蛛网膜下腔出血教案

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,*,蛛网膜下腔出血,Subarachnoid Hemorrhage,SAH,南京医科大学第一附属医院神经内科,牛 琦,学习重点,蛛网膜下腔出血的临床表现、诊断和治疗原则,SAH - Anatomy,SAH - Anatomy,DEFINITION,蛛网膜下腔出血（,subarachnoid hemorrhage,，,SAH,）,: Bleeding that occurs outside of the brain parenchyma and into the CSF,自发性：脑底部动脉瘤或脑动静脉畸形破裂，血液直接流入蛛网膜下腔,继发性：脑实质或脑室出血、外伤性硬膜下或硬膜外出血流入蛛网膜下腔,病因,(Etiology),粟粒样动脉瘤（,Saccular aneurysm,）：约,75,梭形动脉瘤（,berry aneurysm,）：高血压、动脉硬化所致,病因,(Etiology),动静脉畸形（,AVM,）,青年人多见,Moyamoya,病：,儿童多见,其它：,cardiac myxoma, septic aneurysms , pituitary apoplexy, cocaine abuse, anticoagulants, sickle cell, superficial CNS siderosis,发病机制,遗传和先天发育缺陷,+,高血压、动脉粥样硬化或血涡流冲击等,，导致粟粒样动脉瘤和脑动静脉畸形破裂,动脉炎或肿瘤直接侵蚀血管,病理及病理生理,(Pathophysiology),85,90,的先天性粟粒样动脉瘤位于前循环，是血管壁特别是分叉处发育薄弱形成，多为单发；约,20,的病例为多发，多位于两侧相同血管（镜相动脉瘤）。,病理及病理生理,(Pathophysiology),动脉瘤破裂频率为：颈内动脉及,分叉部,40,，大脑前动脉及前交,通动脉,30,，大脑中动脉及分支,20,，椎基底动脉及分支,10,；,后循环常见于基底动脉尖和小脑,后下动脉。,病理,蛛网膜下腔血液沉积在脑底池和脊髓池中，如鞍上池、桥小脑池、环池、小脑延髓池和终池等，呈紫红色，大量出血可见薄层血凝块覆盖于颅底血管、神经和脑表面。蛛网膜呈无菌性炎症反应，蛛网膜及软膜增厚，色素沉着，脑与血管或神经粘连。脑实质内广泛白质水肿，皮质可见多发斑块状缺血灶,临床表现（,Clinical findings,）,流行病学（,epidemiology,） ：,Rupture of aneurysm occurs msot often during the fourth to sixth decades. With an approximately equal sex distribution. Intracranial AVMs, occur twice as often in men and usually bleed in the second to fourth decades.,临床表现（,Clinical findings,）,症状和体征：,Symptoms and signs,剧烈头痛：,severe headache:,”the worst headache ever had in my life”,意识丧失：,Loss of consciousness,呕吐：,vomiting,脑膜刺激征：,Meningeal irritation:neck stiffness,，,Kernig sign, Brudzinshi sign,临床表现（,Clinical findings,）,体温升高：,Temperature elevations,癫痫：,Seizures,玻璃体下出血：,Perertinal globular subhyaloid hemorrhages,动眼神经麻痹：,Oculomotor nerve palsy,偏瘫、失语、视野缺损等,hemiparesis, aphasia, defect of the visual fields and etc.,临床表现（,Clinical findings,）,60,岁以上老年,SAH,患者临床表现常不典型（,atypical,），,起病较缓慢（,slow,），,头痛、脑膜刺激征不明显（,mild,）,意识障碍及脑实质损较重（,severity,），,可以精神症状起病（,mental disorders,）,常伴心脏损害、肺部感染、消化道出血、泌尿系感染和胆道感染等并发症（,complications,）,易漏诊或误诊（,neglected or misdiagnosis,）,临床表现（,Clinical findings,）,并发症（,complications,）,再出血（,recurrence of hemorrhage,）,脑血管痉挛（,cerebrovascular spasm,）,合并脑实质内或脑室出血（,intraparenchymal extension ofhemorrhage,）,急性或亚急性脑积水（,acute or subacute hydrocephalus,）,其它，如癫痫或低钠血症（,others,，,seizures or hyponatremia,，,etc,）,辅助检查（,Investigative Study,）,颅内动脉瘤破裂引起的蛛网膜下腔出血常可根据,CT,平扫显示蛛网膜下腔积血确诊，,若无此征象，腰穿显示脑脊液非血性，可排除,SAH,辅助检查（,Investigative Study,）,CT,（首选，早期诊断，安全敏感,）,DSA,AVM,aneurysms,辅助检查（,Investigative Study,）,MRA,：可见动脉瘤,CSF,：均匀一致血性脑脊液，可有黄变征,TCD,：可发现脑血管痉挛,心电图,血常规、血生化、凝血功能检查等,诊断和鉴别诊断,诊断：,病史体征影像学检查,突发头痛伴呕吐颈强,CT,鉴别诊断：,高血压性脑出血（,hypertensive hemorrhage,）,颅内感染（,CNS infection,）,瘤卒中（,Tumor bleeding,）,其它（,others,）,SAH,与脑出血的鉴别要点,SAH,脑出血,发病年龄,粟粒样动脉瘤多发于,40,60,岁，动静脉畸形青少年多见，常在,10,40,岁发病,50,65,岁多见,常见病因,粟粒样动脉瘤、动静脉畸形,高血压，脑动脉粥样硬化,起病速度,急骤，数分钟达到高峰,数十分钟至数小时达到高峰,高 血 压,正常或增高,通常显著增高,头 痛,极常见，剧烈,常见，较剧烈,昏 迷,重症患者出现一过性昏迷,重症患者持续性昏迷,神经体征,颈强，,Kernig,征等脑膜刺激征,偏瘫、偏身感觉障碍及失语等局灶性体征,眼 底,可见玻璃体膜下片块状出血,眼底动脉硬化，可见视网膜出血,头部,CT,脑池、脑室及蛛网膜下腔高密度出血征,脑实质内高密度病灶,脑脊液,均匀一致血性,洗肉水样,治 疗,Treatment,内科治疗（,medical treatment,）,一般处理：绝对卧床、镇静、通便、止痛、营养支持、禁用损伤血小板功能的药物,控制颅内压：甘露醇、速尿、白蛋白脱水,预防再出血：抗纤溶药、止血药等,钙通道阻滞剂：,nimotop,放脑脊液疗法：严格掌握适应证,手术治疗（,surgical treatment,）,手术治疗是根除病因、防止复发的有效方法,动脉瘤：夹闭、切除或介入，应注意选择手术时机，防治脑血管痉挛,动脉瘤性,SAH,患者,Hunt,和,Hess,临床分级,grade,Level of,consciousness,Associated clinical features,Surgical candidate,0,Normal,Unraptured aneurysm,Normal,None or mild headache and stiff neck,Yes,Normal,Moderate headache and stiff necklminimal neurologic deficit(eg,cranial nerve palsy )in some cases,Yes,Confusional,state,Focal neurologic deficits in some cases,Yes,Stupor,Focal neurologic deficits in some cases,No,Coma,Decerebrate posturing in some cases,No,手术治疗（,surgical treatment,）,动静脉畸形：切除、结扎、介入、,刀等,预后（,prognosis,）,与病因、年龄、动脉瘤部位、大小、出血量、血压增高及波动、合并症及时手术治疗有关,