读书报告小脑出血

小脑出血,汇报人：李达导师：刘春风教授,病例分析,患者，女 ，78岁，因头痛、视物旋转伴呕吐2小时入院。发病后至我急诊科就诊。查体：脉搏70次/分呼吸24次/分，血压 190/100mmHg，意识清楚，语言清晰，对答切题，头颅五官无畸形，双侧瞳孔等大等圆，直径3.0mm对光反射灵敏 .心肺腹未见异常。四肢活动自如，肌张力正常，肌力V级，腱反射对称（+） ，Romberg征因未能站立而拒绝检查感觉系统正常无锥体束征血常规：WBC 17.8xl06、N 91.6，肝功能、肾功能、电解质、血脂检查正常。,病例分析,诊断为：眩晕症：高血压危象。而给予甘露醇、脑复康、奥美拉唑、脱水、营养脑细胞、保护粘膜治疗，入院后有少量呕血，加用止血药物治疗。治疗3天后，血压下降，但仍有明显视物旋转，转头或翻身即可出现，且伴呕吐。考虑存在颅内病变，而行头颅CT检查示：右侧小脑半球出血，出血量约为16.6ml。修正诊断为右侧小脑半球出血。加强脱水、脑细胞营养等治疗，1个月后，出血吸收，症状好转治愈出院 。,林忠如，小脑出血误诊为眩晕症1例，中国误诊学杂志，2011年7月,非典型小脑出血鉴别,1、椎基底动脉供血不足：头晕、呕吐、眼震等症状，部分患者反复发作。2、原发性蛛网膜下腔出血：小脑半球靠近表面出血破入蛛网膜下腔，故以头痛、呕吐、脑膜刺激征为首发症状，血肿扩大后方出现小脑症状；伴有意识障碍，患者不能配合共济运动检查。3、脑干卒中或脑室出血：部分患者血肿向前压迫脑干至昏迷，眼位异常，或破入脑室。,共济失调分类,深感觉性共济失调：明亮的地方不明显，黑暗环境或闭眼时明显（躯干和四肢）；Romberg征阳性；步态异常；踩棉花感；步幅较大，脚间距宽，踵步（抬足较高，跨步大小不一，足跟用力着地，并产生拍击地面的声音）前庭性共济失调：共济失调以平衡障碍为主，表现站立不稳，行走时向病侧倾倒，改变头位症状加重，眩晕、眼球震颤明显Romberg 征,各类共济失调临床表现,大脑性共济失调：共济失调比较轻；常伴有病理征阳性及其他定位体征小脑性共济失调：四肢或躯干的共济失调Romberg征阴性步态不稳（醉汉步态）意向性震颤言语：吟诗样，声音时断时续，爆发性等肌张力减低（钟摆运动）、反击征阳性,小 脑 cerebellum,* 后颅窝* 大脑后下* 脑干后* 借三对小脑脚与 脑干相连接,位置,原裂,蚓部,小脑半球,小脑中脚,绒球,小结,小脑扁桃体tonsil of c.,上面观,下面观,蚓部 vermis半球,：小脑上脚 小脑中脚 小脑下脚 小脑扁桃体,外形,前叶后叶绒球小结叶flocculonodular lobe,分叶分部,后外侧裂,小脑体,蚓部中间部外侧部,皮质 cortex髓体小脑核,顶核 fastigal中间核齿状核 dentate,球状核 globose栓状核 emboliform,内部结构,小脑的主要纤维联系和功能,机能分区 主要传入自 相关小脑核 主要传至 功 能前庭小脑 前庭感受器 前庭N核 维持 前庭N核 平衡,脊髓小脑 脊髓小脑束 顶核 前庭N核 调节肌 网状结构 张力和,大脑小脑 大脑皮质 齿状核 丘脑 调节随 脑桥核 大脑皮质 意运动、 运动起始,中间核 红核丘脑 协调运动,小脑的血液供应：来自椎基底动脉三对动脉：小脑上动脉 小脑前下动脉 小脑后下动脉,小脑的血管供应,小脑血管,侧面观,小脑血管供血区,图片来源：奈特神经解剖图谱,小脑前下动脉,小脑后下动脉,小脑前下动脉,小脑后下动脉,小脑上动脉,小脑后下动脉,小脑上动脉,基底动脉-大脑后动脉,Reviewed non-traumatic cerebellar haemorrhage between 1927 and 2011 including 1579 patients.,Cerebellar haemorrhages,Cerebellar haemorrhages constitute approximately 10% of all intracerebral haemorrhages (ICH), about 15% of cerebellar strokes. Caused by tumour, vascular malformation or aneurysm，trauma， but mostly，primary cerebellar haemorrhage (PCH) Requires timely diagnosis and prompt therapeutical decision-making.,Flaherty ML, Woo D, Haverbusch M, Sekar P, Khoury J, Sauerbeck L, et al.Racial variations in location and risk of intracerebral hemorrhage. Stroke 2005;36:9347,CT scan of a right hemispheric cerebellar haematoma in a 51 year old women with a history of headache 30 min before admission. On admission she was drowsy but orientated (GCS 13).,CT scan of a 78-year old patient who waslast seen healthy 2 h before admission.20 min before admission he was found comatose (GCS 3), brain stem reflexes were absent, and Babinski-signs were positive on both sides. CT scan shows a massive cerebellar haematoma involving both hemispheres,患者，男，68岁因“头晕伴恶心呕吐6.5小时”入院。既往：高血压病史10余年，未服药控制。3年前有“脑出血”病史，遗留左肢拖步。查体：神志清，瞳孔等大光敏，双眼右侧凝视，可及水平眼震，左侧中枢性面舌瘫，四肢肌力尚可，左侧指鼻试验完成差，双侧巴氏征未引出。治疗：甘露醇+速尿q4h交替，控制血压。经治疗2周后，病情较平稳，但出血未完全吸收，要求自动出院。,Complications,brainstem compression 脑干压迫upward or downward herniation 脑疝Hydrocephalus 脑积水,a 60 year old woman Blood is present in the 4th, 3rd and the lateral ventricles. The temporal horns of the lateral ventricles are dilated, indicating hydrocephalus. suboccipital osteoplastic craniotomy external ventricular drain placement,四叠体池消失对脑积水出现有强烈的提示作用,Conservative therapy,Decrease of intracranial pressure（ICP）：elevation of the head by 15 to 30 degree，hyperventilation, osmotherapy, administration of barbiturates巴比妥类.,Surgical therapy,Ventricular drainage脑室引流Suboccipital craniectomy枕骨下去骨瓣minimally invasive hematoma removal 微创血肿清除术,outcome,脑室切开引流,Mortality in patients with primary cerebellar haemorrhage,Clinical outcome in survivors of primary cerebellar haemorrhage,Glasgow outcome scale (GOS) ：5 ，4，2-3modified Rankin scale (mRS) : 0-2，3，4-5,Kobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of hypertensive cerebellar hemorrhage surgical or conservative management? Neurosurgery 1994;34:24650, discussion 250241.Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery 2001;49:137886, discussion 138677Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D. Neurosurgical management of cerebellar haematoma and infarct. Journal of Neurology, Neurosurgery and Psychiatry 1995;59:28792,脑干反射存在BAEP/SEP正常,脑干反射消失病理BAEP/SEP,recommendation,1. For most patients with ICH, the usefulness of surgery is uncertain(Class IIb; Level of Evidence: C).(New recommendation) Specific exceptions to this recommendation follow2. Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compressionand/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible(Class I; Level of Evidence: B).(Revised from the previous guideline) Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended(Class III; Level of Evidence: C).(New recommendation)3. For patients presenting with lobar clots30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered(Class IIb; Level of Evidence: B).(Revised from the previous guideline)4. The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational (Class IIb; Level of Evidence: B).(New recommendation)5. Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding(Class III; Level of Evidence: B).(Revised from the previous guideline),脑出血选择手术指证,1.对于大多数ICH患者而言，手术的作用尚不确定。（b C）2.小脑出血伴神经功能恶化、脑干受压和/或脑室梗阻致脑积水者应尽快手术清除血肿。（ B）不推荐以脑室引流作为该组患者的初始治疗。（ C）3.脑叶出血超过30ml且血肿距皮层表面1cm以内者，可考虑开颅清除幕上血肿。