CVD 浙大英文课件

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深穿支动脉为出血的主要部位,豆纹动脉是脑出血最好发部位,其外侧支称为出血动脉

The mainly hemorrhagic sites are the perforating branches of middle cerebral artery, the most
common sites of ICH are lenticulostriate arteries, lateral branches of those are called
hemorrhagic arteries.

基底节区 Basal ganglia 70%
脑叶 Cerebral lobe 10%
脑干 Brain stem 10%
小脑齿状核区 Cerebellar dentate nucleus 10%

粟粒状动脉瘤:大脑中 动脉深穿支豆纹动脉>基底动脉脑桥支>大脑后动脉丘脑支>小脑上动
脉分支>顶枕交界区和颞叶分支
Granulous aneurysm : the lenticulostriate arteries > branches of the basilar artery supplying the
pons > thalamic branches of the posterior cerebral arteries > branches of the superior cerebellar
arteries > some arteries supplying the junctional zone between parietal and occipital lobe and
branches of temporal lobe

临床表现 clinical manifestations (1)
年龄50-70岁,男>女
Age 50-70 years. The incidence is higher in men than in women
冬春季多发 Mostly occurrs in winter and spring.
多有高血压史 Usually with hypertension.
活动或情绪激动时发生
Occurrs when activities or emotional excitement.
数分钟至数小时症状达高峰
Neurologic deficits may progress over minutes to hours.
全脑症状:头痛、呕吐、意识改变
Global cerebral symptom: headache, vomiting, alterd consciousness

临床表现 clinical manifestions (2)
1. 基底节区出血(内囊区出血)占70%,其中壳核(内囊外侧型)60%,丘脑(内囊内侧
型)10%。
The most common site of hemorrhage is basal ganglia, which occurs in 70% of patients. It consists
of putamen (lateral of the internal capsule) and thalamus (medial of the internal capsule) .
(1)壳核出血:三偏,双眼向病灶对侧同向凝视不能,主侧半球有失语。
(1) Putaminal hemorrhage: hemiplegia, hemisensory deficit, hemiopia, impairment of syntropic
gaze to the contralateral lesion, aphasia with dominant hemisphere

临床表现 clinical manifestions (3)
(2)丘脑出血:丘脑膝状动脉和丘脑穿通动 脉。三偏,上下肢程度相近,深浅感觉障碍,特
征性眼征,意识障碍,中线症状,锥体外系症状,丘脑性 失语,精神症状。
(2)Thalamic hemorrhage: the thalamic genual artery and the long penetrating thalamic artery.
hemiplegia, hemisensory deficit, hemiopia, hemiplegia affecting the arm and leg to a roughly


equal extent, impairment of superficial and deep sensation, marked ocular sign, impairment of
consciousness, symptoms of the median line, the extrapyramidal symptoms, the thalamic aphasia,
mentalsymptoms.

临床表现 clinical manifestions (4)
(3)尾状核头部出血 :少见。脑膜刺激征,无明显瘫痪,头痛,呕吐,颈强,Kernig征(+),
可有对侧中枢性面、舌 瘫
(3)Hemorhage in the head of the caudate nucleus: seldom. meningeal irritation sign, unobvious
paralysis, headache, vomiting, neck stiffness, positive Kernig’s sign, the facial and hypoglossal
paralysis caused by contralateral upper unit opathy.

临床表现 clinical manifestions(5)
2.脑桥出血:10%,多位于脑桥基底与被盖部之间。
2. Pontine hemorrhage: 10%, mostly occurs between the basal pons and the tegmen.
大量出血( >5ml):常破入四脑室。昏迷,针尖样瞳孔,呕吐,中枢性高热,中枢性呼吸困难,
眼球浮动,四肢 瘫,去大脑强直发作,多在48小时内死亡。
Massive hemorrhage(>5ml): usually ruptures into the fourth ventricle. Coma, pinpoint pupils,
vomiting, central fever, central dyspnea, impairment of horizontal eye movements, quadriplegia,
decerebrate rigidity, usually leads to death within 48 hours.

临床表现 clinical manifestions (6)
小量出血:交叉性瘫,共济失调性偏瘫,双眼向病灶侧凝视或核间性眼肌麻痹。
Small hemorrhage: crossed paralysis, ataxic-hemiplegia, both eyes gaze to the ipsilateral lesion or
internuclear ophthalmoplegia.
3.中脑出血:罕见.
Hemorrhage in diencephalon: seldom.
轻症:一侧或双侧动眼神经不全瘫痪,Weber综合征
Mild case: unilateral or bilateral oculomotor nerve partial paralysis, Weber’s syndrome.
重症:深昏迷,四肢弛缓性瘫,迅速死亡
Severe case: deep coma, flaccid quadriplegia, rapidly go to death

临床表现 clinical manifestions (7)
4.小脑出血:10%,小脑齿状核动脉多发。
发病初期有眩晕,呕吐,枕部头痛,平衡障碍,无肢体瘫痪。
llar hemorrhage: 10%, usually occurs in the artery supplying dentate nucleus.
The symptoms including vertigo, vomiting, occipital headache and disorders of equilibrium, but
not quadriplegia appear at onset of bleeding.

临床表现 clinical manifestions (8)
轻症:一侧肢体笨拙,行动不稳,共济失调,眼震,无瘫痪。
Mild case: clumsiness of unilateral body, unstable movement, ataxia, nystagmus, no
paralysis.
重症:双眼向病灶对 侧凝视,吞咽发声困难,锥体束征,一侧瞳孔缩小,光反应迟钝,脑干
受压表现,甚至枕大孔疝。


Severe case: both eyes gaze at the contralateral lesion, difficulty in swallowing and
dysphonia, pyramidal sign, constriction of unilateral pupil , bluntness in response to light, signs of
brainstem compression, even foramen magnum herniation.

临床表现 clinical manifestations (9)
5.脑叶出血:10%,以顶叶最常见。头痛,呕吐,脑膜刺激征,局灶症状,抽搐较多见。
hemorrhage:10%, the most common site is parietal lobe. Headache, vomiting, Meningeal
irritation sign, focal brain sign, sizure
额叶:偏瘫,Broca失语,摸索。
Frontal lobe: hemiplegia, broca’s aphasia, crocidismus.

临床表现 clinical manifestations (10)
颞叶:Wernicke失语,精神症状。
Temporal lobe: Wernicke’s aphasia, mental symptoms.
枕叶:视野缺损。
Occipital lobe: visual field defects.
顶叶:偏身感觉障碍,空间构想障碍。
Parietal lobe: hemisensory deficit, impairment of spatial ability

临床表现 clinical manifestations(11)
6.脑室出血:3%-5%,脉络丛动脉、室管膜下动脉破裂。
6. Hemorrhage in cerebral ventricle: 3%-5%, the arteries of the choroid plexus and the inferior
ependymal arteries rupture.
少量:头痛、呕吐、脑膜刺激征,无意识障碍和局灶症状,血性CSF,预后好。
small: headache, vomiting, Meningeal irritation sign, no impairment of consciousness and focal
brain symptoms, hematoid CSF, good prognosis.

临床表现 clinical manifestations (12)
大量:昏迷,频繁呕吐,针尖样瞳孔,分离性斜视或眼球浮动,四肢弛缓性瘫,去脑强直发< br>作,预后不良。
massive: coma, frequently vomiting, pinpoint pupils, separate strabismus or eyeballs floating,
flaccid quadriplegia, decerebrate rigidity. Poor prognosis.

诊断
50岁以上中老年高血压患者在活动中或激动时突然发病,出现偏瘫、失语等局灶性神经缺
失症 状,应首先考虑脑出血。
While activities or emotional excitement, The hypertension patients over age 50 years suddenly
appear the symptoms of focal neurologic deficits such as hemiplegia, aphasia etc. The first
diagnosis may be intracerebral hemorrhage.

鉴别诊断 differential diagnosis
鉴别:脑梗死 cerebral infarction
中毒、代谢性疾病
toxicosis, metabolic disorders


外伤性出血 traumatic hemorrhage
不同的脑出血原因
different causes of intracerebral hemorrhage

治疗treatment -内科治疗medical treatment

保持安静,卧床休息。监测生命体征、瞳孔、意识,加强护理 To keep quiet, bed rest. monitor
vital signs, pupils and consciousness, intensive nursing.
维持水电解质平衡,注意营养。 To keep the intravenous fluid and electrolyte balance, and close
attention must be given to nutrition.
控制脑水肿,降低颅内压(ICP)To control hydrocephalus and reduce intracranial pressure.
控制高血压 To control hypertension
防治并发症 To prevent and cure complications.

治疗 treatment
—外科治疗 surgical treatment

手术适应症:surgical indications:
脑出血病人逐渐出现颅内压增高伴脑干受压。
Patients suffered with intracerebral hemorrhage gradually
appear the signs of increasing ICP and brainstem compressed.

2.小脑半球出血>15ml,蚓部血肿>6ml,血肿破入四脑 室或脑池受压消失,出现脑干受压表
现和急性阻塞性脑积水征象
Hematoma in cerebellar hemisphere are more than 15ml in bulk, or in vermis are more than
6ml in bulk, hematoma rupture into the fourth ventricle or the compression of the brain pool
disappears, signs of brainstem compressed and acute obstructive hydrocephalus appear

3.脑室出血致阻塞性脑积水
Obstructive hydrocephalus caused by hemorrhage in
ventricles.
4.年轻患者脑叶或壳核中大量出血(>40~50ml),或有明确的血管病灶
Massive hemorrhage ( more than 40-50 ml in bulk ) in
cerebral lobes or putamen (young patients), or a definitive
vascular lesion
5.脑桥出血一般不宜手术。
Generally pontine hemorrhage is not indicative to
surgery

蛛网膜下腔出血
Subarachnoid hemorrhage, SAH

SAH是多种病因所致脑底部或脑及脊髓表面血管破裂的急性出血性脑血管病,血液 直接流
入蛛网膜下腔,又称原发性SAH。


SAH is an acute hemorrhagic cerebrovascular disease caused by many pathogenies, which is result
of the blood vessels from the inferior brain or surface of brain and spinal cord rupture and then
the blood directly flow into subarachnoid space. It is also named primary SAH.
SAH约占急性脑卒中的10%,占出血性脑卒中的20%。
The incidence of SAH is approximately 10 percent of acute stroke, while is 20 percent of
hemorrhagic stoke.

先天性动脉瘤:最常见,约占50%以上
Congenital aneurysm: the most common, approximately over 50%
2.脑血管畸形:占第二位
Cerebrovascular malformation: the second reason
3.高血压动脉硬化性动脉瘤
Hypertensive atherosclerosis aneurysm
ya病
Moyamoya disease
5.其他
others

SAH后的病理过程:
pathophysiology after SAH:
颅内容量增加 intracranial tissues increasing
阻塞性脑积水 obstructive hydrocephalus
化学性脑膜炎 chemical meningitis
下丘脑功能紊乱 disorders of hypothalamic function
自主神经功能紊乱 disorders of the autonomic nervous system
交通性脑积水 communicating hydrocephalus
血管痉挛、蛛网膜颗粒粘连、甚至脑梗死和正常颅压脑积水 cerebrovascular spasm, the
arachnoid villi adhension, even cerebral infarction and hydrocephalus with normal ICP

临床表现 clinical manifestations
< br>任何年龄均可发病,动脉瘤破裂好发于30-60岁间,女>男;血管畸形多见于青少年,两性
无 差异。
Occurs on any age, rupture of aneurysm most occurs on age from 30-60 years, in women more
than in men;
AVM most occurs in adolescent, there’s no difference in gender.
60岁以上老人表现常不典型
The symptoms of old patients over 60 years are atypical.

典型表现:突发剧烈头痛、呕 吐、脑膜刺激征及血性脑脊液。伴随症状有短暂意识障碍、项
背部或下肢痛、畏光。眼底检查可见视网膜 出血、视乳头水肿或玻璃体下出血;可有局灶性
症状、精神症状。
Typical manifestations: a suddenly severe headache, vomiting, meningeal irritation sign and
bloody CSF. The accompanying symptoms are transient impairment of consciousness, back pain


or melosalgia, photesthesia. Retinal hemorrhage, papilledema or globular subhyaloid hemorrhage
found by examination of fundus oculi.
A focal neurologic symptoms, mental synmptoms.

诱因及先驱症状:发病前多有明显诱因,剧烈运动、过劳、激动、用 力、排便、咳嗽、
饮酒等;少数在安静下发病。发病前可有头痛、恶心、呕吐,颅神经麻痹,局灶性缺失 或刺
激症状。
Inducements and prodromes: Usually there are obvious inducements before onset , such as
intense exercise, too tired, excitement, exertion, defecation, cough, drinking et al; Minority occurs
at rest. History of headache, nausea, vomiting, cranial nerves palsy, focal neurologic deficient or
irritative symptoms are common before onset.

诊断

突发剧烈 头痛、恶心呕吐和脑膜刺激征阳性患者,无局灶性神经缺损体征,伴或不伴有
意识障碍,可诊断此病;C SF均匀血性、压力增高、眼底检查玻璃体下出血可临床确诊。常
规行CT检查,并行病因学诊断。
The history of a sudden severe headache, nausea, vomiting and positive Meningeal
irritation sign, no focal neurologic deficit sign with (without) impairment of consciousness is
highly specific for SAH. Uniformity bloody CSF, increased ICP and globular subhyaloid
hemorrhage found by eyeground examination are most suggestive of the clinical diagnosis. CT
scan is the routine test, and then make the aetiological diagnosis.

鉴别诊断 differential diagnosis

鉴别:
脑出血,颅内感染,脑卒中或颅内转移瘤
Differential diagnosis:
cerebral hemorrhage, intracranial infections,
the ischemic stroke or intracranial metastatic tumors

治疗 treatment
原则:控制继续出血、防治迟发性脑血管痉挛、去除病因和防止复发。
Principles: To control continuous hemorrhage, to prevent and cure cerebrovascular spasm, to
remove causes and prevent recurrence.

内科处理:①一般处理:监护、绝对卧床4-6周,保持安静,避免一切引起血压和颅内
压升高的诱因 ,镇静、通便,补液,加强护理,营养支持,防止并发症;②降颅压;③防止
再出血;④防治迟发性血管 痉挛;⑤脑脊液置换疗法。
Medical treatment: ①general treatment: monitor, absolute bed rest for 4-6 weeks, keep
quiet, avoid every cause that induce increased blood and ICP, sedation, purgation, fluid infusion,
intensive nursing, nutritional support, to prevent complications; ② to lower ICP; ③ to prevent
recurrent hemorrhage; ④to prevent and cure tardive cerebrovasular spasm; ⑤CSF replacement
手术治疗 surgical treatment


TIA (transient ischemic attack)
By definition, transient ischemic attack, TIA, is a recurrent ischemia in the brain within a
briefer periods, which produces neurologic deficits, and the symptoms and signs resolve
completely , usually within several minutes to 1 hour, no more than 24 hours.

Clinic Features
Most occurs in those middle and old ages, higher in male than in female.
TIA begins abruptly, within a briefer periods, and resolves quickly without any residual
deficit.
Recurrent, stable symptom.
Risk factor: Hypertension,Dia betesmellitus,Hypercholesterolemia, Heart disease.

Features of Internal Carotid Artery System TIA

Frequent symptom:
contralateral monoplegia, accompanying with contralateral facial to MCA
infarction or watershed infarction between MCA and ACA.
Characteristic symptom:ophthalmic artery crossed palsy, Horner sign crossing palsy, sometimes
accompanying aphasia.
Possible symptom:hemisensory disturbances, hemiablepsia.

Frequent symptom:vertigo, balance disturbance.
Characteristic symptom:drop attack,
transient global amnesia, binocular vision disorder.
Possible symptom:dysphagia, ataxia, conscious disturbance,perioral numbness, ambiopia, crossed
paralysis.

Treatment
Objective:eliminate etiological factor,prevent and decrease recurrence, protect the function of
brain.
Etiological treatment
Prophylactic drug treatment: antiplatelet agents, anticogulant, angiotenic, traditional Chinese
medicine, fluid expansion drugs.
Neuroprotective agents

Cerebral Infarction
Cerebral infarction, CI, other named as cerebral ischemic stroke, CIS, is defined as a local
ischemic necrosis or cerebro- malacia in the brain tissue due to disorder of the cerebral blood
supply, ischemia and hypoxia.
Common typers:cerebral thrombosis, lacunar infarction and cerebral embolism.

Cerebral Thrombosis
The stem or cortical branches of the cerebral arteries occur angiostenosis or obstruction because of
vascular lesion such as artherosclerosis, arteritis and etc, which causes cerebral thrombosis. The


occlusion of a blood vessel interrupts the flow of blood to a specific region of the brain, and
produces ischemia, hypoxia, malacia, necrosis, focal symptoms and signs that correlate with the
area of the brain supplied by the affected blood vessel.

Pathogeny & Mechanism
Arterial canal stenosis and thrombosis
osclerosis,most occur in bifurcation of the vessal.
itis
logical system

Vasospasm
Other:hyper- APLA, pro C, pro S, etc.

Pathophysiology
Ischemic Penumbra: conservation the neuron in the IP, is the key of treatment of acute cerebral
infarction.
Time Window
Reperfusion Damage:means that recover the blood flow of the brain after the time may
aggravate mechanism is regard with free radical, overload of intracellular Ca2+ in the
neuron,excitatory amino acids,etc.

Clinical Features
General features: artherosclerosis is the main etiological factor for the middle and old age,
vasculitis is the common factor for young ones. Generally onset at a calm or rest time, reach the
peak after 1~2 days. Majority have clear consciousness. Part of them are preceded by TIAs.
Clinical classification:
complete stroke, progressive stroke, reversible- ischemic neurological deficit.

Clinical Syndrome
Syndrome of Internal Carotid Artery Occlusion:
homonymy monocular amaurosis
homonymy Horner sign
contralateral hemiplegia,hemisensory- deficit, homonymous hemianopia
aphasia(dominant hemisphere)
carotid arterial pulse to weaken,vascular murmur from cervical or ocular region.

Occlusion of Middle Cerebral Artery
Occlusion of stem: hemiplegia, hemisensory- deficit and hemianopia, with aphasia(dominant
hemisphere), may have different level of conscious disturbance.
Occlusion of cortical branch : occlusion of superior division results in contralateral hemiplegia
that affects the hand, arm and face,combined with Broca aphasia; inferior division results in
Wernicke aphasia, anomic aphasia and behavioral disturbance.
Deep perforating branch: contralateral hemiplegia, hemisensory deficit and subcortex
aphasia,sometimes with hemianopia.


Occlusion of Anterior Cerebral Artery
Occlusion of stem: If the occlusion afterwards the communicating artery: contralateral hemiplegia
that mainly affect the face, tongue and the lower limbs, lightly hemisensory deficit,retention of
urine or urgency and psychiatric symptom.
Occlusion of cortical branch: The main symptom is same as occlusion of stem.
Deep perforating branch: Contralateral hemiplegia that mainly affect the face, tongue and the
upper limbs.

Syndrome of Posterior Inferior Cerebellar Artery or Vertebral Artery Occlusion
(Wallenberg syndrome)
General features :
vertigo,vomit,nystagmus
crossed hemisensory deficit
homonymy Horner sign
dysphagia,cerchus
homonymy cerebellar ataxia

Trentment
Super acute stage:thrombolytic therapy
Neuroprotective therapy
Anticoagulation, defibrase
Antiplatelet therapy
Supportive treatment
surgeryinterventional therapy
Treatment for preventing recurrence

Therapeutic Principle

Neuroprotective therapy
antiedema agents
supportive treatment
preventing recurrence: treatment of primary diseases

CVD
缺血性: 短暂性脑缺血发作
(transient ischemic attack,TIA)
脑血栓形成
(cerebral thrombosis,CT)
脑栓塞
(cerebral embolism)
出血性: 脑出血
(intracerebral hemorrhage,ICH)
蛛网膜下腔出血
(subarachnoid hemorrhage,SAH)


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