出血性脑卒中

出血性脑卒中hemorrhagicapoplexy中南大学湘雅医院神经内科谷文萍WenpingGu,MD.PhD.NeurologyDepartment,XiangyaHospital,centralsouthUniversity脑出血cerebralhemorrhage脑出血cerebralhemorrhage是指原发性非外伤性脑实质内出血80%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发病率高，占全部脑卒中20％—30％Hypertensionisthemostcommonunderlyingcauseofnontraumaticintracerebralhemorrhage病因与发病机制etiopathogenisisandpathogenesy高血压性脑内细小动脉硬化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hypertensionappearstopromotestructuralchangesincludinglipohyalinosis,fibrinoidnecrosisandmicroaneurysmformationinthewallsofpinetratingarteries,predisposingthemtointracerebralhemorrhage.导致脑动脉管壁薄弱的其他疾病血液系统疾病肿瘤卒中原因不明病理pathology多为脑动脉深穿支破裂所致豆纹动脉最为常见，次为丘脑穿通动脉、基底动脉旁中央支多发于大脑半球基底核区，次为脑叶、脑干和小脑Mosthypertensivehemorrhagesoriginateincertainareasofpredilection,correspondingtolong,narrow,penetratingarterialbranches.Theseincludethecaudateandputaminalbranchesofthemiddlecerebralarteies(42%);branchesofthebasilararterysupplyingthepons(16%);thalamicbranchesoftheposteriorcerebralarteries(15%);branchesofthesuperiorcerebellararteriessupplyingthedentatenucleiandthedeepwhitematterofthecerbellum(12%);andsomewhitematterbranchesofthecerebralarteries(10%).出血可直接破坏脑组织血肿挤压周围组织，引起脑组织水肿、颅内压增高，严重可引起脑疝临床表现clinicalmanifestation50岁高血压患者(hypertensivepatients)突然发病,迅速达高峰(suddenlyonset)全脑症状(globalsymptom)局灶症状(focalsymptom)临床表现clinicalmanifestation壳核出血（putamenhemorrhage）内囊外侧型出血，为高血压性脑出血最常见的类型丘脑出血（thalamichemorrhage）脑叶出血（lobehemorrhage）脑干出血（brainstemhemorrhage）中脑出血（midbrainhemorrhage）脑桥出血（pontinehemorrhage）延髓出血（medullaoblongatahemorrhage）小脑出血（cerebellarhemorrhage）脑室出血（cerebroventricularhaemorrhage）辅助检查laboratoryfindings头颅CT(CTscan)头颅MIR脑血管造影(cerebralarteriography)DSA、MRA、CTA腰穿脑脊液检查(lumbarpuncture)血、尿常规、血糖、电解质检查诊断与鉴别诊断diagnosisanddifferentialdiagnosis大于50岁，多有长期高血压病史(oldpatientswithhypertension)活动中或情绪激动时突然发病(suddenlyonset)头痛、呕吐、意识障碍等全身症状(headache,vomitting,impairmentofconsciousness)偏瘫、偏身感觉障碍、失语等局灶神经体征(hemiparesis,hemisensorydeficit,hemianopia,aphasia)CT见脑内出血病灶(CTfindhematomas)与其他类型脑卒中、脑外伤后硬膜下出血、内科疾病鉴别治疗treatment控制脑水肿、颅高压是降低死亡率的关键急性期治疗一般治疗脱水降颅内压(antiedema)调控血压(contralbloodpressure)止血剂和凝血剂(coagulation)手术治疗(surgicalmeasures)并发症处理(complication)上消化道出血(uppergastrointestinalhemorrhage)肺部感染(lunginfection)其他恢复期治疗康复治疗药物治疗预后prognosis出血量大、全身情况差者，病死率高脑干出血病死率高达70%大脑半球出血约为20%总病死率为30%~40%存活患者中，病残率达70%蛛网膜下腔出血subarachnoidhemorrhage蛛网膜下腔出血subarachnoidhemorrhage,SAH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SAHSubarachnoidhemorrhage,SAH—theprimarysubarachnoidhemorrhage.Manyetiologicalfactorsmakecerebralbasalpart,cerebralandspinalcordsurfacebloodvesselsrupture.Followingthese,bloodenterssubarachnoidspace,whichiscalledSAH.Inaddition,succeedingSAHisthatbloodenterssubarachnoidspacewhichiscausedbyrupturingofbloodvesselincerebralparenchyma,epidural,infraduramaterorventricularhemorrhage.病因etiopathogenisis颅内动脉瘤(cerebralarterialaneurysm)，好发于30岁以上成年人脑动静脉畸形(intracranialAVMs)，多见于青少年和儿童高血压脑动脉硬化(hypertention)、脑动脉炎等发病机制pathogenesy颅内容积增加颅内压增高脑疝血液刺激脑膜剧烈头痛及脑膜刺激征刺激丘脑下部和脑干高热、植物神经功能紊乱急慢性梗阻性脑积水、交通性脑积水脑动脉痉挛脑梗死Ruptureofanintracranialarteryelevatesintracranialpressureanddistortspain-sensitivestructures,producingheadacheandcausingthelossofconsciousness.病理pathology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Mostofintracranialaneurysmsoccuranteriorcirculation,speciallyarterycrotchofWillscirculus临床表现clinicalmanifestation青壮年多见；突然起病；可有剧烈运动等诱因；少数起病前有头痛、头晕、视物模糊或长期间歇慢性头痛史主要症状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定位体征脑膜刺激征(meningealirritation)眼底改变(subhyaloidretinalhemorrhagess)Theclassicpresentationofsubarachnoidhemorrhageisthesuddenonsetofanunusuallyseveregeneralizedheadache.Lossofconsciousnessisfrequent,asarevomitingandnecckstiffness.临床表现clinicalmanifestation并发症（complication）再出血(rehemorrhage)，4周内，第2周尤多见脑积水（hydrocephalus）脑动脉痉挛(cerebrovascularspasm)，发病早期或1-2周出现上消化道出血（uppergastrointestinalhemorrhage）发热（fever）辅助检查laboratoryfindings头颅CT或MIR检查CT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CTscanwillusuallyconfirmthathemorrhagehasoccurredandmayhelptoidentifyafocalsource.腰穿脑脊液检查(lumbarpuncture)脑血管造影(cerebralarteriography)DSA、MRA、CTA经颅超声多普勒（TCD）诊断与鉴别诊断diagnosisanddifferentialdiagnosis诊断(diagnosis)根据病史、临床表现、CT检查和CSF的检查结果，可进行确诊鉴别诊断(differentialdiagnosis)各种原因引起的脑膜炎(meningitis)其他类型的脑卒中(stroke)治疗treatment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一般治疗避免继续出血或再出血诱因，绝对卧床4-6周(Absolutebedrest,mildsedationandanalgesicsforheadache)对症处理止血治疗脱水治疗脑脊液置换治疗病因治疗防治并发症（complication）防治脑积水(hydrocephalus)防治脑血管痉挛(vasospasm)预后prognosis动脉瘤首次出血约25%死亡；再出血约40%，第二次出血病死率50%25%diesubsequentlyfromtheinitialhemorrhageoritecomplications,and40%diefronrebleeding.脑血管畸形和动脉硬化引起的预后较好