachnoidhemorrhage（蛛網(wǎng)膜下腔出血）2.Ischemic（缺血性,85~90%）Thrombosis（腦血栓形成）Embolism（腦栓塞）

V.RiskfactorandPrevention（20mins）PrimaryPrevention一級(jí)預(yù)防referstothetreatmentofindividualswithnoprevioushistoryofstrokeSecondaryPrevention二級(jí)預(yù)防referstothetreatmentofindividualswhohavealreadyhadastroke1、RiskfactorsNon-modifiableriskfactors(Age,Sex,Race,Heredity)Modifiableriskfactors1)highbloodpressureHypertensionaccountsfor35-50%ofstrokerisk.2)atrialfibrillation心房纖顫(ariskof5%eachyeartodevelopstroke).3)Diabetes(2to3timesmorelikelytodevelopstroke)4)highbloodcholesterollevels(inconsistentlyassociatedwith(ischemic)stroke)5)cigarettesmoking(activeandpassive),6)Heavyalcoholconsumption7)Drugusecontraceptivedrugs避孕藥cocaine可卡因amphetamines安非他明over-the-countercoughandcolddrugscontainingsympathomimetics8)Lackofphysicalactivity9)Obesity10)Unhealthydiet11)Homocysteine高同型半胱氨酸血癥2、Preventivemeasurement-2、1LifestyleinterventionsSmokingcessationAlcoholconsumptionlimitAlow-fatdiet,lowsaltdiet(Mediterraneandiets)WeightlossRegularexercise2、2Preventivemeasure-Medication2、2、1Bloodpressurecontrol\o"Hypertension"BP-loweringmedicationsThiazidediureticsACEIangiotensin-convertingenzymeinhibitorsARBsangiotensinreceptorblockers（Notlargedifferencesbetweenantihypertensivedrugs）2、2、2AtrialfibrillationRecommendationsoftheAmericanCollegeofChestPhysicians(ACCP)incasesofatrialfibrillation1)Warfarin華法令usedforallhigh-riskpatientsallpatientsolderthan75yearsregardlessoftheirrisk.2)AspirinusedforLow-riskpatientspatientsyoungerthan65years3)TargetINRis2-34)Adverseeffectsexcessivebleeding(intracranialhemorrhage)2、2、3LoweingBloodlipids(HMG-CoAreductaseinhibitors(statins))2、2、4Treatmentofdiabetesmellitus2、2、5Antiplateletagents1.highlyeffectiveinsecondaryprevention1).AspirinLowdosesofaspirin(75-150

mg)effectivefewerside-effects2.notreducetheriskofischemicstrokeinprimaryprevention2、3Preventiveintervention-Surgerycarotidendarterectomyorcarotidangioplasty1)Endarterectomy頸動(dòng)脈內(nèi)膜剝脫術(shù)forasignificantstenosis(50%orgreaterstenosis)usefulinthesecondaryprevention(recurrentriskfrom20%after5yearstoaround5%)forstenosiswithoutsymptomsonlyasmalldecreaseintheriskofstroke2)Carotidarterystenting(angioplasty)頸動(dòng)脈支架成形術(shù)equallyuseful2、4MetabolicinterventionsloweringhomocysteinewithfolicacidandothersupplementsPreventiveintervention(summary)Secondarystrokepreventioncanbesummarizedbythe

mnemonicA,B,C,D,EasfollowsAantiplatelet(aspirin)anticoagulants(warfarin)Bbloodpressure–loweringmedicationsbodyweightlossCcessationofcigarettesmokingcholesterol-loweringmedicationsDdietdiabetesmanagementEexercise五、Treatment（10mins）Treatmentincluding3phasesPrevention,(beforestroke)Acutetreatment,(duringstroke)Subacute/chronictreatment(afterstroke)StrokeunitAwardordedicatedareainhospitalstaffedbynursesandtherapistswithexperienceinstroketreatment.Lesiontwo:TransientIschemicAttack

TIA

短暫性腦缺血發(fā)作一、Definition（2mins）ATIAisabriefepisodeofneurologicdysfunctioncausedbyfocalbrainorretinalischemia,withclinicalsymptomstypicallylastinglessthan1hour,andwithoutevidenceofacuteinfarctions50%ofTIArecoveredwithinthefirsthour90%recoveredwithin4hours.二、Causesandpathophysioloy（5mins）TIAworkupisfocusedonemergent/urgentriskstratification.1.Atherosclerosiscarotidandvertebralarteries(narrow,microemboli)

Thrombusbreaksoff,travels,loadAnticoagulanticsystemactivation2.EmbolicsourcesValvulardiseaseventricularthrombus3.Arterialdissection動(dòng)脈夾層4.Arteritis動(dòng)脈炎Necrotizingvasculitis(primarycause)SyphilisDrugsIrradiationLocaltrauma5.Sympathomimeticdrugs(eg,cocaine)三、ClinicalpresentationandDiagnosis（20mins）HistoryChangesinbehavior,speech,gait,memory,andmovement.2、Carefullyinvestigateonset,duration,fluctuation,andintensityofsymptoms.3、Significantmedicalhistoryquestionsincludethefollowing:Recentsurgery(eg,carotid,cardiac)PreviousstrokesKnowncardiovasculardiseaseSeizuresCNSinfectionsUseofillicitdrugsComorbiditiesrelatedtometabolicdisordersReviewingthepatient'smedicalrecord.Elicitanyriskfactorsforrelevantunderlyingdisease.KnowncoagulopathyHistoryofarteritisNoninfectiousnecrotizingvasculitis,drugs,irradiation,andlocaltraumaareknowntocauseinflammatoryarterialinjury.Thromboembolicriskfactorssuchascarotidarterystenosis,venousorarterialthromboembolism,patentforamenovale卵原孔未閉,atrialfibrillation,priormyocardialinfarction,orleftventriculardysfunction.四、Differentiation(5mins)HypoglycemiaSeizureVertigoIntracranialhemorrhage五、LaboratoryStudies（7mins）1、EmergencypresentationFingerstickbloodglucose指血糖Serumelectrolyte電解質(zhì)SerumchemistryprofileincludingcreatinineCoagulationstudies凝血像CompletebloodcountTypicallyhelpfulandcanoftenbeperformedurgentlyErythrocytesedimentationrate(ESR)紅細(xì)胞沉降率Cardiacenzymes

心肌酶譜Lipidprofile血脂Screeningforhypercoagulablestates(particularlyinpatientsyoungerthan50y)LevelsofproteinCandproteinSAntithrombinIIIlevel凝血酶IIIThrombintime凝血酶原時(shí)間2、AsneededbaseduponhistorySyphilisserology梅毒學(xué)清學(xué)Antiphospholipidantibodies抗磷脂抗體ToxicologyscreensHemoglobinelectrophoresisSerumproteinelectrophoresisCerebrospinalfluidexamination3、ImagingStudies1）.BrainimagingNoncontrastcranialCTscanwidelyavailableinitialimagingevaluation--MRI

lesswidelyavailableonanacutebasis2）Vascularimaging

CarotidDopplerultrasonographyTranscranialDoppler(TCD)Computedtomographicangiography(CTA)Magneticresonanceangiography(MRA)Digitalsubtractionangiography(DSA)3）CardiacimagingTransthoracicortransesophagealechocardiography(TTE/TEE)OtherTests12-Leadelectrocardiography(ECG)Lumbarpuncture(LP)Electroencephalography(EEG)六、Prognosis(ABCD2Score)

(1min)

anABCDscorehigherthan6hadan8%riskofstrokewithin2days,anABCDscorelessthan4hada1%riskofstrokewithin2days.Lesionthree:IschemiacerebralinfarctionCerebralischemicstrokeintroduction(10mins)representsabout80%ofallstrokesAthrombus(血栓形成）Anembolus（栓塞）occludeacerebralarterycauseischemia一、Classificationbasedoncourse:Transientischemiaattack(TIA)(<24h)Progressingischemicstroke(PIS)(>6h)Completestroke(CS)(<6h)二、Pathologyandpathophysiology1、Neuronaldeath(Coagulationnecrosis(CN))缺血壞死cellinitiallyswellsthenshrinksandundergoespyknosis-evolvesover6to12hours.extensivechromatolysisoccursresultinginpan-necrosis.Astrocytesswellandfragment,myelinsheathsdegenerateby24hours.Apoptosis細(xì)胞凋亡nucleardamageoccursfirst.Integrityoftheplasmaandthemitochondrialmembraneismaintaineduntillateintheprocess.Apoptoticmechanismsbeginwithin1hourafterischemicinjurywhereasCNbeginsby6hoursafterarterialocclusion.3、IschemicPenumbra(IP)缺血半暗帶progressionandtheextentofischemicinjuryisinfluencedbymanyfactors:DurationofischemiaCollateralcirculationHealthofsystemiccirculationHematologicalfactors(hypercoagulablestate)TemperatureGlucosemetabolismThromboticstroke一、Etiology(2mins)Atherosclerosishypercoagulablestatefibromusculardysplasiaarteritis(GiantcellandTakayasu),dissectionofavesselwall.二、Pathologyocclusionoflargevessels100to400mm三、Clinicalpresentation(15mins)1、(MCAstrokesyndrome)Maintrunkocclusioncontralateralhemiplegia對(duì)側(cè)偏癱contralateralhemianopia對(duì)側(cè)偏盲contralateralhemianesthesia對(duì)側(cè)偏身感覺(jué)減退eyedeviationtowardthesideoftheinfarct凝視病灶側(cè)classicneglect(rightglobalaphasia失語(yǔ)(dominanthemisphere)SuperiordivisionofMCAinfarctscontralateraldeficitsupperextremityandface(significantinvolvement)legandfoot(partialsparingofthecontralateral)ACAstrokesyndromeConfusion意識(shí)模糊Personalitychange人格改變Incontinence尿失禁Contralateralmotororsensorylossleggreaterthanarm3、Vertebrobasilarsymptom

CommonlyreportedsymptomsassociatedwiththevertebrobasilarstrokesincludethefollowingVertigo眩暈Nauseaandvomiting惡心嘔吐HeadacheAbnormalitiesinthelevelofconsciousness意識(shí)改變Abnormaloculomotorsigns(eg,nystagmus,lateralgazeabnormalities,眼部體征diplopia,pupillarychanges)Ipsilateralcranialnerveweakness同側(cè)顱神經(jīng)麻痹(eg,dysarthria,dysphagia,dysphonia,weaknessoffacialmusclesandtongue)Lateralmedullary(Wallenberg)syndromemostoftenduetovertebralarteryocclusionIpsilateralclinicalfeaturesincludethefollowing:Ataxiaanddysmetria共濟(jì)失調(diào)和辨距不良Nystagmus眼震Hornersyndrome霍納氏征(eg,ptosis,miosis瞳孔縮小,hypohidrosisoranhidrosis,少汗enophthalmos)眼球內(nèi)陷Bulbarpalsy(Dysarthria,Dysphagia)構(gòu)音障礙、吞咽困難FacialpainandtemperaturelossContralateralfindingslossofpainandtemperaturesenseinthebodyandextremitiesCerebellarinfarctionalackofcoordinationClumsiness笨拙intentiontremor意向性震顫ataxia共濟(jì)失調(diào)Dysarthria構(gòu)音障礙scanningspeech吟詩(shī)樣語(yǔ)言difficultieswithmemoryandmotorplanning.Locked-insyndrome閉鎖綜合征Infarctionoftheupperventralpons.Occlusionofthebasilarartery(proximalandmiddlesegments)--ClinicalfeaturesQuadriplegia四肢癱Unabletospeak,Unable

toproducefacialmovement,

UnabletolooktoeithersideConsciousnesspreserved(fullyawake,sensate,andaware)onlymovementsverticaleyemovementsandblinking.Ventralmidbrain(Weber)anocclusionofthemedianand/orparamedianperforatingbranchesofthebasilarartery.TypicalclinicalfindingsIpsilateralCNIIIpalsy(ptosis瞼下垂Mydriasis瞳孔放大Contralateralhemiplegia對(duì)側(cè)偏癱四、ImagingStudies1.CTscanningandCTA2.MRIRoutingMRIDiffusion-weightedimaging(DWI)detectischemicinjurywithin15-30minutesofonsetevidenceofischemicinjurybutnotischemiaitselfsignificantlysuperiortoCTscanninginthediagnosisofacute(<6h)stroke.Perfusion-weightedimaging（PWI)showstheactualzoneofischemicinjury.3.Furtherimaging:Carotidduplexscanning頸動(dòng)脈雙弓TranscranialDopplerultrasonography(TCD)經(jīng)顱多普勒超聲Echocardiography超聲心動(dòng)圖4.Angiography血管造影DSA,CTA,MRA五、DiagnosisAcuteonsetRiskfactorsofastrokebeing55yearsofageorolder,highbloodpressure,highlevelsofcholesterolhomocysteinecigarettesmoking,diabetes,obesity,cardiovasculardisease,personalorfamilyhistoryofastrokeTIA,useofbirthcontrolorotherhormonetherapy,heavyalcoholuseandtheuseofillicitdrugs.FocalneurologicaldeficitLackofsymptomintracranialhypertensionCTscanmanifestlowdensity六、TreatmentRoutineTreatment(10mins)1)Airwayandbreathing2)Circulation3)Bloodglucosecontrol

insulintherapygoalofestablishingnormoglycemia(90-140mg/dL).

4)Bloodpressurecontrol

Theconsensusrecommendationistolowerbloodpressure -onlyifsystolicpressureisinexcessof220mmHg-orifdiastolicpressureisgreaterthan120mmHgRapidreductionofbloodpressure,nomatterthedegreeofhypertensionmayinfactbeharmful.

5)Cerebraledemacontrolmannitolisusedroutinely6)Seizurecontrol

occurin2-23%withinthefirstdaysstandardantiepileptictherapyMedicationofacutestrokearedistributedintothefollowingcategories:(1)Reperfusion(thrombonlysis)(2)Antiplatelet(3)Anticoagulation(4)Inducedhypothermia(5)Fibrinolyticagents(6)Neuroprotective(7)ChinesemedicineRehabilitationProgramPhysicalTherapyOccupationalTherapySpeechTherapyRecreationalTherapy七、PrognosisDisabilityaffects75%ofstrokesurvivorsTheresultsofstrokevarywidelydependingonsizeandlocationofthelesion.Dysfunctionscorrespondtoareasinthebrainthathavebeendamaged.Affectpatientsphysically,mentally,emotionally,oracombinationofthethree.Physicaldisabilitiesparalysis,numbness,pressuresores,pneumonia,incontinenceMentaldisabilitiesapraxia(inabilitytoperformlearnedmovements)difficultiescarryingoutdailyactivitiesappetiteloss,speechproblem,dementia,problemswithattentionandmemoryVisionlossandpainEmotionaldisabilitiesfrustrationanddifficultyadaptingtonewlimitationsAnxiety,panicattacksflataffect(failuretoexpressemotions),mania,apathy,poststrokedepression,characterizedbylethargy,irritability,sleepdisturbances,loweredselfesteem,andwithdrawal.Lesionfour:SpontaneousIntracerebralHemorrhage一、Definition(1min)Spontaneousintracerebralhemorrhage(SICH):bleedingintotheparenchymaofthebrainthatmayextendintotheventriclesandsubarachnoidspaceintheabsenceoftraumaorsurgery.20to30%ofallcasesofstroke二、Cause(2mins)Chronichypertension(78%~88%)AmyloidangiopathyVascularabnormalities(AVM,aneurysm)TumorCoagulopathy三、Epidemiologicfeatures(1min)Incidence10~20casesper100,000IncreaseswithageMen,especiallyolderthan55yearsoldAcircadianandcircannualpatternofSICHonsetinthemorningandwinterhasbeenreported三、Pathophysiologicalfeatures(6mins)OriginofhematomaDegenerativechanges(hyalinosisandfibrinoidnecrosis)inthevesselwallinducedbychronichypertension.Dilatationinthewallsofsmallarterioles.(microaneurysms)theyaremorelikelytoburstandcauseahemorrhage.Mostbleedingoccuratthebifurcationofaffectedarteries.Arupturedbloodvesselwillleakbloodintothebrain,eventuallycausingthebraintocompressduetotheaddedamountoffluid.CommonsiteA.CerebrallobeB.BasalgangliaC.ThalamusD.Brainstem(ponspredominantly)E.CerebellumProgressionofhematoma(3mins)CTscanshowedhematomasexpandovertime.26%within1hours,38%within20hours(Brottetal:103ptsAcutehypertension,localcoagulationdeficitmaybeassociated.SecondaryNeuronalinjuryHematomainitiatesedemaandneuronaldamageinsurroundingparenchyma.Edema5days~2weeksOsmoticallyactiveserumproteinsfromclot,vasogenicedema,cytogenicedema(disruptionofBBB,Napumpfailure,celldeath..)四、Clinicalfeatures(20mins)SymptomofincreasedICPDecreasedlevelofconsciousnessSomnolence(or"drowsiness")StuporComaIncreasedICP,compressionofthethalamicandbrain-stemreticularactivatingsystem.Accompanyingheadache,nausea,vomitingSomnolence(or"drowsiness")isastateofnear-sleep,astrongdesireforsleep,Sleepingforunusuallylongperiods.StuporisthelackofcriticalcognitivefunctionandlevelofconsciousnesslevelAlmostentirelyunresponsiveOnlyrespondstobasestimulisuchaspain.Comaisaprofoundstateofunconsciousness.Cannotbeawakened,Failstorespondnormallytopain,lightorsound,Nothavesleep-wakecycles,Nottakevoluntaryactions.NeurologicstatusatpresentSupratentorialICHContralateralsensorydeficitsContralateralmotordeficitsHemianopia,Aphasia,neglect,gazedeviation,involvingputamen,caudate,thalamus.subcorticalwhitematterorcortexInfratentorialICHBrainstem(crosspalsy)AbnormalgazeLateralcranialnerveContralateralmotordeficitsCerebellumAtaxia,nystagmus,dysmetriaSecondaryDeterioration25%ptsdeteriorationinthelevelofconsciousnesswithinthefirst24hrsExpansionofthehematoma:first3hrsWorseningcerebraledema:24~48hrsLateprogressionofedema:2~3weeks五、Imagetest(1min)CTscaninfarctionorhemorrhageLocationandsizeofthehematomaPresenceofventricularbloodHydrocephalusImagingtestConventionalangiographyforsecondarycauseofICH(AVM,aneurysm..)六、DiagnosisElderSuddenonsetoffocalneurologicaldeficitprogressingoverhoursresultingfromelevatedbloodpressureSymptomofintracranialhypertensionaccompanyingheadache,nausea,vomiting,alteredconsciousness,CTscanmanifesthighdensitymass七、Management(6mins)Evaluation&managementintheERDecreasedlevelofconsciousnessorimpairmentofreflexestheprotectairwayIntubation!UrgentCTscan,Hyperventilation,intravenousmannitolandintraventricularcatheterfordrainage.ManagementMasseffect&intracranialhypertensionHematoma,edematissue,obstructivehydrocephalusherniation!Useofhyperventilationandosmoticagentimprovedthelong-termoutcomeSurgicalevacuationManagementofbloodpressureElevationofbloodpressureexpansionofhematomapooroutcome!AHAguidelineManagementSurgicalevacuationReducemasseffect,BlockthereleaseofneuropathicproductfromthehematomaSurgeryforsupratentorialhemorrhage?InternationalSurgicalTrialinIntracerebralHemorrhage(STITCH)didnotshowanybenefitforsurgicalevacuationofclotinICHcomparedwithmedicalmanagementalone. ControlofhyperglycemiaadministrationofinsulinasanintravenouscontinuousinfusionorsubcutaneousinjectionFevercontroloftemeratureaccomplishedwithmedicationssuchasacetaminophenorthroughuseofexternalorinternalcoolingdevices.ManagementSeizuresMostseizurewithin24hrsAnticonvulsantsdiscontinuedafterthefirstmonthifnoseizure.Seizuresmorethan2weeksatriskoffurtherseizurelong-termtreatment.ManagementPreventionofcomplication1)Deepvenousthrombosisandpulmonaryembolus;accomplishedwitheitherpneumaticcompressiondevicesonthelegssubcutaneousheparinoidcompounds(begun3-4daysafterICHwithcleardocumentationthatbleedinghasstopped).2)Adequatenutritionalsupport,viaafeedingtubeifthepatientcannotswallowshouldbebegunwithinthefirst24-48hoursRehabilitationPhysical,occupational,andspeechtherapyshouldbeinstitutedearlyandaggressivelyduringthecourseofthehospitalizationinordertobegintheprocessofrehabilitationandrecovery.七、Outcome(2mins)Mortalityrate:23%~58%in6months (1)LowGCSscore (2)Largevolumeofthehematoma (3)PresenceofventricularbloodonCTmortalityrateatonemonthwasbestpredictedbyinitialGCS<9,volume>60ml90%GCS9,volume<30ml17%recurrenthemorrhage2%peryear.ReducebyBPcontrol!Lesionfive:SubarachnoidHemorrhage（40mins）一、Introduction(2mins)Subarachnoidhemorrhage(SAH):impliesthepresenceofbloodwithinthesubarachnoidspacefromnontraumaticpathologicprocess,usuallyfromruptureofaberryaneurysmorarteriovenousmalformation(AVM).FrequencyAnnualincidenceis6-25casesper100,000.(UnitedStates)Varyingincidencesofsubarachnoidhemorrhagehavebeenreportedinotherareasoftheworld(2-49cases

per100,000).(International)Sexhigherinwomenthaninmen.AgeMeanageofthoseexperiencingsubarachnoidhemorrhageis50years.Mortality/MorbidityAnestimated10-15%ofpatientsdiebeforereachingthehospital.Mortalityratereachesashighas40%withinthefirstweek.Abouthalfdieinthefirst6months.Mortalityandmorbidityratesincreasewithageandpooreroverallhealthofthepatient.Advancesinthemanagementofsubarachnoidhemorrhagehaveresultedinarelativereductioninmortalityratethatexceeds25%.However,morethanonethirdofsurvivorshavemajorneurologicdeficits.二、Causes(3mins)Saccularaneurysm(Congenitalaneurysm)AVM(AVMalformation)MycoticaneurysmalruptureAngiomaNeoplasmCorticalthrombosis三、ClinicalPresentation(20mins)1、HistoryHeadachessuddenonsetofasevereheadache.nearthebackoftheheadapoppingorsnappingfeelingintheheadProdromal(warning)headache(s)(referredtoassentinelheadache)30-50%ofaneurysmalsubarachnoidhemorrhages.occurafewhourstoafewmonthsbeforetherupture,withmedianof2weekspriortodiagnosisofSAH.Nauseaand/orvomitingSymptomsofmeningealirritationneckstiffness,lowbackpain,bilaterallegpainTheseareseeninmorethan75%ofcasesPhotophobiaandvisualchangesdoublevision,blindspots,ortemporaryvisionlossinoneeyeLossofconsciousness:AbouthalfofpatientsexperiencethisatthetimeofbleedingonsetSeizuresMorethan25%ofpatientsexperienceseizuresclosetotheacuteonset.2、PhysicalExaminationPhysicalexaminationfindingsmaybenormal,Nolocalizingsignsin40%ofpatientsGlobalorfocalneurologicabnormalitiesinmorethan25%ofpatientsMotordeficitsfrommiddlecerebralarteryaneurysmsin15%ofpatientsSyndromesofcranialnervecompressionOculomotornervepalsy(posteriorcommunicatingarteryaneurysms)withorwithoutipsilateralmydriasisAbducensnervepalsyMonocularvisionloss(ophthalmicarteryaneurysmcompressingtheipsilateralopticnerve)OphthalmologicsignsSubhyaloidretinalhemorrhage(smallroundhemorrhage,perhapswithvisiblemeniscus,neartheopticnervehead);otherretinalhemorrhagePapilledemaVitalsignsmild-to-moderatebloodpressure(BP)elevation.(Abouthalfofpatients),labileasICPincreases.Feverbecomescommonafterthefourthdayfrombloodbreakdowninthesubarachnoidspace.Tachycardiapresentforseveraldaysaftertheoccurrenceofahemorrhage.四、Complications(10mins)RebleedingofSAHoccursin20%ofpatientsinthefirst2weeks.PeakincidenceofrebleedingoccursthedayafterSAH.Thismaybefromlysisoftheaneurysmalclot.Vasospasmfromarterialsmoothmusclecontractionissymptomaticin36%ofpatients.Hydrocephalusmaydevelopwithinthefirst24hoursbecauseofobstructionofCSFoutflowintheventricularsystembyclottedblood.

HydrocephalusTemporalhornsdilatedDiffuseSAHBloodinthe4thventricleDiffusecerebraledemaNeurologicdeficitsfromcerebralischemiapeakatdays4-12.Hypothalamicdysfunctioncausesexcessivesympatheticstimulation,whichmayleadtomyocardialischemiaorlabiledetrimentalBP.Hyponatremiamayresultfromcerebralsaltwasting/SIADH(syndromeofinappropriateantidiuretichormonehypersecretion)Nosocomialpneumoniaandothercomplicationsofcriticalcaremayoccur.Pulmonaryedema–neurogenicandnonneurogenic五、Workup1、LaboratoryStudiesLaboratorystudiesincludethefollowing:CompletebloodcountProthrombintime,activatedpartialthromboplastintimeTroponinI(cTnI):Itwasinitiallythoughttobeonlyusefulasapredictorfortheoccurrenceofpulmonaryandcardiac2、ImagingStudies(2mins)HeadCTscanSensitivitydecreaseswithtimefromonsetpositivein100%ofcaseswithin12hoursofonset90-95%within24hoursofonsetofbleeding,80%at3days,50%at1week.CTalsocandetectintracerebralhemorrhage,masseffect,andhydrocephalus.AfalselynegativeCTscancanresultfromsevereanemiaorsmall-volumesubarachnoidhemorrhage..BrainCTscanshowingsubtlefindingofbloodattheareaofthecircleofWillisconsistentwithacutesubarachnoidhemorrhage.Magneticresonanceimaging(MRI)Cerebralangiography(DSA(digitalsubtractionangiography).NoncontrastCTfollowedbyCTangiographyofthebraincanruleoutsubarachnoidhemorrhagewithgreaterthan99%sensitivityMagneticresonanceangiography(MRA)lesssensitivethanangiographyindetectingvascularlesionsProcedures(2mins)LumbarpunctureLumbarpuncture(LP)isindicatedifthepatienthaspossiblesubarachnoidhemorrhageandnegativeCTscanfindings.PerformCTscanpriortoLPtoexcludeanysignificantintracranialmasseffectorobviousintracranialbleed.LPmaybenegativelessthan2hoursafterthebleed;LPismostsensitiveat12hoursaftersymptomonset.Xanthochromiaisaclassicsign,butnotpresentearly–lookforequalorincreasingbloodinthesampletubesorD-dimers4、ECG20%haveECGevidenceofMyocardialischemia,STsegmentelevation,TwavechangesDuetohighlevelsofcirculatingcatecholamines六、Diagnosis“Worstheadacheinmylife”O(jiān)ftenaccompaniedbyaperiodofunconsciousness–50%Neckstiffness,Painful3rdnervepalsyPhotophobiaFudoscopy–subhyo