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1、Conception It means primary and nontraumatic intracerebral hemorrhage. Count for 20%30% in stroke Hypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.第1頁/共53頁Etiology Half of the patients suffer from hypertension combined with arteriolar atherosclerosis, it is t

2、he most common cause of the disease. Others：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy CAA , aneurysm, AVM第2頁/共53頁 Pathophysiology 高血壓小動脈：纖維素樣壞死fibrinoid necrosis、脂質(zhì)透明變性hyaline fatty change、microaneurysm小動脈瘤、微夾層動脈瘤滲出exudation、破裂rupture 高血壓遠端血管痙攣vasospasm缺氧anoxia、壞死angio-necro

3、sis、血栓形成thrombosis斑點狀出血、腦水腫brain edema融合成片(子癇)第3頁/共53頁Pathophysiology 腦內(nèi)動脈：壁薄、中層肌細胞及外膜結(jié)締組織少、缺乏外彈力層隨年齡增長彎曲呈螺旋狀出血主要部位：深穿支penetrating arteries 豆紋動脈lenticulostriate artery：大腦中動脈呈直角分出，易發(fā)生粟粒狀動脈瘤，為腦出血最好發(fā)部位，其外側(cè)支稱為出血動脈bleeding artery第4頁/共53頁 Pathophysiology 一次出血常在30min內(nèi)停止 頭CT動態(tài)觀察：20%-40%患者24小時內(nèi)血腫仍繼續(xù)擴大，為活動性出血

4、active hemorrhage或早期再出血early rebleeding 多發(fā)性腦出血常繼發(fā)于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis第5頁/共53頁 Pathology Hypertensive ICH：基底節(jié)的內(nèi)囊區(qū)inter capsule、殼核putamen占70%，腦葉lobe、腦干brainstem、小腦齒狀核區(qū)各占10% Location of ICH：殼核（內(nèi)囊、側(cè)腦室），丘腦thalamus（第三腦室、內(nèi)囊、側(cè)腦室），腦橋pons、小腦cerebellum、蛛網(wǎng)膜下腔subarachnoid

5、 space、第四腦室forth ventricle第6頁/共53頁Pathology Hypertensive ICH：cerebral penetrating artery miliary aneurysm Non Hypertensive ICH：occur in subcortical white matter without arteriosclerosis第7頁/共53頁Pathology Swelling and congestion of hemisphere 出血灶：充滿血液的空腔，周圍是壞死腦組織及淤點狀出血性軟化帶、腦水腫 血塊溶解吞噬細胞清除含鐵血黃素和壞死腦組織膠質(zhì)增

6、生（膠質(zhì)瘢痕或中風囊）第8頁/共53頁Clinical features age：5070 years old sex：more male patients season：winter or spring past history：hypertension inducement：activity、excitement onset：acute onset第9頁/共53頁Clinical features Hypertensive hemorrhage occurs without warning, most commonly while the patient is awake. Headach

7、e is present in 50% of patients and may be severe, vomiting is common. Blood pressure is elevated after the hemorrhage has occurred. Thus, normal or low blood pressure in a patient with stroke makes the diagnosis of hypertensive hemorrhage unlikely, as does onset before 50 years of age. 第10頁/共53頁Cli

8、nical featuresbasal ganglion hemorrhage The two most common sites of hypertensive hemorrhage are the putamen(figure 1) and thalamus(figure 2), which are separated by the posterior limb of the internal capsule. In general, putaminal hemorrhage leads to a more severe motor deficit (hemiplegia) and tha

9、lamic hemorrhage to a more marked sensory disturbance (hemianesthesia). 第11頁/共53頁Clinical featuresbasal ganglion hemorrhage Homonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage. In large thalamic hemorrhages, th

10、e eyes may deviate downward, as in staring at the tip of the nose, because of impingement on the midbrain center for upward gaze. 第12頁/共53頁Clinical featuresbasal ganglion hemorrhage Aphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas. Large hemorrhages may l

11、ead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.第13頁/共53頁Clinical featuresbasal ganglion hemorrhage 丘腦出血thalamus hemorrhage: 丘腦膝狀動脈、穿通動脈破裂，表現(xiàn)為三偏癥狀，不同于殼核之處為均等癱、深淺感覺障礙、特征性眼征、意識障礙重、中線癥狀等尾狀核頭出血caput nuclei caudati hemorrhage: 少見，僅見腦膜刺激征第14頁/共53頁Clinical featurespontine

12、 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 movements are absent or impaired, but vertical eye movements may be preserved. In some patients, the

13、re may be ocular bobbing.第15頁/共53頁Clinical featurespontine hemorrhage Patients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometimes present. The hemorrhage usually ruptures into the forth ventricle, and rostral extensio

14、n of the hemorrhage into the midbrain with resultant midposition fixed pupils is common. 第16頁/共53頁Clinical featuresmidbrain hemorrhage Midbrain hemorrhage is rarely seen in clinic. The patients often manifest Weber syndrome. Large hemorrhages may lead to coma and flaccid paralysis.第17頁/共53頁Clinical

15、featurescerebellar hemorrhage 小腦齒狀核動脈破裂 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 lead to coma within 12 hours in 75% of patients and within 24 hours

16、 in 90%.They may lead to compression of the brainstem.第18頁/共53頁Clinical featureslobar hemorrhage Etiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumor Hypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal, temporal, and occipital lobes(figure 5). S

17、ymptoms 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 less so.第19頁/共53頁Clinical featurescerebral ventriculus

18、 hemorrhage 脈絡叢plexus chorioideus動脈或室管膜下動脈破裂(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.第20頁/共53頁Supplementary findings CT computerize

19、d tomography is chosen first Lesion:high density(hematoma) surronded by low density(edema)（figure 7） Mass effect is often seen in CT第21頁/共53頁Supplementary findings MRI magnetic resonance image 急性期對幕上及小腦出血顯示不如CT，對腦干出血顯示優(yōu)于CT ICH and cerebral infarction can be distinguished by MRI 45 weeks,but CT can n

20、ot distinguish them Easy to detect AVM、aneurysm Complex stages第22頁/共53頁Supplementary findings DSA：to diagnose AVM、Moyamoya disease、arteritis CSF：elevated pressure,consistently bloody,but not the routine examination 其他：血、尿、便常規(guī)，肝功，腎功，凝血功能，心電圖等第23頁/共53頁Diagnosis Senile patients after 50 years of age Pa

21、st history of hypertension Onset during activity Sudden onset CT scan第24頁/共53頁Differential diagnosis Cerebral infarction:situation and speed of onset,blood pressure,lesion showed by CT Coma due to other causes:present illness history Injury:history of injury Nonhypertensive hemorrhage:without histor

22、y of hypertension第25頁/共53頁Treatmentmedical treatment 保持安靜keep quiet、臥床休息rest in bed、減少探視avoid meeting 水電解質(zhì)平衡keep water_electrolyte balance 和營養(yǎng)nutrition 控制腦水腫control brain edema，降低顱內(nèi)壓decrease ICP:antiedema agents,e.g.mannitol 控制高血壓control blood pressure: antihypertensive agents or diuretic such as fu

23、rosemide 防治并發(fā)癥prevent complications:rebleeding, herniation, infection第26頁/共53頁Treatmentsurgical treatment 時機：超早期 6-24小時 Indication Contraindications 術式第27頁/共53頁Rehabilitation 盡早進行as soon as possible 抗抑郁antidepression第28頁/共53頁Specific treatment Nonhypertensive hemorrhage Poly-cerebral hemorrhage Rebl

24、eeding Unstable cerebral hemorrhage第29頁/共53頁Prognosis The 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.第30頁/共53頁蛛網(wǎng)膜下腔出血蛛網(wǎng)膜下腔出血Subarachnoid hemorrhage, SAHDepartment of Neu

25、rology, The 2nd affiliated hospital, Harbin Medical University第31頁/共53頁 Conception It is an acute hemorrhagic cerebral 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 SAH Secondary SAH：hem

26、orrhages in brain、ventricle or epidural (subdural) space rupture into subarachnoid space Traumatic SAH Count for 10% in stroke，for 20% in hemorrhagic stroke第32頁/共53頁Etiology Congenital aneurysm is most common etiology AVM is a less frequent cause of SAH Hypertensive arteriosclerosis aneurysm is the

27、third cause of SAH Moyamoya disease is the forth cause Others include tumor, arteritis 第33頁/共53頁 Pathophysiology Cerebral artery aneurysm are most commonly congenital “berry” aneurysms, which result from developmental weakness of the vessel wall, especially at the sites of branching. AVM are most co

28、mmon in the middle cerebral artery distribution. Arteritis can also play an important role in the disease. Tumor invasive the vessel wall can not be overlooked.第34頁/共53頁Pathophysiology 顱內(nèi)壓增高increased ICP 阻塞性腦積水obstructive hydrocephalus 化學性腦膜炎aseptic meningitis下丘腦功能紊亂 自主神經(jīng)功能紊亂dysautonimia 交通性腦積水commu

29、nicating hydrocephalus 血管活性物質(zhì)致血管痙攣vascular spasm、蛛網(wǎng)膜顆粒粘連、甚至腦梗死、正常顱壓腦積水第35頁/共53頁 Pathology 85%90% of intracranial aneurysms locate anterior in the circle of Willis,they are mainly single,they are multiple in about 10%20% of cases,locating in the opposite site of the same vessel,called mirror aneurysm

30、. 好發(fā)于Willis環(huán)動脈分叉處 破裂頻度 血液主要沉積在腦底部、腦池 可破入腦室致腦積水 蛛網(wǎng)膜無菌性炎癥反應第36頁/共53頁Clinical features Any age of person may suffer from SAH. The classic (but not invariable) presentation of SAH is the sudden onset of an unusually severe generalized headache, patients often describe it as “the worst headache I ever ha

31、d 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 of day and during either rest or exertion. 第37頁/共53頁Clinical features The most significant feature of the headache is

32、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 (sentinel,or warning, hemorrhages) or aneurysmal stretch.第38頁/共53頁Clinical features The headache is not alway

33、s 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 frequently confusion, stupor, or coma. Nuchal rigidity and other evidence of meningeal irritation ar

34、e 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 diagnosis. 第39頁/共53頁Clinical features Because bleeding occurs mainly in the subarachnoid space in

35、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 occurring ipsilateral to a posterior communicating artery aneurysm. Bilateral extensor plant

36、ar 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.第40頁/共53頁 Clinical features Inducement and aura：inducement include intensive activity、exhaustion、excitement,aura can be “warning leak” and

37、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 other complications第41頁/共53頁Complications Recurrence of hemorrhage:Recurrence of

38、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, termed vasospasm, occurs in vessels surrounded by subarachnoid bloo

39、d and can lead to parenchymal ischemia in more than one- third of cases. 第42頁/共53頁Complications Acute or subacute hydrocephalus:Acute or subacute hydrocephalus may develop during the first day- or after several weeks-as a result of impaired CSF absorption in the subarachnoid space. Progressive somno

40、lence, nonfocal findings, and impaired upgaze should suggest the diagnosis.第43頁/共53頁Complications Seizures: Seizures occur in fewer than 10% of cases and only following damage to the cerebral hemisphere. Others:Although inappropriate secretion of antidiuretic hormone and resultant diabetes insidious

41、 can occur, they are uncommon.第44頁/共53頁 Supplementary findings CT：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. 約15%患者CT僅顯示腳間池少量出血，向中腦環(huán)池、外側(cè)裂池基底擴散，稱非動脈瘤性SAH nA-SAH CSF

42、: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.第45頁/共53頁Supplementary findings DSA:to detect aneurysm or AVM, it is

43、a prerequisite to the rational planning of surgical treatment. MRI and MRA:MRI is especially useful in detecting small AVMs localized to the brainstem (an area poorly seen on CT scan). TCD：to determine CVS 實驗室檢查：血常規(guī)、凝血功能、肝功、免疫學第46頁/共53頁 Diagnosis Symptom：the history of a sudden severe headache with

44、confusion or obtundation Sign：nuchal rigidity, a nonfocal neurologic examination CSF：bloody spinal fluid Fundus oculi：preretinal globular subhyaloid hemorrhages CT findings第47頁/共53頁Differential diagnosis Hypertensive intracranial hemorrhage：there are prominent focal findings. Intracranial infection:

45、it is excluded by the CSF examination. Tumor stroke or metastasis:they can be distinguished from SAH by evidence of tumor. Non-typical SAH第48頁/共53頁Principle of treatment 控制繼續(xù)出血control active hemorrhage 防治遲發(fā)性CVS prevent tardive CVS 去除病因eliminate etiology 防止復發(fā)prevent recurrence第49頁/共53頁Treatmentmedica

46、l treatment 一般處理general treatment：absolute bed rest 46 weeks,preventing elevation of arterial or intracranial pressure(mild sedation, analgesics),but nA-SAH is an exception. 降顱壓decrease ICP：antiedema agents eg.mannitol or surgical decompression 防治再出血prevent recurrence：PAMBA 防治遲發(fā)CVS prevent tardive C

47、VS ：calcium channel antagonist drug e.g. nimodipine CSF置換CSF exchange：it can remove red cells,since the procedure may be accomplished with some complications, it should be used carefully.第50頁/共53頁Treatmentsurgical treatment Opportunity of operation：2472 hours after hemorrhage Subject to operation 術式

48、 血管內(nèi)介入治療、-刀治療第51頁/共53頁Prognosis The probability of survival following aneurysmal rupture is related to the patient s state of consciousness and the elapsed time since the hemorrhage. Hunt grade：gradehave a good outcome,grade have a poor one,grade have a moderate one. Main cause of death ：including recurrence of hemorrhage、tardive CVS Main commemorstive sign：may be cognitive impairment第52頁/共53頁感謝您的觀看！第53頁/共53頁