Transcript Department of Neurology, The 2nd affiliated hospital, Harbin

脑 出 血
Intracerebral hemorrhage
Department of Neurology,
The 2nd affiliated hospital,
Harbin Medical University
Conception
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It means primary and nontraumatic
intracerebral hemorrhage.
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Count for 20%~30% in stroke
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Hypertension is the most common underlying
cause of nontraumatic intracerebral
hemorrhage.
Etiology
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Half of the patients suffer from
hypertension combined with arteriolar
atherosclerosis, it is the most common
cause of the disease.
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Others：cerebral atherosclerosis,
hematopathy, cerebral amyloid angiopathy
CAA , aneurysm, AVM
Pathophysiology
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高血压——小动脉：纤维素样坏死
fibrinoid 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
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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
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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，易发生粟粒状动脉瘤，
为脑出血最好发部位，其外侧支称为出
血动脉bleeding artery
Pathophysiology
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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
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Hypertensive 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%
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
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Hypertensive ICH：cerebral penetrating
artery miliary aneurysm
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Non Hypertensive ICH：occur in
subcortical white matter without
arteriosclerosis
Pathology
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Swelling and congestion of hemisphere
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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
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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
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age：50~70 years old
sex：more male patients
season：winter or spring
past history：hypertension
inducement：activity、excitement
onset：acute onset
Clinical features
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Hypertensive hemorrhage occurs without warning,
most commonly while the patient is awake.
Headache is present in 50% of patients and may
be severe, vomiting is common.
Blood pressure is elevated after the hemorrhage
has occurred. Thus, normal or low blood pressure
in a patient with stroke makes the diagnosis of
hypertensive hemorrhage unlikely, as does onset
before 50 years of age.
Clinical features
basal ganglion hemorrhage
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The 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.
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In general, putaminal hemorrhage leads to
a more severe motor deficit (hemiplegia)
and thalamic hemorrhage to a more marked
sensory disturbance (hemianesthesia).
Clinical features
basal ganglion hemorrhage
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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 impingement on
the midbrain center for upward gaze.
Clinical features
basal ganglion hemorrhage
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Aphasia may occur if hemorrhage at either
site exerts pressure on the cortical language
areas.
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Large hemorrhages may lead to
consciousness disturbance, while minor
hemorrhages lead to lacunar syndrome.
Clinical features
basal ganglion hemorrhage
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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
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With bleeding into the pons(figure 3), coma
occurs within seconds to minutes and
usually leads to death 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
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Patients are commonly quadriparetic or
hemiplegia alternate 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
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Midbrain hemorrhage is rarely seen in
clinic.
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The patients often manifest Weber
syndrome.
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Large hemorrhages may lead to coma and
flaccid paralysis.
Clinical features
cerebellar hemorrhage
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小脑齿状核动脉破裂
The 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.
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
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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 headache, vomiting, hemiparesis,
hemisensory deficits, aphasia, and visual field
abnormalities.
Seizures are more frequent than with hemorrhages
in other locations, while coma is less so.
Clinical features
cerebral ventriculus hemorrhage
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脉络丛plexus chorioideus动脉或室管膜下动
脉破裂(figure 6)
Global symptoms are obvious，but local
symptoms are not.
The patients may have a full recovery and a good
outcome.
Large hemorrhages may lead to coma, vomiting,
pinpoint pupils,implies a poor outcome.
Supplementary findings
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CT computerized tomography is chosen
first
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Lesion:high density(hematoma) surronded
by low density(edema)（figure 7）
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Mass effect is often seen in CT
Supplementary findings
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MRI magnetic resonance image 急性期对幕上
及小脑出血显示不如CT，对脑干出血显示优于
CT
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ICH and cerebral infarction can be
distinguished by MRI 4~5 weeks,but CT can
not distinguish them
Easy to detect AVM、aneurysm
Complex stages
Supplementary findings
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DSA：to diagnose AVM、Moyamoya
disease、arteritis
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CSF：elevated pressure,consistently
bloody,but not the routine examination
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其他：血、尿、便常规，肝功，肾功，凝血功
能，心电图等
Diagnosis
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Senile patients after 50 years of age
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Past history of hypertension
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Onset during activity
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Sudden onset
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CT scan
Differential diagnosis
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Cerebral infarction:situation and speed of
onset,blood pressure,lesion showed by CT
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Coma due to other causes:present illness history
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Injury:history of injury
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Nonhypertensive hemorrhage:without history of
hypertension
Treatment
medical treatment
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保持安静keep quiet、卧床休息rest in bed、减少
探视avoid meeting
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水电解质平衡keep water_electrolyte balance 和营
养nutrition
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控制脑水肿control brain edema，降低颅内压
decrease ICP:antiedema agents,e.g.mannitol
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控制高血压control blood pressure:
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antihypertensive agents or diuretic such as
furosemide
防治并发症prevent complications:rebleeding,
herniation, infection
Treatment
surgical treatment
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时机：超早期 6-24小时
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Indication
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Contraindications
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术式
Rehabilitation
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尽早进行as
soon as possible
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抗抑郁antidepression
Specific treatment
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Nonhypertensive hemorrhage
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Poly-cerebral hemorrhage
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Rebleeding
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Unstable cerebral hemorrhage
Prognosis
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The mortality in 30 days is 35%~52%,half
of the patients die within 2 days,due to
cerebral herniation.
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Large hemorrhages of brainstem、
thalamus 、ventricle implies a poor
prognosis.
蛛网膜下腔出血
Subarachnoid hemorrhage, SAH
Department of Neurology,
The 2nd affiliated hospital,
Harbin Medical University
Conception
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It is an acute hemorrhagic cerebral vascular disease
in which vessels on surface of brain and spinal cord
rupture suddenly due to many causes,blood flow
into the subarachnoid space,called primary SAH
Secondary SAH：hemorrhages in brain、ventricle
or epidural (subdural) space rupture into
subarachnoid space
Traumatic SAH
Count for 10% in stroke，for 20% in hemorrhagic
stroke
Etiology
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Congenital aneurysm is most common etiology
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AVM is a less frequent cause of SAH
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Hypertensive arteriosclerosis aneurysm is the third
cause of SAH
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Moyamoya disease is the forth cause
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Others include tumor, arteritis
Pathophysiology
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Cerebral artery aneurysm are most commonly
congenital “berry” aneurysms, which result from
developmental weakness of the vessel wall,
especially at the sites of branching.
AVM are most common in the middle cerebral
artery distribution.
Arteritis can also play an important role in the
disease.
Tumor invasive the vessel wall can not be
overlooked.
Pathophysiology
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颅内压增高increased ICP
阻塞性脑积水obstructive hydrocephalus
化学性脑膜炎aseptic meningitis下丘脑功能紊
乱
自主神经功能紊乱dysautonimia
交通性脑积水communicating hydrocephalus
血管活性物质致血管痉挛vascular spasm、蛛网
膜颗粒粘连、甚至脑梗死、正常颅压脑积水
Pathology
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85%~90% of intracranial aneurysms locate
anterior in the circle of Willis,they are mainly
single,they are multiple in about 10%—20% of
cases,locating in the opposite site of the same
vessel,called mirror aneurysm.
好发于Willis环动脉分叉处
破裂频度
血液主要沉积在脑底部、脑池
可破入脑室致脑积水
蛛网膜无菌性炎症反应
Clinical features
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Any age of person may suffer from SAH.
The classic (but not invariable) presentation of SAH
is the sudden onset of an unusually severe
generalized headache, patients often describe it as
“the worst headache I ever had in my life”.
The absence of the headache essentially precludes
the diagnosis.
Loss of consciousness is frequent, as are vomiting
and neck stiffness.
Symptoms may begin at any time of day and during
either rest or exertion.
Clinical features
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The most significant feature of the headache is
that it is new.
Milder but otherwise similar headaches may have
occurred in the weeks prior to the acute event.
These earlier headaches are probably the result of
small prodromal hemorrhages (sentinel,or
warning, hemorrhages) or aneurysmal stretch.
Clinical features
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The headache is not always severe, but the intensity
of the headache may remain unchanged for several
days and subside only slowly over the next 2 weeks.
A recrudescent headache usually signifies recurrent
bleeding.
There is frequently confusion, stupor, or coma.
Nuchal rigidity and other evidence of meningeal
irritation are common. Meningeal irritation may
induce temperature elevations to as high as 39℃
during the first 2 weeks.
Preretinal globular subhyaloid hemorrhages (found in
20% of cases) are most suggestive of the diagnosis.
Clinical features
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Because bleeding occurs mainly in the
subarachnoid space in patients with aneurysmal
rupture, prominent focal signs are uncommon on
neurologic examination. When present, they may
bear no relationship to the site of the aneurysm.
An exception is oculomotor nerve palsy occurring
ipsilateral to a posterior communicating artery
aneurysm. Bilateral extensor plantar responses
and ⅵ nerve palsies are frequent in such cases.
Ruptured AVMs may produce focal signs, such as
hemiparesis, aphasia, or a defect of the visual
fields.
Clinical features
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Inducement and aura：inducement include
intensive activity、exhaustion、excitement,aura
can be “warning leak” and localized sign.
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Symptoms of SAH patients above 60 year old are
not typical：slowly onset,headache and
meningeal irritation are not obvious,with severe
consciousness disturbance,often accomplished
with cardiac damage and other complications
Complications
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Recurrence of hemorrhage:Recurrence of
aneurysmal hemorrhage (20% over 10-14 days) is
the major acute complication and roughly doubles
the mortality rate. Recurrence of hemorrhage
from AVM is less common in the acute period.
Arterial vasospasm:Delayed arterial narrowing,
termed vasospasm, occurs in vessels surrounded
by subarachnoid blood and can lead to
parenchymal ischemia in more than one- third of
cases.
Complications
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Acute or subacute hydrocephalus:Acute or
subacute hydrocephalus may develop during
the first day- or after several weeks-as a result
of impaired CSF absorption in the
subarachnoid space. Progressive somnolence,
nonfocal findings, and impaired upgaze should
suggest the diagnosis.
Complications
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Seizures: Seizures occur in fewer than 10%
of cases and only following damage to the
cerebral hemisphere.
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Others:Although inappropriate secretion of
antidiuretic hormone and resultant diabetes
insidious can occur, they are uncommon.
Supplementary findings
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CT：patients presenting with SAH are generally
investigated first by CT scan(figure 8)，which will
usually confirm that hemorrhage has occurred and
may help to identify a focal source. 约15%患者CT
仅显示脚间池少量出血，向中脑环池、外
侧裂池基底扩散，称非动脉瘤性SAH nA
SAH
CSF:if CT scan fails to confirm the clinical diagnosis,
lumber puncture is performed. The fluid is grossly
bloody, the supernatant of the centrifuged CSF
becomes yellow (xanthochromic), the chemical
meningitis may produce pleocytosis.
Supplementary findings
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DSA:to detect aneurysm or AVM, it is a
prerequisite to the rational planning of surgical
treatment.
MRI and MRA:MRI is especially useful in
detecting small AVMs localized to the brainstem
(an area poorly seen on CT scan).
TCD：to determine CVS
实验室检查：血常规、凝血功能、肝功、
免疫学
Diagnosis
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Symptom：the history of a sudden severe
headache with confusion or obtundation
Sign：nuchal rigidity, a nonfocal
neurologic examination
CSF：bloody spinal fluid
Fundus oculi：preretinal globular
subhyaloid hemorrhages
CT findings
Differential diagnosis
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Hypertensive intracranial hemorrhage：
there are prominent focal findings.
Intracranial infection:it is excluded by the
CSF examination.
Tumor stroke or metastasis:they can be
distinguished from SAH by evidence of
tumor.
Non-typical SAH
Principle of treatment
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控制继续出血control active hemorrhage
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防治迟发性CVS prevent tardive CVS
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去除病因eliminate etiology
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防止复发prevent recurrence
Treatment
medical treatment
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一般处理general treatment：absolute bed rest 4~6
weeks,preventing elevation of arterial or intracranial
pressure(mild sedation, analgesics),but nA-SAH is an
exception.
降颅压decrease ICP：antiedema agents eg.mannitol
or surgical decompression
防治再出血prevent recurrence：PAMBA
防治迟发CVS prevent tardive CVS ：calcium
channel antagonist drug e.g. nimodipine
CSF置换CSF exchange：it can remove red
cells,since the procedure may be accomplished with
some complications, it should be used carefully.
Treatment
surgical treatment
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Opportunity of operation：24~72 hours after
hemorrhage
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Subject to operation
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术式
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血管内介入治疗、γ-刀治疗
Prognosis
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The probability of survival following aneurysmal
rupture is related to the patient s state of
consciousness and the elapsed time since the
hemorrhage.
Hunt grade：gradeⅠ~Ⅱhave a good outcome,grade
Ⅳ~Ⅴhave a poor one,grade Ⅲ have a moderate one.
Main cause of death ：including recurrence of
hemorrhage、tardive CVS
Main commemorstive sign：may be cognitive
impairment