指非外伤性脑实质内出血.ppt

(Cerebral Hemorrhage)定义： 指非外伤性脑实质内出血脑 出 血Department of Neurology, The 2nd affiliated hospital, Kunming Medical college ConceptionIt means primary and nontraumatic intracerebral hemorrhage.Count for 20%~30% in strokeHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage. EtiologyHalf of the patients suffer from hypertension combined with arteriolar atherosclerosis, it is the most common cause of the disease.Others：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy CAA , aneurysm, AVM Pathophysiology高血压——小动脉：纤维素样坏死fibrinoid necrosis、脂质透明变性hyaline fatty change、microaneurysm小动脉瘤、微夹层动脉瘤——渗出exudation、破裂rupture高血压——远端血管痉挛vasospasm——缺氧anoxia、坏死angio-necrosis、血栓形成thrombosis——斑点状出血、脑水肿brain edema——融合成片(子痫) Pathophysiology 脑内动脉：壁薄、中层肌细胞及外膜结缔组织少、缺乏外弹力层——随年龄增长弯曲呈螺旋状——出血主要部位：深穿支penetrating arteries豆纹动脉lenticulostriate artery：大脑中动脉呈直角分出，易发生粟粒状动脉瘤，为脑出血最好发部位，其外侧支称为出血动脉bleeding artery Pathophysiology 一次出血常在30min内停止头CT动态观察：20%-40%患者24小时内血肿仍继续扩大，为活动性出血active hemorrhage或早期再出血early rebleeding多发性脑出血常继发于：hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitis PathologyHypertensive ICH：基底节的内囊区inter capsule、壳核putamen占70%，脑叶lobe、脑干brainstem、小脑齿状核区各占10%Location of ICH：壳核（内囊、侧脑室），丘脑thalamus（第三脑室、内囊、侧脑室），脑桥pons、小脑cerebellum、蛛网膜下腔subarachnoid space、第四脑室forth ventricle PathologyHypertensive ICH：cerebral penetrating artery miliary aneurysmNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosis PathologySwelling and congestion of hemisphere出血灶：充满血液的空腔，周围是坏死脑组织及淤点状出血性软化带、脑水肿血块溶解——吞噬细胞清除含铁血黄素和坏死脑组织——胶质增生（胶质瘢痕或中风囊） Clinical featuresage：50~70 years oldsex：more male patientsseason：winter or springpast history：hypertensioninducement：activity、excitementonset：acute onset 临 床 表 现一般症状：中年以上发病。起病突然， 动态起病，病势凶险。高颅压征 intracranial hypertension sign 头痛，呕吐，血压升高，脉搏减慢， 视乳头水肿，意识障碍 易形成脑疝 cerebral herniation神经系统定位体征： 取决于血肿的部位、体积 局灶性神经功能缺损基底节区：内囊“三偏征”