1、Cerebral hemorrhage腦出血Cerebral hemorrhage腦出血Etiology and pathogenesis Hypertension and arteriosclerosisAtherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumorlenticulostriate arteries vertical to MCAMicroaneu

2、rysms rupture Etiology and pathogenesis HypePathology Site: basal ganglia (70%), brain lobe, brain stem, cerebellumLateral hemorrhage: the bleeding is confined lateral to the internal capsule (lenticular nucleus, external capsule) Medial hemorrhage: thalamus hematoma edema herniation hematoma stroke

3、 capsulePathology Site: basal ganglia Clinical featureAge: 50-70Male femaleOccur at physical exertion or excitementSudden onset of focal signsUsually accompanied by headache and vomiting May have consciousness disturbanceClinical featureAge: 50-701. Putamen hemorrhagecontralateral hemiplegia, hemian

4、esthesia, and hemianopiaEyes are frequently deviated toward the side of the affected hemisphereAphasia if dominant hemisphere is affectedClinical feature1. Putamen hemorrhageClinical 2. Thalamus hemorrhage contralateral hemiplegia, hemianesthesia, and hemianopiaDeep sensation disturbanceOcular signs

5、Disturbance of consciousness Clinical feature2. Thalamus hemorrhageClinical3. Pontine hemorrhageMild: crossed paralysisSevere (5ml) coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hoursClinical feature3. Pontine hemorrhageClinical 4. Cerebellar hemorrhageOccipital headache, intense vertigo a

6、nd repeated vomiting, ataxia, nystagmusSevere cerebellar hemorrhage : coma, compression of brain stem, tonsillar herniationClinical feature4. Cerebellar hemorrhageClinic5. Lobar hemorrhageSeen in AVM, Moyamoya disease, Headache, vomiting, neck stiffnessSeizureFocal signsClinical feature5. Lobar hemo

7、rrhageClinical feInvestigation 1. CTFirst choiceHigh density bloodMass effect and edemaHigh density isodensity low densityInvestigation 1. CT2. MRIBrain stem hemorrhage50, with hypertensionSudden onset of headache, vomiting, focal signOccur at physical exertion or excitementCT: high density bloodDia

8、gnosis Age 50, with hypertDifferential diagnosisComa: poisoning, hypoglycemia, hepatic or diabetic comaFocal signs: cerebral infarction, brain tumor, subdural hematoma, SAHDifferential diagnosisComa: poTreatment 1.Keep rest, monitoring, air way, good nursing2. Keep electrolytes and fluid balance.3.

9、Reduce ICP: 20% Mannitol 125-250ml, 3 to 4 times per dayFurosemide, albumin, dexamathasone Treatment 1.Keep rest, monitor4. Control hypertension: 180/105mmHg in acute stage, ACEI, beta-blocker5. Prevent complications:Infection:antibioticsgastric hemorrhage: Cimetidine, LosecVenous thrombosis: hepari

10、n Treatment 4. Control hypertension: 40-50 ml, deterioratingCerebellum: 15ml, diameter3cmThalamus: obstructive hydrocephalus ventricular drainage 7. Rehabilitation Treatment 6. Surgical therapy: TreatmentSubarachnoid hemorrhageSAHSubarachnoid hemorrhageSAHSAH Cranial bone dura mater arachnoid pia ma

11、ter brain lobePrimary spontaneous SAHTraumatic SAHSecondary to cerebral hemorrhageSAH Cranial bone dura mater Etiology 1. Intracranial saccular aneurysm 2. AVM (arteriovenous malformation) 3. Hypertension and atherosclerosis4. Moyamoya disease5. Mycotic aneurysm, tumor, polyarteritis nodasa, bleedin

12、g diseaseEtiology 1. Intracranial saccuPathology Anterior cerebral and anterior communicating Internal carotid Middle cerebralBasilar Pathology Anterior cerebral anClinical feature1. Age of onset: Saccular aneurysm: adult 30-60AVM: juvenile Hypertension: more than 602. Prodromal symptomsWarning leak

13、s: headache, vomitingCranial nerve paralysis: oculomotorClinical feature1. Age of onse3. Acute SAHSudden onset of severe headache: “explode, burst, the worst of my life”VomitingAssociated with physical exertion, excitementTransient loss of consciousness or comaPain of neck, back, legMental symptoms:

14、 apathy, lethargy, deliriumClinical feature3. Acute SAHClinical feature3. Acute SAHSigns of meningeal irritation: neck stiffness, positive Kernigs signFundus examination: papilloedema, sub-hyaloid hemorrhageCranial nerve palsyClinical feature3. Acute SAHClinical feature4. Delayed neurologic deficits

15、Rerupture: in first 4 weeks, again has severe headache, vomiting, unconsciousness, with poor outcome. Due to fibrinolysisCerebrovascular spasm: 4-15 days after initial SAH, cerebral infarction disturbance of consciousness and focal signsHydrocephalus: 2-3 weeks after SAH, gait difficulty, incontinen

16、ce, dementia Clinical feature4. Delayed neurologic deficitsInvestigation1. CTSubarachnoid clot in 75% of casesInvestigation1. CT2. CSFUniformly blood-stainedXanthochromia: 12 hours to 2-3 weeks ICP 3. DSA: etiologic diagnosis, important to surgery4. MRA, CTAInvestigation2. CSFInvestigationDiagnosis

17、Sudden onset of severe headache, vomitingNeck stiffness, positive Kernigs signUniformly blood stained CSFCT shows subarachnoid clotDiagnosis Sudden onset of seveDifferential diagnosisCerebral hemorrhageMeningitisTumorPsychosisDifferential diagnosisCerebralTreatment1. General management Absolute bed rest for 4-6 weeksPrevent constipation, excitementSedatives and analgesics2. Reduce ICPMan