各論01-1顱內(nèi)壓增高腦疝課件

顱內(nèi)壓增高1XinhuaSquare2TrafficAccidents3IraqWar45EmergencyRoomoftheAffiliatedHospital6Craniocerebralinjuryhashighincidencewhetherinpeacetimeorwartimes.ButIncreasedICPistheessentialandtheknottyproblempassingthroughneurosurgicalclinicalandteachingwhichtheteachingprogrammedemandstohold.Importance

SignificanceNecessity7Intracranialpressure,ICP：isthepressureincranialcavity,namelybrainpressure,whichisexpressedinpressureofCSF.Rangeofnormalvalue:0.7-2kPa

(70-200mmH2O),children:0.5-1.0kPa.>2kPaIntracranialhypertension，

<0.7kPaIntracranialhypotensionPathophysiology1.

PathophysiologyDEFINITION8IntracranialthreecontentsPathophysiologyIt’sgeneralvolumeisconstant——1400ml9GenerationofCSFPathophysiologytotalamount:130mlV=0.35ml/minAbsorptionOfCSF10RegulationofICPPathophysiologyRelationtobloodpressure(BP)&respirationSystole—，Diastole—；Expiration—，Inspiration—ButitmainlydependsuponthechangeofvolumeofCSF.“Monroe-KelliePrinciple”11

RegulationofICP

RelationtoCSF

TheabsorptivevelocityofCSFdependsuponthepressuredifferencebetweensubarachnoidspaceandvenoussinus.Ifexcessiveformation,obstructivecirculutionanddisturbancedabsorption

CSFvolumeBeyonditsregulationlevelintracranialpressurePathophysiology12RegulationofICPRelationtoCBF(cerebralbloodflow)Braintissuerequiresmoreoxygenthanothertissues,soit’sthemostsensitivetohypoxiaandischemia.CBF=

Pathophysiologymeansystemicarterialpressure(mSAP)–ICPcerebralvascularresistance(CVR)cerebralperfusionpressure

(CPP)CVRRegulationofCBFislessthanofCSF,it’slimitedthattheabilityof“bulkcompensation”toIntracranialhypertension=13RegulationofICPPathophysiologyRelationtoBraintissueBraintissuehasalittleregulation.Chronic:compensatedbybraintissueatrophyandAmplificationof

subarachnoidspaceandventricles.Acute:can’tbecompressedobviously.14

2.Etiology

ExcessiveCSF：hydrocephalusCBF

：AVM、aneurysmsBraintissuevolume:cerebraledema(braininjury,inflammation,hypoxia,poisoning)Space-occupyinglesion：

hematoma,tumor,abscess,granulomaEtiologyBasilarinvaginationandlargedepressedfractureofskullcontentscranialcavity15BrainInjuryNeurosurgeryMechanismofCloseCraniocerebralInjuryContusionandlacerationofbrain16EpiduralHematomaNeurosurgery17DepressedFractureNeurosurgery183.Influencefatorsof

increasedintracranialpressure

Age：infant,senility

Course：acute,chronic

Langfitttestin1966:

volume/pressurecurve

Position：midline,posteriorfossa

Character：benign,malignant

Generalstate:

severesystemlesionInfluencefactors19ICP(mmH2O)Volume(ml)

VPRInfluencefactorsvolume/pressurecurve203.Influencefatorsof

increasedintracranialpressure

Age：infant,senility

Course：acute,chronic

Langfitttestin1966:

volume/pressurecurve

Position：midline,posteriorfossa

Character：benign,malignant

Generalstate:

severesystemlesionInfluencefactors21

Consequences4.Consequencesof

increasedintracranialpressure

CerebralbloodflowHerniationofbrainCerebraledema:

ICPaffectingcerebralmetabolism&CBFcerebraledemaGastrointestinaldysfunctionPulmonaryedema

Cushingresponse

ICP

Bp,P,Pulsepressuredifference22RegulationofICPRelationtoCBF(cerebralbloodflow)CBF=

Pathophysiologymeansystemicarterialpressure(mSAP)–ICPcerebralvascularresistance(CVR)cerebralperfusionpressure

(CPP)CVR=23

Consequences4.Consequencesof

increasedintracranialpressure

CerebralbloodflowHerniationofbrainCerebraledema:

ICPaffectingcerebralmetabolism&CBFcerebraledemaGastrointestinaldysfunctionPulmonaryedema

Cushingresponse

ICP

Bp,P,Pulsepressuredifference24

5.ClinicalmanifestationsofincreasedICPHeadacheVomitingPapilledemaOthersymptomsChangesofvitalsignsHerniationofbrainClinicalmanifestation25

Headache

Thecommonnestsymptomwhichoftenarisesatmorningoreveningandwithforwardradiationtoorbit,aggravatedwithincreasedICP.Theheadachecanincreasewhencoughing,bendingdown,loweringone’sheads.

ClinicalmanifestationReasons:meninges,bloodvesselsandnervesarepulledupon.26ClinicalmanifestationFrequentlyseenintumorslocatedinposteriorcranialfossaand4thventricle.

Headacheisatypicalinchildren.

VomitingUsuallyappearswhenheadacheissevere,accompaniedbynausea.Thetypicalisprojectile.27

Papilledema

Isthemostobjectivesign.It’scharacterizedbyopticpapillarycongestion,theindistinctmargins,theexcavationdisappearance,opticdiscprojection,venousengorgementandarterialtwistiness.Clinicalmanifestation28papilledema296.Diagnosis30

Placeweightoncasehistory,somatoscopy,especiallyNSexamination.Diagnosis(1)LumbarvertebraepunctureAccessoryexamination.31Accessoryexamination.

Diagnosis(2)Theplainradiographoftheskull32Accessoryexamination.

Diagnosis(3)CerebralVascularAngiographydigitalsubtractionAngiography,

DSA3D-DSA33Accessoryexamination.

Diagnosis(4)CT&MRI34Treatment7.Treatments357.1.GeneraltreatmentObserveT,P,R,Bp,consciousness,pupilPreventinhalationpneumoniaPayattentiontofluidinfusion,acid-basebalancePayattentiontolooseningthebowelsKeepairwayunobstructedOxygeninhalationTreatment7.Treatment367.2.Etiologicaltreatment

Space-occupyingfocus:removalHydrocephalus:by-passoperationofCSF

eg.VentriculoperitonealshuntAcutebrainhernia:emergencysurgeryTreatment377.2.Etiologicaltreatment:OperativetreatmentTreatment38Sphenoidalmeningioma

EtiologicaltreatmentTreatmentSpace-occupyingfocus:removal39IntraoperationTreatmentEtiologicaltreatment40SphenoidalmeningiomaTreatmentEtiologicaltreatment2'38"41TreatmentEtiologicaltreatmentHydrocephalus:by-passoperationofCSFeg.Ventriculoperitonealshunt42434445EtiologicaltreatmentTreatmentAcutebrainhernia:emergencysurgery.eg.Epiduralhematoma46Epiduralhematoma47Thoroughlystopbleeding4849Subduralexploration507.3.VentriculocentesisVeryeffectiveemergencymeasurestosevereincreasedICP!Treatment(Schematicdiagram)51TreatmentPuncturetransanteriorhornoflateralventricleVentriculocentesis52Treatment

7.4.DehydrationtherapyMannitol20%Glucosi50%Furosemide(Lasix)

Glycerinfructose

HydrochlorothiazideDimox53Treatment

7.5.Hormonotherapy

ImprovefunctionofBloodbrainBarrier,BBB，

lowerpermeabilityofcapillary

Desamethasone

Methylprednisolone

Hydrocortisone

Prednisone547.6.SubhypothermiatherapyLowercerebralmetabolism,ReducecerebraloxygenconsumptionPreventdevelopmentofhydrocephalusTreatment55Barbitaltherapy

Overventilation

Antibiotictherapy

Expectanttreatment7.7.Othertreatments568.HerniationofBrain578.1.BasicAnatomyAnatomySchematicdiagramofcranialcavity588.2.CauseofformationICPcausedby

differentreasonsEtiologybraintissuepassdownthepositionwherepressureislowgiverisetoaseriesofclinicsyndromesnamelybrainhernia59CommondiseasesleadingbrainherniaEtiologyIntracranialHematomasTumorsIntracranialAbscessIntracranialParasitosisChronicGranulomas

608.3.PathogenesisPathogenesisThemostimportanceiscausingthesecondarylesionofbrainstem!CirculationofCSFmeetwithobstructionHastenICP

Viciouscircle

618.4

ClinicalmanifestationTranstentorialherniation(Temporaloncusherniation)Clinicalmanifestation①symptomsofincreasedICP:severeheadache,frequentvomitingwhichaggravatedthanpre-hernia,dysphoria②consciousnesschanges:lethargysuperficialcoma

coma62ClinicalmanifestationClinicalmanifestationTranstentorialherniation(Temporaloncusherniation)③pupillarychanges:anisocoria——oculomotornerveispulled.accompaniedby

droopingeyelid,exotropiaplatycoria——Oculomotornucleusiscompressed.63ClinicalmanifestationClinicalmanifestationTranstentorialherniation(Temporaloncusherniation)④dyskinesia

hemiplegia；decerebraterigidity——brainstemisdamagedseverely?、輛italsignsdisordered

T、P、R、Bp64Transforamenmagnaherniation(Tonsillarherniation)ClinicalmanifestationClinicalmanifestationHerniadownwardCerebellartonsiliscompressedIncreasedICPbelowtentorium

Space-occupyinglesionsinposteriorfossa65Severeheadache,repeatedvomiting,disorderedvitalsigns,suddenstoppedrespiration,withoutpupillarychanges.ClinicalmanifestationClinicalmanifestationTransforamenmagnaherniation(Tonsillarherniation)66Treatment8.5.Treatment

DehydrationtherapyVentriculocentesisDecompressionoperationV-PshuntInternaldecompressionoperationOthers67Summary

ICP>2kPa:IncreasedICPHeadache,VomitingandPapilledemaarethethreemajorsignandsymptomsHerniationistheseverestConsequences

68

OperativetreatmentsVentriculocentesisNon-operativetreatmentsSummary69Multiplechoicequ