高血压小动脉纤维素样坏死fibrinoid.ppt

脑 出 血Intracerebral hemorrhage Department of Neurology, The 2nd affiliated hospital, Harbin Medical University Conception It means primary and nontraumatic intracerebral hemorrhage. Count for 20%~30% in stroke Hypertension is the most common underlying cause of nontraumatic 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 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 congestion 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：50~70 years old sex：more male patients season：winter or spring past history：hypertension inducement：activity、excitement onset：acute onset Clinical features 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