中樞神經(jīng)系統(tǒng)影像

1、中樞神經(jīng)系統(tǒng)影像學(xué)表現(xiàn)中樞神經(jīng)系統(tǒng)影像學(xué)表現(xiàn) neuroimaging of the central nervous system 學(xué)習(xí)內(nèi)容：顱腦、脊髓、血管學(xué)習(xí)內(nèi)容：顱腦、脊髓、血管1. 不同成像技不同成像技術(shù)術(shù)的特點(diǎn)和的特點(diǎn)和臨臨床床應(yīng)應(yīng)用用2. 正常影像正常影像學(xué)學(xué)表表現(xiàn)現(xiàn)3. 基本病基本病變變影像影像學(xué)學(xué)表表現(xiàn)現(xiàn)4. 影像新技影像新技術(shù)術(shù)不同成像技不同成像技術(shù)術(shù)的特點(diǎn)和的特點(diǎn)和臨臨床床應(yīng)應(yīng)用用1. x線圖線圖像的特點(diǎn)像的特點(diǎn)2. ct圖圖像的特點(diǎn)像的特點(diǎn)3. mr圖圖像的特點(diǎn)像的特點(diǎn)4. dsa檢查檢查中樞神經(jīng)系統(tǒng)中樞神經(jīng)系統(tǒng)正常影像學(xué)表現(xiàn)正常影像學(xué)表現(xiàn) anatomy of the

2、central nervous system with neuroimaging正常影像學(xué)表現(xiàn)正常影像學(xué)表現(xiàn)顱腦頭顱頭顱x線平片線平片 顱骨最基本的影像學(xué)檢查方法 顯示顱骨骨質(zhì)改變，是診斷顱骨骨折 和骨縫分離的有效方法 僅提示病變存在，但不能確診 臨床表現(xiàn)明顯但無(wú)異常發(fā)現(xiàn) 計(jì)算機(jī)體層攝影（計(jì)算機(jī)體層攝影（ct） 斷層圖像不利于器官結(jié)構(gòu)和病灶的整體顯示 ct檢查對(duì)疾病的定性診斷仍有一定限度 ct檢查使用x線，具有輻射性損傷 是目前常用的影像學(xué)檢查方法 常規(guī)ct圖像采用橫斷層圖像，克服了普通x線檢 查各種組織結(jié)構(gòu)重疊干擾的影響 分辨率高，對(duì)比度強(qiáng)ct定位像掃描基線：采用眥耳線（即眼外眥與外耳道中心

3、的聯(lián)線），層厚8-10mm，共9-12層大腦： 額葉 顳葉 頂葉 枕葉 基底節(jié) 丘腦幕上 小腦：半球、蚓部 腦干：中腦 延髓 橋腦 幕下幕下 腦實(shí)質(zhì)腦實(shí)質(zhì)雙側(cè)腦室第三腦室第四腦室腦室系統(tǒng) 鞍上池 環(huán)池 橋小腦池 枕大池 外側(cè)裂池 大腦縱裂池腦池系統(tǒng)腦池系統(tǒng) 腦室腦池系統(tǒng)腦室腦池系統(tǒng)磁共振成像磁共振成像（mri）優(yōu)勢(shì)：優(yōu)勢(shì)： 組織分辨率高 任意平面成像 多種參數(shù)、序列成像 缺點(diǎn)：缺點(diǎn)： 掃描時(shí)間長(zhǎng) mri對(duì)鈣化不敏感 個(gè)別患者有幽閉恐懼癥， mri檢查有禁忌癥 中樞神經(jīng)系統(tǒng)基本病變中樞神經(jīng)系統(tǒng)基本病變common presentation of neurological diseasexplai

4、n 顱高壓征：顱縫增寬，腦回壓跡增深 顱骨：破壞，增生 蝶鞍：擴(kuò)大、吸收、變形 鈣化：dsa 顱內(nèi)占位使血管移位 腦血管形態(tài)改變計(jì)算機(jī)體層攝影（計(jì)算機(jī)體層攝影（ct）密度異常: 低密度、等密度、高密度、混雜密度增強(qiáng)特征: 不強(qiáng)化、輕中度強(qiáng)化、明顯強(qiáng)化腦結(jié)構(gòu)改變: 占位效應(yīng) 腦萎縮 腦水腫、腦積水顱骨改變： 骨質(zhì)破壞、增生、吸收、 骨折計(jì)算機(jī)體層攝影（計(jì)算機(jī)體層攝影（ct）常規(guī)ct通過通過密度密度 的變化反應(yīng)信息的變化反應(yīng)信息0-1000+1000-10-20-30-40-60-50-70-80-990-98010203040506070990980970960水空氣骨-90脂肪軟組織1 1）低

5、密度低密度病變：病變：2 2）等密度等密度病變：病變：3)高密度病變4) 混雜密度病變腦水腫 腦梗塞 、腦軟化 腦腫瘤炎性病變 慢性血腫腦腫瘤腦梗塞的等密度期顱內(nèi)血腫的等密度期 (亞急性出血)顱內(nèi)血腫鈣化腫瘤炎性肉芽腫腦腫瘤（顱咽管瘤、惡性膠質(zhì)瘤、畸胎瘤）出血性腦梗塞炎性病變1 1）低密度低密度病變：病變： 腦水腫腦水腫 腦梗塞腦梗塞 、腦軟化、腦軟化 腦腫瘤腦腫瘤 炎性病變炎性病變 慢性血腫慢性血腫顱內(nèi)疾病的平掃基本顱內(nèi)疾病的平掃基本ct征象征象2 2）等密度等密度病變：病變： 腦腫瘤 腦梗塞的等密度期 顱內(nèi)血腫的等密度期 (亞急性出血)顱內(nèi)疾病的平掃基本顱內(nèi)疾病的平掃基本ct征象征象3)高

6、密度病變 顱內(nèi)血腫 鈣化 腫瘤 炎性肉芽腫顱內(nèi)疾病的平掃基本顱內(nèi)疾病的平掃基本ct征象征象4) 混雜密度病變 腦腫瘤（顱咽管瘤、惡性膠質(zhì)瘤、畸胎瘤） 出血性腦梗塞 炎性病變顱內(nèi)疾病的平掃基本顱內(nèi)疾病的平掃基本ct征象征象磁共振成像（磁共振成像（mri）mri通過通過磁共振信號(hào)磁共振信號(hào)的變化反應(yīng)信息的變化反應(yīng)信息人體不同器官的正常組織與病理組織的t1和t2是相對(duì)恒定的，而且它們之間有一定的差別，這種組織間馳豫時(shí)間上的差別，是mri成像基礎(chǔ)基本病變信號(hào)特征t1wi t2wi 腫塊腫塊依據(jù)腫塊依據(jù)腫塊 內(nèi)部成分不同信號(hào)不一內(nèi)部成分不同信號(hào)不一 囊腫囊腫低信號(hào)低信號(hào)高信號(hào)高信號(hào) 水腫水腫低信號(hào)低信號(hào)

7、高信號(hào)高信號(hào) 出出 血血急性急性 3天內(nèi)天內(nèi)等等,略低略低亞急性亞急性 3d-2w周圍高向中部推進(jìn)周圍高向中部推進(jìn)慢性慢性 2w以上以上高信號(hào)高信號(hào),環(huán)周含鐵血黃素低信號(hào)環(huán)環(huán)周含鐵血黃素低信號(hào)環(huán) 梗死梗死略低略低/低信號(hào)低信號(hào)高信號(hào)高信號(hào)目的:病灶強(qiáng)化方式: 明顯強(qiáng)化、中度強(qiáng)化、 輕度強(qiáng)化、不強(qiáng)化顯示平掃未發(fā)現(xiàn)病灶；了解病灶血供情況；區(qū)別腫瘤和瘤周水 腫；有利診斷和鑒別診斷 增強(qiáng)檢查增強(qiáng)檢查增強(qiáng)檢查 ct: 對(duì)比劑:含碘非離子型造影劑 劑量:50-100ml 注射速率：1-2ml/sec 注射方式:人工手推或高壓器注射 mri: 對(duì)比劑:順磁性造影劑：gd-dtpa 劑量:15-30ml 注射

8、速率： 1-2 ml/sec 注射方式:人工手推或高壓器注射脊髓和椎管脊髓和椎管內(nèi)病變內(nèi)病變spine common imaging method * plain film (平片) * myelography（脊髓造影） * spinal angiography （脊髓血管造影） * computed tomography * magnetic resonance imagingspine脊髓脊髓 mri 檢查方法 以矢狀面為主，輔以橫斷面和冠狀面，確定病變的三維關(guān)系，方法有平掃和增強(qiáng) 影像觀察和分析 正常脊髓灰質(zhì)、白質(zhì)及腦脊液信號(hào)特點(diǎn)與顱內(nèi)腦質(zhì)及腦脊液一致脊髓 檢查方法 以矢狀面為主，輔以

9、橫斷面和冠狀面，確定病變的三維關(guān)系，方法有平掃和增強(qiáng)掃描 影像觀察與分析 正常脊髓灰質(zhì)、白質(zhì)與腦脊液信號(hào)特點(diǎn)與顱內(nèi)腦實(shí)質(zhì)與腦脊液信號(hào)一致 脊髓基本病變 脊髓外形異常：脊髓增粗、萎縮 脊髓密度（信號(hào)）異常：局限性、彌漫性 蛛網(wǎng)膜下腔形態(tài)異常： 可分為出血性和非出血性損傷，mri可直觀地顯示脊髓損傷的部位、范圍、類型和程度 脊髓水腫：t1wi等、低信號(hào)，t2wi高信號(hào) 出血：t1wi和t2wi均為高信號(hào) 脊髓軟化、囊變、空洞： t1wi低信號(hào)，t2wi高信號(hào) 脊髓萎縮：脊髓變細(xì) 脊髓損傷 腦血管成像 (cerebral vascular angiography) dsa(digital subst

10、raction angiography) cta(computed tomography angiography) mra(magnetic resonance angiography)dsa (數(shù)字減影血管造影) 頸內(nèi)動(dòng)脈、椎動(dòng)脈、頸外動(dòng)脈血管顯示 vertebrobasilar artery (va) 椎基動(dòng)脈 internal carotid artery (ica) 頸內(nèi)動(dòng)脈 extenal corotid artery (eca) 頸外動(dòng)脈 willis環(huán): 大腦前動(dòng)脈, 大腦后動(dòng)脈, 前后交動(dòng)脈, 頸內(nèi)動(dòng)脈末端 診斷動(dòng)脈瘤、動(dòng)靜脈畸形、腫瘤血供vertebrobasilar art

11、ery (va) 椎基動(dòng)脈internal carotid artery (ica) 頸內(nèi)動(dòng)脈extenal corotid artery (eca) 頸外動(dòng)脈willis環(huán): 大腦前動(dòng)脈, 大腦后動(dòng)脈,前后交通動(dòng)脈, 頸內(nèi)動(dòng)脈末端lvascular diseases 血管病變血管病變：hemorrhage, infarct (ischemic infarct, hemorrhagic infarct, lacunar infarct)linfectious diseases 感染性病變感染性病變lvascular malformality 血管畸形血管畸形vascular diseases血

12、管疾病acute intracerebral hemorrhage急性腦出血 臨床表現(xiàn) clinical findings: hypertension,vascular malformation, aneurysm, hematopathy,tumor影像學(xué)表現(xiàn) imaging findings ct: location, density, secondary signs mr: location, signal, secondary signs鑒別診斷 differential diagnosisevolution of evolution of hematomahematoma on ct

13、 on ct 血腫血腫在在ctct上的演變上的演變acute acute hematomahematoma: 4 hrs after ictus : 4 hrs after ictus 急急性腦血腫：發(fā)病后性腦血腫：發(fā)病后4 4小時(shí)小時(shí)4 days after ictus 4 days after ictus 發(fā)發(fā)病后病后4 4天天 3 months after initial ct 3 months after initial ct 首次首次ctct后后3 3個(gè)月個(gè)月evolution of evolution of hematomahematoma on ct on ct 血腫血腫在在ct

14、上的演變上的演變104050607080203012345678910 11 12 13 14isodensehyperdensehypodensedecreasing density of hematoma血腫密度的下降density compared to cortextime in daysintracerebral hemorrhage imaging findingsct: 1)location: 高血壓性腦出血基底節(jié)區(qū)多見2) density: 急性期高密度，隨時(shí)間推移密度漸減低3) secondary signs：占位效應(yīng)明顯，可破入腦室、蛛網(wǎng)膜下腔，繼發(fā)阻塞性腦積水mri：不同

15、的出血時(shí)間信號(hào)不同，反映血腫內(nèi)血紅蛋白、氧合血紅蛋白、脫氧血紅蛋白、正鐵血紅蛋白、含鐵血黃素的演變過程超急性期（6h) : 氧合血紅蛋白（t1wi等，t2wi高信號(hào)）急性期（7-72h）：脫氧血紅蛋白（t1wi等或略低，t2wi低信號(hào)）亞急性期（3 d-2w）: 正鐵血經(jīng)蛋白（t1wi高信號(hào)，t2wi高信號(hào)）慢性期（2w后）：含鐵血黃素（ t1wi低，t2wi低信號(hào)）blood productsblood products 血腫血腫 acute hematoma well seen on ct 急性血腫宜用ct觀察 subacute and chronic hematoma better ev

16、aluated on mri 亞急性和慢性血腫宜用mri觀察primary (hypertensive) bleeds occur in the basal ganglia; for bleeds at other locations, hunt for a cause高血壓出血常在基底節(jié)；其它部高血壓出血常在基底節(jié)；其它部位的話要尋找病因位的話要尋找病因brain infarction腦梗塞l臨床表現(xiàn) clinical findings: thrombosis, embolism, hypotension , high pour-point statel影像學(xué)表現(xiàn) imaging findi

17、ngs ct mr: ischemic infarct ;hemorrhagic infarct; lacunar infarctl鑒別診斷 differential diagnosis左側(cè)大腦前動(dòng)脈閉塞左側(cè)大腦前動(dòng)脈閉塞致左側(cè)額上回腦梗塞：致左側(cè)額上回腦梗塞：ct平掃示左側(cè)額上回長(zhǎng)條狀低密度區(qū)（），邊界較清，輕度占位表現(xiàn)左側(cè)枕葉大腦后左側(cè)枕葉大腦后動(dòng)脈梗塞動(dòng)脈梗塞 ：ct平掃示左側(cè)枕葉低密度區(qū)，未見明顯占位表現(xiàn)左側(cè)大腦中動(dòng)脈梗塞：左側(cè)大腦中動(dòng)脈梗塞：ct平掃示左顳頂葉大片低密度區(qū)，邊界清晰，密度與腦脊液相似，左側(cè)腦室擴(kuò)大，中線結(jié)構(gòu)無(wú)移位。右側(cè)額后頂前出血性腦梗塞：ct平掃示右額頂葉大片低密度

18、區(qū)內(nèi)散在不規(guī)則高密度出血灶fogging effect 模糊效應(yīng): 缺血性腦梗塞2-3周時(shí)病灶變?yōu)榈让芏榷豢梢妉acunar brain infarction 腔隙性腦梗塞：深部髓質(zhì)小動(dòng)脈閉塞所致，大小約10-15mm，好發(fā)于基底節(jié)、丘腦、小腦和腦干。hemorrhagic transformation after infarction出血性腦梗塞：ct示在低密度腦梗塞灶內(nèi)，出現(xiàn)不規(guī)則斑點(diǎn)、片狀高密度出血灶。cerebral infarction imaging findingsct:24h內(nèi)，ct可無(wú)陽(yáng)性發(fā)現(xiàn)，或顯示腦溝回模糊；動(dòng)脈致密征；島帶征。24h后，與閉塞血管供血區(qū)一致，同時(shí)累及皮

19、層和髓質(zhì)，呈底在外的三角形或楔形低密度，邊緣不清，常并發(fā)腦水腫，病灶大時(shí)可出現(xiàn)輕度占位效應(yīng)。4-6周，邊緣清楚、近于腦脊液密度的囊腔, 1個(gè)月后可出現(xiàn)腦萎縮。出血性腦梗塞：扇形低密度梗塞區(qū)內(nèi)出現(xiàn)不規(guī)則高密度出血斑。腔隙性梗塞：好發(fā)于基底節(jié)區(qū)，因小的終末動(dòng)脈閉塞所致，表現(xiàn)為直徑小于15mm低密度灶，邊緣清楚。mri：較早發(fā)現(xiàn)病變subcortical arteriosclerotic encephalopathy bingswangers disease皮層下動(dòng)脈硬化性腦病l臨床表現(xiàn) clinical findingsl影像學(xué)表現(xiàn) imaging findings ct mrl鑒別診斷 diff

20、erential diagnosisinfectious diseases感染性疾病pathogens : bacterium , virus , fungi , parasite pathology : meningitis , encephalitis , vein inflammation l臨床表現(xiàn) clinical findings: otogenic , blood-borne , traumatic , cryptogenic l影像學(xué)表現(xiàn) imaging findings ct mrl鑒別診斷 differential diagnosisbrain abscess imagin

21、g finding on ct ct1、急性炎癥期：平掃大片低密度灶，邊界模糊，伴占位效應(yīng)，增強(qiáng)無(wú)強(qiáng)化2、化膿壞死期：平掃低密度區(qū)內(nèi)出現(xiàn)更低密度壞死灶，增強(qiáng)呈不均勻強(qiáng)化3、膿腫形成期：平掃見等密度環(huán)，內(nèi)為低密度膿腫并可有氣泡影；增強(qiáng)呈環(huán)形強(qiáng)化，其壁完整、光滑、均勻，或多房分隔brain abscess imaging finding on mr mr1、膿腔呈長(zhǎng)t1和長(zhǎng)t2異常信號(hào)2、增強(qiáng)呈薄壁環(huán)形強(qiáng)化，內(nèi)外壁光滑 tuberculosis, cnsl臨床表現(xiàn) clinical findingsl影像學(xué)表現(xiàn) imaging findings ct mrl鑒別診斷 differential di

22、agnosistuberculous meningistis and encephalitis imaging findings ct平掃：1、早期無(wú)異常發(fā)現(xiàn)2、腦底池炎性滲出表現(xiàn)為腦底池密度升高3、腦內(nèi)結(jié)核：腦內(nèi)以基底節(jié)區(qū)多見呈低或等密度灶4、腦積水增強(qiáng)：腦膜增厚強(qiáng)化，結(jié)核球呈結(jié)節(jié)狀或環(huán)形強(qiáng)化tuberculous meningistis and encephalitis imaging findings mr平掃：1、腦底池t1wi信號(hào)升高，t2wi信號(hào)更高，抑水t2wi顯示病灶更清楚，高信號(hào)2、腦內(nèi)結(jié)核球t1wi呈略低信號(hào)，t2wi呈低、等或略高混雜信號(hào)，周圍水腫輕3、腦積水增強(qiáng)：腦膜明

23、顯增厚強(qiáng)化，結(jié)核球呈結(jié)節(jié)狀強(qiáng)化或環(huán)狀強(qiáng)化cerebral cysticercosis imaging finding 分型：腦實(shí)質(zhì)型；腦室型、腦膜型、混合型ct：腦內(nèi)多發(fā)低密度小囊，囊腔內(nèi)可見致密小點(diǎn)狀囊蟲頭節(jié)，囊蟲死亡后呈高密度點(diǎn)狀鈣化mr：腦內(nèi)多發(fā)小囊，小囊主體呈長(zhǎng)t1長(zhǎng)t2信號(hào)，其內(nèi)偏心結(jié)節(jié)呈短t1和長(zhǎng)t2信號(hào)增強(qiáng)：囊壁與頭節(jié)可輕度強(qiáng)化vascular deformality 血管畸形aneurysm 血管瘤臨床表現(xiàn) clinical findings: headache 影像學(xué)表現(xiàn) imaging findings ct: 1)direct signs: no thrombosis ;

24、 part of thrombosis ; totally thrombosis 2) secondary signs: subarachnoid hemorrhage, hematoma, hydrocephalus , encephaledema , infarct mr: dsa鑒別診斷 differential diagnosisl臨床表現(xiàn) clinical findingsl影像學(xué)表現(xiàn) imaging findings ct mr dsal鑒別診斷 differential diagnosistraumatic brain injury- - ctcttraumatic brain

25、injury- clinical featuressigns and symptoms of head injury can include any combination of the following: lose consciousness vomiting seizure weakness headache inability to speak amnesia 健忘癥健忘癥 cns trauma clinical features- consciousness no loss of consciousness(l.o.c) (sdh， edh?， not dai 彌漫性軸索損傷彌漫性軸

26、索損傷) awake at the scene， delayed loc (sdh，edh， swelling， not dai) transient loc-wake-up-delayed loc (“classic” lucid interval for edh) continuous loc following impact (“classic” shearing / diffuse axonal injury dai彌漫性軸索損傷彌漫性軸索損傷) immediate unenhanced head ct scan is the procedure of choice for diagn

27、osis head injury computed tomography (ct)： it is quick, accurate, and widely available head ct scan can show location, volume, effect of the lesions of intracranial injuries. classification of head injury：- centripetal approach ouside to insideextracerebral injury: scalp-hematoma 頭皮血腫頭皮血腫 calvarium-

28、skull fracture 顱骨骨折顱骨骨折 epidural hematoma (edh) 硬膜硬膜外外血腫血腫 subdural hematoma (sdh) 硬膜硬膜下下血腫血腫 subarachnoid hemorrhage (sah) 蛛網(wǎng)膜下腔出血蛛網(wǎng)膜下腔出血 intracerebral injury: brain contusion (edema, hemorrhage) 腦挫傷腦挫傷 intraventricular-hemorrhage（腦室出血）（腦室出血） 1. skull fracture 2. epidural hematoma 3. epidural hemat

29、oma 4. subdural effusion 5. subarachnoid hemorrhage 6. cerebral cortical contusion 7. diffuse axonal injury 8. sequelae of head injury閉合性腦損傷的機(jī)制閉合性腦損傷的機(jī)制沖沖擊擊傷傷作用力作用力接觸力接觸力慣慣性力性力原因原因直接碰撞直接碰撞減速或減速或加速運(yùn)加速運(yùn)動(dòng)動(dòng)腦損傷腦損傷范范圍圍局部局部多多處處彌散性彌散性受受傷時(shí)頭傷時(shí)頭部狀部狀態(tài)態(tài)固定不固定不動(dòng)動(dòng)運(yùn)運(yùn)動(dòng)動(dòng)中中對(duì)對(duì)沖沖傷傷1. skull fracture 骨折骨折 部位部位 形態(tài)形態(tài) 與外界關(guān)系與外

30、界關(guān)系 顱蓋骨折顱蓋骨折 顱底骨折顱底骨折 線線性骨折性骨折 凹陷性骨折凹陷性骨折 粉碎性骨折粉碎性骨折 開放性骨折開放性骨折 閉合性骨折閉合性骨折分類分類v linear fracture 線型骨折：線型骨折： axial ct is not good for linear fracture should carefully to identify the fracture line v depression fracture 凹陷型骨折凹陷型骨折： a more serious fracture downward displacement of the skull bones presse

31、s directly on brain tissue and caused the injury v ct is important for the fracture and other associated intracranial lesions bone window to evaluate fracture skull fracture 骨折ct骨窗觀察 線形骨折的臨床表現(xiàn)累及眶頂和篩骨累及眶頂和篩骨：鼻出血眶周廣泛淤血斑鼻出血眶周廣泛淤血斑， “熊貓眼熊貓眼”征廣泛球結(jié)膜下淤血斑征廣泛球結(jié)膜下淤血斑、腦膜、骨膜均破裂腦膜、骨膜均破裂：腦脊液鼻漏腦脊液鼻漏篩板或視神經(jīng)管骨折篩板或視神經(jīng)

32、管骨折：嗅神經(jīng)或視神經(jīng)損傷嗅神經(jīng)或視神經(jīng)損傷累及蝶骨累及蝶骨：鼻出血鼻出血，腦脊液鼻漏腦脊液鼻漏累及顳骨巖部累及顳骨巖部：腦脊液耳漏、腦脊液耳漏、vii/viiivii/viii腦神經(jīng)損傷腦神經(jīng)損傷蝶骨、顳骨內(nèi)側(cè)部損傷蝶骨、顳骨內(nèi)側(cè)部損傷：垂體垂體/ii-vi/ii-vi腦神經(jīng)損傷腦神經(jīng)損傷累及頸內(nèi)動(dòng)脈海綿竇部累及頸內(nèi)動(dòng)脈海綿竇部：頸內(nèi)動(dòng)脈海綿竇瘺累及破裂孔或頸內(nèi)動(dòng)脈管累及破裂孔或頸內(nèi)動(dòng)脈管：致命性鼻出血、耳出血致命性鼻出血、耳出血累及顳骨巖部后外側(cè)累及顳骨巖部后外側(cè)：battlebattle征征，乳突部皮下淤血累及枕骨基底部累及枕骨基底部：枕下腫脹、皮下淤血斑枕下腫脹、皮下淤血斑枕骨大孔或巖

33、尖后緣附近骨折枕骨大孔或巖尖后緣附近骨折：ix-xiiix-xii腦神經(jīng)損傷腦神經(jīng)損傷顱蓋部發(fā)生率高顱蓋部發(fā)生率高顱前窩骨折顱前窩骨折顱中窩骨折顱中窩骨折顱后窩骨折顱后窩骨折顱前窩骨折 累及眶頂和篩骨，可伴有鼻出血、眶周廣泛淤血(稱“眼鏡”征或“熊貓眼”征)以及廣泛球結(jié)膜下淤血。如硬腦膜及骨膜均破裂，則伴有腦脊液鼻漏，腦脊液經(jīng)額竇或篩竇由鼻孔流出。若骨折線通過篩板或視神經(jīng)管，可合并嗅神經(jīng)或視神經(jīng)損傷。顱中窩骨折 顱底骨折發(fā)生在顱中窩，如累及蝶骨，可有鼻出血或合并腦脊液鼻漏，腦脊液經(jīng)蝶竇由鼻孔流出。如累及顳骨巖部，硬腦膜、骨膜及鼓膜均破裂時(shí)，則合并腦脊液耳漏，腦脊液經(jīng)中耳由外耳道流出；如鼓膜完整

34、，腦脊液則經(jīng)咽鼓管流向鼻咽部而被誤認(rèn)為鼻漏。骨折時(shí)常合并有第、腦神經(jīng)損傷。如骨折線通過蝶骨和顳骨的內(nèi)側(cè)面，尚能傷及垂體或第、v、腦神經(jīng)。如骨折傷及頸動(dòng)脈海綿竇段，可因頸內(nèi)動(dòng)脈海綿竇瘺的形成而出現(xiàn)搏動(dòng)性突眼及顱內(nèi)雜音。破裂孔或頸內(nèi)動(dòng)脈管處的破裂，可發(fā)生致命性鼻出血或耳出血。顱后窩骨折 骨折線通過顳骨巖部后外側(cè)時(shí)，多在傷后數(shù)小時(shí)至2日內(nèi)出現(xiàn)乳突部皮下淤血(稱battle征巴特耳征)。骨折線通過枕骨鱗部和基底部，可在傷后數(shù)小時(shí)出現(xiàn)枕下部頭皮腫脹，骨折線尚可經(jīng)過顳骨巖部向前達(dá)顱中窩底。骨折線累及斜坡時(shí)，可于咽后壁出現(xiàn)黏膜下淤血。枕骨大孔或巖骨后部骨折，可合并后組腦神經(jīng)()損傷癥狀。 what is e

35、pidural hematoma？ 硬膜外血腫硬膜外血腫 edh is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. what is subdural hematoma？ 硬膜下血腫硬膜下血腫 sdh is a form of traumatic brain injury in which blood gathers within the inner meningeal layer of the dura.dura 2 epi

36、dural hematoma (硬膜外血腫)direct trauma to craniumfracture(90%) -laceration （撕裂） of meningeal a. and v.location is 66% temporo-parietal（顳頂部）temporal bone (70-80%)lucid interval（中間清醒期 40%pts）mortality （死亡率）of 15-30%硬腦膜外血腫病人意識(shí)變化的典型特征是:昏迷一清醒一再昏迷,即意識(shí)障礙有中間清醒期,傷后有短暫的原發(fā)性昏迷,在血腫位形成前意識(shí)恢復(fù),當(dāng)血腫形成增大,顱內(nèi)壓增高可出現(xiàn)再次昏迷硬膜外血腫

37、（硬膜外血腫（edh）：顱內(nèi)血腫積聚于）：顱內(nèi)血腫積聚于 顱骨與硬膜之間顱骨與硬膜之間epidural hematoma -ct1 . smoothly marginated, lenticular 透鏡狀透鏡狀, or biconvex 雙雙凸凸homogenous hyperdense 高密高密度度lesion 2. rarely crosses the suture line because the dura is attached more firmly to the skull at sutures （縫）（縫）. 3. frequent incidence of associate

38、d skull fracture（90%）- fracture line acute epidural hematoma the hematoma still contains uncoagulated blood,or still has active bleeding. 血腫包含不凝血或活動(dòng)出血 round,stream-like filling defects may be seen in the hemotoma 血腫內(nèi)可見圓形密度減低影.3 epidural hematoma 硬膜下血腫硬膜下血腫 scoure of blood laceration （撕裂） of cortical

39、（腦皮層血管 ）a a. and v v. (direct: penetrating injury)(直接穿透?jìng)? bridging (cortical) veins（橋靜脈）（橋靜脈） dural sinus （靜脈竇） large contusions (direct /indirect: pulped brain硬膜下血腫（硬膜下血腫（sdh）：）：顱內(nèi)出血積聚于硬腦膜和蛛網(wǎng)膜下腔之間顱內(nèi)出血積聚于硬腦膜和蛛網(wǎng)膜下腔之間subdural hematoma 硬膜下血腫presentation significant head trauma, but chronic subdural - o

40、nly minor or remote history of trauma bilateral in 20% adults (common in elderly), 80-85% bilateral in infants extension into interhemispheric fissure （縱裂）， tentorial （小腦幕）margins brain injury in 50%; complex injury (dai) skull fracture in only 1% subdural hematoma -ct1. sickle-shape (鐮刀型鐮刀型) or new

41、 lunar shape (新月型新月型)2. extends past the sutures3. acute sdh - hyperdense subacute sdh - isodense (1-2 weeks) chronic sdh hypordense4. brain injury in 50%; complex injury (dai) ;5. skull fracture in only 1%acute subdural hematoma 急性硬膜下血腫the hematoma may extending into the subdural space of tentorial

42、 region.血腫可以延伸到小腦幕區(qū). acute subdural hematoma the hematoma may extending into the interhemispheric fissure 血腫延伸至大腦鐮部.chronic subdural hematoma 慢性硬膜下血腫shape： semilunar， fusiform，oval shape外形：半月形、紡錘形、外形：半月形、紡錘形、橢圓形橢圓形.density ：hyperdense isodense hypodense mixed density密度：高密度、等密度、密度：高密度、等密度、低密度、混雜密度低密度

43、、混雜密度 isodense chronic subdural hematoma 等密度等密度 慢性硬膜下血腫慢性硬膜下血腫.hyperintensity of chronic subdural hematoma高密度慢性硬膜下血腫高密度慢性硬膜下血腫（t1/t2均為高信號(hào)）均為高信號(hào)） .等密度硬膜下血腫 雙側(cè)腦室對(duì)稱變小，體部呈長(zhǎng)條狀 兩側(cè)側(cè)腦室前角內(nèi)聚，夾角變小，呈“兔耳征” 腦白質(zhì)變窄塌陷 皮層腦溝消失 membrane hematoma epidural acute biconvex unilateral skull fracture 90% limited by sutures d

44、irect trauma to cranium laceration （撕裂） of meningeal artery lucid interval（中間清醒期 40%pts） subdural acute to chronic new lunar shape bilateral fracture +/- 1% cross sutures contre coup injury對(duì)沖傷 laceration （撕裂） of bridging veins（橋靜脈）4. subdural effusion 硬膜下積液硬膜下積液subdural effusion 硬膜下積液 occurred in ag

45、ed patient or infant 發(fā)生在老人及幼兒發(fā)生在老人及幼兒. developed several days later after a head injury 外傷幾天后形成外傷幾天后形成 often bilateral 常雙側(cè)常雙側(cè) spontaneously resorbed 自發(fā)吸收自發(fā)吸收. craniotomy, v-p shunt,meningitis also may cause subdural effusion 穿顱術(shù)、vp、腦膜炎也可發(fā)生.5. subarachnoid hemorrhage （蛛網(wǎng)膜下腔出血）（蛛網(wǎng)膜下腔出血） the sensitivit

46、y of ct has been reported to range from 85 to 100 %. high density lesion was demonstrated in cerebral cisterns（subarachnoid space over cerebral convexity， suprasella cistem（鞍上池）， interpeduncular cistern（腳間池），pontine cistern，cistern of the lateral fissure（側(cè)裂池） by plain ct scan computed tomography (ct

47、) is the method of choice to detect acute subarachnoid hemorrhage (sah). linear high density in the subarachnoid spaces (sulci， fissures，cistems) often associates with other intracerebral or extracerebral lesions may cause hydrocephalus subarachnoid hemorrhage （sah, 蛛網(wǎng)膜下腔出血）蛛網(wǎng)膜下腔出血）-ct subarachnoid

48、hemorrhage- mri magnetic resonance imaging (mri) using flair sequences shows a comparable sensitivity in acute sah even be superior to ct. (hyperintense on t2 flair ) in subacute sah, starting from day 5 after the suspected hemorrhage, the sensitivity of mri is clearly superior to ct. (hyperintense

49、on t1wi and t2wi) 縱裂池、腦溝sah sah一引起交通性腦積水. 交通性腦積水.2.6 traumatic sah in the sulci, interhemispheric fissure9.10 communicating hydrocephalus6. cerebral cortical contusion （腦挫傷）cerebral cortical contusion presentation loss of consciousness，headache，mental status change usually in a superficial cortical

50、location 50% occur in temporal lobe 33% in frontal lobe (frontal pole and inferior surface) delayed hemorrhage seen in 20%7. diffuse axonal injury （彌漫性軸索損傷）（彌漫性軸索損傷） follows severe decelerating closed head trauma, patients are generally unconscious from the time of the event location of injuries are

51、 typically in areas of large numbers of parallel axons such as the corpus callosum, internal capsule, brain stem, basal ganglia and subcortical white matterdiffuse axonal injury （彌漫性軸索損傷）（彌漫性軸索損傷） usually punctate hyperdensities are seen in the corpus callosum, gray white interfaces, and rostral bra

52、instem the axonal injury itself is not visualized, but the associated micro (and macro) hemorrhages in the characteristic distribution are seendiffuse axonal injury -ct detecting and characterizing brainstem lesions, specifically and predominately non-hemorrhagic contusions appearance depends on pre

53、sence or absence of hemorrhage t1-weighted sequences often normal; multiple hyperintense foci at gray-white junctions and corpus callosum on t2wi diffuse axonal injury -mri0353騎摩托車與另一摩托車相撞，入院時(shí)為淺昏迷，gcs評(píng)分6分，20天后甚至轉(zhuǎn)清，未能言語(yǔ).0366言語(yǔ)模糊，亂語(yǔ)，03616復(fù)查時(shí)對(duì)答正常上圖：傷后4天mri檢查下圖：傷后43天復(fù)查 soon after head injury 8hour later

54、 delayed hemorrhage 遲發(fā)血腫遲發(fā)血腫1. brain atrophy, due to brain contusion2. communicating hydrocephalus,due to sah，ivh3. encephalomalacia or porencephalic cyst，due to brain contusion 腦挫裂傷所致的：腦萎縮腦挫裂傷所致的：腦萎縮. 交通性腦積水交通性腦積水. 腦軟化、腦穿通囊腫腦軟化、腦穿通囊腫.8. sequelae of head injury 腦外傷后遺癥腦外傷后遺癥 顱腦外傷的影像診斷注意點(diǎn)1. 顱腦外傷首選ct檢查

55、，但病情與ct表現(xiàn) 不符時(shí)，要行mri檢查；2 . 病情有變化時(shí)，隨時(shí)復(fù)查ct。答案: aada答案：cddcb答案：ecae顱內(nèi)腫瘤/椎管內(nèi)腫瘤影像診斷intracranial and intraspinal tumor radiology腦腫瘤/椎管內(nèi)腫瘤intracranial and intraspinal tumor ct：with or without tumor，localization and qualitative diagnosis advantages of mri：no bone artifacts, multi-dimensional sections scannin

56、g, a variety of imaging parameters 。therefore, a more accurate positioning and characterization of the tumorimaging signs of intracranial tumors direct signs ： 1）the site of tumor 2）the density (signal) of tumor 3） the number, size, shape and edge of tumor 4）the enhancement extent and morphology of

57、tumor indirect signs ： 1）peritumoral edema 2）changes in skull the expand and damage internal auditory canal can be seen in acoustic neuroma the skull corresponding shows thickening of meningiomas 星形細(xì)胞瘤（astrocytic tumors) astrocytic tumors is the most common primary intracerebral tumours astrocytoma

58、in adults more common in supratentorial, children more common in infratentorial cerebellar astrocytoma mainly located in the white matter, grading - tumor localization signs and symptoms of intracranial hypertension, epilepsy 腦內(nèi)腫瘤腦內(nèi)腫瘤 直接征象直接征象 1）好發(fā)部位:白質(zhì) 2）密度（信號(hào)）：級(jí)低密度，級(jí)高低混雜密度的囊性腫塊，可有鈣化與瘤內(nèi)出血、壞死、囊變 3）數(shù)

59、目、大小、形態(tài)和邊緣： 級(jí)邊界清楚， 級(jí)邊界不清，形態(tài)不規(guī)則 4）增強(qiáng)的程度及形態(tài)： 級(jí)不強(qiáng)化， 級(jí)呈不規(guī)則環(huán)形伴壁結(jié)節(jié)強(qiáng)化 間接征象間接征象1）瘤旁水腫：明顯2）顱骨變化：常無(wú)星形細(xì)胞瘤 astrocytic tumors grade腦膜瘤meningioma meningioma originated from arachnoid granulations cap cells, connected with the dura most tumors occur outside the brain, some can occur even in ventricle a typical sit

60、e followed by frequency of occurrence :腦膜瘤影像特征總結(jié)腦外腫瘤腦外腫瘤直接征象直接征象1）好發(fā)部位:矢狀竇旁、腦凸面、蝶骨嵴、嗅溝、橋小腦角、大腦鐮或小腦幕2）密度（信號(hào)）：ct平掃等或略高密度、常見斑點(diǎn)狀鈣化3）數(shù)目、大小、形態(tài)和邊緣：類圓形，邊界清，常以廣基底與硬膜相連，表現(xiàn)成增厚強(qiáng)化的“腦膜尾征，腦組織受壓形成”皮層扣壓征“4）增強(qiáng)的程度及形態(tài)：均勻性顯著強(qiáng)化腦膜瘤影像特征總結(jié)間接征象：間接征象：1）瘤旁水腫：輕或無(wú)，靜脈或靜脈竇受壓時(shí)可出現(xiàn)中或重度水腫2）顱骨變化：腦膜瘤可見相應(yīng)顱骨增厚atypical meningioma 1) 全瘤以囊性為