腦疝分類及影像學(xué)表現(xiàn)圖解

圖解腦疝北京天壇醫(yī)院神經(jīng)內(nèi)科杜萬良（reflexhammer）腦疝分類及影像學(xué)表現(xiàn)圖解腦疝是指在顱內(nèi)壓增高的情況下，腦組織通過某些腦池向壓力相對較低的部位移位的結(jié)果，即腦組織由其原來正常的位置而進(jìn)入了一個異常的位置。腦疝分類及影像學(xué)表現(xiàn)圖解腦疝的類型：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；②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，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.顱外疝：腦組織通過顱外缺損疝出。e.枕骨大孔疝：后顱凹占位病變時，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高一些，則額眶回可越過蝶骨嵴進(jìn)入顱中凹，可顳葉前部擠向顱前凹。腦疝分類及影像學(xué)表現(xiàn)圖解示意圖a)subfalcial(cingulate)herniation;鐮下疝b)uncalherniation;鉤疝c)downward(central,transtentorial)herniation;下行性小腦幕疝d)externalherniation;顱外疝e)tonsillarherniation.扁桃體疝f)ascendingtranstentorialherniation(reversedtentorial)上行性小腦幕疝g)sphenoidherniation蝶骨嵴疝腦疝分類及影像學(xué)表現(xiàn)圖解類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．枕骨大孔疝小腦扁桃體疝腦疝分類及影像學(xué)表現(xiàn)圖解示意圖腦疝分類及影像學(xué)表現(xiàn)圖解解剖關(guān)系腦疝分類及影像學(xué)表現(xiàn)圖解解剖關(guān)系FQcMb3vTOSyCClvFPOSpCClvss腦疝分類及影像學(xué)表現(xiàn)圖解解剖關(guān)系FTCesPd4thVFTMbCes腦疝分類及影像學(xué)表現(xiàn)圖解Thesuprasellarcistern&thequadrigeminalcisternTheleftandcenterimagesshowthesuprasellarcistern.Itsanteriorbordersareformedbythefrontallobes(F).Itslateralbordersareformedbytheuncus(U)ofthetemporallobes.Theleftimageshowsthe5-pointedstarappearanceofthesuprasellarcisternwheretheposteriorborderisformedbythepons(Po).Theblackarrowpointstothefourthventricle.Thecenterimageshowsahighercutwherethesuprasellarcisternhasa6-pointedstarappearancesincetheposteriorborderisformedbythecerebralpeduncles(P)whichhaveacentralcleft.Therightimageshowsthequadrigeminalcistern(blackarrow).Notethe"baby'sbottom"appearanceofitsanteriorborder.WhenICPisincreased,thequadrigeminalcisternspaceiscompressedorobliterated.腦疝分類及影像學(xué)表現(xiàn)圖解Thesuprasellarcistern

&thequadrigeminalcistern.ThemidlinesagittalMRIscanshowsthelevelsoftheaxialdiagrams.Thequadrigeminalcisternislocatedabove(anteriorto)the"Q"inthehighestcutshown(number9).Theanteriorborderofthequadrigeminalcisternisformedbythesuperiorcolliculi(c).Image8(lowercut)alsoshowsthequadrigeminalcistern.Inthiscase,itsanteriorborderisformedbytheinferiorcolliculi(c).Thisgivestheanteriorborderofthequadrigeminalcisterntheappearanceofa"baby'sbottom".Thequadrigeminalplateiscomprisedofthesuperiorandinferiorcolliculi.Thequadrigeminalcisternisposteriortothisquadrigeminalplate,thusitsanteriorbordermaybeformedbytheinferiororsuperiorcolliculi.腦疝分類及影像學(xué)表現(xiàn)圖解鐮下疝臨床表現(xiàn)影像所見并發(fā)癥頭痛對側(cè)下肢無力同側(cè)額角截斷大腦鐮前份不對稱同側(cè)側(cè)腦室腔消失透明隔移位因大腦前動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及影像學(xué)表現(xiàn)圖解Subfalcineherniation(cingulateherniation)

TranstentorialherniationThesuprasellarcistern(leftimage)isobliterated.Thequadrigeminalcisternisverycompressedandpushedposteriorly(centerimage).Asubduralhematomawithamidlineshiftisnoted.Thereiscentraltranstentorialandsubfalcineherniation.腦疝分類及影像學(xué)表現(xiàn)圖解ACA供血區(qū)梗塞腦疝分類及影像學(xué)表現(xiàn)圖解Uncalherniation臨床表現(xiàn)影像所見并發(fā)癥同側(cè)瞳孔散大、眼動受限（動眼神經(jīng)受壓）對側(cè)偏癱（同側(cè)大腦腳受壓）有時顳葉疝壓跡會導(dǎo)致同側(cè)偏癱（對側(cè)大腦腳受壓。假定位體征）對側(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)入鞍上池大腦后動脈受壓導(dǎo)致枕葉梗塞腦疝分類及影像學(xué)表現(xiàn)圖解鞍上池缺角腦疝分類及影像學(xué)表現(xiàn)圖解冠狀位CT與MRI腦疝分類及影像學(xué)表現(xiàn)圖解海馬旁回褶皺腦疝分類及影像學(xué)表現(xiàn)圖解對側(cè)顳角增寬腦疝分類及影像學(xué)表現(xiàn)圖解同側(cè)橋前池增寬腦疝分類及影像學(xué)表現(xiàn)圖解同側(cè)環(huán)池增寬腦疝分類及影像學(xué)表現(xiàn)圖解Uncalherniation腦疝分類及影像學(xué)表現(xiàn)圖解Uncalherniationobliterationofthesuprasellarcistern(redarrow)andthequadrigeminalcistern(greenarrow)腦疝分類及影像學(xué)表現(xiàn)圖解UncalherniationTheipsilateralventricle,sulci,fissuresarecompressedandobliterated,isappeared.obliterationofthe

suprasellarcistern(s)andquadrigeminalcistern(q)腦疝分類及影像學(xué)表現(xiàn)圖解UncalherniationAcuteinfarction1stdayAcuteinfarction4thdaysq腦疝分類及影像學(xué)表現(xiàn)圖解UncalherniationBeforesurgery,abigGBMinthelefttemporallobewithuncalherniation.Aftersurgery,theGBMwasremoved,thesuprasellarcisternandquadrigeminalcisternsarenormal.腦疝分類及影像學(xué)表現(xiàn)圖解UncalherniationAcuteinfarctionofrightposteriorartery(PCA),thisisacomplicationofuncal/transtentorialherniation,becausethePCAwascompressedbybrainherniation.腦疝分類及影像學(xué)表現(xiàn)圖解雙側(cè)大腦后動脈梗塞腦疝分類及影像學(xué)表現(xiàn)圖解雙側(cè)大腦后動脈梗塞腦疝分類及影像學(xué)表現(xiàn)圖解Durettehemorrhage腦疝分類及影像學(xué)表現(xiàn)圖解Durettehemorrhage腦疝分類及影像學(xué)表現(xiàn)圖解Kernohan’snotch顳葉疝壓跡腦疝分類及影像學(xué)表現(xiàn)圖解UncalherniationWhenmasseffectswithinoradjacenttothetemporallobeoccur,themedialportionofthetemporallobe(uncus)isforcedmediallyanddownwardoverthetentorium.Thereisipsilateralpupillarydilation.Theuncusispushedmediallyintothesuprasellarcistern.Thereisbilateraluncalherniation.Thesuprasellarcisternisobliterated.腦疝分類及影像學(xué)表現(xiàn)圖解earlyuncalherniationTherightuncusispushingintothesuprasellarcistern;earlyrightuncalherniation.腦疝分類及影像學(xué)表現(xiàn)圖解中心疝臨床表現(xiàn)影像所見并發(fā)癥意識改變呼吸模式改變?nèi)テ印⑷ツX小瞳孔因脈絡(luò)膜前動脈受壓引起蒼白球和視束梗塞腦疝分類及影像學(xué)表現(xiàn)圖解中心疝腦疝分類及影像學(xué)表現(xiàn)圖解Superiorvermianherniation(ascendingtranstentorialherniation)由于后顱凹的占位效應(yīng)，小腦蚓和小腦半球通過小腦幕切跡向上移動臨床表現(xiàn)影像所見并發(fā)癥惡心嘔吐意識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脈受壓引起梗塞Galen靜脈移位腦積水意識障礙迅速出現(xiàn)，并可能死亡腦疝分類及影像學(xué)表現(xiàn)圖解陀螺狀外觀腦疝分類及影像學(xué)表現(xiàn)圖解雙側(cè)環(huán)池變窄腦疝分類及影像學(xué)表現(xiàn)圖解四疊體池充滿腦疝分類及影像學(xué)表現(xiàn)圖解不露齒的微笑腦疝分類及影像學(xué)表現(xiàn)圖解皺眉腦疝分類及影像學(xué)表現(xiàn)圖解第一天的四疊體池和環(huán)池腦疝分類及影像學(xué)表現(xiàn)圖解第二天，四疊體池和環(huán)池消失腦疝分類及影像學(xué)表現(xiàn)圖解腦積水腦疝分類及影像學(xué)表現(xiàn)圖解ascendingtranstentorialherniation腦疝分類及影像學(xué)表現(xiàn)圖解枕大孔疝臨床表現(xiàn)影像所見并發(fā)癥雙側(cè)上肢感覺減退意識障礙軸位像見到小腦扁桃體位于齒狀突水平矢狀位見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障礙和死亡腦疝分類及影像學(xué)表現(xiàn)圖解枕大孔疝腦疝分類及影像學(xué)表現(xiàn)圖解TonsillarherniationIntonsillarherniation(rare),amasseffectintheposteriorfossacausesthecerebellartonsilstoherniateinferiorlythroughtheforamenmagnumcompressingthemedullaanduppercervicalspinalcord.Consciouspatientscomplainofneckpainandvomiting.Theymayhavenystagmus,pupillarydilatation,bradycardia,hypertensionandrespiratorydepression.Earlytonsillarherniationisdifficulttorecognizeinanunconsciouspatient.ItmaynotbeevidentonCTscansinceaxialviewscannotseethepathologywell.ItisbestseenonsagittalMRI.Clinicallychangesinvitalsignsmaybetheonlyclinicalclueinanunconsciouspatient.腦疝分類及影像學(xué)表現(xiàn)圖解Tonsillarherniation腦疝分類及影像學(xué)表現(xiàn)圖解amalepatientinhis30'swhodiedofbrainstemherniationaftercompletingamarathon.

TheCTshows(A)lossoftherostralcerebralsulcisuggestingincreaseinICP,(B)and(C)alargehydrocephaluswithwideningofbothtemporalhorns.Thegreymattercanstillbedifferentiatedfromthewhitematter,butallsulciarelost.Thissuggeststhatthebrainoedemaisofrelativerecentonsetandmassivetissueischaemiahasnotyetoccurred.(D)Compressionofthefourthventriclewithdilatationofthethirdventricleandthecaudalaspectofbothtemporalhorns.Thisisobservedwithconsiderablebrainoedemaandobstructivehydrocephalus.(E)Herniationofthemedullaandponsintotheforamenmagnum.(F)Thetonsilsarelocatedatthelevelofthedenswhichisagoodindicatorforforamenmagnumherniation.腦疝分類及影像學(xué)表現(xiàn)圖解(A)Thediscshowsfloridhemorrhageswithrelativelylittleswelling,indicatingarapid,dramaticincreaseinCSFpressure.Progressivechangesofopticdiscoedemaareseeninapatientwithanintracranialtumourwhodeclinedtreatment(B-D).(B)Earlynervefiberdilatationisseenparticularlysuperiorly,inferiorlyandnasally.(C)Thisincreasesandvenousengorgementdevelops.(D)Temporalnervefiberdilatationandswellingofthediscincreasesandhemorrhagesappear.(E)Ingrosschronicdiscoedemathenormalretinalvasculatureismaskedanddilatedsuperfic