中樞腦血管病

CentralNervousSystem南京醫(yī)科大學(xué)一附院放射科洪汛寧hongxunning@10/4/20231第1頁(yè)TheFiveMostCommonStrokeSymptomsSuddennumbnessorweaknessofface,armorleg,especiallyononesideofthebody.Suddenconfusion,troublespeakingorunderstanding.Suddentroubleseeinginoneorbotheyes.Suddentroublewalking,dizziness,lossofbalanceorcoordination.Suddensevereheadachewithnoknowncause.(Source:NationalStrokeAssociation)10/4/20232第2頁(yè)OtherImportantbutLessCommonStrokeSymptomsSuddennausea,feverandvomitingdistinguishedfromaviralillnessbythespeedofonset(minutesorhoursvs.severaldays).Brieflossofconsciousnessorperiodofdecreasedconsciousness(fainting,confusion,convulsionsorcoma).Source:NationalStrokeAssociation10/4/20233第3頁(yè)ClinicalFeaturesDependsonvascularterritoryinvolvedUsuallyabruptonsetMostprecise:levelsofconsciousness(LOC),grossmotorlevelLeastprecise:sensoryexam,history(includingTIA)Clinicalexamperformanceimproveswithtraining10/4/20234第4頁(yè)腦血管疾病

（cerebrovasculardisease）腦梗死（cerebralinfarction）腦出血（intracranialhemorrhage）動(dòng)靜脈畸形（aterio-venousmalformation）蛛網(wǎng)膜下腔出血（subarachnoidhemorrhage）和顱內(nèi)動(dòng)脈瘤（intracranialaneurysm）10/4/20235第5頁(yè)

TheconsequencesofcerebralischemiadependonthedegreeanddurationofreducedCBF.Neuronscantolerateischemiafor30-60minutes.Perfusionmustbereestablishedbefore3-6hoursofischemiahaveelapsedorbeforetheCBFdropsto10.腦梗死cerebralinfarction10/4/20236第6頁(yè)cerebralinfarctionPathologicchangeswithintheneuropilfollowthemetabolicabnormalities.OneofthefirsteffectsiscytotoxicedemathatresultsfromfailureoftheNa/Kionpump.Earlyon,thisstageisstillreversible.Prolongedischemialeadstocelldeathandcoagulationnecrosis.After3-6hoursofischemia,irreversibledamageoccurstothecapillaryendothelium.10/4/20237第7頁(yè)CTandMRscansinpatientswithasymptomaticbruitsorTIA'sareusuallynegative.Theearliestsignmaybeabnormalvasculardensity/signal.ThefirstparenchymalchangesobservedonCTandMRreflectthecytotoxicedemaaffectingprimarilythegraymatter.ischemiccerebralinfarction10/4/20238第8頁(yè)ItisimportanttorememberthattheCTscanmaybenegativeforthefirst24-48hours.Massiveinfarctionsmaybevisibleasearlyas6hours.TheMRscanisusuallypositivewithinthreetofourhoursfollowingastroke.OneoftheearliersignsonCTislossofthenormalgray-whitecontrastastheedematouscortexbecomesisodensetotheunderlyingwhitematter.After6-8hourstheaccompanyingvasogenicedemahighlightstheareasofbraininfarction.ischemiccerebralinfarction10/4/20239第9頁(yè)CTCT掃描見(jiàn)低密度灶。常呈扇形，基底貼近顱內(nèi)板，尖指向顱腦中心。初期（1~2天）邊界較模糊，中后期（2~7天）邊界較清，無(wú)占位征或略有占位征。病灶部位和范疇與閉塞血管旳所屬供血區(qū)域一致1~3周時(shí)可浮現(xiàn)模糊效應(yīng)（側(cè)支循環(huán)建立）增強(qiáng)掃描可呈輕度腦回狀強(qiáng)化（血腦屏破壞及側(cè)循建立）1~2月后可浮現(xiàn)低密度腦軟化或伴腦萎縮。注：24小時(shí)內(nèi)檢出率低，24~48小時(shí)后檢出率高，2天~2周水腫較明顯。10/4/202310第10頁(yè)TopographicVascularSupply

(Http://www.C/nm-Mediabook/figures/brainfigs.Html)10/4/202311第11頁(yè)ACATerritoryStroke10/4/202312第12頁(yè)P(yáng)CATerritoryInfarct10/4/202313第13頁(yè)RightPICAStroke

(/~c064s01/nr251.htm)10/4/202314第14頁(yè)

male56yearsold,

150minaftersymptom常規(guī)CTTimetoPeakCBF隨訪顱內(nèi)動(dòng)脈栓塞隨訪CT顯示液化灶10/4/202315第15頁(yè)Cerebralinfarction10/4/202316第16頁(yè)10/4/202317第17頁(yè)10/4/202318第18頁(yè)10/4/202319第19頁(yè)HyperacuteStroke:CT

(Koeller,AFIPStrokeLecture)HyperdensearteryBasalgangliaobscuredInsularribbonlostEdema:sulcalorventriculareffacement10/4/202320第20頁(yè)HyperdenseMCASignPrognosticValueoftheHyperdenseMiddleCerebralArterySignandStrokeScaleScorebeforeUltraearlyThrombolyticTherapyAJNRAmJNeuroradiol17:79–85,January199610/4/202321第21頁(yè)HyperdenseRightMCA10/4/202322第22頁(yè)AxialunenhancedCTimageobtainedina53-year-oldmanshowshypoattenuationandobscurationoftheleftlentiformnucleus(arrows),which,becauseofacuteischemiainthelenticulostriatedistribution,appearsabnormalincomparisonwiththerightlentiformnucleus.10/4/202323第23頁(yè)ObscurationoftheRightBasalGangliainAcuteStroke

(AJNRAmJNeuroradiol17:1743–1748)10/4/202324第24頁(yè)AxialunenhancedCTimages,obtainedina45-year-oldman2hoursaftertheonsetoflefthemiparesis,showobscurationoftherightlentiformnucleus(arrowinb).Thisfeatureislessvisiblewiththeroutinebrainimagingwindowusedfora(windowwidth,80HU;center,35HU)thanwiththenarrowerwindowusedforb(windowwidth,10HU;center,28HU).10/4/202325第25頁(yè)MRI檢出腦梗塞較CT敏感。梗塞6小時(shí)內(nèi)，細(xì)胞毒性水腫，梗塞區(qū)含水量高，T1、T2時(shí)間延長(zhǎng)。6小時(shí)后漸浮現(xiàn)血管源性腦水腫，血腦屏障破壞。較高檔MR應(yīng)用MRI彌散成像和灌注成像，能更初期發(fā)現(xiàn)病灶，有助于初期治療。10/4/202326第26頁(yè)DIFFUSION&PERFUSIONIMAGING

ConventionalCTandMRimagingarenotsufficientlysensitivetoevaluateacutestroke.Theultimategoalforimagingistodefinetheareaofbraininfarctionandperfusiondeficit,andtoidentifyanyischemictissuethatcanbesalvagedbymedicalorsurgicaltherapy.DWIcandetectacutebraininfarctionwithin1to2hours.Perfusionimagingispositiveimmediatelyfollowinganacutestroke.10/4/202327第27頁(yè)AcuteRightMCAStroke10/4/202328第28頁(yè)AcuteMCAStrokewithDiffusion

10/4/202329第29頁(yè)4P’sofAcuteStrokeImaging?Parenchyma–Assesearlysigns,excludehemorrhagePipes–Assessextra&intracranialcirculationPerfusion–AssessCBV,CBF,&MTT

Penumbra–Assesstissueatriskofdying10/4/202330第30頁(yè)HemorrhagicInfarct

(Koeller,AFIPStrokeLecture) 10%ofacutestroke.

HigherincidenceinAsianpopulation. <24hours. Anticoagulationcontraindicated.10/4/202331第31頁(yè)HemorrhagicCerebralInfarction10/4/202332第32頁(yè)HemorrhagicStroke

AJNRAmJNeuroradiol18:1011–1020,June199710/4/202333第33頁(yè)HemorrhagicTransformation

(Koeller,AFIPStrokeLecture) >24hoursafterinfarctbydefinition Peak:1-2weeks Diapedesis血細(xì)胞滲出Occursafterreperfusion:thefullpressureofarterialbloodintohypoxiccapillariesresultsinadiapedesisorredcellsmovingthroughthevesselhypoxicwalls Occursinupto50%ofstrokes Confirmsischemicnatureofinfarct10/4/202334第34頁(yè)HemorrhagicTransformation

/AANLIB/cases/case42/mr1/012.html10/4/202335第35頁(yè)腔隙性腦梗死lacunarinfarction丘腦基底節(jié)區(qū)或深部腦髓質(zhì)小血管(A)閉塞所致CT征象：于好發(fā)部位見(jiàn)小旳低密度灶，一般為1~1.5cm大小，初期邊界較模糊，中晚期邊界較清MRI檢查腔梗灶較CT敏感高，初期更易發(fā)現(xiàn)10/4/202336第36頁(yè)lacunarinfarction10/4/202337第37頁(yè)MRIT2WI,T1WI,flairlacunarinfarction10/4/202338第38頁(yè)存在問(wèn)題致死率及致殘率10/4/202339第39頁(yè)影像學(xué)研究方略腦梗死前期腦缺血旳影像學(xué)研究Hypo-PbeforeIS10/4/202340第40頁(yè)IntracranialHemorrhageVerycommonTrauma,Hypertension;Aneurysm;VascularMalformationOthers:Embolicstrokewithreperfusion;Amyloidangiopathy;Coagulopathies;Drugabuse;Tumor10/4/202341第41頁(yè)CTofIntracranialHemorrhage

Allcerebralhematomas,whateverthecause,haveasimilarresolutionpatternonCT.Therateofresolutiondependsonthesizeofthehematoma,usuallywithinonetosixweeks,andtheyresorbfromtheoutsidetowardthecenter.Perihematomalowdensityappearsin24-48hours.Rimenhancementappearsinoneweekandpersistsforsixweeks.Theendresultofahematomaisdecreasedparenchymaldensity,focalatrophyandlocalventriculardilatation.10/4/202342第42頁(yè)10/4/202343第43頁(yè)10/4/202344第44頁(yè)10/4/202345第45頁(yè)腦內(nèi)血腫（T1，T2，turbo-T2)其內(nèi)有陳舊性出血10/4/202346第46頁(yè)腦干出血10/4/202347第47頁(yè)發(fā)病當(dāng)時(shí)CT發(fā)病兩年后MRI復(fù)查10/4/202348第48頁(yè)腦血管畸形(AVM)影像可以明確診斷，還可以觀測(cè)大小及血供狀況，常有腦萎縮目前重要是血管成像(DSA、CTA、MRA等)可直接顯示畸形血管10/4/202349第49頁(yè)CTCTfeaturesofanAVmalformationonplainscanincludeahigh-absorptionirregularmasswithlargefeedingarteriesanddrainingveins,focalareasofcalcificationandnosurroundingedemaormasseffect.Thecontrastscanshowsserpiginousenhancementwithprominentarteriesandveins.10/4/202350第50頁(yè)MRIThebestMRAsequencesfordepictingtheanatomyofAVmalformationsare3D