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1、深穿支动脉为出血的主要部位，豆纹动脉是脑出血最好发部位，其外侧支称为出血动脉The mainly hemorrhagic sites are the perforating branches of middle cerebral artery, the most common sites of ICH are lenticulostriate arteries, lateral branches of those are called hemorrhagic arteries.基底节区 Basal ganglia 70% 脑叶 Cerebral lobe 10%脑干 Brain stem 10
2、% 小脑齿状核区 Cerebellar dentate nucleus 10%粟粒状动脉瘤:大脑中动脉深穿支豆纹动脉基底动脉脑桥支大脑后动脉丘脑支小脑上动脉分支顶枕交界区和颞叶分支Granulous aneurysm : the lenticulostriate arteries branches of the basilar artery supplying the pons thalamic branches of the posterior cerebral arteries branches of the superior cerebellar arteries some arteri
3、es supplying the junctional zone between parietal and occipital lobe and branches of temporal lobe临床表现 clinical manifestations (1)年龄50-70岁，男女 Age 50-70 years. The incidence is higher in men than in women 冬春季多发 Mostly occurrs in winter and spring.多有高血压史 Usually with hypertension.活动或情绪激动时发生 Occurrs wh
4、en activities or emotional excitement.数分钟至数小时症状达高峰 Neurologic deficits may progress over minutes to hours.全脑症状：头痛、呕吐、意识改变 Global cerebral symptom: headache, vomiting, alterd consciousness临床表现 clinical manifestions (2)1. 基底节区出血（内囊区出血）占70%，其中壳核（内囊外侧型）60%，丘脑（内囊内侧型）10%。The most common site of hemorrhage
5、 is basal ganglia, which occurs in 70% of patients. It consists of putamen (lateral of the internal capsule) and thalamus (medial of the internal capsule) .(1)壳核出血：三偏，双眼向病灶对侧同向凝视不能，主侧半球有失语。(1) Putaminal hemorrhage: hemiplegia, hemisensory deficit, hemiopia, impairment of syntropic gaze to the contra
6、lateral lesion, aphasia with dominant hemisphere临床表现 clinical manifestions (3)(2)丘脑出血：丘脑膝状动脉和丘脑穿通动脉。三偏，上下肢程度相近，深浅感觉障碍，特征性眼征，意识障碍，中线症状，锥体外系症状，丘脑性失语，精神症状。(2)Thalamic hemorrhage: the thalamic genual artery and the long penetrating thalamic artery. hemiplegia, hemisensory deficit, hemiopia, hemiplegia a
7、ffecting the arm and leg to a roughly equal extent, impairment of superficial and deep sensation, marked ocular sign, impairment of consciousness, symptoms of the median line, the extrapyramidal symptoms, the thalamic aphasia, mentalsymptoms.临床表现 clinical manifestions (4)(3)尾状核头部出血：少见。脑膜刺激征，无明显瘫痪，头痛
8、，呕吐，颈强，Kernig征(+)，可有对侧中枢性面、舌瘫(3)Hemorhage in the head of the caudate nucleus: seldom. meningeal irritation sign, unobvious paralysis, headache, vomiting, neck stiffness, positive Kernigs sign, the facial and hypoglossal paralysis caused by contralateral upper unit opathy.临床表现 clinical manifestions(5
9、)2.脑桥出血:10%，多位于脑桥基底与被盖部之间。2. Pontine hemorrhage: 10%, mostly occurs between the basal pons and the tegmen. 大量出血(5ml)：常破入四脑室。昏迷，针尖样瞳孔，呕吐，中枢性高热，中枢性呼吸困难，眼球浮动，四肢瘫，去大脑强直发作，多在48小时内死亡。Massive hemorrhage(5ml): usually ruptures into the fourth ventricle. Coma, pinpoint pupils, vomiting, central fever, centra
10、l dyspnea, impairment of horizontal eye movements, quadriplegia, decerebrate rigidity, usually leads to death within 48 hours. 临床表现 clinical manifestions (6)小量出血：交叉性瘫，共济失调性偏瘫，双眼向病灶侧凝视或核间性眼肌麻痹。Small hemorrhage: crossed paralysis, ataxic-hemiplegia, both eyes gaze to the ipsilateral lesion or internuc
11、lear ophthalmoplegia.3.中脑出血：罕见Hemorrhage in diencephalon: seldom.轻症：一侧或双侧动眼神经不全瘫痪，Weber综合征Mild case: unilateral or bilateral oculomotor nerve partial paralysis, Webers syndrome.重症：深昏迷，四肢弛缓性瘫，迅速死亡Severe case: deep coma, flaccid quadriplegia, rapidly go to death临床表现 clinical manifestions (7)4.小脑出血：10%
12、，小脑齿状核动脉多发。发病初期有眩晕，呕吐，枕部头痛，平衡障碍，无肢体瘫痪。4.Cerebellar hemorrhage: 10%, usually occurs in the artery supplying dentate nucleus.The symptoms including vertigo, vomiting, occipital headache and disorders of equilibrium, but not quadriplegia appear at onset of bleeding.临床表现 clinical manifestions (8)轻症：一侧肢体
13、笨拙，行动不稳，共济失调，眼震，无瘫痪。 Mild case: clumsiness of unilateral body, unstable movement, ataxia, nystagmus, no paralysis.重症：双眼向病灶对侧凝视，吞咽发声困难，锥体束征，一侧瞳孔缩小，光反应迟钝，脑干受压表现，甚至枕大孔疝。 Severe case: both eyes gaze at the contralateral lesion, difficulty in swallowing and dysphonia, pyramidal sign, constriction of unil
14、ateral pupil , bluntness in response to light, signs of brainstem compression, even foramen magnum herniation.临床表现 clinical manifestations (9)5.脑叶出血：10%，以顶叶最常见。头痛，呕吐，脑膜刺激征，局灶症状，抽搐较多见。5.Lobar hemorrhage:10%, the most common site is parietal lobe. Headache, vomiting, Meningeal irritation sign, focal b
15、rain sign, sizure 额叶：偏瘫，Broca失语，摸索。Frontal lobe: hemiplegia, brocas aphasia, crocidismus.临床表现 clinical manifestations (10)颞叶：Wernicke失语，精神症状。 Temporal lobe: Wernickes aphasia, mental symptoms.枕叶：视野缺损。 Occipital lobe: visual field defects.顶叶：偏身感觉障碍，空间构想障碍。 Parietal lobe: hemisensory deficit, impairme
16、nt of spatial ability临床表现 clinical manifestations(11)6.脑室出血：3%-5%，脉络丛动脉、室管膜下动脉破裂。6. Hemorrhage in cerebral ventricle: 3%-5%, the arteries of the choroid plexus and the inferior ependymal arteries rupture.少量：头痛、呕吐、脑膜刺激征，无意识障碍和局灶症状，血性CSF，预后好。small: headache, vomiting, Meningeal irritation sign, no imp
17、airment of consciousness and focal brain symptoms, hematoid CSF, good prognosis.临床表现 clinical manifestations (12)大量：昏迷，频繁呕吐，针尖样瞳孔，分离性斜视或眼球浮动，四肢弛缓性瘫，去脑强直发作，预后不良。 massive: coma, frequently vomiting, pinpoint pupils, separate strabismus or eyeballs floating, flaccid quadriplegia, decerebrate rigidity.
18、Poor prognosis.诊断50岁以上中老年高血压患者在活动中或激动时突然发病，出现偏瘫、失语等局灶性神经缺失症状，应首先考虑脑出血。While activities or emotional excitement, The hypertension patients over age 50 years suddenly appear the symptoms of focal neurologic deficits such as hemiplegia, aphasia etc. The first diagnosis may be intracerebral hemorrhage.
19、鉴别诊断 differential diagnosis鉴别：脑梗死 cerebral infarction 中毒、代谢性疾病 toxicosis, metabolic disorders 外伤性出血 traumatic hemorrhage 不同的脑出血原因 different causes of intracerebral hemorrhage治疗treatment -内科治疗medical treatment保持安静，卧床休息。监测生命体征、瞳孔、意识，加强护理 To keep quiet, bed rest. monitor vital signs, pupils and conscio
20、usness, intensive nursing. 维持水电解质平衡，注意营养。 To keep the intravenous fluid and electrolyte balance, and close attention must be given to nutrition.控制脑水肿，降低颅内压（ICP）To control hydrocephalus and reduce intracranial pressure.控制高血压 To control hypertension防治并发症 To prevent and cure complications.治疗 treatment
21、外科治疗 surgical treatment手术适应症：surgical indications:脑出血病人逐渐出现颅内压增高伴脑干受压。Patients suffered with intracerebral hemorrhage graduallyappear the signs of increasing ICP and brainstem compressed.2.小脑半球出血15ml，蚓部血肿6ml，血肿破入四脑室或脑池受压消失，出现脑干受压表现和急性阻塞性脑积水征象 Hematoma in cerebellar hemisphere are more than 15ml in b
22、ulk, or in vermis are more than 6ml in bulk, hematoma rupture into the fourth ventricle or the compression of the brain pool disappears, signs of brainstem compressed and acute obstructive hydrocephalus appear3.脑室出血致阻塞性脑积水Obstructive hydrocephalus caused by hemorrhage inventricles.4.年轻患者脑叶或壳核中大量出血（4
23、050ml），或有明确的血管病灶Massive hemorrhage ( more than 40-50 ml in bulk ) incerebral lobes or putamen (young patients), or a definitivevascular lesion5.脑桥出血一般不宜手术。Generally pontine hemorrhage is not indicative tosurgery 蛛网膜下腔出血 Subarachnoid hemorrhage, SAHSAH是多种病因所致脑底部或脑及脊髓表面血管破裂的急性出血性脑血管病，血液直接流入蛛网膜下腔，又称原发性
24、SAH。SAH is an acute hemorrhagic cerebrovascular disease caused by many pathogenies, which is result of the blood vessels from the inferior brain or surface of brain and spinal cord rupture and then the blood directly flow into subarachnoid space. It is also named primary SAH.SAH约占急性脑卒中的10%，占出血性脑卒中的2
25、0%。The incidence of SAH is approximately 10 percent of acute stroke, while is 20 percent of hemorrhagic stoke.先天性动脉瘤：最常见，约占50%以上Congenital aneurysm: the most common, approximately over 50%2.脑血管畸形：占第二位Cerebrovascular malformation: the second reason3.高血压动脉硬化性动脉瘤Hypertensive atherosclerosis aneurysm4.M
26、oyamoya病Moyamoya disease5.其他othersSAH后的病理过程:pathophysiology after SAH:颅内容量增加 intracranial tissues increasing 阻塞性脑积水 obstructive hydrocephalus化学性脑膜炎 chemical meningitis下丘脑功能紊乱 disorders of hypothalamic function自主神经功能紊乱 disorders of the autonomic nervous system交通性脑积水 communicating hydrocephalus血管痉挛、蛛网
27、膜颗粒粘连、甚至脑梗死和正常颅压脑积水 cerebrovascular spasm, the arachnoid villi adhension, even cerebral infarction and hydrocephalus with normal ICP临床表现 clinical manifestations任何年龄均可发病，动脉瘤破裂好发于30-60岁间，女男；血管畸形多见于青少年，两性无差异。Occurs on any age, rupture of aneurysm most occurs on age from 30-60 years, in women more than
28、in men;AVM most occurs in adolescent, theres no difference in gender. 60岁以上老人表现常不典型The symptoms of old patients over 60 years are atypical.典型表现：突发剧烈头痛、呕吐、脑膜刺激征及血性脑脊液。伴随症状有短暂意识障碍、项背部或下肢痛、畏光。眼底检查可见视网膜出血、视乳头水肿或玻璃体下出血；可有局灶性症状、精神症状。 Typical manifestations: a suddenly severe headache, vomiting, meningeal
29、irritation sign and bloody CSF. The accompanying symptoms are transient impairment of consciousness, back pain or melosalgia, photesthesia. Retinal hemorrhage, papilledema or globular subhyaloid hemorrhage found by examination of fundus oculi. A focal neurologic symptoms, mental synmptoms.诱因及先驱症状：发病
30、前多有明显诱因，剧烈运动、过劳、激动、用力、排便、咳嗽、饮酒等；少数在安静下发病。发病前可有头痛、恶心、呕吐，颅神经麻痹，局灶性缺失或刺激症状。Inducements and prodromes: Usually there are obvious inducements before onset , such as intense exercise, too tired, excitement, exertion, defecation, cough, drinking et al; Minority occurs at rest. History of headache, nausea,
31、vomiting, cranial nerves palsy, focal neurologic deficient or irritative symptoms are common before onset.诊断突发剧烈头痛、恶心呕吐和脑膜刺激征阳性患者，无局灶性神经缺损体征，伴或不伴有意识障碍，可诊断此病；CSF均匀血性、压力增高、眼底检查玻璃体下出血可临床确诊。常规行CT检查，并行病因学诊断。 The history of a sudden severe headache, nausea, vomiting and positive Meningeal irritation sign,
32、 no focal neurologic deficit sign with (without) impairment of consciousness is highly specific for SAH. Uniformity bloody CSF, increased ICP and globular subhyaloid hemorrhage found by eyeground examination are most suggestive of the clinical diagnosis. CT scan is the routine test, and then make th
33、e aetiological diagnosis.鉴别诊断 differential diagnosis 鉴别： 脑出血，颅内感染，脑卒中或颅内转移瘤 Differential diagnosis: cerebral hemorrhage, intracranial infections, the ischemic stroke or intracranial metastatic tumors 治疗 treatment原则：控制继续出血、防治迟发性脑血管痉挛、去除病因和防止复发。Principles: To control continuous hemorrhage, to prevent
34、and cure cerebrovascular spasm, to remove causes and prevent recurrence.内科处理：一般处理：监护、绝对卧床4-6周，保持安静，避免一切引起血压和颅内压升高的诱因，镇静、通便，补液，加强护理，营养支持，防止并发症；降颅压；防止再出血；防治迟发性血管痉挛；脑脊液置换疗法。 Medical treatment: general treatment: monitor, absolute bed rest for 4-6 weeks, keep quiet, avoid every cause that induce increas
35、ed blood and ICP, sedation, purgation, fluid infusion, intensive nursing, nutritional support, to prevent complications; to lower ICP; to prevent recurrent hemorrhage; to prevent and cure tardive cerebrovasular spasm; CSF replacement手术治疗 surgical treatment TIA （transient ischemic attack）By definitio
36、n, transient ischemic attack, TIA, is a recurrent ischemia in the brain within a briefer periods, which produces neurologic deficits, and the symptoms and signs resolve completely , usually within several minutes to 1 hour, no more than 24 hours.Clinic Features Most occurs in those middle and old ag
37、es, higher in male than in female. TIA begins abruptly, within a briefer periods, and resolves quickly without any residual deficit. Recurrent, stable symptom. Risk factor: Hypertension,Diabetesmellitus，Hypercholesterolemia, Heart disease.Features of Internal Carotid Artery System TIAFrequent sympto
38、m: contralateral monoplegia, accompanying with contralateral facial paralysis.Due to MCA infarction or watershed infarction between MCA and ACA.Characteristic symptom:ophthalmic artery crossed palsy, Horner sign crossing palsy, sometimes accompanying aphasia.Possible symptom:hemisensory disturbances
39、, hemiablepsia.Frequent symptom:vertigo, balance disturbance.Characteristic symptom:drop attack, transient global amnesia, binocular vision disorder.Possible symptom:dysphagia, ataxia, conscious disturbance,perioral numbness, ambiopia, crossed paralysis.TreatmentObjective:eliminate etiological facto
40、r,prevent and decrease recurrence, protect the function of brain.Etiological treatmentProphylactic drug treatment: antiplatelet agents, anticogulant, angiotenic, traditional Chinese medicine, fluid expansion drugs.Neuroprotective agentsCerebral InfarctionCerebral infarction, CI, other named as cereb
41、ral ischemic stroke, CIS, is defined as a local ischemic necrosis or cerebro- malacia in the brain tissue due to disorder of the cerebral blood supply, ischemia and hypoxia.Common typers:cerebral thrombosis, lacunar infarction and cerebral embolism.Cerebral ThrombosisThe stem or cortical branches of
42、 the cerebral arteries occur angiostenosis or obstruction because of vascular lesion such as artherosclerosis, arteritis and etc, which causes cerebral thrombosis. The occlusion of a blood vessel interrupts the flow of blood to a specific region of the brain, and produces ischemia, hypoxia, malacia,
43、 necrosis, focal symptoms and signs that correlate with the area of the brain supplied by the affected blood vessel.Pathogeny & MechanismArterial canal stenosis and thrombosis 1.artherosclerosis,most occur in bifurcation of the vessal. 2.vasculitis 3.hematological system 4.othersVasospasmOther：hyper
44、-APLA, pro C, pro S, etc.PathophysiologyIschemic Penumbra: conservation the neuron in the IP, is the key of treatment of acute cerebral infarction.Time WindowReperfusion Damage：means that recover the blood flow of the brain after the time window.It may aggravate damage.The mechanism is regard with f
45、ree radical, overload of intracellular Ca2+ in the neuron,excitatory amino acids,etc.Clinical FeaturesGeneral features: artherosclerosis is the main etiological factor for the middle and old age, vasculitis is the common factor for young ones. Generally onset at a calm or rest time, reach the peak a
46、fter 12 days. Majority have clear consciousness. Part of them are preceded by TIAs. Clinical classification: complete stroke, progressive stroke, reversible- ischemic neurological deficit.Clinical Syndrome Syndrome of Internal Carotid Artery Occlusion: homonymy monocular amaurosis homonymy Horner si
47、gn contralateral hemiplegia，hemisensory- deficit, homonymous hemianopia aphasia(dominant hemisphere) carotid arterial pulse to weaken,vascular murmur from cervical or ocular region.Occlusion of Middle Cerebral ArteryOcclusion of stem： hemiplegia, hemisensory- deficit and hemianopia, with aphasia(dominant hemisphere), may have different level of conscious disturbance.Oc