出血性脑卒中.ppt

出血性出血性脑卒中卒中hemorrhagic apoplexy中南大学湘雅医院神中南大学湘雅医院神经经内科内科 谷文萍谷文萍Wenping Gu,MD.PhD.Neurology Wenping Gu,MD.PhD.Neurology Department,Xiangya Hospital,central Department,Xiangya Hospital,central south Universitysouth University1.脑出血出血cerebral hemorrhage2.脑出血出血cerebral hemorrhagen n是指原是指原发性非外性非外伤性性脑实质内出血内出血n n80%以上由高血以上由高血压性性脑内内细小小动脉病脉病变引起引起,固又称高血固又称高血压动脉硬化性脉硬化性脑出血出血n n发病率高，占全部病率高，占全部脑卒中卒中2030n nHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage3.病因与病因与发病机制病机制etiopathogenisis and pathogenesyn n高血高血高血高血压压性性性性脑脑内内内内细细小小小小动动脉硬化脉硬化脉硬化脉硬化n n高血高血高血高血压压性性性性脑动脑动脉硬化脉硬化脉硬化脉硬化时时可有可有可有可有脑脑内内内内细细小小小小动动脉透明脉透明脉透明脉透明变变性、性、性、性、纤维纤维素素素素样样坏死，病坏死，病坏死，病坏死，病变变管壁在血流冲管壁在血流冲管壁在血流冲管壁在血流冲击击下形成微下形成微下形成微下形成微动动脉瘤脉瘤脉瘤脉瘤n nhypertension appears to promote structural hypertension appears to promote structural changes including lipohyalinosis,fibrinoid changes including lipohyalinosis,fibrinoid necrosis and microaneurysm formation in the necrosis and microaneurysm formation in the walls of pinetrating arteries,predisposing them walls of pinetrating arteries,predisposing them to intracerebral hemorrhage.to intracerebral hemorrhage.n n导导致致致致脑动脑动脉管壁薄弱的其他疾病脉管壁薄弱的其他疾病脉管壁薄弱的其他疾病脉管壁薄弱的其他疾病n n血液系血液系血液系血液系统统疾病疾病疾病疾病n n肿肿瘤卒中瘤卒中瘤卒中瘤卒中n n原因不明原因不明原因不明原因不明4.病理病理pathologyn n多多多多为脑动为脑动脉深穿支破裂所致脉深穿支破裂所致脉深穿支破裂所致脉深穿支破裂所致n n豆豆豆豆纹动纹动脉最脉最脉最脉最为为常常常常见见，次，次，次，次为为丘丘丘丘脑脑穿通穿通穿通穿通动动脉、基底脉、基底脉、基底脉、基底动动脉旁中央支脉旁中央支脉旁中央支脉旁中央支n n多多多多发发于大于大于大于大脑脑半球基底核区，次半球基底核区，次半球基底核区，次半球基底核区，次为脑为脑叶、叶、叶、叶、脑脑干和小干和小干和小干和小脑脑n nMost hypertensive hemorrhages originate in certain Most hypertensive hemorrhages originate in certain areas of predilection,corresponding to areas of predilection,corresponding to long,narrow,penetrating arterial branches.These include long,narrow,penetrating arterial branches.These include the caudate and putaminal branches of the middle the caudate and putaminal branches of the middle cerebral arteies(42%);branches of the basilar artery cerebral arteies(42%);branches of the basilar artery supplying the pons(16%);thalamic branches of the supplying the pons(16%);thalamic branches of the posterior cerebral arteries(15%);branches of the superior posterior cerebral arteries(15%);branches of the superior cerebellar arteries supplying the dentate nuclei and the cerebellar arteries supplying the dentate nuclei and the deep white matter of the cerbellum(12%);and some deep white matter of the cerbellum(12%);and some white matter branches of the cerebral arteries(10%).white matter branches of the cerebral arteries(10%).n n出血可直接破坏出血可直接破坏出血可直接破坏出血可直接破坏脑组织脑组织n n血血血血肿挤压肿挤压周周周周围组织围组织，引起，引起，引起，引起脑组织脑组织水水水水肿肿、颅颅内内内内压压增高，增高，增高，增高，严严重可引起重可引起重可引起重可引起脑脑疝疝疝疝5.临床表床表现clinical manifestationn n50岁n n高血高血压患者患者(hypertensive patients)n n突然突然发病病,迅速达高峰迅速达高峰(suddenly onset)n n全全脑症状症状(global symptom)n n局灶症状局灶症状(focal symptom)6.临床表床表现clinical manifestationn n壳核出血（壳核出血（壳核出血（壳核出血（putamen hemorrhageputamen hemorrhage）n n内囊外内囊外内囊外内囊外侧侧型出血，型出血，型出血，型出血，为为高血高血高血高血压压性性性性脑脑出血最常出血最常出血最常出血最常见见的的的的类类型型型型n n丘丘丘丘脑脑出血（出血（出血（出血（thalamic hemorrhagethalamic hemorrhage）n n脑脑叶出血（叶出血（叶出血（叶出血（lobe hemorrhagelobe hemorrhage）n n脑脑干出血（干出血（干出血（干出血（brain stem hemorrhagebrain stem hemorrhage）n n中中中中脑脑出血（出血（出血（出血（midbrain hemorrhagemidbrain hemorrhage）n n脑桥脑桥出血（出血（出血（出血（pontine hemorrhagepontine hemorrhage）n n延髓出血（延髓出血（延髓出血（延髓出血（medulla oblongata hemorrhagemedulla oblongata hemorrhage）n n小小小小脑脑出血（出血（出血（出血（c cerebellar hemorrhageerebellar hemorrhage）n n脑脑室出血（室出血（室出血（室出血（cerebroventricular haemorrhagecerebroventricular haemorrhage）7.辅助助检查laboratory findingsn n头颅CT(CT scan)n n头颅MIRn n脑血管造影血管造影(cerebral arteriography)(cerebral arteriography)n nDSADSA、MRAMRA、CTACTAn n腰穿腰穿脑脊液脊液检查(lumbar puncture)(lumbar puncture)n n血、尿常血、尿常规、血糖、血糖、电解解质检查8.9.10.11.12.13.诊断与断与鉴别诊断断diagnosis and differential diagnosisn n大于大于大于大于5050岁岁，多有，多有，多有，多有长长期高血期高血期高血期高血压压病史病史病史病史(old patients with(old patients with hypertension)hypertension)n n活活活活动动中或情中或情中或情中或情绪绪激激激激动时动时突然突然突然突然发发病病病病(suddenly onset)(suddenly onset)n n头头痛、呕吐、意痛、呕吐、意痛、呕吐、意痛、呕吐、意识识障碍等全身症状障碍等全身症状障碍等全身症状障碍等全身症状(headache,vomitting,impairment of(headache,vomitting,impairment of consciousness)consciousness)n n偏偏偏偏瘫瘫、偏身感、偏身感、偏身感、偏身感觉觉障碍、失障碍、失障碍、失障碍、失语语等局灶神等局灶神等局灶神等局灶神经经体征体征体征体征(hemiparesis,hemisensory(hemiparesis,hemisensory deficit,hemianopia,aphasia)deficit,hemianopia,aphasia)n nCTCT见脑见脑内出血病灶内出血病灶内出血病灶内出血病灶(CT find hematomas)(CT find hematomas)n n与其他与其他与其他与其他类类型型型型脑脑卒中、卒中、卒中、卒中、脑脑外外外外伤伤后硬膜下出血、内科疾病后硬膜下出血、内科疾病后硬膜下出血、内科疾病后硬膜下出血、内科疾病鉴别鉴别14.治治疗treatmentn n控制控制控制控制脑脑水水水水肿肿、颅颅高高高高压压是降低死亡率的关是降低死亡率的关是降低死亡率的关是降低死亡率的关键键n n急性期治急性期治急性期治急性期治疗疗n n一般治一般治一般治一般治疗疗n n脱水降脱水降脱水降脱水降颅颅内内内内压压(antiedema)(antiedema)n n调调控血控血控血控血压压(contral blood pressure)(contral blood pressure)n n止血止血止血止血剂剂和凝血和凝血和凝血和凝血剂剂(coagulation)(coagulation)n n手手手手术术治治治治疗疗(surgical measures)(surgical measures)n n并并并并发发症症症症处处理理理理(complication)(complication)n n上消化道出血上消化道出血上消化道出血上消化道出血(upper gastrointestinal hemorrhage)(upper gastrointestinal hemorrhage)n n肺部感染肺部感染肺部感染肺部感染(lung infection)(lung infection)n n其他其他其他其他n n恢复期治恢复期治恢复期治恢复期治疗疗n n康复治康复治康复治康复治疗疗n n药药物治物治物治物治疗疗15.预后后prognosisn n出血量大、全身情况差者，病死率高出血量大、全身情况差者，病死率高n n脑干出血病死率高达干出血病死率高达70%n n大大脑半球出血半球出血约为20%n n总病死率病死率为30%40%n n存活患者中，病残率达存活患者中，病残率达70%16.蛛网膜下腔出血蛛网膜下腔出血subarachnoid hemorrhage17.蛛网膜下腔出血蛛网膜下腔出血subarachnoid hemorrhage,SAHn n蛛网膜下腔出血是多种病因所致蛛网膜下腔出血是多种病因所致脑脑底部或底部或脑脑及脊髓表面血及脊髓表面血管破裂的急性出血性管破裂的急性出血性脑脑血管病，血液直接流入蛛网膜下腔，血管病，血液直接流入蛛网膜下腔，又称原又称原发发性性SAH SAH。此外，。此外，临临床床还还可可见见因因脑实质脑实质内、内、脑脑室室出血、硬膜外或硬膜下血管破裂等血液穿破出血、硬膜外或硬膜下血管破裂等血液穿破脑组织脑组织流入蛛流入蛛网膜下腔者，称网膜下腔者，称为继发为继发性性SAHSAHn nSubarachnoid hemorrhage,SAHthe primary Subarachnoid hemorrhage,SAHthe primary subarachnoid hemorrhage.Many etiological factors subarachnoid hemorrhage.Many etiological factors make cerebral basal part,cerebral and spinal cord make cerebral basal part,cerebral and spinal cord surface blood vessels rupture.Following these surface blood vessels rupture.Following these,blood enters subarachnoid space,which is called,blood enters subarachnoid space,which is called SAH.In addition,succeeding SAH is that blood SAH.In addition,succeeding SAH is that blood enters subarachnoid space which is caused by enters subarachnoid space which is caused by rupturing of blood vessel in cerebral parenchyma,rupturing of blood vessel in cerebral parenchyma,epidural,infradura mater or ventricular hemorrhageepidural,infradura mater or ventricular hemorrhage.18.病因病因etiopathogenisisn n颅内内动脉瘤脉瘤(cerebral arterial aneurysm)，好好发于于30岁以上成年人以上成年人n n脑动静脉畸形静脉畸形(intracranial AVMs)，多，多见于于青少年和儿童青少年和儿童n n高血高血压脑动脉硬化脉硬化(hypertention)、脑动脉脉炎等炎等19.发病机制病机制 pathogenesyn n颅颅内容内容内容内容积积增加增加增加增加 颅颅内内内内压压增高增高增高增高 脑脑疝疝疝疝n n血液刺激血液刺激血液刺激血液刺激脑脑膜膜膜膜 剧剧烈烈烈烈头头痛及痛及痛及痛及脑脑膜刺激征膜刺激征膜刺激征膜刺激征n n刺激丘刺激丘刺激丘刺激丘脑脑下部和下部和下部和下部和脑脑干干干干 高高高高热热、植物神、植物神、植物神、植物神经经功能紊乱功能紊乱功能紊乱功能紊乱n n急慢性梗阻性急慢性梗阻性急慢性梗阻性急慢性梗阻性脑积脑积水、交通性水、交通性水、交通性水、交通性脑积脑积水水水水n n脑动脑动脉脉脉脉痉挛痉挛 脑脑梗死梗死梗死梗死n nRupture of an intracranial artery elevates Rupture of an intracranial artery elevates intracranial pressure and distorts pain-intracranial pressure and distorts pain-sensitive structures,producing headache and sensitive structures,producing headache and causing the loss of consciousness.causing the loss of consciousness.20.病理病理pathologyn n绝大多数大多数颅内内动脉瘤位于前循脉瘤位于前循环，尤其是，尤其是Wills环的的动脉分叉脉分叉处n nMost of intracranial aneurysms occur anterior circulation,specially artery crotch of Wills circulus21.临床表床表现clinical manifestationn n青壮年多青壮年多青壮年多青壮年多见见；突然起病；可有；突然起病；可有；突然起病；可有；突然起病；可有剧剧烈运烈运烈运烈运动动等等等等诱诱因；少数起病前有因；少数起病前有因；少数起病前有因；少数起病前有头头痛、痛、痛、痛、头晕头晕、视视物模糊或物模糊或物模糊或物模糊或长长期期期期间间歇慢性歇慢性歇慢性歇慢性头头痛史痛史痛史痛史n n主要症状主要症状主要症状主要症状n n突然突然突然突然发发生的生的生的生的头头部部部部剧剧烈烈烈烈胀胀痛，位于前痛，位于前痛，位于前痛，位于前额额、枕部或全、枕部或全、枕部或全、枕部或全头头部，常伴有部，常伴有部，常伴有部，常伴有恶恶心、心、心、心、喷喷射性呕吐，意射性呕吐，意射性呕吐，意射性呕吐，意识识障碍障碍障碍障碍n n定位体征定位体征定位体征定位体征n n脑脑膜刺激征膜刺激征膜刺激征膜刺激征(meningeal irritation)(meningeal irritation)n n眼底改眼底改眼底改眼底改变变(subhyaloid retinal hemorrhagess)(subhyaloid retinal hemorrhagess)n nThe classic presentation of subarachnoid hemorrhage is The classic presentation of subarachnoid hemorrhage is the sudden onset of an unusually severe generalized the sudden onset of an unusually severe generalized headache.Loss of consciousness is frequent,as are headache.Loss of consciousness is frequent,as are vomiting and necckstiffness.vomiting and necckstiffness.22.临床表床表现clinical manifestationn n并并发症（症（complication）n n再出血再出血再出血再出血(rehemorrhage)(rehemorrhage)，4 4周内，第周内，第周内，第周内，第2 2周尤多周尤多周尤多周尤多见见n n脑积脑积水（水（水（水（hydrocephalushydrocephalus）n n脑动脑动脉脉脉脉痉挛痉挛(cerebrovascular spasm)(cerebrovascular spasm)，发发病病病病早期或早期或早期或早期或1-21-2周出周出周出周出现现n n上消化道出血（上消化道出血（上消化道出血（上消化道出血（upper gastrointestinal upper gastrointestinal hemorrhagehemorrhage）n n发热发热（feverfever）23.辅助助检查laboratory findingsn n头颅头颅CTCT或或或或MIRMIR检查检查n nCTCT是是是是诊诊断蛛网膜下腔出血快速、安全的手段，作断蛛网膜下腔出血快速、安全的手段，作断蛛网膜下腔出血快速、安全的手段，作断蛛网膜下腔出血快速、安全的手段，作为诊为诊断本病的首断本病的首断本病的首断本病的首选检查选检查n nCT scan will usually confirm that hemorrhage CT scan will usually confirm that hemorrhage has occurred and may help to identify a focal has occurred and may help to identify a focal source.source.n n腰穿腰穿腰穿腰穿脑脑脊液脊液脊液脊液检查检查(lumbar puncture)(lumbar puncture)n n脑脑血管造影血管造影血管造影血管造影(cerebral arteriography)(cerebral arteriography)n nDSADSA、MRAMRA、CTACTAn n经颅经颅超声多普勒（超声多普勒（超声多普勒（超声多普勒（TCDTCD）24.2024/4/17 周三25.26.27.28.诊断与断与鉴别诊断断diagnosis and differential diagnosisn n诊断断(diagnosis)n n根据病史、根据病史、根据病史、根据病史、临临床表床表床表床表现现、CTCT检查检查和和和和CSFCSF的的的的检查结检查结果，可果，可果，可果，可进进行确行确行确行确诊诊n n鉴别诊断断(differential diagnosis)n n各种原因引起的各种原因引起的各种原因引起的各种原因引起的脑脑膜炎膜炎膜炎膜炎(meningitis)(meningitis)n n其他其他其他其他类类型的型的型的型的脑脑卒中卒中卒中卒中(stroke)(stroke)29.治治疗treatmentn n急性期治急性期治急性期治急性期治疗疗原原原原则则上是制止上是制止上是制止上是制止继续继续出血、降低出血、降低出血、降低出血、降低颅颅内内内内压压、去除病因、防治并、去除病因、防治并、去除病因、防治并、去除病因、防治并发发症症症症n n一般治一般治一般治一般治疗疗n n避免避免避免避免继续继续出血或再出血出血或再出血出血或再出血出血或再出血诱诱因，因，因，因，绝对绝对卧床卧床卧床卧床4-64-6周周周周(Absolute bed(Absolute bed rest,mild sedation and analgesics for headache)rest,mild sedation and analgesics for headache)n n对对症症症症处处理理理理n n止血治止血治止血治止血治疗疗n n脱水治脱水治脱水治脱水治疗疗n n脑脑脊液置脊液置脊液置脊液置换换治治治治疗疗n n病因治病因治病因治病因治疗疗n n防治并防治并防治并防治并发发症症症症（complicationcomplication）n n防治防治防治防治脑积脑积水水水水(hydrocephalus)(hydrocephalus)n n防治防治防治防治脑脑血管血管血管血管痉挛痉挛(vasospasm)(vasospasm)30.预后后prognosisn n动脉瘤首次出血脉瘤首次出血约25%死亡；再出血死亡；再出血约40%，第二次出血病死率，第二次出血病死率50%n n25%die subsequently from the initial hemorrhage or ite complications,and 40%die fron rebleeding.n n脑血管畸形和血管畸形和动脉硬化引起的脉硬化引起的预后后较好好31.32.33.34.35.36.37.38.39.40.41.42.43.44.45.46.47.2024/4/17 周三48.