脑出血

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,脑 出 血,Intracerebral hemorrhage,Department of Neurology,The 2nd affiliated hospital,Harbin Medical University,Conception,It means,primary,and,nontraumatic,intracerebral hemorrhage.,Count for,20%30%,in stroke,Hypertension,is the most common underlying cause of nontraumatic intracerebral hemorrhage.,Etiology,Half of the patients suffer from,hypertension combined with arteriolar atherosclerosis,it is the most common cause of the disease.,Others,：,cerebral atherosclerosis, hematopathy,cerebral amyloid angiopathy CAA,aneurysm, AVM,Pathophysiology,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,rupture,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,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 arteries,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,一次出血常在30,min,内停止,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 rebleeding,多发性脑出血常继发于,：,hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis,Pathology,Hypertensive 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%,Location 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 ventricle,Pathology,Hypertensive ICH：cerebral penetrating artery miliary aneurysm,Non Hypertensive ICH：occur in subcortical white matter without arteriosclerosis,Pathology,Swelling and congestion of hemisphere,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,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 features,age：5070 years old,sex：more male patients,season：winter or spring,past history：hypertension,inducement：activity、excitement,onset：acute onset,Clinical features,Hypertensive hemorrhage,occurs without warning,most commonly while the patient is awake.,Headache,is present in 50% of patients and may be severe,vomiting,is common.,Blood pressure,is elevated after the hemorrhage has occurred. Thus, normal or low blood pressure in a patient with stroke makes the diagnosis of hypertensive hemorrhage unlikely, as does onset before 50 years of age.,Clinical featuresbasal ganglion hemorrhage,The 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.,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,Homonymous hemianopia,may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage.,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 hemorrhage,Aphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas.,Large hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.,Clinical featuresbasal ganglion hemorrhage,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,With bleeding into the,pons(figure 3),coma,occurs within seconds to minutes and usually leads to death within 48 hours.,Ocular 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 hemorrhage,Patients are commonly,quadriparetic,or,hemiplegia alternate,and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometimes present.,The 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 hemorrhage,Midbrain hemorrhage is rarely seen in clinic.,The patients often manifest,Weber syndrome.,Large hemorrhages may lead to coma and flaccid paralysis.,Clinical featurescerebellar hemorrhage,小脑齿状核动脉破裂,The 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.,Large 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 hemorrhage,Etiology,：,AVM,、,Moyamoya disease,、,cerebral amyloid angiopathy,、,tumor,Hypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal, temporal, and occipital lobes,(figure 5),.,Symptoms and signs vary according to the location; they can include headache, vomiting, hemiparesis, hemisensory deficits, aphasia, and visual field abnormalities.,Seizures,are more frequent than with hemorrhages in other locations, while coma is less so.,Clinical featurescerebral ventriculus hemorrhage,脉络丛,plexus chorioideus,动脉或室管膜下动脉破裂,(,figure 6),Global symptoms,are obvious,，,but local symptoms are not.,The patients may have a full recovery and a good outcome.,Large hemorrhages may lead to coma, vomiting, pinpoint pupils,implies a poor outcome.,Supplementary findings,CT computerized tomography is chosen,first,Lesion:,high density,(hematoma) surronded by low density(edema),（figure 7,）,Mass effect,is often seen in CT,Supplementary findings,MRI 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,CT,ICH and cerebral infarction can be distinguished by MRI 45 weeks,but CT can not distinguish them,Easy to detect AVM,、,aneurysm,Complex stages,Supplementary findings,DSA：to diagnose AVM,、,Moyamoya disease,、,arteritis,CSF：elevated pressure,consistently bloody,but not the routine examination,其他：血、尿,、,便常规，肝功，肾功，凝血功能，心电图等,Diagnosis,Senile patients after 50 years of age,Past history of hypertension,Onset during activity,Sudden onset,CT scan,Differential diagnosis,Cerebral infarction:situation and speed of onset,blood pressure,lesion showed by CT,Coma due to other causes:present illness history,Injury:history of injury,Nonhypertensive hemorrhage:without history of hypertension,Treatmentmedical treatment,保持安静,keep quiet、,卧床休息,rest in bed、,减少探视,avoid meeting,水电解质平衡,keep water_electrolyte balance,和营养,nutrition,控制脑水肿,control brain edema，,降低颅内压,控制高血压,control blood pressure: antihypertensive agents or diuretic such as furosemide,防治并发症,prevent complications:rebleeding, herniation, infection,Treatmentsurgical treatment,时机：超早期 6-24小时,Indication,Contraindications,术式,Rehabilitation,尽早进行,as soon as possible,抗抑郁,antidepression,Specific treatment,Nonhypertensive hemorrhage,Poly-cerebral hemorrhage,Rebleeding,Unstable cerebral hemorrhage,Prognosis,The mortality in 30 days is 35%52%,half of the patients die within 2 days,due to cerebral herniation.,Large hemorrhages of brainstem、thalamus 、ventricle implies a poor prognosis.,蛛网膜下腔出血,Subarachnoid hemorrhage, SAH,Department of Neurology,The 2nd affiliated hospital,Harbin Medical University,Conception,It 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 SAH,Secondary SAH：hemorrhages in brain,、,ventricle or epidural (subdural) space rupture into subarachnoid space,Traumatic SAH,Count for,10%,in stroke，for,20%,in hemorrhagic stroke,Etiology,Congenital aneurysm,is most common etiology,AVM,is a less frequent cause of SAH,Hypertensive arteriosclerosis aneurysm,is the third cause of SAH,Moyamoya disease,is the forth cause,Others include tumor, arteritis,Pathophysiology,Cerebral artery aneurysm are most commonly,congenital “berry” aneurysms, which result from developmental,weakness of the vessel wall, especially at the sites of branching.,AVM,are most common in the middle cerebral artery distribution.,Arteritis,can also play an important role in the disease.,Tumor,invasive the vessel wall can not be overlooked.,Pathophysiology,颅内压增高,increased ICP,阻塞性脑积水,obstructive hydrocephalus,化学性脑膜炎,aseptic meningitis,下丘脑功能紊乱,自主神经功能紊乱,dysautonimia,交通性脑积水,communicating hydrocephalus,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,Pathology,85%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,.,好发于,Willis,环动脉分叉处,破裂频度,血液主要沉积在脑底部、脑池,可破入脑室致脑积水,蛛网膜无菌性炎症反应,Clinical features,Any age,of person may suffer from SAH.,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”.,The absence of the headache essentially precludes the diagnosis.,Loss of consciousness,is frequent, as are vomiting and,neck stiffness,.,Symptoms may begin at,any time,of day and during either rest or exertion.,Clinical features,The most significant feature of the headache is that it is,new.,Milder but otherwise similar headaches may have occurred in the weeks prior to the acute event.,These,earlier headaches,are probably the result of small prodromal hemorrhages (sentinel,or warning, hemorrhages) or aneurysmal stretch.,Clinical features,The 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.,There is frequently confusion, stupor, or coma.,Nuchal 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.,Preretinal globular subhyaloid hemorrhages,(found in 20% of cases) are most suggestive of the diagnosis.,Clinical features,Because 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.,An,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.,Ruptured AVMs may produce focal signs, such as hemiparesis, aphasia, or a defect of the visual fields.,Clinical features,Inducement and aura,：inducement include intensive activity,、,exhaustion、excitement,aura can be “warning leak” and localized sign.,Symptoms 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 complications,Complications,Recurrence 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.,Arterial 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.,Complications,Acute 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.,Complications,Seizures,: Seizures occur in fewer than 10% of cases and only following damage to the cerebral hemisphere.,Others:Although inappropriate secretion of antidiuretic hormone and resultant diabetes insidious can occur, they are uncommon.,Supplementary findings,CT：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-SAH,CSF: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 findings,DSA:to detect,aneurysm,or AVM, it is a prerequisite to the rational planning of surgical treatment.,MRI and MRA:MRI is especially useful in detecting small AVMs localized to the brainstem (an area poorly seen on CT scan).,TCD：to determine CVS,实验室检查：血常规、凝血功能、肝功、免疫学,Diagnosis,Symptom：the history of a sudden severe headache with confusion or obtundation,Sign：nuchal rigidity, a nonfocal neurologic examination,CSF：bloody spinal fluid,Fundus oculi,：,preretinal globular subhyaloid hemorrhages,CT findings,Differential diagnosis,Hypertensive intracranial hemorrhage,：,there are prominent focal findings.,Intracranial infection:it is excluded by the CSF examination.,Tumor stroke or metastasis:they can be distinguished from SAH by evidence of tumor.,Non-typical SAH,Principle of treatment,控制继续出血,control active hemorrhage,防治迟发性,CVS prevent tardive CVS,去除病因,eliminate etiology,防止复发,prevent recurrence,Treatmentmedical treatment,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.,降颅压,decrease ICP：antiedema agents eg.mannitol or surgical decompression,防治再出血,prevent recurrence：PAMBA,防治迟发,CVS prevent tardive CVS ：calcium channel antagonist drug e.g. nimodipine,CSF,置换,CSF exchange：it can remove red cells,since the procedure may be accomplished with some complications, it should be used carefully.,Treatmentsurgical treatment,Opportunity of operation,：2472,hours after hemorrhage,Subject to operation,术式,血管内介入治疗、,-,刀治疗,Prognosis,The probability of survival following aneurysmal rupture is related to the patient s state of consciousness and the elapsed time since the hemorrhage.,Hunt grade：grade,have a good outcome,grade,have a poor one,grade, have a moderate one.,Main cause of death ：including recurrence of hemorrhage,、,tardive CVS,Main commemorstive sign：may be cognitive impairment,