CVD 浙大英文课件
放牛娃的春天观后感-于丹百家讲坛
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)