神经内科学脑出血

脑出血IntracerebralHemorrhage,ICH指原发性非外伤性脑实质内出血占脑卒中的20%-30%最常见的原因是高血压PrimarynontraumaticintracerebralhemorrhageIncidenceofICHisapproximately20%-30%ofstroke’s.Hypertensionisthemostcommoncause.

病因etiologicalfactors高血压

Hypertension

脑动脉粥样硬化

Cerebralatherosclerosis血液病

Hematologicdiseases

脑淀粉样血管病变

Amyloidangiopathy动脉瘤

aneurysm

动静脉畸形

ArteriovenousmalformationsMoyamoya病

Moyamoyadisease

脑动脉炎

Cerebralarteritis硬膜静脉窦血栓形成

DuralVenoussinusthrombosis

夹层动脉瘤

Dissectinganeurysm肿瘤Tumors梗死性脑出血

抗凝、溶栓治疗

Anticoagulantandthrombolytictreatment发病机制

Pathogenesis

高血压Hypertension动脉壁纤维素样坏死、脂质透明变性、小动脉瘤、夹层动脉瘤fibrinoidnecrosisinarterywalls,lipidglassydegeneration,smallaneurysm,dissectinganeurysm远端血管痉挛Distantangiospasm小血管缺氧、坏死、血栓形成Smallvesselshypoxia，necrosis，thrombogenesis点状出血punctatehemorrhage血肿hematoma血压骤升BPsuddenlyStepup融合confluen发病机制

Pathogenesis深穿支动脉为出血的主要部位，豆纹动脉是脑出血最好发部位，其外侧支称为出血动脉Themainlyhemorrhagicsitesaretheperforatingbranchesofmiddlecerebralartery,themostcommonsitesofICHarelenticulostriatearteries,lateralbranchesofthosearecalledhemorrhagicarteries.病理

pathology基底节区

Basalganglia70%脑叶

Cerebrallobe10%脑干

Brainstem10%小脑齿状核区

Cerebellardentatenucleus10%粟粒状动脉瘤:大脑中动脉深穿支豆纹动脉>基底动脉脑桥支>大脑后动脉丘脑支>小脑上动脉分支>顶枕交界区和颞叶分支Granulousaneurysm:thelenticulostriatearteries>branchesofthebasilararterysupplyingthepons>thalamicbranchesoftheposteriorcerebralarteries>branchesofthesuperiorcerebellararteries>somearteriessupplyingthejunctionalzonebetweenparietalandoccipitallobeandbranchesoftemporallobe临床表现

clinicalmanifestations(1)年龄50-70岁，男>女

Age50-70years.Theincidenceishigherinmenthaninwomen

冬春季多发

Mostlyoccurrsinwinterandspring.多有高血压史

Usuallywithhypertension.活动或情绪激动时发生

Occurrswhenactivitiesoremotionalexcitement.数分钟至数小时症状达高峰

Neurologicdeficitsmayprogressoverminutestohours.全脑症状：头痛、呕吐、意识改变

Globalcerebralsymptom:headache,vomiting,alterdconsciousness临床表现

clinicalmanifestions(2)1.基底节区出血（内囊区出血）占70%，其中壳核（内囊外侧型）60%，丘脑（内囊内侧型）10%。Themostcommonsiteofhemorrhageisbasalganglia,whichoccursin70%ofpatients.Itconsistsofputamen(lateral

oftheinternalcapsule)andthalamus(medialoftheinternalcapsule).(1)壳核出血：三偏，双眼向病灶对侧同向凝视不能，主侧半球有失语。(1)Putaminalhemorrhage:hemiplegia,hemisensorydeficit,hemiopia,impairmentofsyntropicgazetothecontralaterallesion,aphasiawithdominanthemisphere.临床表现

clinicalmanifestions(3)(2)丘脑出血：丘脑膝状动脉和丘脑穿通动脉。三偏，上下肢程度相近，深浅感觉障碍，特征性眼征，意识障碍，中线症状，锥体外系症状，丘脑性失语，精神症状。(2)Thalamichemorrhage:thethalamicgenualarteryandthelongpenetratingthalamicartery.hemiplegia,hemisensorydeficit,hemiopia,hemiplegiaaffectingthearmandlegtoaroughlyequalextent,impairmentofsuperficialanddeepsensation,markedocularsign,impairmentofconsciousness,symptomsofthemedianline,theextrapyramidalsymptoms,thethalamicaphasia,mentalsymptoms.临床表现

clinicalmanifestions(4)(3)尾状核头部出血：少见。脑膜刺激征，无明显瘫痪，头痛，呕吐，颈强，Kernig征(+)，可有对侧中枢性面、舌瘫(3)Hemorhageintheheadofthecaudatenucleus:seldom.meningealirritationsign,unobviousparalysis,headache,vomiting,neckstiffness,positiveKernig’ssign,thefacialandhypoglossalparalysiscausedbycontralateralupperunitopathy.临床表现

clinicalmanifestions(5)2.脑桥出血:10%，多位于脑桥基底与被盖部之间。2.Pontinehemorrhage:10%,mostlyoccursbetweenthebasalponsandthetegmen.

大量出血(>5ml)：常破入四脑室。昏迷，针尖样瞳孔，呕吐，中枢性高热，中枢性呼吸困难，眼球浮动，四肢瘫，去大脑强直发作，多在48小时内死亡。Massivehemorrhage(>5ml):usuallyrupturesintothefourthventricle.Coma,pinpointpupils,vomiting,centralfever,centraldyspnea,impairmentofhorizontaleyemovements,quadriplegia,decerebraterigidity,usuallyleadstodeathwithin48hours.

临床表现

clinicalmanifestions(6)小量出血：交叉性瘫，共济失调性偏瘫，双眼向病灶侧凝视或核间性眼肌麻痹。Smallhemorrhage:crossedparalysis,ataxic-hemiplegia,botheyesgazetotheipsilaterallesionorinternuclearophthalmoplegia.3.中脑出血：罕见．Hemorrhageindiencephalon:seldom.轻症：一侧或双侧动眼神经不全瘫痪，Weber综合征Mildcase:unilateralorbilateraloculomotornervepartialparalysis,Weber’ssyndrome.重症：深昏迷，四肢弛缓性瘫，迅速死亡Severecase:deepcoma,flaccidquadriplegia,rapidlygotodeath临床表现

clinicalmanifestions(7)4.小脑出血：10%，小脑齿状核动脉多发。发病初期有眩晕，呕吐，枕部头痛，平衡障碍，无肢体瘫痪。4.Cerebellarhemorrhage:10%,usuallyoccursinthearterysupplyingdentatenucleus.Thesymptomsincludingvertigo,vomiting,occipitalheadacheanddisordersofequilibrium,butnotquadriplegiaappearatonsetofbleeding.临床表现

clinicalmanifestions(8)轻症：一侧肢体笨拙，行动不稳，共济失调，眼震，无瘫痪。

Mildcase:clumsinessofunilateralbody,unstablemovement,ataxia,nystagmus,noparalysis.重症：双眼向病灶对侧凝视，吞咽发声困难，锥体束征，一侧瞳孔缩小，光反应迟钝，脑干受压表现，甚至枕大孔疝。

Severecase:botheyesgazeatthecontralaterallesion,difficultyinswallowinganddysphonia,pyramidalsign,constrictionofunilateralpupil,bluntnessinresponsetolight,signsofbrainstemcompression,evenforamenmagnumherniation.临床表现

clinicalmanifestations(9)5.脑叶出血：10%，以顶叶最常见。头痛，呕吐，脑膜刺激征，局灶症状，抽搐较多见。5.Lobarhemorrhage:10%,themostcommonsiteisparietallobe.Headache,vomiting,Meningealirritationsign,focalbrainsign,sizure额叶：偏瘫，Broca失语，摸索。Frontallobe:hemiplegia,broca’saphasia,crocidismus.临床表现clinicalmanifestations(10)颞叶：Wernicke失语，精神症状。

Temporallobe:Wernicke’saphasia,mentalsymptoms.枕叶：视野缺损。

Occipitallobe:visualfielddefects.顶叶：偏身感觉障碍，空间构想障碍。

Parietallobe:hemisensorydeficit,impairmentofspatialability临床表现

clinicalmanifestations(11)6.脑室出血：3%-5%，脉络丛动脉、室管膜下动脉破裂。6.Hemorrhageincerebralventricle:3%-5%,thearteriesofthechoroidplexusandtheinferiorependymalarteriesrupture.少量：头痛、呕吐、脑膜刺激征，无意识障碍和局灶症状，血性CSF，预后好。small:headache,vomiting,Meningealirritationsign,noimpairmentofconsciousnessandfocalbrainsymptoms,hematoidCSF,goodprognosis.临床表现

clinicalmanifestations(12)大量：昏迷，频繁呕吐，针尖样瞳孔，分离性斜视或眼球浮动，四肢弛缓性瘫，去脑强直发作，预后不良。

massive:coma,frequentlyvomiting,pinpointpupils,separatestrabismusoreyeballsfloating,flaccidquadriplegia,decerebraterigidity.Poorprognosis.辅助检查

laboratoryinvestigationsCT：首选

CTscanisthefirstchoice.MRI,MRADSACSF检查

CSFanalysis其他：血常规、尿常规、粪常规、肝肾功能、凝血功能、EKGOthers:bloodroutine,urinalroutine,stoolroutine,liverfunctiontests,kidneyfunctiontests,coagulationtests,EKG

诊断

Diagnosis

50岁以上中老年高血压患者在活动中或激动时突然发病，出现偏瘫、失语等局灶性神经缺失症状，应首先考虑脑出血。Whileactivitiesoremotionalexcitement,Thehypertensionpatientsoverage50yearssuddenlyappearthesymptomsoffocalneurologicdeficitssuchashemiplegia,aphasiaetc.Thefirstdiagnosismaybeintracerebralhemorrhage.鉴别诊断

differentialdiagnosis鉴别：脑梗死

cerebralinfarction

中毒、代谢性疾病

toxicosis,metabolicdisorders

外伤性出血

traumatichemorrhage

不同的脑出血原因

differentcausesofintracerebralhemorrhage治疗treatment-内科治疗medicaltreatment保持安静，卧床休息。监测生命体征、瞳孔、意识，加强护理

Tokeepquiet,bedrest.monitorvitalsigns,pupilsandconsciousness,intensivenursing.

维持水电解质平衡，注意营养。

To

keeptheintravenousfluidandelectrolytebalance,andcloseattentionmustbegiventonutrition.控制脑水肿，降低颅内压（ICP）Tocontrolhydrocephalusandreduceintracranialpressure.控制高血压

Tocontrolhypertension防治并发症

To

preventandcurecomplications.治疗

treatment

—外科治疗

surgicaltreatment手术适应症：surgicalindications:脑出血病人逐渐出现颅内压增高伴脑干受压。PatientssufferedwithintracerebralhemorrhagegraduallyappearthesignsofincreasingICPandbrainstemcompressed.治疗

treatment

—外科治疗

surgicaltreatment2.小脑半球出血>15ml，蚓部血肿>6ml，血肿破入四脑室或脑池受压消失，出现脑干受压表现和急性阻塞性脑积水征象

Hematomaincerebellarhemispherearemorethan15mlinbulk,orinvermisaremorethan6mlinbulk,hematomaruptureintothefourthventricleorthecompressionofthebrainpooldisappears,signsofbrainstemcompressedandacuteobstructivehydrocephalusappear

治疗

treatment

—外科治疗

surgicaltreatment3.脑室出血致阻塞性脑积水Obstructivehydrocephaluscausedbyhemorrhageinventricles.4.年轻患者脑叶或壳核中大量出血（>40~50ml），或有明确的血管病灶Massivehemorrhage(morethan40-50mlinbulk)incerebrallobesorputamen(youngpatients),oradefinitivevascularlesion5.脑桥出血一般不宜手术。Generallypontinehemorrhageisnotindicativetosurgery治疗

treatment康复治疗

rehabilitativetreatment特殊治疗

specialtreatment蛛网膜下腔出血Subarachnoidhemorrhage,SAHSAH是多种病因所致脑底部或脑及脊髓表面血管破裂的急性出血性脑血管病，血液直接流入蛛网膜下腔，又称原发性SAH。SAHisanacutehemorrhagiccerebrovasculardiseasecausedbymanypathogenies,whichisresultofthebloodvesselsfromtheinferiorbrainorsurfaceofbrainandspinalcordruptureandthentheblooddirectlyflowintosubarachnoidspace.ItisalsonamedprimarySAH.SAH约占急性脑卒中的10%，占出血性脑卒中的20%。TheincidenceofSAHis

approximately10percentofacutestroke,whileis20percentofhemorrhagicstoke.病因及发病机制

pathogenesis先天性动脉瘤：最常见，约占50%以上Congenitalaneurysm:themostcommon,approximatelyover50%2.脑血管畸形：占第二位Cerebrovascularmalformation:thesecondreason3.高血压动脉硬化性动脉瘤Hypertensiveatherosclerosisaneurysm4.Moyamoya病Moyamoyadisease5.其他othersSAH后的病理过程:pathophysiologyafterSAH:颅内容量增加

intracranialtissuesincreasing阻塞性脑积水

obstructivehydrocephalus化学性脑膜炎

chemicalmeningitis下丘脑功能紊乱

disordersofhypothalamicfunction自主神经功能紊乱

disordersoftheautonomicnervoussystem交通性脑积水communicatinghydrocephalus血管痉挛、蛛网膜颗粒粘连、甚至脑梗死和正常颅压脑积水

cerebrovascularspasm,thearachnoidvilliadhension,evencerebralinfarctionandhydrocephaluswithnormalICP临床表现

clinicalmanifestations任何年龄均可发病，动脉瘤破裂好发于30-60岁间，女>男；血管畸形多见于青少年，两性无差异。Occursonanyage,ruptureofaneurysmmostoccursonagefrom30-60years,inwomenmorethaninmen;AVMmostoccursinadolescent,there’snodifferenceingender.

60岁以上老人表现常不典型Thesymptomsofoldpatientsover60yearsareatypical.临床表现clinicalmanifestations典型表现：突发剧烈头痛、呕吐、脑膜刺激征及血性脑脊液。伴随症状有短暂意识障碍、项背部或下肢痛、畏光。眼底检查可见视网膜出血、视乳头水肿或玻璃体下出血；可有局灶性症状、精神症状。

Typicalmanifestations:asuddenlysevereheadache,vomiting,meningealirritationsignandbloodyCSF.Theaccompanyingsymptomsaretransientimpairmentofconsciousness,backpainormelosalgia,photesthesia.Retinalhemorrhage,papilledemaorglobularsubhyaloidhemorrhagefoundbyexaminationoffundusoculi.Afocalneurologicsymptoms,mentalsynmptoms.临床表现clinicalmanifestations诱因及先驱症状：发病前多有明显诱因，剧烈运动、过劳、激动、用力、排便、咳嗽、饮酒等；少数在安静下发病。发病前可有头痛、恶心、呕吐，颅神经麻痹，局灶性缺失或刺激症状。Inducementsandprodromes:Usuallythereareobviousinducementsbeforeonset,suchasintenseexercise,tootired,excitement,

exertion,defecation,cough,drinkingetal;Minorityoccursatrest.Historyofheadache,nausea,vomiting,cranialnervespalsy,focalneurologicdeficientorirritativesymptomsarecommonbeforeonset.常见并发症：commoncomplications:再出血

recurrenceofhemorrhage脑血管痉挛

cerebrovascularspasm,CVS脑积水hydrocephalus其他：如抽搐

others:e.g.seizure辅助检查：laboratory

investigations:颅脑CT：首选

brain

computeredtomographyscan:thefirstchoiceCSF检查

cerebrospinalfluidexaminationDSAdigitalsubtractionangiographyMRI、MRA

magneticresonanceimage,magneticresonanceangiographyTCDtranscranialdoppler实验室检查laboratoryexaminations诊断diagnosis

突发剧烈头痛、恶心呕吐和脑膜刺激征阳性患者，无局灶性神经缺损体征，伴或不伴有意识障碍，可诊断此病；CSF均匀血性、压力增高、眼底检查玻璃体下出血可临床确诊。常规行CT检查，并行病因学诊断。

Thehistoryofasuddensevereheadache,nausea,vomitingandpositiveMeningealirritationsign,nofocalneurologicdeficitsignwith(without)impairmentofconsciousnessishighlyspecificforSAH.UniformitybloodyCSF,increasedICPandglobularsubhyaloidhemorrhagefoundbyeyegroundexaminationaremostsuggestiveoftheclinicaldiagnosis.CTscanistheroutinetest,andthenmaketheaetiologicaldiagnosis.鉴别诊断differentialdiagnosis

鉴别：脑出血，颅内感染，脑卒中或颅内转移瘤

Differentialdiagnosis:cerebralhemorrhage,intracranialinfections,theischemicstrokeorintracranialmetastatictumors

SAH与ICH的鉴别要点

SAHICH动脉瘤好发于30~60岁，血管畸形青少年多见发病年龄多见于50-65岁常见病因

动脉瘤、血管畸形高血压及脑动脉粥样硬化起病状态活动、情绪激动活动、情绪激动起病速度急骤，数分钟达高峰数十分钟至数小时达高峰血压多正常，或可增高多明显增高头痛极常见，剧烈常见昏迷见于重症，为短暂性见于重症，为持续性神经体征颈强、Kernig征等脑膜刺激征神经功能缺失症状头颅CT脑池、脑室及蛛网膜下腔内高脑实质内高密度病灶密度影CSF均匀血性血性(洗肉水样)ThedifferentialpointsbetweenSAHandICH

SAH

ICHageofdisease

aneurysmage30-60age50-65AVMadolescentCommoncausesaneurysm,AVMhypertension,cerebralathrosclerosisOnsetofdiseasemovements,emotionalmovements,emotionalexcitementexcitem