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1、Cerebral hemorrhage,Etiology and pathogenesis,Hypertension and arteriosclerosisAtherosclerosis,bleeding tendency(hemophilia,leukemia,aplastic anemia,thrombocytopenia),congenital angiomatous malformation,arteritis,tumorlenticulostriate arteries vertical to MCAMicroaneurysms rupture,Pathology,Site:bas
2、al 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 capsule,Clinical feature,Age:50-70Male femaleOccur at physical exertion
3、 or excitementSudden onset of focal signsUsually accompanied by headache and vomiting May have consciousness disturbance,1.Putamen hemorrhagecontralateral hemiplegia,hemianesthesia,and hemianopiaEyes are frequently deviated toward the side of the affected hemisphereAphasia if dominant hemisphere is
4、affected,Clinical feature,2.Thalamus hemorrhage contralateral hemiplegia,hemianesthesia,and hemianopiaDeep sensation disturbanceOcular signsDisturbance of consciousness,Clinical feature,3.Pontine hemorrhageMild:crossed paralysisSevere(5ml)coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hours
5、,Clinical feature,4.Cerebellar hemorrhageOccipital headache,intense vertigo and repeated vomiting,ataxia,nystagmusSevere cerebellar hemorrhage:coma,compression of brain stem,tonsillar herniation,Clinical feature,5.Lobar hemorrhageSeen in AVM,Moyamoya disease,Headache,vomiting,neck stiffnessSeizureFo
6、cal signs,Clinical feature,Investigation,1.CTFirst choiceHigh density bloodMass effect and edemaHigh density isodensity low density,2.MRIBrain stem hemorrhage24h,not distinguishable with thrombosis3.DSAYoung and with normal blood pressure4.CSFBloodyDone only when the CT is not available and without
7、increased ICP,Investigation,Diagnosis,Age 50,with hypertensionSudden onset of headache,vomiting,focal signOccur at physical exertion or excitementCT:high density blood,Differential diagnosis,Coma:poisoning,hypoglycemia,hepatic or diabetic comaFocal signs:cerebral infarction,brain tumor,subdural hema
8、toma,SAH,Treatment,1.Keep rest,monitoring,air way,good nursing2.Keep electrolytes and fluid balance.3.Reduce ICP:20%Mannitol 125-250ml,3 to 4 times per dayFurosemide,albumin,dexamathasone,4.Control hypertension:180/105mmHg in acute stage,ACEI,beta-blocker5.Prevent complications:Infection:antibiotics
9、gastric hemorrhage:Cimetidine,LosecVenous thrombosis:heparin,Treatment,6.Surgical therapy:Putamen,lobar:40-50 ml,deterioratingCerebellum:15ml,diameter3cmThalamus:obstructive hydrocephalus ventricular drainage 7.Rehabilitation,Treatment,Subarachnoid hemorrhageSAH,SAH,Cranial bone dura mater arachnoid
10、 pia mater brain lobePrimary spontaneous SAHTraumatic SAHSecondary to cerebral hemorrhage,Etiology,1.Intracranial saccular aneurysm 2.AVM(arteriovenous malformation)3.Hypertension and atherosclerosis4.Moyamoya disease5.Mycotic aneurysm,tumor,polyarteritis nodasa,bleeding disease,Pathology,Anterior c
11、erebral and anterior communicating Internal carotid Middle cerebralBasilar,Clinical feature,1.Age of onset:Saccular aneurysm:adult 30-60AVM:juvenile Hypertension:more than 602.Prodromal symptomsWarning leaks:headache,vomitingCranial nerve paralysis:oculomotor,3.Acute SAHSudden onset of severe headac
12、he:“explode,burst,the worst of my life”VomitingAssociated with physical exertion,excitementTransient loss of consciousness or comaPain of neck,back,legMental symptoms:apathy,lethargy,delirium,Clinical feature,3.Acute SAHSigns of meningeal irritation:neck stiffness,positive Kernigs signFundus examina
13、tion:papilloedema,sub-hyaloid hemorrhageCranial nerve palsy,Clinical feature,4.Delayed neurologic deficitsRerupture: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 disturban
14、ce of consciousness and focal signsHydrocephalus:2-3 weeks after SAH,gait difficulty,incontinence,dementia,Clinical feature,Investigation,1.CTSubarachnoid clot in 75%of cases,2.CSFUniformly blood-stainedXanthochromia:12 hours to 2-3 weeks ICP 3.DSA:etiologic diagnosis,important to surgery4.MRA,CTA,I
15、nvestigation,Diagnosis,Sudden onset of severe headache,vomitingNeck stiffness,positive Kernigs signUniformly blood stained CSFCT shows subarachnoid clot,Differential diagnosis,Cerebral hemorrhageMeningitisTumorPsychosis,Treatment,1.General management Absolute bed rest for 4-6 weeksPrevent constipation,excitementSedatives and analgesics2.Reduce ICPMannitol,Furosemide,albumin,3.Prevent reruptureAntifibrinolytic drugs:EACA for 3 weeks4.Prevent cerebrovascular spasmNimodipine,flunarizine5.Lumbar puncture to replace CSF6.Surgery:within 24-72 hours,Treatment,
