ich自发性脑出血诊断与治疗

ich自发性脑出血诊断与治疗introductionIntracranial hemorrhage(ie,the pathological accumulation of blood within the cranial vault)may occur within brain parenchyma.Intracerebral hemorrhage accounts for 8-13%of all strokes.Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue,leading to neurological dysfunction.INCIDENCE&MORTALITY:Each year,approximately 37,000 to 52,400 people in the United States.The case-fatality rate 34.6%at 7 days.50.3%at 30 days.59.0%at 1 year.(Stroke.2009;40:00-00)RISK FACTORS:Hypertension-60-70%.Cerebral Amyloid Angiopathy-15%.Heavy alcohol consumption.Hypercholesterolemia.Anemia.Smoking/anti-platelet agents merging evidence.LOCATIONSSubcortical/lobar:20%Putamen40-50%Thalamus15%Pons8%Cerebellum8%Clinical ManifestionOnset of symptoms of intracerebral hemorrhage is usually during daytime activity,with progressive(ie,minutes to hours)development of the following:Alteration in level of consciousness(approximately 50%)Nausea and vomiting(approximately 40-50%)Headache(approximately 40%)Seizures(approximately 6-7%)Focal neurological deficitsLobar hemorrhage due to cerebral amyloid angiopathy may be preceded by prodromal symptoms of focal numbness,tingling,or weakness.Herniation SyndromesDisplacement of structures with resulting compression of tissue and blood flow1.Uncal2.Central3.Cingulate4.Transcalvarial5.Upward6.TonsillarSmith,Julian;Joe J.Tjandra;Gordon J.A.Clunie;Kaye,Andrew H.(2006).Potential Secondary Brain InjuryIntracranial EffectsSecondary impactEdemaDelayed ICHHyperemiaVasospasmSeizuresSystemic EffectsHypoxia HypercarbiaHypotensionElectrolyte imbalanceAnemia/old bloodHyperthermiaLaboratory StudiesComplete blood count(CBC)with plateletsProthrombin time(PT)/activated partial thromboplastin time(aPTT):Identify a coagulopathy.Serum chemistries including electrolytes and osmolarity:Assess for metabolic derangements,such as hyponatremia,and monitor osmolarity for guidance of osmotic diuresis.Toxicology screen and serum alcohol level if illicit drug use or excessive alcohol intake is suspectedImaging StudiesCT scanCT scan readily demonstrates acute hemorrhage as hyperdense signal intensity.Hematoma volume in cubic centimeters can be approximated by a modified ellipsoid equation:(A x B x C)/2,where A,B,and C represent the longest linear dimensions in centimeters of the hematoma in each orthogonal plane.MRIThe MRI appearance of hemorrhage on conventional T1 and T2 sequences evolves over time because of chemical and physical changes within and around the hematoma.MRI Appearance of Intracerebral HemorrhageMANAGEMENT:Medical:1.Supportive care.2.BP control.3.Prevention of Hematoma growth.4.ICP Surgical options.Acute ManagementICP,CPP TherapyVolume ResuscitationVasopressorsSedation/ParalyticsDraining CSFPerfusionTemperature RegulationBrain Tissue Oxygen MonitoringMedication treatmentAntihypertensive agents reduce blood pressure to prevent exacerbation of intracerebral hemorrhage.Osmotic diuretics,such as mannitol,may be used to decrease intracranial pressure.As hyperthermia may exacerbate neurological injury,acetaminophen may be given to reduce fever and to relieve headache.Anticonvulsants are used routinely to avoid seizures that may be induced by cortical damage.Levetiracetam has shown efficacy in children for prophylaxis of early posthemorrhagic seizures.Vitamin K and protamine may be used to restore normal coagulation parameters.Antacids are used to prevent gastric ulcers associated with intracerebral hemorrhage.SurgicalcareConsider surgery for patients with cerebellar hemorrhage greater than 3 cm,for patients with intracerebral hemorrhage associated with a structural vascular lesion,and for young patients with lobar hemorrhage.Other surgical considerations include the following:Clinical course and timingPatients age and comorbid conditionsEtiologyLocation of the hematomaMass effect and drainage patternsGoals of ICP MonitoringAvoid herniation syndromesPrevent secondary injuryEarly detection of increasing ICPMaintenance of ICP within normal limitsEvaluation of interventionsEvaluation of pathology resolutionICP Monitoring GuidelinesPatients at risk for intracranial hypertensionPatients in comaCT demonstrates Mass lesion;Midline shift;Loss of third ventricleDilatation of contralateral ventricleObliteration of perimesencephalic cisternsNormal CT with 40y/o,GCSm 3,hypotensionGCS 8ICP Monitor PlacementICP Waveform examplesCompliant brainNon-compliant brainMalignant HypertensionDampened waveformBrainBloodCSFIncreasing ICP Stepwise Approach to ICP Management颅内压循序管理的步骤治治疗步步骤循循证等等级治治疗方法方法无无报告告L-3L-3L-3L-2L-3无无报告告无无报告告去骨辦减去骨辦减压代代谢抑制（苯巴比妥抑制（苯巴比妥盐）降低体温降低体温诱导高碳酸血症高碳酸血症高渗性治高渗性治疗，高渗，高渗氯化化钠脑室室脑脊液引流脊液引流增加增加镇静静插管，插管，正常二氧化碳分正常二氧化碳分压通气通气风险咳嗽，人机不同步咳嗽，人机不同步呼吸机相关性肺炎呼吸机相关性肺炎低血低血压感染感染液体液体负平衡平衡高高纳血血肾衰竭衰竭血管血管过度收度收缩，缺血，缺血液体和液体和电解解质紊乱，感染紊乱，感染血血压过低，感染增加低，感染增加感染，感染，迟发血血肿硬膜下硬膜下积液液脑水水肿及开及开颅后后综合征合征Surgical approaches include the following:Craniotomy and clot evacuation under direct visual guidanceStereotactic aspiration with thrombolytic agentsEndoscopic evacuation谢谢