【胸部】胸部急癥CT診斷課件

胸部急癥CT大致分類胸外傷自發(fā)性氣胸支氣管異物心包填塞主動(dòng)脈瘤(非急癥)主動(dòng)脈夾層2013-10-09胸外傷原因：車禍、摔傷、火器傷、刀刺傷陽性徵象：胸廓骨折肺挫裂傷，①肺挫傷②肺裂傷③肺內(nèi)血腫④肺氣囊胸腔積液、氣胸、縱隔氣腫，頸胸部皮下及肌間氣腫心臟、大血管損傷膈肌損傷2013-10-09男，30歲，肺挫裂傷（外傷性肺大泡）2013-10-09女，55歲，外傷後就診，左肺挫裂傷，左側(cè)氣胸2013-10-09同一病例，左側(cè)多發(fā)肋骨骨折2013-10-09同一病例，VR圖像直觀顯示骨折部位、移位情況2013-10-09男，43歲，外傷就診，矢狀位圖像示胸骨骨折、縱隔氣腫，脊柱多發(fā)骨折2013-10-09膈破裂男，55歲，顱腦、胸腹外傷就診2013-10-092013-10-09左側(cè)多發(fā)肋骨骨折2013-10-09心臟破裂男，43歲，剪刀刺傷左胸部3小時(shí)就診，神志不清2013-10-092013-10-092013-10-09自發(fā)性氣胸男，27歲，突發(fā)胸痛就診，肺尖見有多發(fā)肺大泡2013-10-09縱隔氣腫男，24歲，胸部不適就診，無外傷2013-10-09支氣管異物男，33歲，顱腦術(shù)後智障，誤吸花生米嗆咳2013-10-092013-10-09動(dòng)脈瘤定義：主動(dòng)脈擴(kuò)張≥1.5倍正常管徑

升主動(dòng)脈5cm，主動(dòng)脈弓、胸主動(dòng)脈4cm，遠(yuǎn)側(cè)腹主動(dòng)脈3cm原因：變性外傷感染分類：真性假性2013-10-092013-10-09測量血管真正斷面真性動(dòng)脈瘤WallofarteryformstheaneurysmAtleastonevessellayerstillintactFusiformCircumferential,relativelyuniforminshapeSaccularPouchlikewithnarrowneckconnectingbulgetoonesideofarterialwall梭形囊狀2013-10-09假性動(dòng)脈瘤AlsocalledpseudoaneurysmNotananeurysmDisruptionofalllayersofarterialwallResultsinbleedingcontainedbysurroundingstructuresPseudoaneurysm:anoutpouchingofabloodvessel,involvingadefectinthetwoinnermostlayers(thetunicaintimaandmedia)withcontinuityoftheoutermostlayer,theadventitia.Alternatively,allthreelayersaredamagedandbleedingoutsideofthevesseliscontainedbyaclotorbysurroundingtissue2013-10-09病理真性：動(dòng)脈壁各層完整，但被延伸假性：動(dòng)脈壁各層被穿透，瘤壁為纖維組織2013-10-09影像診斷要點(diǎn)：局限性或彌漫型擴(kuò)張形狀與病因關(guān)係：梭形動(dòng)脈瘤多繼發(fā)於變性（與年齡因素相關(guān)）局限並偏心性，多提示感染後、外傷後起源常規(guī)需測量主動(dòng)脈瘤的外徑2013-10-09提供資訊瘤體直徑及累及範(fàn)圍與主動(dòng)脈主要分支的關(guān)係血管腔內(nèi)血栓的情況是否存在洩露、破裂出現(xiàn)的周圍滲出性改變是否存在周圍脂肪的炎性改變2013-10-09動(dòng)脈瘤洩露、破裂徵象輕微：動(dòng)脈瘤附近的模糊區(qū)域或?qū)Ρ葎┚窒扌跃奂▌?dòng)脈瘤與脊柱之間）明顯：血腫臨近或圍繞動(dòng)脈瘤縱隔或腹膜後腔的血腫胸腹腔積血2013-10-09Imagingoftheacuteabdomen,2003,11562013-10-09Imagingoftheacuteabdomen,2003,11572013-10-092013-10-092013-10-09男，57歲發(fā)作性心慌、胸悶2月餘術(shù)前CT（上組圖）示升主動(dòng)脈瘤樣擴(kuò)張，主動(dòng)脈瓣增厚術(shù)後CT（下組圖）示升主動(dòng)脈部分人工血管置換，主動(dòng)脈瓣置換。2013-10-09男，43歲。突發(fā)胸背痛7天。主動(dòng)脈弓降部真性動(dòng)脈瘤形成。2013-10-092013-10-09男，34歲?；顒?dòng)後胸背部疼痛7天。CT示主動(dòng)脈弓降部假性動(dòng)脈瘤形成。胸主動(dòng)脈瘤（男，76歲，以縱隔占位就診）2013-10-092013-10-092013-10-09胸主動(dòng)脈瘤（男，69歲）2013-10-092013-10-092013-10-09男，40歲，主動(dòng)脈瓣置換病史2013-10-092013-10-09男，22歲2013-10-092013-10-092013-10-092013-10-09主動(dòng)脈夾層主動(dòng)脈夾層指主動(dòng)脈腔內(nèi)的血液通過內(nèi)膜的破口進(jìn)入主動(dòng)脈壁中層而形成的壁內(nèi)血腫，並非主動(dòng)脈壁的擴(kuò)張危險(xiǎn)因素CommonpredisposingfactorsintheInternationalRegistryofAorticDissection(IRAD)werehypertensionin72%ofcases,followedbyatherosclerosisin31%andpreviouscardiacsurgeryin18%

國際主動(dòng)脈夾層官方記錄（IRAD）顯示，最常見的危險(xiǎn)因素為高血壓，占病例的72％；其次為動(dòng)脈粥樣硬化，占31％；心臟手術(shù)史，占18％Analysisoftheyoungpatientswithdissection(,40yearsofage)revealedthatyoungerpatientswerelesslikelytohaveahistoryofhypertension(34%)oratherosclerosis(1%),butweremorelikelytohaveMarfansyndrome,bicuspidaorticvalve,and/orprioraorticsurgery

針對(duì)年輕患者的分析顯示年輕患者（<40歲）較少有高血壓病史（占34％）及動(dòng)脈粥樣硬化史（1％），而馬凡氏綜合征史、主動(dòng)脈瓣雙瓣畸形和（或）主動(dòng)脈手術(shù)史可能性更大2013-10-09分型DeBakeyStanford2013-10-09胸主動(dòng)脈解剖2013-10-09Anatomyofthethoracicaortaandsignificantlandmarks.Theascendingaortaextendsfromtheaorticvalvetotheoriginoftheinnominateartery.Itsproximalportion,inrelationtotheaorticvalveandsinusesofValsalva,istermedtheaorticroot.Theaorticarchbeginsattheinnominatearteryandendsattheligamentumarteriosum.Itsmostdistalpart,whichisoftenslightlynarrowed,istermedtheaorticisthmus.Thedescendingaortabeginsattheligamentum.Itsproximalportionmayappearslightlydilatedandhasbeentermedtheaorticspindle.2013-10-09男，30歲，突發(fā)劇烈胸痛就診主動(dòng)脈邊緣毛糙DeBakeyⅠ型，伴左腎梗死2013-10-092013-10-09男，28歲，突發(fā)劇烈胸痛就診2013-10-092013-10-09心電門控掃描，DeBakeyⅠ型，累及右側(cè)冠狀動(dòng)脈起始部斜矢狀圖像2013-10-09VR圖清晰顯示假腔範(fàn)圍，併發(fā)峽部囊狀動(dòng)脈瘤2013-10-09女，49歲，降主動(dòng)脈支架置入病史2013-10-092013-10-09DebakeyⅡ型DebakeyⅢ型，左腎動(dòng)脈起源於假腔2013-10-09鑒別升主動(dòng)脈搏動(dòng)偽影，門控掃描可消除2013-1