1、Etiology and s lHypertension and arteriosclerosislAtherosclerosis,bleeding tendency(hemophilia,leukemia,aplastic anemia,thrombocytopenia),congenital angiomatous malformation,arteritis,tumorllenticulostriate arteries vertical to MCAlMicroaneurysms rupture PathlSite:basal ganglia(70%),brain lobe,brain
2、 stem,cerebellumlLateral hemorrhage:the bleeding is confined lateral to the internal capsule(lenticular nucleus,external capsule)lMedial hemorrhage:thalamus lhematoma edema herniation hematoma stroke capsuleClinicalAge:50-70lMale femalelOccur at physical exertion or excitementlSudden onset of focal
3、signslUsually 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 affectedClinica2.Thalamus hemorr
4、hagel contralateral hemiplegia,hemianesthesia,and hemianopialDeep sensation disturbancelOcular signslDisturbance of consciousness Clinica3.Pontine hemorrhagelMild:crossed paralysislSevere(5ml)coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hoursClinica4.Cerebellar hemorrhagelOccipital headac
5、he,intense vertigo and repeated vomiting,ataxia,nystagmuslSevere cerebellar hemorrhage:coma,compression of brain stem,tonsillar herniationClinica5.Lobar hemorrhagelSeen in AVM,Moyamoya disease,lHeadache,vomiting,neck stiffnesslSeizurelFocal signsClinicaInvest1.CTlFirst choicelHigh density bloodlMass
6、 effect and edemalHigh density isodensity low density2.MRIlBrain stem hemorrhagel50,with hypertensionlSudden onset of headache,vomiting,focal signlOccur at physical exertion or excitementlCT:high density bloodDifferentilComa:poisoning,hypoglycemia,hepatic or diabetic comalFocal signs:cerebral infarc
7、tion,brain tumor,subdural hematoma,SAHTrea1.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:obs
8、tructive hydrocephalus ventricular drainage 7.Rehabilitation TreaSlCranial bone dura mater arachnoid pia mater brain lobelPrimary spontaneous SAHlTraumatic SAHlSecondary to cerebral hemorrhageEtiol1.Intracranial saccular aneurysm l2.AVM(arteriovenous malformation)l3.Hypertension and atherosclerosisl
9、4.Moyamoya diseasel5.Mycotic aneurysm,tumor,polyarteritis nodasa,bleeding diseasePathlAnterior cerebral and anterior communicating lInternal carotid lMiddle cerebrallBasilar Clinica1.Age of onset:lSaccular aneurysm:adult 30-60lAVM:juvenile lHypertension:more than 602.Prodromal symptomslWarning leaks
10、:headache,vomitinglCranial 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,deliriumClinica3.A
11、cute SAHlSigns of meningeal irritation:neck stiffness,positive Kernigs signlFundus examination:papilloedema,sub-hyaloid hemorrhagelCranial nerve palsyClinica4.Delayed neurologic deficitslRerupture:in first 4 weeks,again has severe headache,vomiting,unconsciousness,with poor outcome.Due to fibrinolys
12、islCerebrovascular spasm:4-15 days after initial SAH,cerebral infarction disturbance of consciousness and focal signslHydrocephalus:2-3 weeks after SAH,gait difficulty,incontinence,dementia Invest1.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,CTAInvestDiaglSudden onset of severe headache,vomitinglNeck stiffness,positive Kernigs signlUniformly blood stained CSFlCT shows subarachnoid clotDifferentilCerebral hemorrhagelMeningitislTumorlPsychosisTrea1.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 hoursTrea
