腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解培訓(xùn)課件

1、腦疝是指在顱內(nèi)壓增高的情況下，腦組織通過(guò)某些腦池向壓力相對(duì)較低的部位移位的結(jié)果，即腦組織由其原來(lái)正常的位置而進(jìn)入了一個(gè)異常的位置。腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20221腦疝是指在顱內(nèi)壓增高的情況下，腦組織通過(guò)某些腦池向壓力相對(duì)較腦疝的類(lèi)型：a.大腦鐮疝 ： 一側(cè)大腦半球占位病變可使同側(cè)扣帶回經(jīng)大腦鐮下緣疝入對(duì)側(cè)，胼胝體受壓下移。 小腦幕切跡疝 b.前疝：也稱顳葉溝回疝，是顳葉溝回疝于腳間池及環(huán)池的前部；后疝：顳葉內(nèi)側(cè)部疝于四疊體池及環(huán)池的后部；f.小腦幕切跡上疝：后顱凹占位病變時(shí)，小腦上蚓部可向上疝入小腦幕切跡的四疊體池。c.中心疝：幕上壓力增高，致使大腦深部結(jié)構(gòu)及腦干縱軸牽張移位。 d

2、.顱外疝： 腦組織通過(guò)顱外缺損疝出。e.枕骨大孔疝 ： 后顱凹占位病變時(shí)，可致小腦扁桃體疝入枕骨大孔。g.蝶骨嵴疝：顱前凹和顱中凹的占位病變，由于病變部壓力相對(duì)高一些，則額眶回可越過(guò)蝶骨嵴進(jìn)入顱中凹，可顳葉前部擠向顱前凹。腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20222腦疝的類(lèi)型：a.大腦鐮疝 ： 一側(cè)大腦半球占位病變可使同側(cè)扣示意圖a) subfalcial (cingulate) herniation ;鐮下疝b) uncal herniation ; 鉤疝c) downward (central, transtentorial) herniation ; 下行性小腦幕疝d) external

3、 herniation ; 顱外疝e) tonsillar herniation.扁桃體疝f) ascending transtentorial herniation (reversed tentorial)上行性小腦幕疝g) sphenoid herniation蝶骨嵴疝腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20223示意圖a) subfalcial (cingulate) h類(lèi)型腦疝部位命名別名疝入腦組織命名1大腦鐮下疝扣帶回疝2小腦天幕疝 前疝 后疝小腦幕切跡疝、小腦幕下降疝腳間池疝環(huán)池疝，四疊體疝顳葉鉤回疝海馬回疝3小腦幕孔中心疝間腦 4小腦幕孔上疝小腦幕上疝 小腦蚓部疝 5枕骨大孔疝小腦

4、扁桃體疝 腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20224類(lèi)型腦疝部位命名別名疝入腦組織命名1大腦鐮下疝扣帶回疝2示意圖腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20225示意圖腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/20225解剖關(guān)系腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20226解剖關(guān)系腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/20226解剖關(guān)系FQcMb3vTOSyCClvFPOSpCClvss腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20227解剖關(guān)系FQcMb3vTOSyCClvFPOSpCClvss解剖關(guān)系FTCesPd4th VFTMbCes腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20228解剖關(guān)系FTCesPd4th V

5、FTMbCes腦疝分類(lèi)和影像The suprasellar cistern & the quadrigeminal cisternThe left and center images show the suprasellar cistern. Its anterior borders are formed by the frontal lobes (F). Its lateral borders are formed by the uncus (U) of the temporal lobes. The left image shows the 5-pointed star appearanc

6、e of the suprasellar cistern where the posterior border is formed by the pons (Po). The black arrow points to the fourth ventricle. The center image shows a higher cut where the suprasellar cistern has a 6-pointed star appearance since the posterior border is formed by the cerebral peduncles (P) whi

7、ch have a central cleft. The right image shows the quadrigeminal cistern (black arrow). Note the babys bottom appearance of its anterior border. When ICP is increased, the quadrigeminal cistern space is compressed or obliterated. 腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/20229The suprasellar cistern & the The suprasellar ci

8、stern& the quadrigeminal cistern. The midline sagittal MRI scan shows the levels of the axial diagrams. The quadrigeminal cistern is located above (anterior to) the Q in the highest cut shown (number 9). The anterior border of the quadrigeminal cistern is formed by the superior colliculi (c). Image

9、8 (lower cut) also shows the quadrigeminal cistern. In this case, its anterior border is formed by the inferior colliculi (c). This gives the anterior border of the quadrigeminal cistern the appearance of a babys bottom. The quadrigeminal plate is comprised of the superior and inferior colliculi. Th

10、e quadrigeminal cistern is posterior to this quadrigeminal plate, thus its anterior border may be formed by the inferior or superior colliculi. 腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202210The suprasellar cistern& the 鐮下疝臨床表現(xiàn)影像所見(jiàn)并發(fā)癥頭痛對(duì)側(cè)下肢無(wú)力同側(cè)額角截?cái)啻竽X鐮前份不對(duì)稱同側(cè)側(cè)腦室腔消失透明隔移位因大腦前動(dòng)脈卡壓到大腦鐮上引起同側(cè)ACA供血區(qū)梗塞伴有其他疝腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202211鐮下

11、疝臨床表現(xiàn)影像所見(jiàn)并發(fā)癥頭痛同側(cè)額角截?cái)嘁虼竽X前動(dòng)脈卡壓Subfalcine herniation (cingulate herniation)Transtentorial herniation The suprasellar cistern (left image) is obliterated. The quadrigeminal cistern is very compressed and pushed posteriorly (center image). A subdural hematoma with a midline shift is noted. There is centr

12、al transtentorial and subfalcine herniation.腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202212Subfalcine herniation (cingulaACA供血區(qū)梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202213ACA供血區(qū)梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/20221Uncal herniation臨床表現(xiàn)影像所見(jiàn)并發(fā)癥同側(cè)瞳孔散大、眼動(dòng)受限（動(dòng)眼神經(jīng)受壓）對(duì)側(cè)偏癱（同側(cè)大腦腳受壓）有時(shí)顳葉疝壓跡會(huì)導(dǎo)致同側(cè)偏癱（對(duì)側(cè)大腦腳受壓。假定位體征）對(duì)側(cè)顳角增寬同側(cè)環(huán)池增寬同側(cè)橋前池增寬鉤回進(jìn)入鞍上池大腦后動(dòng)脈受壓導(dǎo)致枕葉梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/

13、5/202214Uncal herniation臨床表現(xiàn)影像所見(jiàn)并發(fā)癥同側(cè)瞳鞍上池缺角腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202215鞍上池缺角腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202215冠狀位CT與MRI腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202216冠狀位CT與MRI腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/2022海馬旁回褶皺腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202217海馬旁回褶皺腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202217對(duì)側(cè)顳角增寬腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202218對(duì)側(cè)顳角增寬腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202218同側(cè)橋前池增寬腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/2022

14、19同側(cè)橋前池增寬腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202219同側(cè)環(huán)池增寬腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202220同側(cè)環(huán)池增寬腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202220Uncal herniation腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202221Uncal herniation腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10Uncal herniationobliteration of the suprasellar cistern (red arrow) and the quadrigeminal cistern (green arrow)腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202222Uncal h

15、erniationobliteration oUncal herniationThe ipsilateral ventricle, sulci, fissures are compressed and obliterated, isappeared.obliteration of the suprasellar cistern(s) and quadrigeminal cistern(q)腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202223Uncal herniationThe ipsilateraUncal herniationAcute infarction1st dayAcute infarc

16、tion 4th daysq腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202224Uncal herniationAcute infarctiUncal herniationBefore surgery, a big GBM in the left temporal lobe with uncal herniation.After surgery, the GBM was removed, the suprasellar cistern and quadrigeminal cisterns are normal.腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202225Uncal herniationBefore

17、 surgeryUncal herniationAcute infarction of right posterior artery (PCA), this is a complication of uncal/transtentorial herniation, because the PCA was compressed by brain herniation.腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202226Uncal herniationAcute infarcti雙側(cè)大腦后動(dòng)脈梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202227雙側(cè)大腦后動(dòng)脈梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/2022雙

18、側(cè)大腦后動(dòng)脈梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202228雙側(cè)大腦后動(dòng)脈梗塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/2022Durette hemorrhage 腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202229Durette hemorrhage 腦疝分類(lèi)和影像學(xué)表現(xiàn)圖Durette hemorrhage腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202230Durette hemorrhage腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解Kernohans notch顳葉疝壓跡腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202231Kernohans notch顳葉疝壓跡腦疝分類(lèi)和影像學(xué)表Uncal herniationWhen mas

19、s effects within or adjacent to the temporal lobe occur, the medial portion of the temporal lobe (uncus) is forced medially and downward over the tentorium. There is ipsilateral pupillary dilation. The uncus is pushed medially into the suprasellar cistern. There is bilateral uncal herniation. The su

20、prasellar cistern is obliterated.腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202232Uncal herniationWhen mass effeearly uncal herniation The right uncus is pushing into the suprasellar cistern; early right uncal herniation. 腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202233early uncal herniation The rig中心疝臨床表現(xiàn)影像所見(jiàn)并發(fā)癥意識(shí)改變呼吸模式改變?nèi)テ印⑷ツX小瞳孔因脈絡(luò)膜前動(dòng)脈受壓引起蒼白球和視束梗

21、塞腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202234中心疝臨床表現(xiàn)影像所見(jiàn)并發(fā)癥意識(shí)改變因脈絡(luò)膜前動(dòng)脈受壓引起蒼中心疝腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202235中心疝腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202235Superior vermian herniation ( ascending transtentorial herniation )由于后顱凹的占位效應(yīng)，小腦蚓和小腦半球通過(guò)小腦幕切跡向上移動(dòng)臨床表現(xiàn)影像所見(jiàn)并發(fā)癥惡心嘔吐意識(shí)障礙中腦外觀呈陀螺狀雙側(cè)環(huán)池變窄四疊體池充滿因小腦上動(dòng)脈受壓引起梗塞Galen靜脈移位腦積水意識(shí)障礙迅速出現(xiàn)，并可能死亡腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202

22、236Superior vermian herniation ( 陀螺狀外觀腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202237陀螺狀外觀腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202237雙側(cè)環(huán)池變窄腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202238雙側(cè)環(huán)池變窄腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202238四疊體池充滿腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202239四疊體池充滿腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202239不露齒的微笑腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202240不露齒的微笑腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202240皺眉腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202241皺眉腦疝分類(lèi)和影像學(xué)表現(xiàn)

23、圖解10/3/202241第一天的四疊體池和環(huán)池腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202242第一天的四疊體池和環(huán)池腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/20第二天，四疊體池和環(huán)池消失腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202243第二天，四疊體池和環(huán)池消失腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/腦積水腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202244腦積水腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202244ascending transtentorial herniation腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202245ascending transtentorial herni枕大孔疝臨床表現(xiàn)影像所見(jiàn)并發(fā)癥雙側(cè)

24、上肢感覺(jué)減退意識(shí)障礙軸位像見(jiàn)到小腦扁桃體位于齒狀突水平矢狀位見(jiàn)到小腦扁桃體低于枕大孔5mm（成人）或7mm（兒童）小腦扁桃體出血性壞死意識(shí)障礙和死亡腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202246枕大孔疝臨床表現(xiàn)影像所見(jiàn)并發(fā)癥雙側(cè)上肢感覺(jué)減退軸位像見(jiàn)到小腦枕大孔疝腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202247枕大孔疝腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/3/202247Tonsillar herniation In tonsillar herniation (rare), a mass effect in the posterior fossa causes the cerebellar tonsils

25、 to herniate inferiorly through the foramen magnum compressing the medulla and upper cervical spinal cord. Conscious patients complain of neck pain and vomiting. They may have nystagmus, pupillary dilatation, bradycardia, hypertension and respiratory depression. Early tonsillar herniation is difficu

26、lt to recognize in an unconscious patient. It may not be evident on CT scan since axial views cannot see the pathology well. It is best seen on sagittal MRI. Clinically changes in vital signs may be the only clinical clue in an unconscious patient.腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202248Tonsillar herniation In tonsi

27、lTonsillar herniation腦疝分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202249Tonsillar herniation腦疝分類(lèi)和影像學(xué)表現(xiàn)a male patient in his 30s who died of brain stem herniation after completing a marathon. The CT shows (A) loss of the rostral cerebral sulci suggesting increase in ICP, (B) and (C) a large hydrocephalus with widening of both t

28、emporal horns. The grey matter can still be differentiated from the white matter, but all sulci are lost. This suggests that the brain oedema is of relative recent onset and massive tissue ischaemia has not yet occurred. (D) Compression of the fourth ventricle with dilatation of the third ventricle

29、and the caudal aspect of both temporal horns. This is observed with considerable brain oedema and obstructive hydrocephalus. (E) Herniation of the medulla and pons into the foramen magnum. (F) The tonsils are located at the level of the dens which is a good indicator for foramen magnum herniation.腦疝

30、分類(lèi)和影像學(xué)表現(xiàn)圖解10/5/202250a male patient in his 30s who(A) The disc shows florid hemorrhages with relatively little swelling, indicating a rapid, dramatic increase in CSF pressure. Progressive changes of optic disc oedema are seen in a patient with an intracranial tumour who declined treatment (B-D). (B)

31、 Early nerve fiber dilatation is seen particularly superiorly, inferiorly and nasally. (C) This increases and venous engorgement develops. (D) Temporal nerve fiber dilatation and swelling of the disc increases and hemorrhages appear. (E) In gross chronic disc oedema the normal retinal vasculature is masked and dilated superficial capil