课件：脑出血认识及处理.pptx

脑出血认识及处理 脑出血的部位基底节出血壳核出血丘脑出血尾状核出血基底节出血壳核出血丘脑出血尾状核出血基底节区出血1、壳核出血约占50%~60%，豆纹动脉外侧在破裂引起肢体症状，临床上较为多见内囊受损的引起的对侧偏瘫，还可有双眼向病灶一侧凝视，偏身感觉障碍等。昏迷、呼吸心跳受影响，甚至出现短时间内死亡丘脑出血丘脑穿支动脉或者丘脑膝状体动脉破裂与壳核出血类似的症状如偏身运动障碍、感觉障碍等，可出现精神障碍，临床上常见的有情绪低落、淡漠等，还可出现痴呆、记忆力下降等症状出血量较大亦可短时间内危急生命。由于位置靠近第三脑室，丘脑出血症状容易反复，还易出现持续性顽固高热等症状。内囊内型出血偏身感觉障碍 尾状核出血较为少见，出血量常不大，多破入脑室，出现急性脑积水症状如恶心、呕吐、头痛等，一般不出现典型的肢体偏瘫症状，临床表现可与蛛网膜下腔出血类似。 脑叶出血发生率较少，约占脑出血的5%~10%，一般合并有颅内血管畸形、血液病、烟雾病等患者常见，血肿常见于一个脑叶内，有时也会累计两个脑叶，临床上以顶叶最为常见，因为出血位置较为表浅，血肿一般较大，根据不同的部位以及出血量，临床表现较为多见复杂，可有肢体偏瘫、癫痫发作、失语、头痛、尿失禁、视野缺损等等。 脑干出血脑桥出血中脑出血延髓出血昏迷、四肢瘫痪、呼吸困难急性应激性溃疡，中枢性顽固高热多数病人在发病后不久就出现多器官功能衰竭，常在发病后48小时内死亡 小脑出血眩晕、共济失调频繁呕吐、后枕部剧烈疼痛一般不会出现肢体偏瘫症状，小脑出血量较大时刻出现脑桥受压影响呼吸功能。小脑蚓部（双侧小脑半球中央部位）出血后血肿可压迫四脑室影响脑脊液循环，短时间内出现急性脑积水 脑室出血突发头痛、呕吐、颈强直少量时：头痛，恶心，呕吐，Kerning征(+)，伴或不伴意识障碍。大量时：很快进入昏迷症状。 “铸型样“，并流入蛛网膜下腔。立即昏迷，患者四肢瘫痪，瞳孔先缩小，随后散大，高热，呼吸深大，取大脑僵直，并迅速死亡。 识别The abrupt onset of focal neurological symptoms is presumed to be vascular in origin until proven otherwise. However, it is impossible to know whether symptoms are due to ischemia or hemorrhage based on clinical characteristics alone. Vomiting, systolic BP 220 mm Hg, severe headache, coma or decreased level of consciousness, and progression over minutes or hours all suggest ICHCT is very sensitive for identifying acute hemorrhage and is considered the gold standard2010 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 高血压处理Blood pressure reduction to a particular target in acute ICH hasbeen explored in one large RCT and two pilot RCTs (23–25).European Stroke Organisation (ESO) guidelines for the management ofspontaneous intracerebral hemorrhage 推荐 止血药物 Additional information:5–10 mg intravenous vitamin K to patients on vitamin K antagonists or intravenous protamine sulfate to patients on heparin. The risk of a thrombotic event occurring due to the normalization of coagulation for shorter periods of time than a week is considered low for most indications compared with the possible benefit of stopping hematoma expansion o