出血性脑卒中

《出血性脑卒中》由会员分享，可在线阅读，更多相关《出血性脑卒中（46页珍藏版）》请在金锄头文库上搜索。

1、出血性脑卒中出血性脑卒中hemorrhagic apoplexy中南大学湘雅医院神经内科中南大学湘雅医院神经内科 谷文萍谷文萍Wenping Gu,MD.PhD. Neurology Wenping Gu,MD.PhD. Neurology Department, Xiangya Hospital, central south Department, Xiangya Hospital, central south UniversityUniversity脑出血脑出血cerebral hemorrhage脑出血脑出血cerebral hemorrhagen n是指原发性非外伤性脑实质内出血是指原

2、发性非外伤性脑实质内出血n n80%以上由高血压性脑内细小动脉病变引起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固又称高血压动脉硬化性脑出血n n发病率高，占全部脑卒中发病率高，占全部脑卒中2030n nHypertension is the most common underlying cause of nontraumatic intracerebral hemorrhage病因与发病机制病因与发病机制etiopathogenisis and pathogenesyn n高血压性脑内细小动脉硬化高血压性脑内细小动脉硬化高血压性脑内细小动脉硬化高血压性脑内细小动脉硬化n

3、 n高血压性脑动脉硬化时可有脑内细小动脉透明变性、高血压性脑动脉硬化时可有脑内细小动脉透明变性、高血压性脑动脉硬化时可有脑内细小动脉透明变性、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纤维素样坏死，病变管壁在血流冲击下形成微动脉瘤纤维素样坏死，病变管壁在血流冲击下形成微动脉瘤纤维素样坏死，病变管壁在血流冲击下形成微动脉瘤n nhypertension appears to promote structural hypertension appears to promote structural changes including lipohya

4、linosis, fibrinoid changes including lipohyalinosis, fibrinoid necrosis and microaneurysm formation in the necrosis and microaneurysm formation in the walls of pinetrating arteries,predisposing them to walls of pinetrating arteries,predisposing them to intracerebral hemorrhage.intracerebral hemorrha

5、ge.n n导致脑动脉管壁薄弱的其他疾病导致脑动脉管壁薄弱的其他疾病导致脑动脉管壁薄弱的其他疾病导致脑动脉管壁薄弱的其他疾病n n血液系统疾病血液系统疾病血液系统疾病血液系统疾病n n肿瘤卒中肿瘤卒中肿瘤卒中肿瘤卒中n n原因不明原因不明原因不明原因不明病理病理pathologyn n多为脑动脉深穿支破裂所致多为脑动脉深穿支破裂所致多为脑动脉深穿支破裂所致多为脑动脉深穿支破裂所致n n豆纹动脉最为常见，次为丘脑穿通动脉、基底动脉旁中央支豆纹动脉最为常见，次为丘脑穿通动脉、基底动脉旁中央支豆纹动脉最为常见，次为丘脑穿通动脉、基底动脉旁中央支豆纹动脉最为常见，次为丘脑穿通动脉、基底动脉旁中央支n

6、n多发于大脑半球基底核区，次为脑叶、脑干和小脑多发于大脑半球基底核区，次为脑叶、脑干和小脑多发于大脑半球基底核区，次为脑叶、脑干和小脑多发于大脑半球基底核区，次为脑叶、脑干和小脑n nMost hypertensive hemorrhages originate in certain areas of Most hypertensive hemorrhages originate in certain areas of predilection,corresponding to long,narrow,penetrating predilection,corresponding to long

7、,narrow,penetrating arterial branches.These include the caudate and putaminal arterial branches.These include the caudate and putaminal branches of the middle cerebral arteies(42%);branches of branches of the middle cerebral arteies(42%);branches of the basilar artery supplying the pons(16%);thalami

8、c the basilar artery supplying the pons(16%);thalamic branches of the posterior cerebral arteries(15%);branches of branches of the posterior cerebral arteries(15%);branches of the superior cerebellar arteries supplying the dentate nuclei the superior cerebellar arteries supplying the dentate nuclei

9、and the deep white matter of the cerbellum(12%);and some and the 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出血可直接破坏脑组织出血可直接破坏脑组织出血可直接破坏脑组织出血可直接破坏脑组织n n血肿挤压周围组织，引起脑组织水肿、颅内压增高，严重可引起血肿挤压周围组织

10、，引起脑组织水肿、颅内压增高，严重可引起血肿挤压周围组织，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，严重可引起脑疝脑疝脑疝脑疝临床表现临床表现clinical manifestationn n50岁岁n n高血压患者高血压患者(hypertensive patients)n n突然发病突然发病,迅速达高峰迅速达高峰(suddenly onset)n n全脑症状全脑症状(global symptom)n n局灶症状局灶症状(focal symptom)临床表现临床表现clinical manifestationn n壳核出血（壳核出血（壳核出血（壳核出血

11、（putamen hemorrhageputamen hemorrhage）n n内囊外侧型出血，为高血压性脑出血最常见的类型内囊外侧型出血，为高血压性脑出血最常见的类型内囊外侧型出血，为高血压性脑出血最常见的类型内囊外侧型出血，为高血压性脑出血最常见的类型n n丘脑出血（丘脑出血（丘脑出血（丘脑出血（thalamic hemorrhagethalamic hemorrhage）n n脑叶出血（脑叶出血（脑叶出血（脑叶出血（lobe hemorrhagelobe hemorrhage）n n脑干出血（脑干出血（脑干出血（脑干出血（brain stem hemorrhagebrain stem

12、hemorrhage）n n中脑出血（中脑出血（中脑出血（中脑出血（midbrain hemorrhagemidbrain hemorrhage）n n脑桥出血（脑桥出血（脑桥出血（脑桥出血（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小脑出血（小脑出血（小脑出血（小脑出血（c cerebellar hemorrhageerebellar hemorrhage）n n脑室出血（脑室出血（脑室出血（脑室

13、出血（cerebroventricular haemorrhagecerebroventricular haemorrhage）辅助检查辅助检查laboratory findingsn n头颅头颅CT(CT scan)n n头颅头颅MIRn n脑血管造影脑血管造影(cerebral arteriography)(cerebral arteriography) n nDSADSA、MRAMRA、CTACTAn n腰穿脑脊液检查腰穿脑脊液检查(lumbar puncture)(lumbar puncture)n n血、尿常规、血糖、电解质检查血、尿常规、血糖、电解质检查诊断与鉴别诊断诊断与鉴别诊断

14、diagnosis and differential diagnosisn n大于大于大于大于5050岁，多有长期高血压病史岁，多有长期高血压病史岁，多有长期高血压病史岁，多有长期高血压病史(old patients with (old patients with hypertension)hypertension)n n活动中或情绪激动时突然发病活动中或情绪激动时突然发病活动中或情绪激动时突然发病活动中或情绪激动时突然发病(suddenly onset)(suddenly onset)n n头痛、呕吐、意识障碍等全身症状头痛、呕吐、意识障碍等全身症状头痛、呕吐、意识障碍等全身症状头痛、呕吐、

15、意识障碍等全身症状(headache,vomitting, impairment of (headache,vomitting, impairment of consciousness)consciousness)n n偏瘫、偏身感觉障碍、失语等局灶神经体征偏瘫、偏身感觉障碍、失语等局灶神经体征偏瘫、偏身感觉障碍、失语等局灶神经体征偏瘫、偏身感觉障碍、失语等局灶神经体征(hemiparesis,hemisensory (hemiparesis,hemisensory deficit,hemianopia,aphasia)deficit,hemianopia,aphasia)n nCTCT见脑内

16、出血病灶见脑内出血病灶见脑内出血病灶见脑内出血病灶(CT find hematomas)(CT find hematomas)n n与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病鉴别鉴别鉴别鉴别治疗治疗treatmentn n控制脑水肿、颅高压是降低死亡率的关键控制脑水肿、颅高压是降低死亡率的关键控制脑水肿、颅高压是降低死亡率的关键控制脑水肿、颅高压是降低死亡率的关键n n急性期治疗急性期治疗急性期治疗急性期治疗n n一般治疗一般治疗一般治疗一般治疗n n脱

17、水降颅内压脱水降颅内压脱水降颅内压脱水降颅内压(antiedema)(antiedema)n n调控血压调控血压调控血压调控血压(contral blood pressure)(contral blood pressure)n n止血剂和凝血剂止血剂和凝血剂止血剂和凝血剂止血剂和凝血剂(coagulation)(coagulation)n n手术治疗手术治疗手术治疗手术治疗(surgical measures)(surgical measures)n n并发症处理并发症处理并发症处理并发症处理(complication)(complication)n n上消化道出血上消化道出血上消化道出血上消

18、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恢复期治疗恢复期治疗恢复期治疗恢复期治疗n n康复治疗康复治疗康复治疗康复治疗n n药物治疗药物治疗药物治疗药物治疗预后预后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脑干出血病死率高达70%n n大脑半球出血约为大脑半球出血约为20%n n总病死率为总

19、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%蛛网膜下腔出血蛛网膜下腔出血subarachnoid hemorrhage蛛网膜下腔出血蛛网膜下腔出血subarachnoid hemorrhage,SAHn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SAHnSubarachnoid hemorrhage, SAHthe primary subarachnoid hemorrhage .Man

20、y etiological factors make 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 cerebra

21、l parenchyma, epidural , infradura mater or ventricular hemorrhage.病因病因etiopathogenisisn n颅内动脉瘤颅内动脉瘤(cerebral arterial aneurysm)，好，好发于发于30岁以上成年人岁以上成年人n n脑动静脉畸形脑动静脉畸形(intracranial AVMs)，多见于青，多见于青少年和儿童少年和儿童n n高血压脑动脉硬化高血压脑动脉硬化(hypertention)、脑动脉炎、脑动脉炎等等发病机制发病机制 pathogenesyn n颅内容积增加颅内容积增加颅内容积增加颅内容积增加颅内压增

22、高颅内压增高颅内压增高颅内压增高脑疝脑疝脑疝脑疝n n血液刺激脑膜血液刺激脑膜血液刺激脑膜血液刺激脑膜剧烈头痛及脑膜刺激征剧烈头痛及脑膜刺激征剧烈头痛及脑膜刺激征剧烈头痛及脑膜刺激征n n刺激丘脑下部和脑干刺激丘脑下部和脑干刺激丘脑下部和脑干刺激丘脑下部和脑干高热、植物神经功能紊乱高热、植物神经功能紊乱高热、植物神经功能紊乱高热、植物神经功能紊乱n n急慢性梗阻性脑积水、交通性脑积水急慢性梗阻性脑积水、交通性脑积水急慢性梗阻性脑积水、交通性脑积水急慢性梗阻性脑积水、交通性脑积水n n脑动脉痉挛脑动脉痉挛脑动脉痉挛脑动脉痉挛脑梗死脑梗死脑梗死脑梗死n nRupture of an intracr

23、anial artery elevates Rupture of an intracranial artery elevates intracranial pressure and distorts pain-sensitive intracranial pressure and distorts pain-sensitive structures, producing headache and causing the structures, producing headache and causing the loss of consciousness.loss of consciousne

24、ss.病理病理pathologyn n绝大多数颅内动脉瘤位于前循环，尤其是绝大多数颅内动脉瘤位于前循环，尤其是Wills环的动脉分叉处环的动脉分叉处n nMost of intracranial aneurysms occur anterior circulation , specially artery crotch of Wills circulus临床表现临床表现clinical manifestationn n青壮年多见；突然起病；可有剧烈运动等诱因；少数起病前有头青壮年多见；突然起病；可有剧烈运动等诱因；少数起病前有头青壮年多见；突然起病；可有剧烈运动等诱因；少数起病前有头青壮年多见

25、；突然起病；可有剧烈运动等诱因；少数起病前有头痛、头晕、视物模糊或长期间歇慢性头痛史痛、头晕、视物模糊或长期间歇慢性头痛史痛、头晕、视物模糊或长期间歇慢性头痛史痛、头晕、视物模糊或长期间歇慢性头痛史n n主要症状主要症状主要症状主要症状n n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，意识障碍心、喷射性呕吐，意识障碍心、喷射性呕吐，意识障碍心、喷射性呕吐，意识障碍n n定位体征定位体征定位体征定位体征

26、n n脑膜刺激征脑膜刺激征脑膜刺激征脑膜刺激征(meningeal irritation)(meningeal irritation)n n眼底改变眼底改变眼底改变眼底改变(subhyaloid retinal hemorrhagess)(subhyaloid retinal hemorrhagess)n nThe classic presentation of subarachnoid hemorrhage is the The classic presentation of subarachnoid hemorrhage is the sudden onset of an unusuall

27、y severe generalized 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.临床表现临床表现clinical manifestationn n并发症（并发症（complication）n n再出血再出血再出血再出血(rehem

28、orrhage)(rehemorrhage)，4 4周内，第周内，第周内，第周内，第2 2周尤多见周尤多见周尤多见周尤多见n n脑积水（脑积水（脑积水（脑积水（hydrocephalushydrocephalus）n n脑动脉痉挛脑动脉痉挛脑动脉痉挛脑动脉痉挛(cerebrovascular spasm)(cerebrovascular spasm)，发病，发病，发病，发病早期或早期或早期或早期或1-21-2周出现周出现周出现周出现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 hemor

29、rhagehemorrhage）n n发热（发热（发热（发热（feverfever）辅助检查辅助检查laboratory findingsn n头颅头颅头颅头颅CTCT或或或或MIRMIR检查检查检查检查n nCTCT是诊断蛛网膜下腔出血快速、安全的手段，作为诊是诊断蛛网膜下腔出血快速、安全的手段，作为诊是诊断蛛网膜下腔出血快速、安全的手段，作为诊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断本病的首选检查断本病的首选检查断本病的首选检查n nCT scan will usually confirm that hemorrhage has CT scan will usuall

30、y confirm that hemorrhage has occurred and may help to identify a focal source.occurred and may help to identify a focal source.n n腰穿脑脊液检查腰穿脑脊液检查腰穿脑脊液检查腰穿脑脊液检查(lumbar puncture)(lumbar puncture)n n脑血管造影脑血管造影脑血管造影脑血管造影(cerebral arteriography)(cerebral arteriography)n nDSADSA、MRAMRA、CTACTAn n经颅超声多普勒（经颅

31、超声多普勒（经颅超声多普勒（经颅超声多普勒（TCDTCD）诊断与鉴别诊断诊断与鉴别诊断diagnosis and differential diagnosisn n诊断诊断(diagnosis)n n根据病史、临床表现、根据病史、临床表现、根据病史、临床表现、根据病史、临床表现、CTCT检查和检查和检查和检查和CSFCSF的检查结的检查结的检查结的检查结果，可进行确诊果，可进行确诊果，可进行确诊果，可进行确诊n n鉴别诊断鉴别诊断(differential diagnosis)n n各种原因引起的脑膜炎各种原因引起的脑膜炎各种原因引起的脑膜炎各种原因引起的脑膜炎(meningitis)(men

32、ingitis)n n其他类型的脑卒中其他类型的脑卒中其他类型的脑卒中其他类型的脑卒中(stroke)(stroke)治疗治疗treatmentn n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、防治并发症发症发症发症n n一般治疗一般治疗一般治疗一般治疗n n避免继续出血或再出血诱因，绝对卧床避免继续出血或再出血诱因，绝对卧床避免继续出血或再出血诱因，绝对卧床避免继续出血或再出血诱因，绝对卧床4-64-6周

33、周周周(Absolute bed rest, (Absolute bed rest, mild sedation and analgesics for headache)mild sedation and analgesics for headache)n n对症处理对症处理对症处理对症处理n n止血治疗止血治疗止血治疗止血治疗n n脱水治疗脱水治疗脱水治疗脱水治疗n n脑脊液置换治疗脑脊液置换治疗脑脊液置换治疗脑脊液置换治疗n n病因治疗病因治疗病因治疗病因治疗n n防治并发症防治并发症防治并发症防治并发症（complicationcomplication）n n防治脑积水防治脑积水防治脑积水防治脑积水(hydrocephalus)(hydrocephalus)n n防治脑血管痉挛防治脑血管痉挛防治脑血管痉挛防治脑血管痉挛(vasospasm)(vasospasm)预后预后prognosisn n动脉瘤首次出血约动脉瘤首次出血约25%死亡；再出血约死亡；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脑血管畸形和动脉硬化引起的预后较好脑血管畸形和动脉硬化引起的预后较好