2022年医学专题—指非外伤性脑实质内出血.ppt

(Cerebral Hemorrhage),定义(dngy)：指非外伤性脑实质内出血,脑 出 血,Department of Neurology,The 2nd affiliated hospital,Kunming Medical college,第一页，共六十页。,Conception,It means primary and nontraumatic intracerebral hemorrhage.Count for 20%30%in strokeHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.,第二页，共六十页。,Etiology,Half of the patients suffer from hypertension combined with arteriolar atherosclerosis,it is the most common cause of the disease.Others：cerebral atherosclerosis,hematopathy,cerebral amyloid angiopathy CAA,aneurysm,AVM,第三页，共六十页。,Pathophysiology,高血压小动脉：纤维素样坏死(hui s)fibrinoid necrosis、脂质透明变性hyaline fatty change、microaneurysm小动脉瘤、微夹层动脉瘤渗出exudation、破裂rupture高血压远端血管痉挛vasospasm缺氧anoxia、坏死angio-necrosis、血栓形成thrombosis斑点状出血、脑水肿brain edema融合成片(子痫),第四页，共六十页。,Pathophysiology,脑内动脉：壁薄、中层(zhngcng)肌细胞及外膜结缔组织少、缺乏外弹力层随年龄增长弯曲呈螺旋状出血主要部位：深穿支penetrating arteries豆纹动脉lenticulostriate artery：大脑中动脉呈直角分出，易发生粟粒状动脉瘤，为脑出血最好发部位，其外侧支称为出血动脉bleeding artery,第五页，共六十页。,Pathophysiology,一次出血(ch xi)常在30min内停止头CT动态观察：20%-40%患者24小时内血肿仍继续扩大，为活动性出血active hemorrhage或早期再出血early rebleeding多发性脑出血常继发于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis,第六页，共六十页。,Pathology,Hypertensive ICH：基底节的内囊(ni nn)区inter capsule、壳核putamen占70%，脑叶lobe、脑干brainstem、小脑齿状核区各占10%Location of ICH：壳核（内囊、侧脑室），丘脑thalamus（第三脑室、内囊、侧脑室），脑桥pons、小脑cerebellum、蛛网膜下腔subarachnoid space、第四脑室forth ventricle,第七页，共六十页。,Pathology,Hypertensive ICH：cerebral penetrating artery miliary aneurysmNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosis,第八页，共六十页。,Pathology,Swelling and congestion of hemisphere出血灶：充满血液的空腔，周围是坏死脑组织及淤点状出血性软化带、脑水肿血块溶解吞噬细胞清除含铁血黄素和坏死脑组织胶质增生（胶质瘢痕(bn hn)或中风囊）,第九页，共六十页。,Clinical features,age：5070 years oldsex：more male patientsseason：winter or springpast history：hypertensioninducement：activity、excitementonset：acute onset,第十页，共六十页。,临 床 表 现,一般症状：中年以上发病。起病突然，动态起病，病势凶险。高颅压征 intracranial hypertension sign 头痛，呕吐，血压升高，脉搏减慢，视乳头水肿(shuzhng)，意识障碍 易形成脑疝 cerebral herniation神经系统定位体征：取决于血肿的部位、体积,第十一页，共六十页。,局灶性神经功能缺损,基底节区：内囊(ni nn)“三偏征”偏瘫 hemiplegia 偏盲 hemiscotosis 偏身感觉障碍 hemihypesthesia脑叶 额叶 颞叶 顶叶 枕叶 各具不同缺损脑干 交叉性瘫痪 hemiplegia alternate小脑 眩晕 vertigo 共济失调 ataxia,第十二页，共六十页。,基底节区的血液(xuy)供应,豆纹动脉的破裂(pli)成因,第十三页，共六十页。,Clinical 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 thalamic hemorrhage to a more marked sensory disturbance(hemianesthesia).,第十四页，共六十页。,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,the eyes may deviate downward,as in staring at the tip of the nose,because of impingement on the midbrain center for upward gaze.,第十五页，共六十页。,Clinical featuresbasal ganglion hemorrhage,Aphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas.Large hemorrhages may lead to consciousness disturbance,while minor hemorrhages lead to lacunar syndrome.,第十六页，共六十页。,Clinical featuresbasal ganglion hemorrhage,丘脑(qino)出血thalamus hemorrhage:丘脑膝状动脉、穿通动脉破裂，表现为三偏症状，不同于壳核之处为均等瘫、深浅感觉障碍、特征性眼征、意识障碍重、中线症状等尾状核头出血caput nuclei caudati hemorrhage:少见，仅见脑膜刺激征,第十七页，共六十页。,Clinical featurespontine 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,there may be ocular bobbing.,第十八页，共六十页。,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 extension of the hemorrhage into the midbrain with resultant midposition fixed pupils is common.,第十九页，共六十页。,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.,第二十页，共六十页。,Clinical featurescerebellar hemorrhage,小脑(xiono)齿状核动脉破裂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 in 90%.They may lead to compression of the brainstem.,第二十一页，共六十页。,Clinical featureslobar hemorrhage,Etiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumorHypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal,temporal,and occipital lobes(figure 5).Symptoms and signs vary according to the location;they can include head