神经内科英文课件脑出血

1、Cerebral hemorrhage脑出血Etiology and pathogenesis Hypertension and arteriosclerosisAtherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumorlenticulostriate arteries vertical to MCAMicroaneurysms rupture Patholog

2、y Site: basal ganglia (70%), brain lobe, brain stem, cerebellumLateral hemorrhage: the bleeding is confined lateral to the internal capsule (lenticular nucleus, external capsule) Medial hemorrhage: thalamus hematoma edema herniation hematoma stroke capsuleClinical featureAge: 50-70Male femaleOccur a

3、t physical exertion or excitementSudden onset of focal signsUsually accompanied by headache and vomiting May have consciousness disturbance1. Putamen hemorrhagecontralateral hemiplegia, hemianesthesia, and hemianopiaEyes are frequently deviated toward the side of the affected hemisphereAphasia if do

4、minant hemisphere is affectedClinical feature2. Thalamus hemorrhage contralateral hemiplegia, hemianesthesia, and hemianopiaDeep sensation disturbanceOcular signsDisturbance of consciousness Clinical feature3. Pontine hemorrhageMild: crossed paralysisSevere (5ml) coma pinpoint pupils hyperpyrexia te

5、traplegia die in 48 hoursClinical feature4. Cerebellar hemorrhageOccipital headache, intense vertigo and repeated vomiting, ataxia, nystagmusSevere cerebellar hemorrhage : coma, compression of brain stem, tonsillar herniationClinical feature5. Lobar hemorrhageSeen in AVM, Moyamoya disease, Headache,

6、 vomiting, neck stiffnessSeizureFocal signsClinical featureInvestigation 1. CTFirst choiceHigh density bloodMass effect and edemaHigh density isodensity low density2. MRIBrain stem hemorrhage50, with hypertensionSudden onset of headache, vomiting, focal signOccur at physical exertion or excitementCT

7、: high density bloodDifferential diagnosisComa: poisoning, hypoglycemia, hepatic or diabetic comaFocal signs: cerebral infarction, brain tumor, subdural hematoma, SAHTreatment 1.Keep rest, monitoring, air way, good nursing2. Keep electrolytes and fluid balance.3. Reduce ICP: 20% Mannitol 125-250ml,

8、3 to 4 times per dayFurosemide, albumin, dexamathasone 4. Control hypertension: 40-50 ml, deterioratingCerebellum: 15ml, diameter3cmThalamus: obstructive hydrocephalus ventricular drainage 7. Rehabilitation Treatment Subarachnoid hemorrhageSAHSAH Cranial bone dura mater arachnoid pia mater brain lob

9、ePrimary spontaneous SAHTraumatic SAHSecondary to cerebral hemorrhageEtiology 1. Intracranial saccular aneurysm 2. AVM (arteriovenous malformation) 3. Hypertension and atherosclerosis4. Moyamoya disease5. Mycotic aneurysm, tumor, polyarteritis nodasa, bleeding diseasePathology Anterior cerebral and

10、anterior communicating Internal carotid Middle cerebralBasilar Clinical feature1. Age of onset: Saccular aneurysm: adult 30-60AVM: juvenile Hypertension: more than 602. Prodromal symptomsWarning leaks: headache, vomitingCranial nerve paralysis: oculomotor3. Acute SAHSudden onset of severe headache:

11、“explode, burst, the worst of my life”VomitingAssociated with physical exertion, excitementTransient loss of consciousness or comaPain of neck, back, legMental symptoms: apathy, lethargy, deliriumClinical feature3. Acute SAHSigns of meningeal irritation: neck stiffness, positive Kernigs signFundus e

12、xamination: papilloedema, sub-hyaloid hemorrhageCranial nerve palsyClinical feature4. Delayed neurologic deficitsRerupture: in first 4 weeks, again has severe headache, vomiting, unconsciousness, with poor outcome. Due to fibrinolysisCerebrovascular spasm: 4-15 days after initial SAH, cerebral infar

13、ction disturbance of consciousness and focal signsHydrocephalus: 2-3 weeks after SAH, gait difficulty, incontinence, dementia Clinical featureInvestigation1. CTSubarachnoid clot in 75% of cases2. CSFUniformly blood-stainedXanthochromia: 12 hours to 2-3 weeks ICP 3. DSA: etiologic diagnosis, importan

14、t to surgery4. MRA, CTAInvestigationDiagnosis Sudden onset of severe headache, vomitingNeck stiffness, positive Kernigs signUniformly blood stained CSFCT shows subarachnoid clotDifferential diagnosisCerebral hemorrhageMeningitisTumorPsychosisTreatment1. General management Absolute bed rest for 4-6 weeksPrevent constipation, excitementSedatives and analgesics2. Red