中枢外伤教材讲义

CentralNervousSystem

南京医科大学一附院放射科洪汛宁hongxunning@2/3/20231ClassificationofHeadInjuryExtracerebrallesions:

Subdural

hematomaSubduraleffusionEpiduralhematomaIntracerebrallesions:Braincontusion(edema,

hemorrhage..)

Subarachnoidhemorrhage

(SAH)

Intraventricularhemorrhage

(IVH)Opencranialinjury.

Skullfracture

Pneumoencephalus2/3/20232颅脑外伤braintrauma硬膜外血肿(epiduralhematoma)硬膜下血肿（subdural

hematoma）脑挫裂伤（lacerationandcontusionofbrain）蛛网膜下腔出血Subarachnoid

haemorrhage2/3/20233硬膜外血肿

(extradural

hematoma)

Thesearisebetweentheinnertableoftheskullandthedura.Theyusuallydevelopfrominjurytothemiddlemeningealarteryoroneofitsbranches,andthereforeareusuallytemporoparietalinlocation.Atemporalbonefractureisoftenthecause,butisnotessential.Theexpandinghaematomastripsthedurafromtheskull;thisattachmentisquitestrongsuchthatthehaematomaisconfined,givingrisetoitscharacteristicbiconvexshape,withawelldefinedmargin.2/3/20234CT征象：颅板内侧梭形(双凸透镜)高密度影(与脑实质比)，CT值50~90Hu；(范围小而厚)密度一般较均匀边缘清楚、光滑锐利局部常见脑水肿征局部蛛网膜下腔常见出血征局部有颅骨骨折征具有占位征：局部脑回受压内移，中线结构向对侧移位2/3/20235

biconvexshape,withawelldefinedmargin.2/3/202362/3/20237血块内含较灰区(箭)，

代表正在出血中，有未凝结的血块EDH：纺垂型，高浓度血块头皮肿(箭)，撞击处2/3/20238硬膜外血肿MRI平扫、Gd-DTPA增强2/3/20239硬膜下血肿

（subdural

hematoma）Thesearisebetweentheduraandarachnoid,oftenfromrupturedveinscrossingthispotentialspace.Thespaceenlargesasthebrainatrophiesandsosubdural

haematomasaremorecommonintheelderly.2/3/202310CT征象颅内板内侧新月状(或带状)高密度影(与脑实质比)，CT值50~90Hu，范围广而薄密度一般较均匀边界清楚，但不光滑锐利局部可有或无脑水肿局部可有或无蛛网膜下腔出血局部一般无颅骨骨折，常为对冲伤出血较多时具有占位效应，局部脑实质受压内移，中线结构向对侧移位2/3/202311

thecrescentichighdensitycollectiontypicalofaacutesubdural

haematoma,withassociatedmidlineshift.

2/3/202312急性硬膜下血肿（SDH）SDH：新月型(A.B)SDH可能在大脑镰内(C)。SDH也可在幕下(D)(不要误为脑內出血)ABCD2/3/202313A.SDH，明显占位效应B.术后，占位效应消失AcutesubduralhematomawithmasseffectAB2/3/202314等密度PlainCTIVcontrast2/3/2023152/3/20231620080209术后200802192/3/202317同一个病人，200807282/3/202318Notethecrescenticlowdensitycollectiontypicalofachronicsubdural

haematoma,withassociatedmidlineshift.2/3/202319subdural

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

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

CT

低密度水肿区,散在高密度出血灶,伴有占位效应。有的表现为广泛的脑水肿或脑内血肿MR

脑水肿T1WI呈等低信号,T2WI高信号;脑血肿T1WI,T2WI均呈高信号2/3/202322Thereisafocalareaofhaemorrhagiccontusionintherightfrontallobe,withsurroundinglowdensityduetoinfarctionoroedema.Thisisafrequentlocationforacontre-coupinjuryfollowingablowtothebackofthehead.2/3/202323出血、异物、气颅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小时随访脑外伤后2/3/202328HeadinjurywithEDHanddelayedcontusionhemorrhages6月22日6月20日2/3/202329ContusionhemorrhagesandSAHA.9月29日

B.9月30日延迟性出血在脑挫伤极常见。脑挫伤：小血块及脑水肿混杂在一起

AB2/3/202330Vaultfractures2/3/202331颅脑外伤后遗症1.脑萎缩2.交通性脑积水，多由于蛛血、脑室内出血3.脑软化或脑穿通性囊肿，多由于脑挫伤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