出血性腦卒中

hemorrhagicapoplexyWenpingGu,MD.PhD.NeurologyDepartment,XiangyaHospital,centralsouthUniversity腦出血

cerebralhemorrhage腦出血

cerebralhemorrhage是指原發(fā)性非外傷性腦實質(zhì)內(nèi)出血80%以上由高血壓性腦內(nèi)細小動脈病變引起,固又稱高血壓動脈硬化性腦出血發(fā)病率高，占全部腦卒中20％—30％Hypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage病理

pathology多為腦動脈深穿支破裂所致豆紋動脈最為常見，次為丘腦穿通動脈、基底動脈旁中央支多發(fā)于大腦半球基底核區(qū)，次為腦葉、腦干和小腦Mosthypertensivehemorrhagesoriginateincertainareasofpredilection,correspondingtolong,narrow,penetratingarterialbranches.Theseincludethecaudateandputaminalbranchesofthemiddlecerebralarteies(42%);branchesofthebasilararterysupplyingthepons(16%);thalamicbranchesoftheposteriorcerebralarteries(15%);branchesofthesuperiorcerebellararteriessupplyingthedentatenucleiandthedeepwhitematterofthecerbellum(12%);andsomewhitematterbranchesofthecerebralarteries(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，嚴重可引起腦疝臨床表現(xiàn)

clinicalmanifestation>50歲高血壓患者(hypertensivepatients)突然發(fā)病,迅速達高峰(suddenlyonset)全腦癥狀(globalsymptom)局灶癥狀(focalsymptom)臨床表現(xiàn)

clinicalmanifestation殼核出血（putamenhemorrhage）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（thalamichemorrhage）腦葉出血（lobehemorrhage）腦干出血（brainstemhemorrhage）中腦出血（midbrainhemorrhage）腦橋出血（pontinehemorrhage）延髓出血（medullaoblongatahemorrhage）小腦出血（cerebellarhemorrhage）腦室出血（cerebroventricularhaemorrhage）診斷與鑒別診斷

diagnosisanddifferentialdiagnosis大于50歲，多有長期高血壓病史(oldpatientswithhypertension)活動中或情緒激動時突然發(fā)病(suddenlyonset)頭痛、嘔吐、意識障礙等全身癥狀(headache,vomitting,impairmentofconsciousness)偏癱、偏身感覺障礙、失語等局灶神經(jīng)體征(hemiparesis,hemisensorydeficit,hemianopia,aphasia)CT見腦內(nèi)出血病灶(CTfindhematomas)與其他類型腦卒中、腦外傷后硬膜下出血、內(nèi)科疾病鑒別治療

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(contralbloodpressure)止血劑和凝血劑(coagulation)手術(shù)治療(surgicalmeasures)并發(fā)癥處理(complication)上消化道出血(uppergastrointestinalhemorrhage)肺部感染(lunginfection)其他恢復期治療康復治療藥物治療蛛網(wǎng)膜下腔出血subarachnoidhemorrhage蛛網(wǎng)膜下腔出血

subarachnoidhemorrhage,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SAHSubarachnoidhemorrhage,SAH—theprimarysubarachnoidhemorrhage.Manyetiologicalfactorsmakecerebralbasalpart,cerebralandspinalcordsurfacebloodvesselsrupture.Followingthese,bloodenterssubarachnoidspace,whichiscalledSAH.Inaddition,succeedingSAHisthatbloodenterssubarachnoidspacewhichiscausedbyrupturingofbloodvesselincerebralparenchyma,epidural,infraduramaterorventricularhemorrhage.病因

etiopathogenisis顱內(nèi)動脈瘤(cerebralarterialaneurysm)，好發(fā)于30歲以上成年人腦動靜脈畸形(intracranialAVMs)，多見于青少年和兒童高血壓腦動脈硬化(hypertention)、腦動脈炎等病理

pathology絕大多數(shù)顱內(nèi)動脈瘤位于前循環(huán)，尤其是Wills環(huán)的動脈分叉處Mostofintracranialaneurysmsoccuranteriorcirculation,speciallyarterycrotchofWillscirculus臨床表現(xiàn)

clinicalmanifestation青壯年多見；突然起??；可有劇烈運動等誘因；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，意識障礙定位體征腦膜刺激征(meningealirritation)眼底改變(subhyaloidretinalhemorrhagess)Theclassicpresentationofsubarachnoidhemorrhageisthesuddenonsetofanunusuallyseveregeneralizedheadache.Lossofconsciousnessisfrequent,asarevomitingandnecckstiffness.臨床表現(xiàn)

clinicalmanifestation并發(fā)癥（complication）再出血(rehemorrhage)，4周內(nèi)，第2周尤多見腦積水（hydrocephalus）腦動脈痙攣(cerebrovascularspasm)，發(fā)病早期或1-2周出現(xiàn)上消化道出血（uppergastrointestinalhemorrhage）發(fā)熱（fever）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，絕對臥床4-6周(Absolutebedrest,mildsedationandanalgesicsforheadache)對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(hydrocepha