第十八章

中樞神經系統影像學診斷

RadiologyofCentralNervousSystem河北醫科大學第三醫院HebeiMedicalUniversity3rdHospital

第十八章

中樞神經系統影像學診斷

Radiologyo1中樞神經系統腦脊髓中樞神經系統腦2檢查方法

Modalities頭顱MRI頭顱CTECT，emissioncomputedtomographySPECT,singlephotonemissioncomputedtomographyPET,positronemissiontomography腦血管造影,cerebralangiography經顱Doppler,transcranialdoppler，TCD頭顱平片,plainfilm最好的檢查方法，為首選Firstchoice檢查方法

Modalities頭顱MRI最好的檢查方法，為首3檢查方法Modalities顯示腦實質parenchymaMRI，MagneticResonanceImagingCT,ComputedTomography檢查方法Modalities顯示腦實質parenchym4檢查方法Modalities顯示腦實質ParenchymaMRI是顱腦最好的檢查方法firstchoice優點：advantage軟組織分辨率最高任意面成像，有利于觀察解剖關系檢查序列多T1WI,T2WI,PDWI等缺點：disadvantage鈣化、骨化、早期出血灶顯示不如CT價格貴檢查方法Modalities顯示腦實質Parenchym5檢查方法

Modalities顯示腦實質parenchymaCT是最常用的檢查方法優點顯示骨和鈣化一般比MRI好顯示早期出血比MRI好缺點對腦組織的分辨率不如MRI檢查方法

Modalities顯示腦實質parenchym6檢查方法Modalities顯示腦血管bloodvessel腦血管造影cerebralangiographyDSA，digitalsubstractiveangiographyMRA,magneticresonanceangiographyCTA,computedtomographyangiographyTCD,transcranialDoppler檢查方法Modalities顯示腦血管bloodves7DSAMRADSAMRA8TranscranialDoppler，TCDTranscranialDoppler，TCD9CTangiographyCTangiography10檢查方法顯示腦功能brainfunctionDWI,diffusionweightedimagingPWI,perfusionweightedimagingBOLD,bloodoxygenationleveldependentECT,emissioncomputedtomography檢查方法顯示腦功能brainfunction11DWIincerebralinfarctDWIincerebralinfarct12AbsoluteCBF(A)τD=timefortheloweredgeofthebolustoreachthetissue(B)Apatientwithrightcarotidocclusionandsmallrightsideinfarction(arrow)PerfusionImagingAbsoluteCBF(A)τD=timefor13BOLD

toshowthevisualcortexBOLD

toshowthevisualcorte14檢查方法顯示腦代謝brainmetabolismECTSPECTPETtracermostcommonis18FDG，analogueofglucoseMRS檢查方法顯示腦代謝brainmetabolism15SPECTSPECT16SinglepixelMRSSinglepixelMRS17正常影像解剖

normalimaginganatomy平片plainfilm正常影像解剖

normalimaginganatomy平18CT掃描技術及正常影像解剖

techniqueandnormalimaginganatomy以聽眥線為基線向上連續掃描9～12層層厚10mmCT掃描技術及正常影像解剖

techniqueandno19中樞神經系統影像學診斷課件20正常影像解剖

normalimaginganatomyMRI定位像(topography，scoutimage)正常影像解剖

normalimaginganatomyM21T1WIaxialT1WI22T2WIaxialT2WI23T1WIcoronalT2WIsagitalT1WIT2WI24基本病變表現

basicimagingsign顱骨平片顱骨破壞顱板增厚顱板變薄骨折線基本病變表現

basicimagingsign顱骨平片25depressedskullfracture

skulldestructionThinningztabledepressedskullfractureskull26ThicknessofskulltableThicknessofskulltable27基本病變表現

basicimagingsignCT平掃密度改變densitychanges占位效應masseffect,spaceoccupyingeffect腦水腫brainedema,cerebraledema腦積水hydrocephalus腦萎縮brainatrophy,cerebralatrophy病灶的強化表現featuresaftercontrastinject基本病變表現

basicimagingsignCT28基本病變表現

basicimagingsignCT平掃密度改變高密度灶：鈣化（腫瘤、血管畸形）、出血出血的演變低密度灶：壞死、水腫、液體、氣體和脂類等密度灶：腫瘤、出血某一階段混雜密度灶：多種成分病變，多見鈣化：正常生理鈣化、血管畸形、少枝膠質瘤等基本病變表現

basicimagingsignCT29等密度isodensity低密度水腫Lowdensity占位效應高密度Highdensity占位效應混雜密度mixeddensity鈣化calcification等密度高密度混雜密度鈣化calcification30占位效應spaceoccupyingeffect,masseffectCommondisease腫瘤tumor出血bleeding顯著腫脹edemamanifestation中線結構移位displacementofmidlinestructures腦室與腦池移位變形腦室、腦池擴大enlargementofventricleandcistern腦溝變化fuci腦體積的改變enlargementofbrainvolume占位效應spaceoccupyingeffect,ma31腦水腫

cerebraledema炎癥性水腫inflammatoryswelling感染infection出血bleeding挫傷contusion等血腦通透性增加increasingpermeabilityofBBB腫瘤tumor感染infection等腦水腫cerebraledema炎癥性水腫inflam32腦積水hydrocephalus原因etiology腦積液產生和吸收失衡腦脊液循環通路障礙所致腦室系統異常擴大類型type交通性腦積水communicativehydrocephalus阻塞性腦積水obstructivehydrocephalus代償性腦積水compensatoryhydrocephalus腦積水hydrocephalus原因etiology33梗阻性腦積水

正常腦壓性腦積水Normalpressurehydrocephalus梗阻性腦積水正常腦壓性腦積水34腦萎縮

cerebralatrophy描述description各種原因引起腦組織減少而繼發的腦室和蛛網膜下腔擴大分類type廣泛性diffuse局限性local皮質cortex白質whitematter腦萎縮cerebralatrophy描述descrip35增強掃描特征機制mechanism血腦屏障通透性增加異常血管增生引起血流量增加常見類型commontype均一強化：腦膜瘤、生殖細胞瘤等環狀強化：腦膿腫、腦轉移瘤、星形細胞瘤等斑狀強化：血管畸形、炎癥等不規則強化：惡性膠質瘤等等增強掃描特征機制mechanism36等密度，均勻強化Isodensity,homogeneousenhancement環形強化Ring-rimenhancement等密度，均勻強化環形強化37顱骨改變增厚thickness變薄thin破壞destruction增生proliferation顱骨改變增厚thickness38giantcellreparativegranulomatrauma顱骨破壞giantcellreparativegranulom39MRI基本病變表現

basicMRIsign與CT類似的表現thesimilarsignastoCT占位效應腦積水腦萎縮信號改變復雜，與CT密度改變不同長T1、長T2信號：腫瘤、腦梗死、炎癥等腦脊液信號：囊性變、囊腫（FLAIR序列變黑）短T1、長T2信號：脂肪、黑色素瘤等無信號：鈣化、晚期疤痕組織血管流空信號：多為無信號MRI基本病變表現

basicMRIsign與CT類似的40MRI基本病變表現水腫edemaT1WI為低信號lowsignalT2WI為略高信號slightlyhighintensity出血bleeding信號變化復雜thechangeofsignaliscomplexMRI基本病變表現水腫edema41長T1、長T2病灶，腫瘤水腫edema鈣化無信號囊性病灶cysticT2WI高信號長T1、長T2病灶，腫瘤水腫edema鈣化無信號囊性病灶42MRI基本病變表現增強環狀均勻不均勻腦回狀MRI基本病變表現增強43腦內血腫

(intracerebralhematoma)

CT分期staging急性期

acutestage＜1周高密度hyperdensity周圍水腫surroundingedema吸收期

absorptionstage2周～2個月始于3~7天，密度逐漸減低囊變期

cysticchangestage＞2個月水樣低密度water-likedensity腦內血腫

(intracerebralhematoma44MRI分期staging超急性期（Hyperacutehematoma）＜6小時T1WI等信號，T2WI為等信號急性期（Acutehematoma）7小時～3天T1WI呈等信號，血腫內緣可見低信號強度的硬膜，T2WI呈低信號亞急性期和慢性期（Subacutehematoma）3天～4周高信號(metahemoglobin)囊變期（Remotehematoma）≥4周液體信號周圍有低信號（hemosiderin)血腫影像學表現ImagingpresentationofhematomaMRI分期staging血腫影像學表現45TheevolutionofhematomaTheevolutionofhematoma46HyperacutehematomaCTT1WIT2WIHyperacutehematomaCT47CTT2WISubacutetochronichematomaAcutehematomaGRET1WICTT2WISubacutetochronichema48常見疾病診斷

commondiseaseofCNS腦外傷

traumaofbrain腦血管病

cerebraovasculardisease腦梗死cerebralinfarction腦出血cerebralhemorrhage腦腫瘤

cerebraltumor常見疾病診斷

commondiseaseofCNS腦外49腦外傷traumaofbrainCT為首選firstchoice顯示骨折、早期出血好方便快速多螺旋可快速形全身檢查MRI的適應癥indicationCT檢查陰性亞急性期慢性期平片已少用CT未普及的地區腦外傷traumaofbrainCT為首選first50腦外傷

traumaofbrain腦挫裂傷

cerebralcontusion腦內血腫

intracerebralhematoma硬膜下血腫

subduralhematoma硬膜外血腫

epiduralhematoma蛛網膜下腔出血

subarachnoidhemorrhage腦外傷

traumaofbrain腦挫裂傷cere51腦挫裂傷名詞的含義腦挫傷

cerebralcontusion腦內散在出血灶，靜脈淤血、腦血腫和腫脹腦裂傷

lacerationofbrain伴有腦膜、腦或血管撕裂發病部位location著力點附近coupsite著力點對沖部位contrecoup病理pathology腦水腫壞死液化散在小出血點腦挫裂傷名詞的含義52腦挫裂傷CT

低密度病灶內散在斑點狀高密度出血灶邊緣模糊ill-definedrim占位效應masseffectMRI腦水腫T1WI呈低或等信號T2WI高信號出血bleeding表現與血腫期齡有關腦挫裂傷CT53Thereisafocalareaofhaemorrhagiccontusionintherightfrontallobe,withsurroundinglowdensityduetoinfarctionoroedema.Thisisafrequentlocationforacontrecoupinjuryfollowingablowtothebackofthehead.Thereisafocalareaofhaemo54中樞神經系統影像學診斷課件55彌漫性軸索損傷

diffuseaxonalinjury,DAI其他名稱synonymy剪切傷shearinjury機制mechanism頭受到旋轉暴力致大腦繞中軸發生旋轉運動白質、灰白質交界區、胼胝體、腦干及小腦等受到剪切力損傷彌漫性軸索斷裂、點片狀出血和水腫臨床clinicalfeatures傷后意識立即喪失，多數立即死亡部分持續昏迷，后果嚴重彌漫性軸索損傷

diffuseaxonalinjury56彌漫性軸索損傷

diffuseaxonalinjuryThisimagedemonstratesasmallpetechialhaemorrhageinatypicallocationatthegrey-whitematterinterface(arrow).Asisoftenthecase,thereweremultiplesuchlesionsonotherslices彌漫性軸索損傷

diffuseaxonalinjury57硬膜下血腫

subduralhematoma出血部位location硬腦膜與蛛網膜之間發生率incidence顱腦外傷的5～6％臨床clinicalfeatures急性硬膜下血腫多與腦挫裂傷同時存在癥狀重慢性硬膜下血腫輕微頭痛有或無明確外傷史EpiduralspacesubiduralspaceDuralmatter硬膜下血腫

subduralhematoma出血部位lo58硬膜下血腫

subduralhematoma顱骨下方新月形高密度影占位效應等密度硬膜下血腫低密度硬膜下血腫硬膜下血腫

subduralhematoma顱骨下方新月形59硬膜外血腫epiduralhematoma部位location顱骨與硬膜之間發生率incidence占顱腦外傷的2～3％臨床clinicalfeatures急性：85％亞急性：12％慢性:少見硬膜外血腫epiduralhematoma部位loca60硬膜外血腫epiduralhematoma顱板下梭形或半圓形高密度影多位于骨折附近不跨越顱縫硬膜外血腫epiduralhematoma顱板下梭形或半61蛛網膜下腔出血

subarachnoidhemorrhage顱內血管破裂進入蛛網膜下腔病因etiology外傷trauma自發性spontaneously動脈瘤51％高血壓動脈硬化15％動靜脈畸形6%臨床clinicalfeatures好發年齡：30～40歲三聯征劇烈頭痛腦膜刺激征血性腦脊液蛛網膜下腔出血

subarachnoidhemorrhag62蛛網膜下腔出血

subarachnoidhemorrhage蛛網膜下腔出血

subarachnoidhemorrha63蛛網膜下腔出血蛛網膜下腔出血64腦血管病cerebrovasculardisease腦出血intracerebralhemorrhage腦梗死infarctofbrain動脈瘤aneurysm血管畸形vascularmalformation腦血管病cerebrovasculardisease腦出血65腦出血

intracranialhemorrhage病因etiology高血壓hypertensiveintracerebralhemorrhage

占40％動脈瘤破裂腦血管畸形出血出血性腦梗死外傷腦腫瘤血液病等

腦出血intracranialhemorrhage病因66高血壓性腦出血

hypertensive

intrcerebralhemorrhage機制微小動脈瘤破裂腦血管玻璃樣變好發部位predominatedlocation基底節、丘腦、腦橋和大腦半球白質內易破潰入腦室并發癥complications腦水腫腦組織受壓壞死高血壓性腦出血

hypertensiveintrcere67腦出血intracranialhemorrhage腦內血腫破入腦室破入蛛網膜下腔腦積水腦出血intracranialhemorrhage腦內血68腦梗死

cerebralinfarction原因etiology腦血栓形成

thrombosis腦栓塞

embolic血壓過低

lowbloodpressure發病率incidence為腦血管病首位腦梗塞？腦梗死

cerebralinfarction原因eti69腦梗死

cerebralinfarctionPathology缺血性腦梗死

ischemicinfarction出血性腦梗死

hemorrhageinfarction腔隙性腦梗死

lacunarinfarction好發于基底節區、腦干、小腦等病灶大小：5～15mm腦梗死

cerebralinfarctionPatholo70腦梗死CT低密度灶，其部位和范圍與閉塞血管供血區一致，可有占位效應2～3周時可出現“模糊效應（foggingeffect）”增強：腦回樣強化1～2個月形成邊界清楚的低密度囊腔腦梗死CT71腦梗死CT演變過程0～24hrnormalorsubtlehypodensity±sulcaeffacement1~7daysMasseffect(peakat3~4days)Daystomonths/yearsHypodensity1~8weeksContrastenhancementWeekstoyearsAtrophy腦梗死CT演變過程0～24hr72腦梗死MRI顯著優于CT急性期acutephase和超急性期superacutephaseDWI,PWI＜6hours傳統MRI，FLAIR＞8hours亞急性期subacutephase慢性期Chronicphase腦梗死MRI73T1WIT2WIFLAIRADCmapDWIMRAT1WI74MultiphasicperfusionCTobtained3hoursafterthesuddenonsetofrighthemiparesisandaphasiaina76-year-oldwoman.F:2daysfollow-upMultiphasicperfusionCTobtai75T1WIT2WIDWIMale,60yearsoldOnset6hoursT1WIT2WIDWIMale,60yearsold76血管畸形

vascularmalformation為胚胎期血管的發育異常，分為動靜脈畸形arteriovenousmalformation,AVM靜脈畸形venousmaformation毛細血管擴張癥capillarytelangiectasia海綿狀血管瘤

cavernoushemangioma等血管畸形

vascularmalformation為胚胎期77動靜脈畸形(AVM)CT不規則混雜密度灶鈣化斑點或弧線形強化無水腫和占位效應不敏感Male,65yr動靜脈畸形(AVM)CTMale,65yr78動靜脈畸形（AVM）MRI擴張流空的畸形血管團鄰近腦質：混雜低信號（hemosiderin）非常敏感Male,48yr動靜脈畸形（AVM）MRIMale,48yr79Male,48yrMale,48yr80海綿狀血管瘤cavernoushemangiomaM，31yr海綿狀血管瘤81顱內動脈瘤

intracranial

aneurysm描述為血管的局限性擴張病因先天性80％后天性20％常見年齡predominatedonsetage30～60yearsoldPredominatedlocationInternalcarotidartery90%Vertebralandbasilararterysystem10%并發癥蛛網膜下腔出血顱內動脈瘤

intracranialaneurysm描述82ThewhitearrowontheblackcardmarksthesiteofarupturedberryaneurysminthecircleofWillisThecircleofWillishasbeendissected,andthreeberryaneurysmsareseen.Thewhitearrowontheblackc83中樞神經系統影像學診斷課件84腦腫瘤Braintumor概況惡性膠質瘤glioma40～50％轉移瘤metastasis3.19~12.92%良性腦膜瘤meningioma15～20％垂體瘤pituitaryadenoma10%顱咽管瘤craniopharyngioma聽神經瘤acousticneurinoma腦腫瘤Braintumor概況85腦腫瘤Braintumor膠質瘤（glioma）星形細胞瘤astrocytoma40%少突膠質細胞瘤oligodendroglioma5~15%室管膜瘤ependymoma髓母細胞瘤medulloblastoma4~8%腦腫瘤Braintumor膠質瘤（glioma）86星形細胞瘤astrocytoma臨床clinicalfeatures局灶性或全身性癲癇發作為最重要表現神經功能障礙顱內壓增高星形細胞瘤astrocytoma臨床clinicalf87星形細胞瘤astrocytomaCTⅠ級低密度灶，分界清楚，占位效應輕，無或輕度強化Ⅱ～Ⅳ級高、低或混雜密度，可呈囊性斑點鈣化和瘤內出血形態不規則，邊界不清占位效應和瘤周水腫明顯不規則環形伴壁結節強化，或不均勻強化星形細胞瘤astrocytomaCT88中樞神經系統影像學診斷課件89星形細胞瘤MRIT1WI稍低或混雜信號T2WI均勻或不均勻性高信號惡性程度越高，其T1、T2值愈長，囊壁和壁結節強化越明顯星形細胞瘤MRI90局灶性彌漫型星形細胞瘤（WHO2級）局灶性彌漫型星形細胞瘤（WHO2級）91間變型星形細胞瘤（WHO3級）

F/68

平掃瘤體內低信號

及條狀高信號，累

及基底節及顳葉周

圍明顯水腫，增強

后明顯不均勻強化間變型星形細胞瘤（WHO3級）

F/68

平掃瘤體內低信號

92OligodendrogliomaMale,43yrOligodendrogliomaMale,43yr93腦膜瘤

meningiomasexpredomination,gender中年女性多見起源于originatedin蛛網膜粒帽細胞多居于腦外，與硬腦膜粘連好發部位location矢狀竇旁、腦凸面、蝶骨嵴、嗅溝、橋小腦角、大腦鐮或小腦幕等，與硬腦膜相鄰部位少數：腦室、眼眶腦膜瘤

meningiomasexpredominatio94腦膜瘤（meningioma）大體病理grasspathology腫瘤包膜完整，多由腦膜動脈供血，血運豐富，常有鈣化，少數有出血、壞死和囊變組織學分型histologictype上皮型纖維型過渡型砂礫型血管瘤型等15型腦膜瘤（meningioma）大體病理grasspath95腦膜瘤

meningiomaCT平掃plainscan等或略高密度常見斑點狀鈣化廣基底與硬腦膜相連邊界清楚可有瘤周水腫顱板：增生或破壞增強掃描enhancement均勻性顯著強化腦膜瘤

meningiomaCT96腦膜瘤

meningiomaMRI平掃T1WI等或稍低信號T2WI等或高信號邊緣清楚與正常腦組織間有時有腦脊液影增強掃描明顯均勻強化腦膜尾癥duraltailsign腦膜瘤

meningiomaMRI97女653月前出現反應遲鈍，記憶力下降，左下肢無力CTplainscanT2WIT1WIT1WIenhancement女65CTplainscanT2WIT1WIT1WIe98Femal,61yr右下肢無力2年，加重2月腦膜瘤侵犯顱骨Femal,61yr腦膜瘤侵犯顱骨99中樞神經系統影像學診斷課件100中樞神經系統影像學診斷課件101轉移瘤

metastasis易發人群predominatedpopulation中老年人易發病部位location頂枕區皮髓質交界處原發灶primarylesionlung,breast,prostate,kidney,andsoon轉移瘤

metastasis易發人群predominate102MetastasisofBrainCT表現多發或單發結節multiplorsinglenodule等或低密度isodensityorlowdensity出血時：高密度hyperdensity瘤周水腫surroundingedema結節或環形強化nodularorringenhancementMRI長T1、長T2信號MetastasisofBrainCT表現103增強容易發現轉移瘤！增強容易發現轉移瘤！104垂體腺瘤（pituitaryadenoma）功能性腺瘤泌乳素、生長激素、性激素和促腎上腺皮質激素瘤非功能性腺瘤微腺瘤：直徑＜10mm病理包膜完整較大可壞死、囊變、出血，偶可鈣化向四周侵犯臨床：壓迫癥狀:視力障礙、垂體功能低下、陽痿、頭痛等內分泌癥狀：泌乳素、生長激素、促腎上腺皮質激素等垂體腺瘤（pituitaryadenoma）功能性腺瘤105垂體腺瘤(pituitaryadenoma)影像表現MRI為首選檢查方法垂體向周圍彭隆，特別向上彭隆垂體柄移位增強多均勻強化少數中心壞死CT必須增強掃描垂體腺瘤(pituitaryadenoma)影像表現106中樞神經系統影像學診斷課件107PituitaryglandtumorMale,41yrPituitaryglandtumor108ThankYou

2006年11月1日青島ThankYou

2006年11月1日青島109ThankYou青島八大關秋色ThankYou青島八大關秋色110DSADSA111CranialMetastasisofHepatocellularCarcinomaHydatidcystofthebrain

CranialMetastasisofHydatid112

第十八章

中樞神經系統影像學診斷

RadiologyofCentralNervousSystem河北醫科大學第三醫院HebeiMedicalUniversity3rdHospital

第十八章

中樞神經系統影像學診斷

Radiologyo113中樞神經系統腦脊髓中樞神經系統腦114檢查方法

Modalities頭顱MRI頭顱CTECT，emissioncomputedtomographySPECT,singlephotonemissioncomputedtomographyPET,positronemissiontomography腦血管造影,cerebralangiography經顱Doppler,transcranialdoppler，TCD頭顱平片,plainfilm最好的檢查方法，為首選Firstchoice檢查方法

Modalities頭顱MRI最好的檢查方法，為首115檢查方法Modalities顯示腦實質parenchymaMRI，MagneticResonanceImagingCT,ComputedTomography檢查方法Modalities顯示腦實質parenchym116檢查方法Modalities顯示腦實質ParenchymaMRI是顱腦最好的檢查方法firstchoice優點：advantage軟組織分辨率最高任意面成像，有利于觀察解剖關系檢查序列多T1WI,T2WI,PDWI等缺點：disadvantage鈣化、骨化、早期出血灶顯示不如CT價格貴檢查方法Modalities顯示腦實質Parenchym117檢查方法

Modalities顯示腦實質parenchymaCT是最常用的檢查方法優點顯示骨和鈣化一般比MRI好顯示早期出血比MRI好缺點對腦組織的分辨率不如MRI檢查方法

Modalities顯示腦實質parenchym118檢查方法Modalities顯示腦血管bloodvessel腦血管造影cerebralangiographyDSA，digitalsubstractiveangiographyMRA,magneticresonanceangiographyCTA,computedtomographyangiographyTCD,transcranialDoppler檢查方法Modalities顯示腦血管bloodves119DSAMRADSAMRA120TranscranialDoppler，TCDTranscranialDoppler，TCD121CTangiographyCTangiography122檢查方法顯示腦功能brainfunctionDWI,diffusionweightedimagingPWI,perfusionweightedimagingBOLD,bloodoxygenationleveldependentECT,emissioncomputedtomography檢查方法顯示腦功能brainfunction123DWIincerebralinfarctDWIincerebralinfarct124AbsoluteCBF(A)τD=timefortheloweredgeofthebolustoreachthetissue(B)Apatientwithrightcarotidocclusionandsmallrightsideinfarction(arrow)PerfusionImagingAbsoluteCBF(A)τD=timefor125BOLD

toshowthevisualcortexBOLD

toshowthevisualcorte126檢查方法顯示腦代謝brainmetabolismECTSPECTPETtracermostcommonis18FDG，analogueofglucoseMRS檢查方法顯示腦代謝brainmetabolism127SPECTSPECT128SinglepixelMRSSinglepixelMRS129正常影像解剖

normalimaginganatomy平片plainfilm正常影像解剖

normalimaginganatomy平130CT掃描技術及正常影像解剖

techniqueandnormalimaginganatomy以聽眥線為基線向上連續掃描9～12層層厚10mmCT掃描技術及正常影像解剖

techniqueandno131中樞神經系統影像學診斷課件132正常影像解剖

normalimaginganatomyMRI定位像(topography，scoutimage)正常影像解剖

normalimaginganatomyM133T1WIaxialT1WI134T2WIaxialT2WI135T1WIcoronalT2WIsagitalT1WIT2WI136基本病變表現

basicimagingsign顱骨平片顱骨破壞顱板增厚顱板變薄骨折線基本病變表現

basicimagingsign顱骨平片137depressedskullfracture

skulldestructionThinningztabledepressedskullfractureskull138ThicknessofskulltableThicknessofskulltable139基本病變表現

basicimagingsignCT平掃密度改變densitychanges占位效應masseffect,spaceoccupyingeffect腦水腫brainedema,cerebraledema腦積水hydrocephalus腦萎縮brainatrophy,cerebralatrophy病灶的強化表現featuresaftercontrastinject基本病變表現

basicimagingsignCT140基本病變表現

basicimagingsignCT平掃密度改變高密度灶：鈣化（腫瘤、血管畸形）、出血出血的演變低密度灶：壞死、水腫、液體、氣體和脂類等密度灶：腫瘤、出血某一階段混雜密度灶：多種成分病變，多見鈣化：正常生理鈣化、血管畸形、少枝膠質瘤等基本病變表現

basicimagingsignCT141等密度isodensity低密度水腫Lowdensity占位效應高密度Highdensity占位效應混雜密度mixeddensity鈣化calcification等密度高密度混雜密度鈣化calcification142占位效應spaceoccupyingeffect,masseffectCommondisease腫瘤tumor出血bleeding顯著腫脹edemamanifestation中線結構移位displacementofmidlinestructures腦室與腦池移位變形腦室、腦池擴大enlargementofventricleandcistern腦溝變化fuci腦體積的改變enlargementofbrainvolume占位效應spaceoccupyingeffect,ma143腦水腫

cerebraledema炎癥性水腫inflammatoryswelling感染infection出血bleeding挫傷contusion等血腦通透性增加increasingpermeabilityofBBB腫瘤tumor感染infection等腦水腫cerebraledema炎癥性水腫inflam144腦積水hydrocephalus原因etiology腦積液產生和吸收失衡腦脊液循環通路障礙所致腦室系統異常擴大類型type交通性腦積水communicativehydrocephalus阻塞性腦積水obstructivehydrocephalus代償性腦積水compensatoryhydrocephalus腦積水hydrocephalus原因etiology145梗阻性腦積水

正常腦壓性腦積水Normalpressurehydrocephalus梗阻性腦積水正常腦壓性腦積水146腦萎縮

cerebralatrophy描述description各種原因引起腦組織減少而繼發的腦室和蛛網膜下腔擴大分類type廣泛性diffuse局限性local皮質cortex白質whitematter腦萎縮cerebralatrophy描述descrip147增強掃描特征機制mechanism血腦屏障通透性增加異常血管增生引起血流量增加常見類型commontype均一強化：腦膜瘤、生殖細胞瘤等環狀強化：腦膿腫、腦轉移瘤、星形細胞瘤等斑狀強化：血管畸形、炎癥等不規則強化：惡性膠質瘤等等增強掃描特征機制mechanism148等密度，均勻強化Isodensity,homogeneousenhancement環形強化Ring-rimenhancement等密度，均勻強化環形強化149顱骨改變增厚thickness變薄thin破壞destruction增生proliferation顱骨改變增厚thickness150giantcellreparativegranulomatrauma顱骨破壞giantcellreparativegranulom151MRI基本病變表現

basicMRIsign與CT類似的表現thesimilarsignastoCT占位效應腦積水腦萎縮信號改變復雜，與CT密度改變不同長T1、長T2信號：腫瘤、腦梗死、炎癥等腦脊液信號：囊性變、囊腫（FLAIR序列變黑）短T1、長T2信號：脂肪、黑色素瘤等無信號：鈣化、晚期疤痕組織血管流空信號：多為無信號MRI基本病變表現

basicMRIsign與CT類似的152MRI基本病變表現水腫edemaT1WI為低信號lowsignalT2WI為略高信號slightlyhighintensity出血bleeding信號變化復雜thechangeofsignaliscomplexMRI基本病變表現水腫edema153長T1、長T2病灶，腫瘤水腫edema鈣化無信號囊性病灶cysticT2WI高信號長T1、長T2病灶，腫瘤水腫edema鈣化無信號囊性病灶154MRI基本病變表現增強環狀均勻不均勻腦回狀MRI基本病變表現增強155腦內血腫

(intracerebralhematoma)

CT分期staging急性期

acutestage＜1周高密度hyperdensity周圍水腫surroundingedema吸收期

absorptionstage2周～2個月始于3~7天，密度逐漸減低囊變期

cysticchangestage＞2個月水樣低密度water-likedensity腦內血腫

(intracerebralhematoma156MRI分期staging超急性期（Hyperacutehematoma）＜6小時T1WI等信號，T2WI為等信號急性期（Acutehematoma）7小時～3天T1WI呈等信號，血腫內緣可見低信號強度的硬膜，T2WI呈低信號亞急性期和慢性期（Subacutehematoma）3天～4周高信號(metahemoglobin)囊變期（Remotehematoma）≥4周液體信號周圍有低信號（hemosiderin)血腫影像學表現ImagingpresentationofhematomaMRI分期staging血腫影像學表現157TheevolutionofhematomaTheevolutionofhematoma158HyperacutehematomaCTT1WIT2WIHyperacutehematomaCT159CTT2WISubacutetochronichematomaAcutehematomaGRET1WICTT2WISubacutetochronichema160常見疾病診斷

commondiseaseofCNS腦外傷

traumaofbrain腦血管病

cerebraovasculardisease腦梗死cerebralinfarction腦出血cerebralhemorrhage腦腫瘤

cerebraltumor常見疾病診斷

commondiseaseofCNS腦外161腦外傷traumaofbrainCT為首選firstchoice顯示骨折、早期出血好方便快速多螺旋可快速形全身檢查MRI的適應癥indicationCT檢查陰性亞急性期慢性期平片已少用CT未普及的地區腦外傷traumaofbrainCT為首選first162腦外傷

traumaofbrain腦挫裂傷

cerebralcontusion腦內血腫

intracerebralhematoma硬膜下血腫

subduralhematoma硬膜外血腫

epiduralhematoma蛛網膜下腔出血

subarachnoidhemorrhage腦外傷

traumaofbrain腦挫裂傷cere163腦挫裂傷名詞的含義腦挫傷

cerebralcontusion腦內散在出血灶，靜脈淤血、腦血腫和腫脹腦裂傷

lacerationofbrain伴有腦膜、腦或血管撕裂發病部位location著力點附近coupsite著力點對沖部位contrecoup病理pathology腦水腫壞死液化散在小出血點腦挫裂傷名詞的含義164腦挫裂傷CT

低密度病灶內散在斑點狀高密度出血灶邊緣模糊ill-definedrim占位效應masseffectMRI腦水腫T1WI呈低或等信號T2WI高信號出血bleeding表現與血腫期齡有關腦挫裂傷CT165Thereisafocalareaofhaemorrhagiccontusionintherightfrontallobe,withsurroundinglowdensityduetoinfarctionoroedema.Thisisafrequentlocationforacontrecoupinjuryfollowingablowtothebackofthehead.Thereisafocalareaofhaemo166中樞神經系統影像學診斷課件167彌漫性軸索損傷

diffuseaxonalinjury,DAI其他名稱synonymy剪切傷shearinjury機制mechanism頭受到旋轉暴力致大腦繞中軸發生旋轉運動白質、灰白質交界區、胼胝體、腦干及小腦等受到剪切力損傷彌漫性軸索斷裂、點片狀出血和水腫臨床clinicalfeatures傷后意識立即喪失，多數立即死亡部分持續昏迷，后果嚴重彌漫性軸索損傷

diffuseaxonalinjury168彌漫性軸索損傷

diffuseaxonalinjuryThisimagedemonstratesasmallpetechialhaemorrhageinatypicallocationatthegrey-whitematterinterface(arrow).Asisoftenthecase,thereweremultiplesuchlesionsonotherslices彌漫性軸索損傷

diffuseaxonalinjury169硬膜下血腫

subduralhematoma出血部位location硬腦膜與蛛網膜之間發生率incidence顱腦外傷的5～6％臨床clinicalfeatures急性硬膜下血腫多與腦挫裂傷同時存在癥狀重慢性硬膜下血腫輕微頭痛有或無明確外傷史EpiduralspacesubiduralspaceDuralmatter硬膜下血腫

subduralhematoma出血部位lo170硬膜下血腫

subduralhematoma顱骨下方新月形高密度影占位效應等密度硬膜下血腫低密度硬膜下血腫硬膜下血腫

subduralhematoma顱骨下方新月形171硬膜外血腫epiduralhematoma部位location顱骨與硬膜之間發生率incidence占顱腦外傷的2～3％臨床clinicalfeatures急性：85％亞急性：12％慢性:少見硬膜外血腫epiduralhematoma部位loca172硬膜外血腫epiduralhematoma顱板下梭形或半圓形高密度影多位于骨折附近不跨越顱縫硬膜外血腫epiduralhematoma顱板下梭形或半173蛛網膜下腔出血

subarachnoidhemorrhage顱內血管破裂進入蛛網膜下腔病因etiology外傷trauma自發性spontaneously動脈瘤51％高血壓動脈硬化15％動靜脈畸形6%臨床clinicalfeatures好發年齡：30～40歲三聯征劇烈頭痛腦膜刺激征血性腦脊液蛛網膜下腔出血

subarachnoidhemorrhag174蛛網膜下腔出血

subarachnoidhemorrhage蛛網膜下腔出血

subarachnoidhemorrha175蛛網膜下腔出血蛛網膜下腔出血176腦血管病cerebrovasculardisease腦出血intracerebralhemorrhage腦梗死infarctofbrain動脈瘤aneurysm血管畸形vascularmalformation腦血管病cerebrovasculardisease腦出血177腦出血

intracranialhemorrhage病因etiology高血壓hypertensiveintracerebralhemorrhage

占40％動脈瘤破裂腦血管畸形出血出血性腦梗死外傷腦腫瘤血液病等

腦出血intracranialhemorrhage病因178高血壓性腦出血

hypertensive

intrcerebralhemorrhage機制微小動脈瘤破裂腦血管玻璃樣變好發部位predominatedlocation基底節、丘腦、腦橋和大腦半球白質內易破潰入腦室并發癥complications腦水腫腦組織受壓壞死高血壓性腦出血

hypertensiveintrcere179腦出血intracranialhemorrhage腦內血腫破入腦室破入蛛網膜下腔腦積水腦出血intracranialhemorrhage腦內血180腦梗死

cerebralinfarction原因etiology腦血栓形成

thrombosis腦栓塞

embolic血壓過低

lowbloodpressure發病率incidence為腦血管病首位腦梗塞？腦梗死

cerebralinfarction原因eti181腦梗死

cerebralinfarctionPathology缺血性腦梗死

ischemicinfarction出血性腦梗死

hemorrhageinfarction腔隙性腦梗死

lacunarinfarction好發于基底節區、腦干、小腦等病灶大小：5～15mm腦梗死

cerebralinfarctionPatholo182腦梗死CT低密度灶，其部位和范圍與閉塞血管供血區一致，可有占位效應2～3周時可出現“模糊效應（foggingeffect）”增強：腦回樣強化1～2個月形成邊界清楚的低密度囊腔腦梗死CT183腦梗死CT演變過程0～24hrnormalorsubtlehypodensity±sulcaeffacement1~7daysMasseffect(peakat3~4days)Daystomonths/yearsHypodensity1~8weeksContrastenhancementWeekstoyearsAtrophy腦梗死CT演變過程0～24hr184腦梗死MRI顯著優于CT急性期acutephase和超急性期superacutephaseDWI,PWI＜6hours傳統MRI，FLAIR＞8hours亞急性期subacutephase慢性期Chronicphase腦梗死MRI185T1WIT2WIFLAIRADCmapDWIMRAT1WI186MultiphasicperfusionCTobtained3hoursafterthesuddenonsetofrighthemiparesisandaphasiaina76-year-oldwoman.F:2daysfollow-upMultiphasicperfusionCTobtai187T1WIT2WIDWIMale,60yearsoldOnset6hoursT1WIT2WIDWIMale,60yearsold188血管畸形

vascularmalformation為胚胎期血管的發育異常，分為動靜脈畸形arteriovenousmalformation,AVM靜脈畸形venousmaformation毛細血管擴張癥capillarytelangiectasia海綿狀血管瘤

cavernoushemangioma等血管畸形

vascularmalformation為胚胎期189動靜脈畸形(AVM)CT不規則混雜密度灶鈣化斑點或弧線形強化無水腫和占位效應不敏感Male,65yr動靜脈畸形(AVM)CTMale,65yr190動靜脈畸形（AVM）MRI擴張流空的畸形血管團鄰近腦質：混雜低信號（hemosiderin）非常敏感Male,48yr動靜脈畸形（AVM）MRIMale,48yr191Male,48yrMale,48yr192海綿狀血管瘤cavernoushemangiomaM，31yr海綿狀血管瘤193顱內動脈瘤

intracranial

aneurysm描述為血管的局限性擴張病因先天性80％后天性20％常見年齡predominatedonsetage30～60yearsoldPredominatedlocationInternalcarotidartery90%Vertebralandbasilararterysystem10%并發癥蛛網膜下腔出血顱內動脈瘤

intracranialaneurysm描述194ThewhitearrowontheblackcardmarksthesiteofarupturedberryaneurysminthecircleofWillisThecircleofWillishasbeendissected,andthreeberryaneurysmsareseen.Thewhitearrowontheblackc195中樞神經系統影像學診斷課件196腦腫瘤Braintumor概況惡性膠質瘤glioma