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1、出血性脑卒中hemorrhagic apoplexy,中南大学湘雅医院神经内科 谷文萍Wenping Gu,MD.PhD.Neurology Department,Xiangya Hospital,central south University,脑出血cerebral hemorrhage,脑出血cerebral hemorrhage,是指原发性非外伤性脑实质内出血80%以上由高血压性脑内细小动脉病变引起,固又称高血压动脉硬化性脑出血发病率高，占全部脑卒中2030Hypertension is the most common underlying cause of nontraumatic
2、intracerebral hemorrhage,病因与发病机制etiopathogenisis and pathogenesy,高血压性脑内细小动脉硬化高血压性脑动脉硬化时可有脑内细小动脉透明变性、纤维素样坏死，病变管壁在血流冲击下形成微动脉瘤hypertension appears to promote structural changes including lipohyalinosis,fibrinoid necrosis and microaneurysm formation in the walls of pinetrating arteries,predisposing them
3、 to intracerebral hemorrhage.导致脑动脉管壁薄弱的其他疾病血液系统疾病肿瘤卒中原因不明,病理pathology,多为脑动脉深穿支破裂所致豆纹动脉最为常见，次为丘脑穿通动脉、基底动脉旁中央支多发于大脑半球基底核区，次为脑叶、脑干和小脑Most hypertensive hemorrhages originate in certain areas of predilection,corresponding to long,narrow,penetrating arterial branches.These include the caudate and putamina
4、l branches of the middle cerebral arteies(42%);branches of the basilar artery supplying the pons(16%);thalamic branches of the posterior cerebral arteries(15%);branches of the superior cerebellar arteries supplying the dentate nuclei and the deep white matter of the cerbellum(12%);and some white mat
5、ter branches of the cerebral arteries(10%).出血可直接破坏脑组织血肿挤压周围组织，引起脑组织水肿、颅内压增高，严重可引起脑疝,临床表现clinical manifestation,50岁高血压患者(hypertensive patients)突然发病,迅速达高峰(suddenly onset)全脑症状(global symptom)局灶症状(focal symptom),临床表现clinical manifestation,壳核出血（putamen hemorrhage）内囊外侧型出血，为高血压性脑出血最常见的类型丘脑出血（thalamic hemor
6、rhage）脑叶出血（lobe hemorrhage）脑干出血（brain stem hemorrhage）中脑出血（midbrain hemorrhage）脑桥出血（pontine hemorrhage）延髓出血（medulla oblongata hemorrhage）小脑出血（cerebellar hemorrhage）脑室出血（cerebroventricular haemorrhage）,辅助检查laboratory findings,头颅CT(CT scan)头颅MIR脑血管造影(cerebral arteriography)DSA、MRA、CTA腰穿脑脊液检查(lumbar pu
7、ncture)血、尿常规、血糖、电解质检查,诊断与鉴别诊断diagnosis and differential diagnosis,大于50岁，多有长期高血压病史(old patients with hypertension)活动中或情绪激动时突然发病(suddenly onset)头痛、呕吐、意识障碍等全身症状(headache,vomitting,impairment of consciousness)偏瘫、偏身感觉障碍、失语等局灶神经体征(hemiparesis,hemisensory deficit,hemianopia,aphasia)CT见脑内出血病灶(CT find hemato
8、mas)与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病鉴别,治疗treatment,控制脑水肿、颅高压是降低死亡率的关键急性期治疗一般治疗脱水降颅内压(antiedema)调控血压(contral blood pressure)止血剂和凝血剂(coagulation)手术治疗(surgical measures)并发症处理(complication)上消化道出血(upper gastrointestinal hemorrhage)肺部感染(lung infection)其他恢复期治疗康复治疗药物治疗,预后prognosis,出血量大、全身情况差者，病死率高脑干出血病死率高达70%大脑半球出血约
9、为20%总病死率为30%40%存活患者中，病残率达70%,蛛网膜下腔出血,subarachnoid hemorrhage,蛛网膜下腔出血subarachnoid hemorrhage,SAH,蛛网膜下腔出血是多种病因所致脑底部或脑及脊髓表面血管破裂的急性出血性脑血管病，血液直接流入蛛网膜下腔，又称原发性SAH。此外，临床还可见因脑实质内、脑室出血、硬膜外或硬膜下血管破裂等血液穿破脑组织流入蛛网膜下腔者，称为继发性SAHSubarachnoid hemorrhage,SAHthe primary subarachnoid hemorrhage.Many etiological factors m
10、ake cerebral basal part,cerebral and spinal cord surface blood vessels rupture.Following these,blood enters subarachnoid space,which is called SAH.In addition,succeeding SAH is that blood enters subarachnoid space which is caused by rupturing of blood vessel in cerebral parenchyma,epidural,infradura
11、 mater or ventricular hemorrhage.,病因etiopathogenisis,颅内动脉瘤(cerebral arterial aneurysm)，好发于30岁以上成年人脑动静脉畸形(intracranial AVMs)，多见于青少年和儿童高血压脑动脉硬化(hypertention)、脑动脉炎等,发病机制 pathogenesy,颅内容积增加 颅内压增高 脑疝血液刺激脑膜 剧烈头痛及脑膜刺激征刺激丘脑下部和脑干 高热、植物神经功能紊乱急慢性梗阻性脑积水、交通性脑积水脑动脉痉挛 脑梗死Rupture of an intracranial artery elevates
12、intracranial pressure and distorts pain-sensitive structures,producing headache and causing the loss of consciousness.,病理pathology,绝大多数颅内动脉瘤位于前循环，尤其是Wills环的动脉分叉处Most of intracranial aneurysms occur anterior circulation,specially artery crotch of Wills circulus,临床表现clinical manifestation,青壮年多见；突然起病；可
13、有剧烈运动等诱因；少数起病前有头痛、头晕、视物模糊或长期间歇慢性头痛史主要症状突然发生的头部剧烈胀痛，位于前额、枕部或全头部，常伴有恶心、喷射性呕吐，意识障碍定位体征脑膜刺激征(meningeal irritation)眼底改变(subhyaloid retinal hemorrhagess)The classic presentation of subarachnoid hemorrhage is the sudden onset of an unusually severe generalized headache.Loss of consciousness is frequent,as
14、are vomiting and necckstiffness.,临床表现clinical manifestation,并发症（complication）再出血(rehemorrhage)，4周内，第2周尤多见脑积水（hydrocephalus）脑动脉痉挛(cerebrovascular spasm)，发病早期或1-2周出现上消化道出血（upper gastrointestinal hemorrhage）发热（fever）,辅助检查laboratory findings,头颅CT或MIR检查CT是诊断蛛网膜下腔出血快速、安全的手段，作为诊断本病的首选检查CT scan will usually
15、 confirm that hemorrhage has occurred and may help to identify a focal source.腰穿脑脊液检查(lumbar puncture)脑血管造影(cerebral arteriography)DSA、MRA、CTA经颅超声多普勒（TCD）,诊断与鉴别诊断diagnosis and differential diagnosis,诊断(diagnosis)根据病史、临床表现、CT检查和CSF的检查结果，可进行确诊鉴别诊断(differential diagnosis)各种原因引起的脑膜炎(meningitis)其他类型的脑卒中(
16、stroke),治疗treatment,急性期治疗原则上是制止继续出血、降低颅内压、去除病因、防治并发症一般治疗避免继续出血或再出血诱因，绝对卧床4-6周(Absolute bed rest,mild sedation and analgesics for headache)对症处理止血治疗脱水治疗脑脊液置换治疗病因治疗防治并发症（complication）防治脑积水(hydrocephalus)防治脑血管痉挛(vasospasm),预后prognosis,动脉瘤首次出血约25%死亡；再出血约40%，第二次出血病死率50%25%die subsequently from the initial hemorrhage or ite complications,and 40%die fron rebleeding.脑血管畸形和动脉硬化引起的预后较好,
