指非外伤性脑实质内出血VIP免费

(CerebralHemorrhage)定义：指非外伤性脑实质内出血DepartmentofNeurology,The2ndaffiliatedhospital,KunmingMedicalcollegeConceptionItmeansprimaryandnontraumaticintracerebralhemorrhage.Countfor20%~30%instrokeHypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage.EtiologyHalfofthepatientssufferfromhypertensioncombinedwitharteriolaratherosclerosis,itisthemostcommoncauseofthedisease.Others：cerebralatherosclerosis,hematopathy,cerebralamyloidangiopathyCAA,aneurysm,AVMPathophysiology高血压——小动脉：纤维素样坏死fibrinoidnecrosis、脂质透明变性hyalinefattychange、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brainedema——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penetratingarteries豆纹动脉lenticulostriateartery：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bleedingarteryPathophysiology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activehemorrhage或早期再出血earlyrebleeding多发性脑出血常继发于：hematopathy,cerebralamyloidangiopathy,neoplasm,vasculitisPathologyHypertensiveICH：基底节的内囊区intercapsule、壳核putamen占70%，脑叶lobe、脑干brainstem、小脑齿状核区各占10%LocationofICH：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subarachnoidspace、第四脑室forthventriclePathologyHypertensiveICH：cerebralpenetratingarterymiliaryaneurysmNonHypertensiveICH：occurinsubcorticalwhitematterwithoutarteriosclerosisPathologySwellingandcongestionofhemisphere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）Clinicalfeaturesage：50~70yearsoldsex：moremalepatientsseason：winterorspringpasthistory：hypertensioninducement：activity、excitementonset：acuteonset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intracranialhypertensionsign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cerebralherniation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”偏瘫hemiplegia偏盲hemiscotosis偏身感觉障碍hemihypesthesia脑叶额叶颞叶顶叶枕叶各具不同缺损脑干交叉性瘫痪hemiplegiaalternate小脑眩晕vertigo共济失调ataxia基底节区的血液供应豆纹动脉的破裂成因ClinicalfeaturesbasalganglionhemorrhageThetwomostcommonsitesofhypertensivehemorrhagearetheputamen(figure1)andthalamus(figure2),whichareseparatedbytheposteriorlimboftheinternalcapsule.Ingeneral,putaminalhemorrhageleadstoamoreseveremotordeficit(hemiplegia)andthalamichemorrhagetoamoremarkedsensorydisturbance(hemianesthesia).ClinicalfeaturesbasalganglionhemorrhageHomonymoushemianopiamayoccurasatransientphenomenonafterthalamichemorrhageandisoftenapersistentfindinginputaminalhemorrhage.Inlargethalamichemorrhages,theeyesmaydeviatedownward,asinstaringatthetipofthenose,becauseofimpingementonthemidbraincenterforupwardgaze.ClinicalfeaturesbasalganglionhemorrhageAphasiamayoccurifhemorrhageateithersiteexertspressureonthecorticallanguageareas.Largehemorrhagesmayleadtoconsciousnessdisturbance,whilemi...