各論01-1顱內(nèi)壓增高腦疝

顱內(nèi)壓增高1編輯pptXinhuaSquare2編輯pptTrafficAccidents3編輯pptIraqWar4編輯ppt5編輯pptEmergencyRoomoftheAffiliatedHospital6編輯pptCraniocerebralinjuryhashighincidencewhetherinpeacetimeorwartimes.ButIncreasedICPistheessentialandtheknottyproblempassingthroughneurosurgicalclinicalandteachingwhichtheteachingprogrammedemandstohold.Importance

SignificanceNecessity7編輯pptIntracranialpressure,ICP：isthepressureincranialcavity,namelybrainpressure,whichisexpressedinpressureofCSF.Rangeofnormalvalue:0.7-2kPa

(70-200mmH2O),children:0.5-1.0kPa.>2kPaIntracranialhypertension，

<0.7kPaIntracranialhypotensionPathophysiology1.

PathophysiologyDEFINITION8編輯pptIntracranialthreecontentsPathophysiologyIt’sgeneralvolumeisconstant——1400ml9編輯pptGenerationofCSFPathophysiologytotalamount:130mlV=0.35ml/minAbsorptionOfCSF10編輯pptRegulationofICPPathophysiologyRelationtobloodpressure(BP)&respirationSystole—，Diastole—；Expiration—，Inspiration—ButitmainlydependsuponthechangeofvolumeofCSF.“Monroe-KelliePrinciple〞11編輯ppt

RegulationofICP

RelationtoCSF

TheabsorptivevelocityofCSFdependsuponthepressuredifferencebetweensubarachnoidspaceandvenoussinus.Ifexcessiveformation,obstructivecirculutionanddisturbancedabsorption

CSFvolumeBeyonditsregulationlevelintracranialpressurePathophysiology12編輯pptRegulationofICPRelationtoCBF(cerebralbloodflow)Braintissuerequiresmoreoxygenthanothertissues,soit’sthemostsensitivetohypoxiaandischemia.CBF=

Pathophysiologymeansystemicarterialpressure(mSAP)–ICPcerebralvascularresistance(CVR)cerebralperfusionpressure

(CPP)CVRRegulationofCBFislessthanofCSF,it’slimitedthattheabilityof“bulkcompensation〞toIntracranialhypertension=13編輯pptRegulationofICPPathophysiologyRelationtoBraintissueBraintissuehasalittleregulation.Chronic:compensatedbybraintissueatrophyandAmplificationofsubarachnoidspaceandventricles.Acute:can’tbecompressedobviously.14編輯ppt

2.Etiology

ExcessiveCSF：hydrocephalusCBF

：AVM、aneurysmsBraintissuevolume:cerebraledema(braininjury,inflammation,hypoxia,poisoning)Space-occupyinglesion：

hematoma,tumor,abscess,granulomaEtiologyBasilarinvaginationandlargedepressedfractureofskullcontentscranialcavity15編輯pptBrainInjuryNeurosurgeryMechanismofCloseCraniocerebralInjuryContusionandlacerationofbrain16編輯pptEpiduralHematomaNeurosurgery17編輯pptDepressedFractureNeurosurgery18編輯ppt3.Influencefatorsof

increasedintracranialpressure

Age：infant,senility

Course：acute,chronic

Langfitttestin1966:

volume/pressurecurve

Position：midline,posteriorfossa

Character：benign,malignant

Generalstate:

severesystemlesionInfluencefactors19編輯pptICP(mmH2O)Volume(ml)

VPRInfluencefactorsvolume/pressurecurve20編輯ppt3.Influencefatorsof

increasedintracranialpressure

Age：infant,senility

Course：acute,chronic

Langfitttestin1966:

volume/pressurecurve

Position：midline,posteriorfossa

Character：benign,malignant

Generalstate:

severesystemlesionInfluencefactors21編輯ppt

Consequences4.Consequencesof

increasedintracranialpressure

CerebralbloodflowHerniationofbrainCerebraledema:

ICPaffectingcerebralmetabolism&CBFcerebraledemaGastrointestinaldysfunctionPulmonaryedema

Cushingresponse

ICP

Bp,P,Pulsepressuredifference22編輯pptRegulationofICPRelationtoCBF(cerebralbloodflow)CBF=

Pathophysiologymeansystemicarterialpressure(mSAP)–ICPcerebralvascularresistance(CVR)cerebralperfusionpressure

(CPP)CVR=23編輯ppt

Consequences4.Consequencesof

increasedintracranialpressure

CerebralbloodflowHerniationofbrainCerebraledema:

ICPaffectingcerebralmetabolism&CBFcerebraledemaGastrointestinaldysfunctionPulmonaryedema

Cushingresponse

ICP

Bp,P,Pulsepressuredifference24編輯ppt

5.ClinicalmanifestationsofincreasedICPHeadacheVomitingPapilledemaOthersymptomsChangesofvitalsignsHerniationofbrainClinicalmanifestation25編輯ppt

Headache

Thecommonnestsymptomwhichoftenarisesatmorningoreveningandwithforwardradiationtoorbit,aggravatedwithincreasedICP.Theheadachecanincreasewhencoughing,bendingdown,loweringone’sheads.

ClinicalmanifestationReasons:meninges,bloodvesselsandnervesarepulledupon.26編輯pptClinicalmanifestationFrequentlyseenintumorslocatedinposteriorcranialfossaand4thventricle.

Headacheisatypicalinchildren.

VomitingUsuallyappearswhenheadacheissevere,accompaniedbynausea.Thetypicalisprojectile.27編輯ppt

Papilledema

Isthemostobjectivesign.It’scharacterizedbyopticpapillarycongestion,theindistinctmargins,theexcavationdisappearance,opticdiscprojection,venousengorgementandarterialtwistiness.Clinicalmanifestation28編輯pptpapilledema29編輯ppt6.Diagnosis30編輯ppt

Placeweightoncasehistory,somatoscopy,especiallyNSexamination.Diagnosis(1)LumbarvertebraepunctureAccessoryexamination.31編輯pptAccessoryexamination.

Diagnosis(2)Theplainradiographoftheskull32編輯pptAccessoryexamination.

Diagnosis(3)CerebralVascularAngiographydigitalsubtractionAngiography,DSA3D-DSA33編輯pptAccessoryexamination.

Diagnosis(4)CT&MRI34編輯pptTreatment7.Treatments35編輯ppt7.1.GeneraltreatmentObserveT,P,R,Bp,consciousness,pupilPreventinhalationpneumoniaPayattentiontofluidinfusion,acid-basebalancePayattentiontolooseningthebowelsKeepairwayunobstructedOxygeninhalationTreatment7.Treatment36編輯ppt7.2.Etiologicaltreatment

Space-occupyingfocus:removalHydrocephalus:by-passoperationofCSF

eg.VentriculoperitonealshuntAcutebrainhernia:emergencysurgeryTreatment37編輯ppt7.2.Etiologicaltreatment:OperativetreatmentTreatment38編輯pptSphenoidalmeningioma

EtiologicaltreatmentTreatmentSpace-occupyingfocus:removal39編輯pptIntraoperationTreatmentEtiologicaltreatment40編輯pptSphenoidalmeningiomaTreatmentEtiologicaltreatment2'38"41編輯pptTreatmentEtiologicaltreatmentHydrocephalus:by-passoperationofCSFeg.Ventriculoperitonealshunt42編輯ppt43編輯ppt44編輯ppt45編輯pptEtiologicaltreatmentTreatmentAcutebrainhernia:emergencysurgery.eg.Epiduralhematoma46編輯pptEpiduralhematoma47編輯pptThoroughlystopbleeding48編輯ppt49編輯pptSubduralexploration50編輯ppt7.3.VentriculocentesisVeryeffectiveemergencymeasurestosevereincreasedICP!Treatment(Schematicdiagram)51編輯pptTreatmentPuncturetransanteriorhornoflateralventricleVentriculocentesis52編輯pptTreatment

7.4.DehydrationtherapyMannitol20%Glucosi50%Furosemide(Lasix)

Glycerinfructose

HydrochlorothiazideDimox53編輯pptTreatment

7.5.Hormonotherapy

ImprovefunctionofBloodbrainBarrier,BBB，

lowerpermeabilityofcapillary

Desamethasone

Methylprednisolone

Hydrocortisone

Prednisone54編輯ppt7.6.SubhypothermiatherapyLowercerebralmetabolism,ReducecerebraloxygenconsumptionPreventdevelopmentofhydrocephalusTreatment55編輯pptBarbitaltherapy

Overventilation

Antibiotictherapy

Expectanttreatment7.7.Othertreatments56編輯ppt8.HerniationofBrain57編輯ppt8.1.BasicAnatomyAnatomySchematicdiagramofcranialcavity58編輯ppt8.2.CauseofformationICPcausedby

differentreasonsEtiologybraintissuepassdownthepositionwherepressureislowgiverisetoaseriesofclinicsyndromesnamelybrainhernia59編輯pptCommondiseasesleadingbrainherniaEtiologyIntracranialHematomasTumorsIntracranialAbscessIntracranialParasitosisChronicGranulomas

60編輯ppt8.3.PathogenesisPathogenesisThemostimportanceiscausingthesecondarylesionofbrainstem!CirculationofCSFmeetwithobstructionHastenICP

Viciouscircle

61編輯ppt8.4

ClinicalmanifestationTranstentorialherniation(Temporaloncusherniation)Clinicalmanifestation①symptomsofincreasedICP:severeheadache,frequentvomitingwhichaggravatedthanpre-hernia,dysphoria②consciousnesschanges:lethargysuperficialcoma

coma62編輯pptClinicalmanifestationClinicalmanifestationTranstentorialherniation(Temporaloncusherniation)③pupillarychanges:anisocoria——oculomotornerveispulled.accompaniedby

droopingeyelid,exotropiaplatycoria——Oculomotornucleusiscompressed.63編輯pptClinicalmanifestationClinicalmanifestationTranstentorialherniation(Temporaloncusherniation)④dyskinesia

hemiplegia；decerebraterigidity——brainstemisdamagedseverely?、輛italsignsdisordered

T、P、R、Bp64編輯pptTransforamenmagnaherniation(Tonsillarherniation)ClinicalmanifestationClinicalmanifestationHerniadownwardCerebellartonsiliscompressedIncreasedICPbelowtentorium

Space-occupyinglesionsinposteriorfossa65編輯pptSevereheadache,repeatedvomiting,disorderedvitalsigns,suddenstoppedrespiration,withoutpupillarychanges.ClinicalmanifestationClinicalmanifestationTransforamenmagnaherniation(Tonsillarherniation)66編輯pptTreatment8.5.Treatment

DehydrationtherapyVentriculocentesisDecompressionoperationV-PshuntInternaldecompressionoperationOthers67編輯pptSummary

ICP>2kPa:IncreasedICPHeadache,VomitingandPapilledemaarethethreemajorsignandsymptomsHerniationistheseverestConsequences

68編輯ppt

OperativetreatmentsVentriculocentesisNon-operativetreatmentsSummary69編輯pptMultiplechoicequest