中樞外傷教材講義

CentralNervousSystem

南京醫(yī)科大學(xué)一附院放射科洪汛寧hongxunning@2/3/20231ClassificationofHeadInjuryExtracerebrallesions:

Subdural

hematomaSubduraleffusionEpiduralhematomaIntracerebrallesions:Braincontusion(edema,

hemorrhage..)

Subarachnoidhemorrhage

(SAH)

Intraventricularhemorrhage

(IVH)Opencranialinjury.

Skullfracture

Pneumoencephalus2/3/20232顱腦外傷braintrauma硬膜外血腫(epiduralhematoma)硬膜下血腫（subdural

hematoma）腦挫裂傷（lacerationandcontusionofbrain）蛛網(wǎng)膜下腔出血Subarachnoid

haemorrhage2/3/20233硬膜外血腫

(extradural

hematoma)

Thesearisebetweentheinnertableoftheskullandthedura.Theyusuallydevelopfrominjurytothemiddlemeningealarteryoroneofitsbranches,andthereforeareusuallytemporoparietalinlocation.Atemporalbonefractureisoftenthecause,butisnotessential.Theexpandinghaematomastripsthedurafromtheskull;thisattachmentisquitestrongsuchthatthehaematomaisconfined,givingrisetoitscharacteristicbiconvexshape,withawelldefinedmargin.2/3/20234CT征象：顱板內(nèi)側(cè)梭形(雙凸透鏡)高密度影(與腦實質(zhì)比)，CT值50~90Hu；(范圍小而厚)密度一般較均勻邊緣清楚、光滑銳利局部常見腦水腫征局部蛛網(wǎng)膜下腔常見出血征局部有顱骨骨折征具有占位征：局部腦回受壓內(nèi)移，中線結(jié)構(gòu)向?qū)?cè)移位2/3/20235

biconvexshape,withawelldefinedmargin.2/3/202362/3/20237血塊內(nèi)含較灰區(qū)(箭)，

代表正在出血中，有未凝結(jié)的血塊EDH：紡垂型，高濃度血塊頭皮腫(箭)，撞擊處2/3/20238硬膜外血腫MRI平掃、Gd-DTPA增強(qiáng)2/3/20239硬膜下血腫

（subdural

hematoma）Thesearisebetweentheduraandarachnoid,oftenfromrupturedveinscrossingthispotentialspace.Thespaceenlargesasthebrainatrophiesandsosubdural

haematomasaremorecommonintheelderly.2/3/202310CT征象顱內(nèi)板內(nèi)側(cè)新月狀(或帶狀)高密度影(與腦實質(zhì)比)，CT值50~90Hu，范圍廣而薄密度一般較均勻邊界清楚，但不光滑銳利局部可有或無腦水腫局部可有或無蛛網(wǎng)膜下腔出血局部一般無顱骨骨折，常為對沖傷出血較多時具有占位效應(yīng)，局部腦實質(zhì)受壓內(nèi)移，中線結(jié)構(gòu)向?qū)?cè)移位2/3/202311

thecrescentichighdensitycollectiontypicalofaacutesubdural

haematoma,withassociatedmidlineshift.

2/3/202312急性硬膜下血腫（SDH）SDH：新月型(A.B)SDH可能在大腦鐮內(nèi)(C)。SDH也可在幕下(D)(不要誤為腦內(nèi)出血)ABCD2/3/202313A.SDH，明顯占位效應(yīng)B.術(shù)后，占位效應(yīng)消失AcutesubduralhematomawithmasseffectAB2/3/202314等密度PlainCTIVcontrast2/3/2023152/3/20231620080209術(shù)后200802192/3/202317同一個病人，200807282/3/202318Notethecrescenticlowdensitycollectiontypicalofachronicsubdural

haematoma,withassociatedmidlineshift.2/3/202319subdural

hematoma2/3/202320腦挫裂傷（lacerationandcontusionofbrain）Theseoccurduetostretchingandshearinginjury,oftenduetoimpactionofthebrainagainsttheskullonthesideoppositetotheinjury.Thustheymaybeseendirectlyoppositetheimpactsite,subcutaneoushaematoma,fracture,orextradural

haematoma(contrecoupinjury).Theinferiorfrontallobesandanteriortemporallobesarecommonsitesafterablowtothebackofthehead.2/3/202321

CT

低密度水腫區(qū),散在高密度出血灶,伴有占位效應(yīng)。有的表現(xiàn)為廣泛的腦水腫或腦內(nèi)血腫MR

腦水腫T1WI呈等低信號,T2WI高信號;腦血腫T1WI,T2WI均呈高信號2/3/202322Thereisafocalareaofhaemorrhagiccontusionintherightfrontallobe,withsurroundinglowdensityduetoinfarctionoroedema.Thisisafrequentlocationforacontre-coupinjuryfollowingablowtothebackofthehead.2/3/202323出血、異物、氣顱2/3/202324Intracerebral

Haemorrhage

2/3/202325Subarachnoid

haemorrhageThismayoccuraloneorinassociationwithotherintracerebralorextracerebral

haematomas.IncreasedattenuationisseenintheCSFspaces,overthecerebralhemispheres(lookcloselyattheSylvianfissure),inthebasalcisternsorintheventricularsystem.SAHmaybecomplicatedbyhydrocephalus.ConfusioncansometimesarisebetweenSAHduetotraumaandduetoarupturedaneurysmorarteriovenousmalformation(AVM);thepatientmaycollapseandhittheirheadasaresultofableedandthehistory(fromthepatientorawitness)isimportant.2/3/202326Thispatienthasanacuteextradural

haematomaontherightside,andacutetraumaticsubarachnoid

haemorrhageontheleftside.2/3/202327Delayedhemorrhage,severalhoursordaysafterheadinjury8小時隨訪腦外傷后2/3/202328HeadinjurywithEDHanddelayedcontusionhemorrhages6月22日6月20日2/3/202329ContusionhemorrhagesandSAHA.9月29日

B.9月30日延遲性出血在腦挫傷極常見。腦挫傷：小血塊及腦水腫混雜在一起

AB2/3/202330Vaultfractures2/3/202331顱腦外傷后遺癥1.腦萎縮2.交通性腦積水，多由于蛛血、腦室內(nèi)出血3.腦軟化或腦穿通性囊腫，多由于腦挫傷2/3/20233286,5,14AcuteSDH&contusionhemorrhage86,5,16Post-craniotomy,theSDHdisappeared,delayedhemorrhage;SAHinRt.tentorium86,8,13EncephalomalaciachangewithmildhydrocephalusDecompressionhemorrhagewithencephalomalaciachange2/3/20233386,9,10:Communicatinghydrocephalus86,2,6:TraumaticSAHinthesulci,interhemisphericfissureSAHcausedcommunicatinghydrocephalus2/3/202334DiffuseAxonalInjury(DAI)Duetoaxonaldisruptionfromshearingforcesofacceleration/deceleration.MostcommonlyseeninsevereheadinjuryClinical:LossofconsciousnessattimeofinjuryMarkeddiscrepancybetweentheinitialCTandclinicalstatusofthepatientVerysmallDAIhaveprofoundclinicalsequelasincetheyaffectdenselypackedbundlesofaxonslocateddeepwithinthebrain2/3/202335DiffuseAxonalInjuryRadiographicfeatures:Characteristiclocations:lobargraymatter/whitematterjunction,corpuscallosum,dorsolateralbrainstemInitialCTisoftenreadasnormalDAIlesionscanbeverysmallandprimarilynon-hemorrhagicrenderingthemquiteinconspiciousonthe1stCTscanPetechialhemorrhagedevelopslateronMultifocalT2brightlesions(MRImoresensitive)2/3/202336DiffuseAxonalInjurySurvivorsofsevereDAIusuallyhavepoorneurologicoutcomes2/3/2023371stday4monthslater--brainatrophy5thdayComaafterheadinjury4m