1、lHypertension and arteriosclerosislAtherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumorllenticulostriate arteries vertical to MCAlMicroaneurysms rupture lSite: basal ganglia (70%), brain lobe, brain stem,
2、cerebellumlLateral hemorrhage: the bleeding is confined lateral to the internal capsule (lenticular nucleus, external capsule) lMedial hemorrhage: thalamus lhematoma edema herniation hematoma stroke capsulelAge: 50-70lMale femalelOccur at physical exertion or excitementlSudden onset of focal signslU
3、sually accompanied by headache and vomiting lMay have consciousness disturbance1. Putamen hemorrhagelcontralateral hemiplegia, hemianesthesia, and hemianopialEyes are frequently deviated toward the side of the affected hemispherelAphasia if dominant hemisphere is affected2. Thalamus hemorrhagel cont
4、ralateral hemiplegia, hemianesthesia, and hemianopialDeep sensation disturbancelOcular signslDisturbance of consciousness 3. Pontine hemorrhagelMild: crossed paralysislSevere (5ml) coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hours4. Cerebellar hemorrhagelOccipital headache, intense verti
5、go and repeated vomiting, ataxia, nystagmuslSevere cerebellar hemorrhage : coma, compression of brain stem, tonsillar herniation5. Lobar hemorrhagelSeen in AVM, Moyamoya disease, lHeadache, vomiting, neck stiffnesslSeizurelFocal signs1. CTlFirst choicelHigh density bloodlMass effect and edemalHigh d
6、ensity isodensity low density2. MRIlBrain stem hemorrhagel50, with hypertensionlSudden onset of headache, vomiting, focal signlOccur at physical exertion or excitementlCT: high density bloodlComa: poisoning, hypoglycemia, hepatic or diabetic comalFocal signs: cerebral infarction, brain tumor, subdur
7、al hematoma, SAH1.Keep rest, monitoring, air way, good nursing2. Keep electrolytes and fluid balance.3. Reduce ICP:l 20% Mannitol 125-250ml, 3 to 4 times per daylFurosemide, albumin, dexamathasone 4. Control hypertension: 40-50 ml, deterioratinglCerebellum: 15ml, diameter3cmlThalamus: obstructive hy
8、drocephalus ventricular drainage 7. Rehabilitation lCranial bone dura mater arachnoid pia mater brain lobelPrimary spontaneous SAHlTraumatic SAHlSecondary to cerebral hemorrhagel1. Intracranial saccular aneurysm l2. AVM (arteriovenous malformation) l3. Hypertension and atherosclerosisl4. Moyamoya di
9、seasel5. Mycotic aneurysm, tumor, polyarteritis nodasa, bleeding diseaselAnterior cerebral and anterior communicating lInternal carotid lMiddle cerebrallBasilar 1. Age of onset: lSaccular aneurysm: adult 30-60lAVM: juvenile lHypertension: more than 602. Prodromal symptomslWarning leaks: headache, vo
10、mitinglCranial nerve paralysis: oculomotor3. Acute SAHlSudden onset of severe headache: “explode, burst, the worst of my life”lVomitinglAssociated with physical exertion, excitementlTransient loss of consciousness or comalPain of neck, back, leglMental symptoms: apathy, lethargy, delirium3. Acute SA
11、HlSigns of meningeal irritation: neck stiffness, positive Kernigs signlFundus examination: papilloedema, sub-hyaloid hemorrhagelCranial nerve palsy4. Delayed neurologic deficitslRerupture: in first 4 weeks, again has severe headache, vomiting, unconsciousness, with poor outcome. Due to fibrinolysisl
12、Cerebrovascular spasm: 4-15 days after initial SAH, cerebral infarction disturbance of consciousness and focal signslHydrocephalus: 2-3 weeks after SAH, gait difficulty, incontinence, dementia 1. CTlSubarachnoid clot in 75% of cases2. CSFlUniformly blood-stainedlXanthochromia: 12 hours to 2-3 weeksl
13、 ICP 3. DSA: etiologic diagnosis, important to surgery4. MRA, CTAlSudden onset of severe headache, vomitinglNeck stiffness, positive Kernigs signlUniformly blood stained CSFlCT shows subarachnoid clotlCerebral hemorrhagelMeningitislTumorlPsychosis1. General management lAbsolute bed rest for 4-6 weekslPrevent constipation, excitementlSedatives and analgesics2. Reduce ICPlMannitol, Furosemide, albumin 3. Prevent rerupturelAntifibrinolytic drugs: EACA for 3 weeks4. Prevent cerebrovascular spasmlNimodipine, flunarizine5. Lumbar puncture to replace CSF6. Surgery: within 24-72 hours
