(CerebralHemorrhage)脑出血定义和鉴别诊断

1、(Cerebral Hemorrhage)脑 出 血定义和鉴别诊断ConceptionIt means primary and nontraumatic intracerebral hemorrhage.Count for 20%30% in strokeHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.EtiologyHalf of the patients suffer from hypertension combined with arteriolar ath

2、erosclerosis, 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a

3、ngio-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 h

4、emorrhage或早期再出血early rebleeding多发性脑出血常继发于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis PathologyHypertensive 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%Location 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 ve

5、ntriclePathologyHypertensive ICH：cerebral penetrating artery miliary aneurysmNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosisPathologySwelling and congestion of 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 featuresage：5070 yea

6、rs oldsex：more male patientsseason：winter or springpast history：hypertensioninducement：activity、excitementonset：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 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 hemipl

7、egia 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 featuresbasal ganglion hemorrhageThe two most common sites of hypertensive hemorrhage are the putamen(figure 1) and thalamus(figure 2), which are separated

8、 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 marked sensory disturbance (hemianesthesia). Clinical featuresbasal ganglion hemorrhage Homonymous hemianopia may occur as a transient

9、phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage. In large thalamic hemorrhages, the eyes may deviate downward, as in staring at the tip of the nose, because of impingement on the midbrain center for upward gaze. Clinical featuresbasal ganglion hemorrhag

10、eAphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas. Large hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.Clinical featuresbasal 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

11、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 featurespontine hemorrhage With bleeding into the pons(figure 3), coma occurs within seconds to minutes and usually leads to death within 48 hours. Ocular findings typically include pinpoint pupils. Horizontal eyes

12、movements are absent or impaired, but vertical eye movements may be preserved. In some patients, there may be ocular bobbing.Clinical featurespontine hemorrhagePatients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometim

13、es present. The hemorrhage usually ruptures into the forth ventricle, and rostral extension of the hemorrhage into the midbrain with resultant midposition fixed pupils is common. Clinical featuresmidbrain hemorrhageMidbrain hemorrhage is rarely seen in clinic.The patients often manifest Weber syndro

14、me.Large hemorrhages may lead to coma and flaccid paralysis.Clinical featurescerebellar hemorrhage小脑齿状核动脉破裂The distinctive symptoms of cerebellar hemorrhage(figure 4) are severe headache, dizziness, vomiting, and the inability to stand or walk, but strength in the limbs is normal.Large hemorrhages l

15、ead to coma within 12 hours in 75% of patients and within 24 hours in 90%.They may lead to compression of the brainstem.Clinical featureslobar hemorrhageEtiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumorHypertensive hemorrhages also occur in subcortical white matter underlying the front

16、al,parietal, temporal, and occipital lobes(figure 5).Symptoms and signs vary according to the location; they can include headache, vomiting, hemiparesis, hemisensory deficits, aphasia, and visual field abnormalities.Seizures are more frequent than with hemorrhages in other locations, while coma is l

17、ess so.Clinical featurescerebral 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 symptoms 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.Supple

18、mentary findingsCT computerized tomography is chosen firstLesion:high density(hematoma) surronded by low density(edema)（figure 7）Mass effect is often seen in CTSupplementary findingsMRI 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CTICH and cerebral infarction can be distinguished by MRI 45 w

19、eeks,but CT can not distinguish themEasy to detect AVM、aneurysmComplex stagesSupplementary findingsDSA：to diagnose AVM、Moyamoya disease、arteritisCSF：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Di

20、agnosisSenile patients after 50 years of agePast history of hypertensionOnset during activitySudden onset CT scanDifferential diagnosisCerebral infarction:situation and speed of onset,blood pressure,lesion showed by CTComa due to other causes:present illness historyInjury:history of injuryNonhyperte

21、nsive 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Treatmentmedical treatment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，降低颅内压控制高血压control blood pressure: antihypertensive agents or diuretic su

22、ch as furosemide防治并发症prevent complications:rebleeding, herniation, infectionTreatmentsurgical 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antidepressionSpecific treatmentNonhypertensive hemorrhagePoly-cerebral hemorrhage RebleedingUnstable cerebral he

23、morrhagePrognosisThe mortality in 30 days 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 ConceptionIt is an acute hemorrhagic cerebral

24、 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 SAHSecondary SAH：hemorrhages in brain、ventricle or epidural (subdural) space rupture into subarachnoid spaceTraumatic SAHCount for 10% in s

25、troke，for 20% in hemorrhagic strokeEtiologyCongenital aneurysm is most common etiologyAVM is a less frequent cause of SAHHypertensive arteriosclerosis aneurysm is the third cause of SAHMoyamoya disease is the forth causeOthers include tumor, arteritis 病因和发病机制 PathophysiologyCerebral artery aneurysm

26、are most commonly congenital “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

27、 not be overlooked.Pathophysiology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 Pathology85%90% of intracranial aneurysms locate anterior in the circle of Willis,the

28、y are mainly single,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 featuresAny age of person may suffer from SAH. The classic (but not invariable) presentation of SAH is th

29、e sudden 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

30、 of day and during either rest or exertion. Clinical featuresThe 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

31、(sentinel,or warning, hemorrhages) or aneurysmal stretch.Clinical featuresThe 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 fr

32、equently 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

33、diagnosis. Clinical featuresBecause 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 occu

34、rring 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 featuresInducement and aura：inducement in

35、clude 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 othe

36、r complicationsComplicationsRecurrence 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, t

37、ermed vasospasm, occurs in vessels surrounded by subarachnoid blood and can lead to parenchymal ischemia in more than one- third of cases. ComplicationsAcute or subacute hydrocephalus:Acute or subacute hydrocephalus may develop during the first day- or after several weeks-as a result of impaired CSF

38、 absorption in the subarachnoid space. Progressive somnolence, nonfocal findings, and impaired upgaze should suggest the diagnosis.ComplicationsSeizures: Seizures occur in fewer than 10% of cases and only following damage to the cerebral hemisphere. Others:Although inappropriate secretion of antidiu

39、retic hormone and resultant diabetes insidious can occur, they are uncommon. Supplementary findingsCT：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仅显示脚间池少量出血

40、，向中脑环池、外侧裂池基底扩散，称非动脉瘤性SAH nA-SAHCSF: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 findingsDSA:to detect aneurysm or AVM, it is a prerequisite to the rational planning of surgical treatment.MRI and MRA:MRI is especially useful in detectin