急性期卒中课件

As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性脑卒中北京大学第三医院神经内科张燕急性脑卒中北京大学第三医院1As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）1.患者，男性67岁，近一个月来，反复出现右侧肢体乏力、言语不能来诊。请问：社区全科团队应该如何接诊、处置病人？岗位练兵理论考题题库（神经内科）患者，男性 67岁，近一个2As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）2.患者男性，70岁，2小时前晨起感到右侧肢体麻木、无力，1小时前出现说话吐字不清，来社区中心就诊。请问：社区全科团队应该如何接诊、处置病人？岗位练兵理论考题题库（神经内科）2.患者男性，70岁，2小3As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）3.辖区居民王某，男性，62岁，退休工人，半小时在家晾衣服时突然出现头晕，伴右侧肢体不能活动，数分钟后自行缓解，被家人送来社区卫生服务中心就诊。请问：社区全科团队应该如何出诊、处置病人？岗位练兵理论考题题库（神经内科）3.辖区居民王某，男性，64As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）4.女性，67岁，右侧肢体麻木、无力6小时，说话吐字不清1小时，来社区中心就诊。请问：社区全科团队应该如何出诊、处置病人？岗位练兵理论考题题库（神经内科）4.女性，67岁，右侧肢体5As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）5.患者，男性，57岁，主因“突发言语不利伴左侧肢体无力7小时”就诊。请问：社区全科团队应该如何接诊、处置病人？岗位练兵理论考题题库（神经内科）5.患者，男性，57岁，主6As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.我国卒中死亡率逐年上升每年有250万中国人新发卒中每年有160万中国人死于卒中现存脑卒中患者近700万卒中致残率高达75%卒中复发率超过30%每年脑卒中治疗费用约400亿元人民币2009年卒中死亡粗率，相比2006年：城市地区上升1.41倍农村地区上升1.44倍城乡地区脑血管病粗死亡率变化趋势LiuL,etal.Stroke.2011;42(12):3651-4.王陇德.中国医学前沿杂志（电子版）.2011;3(3):1-3.中国心脑血管病报告2011我国卒中死亡率逐年上升每年有250万中国人新发卒中2009年7As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑表面主要血管流域脑表面主要血管流域8As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑表面主要血管流域脑表面主要血管流域9As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑表面主要血管流域脑表面主要血管流域10As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.大脑半球表面和深部血液供应：冠状面大脑半球表面和深部血液供应：冠状面11As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.大脑半球表面和深部血液供应：轴面大脑半球表面和深部血液供应：轴面12As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.分水岭区（分水岭区（Watershed area）ACA 分布区分布区MCA 分布区分布区PCA 分布区分布区ICA ICA发出脉络膜前动脉发出脉络膜前动脉MCA豆纹动脉豆纹动脉(MCA深穿支深穿支)PCA发出深穿支发出深穿支分水岭区（Watershed area）ACA 分布区MCA13As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.ACA 分布区分布区ACA发出内侧纹状动脉发出内侧纹状动脉(recurrent artery of Heubner)MCA 分布区分布区外侧纹状动脉外侧纹状动脉PCA 分布区分布区PCA深穿支深穿支ICA发出脉络膜前动脉发出脉络膜前动脉ACA 分布区ACA发出内侧纹状动脉 MCA 分布区外侧纹状14As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.ACA的内侧纹状动脉的内侧纹状动脉(recurrent artery of Heubner)MCA的外侧纹状动脉的外侧纹状动脉 ICA的脉络膜前动脉的脉络膜前动脉脉络膜前动脉液供应视放射脉络膜前动脉液供应视放射内囊的血液供应ACA的内侧纹状动脉 MCA的外侧纹状动脉 ICA的脉络膜前15As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑干的血液供应脑干的血液供应16As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.小脑的血液供应小脑的血液供应 17As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.小脑的血液供应小脑的血液供应18As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.不同梗死形态意味不同的机制A.皮层梗死流域性梗死：栓塞（心源性可能性大）B.皮层下梗死：栓塞C.多发皮层：栓塞（动脉源性可能性大）D.低灌注栓子清除障碍梗死不同梗死形态意味不同的机制皮层梗死流域性梗死：栓塞（心源性19As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性脑卒中（急性脑梗死）是最常见的卒中类型；约占全部脑卒中的6080；急性期一般指发病后2周内。急性缺血性脑卒中 急性缺血性脑卒中（急性脑梗死）是最常见的卒中类型；急性缺血20As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.p急性缺血性脑卒中的处理应强调：早期诊断早期治疗早期康复早期预防再发急性缺血性脑卒中急性缺血性脑卒中21As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.院前处理院前脑卒中的识别p迅速识别疑似患者并尽快送到医院，尽快对适合溶栓的患者进行溶栓治疗。若患者突然出现以下任一症状时应考虑脑卒中可能：(1)一侧肢体(伴或不伴面部)无力或麻木；(2)一侧面部麻木或口角歪斜；(3)说话不清或理解语言困难；(4)双眼向一侧凝视；(5)一侧或双眼视力丧失或模糊；(6)眩晕伴呕吐；(7)既往少见的严重头痛、呕吐；(8)意识障碍或抽搐。院前处理院前脑卒中的识别迅速识别疑似患者并尽快送到医院，22As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.院前处理现场处理及运送p尽快进行简要评估和必要的急救处理。处理气道、呼吸和循环问题；心脏监护；建立静脉通道；吸氧；评估有无低血糖。院前处理现场处理及运送 尽快进行简要评估和必要的急救处理23As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.院前处理现场处理及运送应迅速获取简要病史，包括：症状开始时间，若于睡眠中起病，应以最后表现正常的时间作为起病时间；近期患病史；既往病史；近期用药史。院前处理现场处理及运送应迅速获取简要病史，包括：24As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急诊室处理p诊断：是否为卒中？是缺血性还是出血性卒中？是否适合溶栓治疗？p对疑似脑卒中患者进行快速诊断，尽可能在到达急诊室后60min内完成脑CT等基本评估并做出治疗决定。急诊室处理诊断：对疑似脑卒中患者进行快速诊断，尽可能在到达急25As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急诊室处理p处理密切监护患者基本生命体征需紧急处理的情况：颅内压增高，严重血压异常、血糖异常和体温异常，癫痫等。急诊室处理26As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性脑卒中诊断流程应包括如下5个步骤：第一步：是否为脑卒中?排除非血管性疾病。第二步：是否为缺血性脑卒中?进行脑CT/MRI检查排除出血性脑卒中。第三步：卒中严重程度?根据神经功能缺损量表评估。第四步：能否进行溶栓治疗?核对适应证和禁忌证。第五步：病因分型?参考TOAST标准，结合病史、实验室、脑病变和血管病变等影像检查资料确定病因。急性期诊断与治疗评估和诊断急性缺血性脑卒中诊断流程应包括如下5个步骤：急性期诊断与治疗27As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.(1)对所有疑似脑卒中患者应进行头颅平扫CTMRI检查。(2)在溶栓等治疗前，应进行头颅平扫CTMRI检查，排除颅内出血。(3)应进行上述血液学、凝血功能和生化检查。(4)所有脑卒中患者应进行心电图检查，有条件时应持续心电监测。急性期诊断与治疗评估和诊断(1)对所有疑似脑卒中患者应进行头颅平扫CTMRI检查。急28As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.(5)用神经功能缺损量表评估病情程度。(6)应进行血管病变检查，但在起病早期，应注意避免因此类检查而延误溶栓时机。(7)根据上述规范的诊断流程进行诊断。急性期诊断与治疗评估和诊断(5)用神经功能缺损量表评估病情程度。急性期诊断与治疗评29As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗一般处理(1)准备溶栓者，血压应控制在收缩压180mmHg、舒张压100mmHg。(2)缺血性脑卒中后24h内血压升高的患者应谨慎处理（紧张焦虑、疼痛、恶心呕吐及颅内压增高等情况）。血压持续升高，收缩压200mmHg或舒张压110mmHg，或伴有严重心功能不全、主动脉夹层、高血压脑病的患者，可予降压治疗，并严密观察血压变化。急性期诊断与治疗一般处理(1)准备溶栓者，血压应控制在收30As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗一般处理(3)卒中后若病情稳定，血压持续140mmHg90mmHg，无禁忌证，可于起病数天后恢复使用发病前服用的降压药物或开始启动降压治疗。(4)卒中后低血压的患者应积极寻找和处理原因，必要时可采用扩容升压措施。可静脉输注0.9氯化钠溶液纠正低血容量，处理可能引起心输出量减少的心脏问题。急性期诊断与治疗一般处理(3)卒中后若病情稳定，血压持续31As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗一般处理(1)血糖超过10mmolL时可给予胰岛素治疗。应加强血糖监测，血糖值可控制在7.710mmolL。(2)血糖低于3.3mmolL时，可给予1020葡萄糖口服或注射治疗。目标是达到正常血糖。急性期诊断与治疗一般处理(1)血糖超过10 mmolL32As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗特异性治疗改善脑血循环溶栓抗血小板抗凝降纤扩容神经保护急性期诊断与治疗 特异性治疗 改善脑血循环33As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓纳入标准：1.诊断缺血性卒中导致的可评估的神经功能损害2.治疗前症状发生3h及3-4.5小时3.年龄18岁纳入标准：34As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓绝对禁忌绝对禁忌35As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓绝对禁忌绝对禁忌36As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓绝对禁忌绝对禁忌37As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌相对禁忌38As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌相对禁忌39As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌相对禁忌40As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌相对禁忌41As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.短暂性脑缺血发作的诊治短暂性脑缺血发作的诊治42As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.2009年6月ASA的TIA新定义一项荟萃分析表明，即使在症状持续时间140/90mmHg(1分)单侧力弱(2分)或言语障碍不伴力弱(1分)症状持续时间60min(2分)或10-59min(1分)ABCD2评分是目前使用比较广泛的低危组(0-3分)鞠奕等.49As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.ESSEN :Essen Stroke Risk Score危危险因素因素分分值75岁2高血高血压1糖尿病糖尿病1既往既往MI1其他心血管疾病（除外心房其他心血管疾病（除外心房颤动和和MI）1PAD1吸烟者吸烟者1既往缺血性卒中既往缺血性卒中/TIA史史1最高分最高分值90123456789极高危高危：卒中危险4%低危：卒中危险4%1.2010中国缺血性卒中/短暂性脑缺血发作二级预防指南，中华神经科杂志 2010；43（2）：154160卒中复发风险评估-ESSEN评分ESSEN :Essen Stroke Risk ScoAs the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.TIA早期评价与诊断流程TIA早期评价与诊断流程51As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.缺血性卒中二级预防评价：Essen评分高危高危卒中风险卒中风险44中危中危卒中风险卒中风险44极高危极高危CAPRIE Steering Committee.A randomised,blinded,trial of clopidogrel versus aspirin in patients at risk of ischaemic events Lancet 1996;348:1329-1339缺血性卒中二级预防评价：Essen评分高危中危极高危CAPR52As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.卒中发病数日后即开启降压二级预防治疗2014AHA/ASA卒中和TIA二级预防指南：卒中和TIA患者的血压管理既往未接受降压治疗的缺血性卒中或TIA患者，若发病后数日血压持续高于140/90mmHg，应启动降压药物治疗发病前患者已接受降压药物治疗，应在数日后恢复治疗Stroke.2014;45(7):2160-236ChinJStroke.2014,9(8):679-6852014中国卒中和TIA二级预防指南最初发病的几天，血压140/90mmHg者，以前未治疗的缺血性卒中和TIA患者可启动降压治疗。但对于血压140/90mmHg患者而言，启动降压治疗的获益尚不明确（b类建议；B级证据）既往已知高血压并接受药物治疗的患者，本次缺血性卒中或TIA发病数天后，为预防卒中复发或其他血管事件，应恢复降压治疗（类建议；A级证据）卒中发病数日后即开启降压二级预防治疗2014AHA/ASA 卒53As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.权威指南推荐：轻型卒中患者应尽早给予双抗治疗，此后氯吡格雷单药可作为长期二级预防一线用药1.短暂性脑缺血发作中国专家共识组.中华医学杂志2014;94(27):2092-2096.2.中华医学会神经病学分会.中华神经科杂志2015;48(4):258-273.轻型卒中(NIHSS评分3分)急性期患者(起病24h内)，应尽早给予氯吡格雷联合阿司匹林治疗21d，随后氯吡格雷单药治疗(75mg/d)，总疗程为90天。此后氯吡格雷、阿司匹林可作为长期二级预防一线用药(I/A)2014TIA与轻型卒中抗血小板治疗中国专家共识1轻型缺血性脑卒中患者(NIHSS评分3分)给予阿司匹林联合氯吡格雷治疗21天后，可单用阿司匹林或氯吡格雷作为缺血性脑卒中长期二级预防一线用药(I/A)2014中国缺血性脑卒中和TIA二级预防指南2权威指南推荐：轻型卒中患者应尽早给予双抗治疗，此后氯吡格雷单54As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.指南推荐的缺血性卒中他汀治疗策略：规范他汀治疗，积极管理ASCVD风险心肌梗死或其他急性冠脉综合征有证据的冠状动脉粥样硬化性疾病（如心绞痛）冠脉或其他血管重建手术短暂性脑缺血发作（TIA）缺血性卒中外周动脉粥样硬化性疾病其他有证据的动脉粥样硬化性疾病，如：肾动脉粥样硬化、继发于动脉粥样硬化的主动脉瘤、颈动脉斑块管腔狭窄50%患者识别循证优化他汀治疗中-高强度他汀LDL-C参考值70mg/dL管理目标减少ASCVD事件（如，缺血性卒中/TIA）确诊的ASCVD患者JacobsonTA,etal.JClinLipidol.2014Sep-Oct;8(5):473-88指南推荐的缺血性卒中他汀治疗策略：规范他汀治疗，积极管理AS55As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.出血性脑血管病出血性脑血管病56As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.患者，男性，66岁主因“突发头痛，伴恶心、呕吐，左侧肢体活动不利1天”于急诊收入院。入院前1天在行走时突然出现头痛，伴恶心、呕吐，为喷射样，吐出咖啡样胃内容物，伴有左上肢不能抬起，左下肢力弱、不能行走。既往：高血压史2个月，最高200/120mmHg，未予治疗。病例摘要病例摘要Case reportCase report 患者，男性，66岁病例摘要Case report57As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.查体：血压180/100mmHg,嗜睡，言语不清双瞳孔等大正圆，直径3.5mm，对光反射灵敏，双侧额纹对称，左侧鼻唇沟浅，伸舌左偏左侧肢体肌张力低，左侧上下肢肌力II级，左侧深浅感觉减退，左侧病理征（+）病例摘要病例摘要Case reportCase report 查体：血压180/100mmHg,嗜睡，言语不清病例摘要58As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.头CT右侧基底节区类圆形高密度影右侧基底节区类圆形高密度影头 CT右侧基底节区类圆形高密度影59As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.v脑动脉、静脉或毛细血管破裂导致脑实质内的出血。Definition脑出血（Cerebral Hemorrhage）脑动脉、静脉或毛细血管破裂导致脑实质内的出血。Defini60As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.v高血压v动脉瘤v动静脉畸形v淀粉样脑血管病v血管炎v血液病v抗凝药物v瘤卒中凝血血管Etiologies凝血血管Etiologies61As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.部位：部位：大脑半球，基底节附近（大脑中动脉的深穿大脑半球，基底节附近（大脑中动脉的深穿支破裂）支破裂）80%各脑叶的皮质下白质、脑干、及小脑各脑叶的皮质下白质、脑干、及小脑外观：外观：明显动脉粥样硬化明显动脉粥样硬化pathology部位：pathology62As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.50岁以上的高血压患者多见。诱因：情绪紧张、兴奋、排便、用力时发病，气候变化剧烈时发病较多。起病特点：突然，在数分钟至数小时达高峰clinical features50岁以上的高血压患者多见。clinical feature63As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.全脑症状全脑症状高颅压（血压多增高）高颅压（血压多增高）意识障碍、大小便失禁意识障碍、大小便失禁Clinical featuresClinical features局灶症状局灶症状不同部位不同症状不同部位不同症状不同部位不同症状不同部位不同症状全脑症状Clinical features局灶症状64As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.基底节出血最常见，占60%典型有“三偏征”，共同偏视，优势半球可有失语严重的意识障碍重，呕吐频繁，损伤丘脑下部和脑干，可有脑疝形成基底节出血最常见，占60%65As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.不同部位脑出血不同症状不同部位脑出血不同症状66As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.头颅CT：首选头颅MRI脑血管造影DSAMRA腰穿脑脊液检查Laboratory Studies头颅CT：首选Laboratory Studies67As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.发病年龄:50岁以上既往：高血压病史诱发因素：情绪激动，活动后起病急，高颅压症状，局灶体征脑出血Diagnosis头CT：局灶高密度影发病年龄:50岁以上既往：高血压病史诱发因素：情绪激动，活动68As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑出血脑梗塞好发年龄60岁以下多60岁以上多起病状态活动中安静状态起病方式急骤（min/h）急(h/d)起病时血压明显增高增高或正常意识障碍重轻全脑症状持续/较重轻局灶性脑损害有有脑膜刺激征可有无头CT脑内高密度灶低密度Differential Diagnosis脑出血脑梗塞好发年龄60岁以下多60岁以上多起病状态活动中安69As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.1.脑梗塞2.蛛网膜下腔出血3.脑肿瘤Differential Diagnosis脑梗塞Differential Diagnosis70As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.一内科治疗原则：一内科治疗原则：保持安静，防止继续出血保持安静，防止继续出血治疗脑水肿，减低颅压治疗脑水肿，减低颅压调整血压，改善循环调整血压，改善循环加强护理，防治并发症加强护理，防治并发症二二 外科治疗外科治疗壳核出血壳核出血50ml50ml小脑出血小脑出血10ml10ml三三 康复治疗康复治疗早期肢体功能位早期肢体功能位及早功能训练及早功能训练treatment一内科治疗原则：二 外科治疗壳核出血50ml三 康复治疗早71As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.蛛网膜下腔出血（SubarachnoidHemorrhage，SAH）p颅内血管破裂后，血液流入蛛网膜下腔称为蛛网膜下腔出血。p临床上将SAH分为外伤性与非外伤性两大类。p非外伤性SAH又称为自发性SAH，是一种常见且致死率极高的疾病，病因主要是动脉瘤，约占全部病例的85左右，其他病因包括中脑周围非动脉瘤性出血、血管畸形、硬脑膜动-静脉瘘、凝血功能障碍、吸食可卡因和垂体卒中等。蛛网膜下腔出血颅内血管破裂后，血液流入蛛网膜下腔称为蛛网膜下72As the only big agricultural village in Tianding Township,some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.患者，男，52岁2小时前于