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"code": "I61",
"name": "Внутримозговое кровоизлияние",
"icd_name": "Внутримозговое кровоизлияние",
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"slug": "i61_vnutrimozgovoe_krovoizliyanie",
"lead": "Нарушение здоровья, относящееся к группе цереброваскулярные болезни",
"description": "Внутримозговое кровоизлияние - локальное кровотечение из кровеносных сосудов в пределах паренхимы мозга, обусловленное разрывом патологически изменённых стенок церебральных сосудов или просачиванием плазмы и форменных элементов сквозь стенку сосудов.",
"etiology": "<p>К предрасполагающим факторам относят:</p>\r\n<ul>\r\n<li>Аневризма сосуда – выпячивание стенки сосуда вследствие ее истончения или растяжения.</li>\r\n<li>Сосудистая мальформация – аномальное строение и коммуникации сосудов головного мозга.</li>\r\n<li>Васкулит – воспаление стенки сосуда.</li>\r\n<li>Атеросклеротическое повреждение стенки сосуда.</li>\r\n</ul>\r\n<p> </p>\r\n<p>Однако одних только предрасполагающих факторов недостаточно. Для разрыва сосуда должен воздействовать инициирующий фактор:</p>\r\n<ul>\r\n<li>гипертонический криз (часто у пожилых);</li>\r\n<li>нарушения свертываемости крови;</li>\r\n<li>ряд наркотических веществ, которые нарушают тонус сосудов;</li>\r\n<li>внутриопухолевое кровоизлияние.</li>\r\n</ul>\r\n<p> </p>",
"pathogenesis": "<p>Основным патогенетическим фактором кровоизлияния являются артериальная гипертензия и гипертонические кризы, при которых возникают спазмы или параличи мозговых артерий и артериол. Обменные нарушения, возникающие в очаге ишемии (сниженного кровоснабжения), способствуют дезорганизации стенок сосудов, которые в этих условиях становятся проницаемыми для плазмы и эритроцитов – так называемое диапедезное кровотечение. Одновременное развитие спазма многих сосудистых ветвей в сочетании с проникновением крови в мозговое вещество может привести к образованию обширного очага кровоизлияния, а иногда и множественных очагов. В основе гипертонического криза может быть резкое расширение артерий с увеличением мозгового кровотока, обусловленное срывом его саморегуляции при высоком артериальном давлении. В этих условиях артерии утрачивают способность к сужению и пассивно расширяются. Под повышенным давлением кровь заполняет не только артерии, но и капилляры и вены. При этом повышается проницаемость сосудов, что приводит к просачиванию плазмы крови и эритроцитов. В механизме возникновения такого диапедезного кровотечения задействовано нарушение взаимосвязи между свертывающей и противосвертывающей системами крови. В патогенезе разрыва сосудов играют роль и функционально-динамические нарушения сосудистого тонуса. Паралич стенки мелких мозговых сосудов ведет к острому нарастанию проницаемости сосудистых стенок и выходу плазмы крови из сосудистого русла.</p>",
"diagnostics": "<p>Методом выбора в диагностике внутримозгового кровоизлияния является компьютерная томография головного мозга, позволяющая не только определить наличие внутримозговой гематомы, но и оценить её локализацию, распространённость и объём, выраженность отёка мозга и степень дислокации. Для диагностики небольших гематом в стволе мозга и изоденсивных веществу головного мозга («несвежих») гематом предпочтительна магнитно-резонансная томография.</p>\r\n<p>В случае невозможности проведения компьютерной томографии при отсутствии противопоказаний проводится исследование цереброспинальной жидкости, кровь в которой может свидетельствовать о кровоизлиянии в структуры задней черепной ямки или субарахноидальном кровоизлиянии. Небольшие кровоизлияния в подкорковые структуры головного мозга проявляются наличием эритроцитов в ликворе лишь через 2—3 суток</p>",
"treatment": "<p>Лечение больных с внутримозговым кровоизлиянием делится на два больших подвида: консервативное и хирургическое.</p>\r\n<p>Консервативная терапия проводится всем больным с внутримозговым кровоизлиянием и включает в себя поддержание функции дыхательной и сердечно-сосудистой системы. Как правило, пациентам показано подключение к аппарату искусственной вентиляции легких (ИВЛ). Внимание уделяют профилактике последующей тромбоэмболии, а также лечению сопутствующих заболеваний.</p>\r\n<p>Нейрохирургическое лечение назначается после проведения компьютерной или магнитно-резонансной томографии и показано в следующих случаях:</p>\r\n<ol>\r\n<li>Локализация гематомы позволяет провести ее хирургическое удаление (поверхностное расположение в полушариях мозга, мозжечок, ствол головного мозга).</li>\r\n<li>Разрыв сосуда, обусловленный аневризмой.</li>\r\n</ol>\r\n<p>Адекватное нейрохирургическое лечение должно быть проведено в первые два дня после начала заболевания.</p>\r\n<p>Также в некоторых случаях можно выполнить декомпрессивную трепанацию черепа для снижения давления и профилактики отёка – набухания головного мозга.</p>",
"prevention": "<p>Первичная профилактика включает в себя:</p>\r\n<ul>\r\n<li>Своевременное лечиние выявленной патологии сосудов.</li>\r\n<li>Недопущение развития гипертонической болезни.</li>\r\n<li>Избавление от избыточной массы тела.</li>\r\n</ul>\r\n<p>Задача вторичной профилактики заключается в недопущении возникновения повторного кровоизлияния. Этого можно добиться современной медикаментозной терапией, хирургическим вмешательством</p>\r\n<p> </p>",
"clinical_picture": "<p>Симптомы кровоизлияния делятся на две группы: общемозговые и очаговые.</p>\r\n<p>Быстрое прогрессирование общемозговой симптоматики в самом начале говорит о неблагоприятном прогнозе, ведь параличи и другие неврологические нарушения просто не успевают развиться.</p>\r\n<p>К общемозговым симптомам относят:</p>\r\n<ol>\r\n<li>Сильную головную боль, а в случае субарахноидального кровоизлияния – резчайшую, до крика, по типу «удара».</li>\r\n<li>Тошноту и рвоту, иногда рвоту без предшествующей тошноты, «фонтаном». Это говорит о раздражении кровью ядер черепно-мозговых нервов и о резком повышении внутричерепного давления.</li>\r\n<li>Головокружение.</li>\r\n<li>Покраснение лица и конечностей, «апоплексическое» лицо.</li>\r\n<li>Постепенное угнетение сознания, сонливость, затруднение контакта, пациент «загружается», в тяжёлых случаях развивается мозговая кома.</li>\r\n<li>Появление эпилептиформных судорог, что может говорить о прорыве крови в желудочки мозга, в тяжёлых случаях – потеря сознания, появлении анизокории – расширения зрачка с одной стороны, что говорит о том, что головной мозг подвергся сдавливанию и смещению, развилось состояние его отёка – набухания. В таком случае очень вероятно вклинение миндаликов мозжечка в большое затылочное отверстие, паралич жизненно важных центров кровообращения и дыхания, расположенных в продолговатом мозге и летальный исход.</li>\r\n</ol>\r\n<p>Если пациент остался жив, ситуация стабилизирована, то через некоторое время вследствие гибели нейронов становятся заметны очаговые симптомы, которые зависят от локализации кровоизлияния. Это могут быть:</p>\r\n<ol>\r\n<li>Контралатеральные (противоположные стороне поражения) полные параличи и частичные (парезы) мышц конечностей и лица.</li>\r\n<li>Расстройства речи (афазия), как при восприятии, так и при произнесении речи. В первом случае афазия именуется сенсорной (чувствительной), во втором – моторной (двигательной). Так как речь человека чрезвычайно сложна, то чаще всего имеется сенсомоторная афазия, выраженная по-разному.</li>\r\n<li>Различные глазодвигательные расстройства (отведение яблока в сторону, т. е. нарушение взора), анизокория (зрачки разного диаметра).</li>\r\n<li>Снижение чувствительности на различных участках, нарушение чувствительности, онемение.</li>\r\n<li>Недержание мочи и кала.</li>\r\n<li>Различные нарушения психики, адекватности поведения, памяти, целенаправленности действий, интеллекта. Это случается при кровоизлиянии в лобные доли. Например, пациент может вначале встать, затем помочиться, а уже затем расстегнуть штаны и зайти в туалет. Такой симптомокомплекс именуется «лобной психикой».</li>\r\n<li>Симптомы раздражения оболочек (менингеальная симптоматика), с напряжением затылочных мышц, свето – и звукобоязнью, общей гиперестезией.</li>\r\n<li>Гипертермия, или повышение температуры тела вследствие изменения установочной точки температуры тела «отказом центра терморегуляции». Злокачественная гипертермия чрезвычайно опасна, и свидетельствует о неблагоприятном течении заболевания.</li>\r\n</ol>",
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