《出血性腦卒中》課件

1、出血性腦卒中hemorrhagic apoplexy中南大學(xué)湘雅醫(yī)院神經(jīng)內(nèi)科 谷文萍Wenping Gu,MD.PhD. Neurology Department, Xiangya Hospital, central south University出血性腦卒中hemorrhagic apoplexy中南大腦出血cerebral hemorrhage腦出血cerebral hemorrhage腦出血cerebral hemorrhage是指原發(fā)性非外傷性腦實(shí)質(zhì)內(nèi)出血80%以上由高血壓性腦內(nèi)細(xì)小動(dòng)脈病變引起,固又稱高血壓動(dòng)脈硬化性腦出血發(fā)病率高，占全部腦卒中2030Hypertension is

2、 the most common underlying cause of nontraumatic intracerebral hemorrhage腦出血cerebral hemorrhage是指原發(fā)性非外病因與發(fā)病機(jī)制etiopathogenisis and pathogenesy高血壓性腦內(nèi)細(xì)小動(dòng)脈硬化高血壓性腦動(dòng)脈硬化時(shí)可有腦內(nèi)細(xì)小動(dòng)脈透明變性、纖維素樣壞死，病變管壁在血流沖擊下形成微動(dòng)脈瘤hypertension appears to promote structural changes including lipohyalinosis, fibrinoid necrosis and

3、microaneurysm formation in the walls of pinetrating arteries,predisposing them to intracerebral hemorrhage.導(dǎo)致腦動(dòng)脈管壁薄弱的其他疾病血液系統(tǒng)疾病腫瘤卒中原因不明病因與發(fā)病機(jī)制etiopathogenisis and p病理pathology多為腦動(dòng)脈深穿支破裂所致豆紋動(dòng)脈最為常見，次為丘腦穿通動(dòng)脈、基底動(dòng)脈旁中央支多發(fā)于大腦半球基底核區(qū)，次為腦葉、腦干和小腦Most hypertensive hemorrhages originate in certain areas of predi

4、lection,corresponding to long,narrow,penetrating arterial branches.These include the caudate and putaminal branches of the middle cerebral arteies(42%);branches of the basilar artery supplying the pons(16%);thalamic branches of the posterior cerebral arteries(15%);branches of the superior cerebellar

5、 arteries supplying the dentate nuclei and the deep white matter of the cerbellum(12%);and some white matter branches of the cerebral arteries(10%).出血可直接破壞腦組織血腫擠壓周圍組織，引起腦組織水腫、顱內(nèi)壓增高，嚴(yán)重可引起腦疝病理pathology多為腦動(dòng)脈深穿支破裂所致臨床表現(xiàn)clinical manifestation50歲高血壓患者(hypertensive patients)突然發(fā)病,迅速達(dá)高峰(suddenly onset)全腦癥狀(g

6、lobal symptom)局灶癥狀(focal symptom)臨床表現(xiàn)clinical manifestation50臨床表現(xiàn)clinical manifestation殼核出血（putamen hemorrhage）內(nèi)囊外側(cè)型出血，為高血壓性腦出血最常見的類型丘腦出血（thalamic hemorrhage）腦葉出血（lobe hemorrhage）腦干出血（brain stem hemorrhage）中腦出血（midbrain hemorrhage）腦橋出血（pontine hemorrhage）延髓出血（medulla oblongata hemorrhage）小腦出血（cerebe

7、llar hemorrhage）腦室出血（cerebroventricular haemorrhage）臨床表現(xiàn)clinical manifestation殼核出輔助檢查laboratory findings頭顱CT(CT scan)頭顱MIR腦血管造影(cerebral arteriography) DSA、MRA、CTA腰穿腦脊液檢查(lumbar puncture)血、尿常規(guī)、血糖、電解質(zhì)檢查輔助檢查laboratory findings頭顱CT(C出血性腦卒中課件出血性腦卒中課件出血性腦卒中課件出血性腦卒中課件出血性腦卒中課件診斷與鑒別診斷diagnosis and different

8、ial diagnosis大于50歲，多有長期高血壓病史(old patients with hypertension)活動(dòng)中或情緒激動(dòng)時(shí)突然發(fā)病(suddenly onset)頭痛、嘔吐、意識(shí)障礙等全身癥狀(headache,vomitting, impairment of consciousness)偏癱、偏身感覺障礙、失語等局灶神經(jīng)體征(hemiparesis,hemisensory deficit,hemianopia,aphasia)CT見腦內(nèi)出血病灶(CT find hematomas)與其他類型腦卒中、腦外傷后硬膜下出血、內(nèi)科疾病鑒別診斷與鑒別診斷diagnosis and di

9、fferen治療treatment控制腦水腫、顱高壓是降低死亡率的關(guān)鍵急性期治療一般治療脫水降顱內(nèi)壓(antiedema)調(diào)控血壓(contral blood pressure)止血?jiǎng)┖湍獎(jiǎng)?coagulation)手術(shù)治療(surgical measures)并發(fā)癥處理(complication)上消化道出血(upper gastrointestinal hemorrhage)肺部感染(lung infection)其他恢復(fù)期治療康復(fù)治療藥物治療治療treatment控制腦水腫、顱高壓是降低死亡率的關(guān)鍵預(yù)后prognosis出血量大、全身情況差者，病死率高腦干出血病死率高達(dá)70%大腦半球出

10、血約為20%總病死率為30%40%存活患者中，病殘率達(dá)70%預(yù)后prognosis出血量大、全身情況差者，病死率高蛛網(wǎng)膜下腔出血subarachnoid hemorrhage蛛網(wǎng)膜下腔出血subarachnoid hemorrhag蛛網(wǎng)膜下腔出血subarachnoid hemorrhage,SAH蛛網(wǎng)膜下腔出血是多種病因所致腦底部或腦及脊髓表面血管破裂的急性出血性腦血管病，血液直接流入蛛網(wǎng)膜下腔，又稱原發(fā)性SAH 。此外，臨床還可見因腦實(shí)質(zhì)內(nèi)、腦室出血、硬膜外或硬膜下血管破裂等血液穿破腦組織流入蛛網(wǎng)膜下腔者，稱為繼發(fā)性SAHSubarachnoid hemorrhage, SAHthe pr

11、imary subarachnoid hemorrhage .Many etiological factors make cerebral basal part ,cerebral and spinal cord surface blood vessels rupture . Following these ,blood enters subarachnoid space ,which is called SAH. In addition , succeeding SAH is that blood enters subarachnoid space which is caused by ru

12、pturing of blood vessel in cerebral parenchyma, epidural , infradura mater or ventricular hemorrhage.蛛網(wǎng)膜下腔出血subarachnoid hemorrha病因etiopathogenisis顱內(nèi)動(dòng)脈瘤(cerebral arterial aneurysm)，好發(fā)于30歲以上成年人腦動(dòng)靜脈畸形(intracranial AVMs)，多見于青少年和兒童高血壓腦動(dòng)脈硬化(hypertention)、腦動(dòng)脈炎等病因etiopathogenisis顱內(nèi)動(dòng)脈瘤(cereb發(fā)病機(jī)制 pathogenesy

13、顱內(nèi)容積增加 顱內(nèi)壓增高 腦疝血液刺激腦膜 劇烈頭痛及腦膜刺激征刺激丘腦下部和腦干 高熱、植物神經(jīng)功能紊亂急慢性梗阻性腦積水、交通性腦積水腦動(dòng)脈痙攣 腦梗死Rupture of an intracranial artery elevates intracranial pressure and distorts pain-sensitive structures, producing headache and causing the loss of consciousness.發(fā)病機(jī)制 pathogenesy顱內(nèi)容積增加 病理pathology絕大多數(shù)顱內(nèi)動(dòng)脈瘤位于前循環(huán)，尤其是Wills環(huán)的動(dòng)

14、脈分叉處Most of intracranial aneurysms occur anterior circulation , specially artery crotch of Wills circulus病理pathology絕大多數(shù)顱內(nèi)動(dòng)脈瘤位于前循環(huán)，尤其是臨床表現(xiàn)clinical manifestation青壯年多見；突然起??；可有劇烈運(yùn)動(dòng)等誘因；少數(shù)起病前有頭痛、頭暈、視物模糊或長期間歇慢性頭痛史主要癥狀突然發(fā)生的頭部劇烈脹痛，位于前額、枕部或全頭部，常伴有惡心、噴射性嘔吐，意識(shí)障礙定位體征腦膜刺激征(meningeal irritation)眼底改變(subhyaloid re

15、tinal hemorrhagess)The classic presentation of subarachnoid hemorrhage is the sudden onset of an unusually severe generalized headache.Loss of consciousness is frequent,as are vomiting and necckstiffness.臨床表現(xiàn)clinical manifestation青壯年臨床表現(xiàn)clinical manifestation并發(fā)癥（complication）再出血(rehemorrhage)，4周內(nèi)，第2

16、周尤多見腦積水（hydrocephalus）腦動(dòng)脈痙攣(cerebrovascular spasm)，發(fā)病早期或1-2周出現(xiàn)上消化道出血（upper gastrointestinal hemorrhage）發(fā)熱（fever）臨床表現(xiàn)clinical manifestation并發(fā)癥輔助檢查laboratory findings頭顱CT或MIR檢查CT是診斷蛛網(wǎng)膜下腔出血快速、安全的手段，作為診斷本病的首選檢查CT scan will usually confirm that hemorrhage has occurred and may help to identify a focal sou

17、rce.腰穿腦脊液檢查(lumbar puncture)腦血管造影(cerebral arteriography)DSA、MRA、CTA經(jīng)顱超聲多普勒（TCD）輔助檢查laboratory findings頭顱CT或M出血性腦卒中課件出血性腦卒中課件出血性腦卒中課件診斷與鑒別診斷diagnosis and differential diagnosis診斷(diagnosis)根據(jù)病史、臨床表現(xiàn)、CT檢查和CSF的檢查結(jié)果，可進(jìn)行確診鑒別診斷(differential diagnosis)各種原因引起的腦膜炎(meningitis)其他類型的腦卒中(stroke)診斷與鑒別診斷diagnosis and differen治療treatment急性期治療原則上是制止繼續(xù)出血、降低顱內(nèi)壓、去除病因、防治并發(fā)癥一般治療避免繼續(xù)出血或再出血誘因，絕對(duì)臥床4-6周(Absolute bed rest, mild sedation and analgesics for headache)對(duì)癥處理止血治療脫水治療腦脊液置換治療病因治療防治并發(fā)癥（complication）防治腦積水(hydrocephalus)防治腦血管痙攣(vasospasm)治療treatment急性期治療原則上是制止繼續(xù)出血、降低預(yù)后prognosis動(dòng)脈瘤首次出血約25%死亡；再出血約40%，