中枢神经系统影像课件

中枢神经系统影像学表现

Neuroimaging

of

theCentralNervousSystem

学习内容：颅脑、脊髓、血管1.不同成像技术的特点和临床应用2.正常影像学表现3.基本病变影像学表现4.影像新技术不同成像技术的特点和临床应用1.X线图像的特点2.CT图像的特点3.MR图像的特点4.DSA检查正常影像学表现颅脑头颅X线平片

颅骨最基本的影像学检查方法显示颅骨骨质改变，是诊断颅骨骨折和骨缝分离的有效方法特点局限性

仅提示病变存在，但不能确诊临床表现明显但无异常发现计算机体层摄影（CT）

CT图像的特点局限性

断层图像不利于器官结构和病灶的整体显示

CT检查对疾病的定性诊断仍有一定限度

CT检查使用X线，具有辐射性损伤

是目前常用的影像学检查方法常规CT图像采用横断层图像，克服了普通X线检查各种组织结构重叠干扰的影响分辨率高，对比度强大脑：额叶颞叶顶叶枕叶

基底节丘脑幕上

小脑：半球、蚓部脑干：中脑延髓桥脑幕下

脑实质双侧脑室第三脑室第四脑室脑室系统

鞍上池环池桥小脑池枕大池外侧裂池大脑纵裂池脑池系统脑室脑池系统磁共振成像（MRI）优势：

组织分辨率高任意平面成像多种参数、序列成像

缺点：

扫描时间长

MRI对钙化不敏感个别患者有幽闭恐惧症，MRI检查有禁忌症

X－Plain

颅高压征：颅缝增宽，脑回压迹增深颅骨：破坏，增生蝶鞍：扩大、吸收、变形钙化：DSA颅内占位使血管移位脑血管形态改变计算机体层摄影（CT）密度异常:低密度、等密度、高密度、混杂密度增强特征:不强化、轻中度强化、明显强化脑结构改变:占位效应脑萎缩脑水肿、脑积水颅骨改变：骨质破坏、增生、吸收、骨折1）低密度病变：2）等密度病变：3)高密度病变4)混杂密度病变脑水肿脑梗塞、脑软化脑肿瘤炎性病变慢性血肿脑肿瘤脑梗塞的等密度期颅内血肿的等密度期

(亚急性出血)颅内血肿钙化肿瘤炎性肉芽肿脑肿瘤（颅咽管瘤、恶性胶质瘤、畸胎瘤）出血性脑梗塞炎性病变1）低密度病变：脑水肿脑梗塞、脑软化脑肿瘤炎性病变慢性血肿颅内疾病的平扫基本CT征象2）等密度病变：脑肿瘤脑梗塞的等密度期颅内血肿的等密度期

(亚急性出血)颅内疾病的平扫基本CT征象4)混杂密度病变脑肿瘤（颅咽管瘤、恶性胶质瘤、畸胎瘤）出血性脑梗塞炎性病变颅内疾病的平扫基本CT征象磁共振成像（MRI）MRI通过磁共振信号的变化反应信息人体不同器官的正常组织与病理组织的T1和T2是相对恒定的，而且它们之间有一定的差别，这种组织间驰豫时间上的差别，是MRI成像基础基本病变信号特征T1WI

T2WI肿块依据肿块内部成分不同信号不一囊肿低信号高信号水肿低信号高信号

出血急性3天内等,略低亚急性3d-2w周围高向中部推进慢性2w以上高信号,环周含铁血黄素低信号环梗死略低/低信号高信号增强检查CT:对比剂:含碘非离子型造影剂剂量:50-100ml注射速率：1-2ml/sec注射方式:人工手推或高压器注射MRI:对比剂:顺磁性造影剂：Gd-DTPA剂量:15-30ml注射速率：

1-2ml/sec注射方式:人工手推或高压器注射脊髓和椎管内病变脊髓检查方法以矢状面为主，辅以横断面和冠状面，确定病变的三维关系，方法有平扫和增强扫描影像观察与分析

正常脊髓灰质、白质与脑脊液信号特点与颅内脑实质与脑脊液信号一致

脊髓基本病变脊髓外形异常：脊髓增粗、萎缩脊髓密度（信号）异常：局限性、弥漫性蛛网膜下腔形态异常：

可分为出血性和非出血性损伤，MRI可直观地显示脊髓损伤的部位、范围、类型和程度

脊髓水肿：T1WI等、低信号，T2WI高信号出血：T1WI和T2WI均为高信号

脊髓软化、囊变、空洞：

T1WI低信号，T2WI高信号

脊髓萎缩：脊髓变细

脊髓损伤

脑血管成像(Cerebralvascularangiography)

DSA(digitalsubstractionangiography)CTA(computedtomographyangiography)MRA(magneticresonanceangiography)DSA(数字减影血管造影)

颈内动脉、椎动脉、颈外动脉血管显示

Vertebrobasilarartery(VA)椎基动脉

Internalcarotidartery(ICA)颈内动脉

Extenalcorotidartery(ECA)颈外动脉

Willis环:大脑前动脉,大脑后动脉,前后交动脉,

颈内动脉末端诊断动脉瘤、动静脉畸形、肿瘤血供Vertebrobasilarartery(VA)椎基动脉

Internalcarotidartery(ICA)颈内动脉

Extenalcorotidartery(ECA)颈外动脉

Willis环:大脑前动脉,大脑后动脉,前后交通动脉,颈内动脉末端

Advantageof64sliceVCT：CTADiseasesofCNSVasculardiseases血管病变：hemorrhage,infarct(ischemicinfarct,hemorrhagicinfarct,lacunarinfarct)Infectiousdiseases

感染性病变VascularMalformality血管畸形Vasculardiseases

血管疾病AcuteIntracerebralHemorrhage

急性脑出血

临床表现Clinicalfindings:

Hypertension,Vascularmalformation,Aneurysm,Hematopathy,Tumor影像学表现ImagingfindingsCT:Location,Density,SecondarysignsMR:Location,Signal,Secondarysigns鉴别诊断DifferentialDiagnosisEvolutionofHematomaonCT血肿在CT上的演变Acutehematoma:4hrsafterictus急性脑血肿：发病后4小时4daysafterictus发病后4天3monthsafterinitialCT首次CT后3个月EvolutionofHematomaonCT血肿在CT上的演变10405060708020301234567891011121314ISODENSEHYPERDENSEHYPODENSEDecreasingDensityofHematoma血肿密度的下降DensityComparedtoCortexTimeinDaysIntracerebralHemorrhageImagingfindingsCT:1)Location:高血压性脑出血基底节区多见2)Density:急性期高密度，随时间推移密度渐减低3)Secondarysigns：占位效应明显，可破入脑室、蛛网膜下腔，继发阻塞性脑积水MRI：不同的出血时间信号不同，反映血肿内血红蛋白、氧合血红蛋白、脱氧血红蛋白、正铁血红蛋白、含铁血黄素的演变过程超急性期（≦6h):氧合血红蛋白（T1WI等，T2WI高信号）急性期（7-72h）：脱氧血红蛋白（T1WI等或略低，T2WI低信号）亚急性期（3d-2W）:正铁血经蛋白（T1WI高信号，T2WI高信号）慢性期（2W后）：含铁血黄素（T1WI低，T2WI低信号）BloodProducts血肿

AcutehematomawellseenonCT急性血肿宜用CT观察

Subacuteandchronichematomabetter evaluatedonMRI亚急性和慢性血肿宜用MRI观察Primary(hypertensive)bleedsoccurinthebasalganglia;forbleedsatotherlocations,huntforacause高血压出血常在基底节；其它部位的话要寻找病因BrainInfarction

脑梗塞临床表现Clinicalfindings:

Thrombosis,Embolism,Hypotension,Highpour-pointstate影像学表现ImagingfindingsCT

MR:Ischemicinfarct;Hemorrhagicinfarct;Lacunarinfarct鉴别诊断DifferentialDiagnosis左侧大脑前动脉闭塞致左侧额上回脑梗塞：CT平扫示左侧额上回长条状低密度区（↑），边界较清，轻度占位表现

左侧枕叶大脑后动脉梗塞：CT平扫示左侧枕叶低密度区，未见明显占位表现

左侧大脑中动脉梗塞：CT平扫示左颞顶叶大片低密度区，边界清晰，密度与脑脊液相似，左侧脑室扩大，中线结构无移位。

右侧额后顶前出血性脑梗塞：CT平扫示右额顶叶大片低密度区内散在不规则高密度出血灶

Foggingeffect模糊效应:缺血性脑梗塞2-3周时病灶变为等密度而不可见Lacunarbraininfarction腔隙性脑梗塞：深部髓质小动脉闭塞所致，大小约10-15mm，好发于基底节、丘脑、小脑和脑干。Hemorrhagictransformationafterinfarction出血性脑梗塞：CT示在低密度脑梗塞灶内，出现不规则斑点、片状高密度出血灶。CerebralinfarctionimagingfindingsCT:24h内，CT可无阳性发现，或显示脑沟回模糊；动脉致密征；岛带征。24h后，与闭塞血管供血区一致，同时累及皮层和髓质，呈底在外的三角形或楔形低密度，边缘不清，常并发脑水肿，病灶大时可出现轻度占位效应。4-6周，边缘清楚、近于脑脊液密度的囊腔,1个月后可出现脑萎缩。出血性脑梗塞：扇形低密度梗塞区内出现不规则高密度出血斑。腔隙性梗塞：好发于基底节区，因小的终末动脉闭塞所致，表现为直径小于15mm低密度灶，边缘清楚。MRI：较早发现病变Subcorticalarterioscleroticencephalopathy

Bingswanger’sdisease

皮层下动脉硬化性脑病临床表现Clinicalfindings影像学表现ImagingfindingsCTMR鉴别诊断DifferentialDiagnosisInfectiousdiseases

感染性疾病Pathogens:Bacterium,Virus,Fungi,ParasitePathology:Meningitis,Encephalitis,VeininflammationBrainabscess

脑脓肿临床表现Clinicalfindings:Otogenic,Blood-borne,Traumatic,Cryptogenic影像学表现ImagingfindingsCT

MR鉴别诊断DifferentialDiagnosisBrainabscessImagingfindingonCTCT1、急性炎症期：平扫大片低密度灶，边界模糊，伴占位效应，增强无强化2、化脓坏死期：平扫低密度区内出现更低密度坏死灶，增强呈不均匀强化3、脓肿形成期：平扫见等密度环，内为低密度脓肿并可有气泡影；增强呈环形强化，其壁完整、光滑、均匀，或多房分隔BrainabscessImagingfindingonMRMR1、脓腔呈长T1和长T2异常信号2、增强呈薄壁环形强化，内外壁光滑Tuberculosis,CNS临床表现Clinicalfindings影像学表现ImagingfindingsCTMR鉴别诊断DifferentialDiagnosisTuberculousmeningistisandencephalitisImagingfindingsCT平扫：1、早期无异常发现2、脑底池炎性渗出表现为脑底池密度升高3、脑内结核：脑内以基底节区多见呈低或等密度灶4、脑积水增强：脑膜增厚强化，结核球呈结节状或环形强化TuberculousmeningistisandencephalitisImagingfindingsMR平扫：1、脑底池T1WI信号升高，T2WI信号更高，抑水T2WI显示病灶更清楚，高信号2、脑内结核球T1WI呈略低信号，T2WI呈低、等或略高混杂信号，周围水肿轻3、脑积水增强：脑膜明显增厚强化，结核球呈结节状强化或环状强化cerebralcysticercosisimagingfinding分型：脑实质型；脑室型、脑膜型、混合型CT：脑内多发低密度小囊，囊腔内可见致密小点状囊虫头节，囊虫死亡后呈高密度点状钙化MR：脑内多发小囊，小囊主体呈长T1长T2信号，其内偏心结节呈短T1和长T2信号增强：囊壁与头节可轻度强化VascularDeformality血管畸形Aneurysm血管瘤临床表现Clinicalfindings:headache

影像学表现ImagingfindingsCT:1)Directsigns:nothrombosis;partofthrombosis;totallythrombosis2)Secondarysigns:subarachnoidhemorrhage,hematoma,hydrocephalus,encephaledema,infarctMR:DSA鉴别诊断DifferentialDiagnosisBrainArteriovenousMalformations脑动静脉畸形临床表现Clinicalfindings影像学表现ImagingfindingsCTMRDSA鉴别诊断DifferentialDiagnosisTraumaticBrainInjury-CTTraumaticBrainInjury-ClinicalFeaturesSignsandSymptomsofheadinjurycanincludeanycombinationofthefollowing:

loseconsciousnessVomitingSeizure

WeaknessHeadacheInabilitytospeakAmnesia健忘症

●●●●●●

CNStraumaClinicalFeatures

-consciousnessNoLossofconsciousness(L.O.C)(SDH，EDH?，NotDAI弥漫性轴索损伤)Awakeatthescene，DelayedLOC(SDH，EDH，Swelling，NotDAI)TransientLOC-Wake-up-DelayedLOC(“Classic”lucidintervalfor

EDH)ContinuousLOCFollowingImpact(“Classic”shearing/DiffuseAxonalinjury

DAI弥漫性轴索损伤)

Immediateunenhanced

headCTscanistheprocedureofchoicefordiagnosisheadinjury

Computedtomography

(CT)：

itisquick,accurate,andwidelyavailableHeadCTscancanshowlocation,volume,effectofthelesionsofintracranialinjuries.ClassificationofHeadInjury：

-centripetalapproachousidetoinsideExtracerebralinjury:

★Scalp-hematoma头皮血肿★Calvarium-skullfracture颅骨骨折★Epiduralhematoma(EDH)硬膜外血肿

★Subduralhematoma(SDH)硬膜下血肿

★Subarachnoidhemorrhage(SAH)蛛网膜下腔出血

Intracerebralinjury:

★Braincontusion(edema,hemorrhage)脑挫伤

★Intraventricular-hemorrhage（脑室出血）

★1.Skullfracture

★2.Epiduralhematoma★3.EpiduralHematoma★4.SubduralEffusion

★5.

Subarachnoidhemorrhage★6.

CerebralCorticalContusion★7.

Diffuseaxonalinjury

★8.

SequelaeofHeadInjury闭合性脑损伤的机制冲击伤

作用力接触力惯性力原因直接碰撞减速或加速运动脑损伤范围局部多处弥散性受伤时头部状态固定不动运动中对冲伤1.Skullfracture骨折部位形态与外界关系颅盖骨折颅底骨折线性骨折凹陷性骨折粉碎性骨折开放性骨折闭合性骨折分类

Linearfracture

线型骨折：

AxialCTisnotgoodforlinearfracture

Shouldcarefullytoidentifythefractureline

Depressionfracture

凹陷型骨折：

Amoreseriousfracture

DownwarddisplacementoftheskullbonespressesdirectlyonbraintissueandcausedtheinjuryCTisimportantforthefractureandother

associatedintracraniallesionsBonewindowtoevaluatefracture

Skullfracture骨折CT骨窗观察

线形骨折的临床表现累及眶顶和筛骨：鼻出血眶周广泛淤血斑，“熊猫眼”征广泛球结膜下淤血斑、脑膜、骨膜均破裂：脑脊液鼻漏筛板或视神经管骨折：嗅神经或视神经损伤累及蝶骨：鼻出血，脑脊液鼻漏累及颞骨岩部：脑脊液耳漏、VII/VIII脑神经损伤蝶骨、颞骨内侧部损伤：垂体/II-VI脑神经损伤累及颈内动脉海绵窦部：颈内动脉—海绵窦瘘累及破裂孔或颈内动脉管：致命性鼻出血、耳出血累及颞骨岩部后外侧：Battle征，乳突部皮下淤血累及枕骨基底部：枕下肿胀、皮下淤血斑枕骨大孔或岩尖后缘附近骨折：IX-XII脑神经损伤颅底部线形骨折颅盖部发生率高颅前窝骨折颅中窝骨折颅后窝骨折颅前窝骨折累及眶顶和筛骨，可伴有鼻出血、眶周广泛淤血(称“眼镜”征或“熊猫眼”征)以及广泛球结膜下淤血。如硬脑膜及骨膜均破裂，则伴有脑脊液鼻漏，脑脊液经额窦或筛窦由鼻孔流出。若骨折线通过筛板或视神经管，可合并嗅神经或视神经损伤。颅中窝骨折颅底骨折发生在颅中窝，如累及蝶骨，可有鼻出血或合并脑脊液鼻漏，脑脊液经蝶窦由鼻孔流出。如累及颞骨岩部，硬脑膜、骨膜及鼓膜均破裂时，则合并脑脊液耳漏，脑脊液经中耳由外耳道流出；如鼓膜完整，脑脊液则经咽鼓管流向鼻咽部而被误认为鼻漏。骨折时常合并有第Ⅶ、Ⅷ脑神经损伤。如骨折线通过蝶骨和颞骨的内侧面，尚能伤及垂体或第Ⅱ、Ⅲ、Ⅳ、V、Ⅵ脑神经。如骨折伤及颈动脉海绵窦段，可因颈内动脉—海绵窦瘘的形成而出现搏动性突眼及颅内杂音。破裂孔或颈内动脉管处的破裂，可发生致命性鼻出血或耳出血。颅后窝骨折骨折线通过颞骨岩部后外侧时，多在伤后数小时至2日内出现乳突部皮下淤血(称Battle征巴特耳征)。骨折线通过枕骨鳞部和基底部，可在伤后数小时出现枕下部头皮肿胀，骨折线尚可经过颞骨岩部向前达颅中窝底。骨折线累及斜坡时，可于咽后壁出现黏膜下淤血。枕骨大孔或岩骨后部骨折，可合并后组脑神经(Ⅸ～Ⅻ)损伤症状。WhatisEpiduralhematoma？硬膜外血肿

EDHisatraumaticaccumulationofbloodbetweentheinnertableoftheskullandthestripped-offduralmembrane.

WhatisSubduralhematoma？硬膜下血肿

SDHisaformoftraumaticbraininjuryinwhichbloodgatherswithintheinnermeningeallayerofthedura.dura

2Epiduralhematoma

(硬膜外血肿)

DirecttraumatocraniumFracture(90%)-Laceration（撕裂）

ofMeningealA.andV.Locationis66%temporo-parietal（颞顶部）Temporal

Bone(70-80%)lucidinterval（中间清醒期40%pts）Mortality（死亡率）of15-30%硬脑膜外血肿病人意识变化的典型特征是:昏迷一清醒一再昏迷,即意识障碍有"中间清醒期",伤后有短暂的原发性昏迷,在血肿位形成前意识恢复,当血肿形成增大,颅内压增高可出现再次昏迷硬膜外血肿（EDH）：颅内血肿积聚于颅骨与硬膜之间Epiduralhematoma-CT1.Smoothlymarginated,lenticular透镜状,orbiconvex

双凸homogenoushyperdense高密度lesion

2.Rarelycrossesthesuturelinebecausetheduraisattachedmorefirmlytotheskullatsutures（缝）.3.Frequentincidenceofassociatedskullfracture（90%）-

fractureline

AcuteEpiduralHematomaThehematomastillcontainsuncoagulatedblood,orstillhasactivebleeding.

血肿包含不凝血或活动出血Round,stream-likefillingdefectsmaybeseeninthehemotoma

血肿内可见圆形密度减低影.3EpiduralHematoma

硬膜下血肿

ScoureofbloodLaceration（撕裂）ofCortical（脑皮层血管）AA.andVV.(Direct:penetratinginjury)(直接穿透伤)Bridging(Cortical)Veins（桥静脉）

Duralsinus（静脉窦）LargeContusions(Direct/indirect:PulpedBrain硬膜下血肿（SDH）：

颅内出血积聚于硬脑膜和蛛网膜下腔之间SubduralHematoma

硬膜下血肿

PresentationSignificantheadtrauma,butchronicsubdural-onlyminororremotehistoryoftraumaBilateralin20%adults(commoninelderly),80-85%bilateralininfantsExtensionintointerhemisphericfissure

（纵裂），tentorial（小脑幕）marginsBraininjuryin50%;ComplexInjury(DAI)Skullfractureinonly1%

SubduralHematoma

-CT1.Sickle-shape

(镰刀型)or

newlunar

shape

(新月型)2.Extendspastthesutures3.AcuteSDH-HyperdenseSubacuteSDH-Isodense(1-2weeks)ChronicSDH–Hypordense4.Braininjuryin50%;ComplexInjury(DAI);5.Skullfractureinonly1%AcuteSubduralHematoma急性硬膜下血肿Thehematomamayextendingintothesubduralspaceoftentorialregion.血肿可以延伸到小脑幕区.

AcuteSubduralHematomaThehematomamayextendingintotheinterhemisphericfissure

血肿延伸至大脑镰部.ChronicSubduralHematoma

慢性硬膜下血肿Shape：Semilunar，fusiform，Ovalshape外形：半月形、纺锤形、椭圆形.Density：HyperdenseIsodenseHypodenseMixeddensity密度：高密度、等密度、低密度、混杂密度IsodenseChronicsubduralhematoma等密度慢性硬膜下血肿.Hyperintensityofchronicsubduralhematoma高密度慢性硬膜下血肿

（T1/T2均为高信号）

.等密度硬膜下血肿双侧脑室对称变小，体部呈长条状两侧侧脑室前角内聚，夹角变小，呈“兔耳征”脑白质变窄塌陷皮层脑沟消失

MembraneHematoma

EpiduralAcute

BiconvexUnilateralSkullFracture90%

Limitedbysutures

DirecttraumatocraniumLaceration（撕裂）of

MeningealArtery

lucidinterval（中间清醒期40%pts）

SubduralAcutetoChronic

Newlunarshape

Bilateral

Fracture+/-1%CrosssuturesContrecoupInjury对冲伤

Laceration（撕裂）ofBridgingVeins（桥静脉）4.SubduralEffusion硬膜下积液SubduralEffusion硬膜下积液

Occurredinagedpatientorinfant发生在老人及幼儿.Developedseveraldayslaterafteraheadinjury外伤几天后形成Oftenbilateral常双侧Spontaneouslyresorbed自发吸收.Craniotomy,V-Pshunt,meningitisalsomaycausesubduraleffusion

穿颅术、VP、脑膜炎也可发生.5.

Subarachnoidhemorrhage

（蛛网膜下腔出血）

SubarachnoidhemorrhageThesensitivityofCThasbeenreportedtorangefrom85to100%.Highdensitylesionwasdemonstratedincerebralcisterns（Subarachnoidspaceovercerebralconvexity，Suprasellacistem（鞍上池），interpeduncularcistern（脚间池），pontinecistern，cisternofthelateralfissure（侧裂池）byplainCTscanComputedtomography(CT)isthemethodofchoicetodetectacutesubarachnoidhemorrhage(SAH).

Linearhighdensityinthesubarachnoidspaces(sulci，fissures，cistems)OftenassociateswithotherintracerebralorextracerebrallesionsMaycausehydrocephalus

Subarachnoidhemorrhage（SAH,蛛网膜下腔出血）-CT

Subarachnoidhemorrhage-MRIMagneticresonanceimaging(MRI)usingFLAIRsequencesshowsacomparablesensitivityinacuteSAHevenbesuperiortoCT.(hyperintenseonT2FLAIR)InsubacuteSAH,startingfromday5afterthesuspectedhemorrhage,thesensitivityofMRIisclearlysuperiortoCT.(hyperintenseonT1WIandT2WI)

纵裂池、脑沟SAH

SAH一引起交通性脑积水.

交通性脑积水.2.6TraumaticSAHinthesulci,interhemisphericfissure9.10Communicatinghydrocephalus6.CerebralCorticalContusion

（脑挫伤）CerebralCorticalContusion

Presentation

Lossofconsciousness，headache，mentalstatuschangeUsuallyinasuperficialcorticallocation50%occurintemporallobe33%infrontallobe(frontalpoleandinferiorsurface)Delayedhemorrhageseenin20%7.Diffuseaxonalinjury

（弥漫性轴索损伤）Followsseveredeceleratingclosedheadtrauma,patientsaregenerallyunconsciousfromthetimeoftheeventLocationofinjuriesaretypicallyinareasoflargenumbersofparallelaxonssuchasthecorpuscallosum,internalcapsule,brainstem,basalgangliaandsubcorticalwhitematterDiffuseaxonalinjury（弥漫性轴索损伤）Usuallypunctatehyperdensitiesareseeninthecorpuscallosum,graywhiteinterfaces,androstralbrainstemTheaxonalinjuryitselfisnotvisualized,buttheassociatedmicro(andmacro)hemorrhagesinthecharacteristicdistributionareseenDiffuseaxonalinjury-CTDetectingandcharacterizingbrainstemlesions,specificallyandpredominatelynon-hemorrhagiccontusionsAppearancedependsonpresenceorabsenceofhemorrhageT1-weightedsequencesoftennormal;multiplehyperintensefociatgray-whitejunctionsandcorpuscallosumonT2WIDiffuseAxonalInjury-MRI03－5－3骑摩托车与另一摩托车相撞，入院时为浅昏迷，GCS评分6分，20天后甚至转清，未能言语.

03－6－6言语模糊，乱语，03－6－16复查时对答正常

上图：伤后4天MRI检查

下图：伤后43天复查

Soonafterheadinjury8hourlater

DelayedHemorrhage

迟发血肿Brainatrophy,duetobraincontusionCommunicatinghydrocephalus,duetoSAH，IVHEncephalomalaciaorporencephaliccyst，duetobraincontusion

脑挫裂伤所致的：脑萎缩.

交通性脑积水.

脑软化、脑穿通囊肿.8.SequelaeofHeadInjury

脑外伤后遗症颅脑外伤的影像诊断注意点1.颅脑外伤首选CT检查，但病情与CT表现不符时，要行MRI检查；2.病情有变化时，随时复查CT。答案:AADA答案：CDDCB答案：ECAE颅内肿瘤/椎管内肿瘤影像诊断

Intracranialandintraspinaltumor

radiology脑肿瘤/椎管内肿瘤

Intracranialandintraspinaltumor

CT：Withorwithouttumor，localizationandqualitativediagnosis

AdvantagesofMRI：Noboneartifacts,multi-dimensionalsectionsscanning,avarietyofimagingparameters。Therefore,amoreaccuratepositioningandcharacterization

ofthetumorImagingsignsofintracranialtumors

Directsigns：1）Thesiteoftumor2）Thedensity(signal)oftumor3）Thenumber,size,shapeandedgeoftumor4）TheenhancementextentandmorphologyoftumorIndirectsigns：1）Peritumoraledema2）ChangesinskullTheexpandanddamageinternalauditorycanalcanbeseeninacousticneuromaTheskullcorrespondingshowsthickeningofmeningiomas星形细胞瘤（astrocytictumors)AstrocytictumorsisthemostcommonprimaryintracerebraltumoursAstrocytomainadultsmorecommoninSupratentorial,childrenmorecommonininfratentorialcerebellarAstrocytomamainlylocatedinthewhitematter,gradingⅠ-ⅣTumorlocalizationsignsandsymptomsofintracranialhypertension,Epilepsy脑内肿瘤直接征象1）好发部位:白质2）密度（信号）：Ⅰ级低密度，Ⅱ~Ⅳ级高低混杂密度的囊性肿块，可有钙化与瘤内出血、坏死、囊变3）数目、大小、形态和边缘：Ⅰ级边界清楚，Ⅱ~Ⅳ级边界不清，形态不规则4）增强的程度及形态：Ⅰ级不强化，Ⅱ~Ⅳ级呈不规则环形伴壁结节强化间接征象1）瘤旁水肿：明显2）颅骨变化：常无星形细胞瘤

astrocytictumorsⅠ~Ⅳgrade脑膜瘤

MeningiomaMeningiomaoriginatedfromarachnoidgranulationscapcells,connectedwiththeduraMosttumorsoccuroutsidethebrain,somecanoccureveninventricleAtypicalsitefollowedbyfrequencyofoccurrence:脑膜瘤影像特征总结脑外肿瘤直接征象1）好发部位:矢状窦旁、脑凸面、蝶骨嵴、嗅沟、桥小脑角、大脑镰或小脑幕2）密度（信号）：CT平扫等或略高密度、常见斑点状钙化3）数目、大小、形态和边缘：类圆形，边界清，常以广基底与硬膜相连，表现成增厚强化的“脑膜尾征，脑组织受压形成”皮层扣压征“4）增强的程度及形态：均匀性显著强化脑膜瘤影像特征总结间接征象：1）瘤旁水肿：轻或无，静脉或静脉窦受压时可出现中或重度水肿2）颅骨变化：脑膜瘤可见相应颅骨增厚AtypicalMeningioma1)全瘤以囊性为主2）肿瘤内密度不均匀3）壁结节4）瘤内有高密度出血5）肿瘤完全钙化6）全瘤密度低，并呈不均匀强化7）环形强化8）骨化性脑膜瘤9）瘤周脑脊液样低密度区10）酷似脑内的肿瘤11）多发性脑膜瘤MeningiomaDifferentialdiagnosisCerebralconvexityandfalxmeningiomas：Metastases,malignantlymphoma,anaplasticastrocytomaSuprasellarregionandtheanteriorcranialfossameningiomaMiddlecranialfossameningiomaPosteriorfossameningiomaIntraventricularmeningioma垂体腺瘤（pituitaryadenoma)Clinicalsymptoms：Compressionsymptoms；EndocrinedisorderPathology:Outsidethebrain;Encapsulatedpituitaryadenomapituitarymicroadenoma:≤10mm,Limitedtotheintrasellarpituitarymacroadenoma:﹥10mmpituitarymicroadenomaDirectsigns：Abnormaldensity（orsignal)withinthepituitaryAftertreatment,thetumorshrink,higherdensityIndirectsigns

3)Pituitaryheightabnormaly4)Bulgeontheupperedgeorcollapseoftheloweredgeof

thepituitary5)Pituitarystalkdeviation垂体瘤的影像特征脑外肿瘤直接征象1）好发部位:鞍内，可穿破鞍隔突入鞍上池、侵入蝶窦、侵入两侧海绵窦2）密度（信号）：CT平扫等或略高密度，易出血、坏死、囊变，偶见钙化3）数目、大小、形态和边缘：大于10mm为大腺瘤，哑铃状或葫芦状，有雪人征或束腰征4）增强的程度及形态：多数均匀、少数非均匀强化间接征象1）瘤旁水肿：无或少2）颅骨变化：常有蝶鞍扩大pituitaryadenomadifferentialdiagnosispituitarymicroadenoma:

Pituitarycysts,metastases,pituitaryabscess,pituitaryinfarctionpituitarymacroadenoma:

Craniopharyngioma,meningioma,epidermoidcyst,arachnoidcyst,astrocytoma,aneurysm颅咽管瘤（craniopharyngioma)Clinicalsymptoms：Childrenwithdevelopmentaldisorders,increasedintracranialpressure；Adultswithvision,visualfielddisorders,psychosisandhypopituitarismPathology:Cysticorpartiallycystic;CalcificationImagingfeaturesofcraniopharyngioma脑外肿瘤直接征象1）好发部位:鞍区，鞍上多见2）密度（信号）：CT平扫囊性或部分囊性为多，CT值变化较多（MRI混杂信号），含胆固醇多则低，含蛋白质与钙质多则高，沿囊壁壳状钙化3）数目、大小、形态和边缘：圆形或类圆形，边清4）增强的程度及形态：囊壁环状强化，实性部分呈均匀或不均匀强化间接征象1）瘤旁水肿：无或少2）颅骨变化：蝶鞍可扩大craniopharyngiomadifferentialdiagnosisCysticcraniopharyngioma:epidermalcyst,dermoidcyst,teratoma,arachnoidcystSolidcraniopharyngioma:

germinoma,astrocytoma,hamartoma