09級大5上課件-外科學(xué)11擇譯disorders

1、Chapter 4. Cerebrovascular DisordersNeurosurgeryZongyi Xie, Ph.D.MDNeurosurgery Department, 2nd Hospital, CQMUNeurosurgery Department, 2nd Hospital, CQMUSubarachnoid Hemorrhage and Intracranial Aneurysm Neurosurgery Department, 2nd Hospital, CQMUGeneral introduction 1Clinical aspects 2Epidemiologica

2、l Aspects 3 e 4Cause of SAH 5Investigations 6Management 7contentNeurosurgery Department, 2nd Hospital, CQMU1. General introduction Subarachnoid hemorrhage(SAH) is not a disorder, that occurs when some diseases cause a vessel rupture into this subarachnoid layer SAH occurs at the relatively young age

3、 with the poor e.The circle of WillisNeurosurgery Department, 2nd Hospital, CQMU 2. Clinical aspects2.1 Symptom and sign of the haemorrhage sudden, unusually severe headache-clinical hallmark nausea and vomiting back and radicular pain (rare) consciousness disorders hydrocephalus meningeal irritatio

4、n sign: neck stiffness and positive Kernigs sign Neurosurgery Department, 2nd Hospital, CQMU2.2 Focal neurological deficit 2.3 Epilepsy the third nerve (oculomotor nerve) palsyhemiplegia2.4 Others: Fever, hypertension and leucocytosisNeurosurgery Department, 2nd Hospital, CQMU3. Epidemiological Aspe

5、cts3.1 Annual incidence of SAH: varied with different countries, from 2.0 cases per 100 000 population in China to 22.5 per 100 000 in Finland. 3.2 Average age: is substantially lower than for other types of stroke, peaking in the sixth decade. 3.3 Factors affecting the incidence: Gender, race, and

6、region 3.4 Genetic factors: a positive family history Women have a 1.6 times higher risk than men Black people a 2.1 times higher risk than whites. Neurosurgery Department, 2nd Hospital, CQMU4. e of SAH4.1 Case fatality of SAH ranges between 32 and 67%. 4.2 One-third of SAH survivors remain dependen

7、t. 4.3 The three baseline variables most closely related to poor e the neurological condition of the patient on admission-the level of consciousness age the amount of subarachnoid blood on the in initial CT scan Neurosurgery Department, 2nd Hospital, CQMUHunt-hess scaleNeurosurgery Department, 2nd H

8、ospital, CQMU 5. Cause of SAH5.1 Intracranial aneurysms 顱內(nèi)動(dòng)脈瘤 (account for 7085%)5.2 Vascular malformations 5.3 Moyamoya disease5.4 rare conditions: microbial aneurysm細(xì)菌性動(dòng)脈瘤, traumatic brain injury, etcNeurosurgery Department, 2nd Hospital, CQMUNeurosurgery Department, 2nd Hospital, CQMUNeurosurgery

9、 Department, 2nd Hospital, CQMU 6. Investigations6.1 Brain Scanning (CT, MRI) CT scanning-first-line investigation, cornerstone of SAH diagnosis CT show the characteristically hyperdense appearance of extravasated blood in the basal cisterns. Neurosurgery Department, 2nd Hospital, CQMU MRI: is impra

10、cticable in the acute phaseHowever, MRI is increasingly superior to CT in detecting extravasated blood, up to 40 days later. The probability of CT detecting a hemorrhage is proportional to the clinical grade and the time from hemorrhage. In the first 12 hours after SAH, the sensitivity of CT for SAH

11、 is 98% to 100%, declining to 93% at 24 hours and to 57% to 85% 6 days after SAH Neurosurgery Department, 2nd Hospital, CQMU6.2 Lumbar PunctureLumbar puncture is still an indispensable step in the exclusion of SAH in patients with a convincing history and negative brain imaging.Neurosurgery Departme

12、nt, 2nd Hospital, CQMU6.3 MRA and CTA MRA is safe but less suitable in the acute stage CTA has sensitivities approaching equivalence to DSA for larger aneurysms. Neurosurgery Department, 2nd Hospital, CQMU6.4 Digital subtraction angiography (DSA)DSA is the gold standard for diagnosing aneurysms as t

13、he cause of SAH show the presence and anatomic features of aneurysms 2D-DSA3D-DSANeurosurgery Department, 2nd Hospital, CQMUDiagnosis of SAH: Summary 1. SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for SAH should exist in patients with acute onset of sudden s

14、evere headache.2. CT for suspected SAH is the first-line investigation, and lumbar puncture for analysis of CSF is strongly mended when the CT scan is negative.3. DSA is the gold standard for diagnosing aneurysms.4. MRA and CTA may be considered when conventional angiography cannot be performed in a

15、 timely fashion.Neurosurgery Department, 2nd Hospital, CQMU7. Management Complications of aSAH rebleeding delayed ischaemic neurological deficit (DIND) cerebral vasospasm (CVS)The risk of rebleeding is 4% in the first 24 hours and 19% in the first 2 weeks, and carries a mortality and morbidity of 60

16、% CVS is seen in 30% to 70% of patients, with a typical onset 3 to 5 days after the hemorrhage, maximal narrowing at 5 to 14 days Neurosurgery Department, 2nd Hospital, CQMU7.1 Treatment strategy for prevent rebleeding Control blood pressure Bedrest Antifibrinolytic抗纖溶藥 therapy: 6-EACA Surgical clip

17、ping 手術(shù)夾閉or endovascular coiling 血管內(nèi)栓塞Neurosurgery Department, 2nd Hospital, CQMUNeurosurgery Department, 2nd Hospital, CQMUSurgical clippingNeurosurgery Department, 2nd Hospital, CQMUendovascular coilingNeurosurgery Department, 2nd Hospital, CQMU7.2 Treatment strategy for CVS triple-H therapy: hypervolemia, hypertension, and hemodilution血液稀釋 ni