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1、脑 出 血 Intracerebral hemorrhage Department of Neurology, The 2nd affiliated hospital, Harbin Medical UniversityConceptionnIt means primary and nontraumatic intracerebral hemorrhage.nCount for 20%30% in strokenHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage.Et
2、iologynHalf of the patients suffer from hypertension combined with arteriolar atherosclerosis, it is the most common cause of the disease.nOthers：cerebral atherosclerosis, hematopathy, cerebral amyloid angiopathy CAA , aneurysm, AVMPathophysiologyn高血压小动脉：纤维素样坏死 fibrinoid necrosis、脂质透明变性hyaline fatty
3、 change、microaneurysm小动脉瘤、 微夹层动脉瘤渗出exudation、破裂 rupturen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 n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 arteriesn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
4、称为出 血动脉bleeding arteryPathophysiology n一次出血常在30min内停止n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 rebleedingn多发性脑出血常继发于： hematopathy,cerebral amyloid angiopathy,neoplasm,vasculitisPatholog ynHypertensive 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%nLo
5、cation 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 ventriclePathologynHypertensive ICH：cerebral penetrating artery miliary aneurysmnNon Hypertensive ICH：occur in subcortical white matter without arteriosclerosisPathologynSwelling and congestion
6、 of hemispheren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n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 featuresnage：5070 years oldnsex：more male patientsnseason：winter or springnpast history：hypertensionninducement：activity、excitementnonset：acute onsetClinical featuresnHypertensive hemorrhage occurs witho
7、ut warning, most commonly while the patient is awake. nHeadache is present in 50% of patients and may be severe, vomiting is common.nBlood pressure is elevated after the hemorrhage has occurred. Thus, normal or low blood pressure in a patient with stroke makes the diagnosis of hypertensive hemorrhag
8、e unlikely, as does onset before 50 years of age. Clinical features basal ganglion hemorrhagenThe two most common sites of hypertensive hemorrhage are the putamen(figure 1) and thalamus(figure 2), which are separated by the posterior limb of the internal capsule. n In general, putaminal hemorrhage l
9、eads to a more severe motor deficit (hemiplegia) and thalamic hemorrhage to a more marked sensory disturbance (hemianesthesia). Clinical features basal ganglion hemorrhage nHomonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putami
10、nal hemorrhage.n In large thalamic hemorrhages, the eyes may deviate downward, as in staring at the tip of the nose, because of impingement on the midbrain center for upward gaze. Clinical features basal ganglion hemorrhagenAphasia may occur if hemorrhage at either site exerts pressure on the cortic
11、al language areas. nLarge hemorrhages may lead to consciousness disturbance, while minor hemorrhages lead to lacunar syndrome.Clinical features basal ganglion hemorrhagen丘脑出血thalamus hemorrhage:丘脑膝状动脉、穿通动脉破裂，表现为三偏症状 ，不同于壳核之处为均等瘫、深浅感觉障碍、特 征性眼征、意识障碍重、中线症状等 尾状核头出血caput nuclei caudati hemorrhage:少见，仅见脑膜
12、刺激征Clinical features pontine hemorrhage nWith bleeding into the pons(figure 3), coma occurs within seconds to minutes and usually leads to death within 48 hours. nOcular findings typically include pinpoint pupils. Horizontal eyes movements are absent or impaired, but vertical eye movements may be pr
13、eserved. In some patients, there may be ocular bobbing.Clinical features pontine hemorrhagenPatients are commonly quadriparetic or hemiplegia alternate and exhibit decerebrate posturing. Hyperthermia, respiration disorder is sometimes present. nThe hemorrhage usually ruptures into the forth ventricl
14、e, and rostral extension of the hemorrhage into the midbrain with resultant midposition fixed pupils is common. Clinical features midbrain hemorrhagenMidbrain hemorrhage is rarely seen in clinic.nThe patients often manifest Weber syndrome.nLarge hemorrhages may lead to coma and flaccid paralysis.Cli
15、nical features cerebellar hemorrhagen小脑齿状核动脉破裂nThe distinctive symptoms of cerebellar hemorrhage(figure 4) are severe headache, dizziness, vomiting, and the inability to stand or walk, but strength in the limbs is normal.nLarge hemorrhages lead to coma within 12 hours in 75% of patients and within 2
16、4 hours in 90%.They may lead to compression of the brainstem.Clinical features lobar hemorrhagenEtiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumornHypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal, temporal, and occipital lobes(figure 5).nSymptoms and signs vary according to the location; they can include headache, vomiting, hemiparesi
