(神经病学)8.1GJC-ICH-SAH.ppt

* * * * * * * * * Common sites of aneurysms Clinical features Female preponderance(F:M=1.6:1) Symptom onset: exercise, emotional stress Sudden severe headache, ~80% of patients “Worst headache in my life” 30~50% warning headache ~2wks before aneurysms rupture Nausea and vomiting(~77%) Confusion, stupor, coma seizure Symptoms Meningeal irritation sign: nuchal rigidity, Kernig sign and Brudzinski sign Not obvious in older patients Ophthalmoscope: vitreous membrane hemorrhage, papilledema, retinal hemorrhage Focal neurological deficits: 3rd nerve palsy Subhyaloid hemorrhage Flame and dot hemorrhages Rebleeding Vasospasm Hydrocephalus Others: Seizures Osmolar disturbances Myocardial infarction and /or arrhythmias COMPLICATIONS Rebleeding associated with ~ 50% fatality rate ~ 4% of re-bleeding occurs within the first 24 hours ~20-30% within the first month and ~ 3% per year thereafter Risk factors for re-bleeding: Higher initial blood pressure170 mmHg Worse neurological status on admission (coma) Headache and symptoms occur one more time or become worse, CT shows more bleeding Vasospasm 20~30% of patients, is associated with delayed ischemia and death Signs of ischemia appear 4~14days, most often at 7 days Potential mechanisms RBC hemolysis and subsequent release of oxygen, Hb, and other active oxygen species Secondary effects -Vessel wall changes Hydrocephalus 15~20% patients May develops at any time. Acute, or over a few days or weeks Progressive drowsiness, gait difficulties, abulia(意志力丧失) with incontinence CT scanning shows enlarged ventricles Diagnostic approaches CT Sensitivity 90~95% with in 24hrs intracerebral hemorrhage, mass effect, and hydrocephalus MRI 4 days ~2wks, detects deoxygenated hemoglobin DSA Useful for aneurysm location and vasospasm Done within 3 d or after 4 wks to avoid rebleeding and vasospasm Diagnostic approaches Lumbar puncture (LP) Suspected SAH with negative CT, not for first choice Better be performed 12 hrs after SAH “Trau