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,cerebellumlLa
2、teral 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 signslUsually accompanied
3、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 contralateral hemiplegia,he
4、mianesthesia,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 vertigo and repeated vomiting,ataxia
5、,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 density isodensity low density2.MRIlBrain st
6、em 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,subdural hematoma,SAH1.Keep rest,monitoring,air way,good nur
7、sing2.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 hydrocephalus ventricular drainage 7.Rehabilitation lCranial bone dura m
8、ater arachnoid pia mater brain lobelPrimary spontaneous SAHlTraumatic SAHlSecondary to cerebral hemorrhagel1.Intracranial saccular aneurysm l2.AVM(arteriovenous malformation)l3.Hypertension and atherosclerosisl4.Moyamoya diseasel5.Mycotic aneurysm,tumor,polyarteritis nodasa,bleeding diseaselAnterior
9、 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,vomitinglCranial nerve paralysis:oculomotor3.Acute SAHlSudden onset of severe headache:“exp
10、lode,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 SAHlSigns of meningeal irritation:neck stiffness,positive Kernigs signlFundus examination:papilloedema,
11、sub-hyaloid hemorrhagelCranial nerve palsy4.Delayed neurologic deficitslRerupture:in first 4 weeks,again has severe headache,vomiting,unconsciousness,with poor outcome.Due to fibrinolysislCerebrovascular spasm:4-15 days after initial SAH,cerebral infarction disturbance of consciousness and focal sig
12、nslHydrocephalus: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 ICP 3.DSA:etiologic diagnosis,important to surgery4.MRA,CTAlSudden onset of severe headache,vomitinglNeck stiffness,posit
13、ive 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
