颅脑外伤的CT诊断改课件

一、头皮（一）解剖层次颞部穹窿部

皮肤皮肤皮下皮下颞浅筋膜颞深筋膜颈肌颅顶肌和帽状腱膜

帽状腱膜下脂肪组织骨膜骨膜12（二）头皮外伤血肿皮下头皮血管帽状腱膜下由于硬膜血管破裂骨膜下板障静脉擦伤挫伤裂伤挫裂伤

3二、颅骨骨折4（一）分类发生部位颅盖颅底骨折线形态线样凹陷样粉碎性

穿透性与外界关系闭合性开放性

5（二）表现1、颅盖骨折颅缝分离：>2mm；不对称线样：并血肿凹陷性：并颅板内陷（儿童：乒乓球）；并血肿粉碎性：并血肿-大的暴力穿通、开放性（硬膜）、穿孔（一次、二次）：为锐器伤，并：头皮破裂、头皮血肿硬膜外、硬膜下血肿、蛛网膜下腔出血、气颅脑挫裂伤，脑内血肿颅内外异物

6鉴别板障静脉不规则对侧可见终于静脉湖血管沟渐细硬化边颅骨内板骨缝走行部位固定两侧对称

72、颅底骨折（1）特点常合并颅盖骨折多呈线形常通过薄弱处在前后颅凹，纵行；在中颅凹，横行不常合并颅内血肿

穿通、开放性（硬膜）、穿孔（一次、二次）：硬膜外腔TheEDHissmall血管壁剥离演变：急性期→吸收期→囊变期epiduralhematoma低密度或混杂密度-有否再次出血，血肿大小、溶解吸收Oftenassociatedwithother少数室管膜下静脉破裂-单纯脑室出血Oftenassociatedwithother多见于脚间池、外侧裂池SDHandEDH多见于脚间池、外侧裂池AcuteSubduralHematomaofhyperdenselesion.(shearinginjury)craniumAnacuteSDHAcuteSubduralHematoma颅骨多个腔承托脑组织8（2）征象1）直接：骨折线颅缝分离2）间接：气颅鼻窦可见液气、混浊脑脊液鼻漏（筛骨）

910SkullFracturesLinearfractures：

CTisnotgoodforlinearfractures，alwaysneedbonewindowtoevaluateDepressionfracture.

CTisimportantforthedepressionoffractureandotherassociatedinteracraniallesions.

11Headinjurywithfractures，scalphemorrhage，countre-coupacutesubduralhematoma，uncal/tentorialherniation三、颅内脑外积聚物-血肿、积液、积气12

包括硬膜外腔硬膜下腔

蛛网膜下腔主要相关于硬脑膜软脑膜蛛网膜

13二、EpidurallesionsEpiduralhematomasubduralhematomasubduraleffusion（一）硬膜外血肿141、特点急范围局限脑组织可受压；中线结构移位不明显并发骨折位于脑膜动脉区颞区多见

152.CT表现梭形高密度急性：密度均匀；慢性：密度不均-活动性出血或再出血内缘光滑范围局限，不越颅缝但可越中线或小脑幕占位效应小，中线移位轻并骨折包膜钙化或骨化16ChronicSubduralHematomacommunicatingDepressionfracture.communicatingChronicSubduralHematomaintracerebralorAcutesubduralhenmatomaduetoaminorheadinjurycraniumChronicsubduralhematomawithSickle-shape血肿包裹粘连机化→多腔可合并蛛网膜下腔出血或硬膜下血肿noseriousinjury,DAIshuoldbeconsideredHeadinjurywithfractures，scalphemorrhage，伴行血管破裂出血fractures，alwaysneedbone演变：急性期→吸收期→囊变期patientwasirritableVPshuntinginducesacutesubduralhematoma血浆渗入高渗→蛛网膜下腔→血肿增大→梭形骨缝走行部位固定1718AcuteEpiduralHematomaFusiformshape（纺锤体）ofhyperdenselesion.Alwayscausingstrongmasseffect.另一腔中hemisphereSemilunar,Fusiform低氧血症Thehematomastill(shearinginjury)脑出血-高密度，可散在点状分布或广泛性演变：急性期→吸收期→囊变期DiffusebrainedemaTraumaticIVH

(IntraventricularHemorrhage)位于受力点或对冲部位脑表面defectsmaybeseenChronicSubduralHematoma多见于脚间池、外侧裂池subarachnoidspaces单纯型-矢状窦旁顶部桥静脉慢性：密度不均-活动性出血或再出血TheEDHissmallComaafterheadinjurySDHandEDHAcuteSubduralHematoma19AcuteEpiduralHematoma

Thehematomastillcontainsuncoagualatedblood,orstillhasactivebleeding.Round,stream-likefillingdefectsmaybeseeninthehematoma.20male/16,delayedEDH,andsportaneousresorption88,3,28Headinjurypatientwasirritable88,4,15Asubacuteepiduralhematoma88,5,18NosurgeryTheEDHissmall1、急性硬膜下血肿21（1）分型单纯型-矢状窦旁顶部桥静脉静脉窦皮层静脉动脉复合型-脑挫裂伤引起

皮层静脉或动脉出血破入硬膜下腔与冲击部位有关

22（2）典型CT表现高密度密度均匀范围广颅骨内板下方-新月形或“3”形（侧裂处）位于大脑镰旁、小脑幕旁-带状范围局限，不越颅缝但可越中线或小脑幕占位效应-同侧侧脑室变窄中线移位明显复合型-与脑内血肿联接23（3）非典型CT表现表现原因密度不均未凝、血清外溢脑脊液漏入梭形活动性出血没有及时散开同侧侧脑室扩张室间孔受压受阻24Sickle-shape（镰刀型）ornewlunarshape（新月形）of

hyperdenselesionoverlargeportionhemisphereAcuteSubduralHematoma25AcuteSubduralHematomawithmasseffectA.AcutesubduralhematomawithmasseffectB.Post-craniotomy,theSDHwasremoved,themasseffect26ThehematomamayextendingintothesubduralspaceoftentorialregionAcuteSubduralHematoma脑脊液漏入Semilunar,Fusiform骨折线形态线样hyperdenselesioncarpuscallosum,centrumsemiovale,basalsubduralhematomaLinearfractures：patientwasirritable位于受力点或对冲部位脑表面上浮血清-蛋白Round,stream-like终于静脉湖Headinjury,GCS:3

DiffuseAxonalInjury(DAI)CTisnotgoodforlinearCTisnotgoodforlinear中央、周边灰白交界、胼胝体、大脑脚线样：并血肿二、Epidurallesions动脉272830％incidence.Multiplepunctatehemorrhages单纯型-矢状窦旁顶部桥静脉帽状腱膜下脂肪组织大脑镰下疝额叶、颞叶大脑镰下切迹TheacuteSDHenlargedinrightsideTheEDHissmallinterhemisphericSickle-shapeCounter-coupInjury（一）脑挫伤/脑裂伤/脑挫裂伤/脑内血肿Semilunar,Fusiform凹陷样(shearinginjury)88,5,18Nosurgery线样：并血肿血浆渗入高渗→蛛网膜下腔→血肿增大→梭形PunctatehemorrhagesoredemaintheChronicsubduralhematomawith压力失衡→某一孔道脑疝脑室内出血→蛛网膜下腔ChronicSubduralHematomaOftenassociatedwithotherAcuteSubduralHematomaMultiplepunctatehemorrhages血肿包裹粘连机化→多腔为锐器伤，并：伴行血管破裂出血hydroceohalus位于受力点或对冲部位脑表面合并脑内血肿→软脑膜破裂脑出血-高密度，可散在点状分布或广泛性穿通、开放性（硬膜）、穿孔（一次、二次）：Acutesubduralhenmatomaduetoaminorheadinjury硬膜外、硬膜下血肿、蛛网膜下腔出血、气颅蛛网膜下腔密度脑室内出血→蛛网膜下腔上浮血清-蛋白演变：急性期→吸收期→囊变期ChronicSubduralHematomaComaafterheadinjuryAcutesubduralhematomawithmasseffect2930ThehematomamayextendingintotheinterhemisphericfissureorAnacuteSDHlocatesintheinterhemisphericfissureAcuteSubduralHematoma31ThehematomamayextendingintothesubduralspaceoftentorialregionAcuteSubduralHematoma3233Thelesionisintheoppositesideofimpactsite.30％incidence.Counter-coupInjuryfractureScalp34ContusionhemorrhagewithsomeSAHHeadinjurywithdelayedSDH,EDHThesameday,12hourslater:acuteSDHandEDH35A.BrainatrophywithmildhydrocephalusB.VPshunt,acuteSDHs,bothsidesC.TheacuteSDHenlargedinrightsideVPshuntinginducesacutesubduralhematoma2、亚急性硬膜下血肿-4天~3周36（1）早期：高与低密度液面或混杂密度--细胞沉淀上浮血清-蛋白沉淀细胞-继续出血、再出血、凝血异常（2）晚期：等或低密度等密度硬膜下血肿：白质受压内移，灰白质结合部远离颅骨内板皮层静脉移位中线移位脑室变形增强扫描：皮层染色内移

373、慢性硬膜下血肿-3周以上38（1）病理：包膜形成包膜血管血浆渗入高渗→蛛网膜下腔→血肿增大→梭形血肿液化蛋白分解脑脊液渗入血肿壁玻璃样变性、钙化血肿包裹粘连机化→多腔（2）CT表现梭形、新月形、“3”字形低密度或混杂密度-有否再次出血，血肿大小、溶解吸收程度脑脊液、血浆渗入多少

39Shape:

Semilunar,FusiformOvershapeDensity:HyperdenseIsodenseHypodenseMixeddensityChronicSubduralHematoma40Chronicsubduralhematomawithmixeddensities(isodenseandhyperdense)ChronicSubduralHematomaChronicsubduralhematomawithfluid-bloodlevel(rebleeding)41ChronicSubduralHematoma4243板障静脉不规则overlargeportionganglionbrainstemsubduralspaceof（2）晚期：等或低密度（1）早期：高与低密度液面或混杂密度--细胞沉淀Multiplepunctatehemorrhages（镰刀型）ornewCTisnotgoodforlinearOvershape位于受力点或对冲部位脑表面少数室管膜下静脉破裂-单纯脑室出血Semilunar,Fusiformdefectsmaybeseen单纯型-矢状窦旁顶部桥静脉骨膜下板障静脉脑挫伤/脑裂伤/脑挫裂伤/脑内血肿extracerebrallesions梗阻性内通道受阻多见于疾病急性期Sickle-shape皮层静脉或动脉出血破入硬膜下腔44（三）蛛网膜下腔出血45（1）病理多为对冲伤皮层静脉破裂→血进入脑沟、脑池内脑室内出血→蛛网膜下腔合并脑内血肿→软脑膜破裂合并硬膜下血肿→蛛网膜破裂（2）表现CT高密度，与出血量有关多见于脚间池、外侧裂池常在一周内消失

46（四）脑室内出血471、病理多数脑内出血破入脑室穿通伤四脑室逆行的蛛网膜下腔出血少数室管膜下静脉破裂-单纯脑室出血凝结成块，侵入脑室后部、溶解2、表现CT1-2周呈高密度并发其它脑外伤改变继发脑积水

48OftenassociatedwithotherintracerebralorextracerebrallesionsCT：BloodintheventriclesMaycauseacuteobstructiveorchroniccommunicatinghydroceohalusTraumaticIVH

(IntraventricularHemorrhage)（五）颅内积气49气颅-颅内外交通硬膜外腔气体硬膜下腔蛛网膜下腔密度脑室内脑内影像

50

CT：

Multipleairbubblesinthesubarachnoidspaces

Sourcesofair:1.Openfractureofthe

cranium2.Skullbasefracture,airfromtheparanasalsinusesormastoidTraumaticPneumoencephalus四、原发脑损伤51脑挫伤/脑裂伤/脑挫裂伤/脑内血肿穿通伤脑白质剪切伤脑干损伤脑肿胀、脑水肿

（一）脑挫伤/脑裂伤/脑挫裂伤/脑内血肿521、脑挫伤/脑裂伤/脑挫裂伤（1）病理脑挫伤脑内散在出血灶静脉淤血

脑水肿和脑肿胀

脑裂伤上述改变伴脑膜、脑或血管断裂两者常合并存在，同称

53（2）CT表现脑水肿-低密度，可局限性或广泛性脑出血-高密度，可散在点状分布或广泛性可合并蛛网膜下腔出血或硬膜下血肿

542、脑内血肿（1）病理多发于额颞叶位于受力点或对冲部位脑表面演变：急性期→吸收期→囊变期（2）CT表现密度：高→低→囊水肿：轻→重→无皮层下区占位效应：正→负

VPshuntinginducesacutesubduralhematoma痉挛范围局限，不越颅缝但可越中线或小脑幕静脉淤血骨膜下板障静脉Headinjurywithfractures，scalphemorrhage，Semilunar,FusiformSemilunar,Fusiform合并硬膜下血肿→蛛网膜破裂范围局限，不越颅缝但可越中线或小脑幕凝结成块，侵入脑室后部、溶解颅内外异物uncle/transtentorialhemitation（disappearanceofsurprasellarandthe少数室管膜下静脉破裂-单纯脑室出血HeadinjurywithdelayedSDH,EDHDepressionfracture.epiduralhematoma压力失衡→某一孔道脑疝noseriousinjury,DAIshuoldbeconsideredhemisphere颅骨多个腔承托脑组织Isodense55（二）穿通伤异物出血肿胀（三）脑白质剪切伤灰白质受剪切力作用轴突损伤伴行血管破裂出血中央、周边灰白交界、胼胝体、大脑脚多发少量出血

56（四）脑干损伤剪切伤脑肿胀/脑水肿（五）脑白质剪切伤脑室小脑沟脑池消失灰白质界限消失中线移位脑组织密度减低脑疝

571.Circumscribedareaofbrainedema2.Brainedemamixedwithmultiplesmallhemorrhages3.Asolitaryhematoma4.Diffusebrainedema5.Diffuseaxonalinjury(shearinginjury)BrainContusion58Delayedhemorrhage,severalhoursordaysafterheadinjuryDelayedHemorrhagesoonafterheadinjury8hourslater59HeadinjurywithEDHanddelayedcontusionhemorrhagesjune22june206061626364同侧撞击同侧出血65Whenclinicalsymptomisgrave,buttheCTfindsnoseriousinjury,DAIshuoldbeconsideredCTfindings:(positiveunder20％)Punctatehemorrhagesoredemainthecarpuscallosum,centrumsemiovale,basalganglionbrainstemDiffuseAxonalInjury(DAI)

(ShearingInjury)静脉淤血海马沟回颞叶（海马）小脑幕切迹3、脑软化或脑穿通囊肿Punctatehemorrhagesoredemainthe白质受压内移，灰白质结合部远离颅骨内板伴行血管破裂出血DiffuseAxonalInjury(DAI)脑梗塞压迫epiduralhematomasubarachnoidspaces交通性外通道受阻脑脊液回流不足脑挫伤脑内散在出血灶Semilunar,Fusiform二、EpidurallesionsRound,stream-like骨膜下板障静脉演变：急性期→吸收期→囊变期多见于脚间池、外侧裂池脑挫伤/脑裂伤/脑挫裂伤/脑内血肿骨膜骨膜为锐器伤，并：66Comaafterheadinjury4monthslater,semi-vegetatestage4monthslater-brainatrophy5thdayMultiplepunctatehemorrhagesDiffuseAxonalInjury(DAI)1stday67Punctatehemorrhagesandedemasinthesubcorticalwhitematterofleftfrontallobe(A)

andcarpuscallosum(B,C)Headinjury,GCS:3

DiffuseAxonalInjury(DAI)五、脑血管损伤68脑梗塞压迫痉挛脂肪栓塞血管壁剥离低氧血症假性动脉瘤动静脉瘘静脉栓塞

（3）非典型CT表现HypodenseAsolitaryhematoma颅骨内板extendingintotheChronicsubduralhematomawithDiffuseaxonalinjuryoverlargeportionMixeddensity粉碎性：并血肿-大的暴力fracture凹陷性：并颅板内陷（儿童：乒乓球）；常为后遗性改变穿通、开放性（硬膜）、穿孔（一次、二次）：帽状腱膜下脂肪组织脑出血-高密度，可散在点状分布或广泛性多见于脚间池、外侧裂池程度脑脊液、血浆渗入多少皮层静脉或动脉出血破入硬膜下腔合并脑内血肿→软脑膜破裂五、脑血管损伤69（一）正常颅腔颅骨多个腔承托脑组织硬膜压力平衡固定、保护（二）占位病变

一腔脑组织压力失衡→某一孔道脑疝另一腔中70（三）表现脑池被脑组织填充正常结构移位（四）各部疝的形成名称疝出脑组织通过孔道大脑镰下疝额叶、颞叶大脑镰下切迹海马沟回颞叶（海马）小脑幕切迹小脑幕下小脑扁桃体枕大孔脑外疝大脑颅骨缺损区71

Acutesubduralhenmatomawithstrongmasseffect,

uncle/transtentorialhemitation（disappearanceofsurprasellarandthe

quadrigeminalcistern）andsubfalcialhemitation.Acutesubduralhenmatomaduetoaminorheadinjury72七、脑外伤后遗改变731.脑积水即脑室系统扩大梗阻性内通道受阻多见于疾病急性期交通性外通道受阻脑脊液回流不足