出血性卒中.ppt
Hemorrhagic StrokeCase Discuss May 9,2001part 1-case reportpart 2-case analysispart 3-related infopart 4-anatomy reviewPart oneCase reportMedical record Mrs.Zhou,married,female,age 37,nurse,was admitted on April 13,2001 with a chief complaint of sudden right-limb weakness and slurred speech for 13 days.History of Present Illness-1 Mrs.Zhou had right-limb weakness abruptly on her way home 13 days prior.Then she was unable to stand up and hold something by right hand,with disturbance of speech at same moment.Moreover,she still felt mild dizziness concurrently.She denied headache,nausea nor vomiting.Limb convulsive seizure and loss of consciousness were not found during the course.There was no urinary or fecal incontinence as well.She was sent to Han Dan Hospital by her mates immediately.The CT scan showed intracerebral hemorrhage and her blood pressure at that time rose to 165/90 mmHg.History of Present Illness-2She had poor appetite and fatigue since she was sick.Only liquid diet was taken after illness.There was no dysipsia.Bowel movement and urination were normal.History of Present Illness-3On physical examination,she was alert but aphasia;the muscle power of right-limb was 0 and Babinskis sign on both sides was positive.There was also numbness(hemihypoesthesia)on right-side.Then she was put on dehydrating agent,hemostatic,multiple vitamins and so on.The patient was on state of over-drowsy for three days until she revived.Then the disturbance of speech had somewhat improved but still slurred.And furthermore,paralysis of right-limb didnt improve apparently.She was transferred to our hospital on April 13,2001 to receive further diagnosis and treatment.Past medical history Occasionally hypertension after exertion,usually 135/90-95 mmHg.Her blood pressure rose to 165/90 mmHg for several times after sick.Deny the history of cardiopathy,diabetes mellitus or stroke.Suffered from miliary tuberculosis of lung at the age of 15.Allergic history for drugs include cephalexia,ciproflexin and aglumin ethamsylate.Personal history/Family historyDeny smoking and drinking.Mild charater.Married with a child.Has a family history of stroke(mother and father).N.S physical exam-1Mental state:Alert,oriented;intact intelligence.Speech:alalia.Cranial nerves:(optic nerve)-Pupils are equal and react to light normally.,(oculogyric nerve)-No strabismus.EOM(extraocular movement)normal.No nystagmus.(trigeminal nerve)-Pinprick of right-side absent.N.S physical exam-2(facial nerve)-Facial paralysis on right-side.(auditory nerve)-Hearing normal.,(glossopharygeal and pneumogastric nerve)-Uvula elevates symmetrically.(accessory nerve)-Trapezius,sternomastoid normal.(ligual nerve)-Tongue protrudes right.No atrophy nor tremor.N.S physical exam-3Motor:R:0 muscle power,elevated tone,hyperactive reflex.Hoffmanns positive.Babinskis sign positive.L:Normal.Sensory:R:Disturbance sensation.(including pinprick,touch and vibration)L:Normal.N.S physical exam-4Cerebellar:Gait,finger-nose,heel-knee and Romberg incompatible due to paralysis.Menigeal irritation:negative.Palm-chin reflex and sucking refles:positive on right-side.Lab testCBC:WBC,neutrophils,Hemoglobin Urine and stool analysis（-）ESR:Lipid profile shows:TG,LDL,HDLEtiological examination:Leptospira-Ab（钩端螺旋体）and toxoplasmatic Ab（弓形体）（-）Immunologic test:Nothing special.Ultrasound:Nothing special.Neuro-imagingCT shows:hemorrhage from left putaminal involves internal capsule,rupture into ventricle and sulcus lateralis.(左壳核出血累及内囊，破入脑室和外侧裂)MRI suggests:hemorrhage from left basal ganglia involves lateral cleft.DSA reveals:Moyamoya disease.Part twoCase analysisIntracerebral hemorrhage(ICH)Synonymsalternative namesBrain hemorrhageCerebral hemorrhageCerebral parenchymal hemorrhageIntracranial hemorrhageIntracerebral hemorrhage(ICH)Some helpful wordsCVD;cerebrovascular diseaseCVA;cerebrovascular accidentBrain attack=strokeSAH:subarachnoid hemorrhage ICH:intracerebral hemorrhage AVM:arteriovenous malformationCT:computed tomographyMRI;magnetic resonance imagingMRA:magnetic resonance angiographyDSA:digital subtraction angiographyLocalizition-L.putamenRight limbs paralysis+pathologic reflexes suggests lesion involved L.corticospinal tract;Right central facial+tongue paralysis revealed L corticonuclear tract;Deficit sensation at R.face and R.limbs means lesions also damage L.thalamic radiation pathway;CT,MRI support the clinical analysisBased on above information,localizition of hemorrhage is clearly comfirmed.DiagnosisICH(intracerebral hemorrhage)Abruptly onset,symptoms progress over minutes,deteriorated rapidly;Focal NS deficit,with progressive decrease in level of consciousnessBP elevated after attack;CT,MRI showed high density signal at the site of putamen,involved internal capsule and subarachnoid space,ventricular systemICH is confirmed based on above info.Intracerebral hemorrhageAccount for only 15%of all strokesMuch higher mortality rate45 yrs,maleTwo types:SAH,ICHThe risk for ICH doubles every 10 yearsDifferential Diagnosis-1 Hypertensive hemorrhageElevated BP after brain attack,Typical location of hypertensive hemorrhage,6 main locations:putamen,subcortical cerebral lobe,thalamus,cerebellum,brainstem,and caudate nucleusMay extend into the ventricular system or subarachnoid space.But without HTX past history,Middle-agedCauses ICHOther causes and risk factors for ICHIntracranial infection,vasculitis感染，血管炎Vascular malformation(AVM),moyamoyaBrain tumorsCerebral amyloid angiopathy淀粉样变血管病Blood dyscrasias(bleeding disorders)Collagen vascular diseases胶原病Bleeding systemic diseases(liver,kidney)Drug and alcohol abuse_cocaine,illicit drugsAnti-coagulants_warfarin,heparin,aspirin(blood tinners)*Cerebral venous thrombosis(CVT)静脉窦血栓Thrombolytics(tpA,streptokinase)溶栓Bp controlLowering BP-decrease the risk of ongoing bleeding but decrease cerebral perfusion pressure and worsen brain injury,even increase intracranial pressureBalance these 2 theories,BP should be maintained below a mean arterial pressure（平均动脉压）of 130 in persons with a history of hypertension.Fluid balance is calculated by measuring daily urine production and adding for insensible water loss(input=urine output+500ml for insensible water loss,+300 ml per degree in febrile patients)When we need neurosurgeons help?Small hemorrhage 4,with poor outcome that cant be improved by surgery.-Cerebellar hemorrhage 3cm or who have brain stem compression（脑干受压）and hydrocephalus（脑积水）from ventricular obstruction-ASAP Young patients with large lobar hemorrhage 50cm3 who deteriorate during observation-ICH with aneurysm or AVM,moyamoya,who has a chance for a good outcome-Vascular malformation(AVM)Relatively common,esp in younger patients,45Small lesions are more likely to bleed than large lesionsLobar ICH is the most common hemorrhage associated with Large AVMS,also called angiomas(血管瘤),occur in males more often than in females.Symptoms may occur at any time,most often symptoms develop before age 30.Intracranial aneurysm more common in adults than in childrenMultiple and asymptomaticThe peak age for rupture of it:40-60 Maybe associated with polycystic kidney（多囊肾）and coarctation of the aorta（主动脉缩窄）Locates on the anterior part of the circle of Willis,particularly on the anterior communicating arteries,at the bifurcation of the middle cerebral artery（MCA）and the internal carotid artery（ICA）Amyloid angiopathyBlood vessels become friable in some individuals from build-up of an abnormal protein call amyloid.Elderly personLobar hemorrhageRecurrentDiagnosis:pathology supportPart threeMoyamoya diseaseWhat is moyamoya-1First diagnosed by Jiro Suzuki,1963Moyamoya_a Japanese word means”something hazy like a puff of cigarette smoke,drifting in the air”,occurs mainly in females,particularly of Japanese origin.On cerebral angiography these unusual vessels resemble puffs of smoke.Takes its name from the wispy tangles of friable vessels that from at the base of the brain following occlusion of major intracranial arteries.What is moyamoya-2 It is most frequently in children,adolescents and young adultsHigher incidence in Japan,Two age peaks:10,3rd decadeCharacterized by the spontaneous occlusion of base of the brain.(both internal carotid arteries)What is moyamoya-3Aetiologyunknown,arteritis(Takayasus disease),radiation induced vascular damage,sickle cell disease.genetic basis,bacterial infections(nasopharyngeal infections)Can cause ischemic stroke,TIA,or intracranial bleeding.Progressive neurologic worsening and recurrent eventsWhat are the symptoms-1In children:Ischemic symptoms,recurrent,alternative episode of focal deficitSeizuresInvoluntary movement disordersIntracranial hemorrhageWhat are the symptoms-2In adultsIntracranial hemorrhage is the most common presenting event,SAH is equally common as well,it results from rupture of small fragile moyamoya vessels;Ischemic symptoms=see also childrenWhat conditions is associated withNeurofibromatosis（神经纤维瘤病）Tuberous sclerosis（结节硬化）Sickle cell anemia（镰刀红细胞贫血）MeningitisFibromuscular dysplasia（纤维肌发育不良）atherosclerosisDowns synFollowing radiation to the skull base in children 颅底放疗How is moyamoya diagnosed-1Female more commonly affected than males 1:1.5Moyamoya should be suspected when TIAs or stroke occur in children or young adultsInvolves the large intracranial arteries especially,the internal carotid and the stem of anterior and middle cerebral arteries.How is moyamoya diagnosed-3The relevant investigations of choice of moyamoya include:AngiographyDSAStenosis or occlusion of the terminal protion of intracranial internal carotid artery or anterior or middle cerebral arteries.(MCA)the characteristics“puff of smoke”appearanceBilateral involvementHow is it treated-1Vasodilators,steroids,antibiotics,anti platlet drugs/warfarinfor ischemic attack maybe helpful calcium blockersProgressive disease with serious consequences,difficult to treat.Most victims do not survive beyond the age of 30-40 yrs currently.How is it treated-2Surgical proceduresbypass operation,transposition of muscle or omentum（网膜）to the surface of the brainShunting procedureGamma knife is pendingSTA(superficial temporal artery)to MCA(middle cerebral artery)Encephalo-myo-synangiosis(EMS):laying of the temporalis muscle on the surface of the brain leading to the formation of new blood supply to the brainEncephaloduroarteriosynangiosis(EDAS):Reference reviewReference article-130 yrs,male,who was admitted in a status epilepticus for 6 hrs,CT scan revealed a left frontoparietal bleed with intraventricular extension.DSA turned out to be a Moyamoya diseaseReference article-2Hemorrhagic moyamoya disease during pregnancyPregnant 31 weeks female,with hypertension and progressive decrease in her level of consciousnessCT:a large putamental intracerebral hemorrhageDelivered a 1185g infantDied from malignant brain edema post c/s(剖腹产),10 th day.Confirmed moyamoyaPart fouranatomy reviewsee you next 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