神经病学 脑血管病英文学习课件

重庆医科大学临床学院教案讲稿PAGEPAGE1制表时间：2013年8月重庆医科大学临床学院教案及讲稿（教案）课程名称神经病学年级授课专业教师陈国俊职称教授授课方式大课学时5题目章节脑血管病教材名称神经病学作者吴江出版社人民卫生出版社版次第二版教学目的要求掌握脑血管病的病因与危险因素掌握TIA、不同类型脑梗死的诊断、鉴别诊断、预防和治疗原则掌握常见部位脑出血的临床表现、诊断和治疗掌握蛛网膜下腔出血的临床表现、诊断及治疗教学难点脑血循环的解剖与生理是教学难点。TIA、脑梗死的病因及发病机制是教学难点脑出血的发病机理、病理是教学难点。蛛网膜下腔出血的病因、发病机理与并发症的诊治教学重点脑血管病的病因与危险因素及临床表现重点讲授短暂性脑缺血发作(TIA)的定义、脑梗死的主要类型临床表现、诊断与治疗。常见部位脑出血的临床表现、诊断与治疗是教学重点，蛛网膜下腔出血的临床表现、诊断及治疗。外语要求通过课堂教学让学生了解一些有关的名词。教学方法手段多媒体教学参考资料Harrison’sNeurologyinClinicalMedicine教研室意见同意教学组长：王学峰教研室主任：王学峰2013年8月15日重庆医科大学临床学院教案讲稿PAGEPAGE2制表时间：2012年8月（讲稿）教学内容辅助手段时间分配Lesionone:CerebrovascularDiseaseIntroduction(40mins)Definition（2mins）Cerebrovasculardisease:agroupofbraindysfunctionsrelatedtodiseaseofthebloodvesselssupplyingthebrain.Stroke:suddenlossofbloodcirculationtoanareaofthebrain,withcorrespondinglossofneurologicfunction..Thirdleadingcauseofdeath,approximately2,000,000newstrokeseachyearinchinaII.Bloodsupplyinthebrain（8mins）1.InternalcarotidarteryAnteriorcerebralartery（大脑前动脉）Middlecerebralartery（大脑中动脉）2.VertebralbasillaarteryVertebralartery（椎动脉）Posteriorinferiorcerebellarartery（小脑后下动脉）Basillarartery（基底动脉）Anteriorinferiorcerebellarartery（小脑前下动脉）Superiorcerebellarartery（小脑上动脉）Posteriorcerebralartery（大脑后动脉）3.CircleofWillisThecircleofWilliscomprisesthefollowingarteries:Anteriorcerebralartery(leftandright)大脑前动脉Anteriorcommunicatingartery前交通动脉Internalcarotidartery(leftandright)颈内动脉Posteriorcerebralartery(leftandright)大脑后动脉Posteriorcommunicatingartery(leftandright)后交通动脉Physiologicsignificance:arrangementofthebrain'sarteriesintothecircleofWilliscreatesredundanciesinthecerebralcirculation.III.Regulationofcerebralbloodflow(CBF)-Averagebrainweightis1500g,accountsfor2%~3%ofbodyweight.However,thebrainutilizes20%~25%ofglucoseandenergyofwholebody(almost10timeofproportionalCBF).-Thebraindoesnotstoreglycogenandrequires60-70mL/100gtissueperminutefornormalfunction.RegulationofCBFBloodpressure:CBFisautomaticallyregulatedwhenmeanarterialpressure(MAP)isbetween60-160mmHg,whichmaintainsCBFatrelativestablelevel(Baylisseffect).AutonomicregulationwillnotbeeffectivewhenMAPisbelow60mmHgorabove160mmHg(hypertension).Meanarterialpressure(MAP)=diastolicpressure+1/3pulsepressure(systolicpressure-diastolicpressure).1mmHg=7.5×kPa(kilopascal)Chemicals:O2,CO2andpHinbloodandCSF.Classificationofstroke（1min）1.Hemorrhagic（出血性,10~15%）-Intercranialcerebralhemorrhage（脑出血）-Subarachnoidhemorrhage（蛛网膜下腔出血）2.Ischemic（缺血性,85~90%）Thrombosis（脑血栓形成）Embolism（脑栓塞）

V.RiskfactorandPrevention（20mins）PrimaryPrevention一级预防referstothetreatmentofindividualswithnoprevioushistoryofstrokeSecondaryPrevention二级预防referstothetreatmentofindividualswhohavealreadyhadastroke1、RiskfactorsNon-modifiableriskfactors(Age,Sex,Race,Heredity)Modifiableriskfactors1)highbloodpressureHypertensionaccountsfor35-50%ofstrokerisk.2)atrialfibrillation心房纤颤(ariskof5%eachyeartodevelopstroke).3)Diabetes(2to3timesmorelikelytodevelopstroke)4)highbloodcholesterollevels(inconsistentlyassociatedwith(ischemic)stroke)5)cigarettesmoking(activeandpassive),6)Heavyalcoholconsumption7)Drugusecontraceptivedrugs避孕药cocaine可卡因amphetamines安非他明over-the-countercoughandcolddrugscontainingsympathomimetics8)Lackofphysicalactivity9)Obesity10)Unhealthydiet11)Homocysteine高同型半胱氨酸血症2、Preventivemeasurement-2、1LifestyleinterventionsSmokingcessationAlcoholconsumptionlimitAlow-fatdiet,lowsaltdiet(Mediterraneandiets)WeightlossRegularexercise2、2Preventivemeasure-Medication2、2、1Bloodpressurecontrol\o"Hypertension"BP-loweringmedicationsThiazidediureticsACEIangiotensin-convertingenzymeinhibitorsARBsangiotensinreceptorblockers（Notlargedifferencesbetweenantihypertensivedrugs）2、2、2AtrialfibrillationRecommendationsoftheAmericanCollegeofChestPhysicians(ACCP)incasesofatrialfibrillation1)Warfarin华法令usedforallhigh-riskpatientsallpatientsolderthan75yearsregardlessoftheirrisk.2)AspirinusedforLow-riskpatientspatientsyoungerthan65years3)TargetINRis2-34)Adverseeffectsexcessivebleeding(intracranialhemorrhage)2、2、3LoweingBloodlipids(HMG-CoAreductaseinhibitors(statins))2、2、4Treatmentofdiabetesmellitus2、2、5Antiplateletagents1.highlyeffectiveinsecondaryprevention1).AspirinLowdosesofaspirin(75-150

mg)effectivefewerside-effects2.notreducetheriskofischemicstrokeinprimaryprevention2、3Preventiveintervention-Surgerycarotidendarterectomyorcarotidangioplasty1)Endarterectomy颈动脉内膜剥脱术forasignificantstenosis(50%orgreaterstenosis)usefulinthesecondaryprevention(recurrentriskfrom20%after5yearstoaround5%)forstenosiswithoutsymptomsonlyasmalldecreaseintheriskofstroke2)Carotidarterystenting(angioplasty)颈动脉支架成形术equallyuseful2、4MetabolicinterventionsloweringhomocysteinewithfolicacidandothersupplementsPreventiveintervention(summary)Secondarystrokepreventioncanbesummarizedbythe

mnemonicA,B,C,D,EasfollowsAantiplatelet(aspirin)anticoagulants(warfarin)Bbloodpressure–loweringmedicationsbodyweightlossCcessationofcigarettesmokingcholesterol-loweringmedicationsDdietdiabetesmanagementEexercise五、Treatment（10mins）Treatmentincluding3phasesPrevention,(beforestroke)Acutetreatment,(duringstroke)Subacute/chronictreatment(afterstroke)StrokeunitAwardordedicatedareainhospitalstaffedbynursesandtherapistswithexperienceinstroketreatment.Lesiontwo:TransientIschemicAttack

TIA

短暂性脑缺血发作一、Definition（2mins）ATIAisabriefepisodeofneurologicdysfunctioncausedbyfocalbrainorretinalischemia,withclinicalsymptomstypicallylastinglessthan1hour,andwithoutevidenceofacuteinfarctions50%ofTIArecoveredwithinthefirsthour90%recoveredwithin4hours.二、Causesandpathophysioloy（5mins）TIAworkupisfocusedonemergent/urgentriskstratification.1.Atherosclerosiscarotidandvertebralarteries(narrow,microemboli)

Thrombusbreaksoff,travels,loadAnticoagulanticsystemactivation2.EmbolicsourcesValvulardiseaseventricularthrombus3.Arterialdissection动脉夹层4.Arteritis动脉炎Necrotizingvasculitis(primarycause)SyphilisDrugsIrradiationLocaltrauma5.Sympathomimeticdrugs(eg,cocaine)三、ClinicalpresentationandDiagnosis（20mins）HistoryChangesinbehavior,speech,gait,memory,andmovement.2、Carefullyinvestigateonset,duration,fluctuation,andintensityofsymptoms.3、Significantmedicalhistoryquestionsincludethefollowing:Recentsurgery(eg,carotid,cardiac)PreviousstrokesKnowncardiovasculardiseaseSeizuresCNSinfectionsUseofillicitdrugsComorbiditiesrelatedtometabolicdisordersReviewingthepatient'smedicalrecord.Elicitanyriskfactorsforrelevantunderlyingdisease.KnowncoagulopathyHistoryofarteritisNoninfectiousnecrotizingvasculitis,drugs,irradiation,andlocaltraumaareknowntocauseinflammatoryarterialinjury.Thromboembolicriskfactorssuchascarotidarterystenosis,venousorarterialthromboembolism,patentforamenovale卵原孔未闭,atrialfibrillation,priormyocardialinfarction,orleftventriculardysfunction.四、Differentiation(5mins)HypoglycemiaSeizureVertigoIntracranialhemorrhage五、LaboratoryStudies（7mins）1、EmergencypresentationFingerstickbloodglucose指血糖Serumelectrolyte电解质SerumchemistryprofileincludingcreatinineCoagulationstudies凝血像CompletebloodcountTypicallyhelpfulandcanoftenbeperformedurgentlyErythrocytesedimentationrate(ESR)红细胞沉降率Cardiacenzymes

心肌酶谱Lipidprofile血脂Screeningforhypercoagulablestates(particularlyinpatientsyoungerthan50y)LevelsofproteinCandproteinSAntithrombinIIIlevel凝血酶IIIThrombintime凝血酶原时间2、AsneededbaseduponhistorySyphilisserology梅毒学清学Antiphospholipidantibodies抗磷脂抗体ToxicologyscreensHemoglobinelectrophoresisSerumproteinelectrophoresisCerebrospinalfluidexamination3、ImagingStudies1）.BrainimagingNoncontrastcranialCTscanwidelyavailableinitialimagingevaluation--MRI

lesswidelyavailableonanacutebasis2）Vascularimaging

CarotidDopplerultrasonographyTranscranialDoppler(TCD)Computedtomographicangiography(CTA)Magneticresonanceangiography(MRA)Digitalsubtractionangiography(DSA)3）CardiacimagingTransthoracicortransesophagealechocardiography(TTE/TEE)OtherTests12-Leadelectrocardiography(ECG)Lumbarpuncture(LP)Electroencephalography(EEG)六、Prognosis(ABCD2Score)

(1min)

anABCDscorehigherthan6hadan8%riskofstrokewithin2days,anABCDscorelessthan4hada1%riskofstrokewithin2days.Lesionthree:IschemiacerebralinfarctionCerebralischemicstrokeintroduction(10mins)representsabout80%ofallstrokesAthrombus(血栓形成）Anembolus（栓塞）occludeacerebralarterycauseischemia一、Classificationbasedoncourse:Transientischemiaattack(TIA)(<24h)Progressingischemicstroke(PIS)(>6h)Completestroke(CS)(<6h)二、Pathologyandpathophysiology1、Neuronaldeath(Coagulationnecrosis(CN))缺血坏死cellinitiallyswellsthenshrinksandundergoespyknosis-evolvesover6to12hours.extensivechromatolysisoccursresultinginpan-necrosis.Astrocytesswellandfragment,myelinsheathsdegenerateby24hours.Apoptosis细胞凋亡nucleardamageoccursfirst.Integrityoftheplasmaandthemitochondrialmembraneismaintaineduntillateintheprocess.Apoptoticmechanismsbeginwithin1hourafterischemicinjurywhereasCNbeginsby6hoursafterarterialocclusion.3、IschemicPenumbra(IP)缺血半暗带progressionandtheextentofischemicinjuryisinfluencedbymanyfactors:DurationofischemiaCollateralcirculationHealthofsystemiccirculationHematologicalfactors(hypercoagulablestate)TemperatureGlucosemetabolismThromboticstroke一、Etiology(2mins)Atherosclerosishypercoagulablestatefibromusculardysplasiaarteritis(GiantcellandTakayasu),dissectionofavesselwall.二、Pathologyocclusionoflargevessels100to400mm三、Clinicalpresentation(15mins)1、(MCAstrokesyndrome)Maintrunkocclusioncontralateralhemiplegia对侧偏瘫contralateralhemianopia对侧偏盲contralateralhemianesthesia对侧偏身感觉减退eyedeviationtowardthesideoftheinfarct凝视病灶侧classicneglect(rightglobalaphasia失语(dominanthemisphere)SuperiordivisionofMCAinfarctscontralateraldeficitsupperextremityandface(significantinvolvement)legandfoot(partialsparingofthecontralateral)ACAstrokesyndromeConfusion意识模糊Personalitychange人格改变Incontinence尿失禁Contralateralmotororsensorylossleggreaterthanarm3、Vertebrobasilarsymptom

CommonlyreportedsymptomsassociatedwiththevertebrobasilarstrokesincludethefollowingVertigo眩晕Nauseaandvomiting恶心呕吐HeadacheAbnormalitiesinthelevelofconsciousness意识改变Abnormaloculomotorsigns(eg,nystagmus,lateralgazeabnormalities,眼部体征diplopia,pupillarychanges)Ipsilateralcranialnerveweakness同侧颅神经麻痹(eg,dysarthria,dysphagia,dysphonia,weaknessoffacialmusclesandtongue)Lateralmedullary(Wallenberg)syndromemostoftenduetovertebralarteryocclusionIpsilateralclinicalfeaturesincludethefollowing:Ataxiaanddysmetria共济失调和辨距不良Nystagmus眼震Hornersyndrome霍纳氏征(eg,ptosis,miosis瞳孔缩小,hypohidrosisoranhidrosis,少汗enophthalmos)眼球内陷Bulbarpalsy(Dysarthria,Dysphagia)构音障碍、吞咽困难FacialpainandtemperaturelossContralateralfindingslossofpainandtemperaturesenseinthebodyandextremitiesCerebellarinfarctionalackofcoordinationClumsiness笨拙intentiontremor意向性震颤ataxia共济失调Dysarthria构音障碍scanningspeech吟诗样语言difficultieswithmemoryandmotorplanning.Locked-insyndrome闭锁综合征Infarctionoftheupperventralpons.Occlusionofthebasilarartery(proximalandmiddlesegments)--ClinicalfeaturesQuadriplegia四肢瘫Unabletospeak,Unable

toproducefacialmovement,

UnabletolooktoeithersideConsciousnesspreserved(fullyawake,sensate,andaware)onlymovementsverticaleyemovementsandblinking.Ventralmidbrain(Weber)anocclusionofthemedianand/orparamedianperforatingbranchesofthebasilarartery.TypicalclinicalfindingsIpsilateralCNIIIpalsy(ptosis睑下垂Mydriasis瞳孔放大Contralateralhemiplegia对侧偏瘫四、ImagingStudies1.CTscanningandCTA2.MRIRoutingMRIDiffusion-weightedimaging(DWI)detectischemicinjurywithin15-30minutesofonsetevidenceofischemicinjurybutnotischemiaitselfsignificantlysuperiortoCTscanninginthediagnosisofacute(<6h)stroke.Perfusion-weightedimaging（PWI)showstheactualzoneofischemicinjury.3.Furtherimaging:Carotidduplexscanning颈动脉双弓TranscranialDopplerultrasonography(TCD)经颅多普勒超声Echocardiography超声心动图4.Angiography血管造影DSA,CTA,MRA五、DiagnosisAcuteonsetRiskfactorsofastrokebeing55yearsofageorolder,highbloodpressure,highlevelsofcholesterolhomocysteinecigarettesmoking,diabetes,obesity,cardiovasculardisease,personalorfamilyhistoryofastrokeTIA,useofbirthcontrolorotherhormonetherapy,heavyalcoholuseandtheuseofillicitdrugs.FocalneurologicaldeficitLackofsymptomintracranialhypertensionCTscanmanifestlowdensity六、TreatmentRoutineTreatment(10mins)1)Airwayandbreathing2)Circulation3)Bloodglucosecontrol

insulintherapygoalofestablishingnormoglycemia(90-140mg/dL).

4)Bloodpressurecontrol

Theconsensusrecommendationistolowerbloodpressure -onlyifsystolicpressureisinexcessof220mmHg-orifdiastolicpressureisgreaterthan120mmHgRapidreductionofbloodpressure,nomatterthedegreeofhypertensionmayinfactbeharmful.

5)Cerebraledemacontrolmannitolisusedroutinely6)Seizurecontrol

occurin2-23%withinthefirstdaysstandardantiepileptictherapyMedicationofacutestrokearedistributedintothefollowingcategories:(1)Reperfusion(thrombonlysis)(2)Antiplatelet(3)Anticoagulation(4)Inducedhypothermia(5)Fibrinolyticagents(6)Neuroprotective(7)ChinesemedicineRehabilitationProgramPhysicalTherapyOccupationalTherapySpeechTherapyRecreationalTherapy七、PrognosisDisabilityaffects75%ofstrokesurvivorsTheresultsofstrokevarywidelydependingonsizeandlocationofthelesion.Dysfunctionscorrespondtoareasinthebrainthathavebeendamaged.Affectpatientsphysically,mentally,emotionally,oracombinationofthethree.Physicaldisabilitiesparalysis,numbness,pressuresores,pneumonia,incontinenceMentaldisabilitiesapraxia(inabilitytoperformlearnedmovements)difficultiescarryingoutdailyactivitiesappetiteloss,speechproblem,dementia,problemswithattentionandmemoryVisionlossandpainEmotionaldisabilitiesfrustrationanddifficultyadaptingtonewlimitationsAnxiety,panicattacksflataffect(failuretoexpressemotions),mania,apathy,poststrokedepression,characterizedbylethargy,irritability,sleepdisturbances,loweredselfesteem,andwithdrawal.Lesionfour:SpontaneousIntracerebralHemorrhage一、Definition(1min)Spontaneousintracerebralhemorrhage(SICH):bleedingintotheparenchymaofthebrainthatmayextendintotheventriclesandsubarachnoidspaceintheabsenceoftraumaorsurgery.20to30%ofallcasesofstroke二、Cause(2mins)Chronichypertension(78%~88%)AmyloidangiopathyVascularabnormalities(AVM,aneurysm)TumorCoagulopathy三、Epidemiologicfeatures(1min)Incidence10~20casesper100,000IncreaseswithageMen,especiallyolderthan55yearsoldAcircadianandcircannualpatternofSICHonsetinthemorningandwinterhasbeenreported三、Pathophysiologicalfeatures(6mins)OriginofhematomaDegenerativechanges(hyalinosisandfibrinoidnecrosis)inthevesselwallinducedbychronichypertension.Dilatationinthewallsofsmallarterioles.(microaneurysms)theyaremorelikelytoburstandcauseahemorrhage.Mostbleedingoccuratthebifurcationofaffectedarteries.Arupturedbloodvesselwillleakbloodintothebrain,eventuallycausingthebraintocompressduetotheaddedamountoffluid.CommonsiteA.CerebrallobeB.BasalgangliaC.ThalamusD.Brainstem(ponspredominantly)E.CerebellumProgressionofhematoma(3mins)CTscanshowedhematomasexpandovertime.26%within1hours,38%within20hours(Brottetal:103ptsAcutehypertension,localcoagulationdeficitmaybeassociated.SecondaryNeuronalinjuryHematomainitiatesedemaandneuronaldamageinsurroundingparenchyma.Edema5days~2weeksOsmoticallyactiveserumproteinsfromclot,vasogenicedema,cytogenicedema(disruptionofBBB,Napumpfailure,celldeath..)四、Clinicalfeatures(20mins)SymptomofincreasedICPDecreasedlevelofconsciousnessSomnolence(or"drowsiness")StuporComaIncreasedICP,compressionofthethalamicandbrain-stemreticularactivatingsystem.Accompanyingheadache,nausea,vomitingSomnolence(or"drowsiness")isastateofnear-sleep,astrongdesireforsleep,Sleepingforunusuallylongperiods.StuporisthelackofcriticalcognitivefunctionandlevelofconsciousnesslevelAlmostentirelyunresponsiveOnlyrespondstobasestimulisuchaspain.Comaisaprofoundstateofunconsciousness.Cannotbeawakened,Failstorespondnormallytopain,lightorsound,Nothavesleep-wakecycles,Nottakevoluntaryactions.NeurologicstatusatpresentSupratentorialICHContralateralsensorydeficitsContralateralmotordeficitsHemianopia,Aphasia,neglect,gazedeviation,involvingputamen,caudate,thalamus.subcorticalwhitematterorcortexInfratentorialICHBrainstem(crosspalsy)AbnormalgazeLateralcranialnerveContralateralmotordeficitsCerebellumAtaxia,nystagmus,dysmetriaSecondaryDeterioration25%ptsdeteriorationinthelevelofconsciousnesswithinthefirst24hrsExpansionofthehematoma:first3hrsWorseningcerebraledema:24~48hrsLateprogressionofedema:2~3weeks五、Imagetest(1min)CTscaninfarctionorhemorrhageLocationandsizeofthehematomaPresenceofventricularbloodHydrocephalusImagingtestConventionalangiographyforsecondarycauseofICH(AVM,aneurysm..)六、DiagnosisElderSuddenonsetoffocalneurologicaldeficitprogressingoverhoursresultingfromelevatedbloodpressureSymptomofintracranialhypertensionaccompanyingheadache,nausea,vomiting,alteredconsciousness,CTscanmanifesthighdensitymass七、Management(6mins)Evaluation&managementintheERDecreasedlevelofconsciousnessorimpairmentofreflexestheprotectairwayIntubation!UrgentCTscan,Hyperventilation,intravenousmannitolandintraventricularcatheterfordrainage.ManagementMasseffect&intracranialhypertensionHematoma,edematissue,obstructivehydrocephalusherniation!Useofhyperventilationandosmoticagentimprovedthelong-termoutcomeSurgicalevacuationManagementofbloodpressureElevationofbloodpressureexpansionofhematomapooroutcome!AHAguidelineManagementSurgicalevacuationReducemasseffect,BlockthereleaseofneuropathicproductfromthehematomaSurgeryforsupratentorialhemorrhage?InternationalSurgicalTrialinIntracerebralHemorrhage(STITCH)didnotshowanybenefitforsurgicalevacuationofclotinICHcomparedwithmedicalmanagementalone. ControlofhyperglycemiaadministrationofinsulinasanintravenouscontinuousinfusionorsubcutaneousinjectionFevercontroloftemeratureaccomplishedwithmedicationssuchasacetaminophenorthroughuseofexternalorinternalcoolingdevices.ManagementSeizuresMostseizurewithin24hrsAnticonvulsantsdiscontinuedafterthefirstmonthifnoseizure.Seizuresmorethan2weeksatriskoffurtherseizurelong-termtreatment.ManagementPreventionofcomplication1)Deepvenousthrombosisandpulmonaryembolus;accomplishedwitheitherpneumaticcompressiondevicesonthelegssubcutaneousheparinoidcompounds(begun3-4daysafterICHwithcleardocumentationthatbleedinghasstopped).2)Adequatenutritionalsupport,viaafeedingtubeifthepatientcannotswallowshouldbebegunwithinthefirst24-48hoursRehabilitationPhysical,occupational,andspeechtherapyshouldbeinstitutedearlyandaggressivelyduringthecourseofthehospitalizationinordertobegintheprocessofrehabilitationandrecovery.七、Outcome(2mins)Mortalityrate:23%~58%in6months (1)LowGCSscore (2)Largevolumeofthehematoma (3)PresenceofventricularbloodonCTmortalityrateatonemonthwasbestpredictedbyinitialGCS<9,volume>60ml90%GCS9,volume<30ml17%recurrenthemorrhage2%peryear.ReducebyBPcontrol!Lesionfive:SubarachnoidHemorrhage（40mins）一、Introduction(2mins)Subarachnoidhemorrhage(SAH):impliesthepresenceofbloodwithinthesubarachnoidspacefromnontraumaticpathologicprocess,usuallyfromruptureofaberryaneurysmorarteriovenousmalformation(AVM).FrequencyAnnualincidenceis6-25casesper100,000.(UnitedStates)Varyingincidencesofsubarachnoidhemorrhagehavebeenreportedinotherareasoftheworld(2-49cases

per100,000).(International)Sexhigherinwomenthaninmen.AgeMeanageofthoseexperiencingsubarachnoidhemorrhageis50years.Mortality/MorbidityAnestimated10-15%ofpatientsdiebeforereachingthehospital.Mortalityratereachesashighas40%withinthefirstweek.Abouthalfdieinthefirst6months.Mortalityandmorbidityratesincreasewithageandpooreroverallhealthofthepatient.Advancesinthemanagementofsubarachnoidhemorrhagehaveresultedinarelativereductioninmortalityratethatexceeds25%.However,morethanonethirdofsurvivorshavemajorneurologicdeficits.二、Causes(3mins)Saccularaneurysm(Congenitalaneurysm)AVM(AVMalformation)MycoticaneurysmalruptureAngiomaNeoplasmCorticalthrombosis三、ClinicalPresentation(20mins)1、HistoryHeadachessuddenonsetofasevereheadache.nearthebackoftheheadapoppingorsnappingfeelingintheheadProdromal(warning)headache(s)(referredtoassentinelheadache)30-50%ofaneurysmalsubarachnoidhemorrhages.occurafewhourstoafewmonthsbeforetherupture,withmedianof2weekspriortodiagnosisofSAH.Nauseaand/orvomitingSymptomsofmeningealirritationneckstiffness,lowbackpain,bilaterallegpainTheseareseeninmorethan75%ofcasesPhotophobiaandvisualchangesdoublevision,blindspots,ortemporaryvisionlossinoneeyeLossofconsciousness:AbouthalfofpatientsexperiencethisatthetimeofbleedingonsetSeizuresMorethan25%ofpatientsexperienceseizuresclosetotheacuteonset.2、PhysicalExaminationPhysicalexaminationfindingsmaybenormal,Nolocalizingsignsin40%ofpatientsGlobalorfocalneurologicabnormalitiesinmorethan25%ofpatientsMotordeficitsfrommiddlecerebralarteryaneurysmsin15%ofpatientsSyndromesofcranialnervecompressionOculomotornervepalsy(posteriorcommunicatingarteryaneurysms)withorwithoutipsilateralmydriasisAbducensnervepalsyMonocularvisionloss(ophthalmicarteryaneurysmcompressingtheipsilateralopticnerve)OphthalmologicsignsSubhyaloidretinalhemorrhage(smallroundhemorrhage,perhapswithvisiblemeniscus,neartheopticnervehead);otherretinalhemorrhagePapilledemaVitalsignsmild-to-moderatebloodpressure(BP)elevation.(Abouthalfofpatients),labileasICPincreases.Feverbecomescommonafterthefourthdayfrombloodbreakdowninthesubarachnoidspace.Tachycardiapresentforseveraldaysaftertheoccurrenceofahemorrhage.四、Complications(10mins)RebleedingofSAHoccursin20%ofpatientsinthefirst2weeks.PeakincidenceofrebleedingoccursthedayafterSAH.Thismaybefromlysisoftheaneurysmalclot.Vasospasmfromarterialsmoothmusclecontractionissymptomaticin36%ofpatients.Hydrocephalusmaydevelopwithinthefirst24hoursbecauseofobstructionofCSFoutflowintheventricularsystembyclottedblood.

HydrocephalusTemporalhornsdilatedDiffuseSAHBloodinthe4thventricleDiffusecerebraledemaNeurologicdeficitsfromcerebralischemiapeakatdays4-12.Hypothalamicdysfunctioncausesexcessivesympatheticstimulation,whichmayleadtomyocardialischemiaorlabiledetrimentalBP.Hyponatremiamayresultfromcerebralsaltwasting/SIADH(syndromeofinappropriateantidiuretichormonehypersecretion)Nosocomialpneumoniaandothercomplicationsofcriticalcaremayoccur.Pulmonaryedema–neurogenicandnonneurogenic五、Workup1、LaboratoryStudiesLaboratorystudiesincludethefollowing:CompletebloodcountProthrombintime,activatedpartialthromboplastintimeTroponinI(cTnI):Itwasinitiallythoughttobeonlyusefulasapredictorfortheoccurrenceofpulmonaryandcardiac2、ImagingStudies(2mins)HeadCTscanSensitivitydecreaseswithtimefromonsetpositivein100%ofcaseswithin12hoursofonset90-95%within24hoursofonsetofbleeding,80%at3days,50%at1week.CTalsocandetectintracerebralhemorrhage,masseffect,andhydrocephalus.AfalselynegativeCTscancanresultfromsevereanemiaorsmall-volumesubarachnoidhemorrhage..BrainCTscanshowingsubtlefindingofbloodattheareaofthecircleofWillisconsistentwithacutesubarachnoidhemorrhage.Magneticresonanceimaging(MRI)Cerebralangiography(DSA(digitalsubtractionangiography).NoncontrastCTfollowedbyCTangiographyofthebraincanruleoutsubarachnoidhemorrhagewithgreaterthan99%sensitivityMagneticresonanceangiography(MRA)lesssensitivethanangiographyindetectingvascularlesionsProcedures(2mins)LumbarpunctureLumbarpuncture(LP)isindicatedifthepatienthaspossiblesubarachnoidhemorrhageandnegativeCTscanfindings.PerformCTscanpriortoLPtoexcludeanysignificantintracranialmasseffectorobviousintracranialbleed.LPmaybenegativelessthan2hoursafterthebleed;LPismostsensitiveat12hoursaftersymptomonset.Xanthochromiaisaclassicsign,butnotpresentearly–lookforequalorincreasingbloodinthesampletubesorD-dimers4、ECG20%haveECGevidenceofMyocardialischemia,STsegmentelevation,TwavechangesDuetohighlevelsofcirculatingcatecholamines六、Diagnosis“Worstheadacheinmylife”Oftenaccompaniedbyaperiodofunconsciousness–50%Neckstiffness,Painful3rdnervepalsyPhotophobiaFudoscopy–subhyo