指非外伤性脑实质内出血

(Cerebral Hemorrhage)(Cerebral Hemorrhage)定义：定义：指非外伤性脑实质内出血指非外伤性脑实质内出血Department of Neurology,The 2nd affiliated hospital,Kunming Medical college ConceptionnIt means primary and nontraumatic intracerebral hemorrhage.nCount for 20%30%in strokenHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.EtiologynHalf of the patients suffer from hypertension combined with arteriolar atherosclerosis,it is the most common cause of the disease.nOthers：cerebral atherosclerosis,hematopathy,cerebral amyloid angiopathy CAA,aneurysm,AVM Pathophysiologyn高血压小动脉：纤维素样坏死fibrinoid necrosis、脂质透明变性hyaline fatty change、microaneurysm小动脉瘤、微夹层动脉瘤渗出exudation、破裂rupturen高血压远端血管痉挛vasospasm缺氧anoxia、坏死angio-necrosis、血栓形成thrombosis斑点状出血、脑水肿brain edema融合成片(子痫)Pathophysiology n脑内动脉：壁薄、中层肌细胞及外膜结缔组织少、缺乏外弹力层随年龄增长弯曲呈螺旋状出血主要部位：深穿支penetrating arteriesn豆纹动脉lenticulostriate artery：大脑中动脉呈直角分出，易发生粟粒状动脉瘤，为脑出血最好发部位，其外侧支称为出血动脉bleeding artery Pathophysiology n一次出血常在30min内停止n头CT动态观察：20%-40%患者24小时内血肿仍继续扩大，为活动性出血active hemorrhage或早期再出血early rebleedingn多发性脑出血常继发于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis PathologynHypertensive ICH：基底节的内囊区inter capsule、壳核putamen占70%，脑叶lobe、脑干brainstem、小脑齿状核区各占10%nLocation of ICH：壳核（内囊、侧脑室），丘脑thalamus（第三脑室、内囊、侧脑室），脑桥pons、小脑cerebellum、蛛网膜下腔subarachnoid space、第四脑室forth ventriclePathologynHypertensive ICH：cerebral penetrating artery miliary aneurysmnNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosisPathologynSwelling and congestion of hemispheren出血灶：充满血液的空腔，周围是坏死脑组织及淤点状出血性软化带、脑水肿n血块溶解吞噬细胞清除含铁血黄素和坏死脑组织胶质增生（胶质瘢痕或中风囊）Clinical featuresnage：5070 years oldnsex：more male patientsnseason：winter or springnpast history：hypertensionninducement：activity、excitementnonset：acute onset临临 床床 表表 现现n一般症状：中年以上发病。起病突然，一般症状：中年以上发病。起病突然，动态起病，病势凶险。动态起病，病势凶险。n高颅压征高颅压征 intracranial hypertension signintracranial hypertension sign 头痛，呕吐，血压升高，脉搏减慢，头痛，呕吐，血压升高，脉搏减慢，视乳头水肿，意识障碍视乳头水肿，意识障碍 易形成脑疝易形成脑疝 cerebral cerebral herniationherniationn神经系统定位体征：神经系统定位体征：取决于血肿的部位、体积取决于血肿的部位、体积 局灶性神经功能缺损基底节区基底节区：内囊：内囊“三偏征三偏征”偏瘫偏瘫 hemiplegiahemiplegia 偏盲偏盲 hemiscotosishemiscotosis 偏身感觉障碍偏身感觉障碍 hemihypesthesiahemihypesthesia脑叶脑叶 额叶额叶 颞叶颞叶 顶叶顶叶 枕叶枕叶 各具不同缺损各具不同缺损脑干脑干 交叉性瘫痪交叉性瘫痪 hemiplegiahemiplegia alternate alternate小脑小脑 眩晕眩晕 vertigovertigo 共济失调共济失调 ataxiaataxia基底节区的血液供应基底节区的血液供应豆纹动脉的破裂成因豆纹动脉的破裂成因Clinical featuresbasal ganglion hemorrhagenThe two most common sites of hypertensive hemorrhage are the putamen(figure 1)and thalamus(figure 2),which are separated by the posterior limb of the internal capsule.n 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 nHomonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage.n 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 hemorrhagenAphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas.nLarge hemorrhages may lead to consciousness disturbance,while minor hemorrhages lead to lacunar syndrome.Clinical featuresbasal ganglion hemorrhagen丘脑出血thalamus hemorrhage:丘脑膝状动脉、穿通动脉破裂，表现为三偏症状，不同于壳核之处为均等瘫、深浅感觉障碍、特征性眼征、意识障碍重、中线症状等尾状核头出血caput nuclei caudati hemorrhage:少见，仅见脑膜刺激征Clinical featurespontine hemorrhage nWith bleeding into the pons(figure 3),coma occurs within seconds to minutes and usually leads to death within 48 hours.nOcular findings typically include pinpoint pupils.Horizontal eyes movements are absent or impaired,but vertical eye movements may be preserved.In some patients,there may be ocular bobbing.Clinical featurespontine hemorrhagenPatients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing.Hyperthermia,respiration disorder is sometimes present.nThe 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 hemorrhagenMidbrain hemorrhage is rarely seen in clinic.nThe patients often manifest Weber syndrome.nLarge hemorrhages may lead to coma and flaccid paralysis.Clinical featurescerebellar hemorrhagen小脑齿状核动脉破裂nThe 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.nLarge hemorrhages lead 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 hemorrhagenEtiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumornHypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal,temporal,and occipital lobes(figure 5).nSymptoms and signs vary according to the location;they can include headache,vomiting,hemiparesis,hemisensory deficits,aphasia,and visual field abnormalities.nSeizures are more frequent than with hemorrhages in other locations,while coma is less so.Clinical featurescerebral ventriculus hemorrhagen脉络丛plexus chorioideus动脉或室管膜下动脉破裂(figure 6)nGlobal symptoms are obvious，but local symptoms are not.nThe patients may have a full recovery and a good outcome.nLarge hemorrhages may lead to coma,vomiting,pinpoint pupils,implies a poor outcome.Supplementary findingsnCT computerized tomography is chosen firstnLesion:high density(hematoma)surronded by low density(edema)（figure 7）nMass effect is often seen in CTSupplementary findingsnMRI magnetic resonance image 急性期对幕上及小脑出血显示不如CT，对脑干出血显示优于CTnICH and cerebral infarction can be distinguished by MRI 45 weeks,but CT can not distinguish themnEasy to detect AVM、aneurysmnComplex stagesSupplementary findingsnDSA：to diagnose AVM、Moyamoya disease、arteritisnCSF：elevated pressure,consistently bloody,but not the routine examinationn其他：血、尿、便常规，肝功，肾功，凝血功能，心电图等诊诊 断断 依依 据据n病史病史n高颅压征：头痛，呕吐，血压高高颅压征：头痛，呕吐，血压高 早期意识障碍早期意识障碍n局灶性定位体征局灶性定位体征n头颅头颅CTCT：脑实质内局灶性高密度病灶脑实质内局灶性高密度病灶DiagnosisnSenile patients after 50 years of agenPast history of hypertensionnOnset during activitynSudden onset nCT scanDifferential diagnosisnCerebral infarction:situation and speed of onset,blood pressure,lesion showed by CTnComa due to other causes:present illness historynInjury:history of injurynNonhypertensive hemorrhage:without history of hypertension治治 疗疗 原原 则则n防止再出血防止再出血n降颅压降颅压n控制血压控制血压n防止并发症防止并发症n根据病情选择手术根据病情选择手术Treatmentmedical treatmentn保持安静keep quiet、卧床休息rest in bed、减少探视avoid meetingn水电解质平衡keep water_electrolyte balance 和营养nutritionn控制脑水肿control brain edema，降低颅内压decrease ICP:antiedema agents,e.g.mannitoln控制高血压control blood pressure:antihypertensive agents or diuretic such as furosemiden防治并发症prevent complications:rebleeding,herniation,infectionTreatmentsurgical treatmentn时机：超早期 6-24小时nIndication nContraindicationsn术式Rehabilitation n尽早进行as soon as possiblen抗抑郁antidepressionSpecific treatmentnNonhypertensive hemorrhagenPoly-cerebral hemorrhage nRebleedingnUnstable cerebral hemorrhagePrognosisnThe mortality in 30 days is 35%52%,half of the patients die within 2 days,due to cerebral herniation.nLarge hemorrhages of brainstem、thalamus、ventricle implies a poor prognosis.（Subarachnoid HemorrhageSubarachnoid Hemorrhage）定义定义 各种原因引起的软脑膜血管破各种原因引起的软脑膜血管破裂，血液流入蛛网膜下腔。裂，血液流入蛛网膜下腔。ConceptionnIt is an acute hemorrhagic cerebral 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 SAHnSecondary SAH：hemorrhages in brain、ventricle or epidural(subdural)space rupture into subarachnoid spacenTraumatic SAHnCount for 10%in stroke，for 20%in hemorrhagic strokeEtiologynCongenital aneurysm is most common etiologynAVM is a less frequent cause of SAHnHypertensive arteriosclerosis aneurysm is the third cause of SAHnMoyamoya disease is the forth causenOthers include tumor,arteritis 病因和发病机制病因和发病机制先天性动脉瘤破裂先天性动脉瘤破裂 动静脉畸形出血动静脉畸形出血 血血 液液 进进 入入 蛛蛛 网网 膜膜 下下 腔腔 动脉粥样硬化性破裂动脉粥样硬化性破裂 刺激刺激 刺激刺激 形成形成 脑膜脑膜 血管壁血管壁 血凝块血凝块 脑血管脑血管 阻塞蛛网阻塞蛛网 痉挛缺血痉挛缺血 膜颗粒膜颗粒 脑水肿脑水肿 颅内压增高颅内压增高 PathophysiologynCerebral artery aneurysm are most commonly congenital“berry”aneurysms,which result from developmental weakness of the vessel wall,especially at the sites of branching.nAVM are most common in the middle cerebral artery distribution.nArteritis can also play an important role in the disease.nTumor invasive the vessel wall can not be overlooked.Pathophysiologyn颅内压增高increased ICPn阻塞性脑积水obstructive hydrocephalusn化学性脑膜炎aseptic meningitis下丘脑功能紊乱n自主神经功能紊乱dysautonimian交通性脑积水communicating hydrocephalusn血管活性物质致血管痉挛vascular spasm、蛛网膜颗粒粘连、甚至脑梗死、正常颅压脑积水 Pathologyn85%90%of intracranial aneurysms locate anterior in the circle of Willis,they are mainly single,they are multiple in about 10%20%of cases,locating in the opposite site of the same vessel,called mirror aneurysm.n好发于Willis环动脉分叉处n破裂频度n血液主要沉积在脑底部、脑池n可破入脑室致脑积水n蛛网膜无菌性炎症反应Clinical featuresnAny age of person may suffer from SAH.n The classic(but not invariable)presentation of SAH is the sudden onset of an unusually severe generalized headache,patients often describe it as“the worst headache I ever had in my life”.n The absence of the headache essentially precludes the diagnosis.n Loss of consciousness is frequent,as are vomiting and neck stiffness.n Symptoms may begin at any time of day and during either rest or exertion.Clinical featuresnThe most significant feature of the headache is that it is new.nMilder but otherwise similar headaches may have occurred in the weeks prior to the acute event.nThese earlier headaches are probably the result of small prodromal hemorrhages(sentinel,or warning,hemorrhages)or aneurysmal stretch.Clinical featuresnThe 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.nThere is frequently confusion,stupor,or coma.nNuchal 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.nPreretinal globular subhyaloid hemorrhages(found in 20%of cases)are most suggestive of the diagnosis.Clinical featuresnBecause 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.nAn exception is oculomotor nerve palsy occurring ipsilateral to a posterior communicating artery aneurysm.Bilateral extensor plantar responses and nerve palsies are frequent in such cases.nRuptured AVMs may produce focal signs,such as hemiparesis,aphasia,or a defect of the visual fields.Clinical featuresnInducement and aura：inducement include intensive activity、exhaustion、excitement,aura can be“warning leak”and localized sign.nSymptoms 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 other complicationsComplicationsnRecurrence 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.nArterial vasospasm:Delayed arterial narrowing,termed vasospasm,occurs in vessels surrounded by subarachnoid blood and can lead to parenchymal ischemia in more than one-third of cases.ComplicationsnAcute or subacute hydrocephalus:Acute or subacute hydrocephalus may develop during the first day-or after several weeks-as a result of impaired CSF absorption in the subarachnoid space.Progressive somnolence,nonfocal findings,and impaired upgaze should suggest the diagnosis.ComplicationsnSeizures:Seizures occur in fewer than 10%of cases and only following damage to the cerebral hemisphere.nOthers:Although inappropriate secretion of antidiuretic hormone and resultant diabetes insidious can occur,they are uncommon.Supplementary findingsnCT：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.约15%患者CT仅显示脚间池少量出血，向中脑环池、外侧裂池基底扩散，称非动脉瘤性SAH nA-SAHnCSF: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 findingsnDSA:to detect aneurysm or AVM,it is a prerequisite to the rational planning of surgical treatment.nMRI and MRA:MRI is especially useful in detecting small AVMs localized to the brainstem(an area poorly seen on CT scan).nTCD：to determine CVSn实验室检查：血常规、凝血功能、肝功、免疫学 DiagnosisnSymptom：the history of a sudden severe headache with confusion or obtundationnSign：nuchal rigidity,a nonfocal neurologic examinationnCSF：bloody spinal fluidnFundus oculi：preretinal globular subhyaloid hemorrhagesnCT findings鉴鉴 别别 诊诊 断断n脑出血脑出血n颅内感染颅内感染Differential diagnosisnHypertensive intracranial hemorrhage：there are prominent focal findings.nIntracranial infection:it is excluded by the CSF examination.nTumor stroke or metastasis:they can be distinguished from SAH by evidence of tumor.nNon-typical SAHPrinciple of treatmentn控制继续出血control active hemorrhagen防治迟发性CVS prevent tardive CVS n去除病因eliminate etiologyn防止复发prevent recurrenceTreatmentmedical treatmentn一般处理general treatment：absolute bed rest 46 weeks,preventing elevation of arterial or intracranial pressure(mild sedation,analgesics),but nA-SAH is an exception.n降颅压decrease ICP：antiedema agents eg.mannitol or surgical decompressionn防治再出血prevent recurrence：PAMBAn防治迟发CVS prevent tardive CVS：calcium channel antagonist drug e.g.nimodipinenCSF置换CSF exchange：it can remove red cells,since the procedure may be accomplished with some complications,it should be used carefully.Treatmentsurgical treatmentnOpportunity of operation：2472 hours after hemorrhagenSubject to operationn术式n血管内介入治疗、-刀治疗PrognosisnThe probability of survival following aneurysmal rupture is related to the patient s state of consciousness and the elapsed time since the hemorrhage.nHunt grade：gradehave a good outcome,grade have a poor one,grade have a moderate one.nMain cause of death：including recurrence of hemorrhage、tardive CVSnMain commemorstive sign：may be cognitive impairment