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1、Conception nIt means primary and nontraumatic intracerebral hemorrhage. nCount for 20%30% in stroke nHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage. Etiology nHalf of the patients suffer from hypertension combined with arteriolar atherosclerosis, it is the
2、most common cause of the disease. nOthers：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy CAA , aneurysm, AVM Pathophysiology n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 n高血压远端血管痉挛vasospasm 缺氧anoxia、坏死angio-necrosis、
3、血栓形 成thrombosis斑点状出血、脑水肿 brain edema融合成片(子痫) Pathophysiology n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 n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 n一次出血常在30min内停止 n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
4、 hemorrhage或早期再出血early rebleeding n多发性脑出血常继发于： hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis Patholog y nHypertensive 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% nLocation 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 spa
5、ce、第四脑 室forth ventricle Pathology nHypertensive ICH：cerebral penetrating artery miliary aneurysm nNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosis Pathology nSwelling and congestion of hemisphere n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 n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
6、囊） Clinical features nage：5070 years old nsex：more male patients nseason：winter or spring npast history：hypertension ninducement：activity、excitement nonset：acute onset 临 床 表 现 n一般症状：中年以上发病。起病突然， 动态起病，病势凶险。 n高颅压征 intracranial hypertension sign 头痛，呕吐，血压升高，脉搏减慢， 视乳头水肿，意识障碍 易形成脑疝 cerebral herniation n神经
7、系统定位体征： 取决于血肿的部位、体积 局灶性神经功能缺损 基底节区：内囊“三偏征” 偏瘫 hemiplegia 偏盲 hemiscotosis 偏身感觉障碍 hemihypesthesia 脑叶 额叶 颞叶 顶叶 枕叶 各具不同缺损 脑干 交叉性瘫痪 hemiplegia alternate 小脑 眩晕 vertigo 共济失调 ataxia 基底节区的血液供应 豆纹动脉的破裂成因 Clinical features basal ganglion hemorrhage nThe two most common sites of hypertensive hemorrhage are the
8、putamen(figure 1) and thalamus(figure 2), which are separated by the posterior limb of the internal capsule. n In general, putaminal hemorrhage leads to a more severe motor deficit (hemiplegia) and thalamic hemorrhage to a more marked sensory disturbance (hemianesthesia). Clinical features basal gan
9、glion hemorrhage nHomonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage. n In large thalamic hemorrhages, the eyes may deviate downward, as in staring at the tip of the nose, because of impingement on the midbrai
10、n center for upward gaze. Clinical features basal ganglion hemorrhage nAphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas. nLarge hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome. Clinical features basal ga
11、nglion hemorrhage n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 features pontine hemorrhage nWith bleeding into the pons(figure 3), coma occurs within seconds to minutes and usually leads to death wit
12、hin 48 hours. nOcular 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 features pontine hemorrhage nPatients are commonly quadriparetic or hemiplegia alte
13、rnate and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometimes present. nThe hemorrhage usually ruptures into the forth ventricle, and rostral extension of the hemorrhage into the midbrain with resultant midposition fixed pupils is common. Clinical features midbrain hemorrh
14、age nMidbrain hemorrhage is rarely seen in clinic. nThe patients often manifest Weber syndrome. nLarge hemorrhages may lead to coma and flaccid paralysis. Clinical features cerebellar hemorrhage n小脑齿状核动脉破裂 nThe distinctive symptoms of cerebellar hemorrhage(figure 4) are severe headache, dizziness, v
15、omiting, and the inability to stand or walk, but strength in the limbs is normal. nLarge 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 features lobar hemorrhage nEtiology：AVM、Moyamoya disease、cerebral am
16、yloid angiopathy、tumor nHypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal, temporal, and occipital lobes(figure 5). nSymptoms and signs vary according to the location; they can include headache, vomiting, hemiparesis, hemisensory deficits, aphasia, and v
17、isual field abnormalities. nSeizures are more frequent than with hemorrhages in other locations, while coma is less so. Clinical features cerebral ventriculus hemorrhage n脉络丛plexus chorioideus动脉或室管膜下动 脉破裂(figure 6) nGlobal symptoms are obvious，but local symptoms are not. nThe patients may have a ful
18、l recovery and a good outcome. nLarge hemorrhages may lead to coma, vomiting, pinpoint pupils,implies a poor outcome. Supplementary findings nCT computerized tomography is chosen first nLesion:high density(hematoma) surronded by low density(edema)（figure 7） nMass effect is often seen in CT Supplemen
19、tary findings nMRI 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 nICH and cerebral infarction can be distinguished by MRI 45 weeks,but CT can not distinguish them nEasy to detect AVM、aneurysm nComplex stages Supplementary findings nDSA：to diagnose AVM、Moyamoya disease、arteritis nCSF：eleva
20、ted pressure,consistently bloody,but not the routine examination n其他：血、尿、便常规，肝功，肾功，凝血功 能，心电图等 诊 断 依 据 n病史 n高颅压征：头痛，呕吐，血压高 早期意识障碍 n局灶性定位体征 n头颅CT：脑实质内局灶性高密度病灶 Diagnosis nSenile patients after 50 years of age nPast history of hypertension nOnset during activity nSudden onset nCT scan Differential diagn
21、osis nCerebral infarction:situation and speed of onset,blood pressure,lesion showed by CT nComa due to other causes:present illness history nInjury:history of injury nNonhypertensive hemorrhage:without history of hypertension 治 疗 原 则 n防止再出血 n降颅压 n控制血压 n防止并发症 n根据病情选择手术 Treatment medical treatment n保持
22、安静keep quiet、卧床休息rest in bed、减少 探视avoid meeting n水电解质平衡keep water_electrolyte balance 和营 养nutrition n控制脑水肿control brain edema，降低颅内压 decrease ICP:antiedema agents,e.g.mannitol n控制高血压control blood pressure: antihypertensive agents or diuretic such as furosemide n防治并发症prevent complications:rebleeding,
23、herniation, infection Treatment surgical treatment n时机：超早期 6-24小时 nIndication nContraindications n术式 Rehabilitation n尽早进行as soon as possible n抗抑郁antidepression Specific treatment nNonhypertensive hemorrhage nPoly-cerebral hemorrhage nRebleeding nUnstable cerebral hemorrhage Prognosis nThe mortality
24、in 30 days is 35%52%,half of the patients die within 2 days,due to cerebral herniation. nLarge hemorrhages of brainstem、 thalamus 、ventricle implies a poor prognosis. 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *35 （Subarachnoid Hemorrhage） 定义 各种原因引起的软脑膜血管破裂，血液流入蛛网膜下腔。 Conception nIt is an acute hemorrhagic cerebral
25、 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 nSecondary SAH：hemorrhages in brain、ventricle or epidural (subdural) space rupture into subarachnoid space nTraumatic SAH nCount for 10
26、% in stroke，for 20% in hemorrhagic stroke Etiology nCongenital aneurysm is most common etiology nAVM is a less frequent cause of SAH nHypertensive arteriosclerosis aneurysm is the third cause of SAH nMoyamoya disease is the forth cause nOthers include tumor, arteritis 病因和发病机制 Pathophysiology nCerebr
27、al artery aneurysm are most commonly congenital “berry” aneurysms, which result from developmental weakness of the vessel wall, especially at the sites of branching. nAVM are most common in the middle cerebral artery distribution. nArteritis can also play an important role in the disease. nTumor inv
28、asive the vessel wall can not be overlooked. Pathophysiology n颅内压增高increased ICP n阻塞性脑积水obstructive hydrocephalus n化学性脑膜炎aseptic meningitis下丘脑功能紊 乱 n自主神经功能紊乱dysautonimia n交通性脑积水communicating hydrocephalus n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 n85%90% of intracranial aneurysms l
29、ocate 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. n好发于Willis环动脉分叉处 n破裂频度 n血液主要沉积在脑底部、脑池 n可破入脑室致脑积水 n蛛网膜无菌性炎症反应 Clinical features nAny age of person may suffer from SAH. n T
30、he 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”. n The absence of the headache essentially precludes the diagnosis. n Loss of consciousness is frequent, as ar
31、e vomiting and neck stiffness. n Symptoms may begin at any time of day and during either rest or exertion. Clinical features nThe most significant feature of the headache is that it is new. nMilder but otherwise similar headaches may have occurred in the weeks prior to the acute event. nThese earlie
32、r headaches are probably the result of small prodromal hemorrhages (sentinel,or warning, hemorrhages) or aneurysmal stretch. Clinical features nThe 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
33、recrudescent headache usually signifies recurrent bleeding. nThere is frequently confusion, stupor, or coma. nNuchal 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. nPreretinal globular
34、subhyaloid hemorrhages (found in 20% of cases) are most suggestive of the diagnosis. Clinical features nBecause 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 relations
35、hip to the site of the aneurysm. nAn 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. nRuptured AVMs may produce focal signs, such as hemiparesis, aphasia, or a d
36、efect of the visual fields. Clinical features nInducement and aura：inducement include intensive activity、exhaustion、excitement,aura can be “warning leak” and localized sign. nSymptoms of SAH patients above 60 year old are not typical：slowly onset,headache and meningeal irritation are not obvious,wit
37、h severe consciousness disturbance,often accomplished with cardiac damage and other complications Complications nRecurrence 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 AV
38、M is less common in the acute period. nArterial 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 nAcute or subacute hydrocephalus:Acute or subacute hydroceph
39、alus 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 nSeizures: Seizures occur in fewer than 10% of cases and only fol
40、lowing damage to the cerebral hemisphere. nOthers:Although inappropriate secretion of antidiuretic hormone and resultant diabetes insidious can occur, they are uncommon. Supplementary findings nCT：patients presenting with SAH are generally investigated first by CT scan(figure 8)，which will usually c
41、onfirm 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 nCSF: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
42、 (xanthochromic), the chemical meningitis may produce pleocytosis. Supplementary findings nDSA:to detect aneurysm or AVM, it is a prerequisite to the rational planning of surgical treatment. nMRI and MRA:MRI is especially useful in detecting small AVMs localized to the brainstem (an area poorly seen
43、 on CT scan). nTCD：to determine CVS n实验室检查：血常规、凝血功能、肝功 、免疫学 Diagnosis nSymptom：the history of a sudden severe headache with confusion or obtundation nSign：nuchal rigidity, a nonfocal neurologic examination nCSF：bloody spinal fluid nFundus oculi：preretinal globular subhyaloid hemorrhages nCT findings
44、 鉴 别 诊 断 n脑出血 n颅内感染 Differential diagnosis nHypertensive intracranial hemorrhage： there are prominent focal findings. nIntracranial infection:it is excluded by the CSF examination. nTumor stroke or metastasis:they can be distinguished from SAH by evidence of tumor. nNon-typical SAH Principle of trea
45、tment n控制继续出血control active hemorrhage n防治迟发性CVS prevent tardive CVS n去除病因eliminate etiology n防止复发prevent recurrence Treatment medical treatment n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 exc
46、eption. n降颅压decrease ICP：antiedema agents eg.mannitol or surgical decompression n防治再出血prevent recurrence：PAMBA n防治迟发CVS prevent tardive CVS ：calcium channel antagonist drug e.g. nimodipine nCSF置换CSF exchange：it can remove red cells,since the procedure may be accomplished with some complications, it
47、should be used carefully. Treatment surgical treatment nOpportunity of operation：2472 hours after hemorrhage nSubject to operation n术式 n血管内介入治疗、-刀治疗 Prognosis nThe probability of survival following aneurysmal rupture is related to the patient s state of consciousness and the elapsed time since the hemorrhage. nHunt grade：gradehave a good outcome,grade have a poor one,grade have a moderate one. nMain cause of death ：including recurrence of hemorrhage、tardive CVS nMain commemorstive sign：may be cognitive impairment