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1、(Cerebral Hemorrhage),定义： 指非外伤性脑实质内出血,脑 出 血,Department of Neurology, The 2nd affiliated hospital, Kunming Medical college,Conception,It means primary and nontraumatic intracerebral hemorrhage. Count for 20%30% in stroke Hypertension is the most common underlying cause of nontraumatic intracerebral h
2、emorrhage.,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
3、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
4、外侧支称为出血动脉bleeding artery,Pathophysiology,一次出血常在30min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% Loca
5、tion 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
6、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,临 床 表 现,一般症状：中年以上发病。起病突然， 动态起病，病势凶险。 高颅压征 intracranial hype
7、rtension 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 神经系统定位体征： 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 hem
8、orrhage,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 marke
9、d sensory disturbance (hemianesthesia).,Clinical features basal 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 stari
10、ng at the tip of the nose, because of impingement on the midbrain center for upward gaze.,Clinical features basal 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 he
11、morrhages lead to lacunar syndrome.,Clinical features basal 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 features pontine hemorrhage,With bleeding into the pons(figure 3), coma occur
12、s 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 features pontine hemorrhag
13、e,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 fix
14、ed pupils is common.,Clinical features midbrain hemorrhage,Midbrain hemorrhage is rarely seen in clinic. The patients often manifest Weber syndrome. Large hemorrhages may lead to coma and flaccid paralysis.,Clinical features cerebellar hemorrhage,小脑齿状核动脉破裂 The distinctive symptoms of cerebellar hemo
15、rrhage(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 features lobar hemo
16、rrhage,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, hem
17、iparesis, hemisensory deficits, aphasia, and visual field abnormalities. Seizures are more frequent than with hemorrhages in other locations, while coma is less so.,Clinical features cerebral 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 symp
18、toms 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
19、 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、Moyamoy
20、a 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,诊 断 依 据,病史 高颅压征：头痛，呕吐，血压高 早期意识障碍 局灶性定位体征 头颅CT：脑实质内局灶性高密度病灶,Diagnosis,Senile patients after 50 years of age Past history of hypertension Onset during activity Sudden onset CT scan,
21、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,治 疗 原 则,防止再出血 降颅压 控制血压 防止并发症 根据病情选择手术,Treatment medical trea
22、tment,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decrease ICP:antiedema agents,e.g.mannitol 控制高血压control blood pressure: antihypertensive agents or diuretic such as furosemide 防治并发症prevent complications:rebleeding,
23、 herniation, infection,Treatment surgical 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
24、 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.,（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。,蛛网膜下腔出血,Conception,It is an acute hemorrhagic cerebral vascular disease in which vessels o
25、n 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 stro
26、ke,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,病因和发病机制,Pathophysiology,Cerebral artery aneurysm are most commonly congenit
27、al “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.,Pat
28、hophysiology,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 si
29、ngle,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
30、 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
31、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 (sentin
32、el,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 freque
33、ntly 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 diag
34、nosis.,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 occurri
35、ng 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 incl
36、ude 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
37、 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,
38、 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
39、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 an
40、tidiuretic 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
41、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
42、: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 sud
43、den 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,鉴 别 诊 断,脑出血 颅内感染,Differential diagnosis,Hypertensive intracranial hemorrhage：there are prominent focal
44、 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 recurren
45、ce,Treatment medical 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CV
46、S 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.,Treatment surgical treatment,Opportunity of operation：2472 hours after hemorrhage Subject to
47、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：gradehave 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,