1、(Cerebral Hemorrhage)(Cerebral Hemorrhage)定义：定义：指非外伤性脑实质内出血指非外伤性脑实质内出血 Department of Neurology,The 2nd affiliated hospital,Kunming Medical college Conception It means primary and nontraumatic intracerebral hemorrhage.Count for 20%30%in stroke Hypertension is the most common underlying cause of nontr
2、aumatic intracerebral hemorrhage.Etiology Half 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
3、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
4、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 Pathology Hypertensive ICH：基底节的内囊区inter capsule、壳核putamen占70%，脑叶lobe、脑干brainstem、小脑
5、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 Pathology Hypertensive ICH：cerebral penetrating artery miliary aneurysm Non Hypertensive ICH：occur in subcortical white matter without arteriosclerosis Pathology Swelling and c
6、ongestion 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 features age：5070 years old sex：more male patients season：winter or spring past history：hypertension inducement：activity、excitement onset：acute onset 临临 床床 表表 现现 一般症状：中年以上发病一般症状：中年以上发病。起病突然起病突然，动态起
7、病动态起病，病势凶险病势凶险。高颅压征高颅压征 intracranialintracranial hypertensionhypertension signsign 头痛头痛，呕吐呕吐，血压升高血压升高，脉搏减慢脉搏减慢，视乳头水肿视乳头水肿，意识障碍意识障碍 易形成脑疝易形成脑疝 cerebralcerebral herniationherniation 神经系统定位体征：神经系统定位体征：取决于血肿的部位取决于血肿的部位、体积体积 局灶性神经功能缺损 基底节区基底节区：内囊：内囊“三偏征三偏征”偏瘫偏瘫 hemiplegiahemiplegia 偏盲偏盲 hemiscotosishemis
8、cotosis 偏身感觉障碍偏身感觉障碍 hemihypesthesiahemihypesthesia 脑叶脑叶 额叶额叶 颞叶颞叶 顶叶顶叶 枕叶枕叶 各具不同缺损各具不同缺损 脑干脑干 交叉性瘫痪交叉性瘫痪 hemiplegiahemiplegia alternatealternate 小脑小脑 眩晕眩晕 vertigovertigo 共济失调共济失调 ataxiaataxia 基底节区的血液供应基底节区的血液供应 豆纹动脉的破裂成因豆纹动脉的破裂成因 Clinical features basal ganglion hemorrhage The two most common sites
9、 of hypertensive hemorrhage are the putamen(figure 1)and thalamus(figure 2),which are separated by the posterior limb of the internal capsule.In general,putaminal hemorrhage leads to a more severe motor deficit(hemiplegia)and thalamic hemorrhage to a more marked sensory disturbance(hemianesthesia).C
10、linical features basal ganglion hemorrhage Homonymous hemianopia may occur as a transient phenomenon after thalamic hemorrhage and is often a persistent finding in putaminal hemorrhage.In large thalamic hemorrhages,the eyes may deviate downward,as in staring at the tip of the nose,because of impinge
11、ment on the midbrain center for upward gaze.Clinical features basal ganglion hemorrhage Aphasia may occur if hemorrhage at either site exerts pressure on the cortical language areas.Large hemorrhages may lead to consciousness disturbance,while minor hemorrhages lead to lacunar syndrome.Clinical feat
12、ures basal ganglion hemorrhage 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，仅见脑膜刺激征 Clinical features pontine hemorrhage With bleeding into the pons(figure 3),coma occurs within seconds to minutes and usually leads to dea
13、th within 48 hours.Ocular findings typically include pinpoint pupils.Horizontal eyes movements are absent or impaired,but vertical eye movements may be preserved.In some patients,there may be ocular bobbing.Clinical features pontine hemorrhage Patients are commonly quadriparetic or hemiplegia altern
14、ate and exhibit decerebrate posturing.Hyperthermia,respiration disorder is sometimes present.The hemorrhage usually ruptures into the forth ventricle,and rostral extension of the hemorrhage into the midbrain with resultant midposition fixed pupils is common.Clinical features midbrain hemorrhage Midb
15、rain hemorrhage is rarely seen in clinic.The patients often manifest Weber syndrome.Large hemorrhages may lead to coma and flaccid paralysis.Clinical features cerebellar hemorrhage 小脑齿状核动脉破裂 The distinctive symptoms of cerebellar hemorrhage(figure 4)are severe headache,dizziness,vomiting,and the ina
16、bility to stand or walk,but strength in the limbs is normal.Large hemorrhages lead to coma within 12 hours in 75%of patients and within 24 hours in 90%.They may lead to compression of the brainstem.Clinical features lobar hemorrhage Etiology：AVM、Moyamoya disease、cerebral amyloid angiopathy、tumor Hypertensive hemorrhages also occur in subcortical white matter underlying the frontal,parietal,temporal,and occipital lobes(figure 5).Symptoms and signs vary according to the location;they can include h