(CerebralHemorrhage)定義：指非外傷性腦實質內出血腦出血DepartmentofNeurology,The2ndaffiliatedhospital,KunmingMedicalcollege編輯pptConceptionItmeansprimaryandnontraumaticintracerebralhemorrhage.Countfor20%~30%instrokeHypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage.編輯pptEtiologyHalfofthepatientssufferfromhypertensioncombinedwitharteriolaratherosclerosis,itisthemostcommoncauseofthedisease.Others：cerebralatherosclerosis,hematopathy,

cerebralamyloidangiopathyCAA,aneurysm,AVM編輯pptPathophysiology高血壓——小動脈：纖維素樣壞死fibrinoidnecrosis、脂質透明變性hyalinefattychange、microaneurysm小動脈瘤、微夾層動脈瘤——滲出exudation、破裂rupture高血壓——遠端血管痙攣vasospasm——缺氧anoxia、壞死angio-necrosis、血栓形成thrombosis——斑點狀出血、腦水腫brainedema——融合成片(子癇)編輯pptPathophysiology腦內動脈：壁薄、中層肌細胞及外膜結締組織少、缺乏外彈力層——隨年齡增長彎曲呈螺旋狀——出血主要部位：深穿支penetratingarteries豆紋動脈lenticulostriateartery：大腦中動脈呈直角分出，易發生粟粒狀動脈瘤，為腦出血最好發部位，其外側支稱為出血動脈bleedingartery編輯pptPathophysiology一次出血常在30min內停止頭CT動態觀察：20%-40%患者24小時內血腫仍繼續擴大，為活動性出血activehemorrhage或早期再出血earlyrebleeding多發性腦出血常繼發于：hematopathy,cerebralamyloidangiopathy,neoplasm,vasculitis編輯pptPathologyHypertensiveICH：基底節的內囊區intercapsule、殼核putamen占70%，腦葉lobe、腦干brainstem、小腦齒狀核區各占10%LocationofICH：殼核〔內囊、側腦室〕，丘腦thalamus〔第三腦室、內囊、側腦室〕，腦橋pons、小腦cerebellum、蛛網膜下腔subarachnoidspace、第四腦室forthventricle編輯pptPathologyHypertensiveICH：cerebralpenetratingarterymiliaryaneurysmNonHypertensiveICH：occurinsubcorticalwhitematterwithoutarteriosclerosis編輯pptPathologySwellingandcongestionofhemisphere出血灶：充滿血液的空腔，周圍是壞死腦組織及淤點狀出血性軟化帶、腦水腫血塊溶解——吞噬細胞去除含鐵血黃素和壞死腦組織——膠質增生〔膠質瘢痕或中風囊〕編輯pptClinicalfeaturesage：50~70yearsoldsex：moremalepatientsseason：winterorspringpasthistory：hypertensioninducement：activity、excitementonset：acuteonset編輯ppt臨床表現一般病癥：中年以上發病。起病突然，動態起病，病勢兇險。高顱壓征intracranialhypertensionsign頭痛，嘔吐，血壓升高，脈搏減慢，視乳頭水腫，意識障礙易形成腦疝cerebralherniation神經系統定位體征：取決于血腫的部位、體積

編輯ppt局灶性神經功能缺損基底節區：內囊“三偏征〞偏癱hemiplegia偏盲hemiscotosis偏身感覺障礙hemihypesthesia腦葉額葉顳葉頂葉枕葉各具不同缺損腦干交叉性癱瘓hemiplegiaalternate小腦眩暈vertigo共濟失調ataxia編輯ppt基底節區的血液供給豆紋動脈的破裂成因編輯pptClinicalfeatures

basalganglionhemorrhageThetwomostcommonsitesofhypertensivehemorrhagearetheputamen(figure1)andthalamus(figure2),whichareseparatedbytheposteriorlimboftheinternalcapsule.Ingeneral,putaminalhemorrhageleadstoamoreseveremotordeficit(hemiplegia)andthalamichemorrhagetoamoremarkedsensorydisturbance(hemianesthesia).編輯pptClinicalfeatures

basalganglionhemorrhage

Homonymoushemianopiamayoccurasatransientphenomenonafterthalamichemorrhageandisoftenapersistentfindinginputaminalhemorrhage.Inlargethalamichemorrhages,theeyesmaydeviatedownward,asinstaringatthetipofthenose,becauseofimpingementonthemidbraincenterforupwardgaze.編輯pptClinicalfeatures

basalganglionhemorrhageAphasiamayoccurifhemorrhageateithersiteexertspressureonthecorticallanguageareas.Largehemorrhagesmayleadtoconsciousnessdisturbance,whileminorhemorrhagesleadtolacunarsyndrome.編輯pptClinicalfeatures

basalganglionhemorrhage丘腦出血thalamushemorrhage:丘腦膝狀動脈、穿通動脈破裂，表現為三偏病癥，不同于殼核之處為均等癱、深淺感覺障礙、特征性眼征、意識障礙重、中線病癥等尾狀核頭出血caputnucleicaudatihemorrhage:少見，僅見腦膜刺激征編輯pptClinicalfeatures

pontinehemorrhage

Withbleedingintothepons(figure3),coma

occurswithinsecondstominutesandusuallyleadstodeathwithin48hours.Ocularfindingstypicallyincludepinpointpupils.Horizontaleyesmovementsareabsentorimpaired,butverticaleyemovementsmaybepreserved.Insomepatients,theremaybeocularbobbing.編輯pptClinicalfeatures

pontinehemorrhagePatientsarecommonlyquadripareticorhemiplegiaalternateandexhibitdecerebrateposturing.Hyperthermia,respirationdisorderissometimespresent.Thehemorrhageusuallyrupturesintotheforthventricle,androstralextensionofthehemorrhageintothemidbrainwithresultantmidpositionfixedpupilsiscommon.編輯pptClinicalfeatures

midbrainhemorrhageMidbrainhemorrhageisrarelyseeninclinic.ThepatientsoftenmanifestWebersyndrome.Largehemorrhagesmayleadtocomaandflaccidparalysis.編輯pptClinicalfeatures

cerebellarhemorrhage小腦齒狀核動脈破裂Thedistinctivesymptomsofcerebellarhemorrhage(figure4)aresevereheadache,dizziness,vomiting,andtheinabilitytostandorwalk,butstrengthinthelimbsisnormal.Largehemorrhagesleadtocomawithin12hoursin75%ofpatientsandwithin24hoursin90%.Theymayleadtocompressionofthebrainstem.編輯pptClinicalfeatures

lobarhemorrhageEtiology：AVM、Moyamoyadisease、cerebralamyloidangiopathy、tumorHypertensivehemorrhagesalsooccurinsubcorticalwhitematterunderlyingthefrontal,parietal,temporal,andoccipitallobes(figure5).Symptomsandsignsvaryaccordingtothelocation;theycanincludeheadache,vomiting,hemiparesis,hemisensorydeficits,aphasia,andvisualfieldabnormalities.Seizuresaremorefrequentthanwithhemorrhagesinotherlocations,whilecomaislessso.編輯pptClinicalfeatures

cerebralventriculushemorrhage脈絡叢plexuschorioideus動脈或室管膜下動脈破裂(figure6)Globalsymptomsareobvious，butlocalsymptomsarenot.Thepatientsmayhaveafullrecoveryandagoodoutcome.Largehemorrhagesmayleadtocoma,vomiting,pinpointpupils,impliesapooroutcome.編輯pptSupplementaryfindingsCTcomputerizedtomographyischosenfirstLesion:highdensity(hematoma)surrondedbylowdensity(edema)〔figure7〕MasseffectisoftenseeninCT編輯pptSupplementaryfindingsMRImagneticresonanceimage急性期對幕上及小腦出血顯示不如CT，對腦干出血顯示優于CTICHandcerebralinfarctioncanbedistinguishedbyMRI4~5weeks,butCTcannotdistinguishthemEasytodetectAVM、aneurysmComplexstages編輯pptSupplementaryfindingsDSA：todiagnoseAVM、Moyamoyadisease、arteritisCSF：elevatedpressure,consistentlybloody,butnottheroutineexamination其他：血、尿、便常規，肝功，腎功，凝血功能，心電圖等編輯ppt診斷依據病史高顱壓征：頭痛，嘔吐，血壓高早期意識障礙局灶性定位體征頭顱CT：腦實質內局灶性高密度病灶編輯pptDiagnosisSenilepatientsafter50yearsofagePasthistoryofhypertensionOnsetduringactivitySuddenonsetCTscan編輯pptDifferentialdiagnosisCerebralinfarction:situationandspeedofonset,bloodpressure,lesionshowedbyCTComaduetoothercauses:presentillnesshistoryInjury:historyofinjuryNonhypertensivehemorrhage:withouthistoryofhypertension編輯ppt治療原那么防止再出血降顱壓控制血壓防止并發癥根據病情選擇手術編輯pptTreatment

medicaltreatment保持安靜keepquiet、臥床休息restinbed、減少探視avoidmeeting水電解質平衡keepwater_electrolytebalance和營養nutrition控制腦水腫controlbrainedema，降低顱內壓decreaseICP:antiedemaagents,e.g.mannitol控制高血壓controlbloodpressure:antihypertensiveagentsordiureticsuchasfurosemide防治并發癥preventcomplications:rebleeding,herniation,infection編輯pptTreatment

surgicaltreatment時機：超早期6-24小時IndicationContraindications術式編輯pptRehabilitation盡早進行assoonaspossible抗抑郁antidepression編輯pptSpecifictreatmentNonhypertensivehemorrhagePoly-cerebralhemorrhageRebleedingUnstablecerebralhemorrhage編輯pptPrognosisThemortalityin30daysis35%~52%,halfofthepatientsdiewithin2days,duetocerebralherniation.Largehemorrhagesofbrainstem、thalamus、ventricleimpliesapoorprognosis.編輯ppt〔SubarachnoidHemorrhage〕定義各種原因引起的軟腦膜血管破裂，血液流入蛛網膜下腔。蛛網膜下腔出血編輯ppt

ConceptionItisanacutehemorrhagiccerebralvasculardiseaseinwhichvesselsonsurfaceofbrainandspinalcordrupturesuddenlyduetomanycauses,bloodflowintothesubarachnoidspace,calledprimarySAHSecondarySAH：hemorrhagesinbrain、ventricleorepidural(subdural)spaceruptureintosubarachnoidspaceTraumaticSAHCountfor10%instroke，for20%inhemorrhagicstroke編輯pptEtiologyCongenitalaneurysmismostcommonetiologyAVM

isalessfrequentcauseofSAHHypertensivearteriosclerosisaneurysmisthethirdcauseofSAHMoyamoyadiseaseistheforthcauseOthersincludetumor,arteritis編輯ppt病因和發病機制編輯pptPathophysiologyCerebralarteryaneurysmaremostcommonlycongenital“berry〞aneurysms,whichresultfromdevelopmentalweaknessofthevesselwall,especiallyatthesitesofbranching.AVMaremostcommoninthemiddlecerebralarterydistribution.Arteritiscanalsoplayanimportantroleinthedisease.Tumorinvasivethevesselwallcannotbeoverlooked.編輯pptPathophysiology顱內壓增高increasedICP阻塞性腦積水obstructivehydrocephalus化學性腦膜炎asepticmeningitis下丘腦功能紊亂自主神經功能紊亂dysautonimia交通性腦積水communicatinghydrocephalus血管活性物質致血管痙攣vascularspasm、蛛網膜顆粒粘連、甚至腦梗死、正常顱壓腦積水編輯pptPathology85%~90%ofintracranialaneurysmslocateanteriorinthecircleofWillis,theyaremainlysingle,theyaremultipleinabout10%—20%ofcases,locatingintheoppositesiteofthesamevessel,calledmirroraneurysm.好發于Willis環動脈分叉處破裂頻度血液主要沉積在腦底部、腦池可破入腦室致腦積水蛛網膜無菌性炎癥反響編輯pptClinicalfeaturesAnyageofpersonmaysufferfromSAH.Theclassic(butnotinvariable)presentationofSAHisthesuddenonsetofanunusuallyseveregeneralizedheadache,patientsoftendescribeitas“theworstheadacheIeverhadinmylife〞.Theabsenceoftheheadacheessentiallyprecludesthediagnosis.Lossofconsciousnessisfrequent,asarevomitingandneckstiffness.Symptomsmaybeginatanytimeofdayandduringeitherrestorexertion.編輯pptClinicalfeaturesThemostsignificantfeatureoftheheadacheisthatitis

new.

Milderbutotherwisesimilarheadachesmayhaveoccurredintheweekspriortotheacuteevent.Theseearlierheadachesareprobablytheresultofsmallprodromalhemorrhages(sentinel,orwarning,hemorrhages)oraneurysmalstretch.編輯pptClinicalfeaturesTheheadacheisnotalwayssevere,buttheintensityoftheheadachemayremainunchangedforseveraldaysandsubsideonlyslowlyoverthenext2weeks.Arecrudescentheadacheusuallysignifiesrecurrentbleeding.Thereisfrequentlyconfusion,stupor,orcoma.Nuchalrigidityandotherevidenceofmeningealirritationarecommon.Meningealirritationmayinducetemperatureelevationstoashighas39℃duringthefirst2weeks.Preretinalglobularsubhyaloidhemorrhages(foundin20%ofcases)aremostsuggestiveofthediagnosis.編輯pptClinicalfeaturesBecausebleedingoccursmainlyinthesubarachnoidspaceinpatientswithaneurysmalrupture,prominentfocalsignsareuncommononneurologicexamination.Whenpresent,theymaybearnorelationshiptothesiteoftheaneurysm.Anexceptionisoculomotornervepalsyoccurringipsilateraltoaposteriorcommunicatingarteryaneurysm.Bilateralextensorplantarresponsesandⅵnervepalsiesarefrequentinsuchcases.RupturedAVMsmayproducefocalsigns,suchashemiparesis,aphasia,oradefectofthevisualfields.編輯ppt

ClinicalfeaturesInducementandaura：inducementincludeintensiveactivity、exhaustion、excitement,auracanbe“warningleak〞andlocalizedsign.SymptomsofSAHpatientsabove60yearoldarenottypical：slowlyonset,headacheandmeningealirritationarenotobvious,withsevereconsciousnessdisturbance,oftenaccomplishedwithcardiacdamageandothercomplications編輯pptComplicationsRecurrenceofhemorrhage:Recurrenceofaneurysmalhemorrhage(20%over10-14days)isthemajoracutecomplicationandroughlydoublesthemortalityrate.RecurrenceofhemorrhagefromAVMislesscommonintheacuteperiod.Arterialvasospasm:Delayedarterialnarrowing,termedvasospasm,occursinvesselssurroundedbysubarachnoidbloodandcanleadtoparenchymalischemiainmorethanone-thirdofcases.編輯pptComplicationsAcuteorsubacutehydrocephalus:Acuteorsubacutehydrocephalusmaydevelopduringthefirstday-orafterseveralweeks-asaresultofimpairedCSFabsorptioninthesubarachnoidspace.Progressivesomnolence,nonfocalfindings,andimpairedupgazeshouldsuggestthediagnosis.編輯pptComplicationsSeizures:Seizuresoccurinfewerthan10%ofcasesandonlyfollowingdamagetothecerebralhemisphere.Others:Althoughinappropriatesecretionofantidiuretichormoneandresultantdiabetesinsidiouscanoccur,theyareuncommon.編輯ppt

SupplementaryfindingsCT：patientspresentingwithSAHaregenerallyinvestigatedfirstbyCTscan(figure8)，whichwillusuallyconfirmthathemorrhagehasoccurredandmayhelptoidentifyafocalsource.約15%患者CT僅顯示腳間池少量出血，向中腦環池、外側裂池基底擴散，稱非動脈瘤性SAHnA-SAHCSF:ifCTscanfailstoconfirmtheclinicaldiagnosis,lumberpunctureisperformed.Thefluidisgrosslybloody,thesupernatantofthecentrifugedCSFbecomesyellow(xanthochromic),thechemicalmeningitismayproducepleocytosis.編輯pptSupplementaryfindingsDSA:todetectaneurysmorAVM,itisaprerequisitetotherationalplanningofsurgicaltreatment.MRIandMRA:MRIisespeciallyusefulindetectingsmallAVMslocalizedtothebrainstem(anareapoorlyseenonCTscan).TCD：todetermineCVS實驗室檢查：血常規、凝血功能、肝功、免疫學編輯pptDiagnosisSymptom：thehistoryofasuddensevereheadachewithconfusionorobtundationSign：nuchalrigidity,anonfocalneurologicexaminationCSF：bloodyspinalfluidFundusoculi：preretinalglobularsu