颅内高压的病理生理

颅内高压的病理生理 一、概 述 , 颅内压的正常值 成人:70,200 mmH2O 儿童:50,100 mmH2O , 颅内压的形成 总容积:1400,1500ml 脑组织(80,、1150,1350cm3) 脑脊液(10,、150ml) 血液 (2,,11,) 颅内压的调节与代偿 , 颅内压的生理调节与代偿 脑组织:几乎无调节能力 血液:依靠静脉血排挤到颅外，调节能力极为有限 脑脊液:调节能力相对强，最为主要 两种途径:1、改变蛛网膜颗粒的吸收能力 2、改变脉络丛的分泌能力 颅内压的调节与代偿 颅内压的人工干预 脑组织:肿瘤切除或内减压手术 血液:过度换气 ? PaO2升高 、PaCO2下降?颅内血液，容积减少 增大死腔 ?PaO2下降、PaCO2升高 ?颅内血液容积增大 脑脊液:增加颅内压,脊膜囊灌注 减少颅内压,脊液外引流或分流术 颅内压增高的原因 , 颅腔内容物体积增大 脑组织体积?(脑水肿) 脑血流量? (静脉回流受阻/动脉过度灌注) 脑脊液容量?(脑积水) , 颅内占位性病变(脑肿瘤、脓肿、血肿) , 颅腔容积变小(先天性畸形,狭颅症、颅底凹陷) p the right to recovery of principal and interest and costs; Waiver of recourse against the party of individual credit rights; Behavior of other claims against the Bank. The Agency shall, in accordance with the Bank's records management systems requirements, regulate the collection, safekeeping of personal credit file, pay attention to the following risks: customers based on incomplete information; Review and approval 影响颅内压增高的因素 , 年龄:小儿颅缝未闭 代偿颅高压，减缓病情 老人存在脑萎缩 , 病变扩张速度:体积/压力曲线,指数关系 临界点,代偿/失代偿的分界 2following risks: customers based on incomplete information; Review and approval s records management systems requirements, regulate the collection, safekeeping of personal credit file, pay attention to the; Behavior of other claims against the Bank. The Agency shall, in accordance with the Bank'p the right to recovery of principal and interest and costs; Waiver of recourse against the party of individual credit rights , 病变部位:靠近脑中线/后颅窝,压迫静脉窦、中 脑导水管,颅压增高快、病情发展迅速 , 伴发脑水肿的程度:炎症性占位病变,水肿明显 , 全身系统性疾病:尿毒、肝昏、肺感、酸碱失衡、高热,继发性 脑水肿 颅内压增高的后果 , 脑血流量下降，脑缺血 脑血流量(CBF),〔平均动脉压(MAP),颅内压(ICP)〕?脑 血管阻力(CVR),脑灌注压(CPP) ?脑血管阻力(CVR) 当CPP,40mmHg，脑血管自动调节功能失效，脑缺血产生 , 脑移位和脑疝:局灶性颅高压、存在分腔压力 , 脑水肿:颅高压影响脑细胞代谢，互为因果、恶性循环 , Cushing反应:两低一高 , 胃肠功能紊乱、消化道出血:下丘脑刺激、应激性溃疡 , 神经源性肺水肿:血压?、左心负荷? 二、颅内压增高 , 类型(范围): 弥漫性:脑膜脑炎、弥漫性脑水肿、交通性脑积水等 特点:颅腔 内压力均匀，无明显分腔压力差，病人耐受性好 局灶性: 特点:局部压力高，有分腔压力，易造成脑疝，病人耐 受性差 3of personal credit file, pay attention to the following risks: customers based on incomplete information; Review and approval eepingBank. The Agency shall, in accordance with the Bank's records management systems requirements, regulate the collection, safekd interest and costs; Waiver of recourse against the party of individual credit rights; Behavior of other claims against the p the right to recovery of principal an , 类型(时间): 急性:急性颅脑损伤所致颅内血肿、高血 压脑出血,严重、变化快 亚急性:颅内恶性肿瘤、转移瘤、炎症 慢性:颅内良性肿瘤、慢性硬膜下血肿 , 引起颅压增高的疾病 颅脑损伤:颅内血肿、脑挫裂伤、 颅内肿瘤:良恶性、大小、部位 颅内感染:脓肿、脑膜脑炎 脑血管疾病:出血、缺血软化灶 脑寄生虫病:脑囊虫、脑包虫，占位效应 先天性疾病:脑积水、狭颅、颅底凹陷、小脑扁桃下疝 4following risks: customers based on incomplete information; Review and approval s records management systems requirements, regulate the collection, safekeeping of personal credit file, pay attention to the; Behavior of other claims against the Bank. The Agency shall, in accordance with the Bank'p the right to recovery of principal and interest and costs; Waiver of recourse against the party of individual credit rights 良性颅压增高:蛛网膜炎、静脉窦栓、中毒性脑病 脑缺氧:继发性脑水肿 急性脑水肿术中严重脑膨出 , 临床现—三主征 头痛:最常见，早晚较重。压力增高刺激、牵张了脑膜、脑血管神经。 呕吐:喷射状，压力刺激了延髓呕吐中枢。 视乳头水肿:视神经蛛网膜下间隙压力?，影响回流致水分潴留、渗 出等。 意识障碍及生命征变化:嗜睡?昏迷，两低一高( Cushing反应) 其他:头皮静脉怒张、大头儿 , 诊断:症状和体征—三主征 , 辅助检查:CT、MRI、DSA、头颅X,ray、腰椎穿刺 5of personal credit file, pay attention to the following risks: customers based on incomplete information; Review and approval eepingBank. The Agency shall, in accordance with the Bank's records management systems requirements, regulate the collection, safekd interest and costs; Waiver of recourse against the party of individual credit rights; Behavior of other claims against the p the right to recovery of principal an 治疗原则 1. 一般处理:观察、颅内压监护、呕吐者禁食、通便、吸氧、昏迷者必 要时气切… 2. 病因治疗:切除病变、减压术、分流术… 3. 降颅压治疗:高渗脱水剂利尿剂，注意时相、电解肾功等变化 4. 激素应用:地米、甲强龙，保护细胞膜 5. 5.冬眠/亚低温:代谢率?、氧耗?、水肿? 6. 6.脑脊液外引流:颅内压监护、缓慢放液 7. 7.巴比妥治疗:代谢率?、氧耗?、耐受力?， 药物浓度检测 8. 过度换气:动脉血PaCO2 ?、脑血流? 9. 抗生素治疗:控制感染、药敏、选择广谱 10.症状治疗:镇痛、镇静、抗癫痫 三、急性脑疝 , 脑疝概念:颅内分腔有占位性病变?分腔间存 在压力差?脑组织从高压区移向低压区?脑组织、 血管、神经等受压移位?被挤入硬脑膜间隙孔道中 ?出现系列严重的临床症状、体征。 , 病因:1.各种外伤性血肿;2.颅内脓肿;3.颅 内肿瘤;4.颅内寄生虫病、肉芽肿;5.医源性:不 当腰穿 , 分类:小脑幕裂孔疝(颞叶疝)、枕骨大孔疝(小脑扁桃体疝)、大脑镰下疝(扣带回疝) , 病理:移位脑组织在小脑幕切迹或枕骨大孔处挤压脑干?脑干内血管受牵拉、出血;同侧大脑脚受压?对侧偏瘫;同侧动眼神经受压?麻痹?瞳孔散大;大脑后动脉受压于小脑幕切迹缘?枕叶梗死;脑脊液通道受阻?颅内压? ?恶性循环。 , 临床表现 1. 小脑幕切迹疝:颅内压增高(剧烈头痛、喷射性 呕吐、烦躁)、瞳孔改变(患侧瞳孔变小对光迟钝 ? 瞳孔散大对光消失? 双侧散大)、运动障碍 (病变对侧肢体肌力? 病理征， ? 双侧肢体 活动消失、去脑强直)、意识改变(脑干内网状系 6following risks: customers based on incomplete information; Review and approval s records management systems requirements, regulate the collection, safekeeping of personal credit file, pay attention to the; Behavior of other claims against the Bank. The Agency shall, in accordance with the Bank'p the right to recovery of principal and interest and costs; Waiver of recourse against the party of individual credit rights 统受累? 嗜睡? 昏迷)、生命征紊乱(心率、血压、呼吸、体温等 不规则? 呼吸停止、血压、心脏停搏) 2.枕骨大孔疝:脑脊液通道受阻?颅内压? ?剧烈 头痛、频繁呕吐、颈项强直、强迫头位?生命征紊 乱早、意识障碍晚?呼吸中枢受损? 突发呼吸骤停?死亡。 , 处理 1. 紧急输注高渗脱水、利尿药物:甘露醇、甘油 果糖、速尿 2. 病因明确:手术降颅压—清除血肿、切除肿瘤 等 3. 姑息性手术:侧脑室体外引流术(术前常用)、脑脊液分流术(侧 脑室,腹腔分流常用)、减压术(颞肌下减压术、枕肌下减压术、 去骨瓣、内减压术) 7of personal credit file, pay attention to the following risks: customers based on incomplete information; Review and approval eepingBank. The Agency shall, in accordance with the Bank's records management systems requirements, regulate the collection, safekd interest and costs; Waiver of recourse against the party of individual credit rights; Behavior of other claims against the p the right to recovery of principal an