《脑梗死的血管定位》课件

脑梗死的血管定位5/9/20241《脑梗死的血管定位》课件内容脑供血动脉解剖脑梗死的血管定位5/9/20242《脑梗死的血管定位》课件人脑动脉解剖5/9/20243《脑梗死的血管定位》课件脑动脉两大体系颈内动脉系：大脑前部＋部分间脑

椎基底动脉系：

大脑后部＋部分间脑＋脑干＋小脑小脑幕为界顶枕沟为界（3/2)5/9/20244《脑梗死的血管定位》课件脑动脉供血系统模式图5/9/20245《脑梗死的血管定位》课件脑的主要供血动脉。(A)脑腹侧观。方块区域放大图显示Willis动脉环。(B)脑外侧面观和(C)中间矢状面显示大脑中/前/后动脉。(D)冠状切面显示大脑中动脉行程。5/9/20246《脑梗死的血管定位》课件颈内动脉系统MCA＋ACA＋脉络丛前动脉5/9/20247《脑梗死的血管定位》课件大脑中动脉（MCA）供血范围MCAACAPCAMCA皮质支供应：半球外侧面（额中回以下、中央前后回下3/4、顶下小叶、枕叶月状沟或枕外侧沟以前、颞下回上缘或上半以上的部分）；岛叶；颞极内外侧；额叶眶面一部分。5/9/20248《脑梗死的血管定位》课件MCA中央支供应：壳核、尾状核、内囊前肢、内囊膝的背外侧和内囊后肢的背部区域。立体看，供应内囊上3/55/9/20249《脑梗死的血管定位》课件5/9/202410《脑梗死的血管定位》课件大脑中动脉（MCA）供血范围5/9/202411《脑梗死的血管定位》课件大脑前动脉（ACA）血液供应ACA皮质支供应：半球内侧面为顶枕裂以前皮质和胼胝体；在背外侧面达额中回上缘或上半、额上回、中央前后回上1/4、顶上小叶及眶部内侧半等区域。ACA中央支供应：部分额叶眶面皮质、外囊、尾状核和豆状核前部、内囊前肢和内囊膝部和后肢前边部分。5/9/202412《脑梗死的血管定位》课件5/9/202413《脑梗死的血管定位》课件脉络丛前动脉：→侧脑室下角的脉络丛，并供应外侧膝状体、内囊后肢的后下部、大脑脚底的中1/3、苍白球等，易形成血栓阻塞。脉络膜前动脉的供血范围左图详示：基底节区的血液供应。5/9/202414《脑梗死的血管定位》课件5/9/202415《脑梗死的血管定位》课件脉络膜前动脉脉络膜前动脉，1～4支，以3支最多，为一组较细小而恒定的血管，在后交通动脉起始远侧2mm处由颈内动脉脉直接发出。该动脉在未穿入侧脑室下脚之前，除发1～3个皮质支外，还发出2～3个穿支，1支穿视神经内侧至大脑脚，另两支即为纹状体内囊动脉。此动脉主要营养尾状核尾，行程长，管径较小，易发生栓塞。5/9/202416《脑梗死的血管定位》课件D.AxialT2-weightedimage(2500/80)revealsthepresenceofaninhomogeneousmassintherightlateralventricle.Thelowsignalintensitysuggetsthepresenceofcalcificationandhemorrhage.E.Angiogramoftherightinternalcarotidarteryobtainedonday3demonstratesahypervascularmassfedfromtherightanteriorchoroidalartery(arrows).5/9/202417《脑梗死的血管定位》课件WhichoneistheAnteriorChoroidalArtery?5/9/202418《脑梗死的血管定位》课件5/9/202419《脑梗死的血管定位》课件脉络膜前动脉闭塞常引起三偏症状群，特点为偏身感觉障碍重于偏瘫，而对侧同向偏盲又重于偏身感觉障碍，有的尚有感觉过度、丘脑手、患肢水肿等。5/9/202420《脑梗死的血管定位》课件内囊额状断面脑后片图显示各部位血液供应来源。5/9/202421《脑梗死的血管定位》课件中央前回及中央后回的血液供应图5/9/202422《脑梗死的血管定位》课件椎基底动脉系统VA＋BA5/9/202423《脑梗死的血管定位》课件椎动脉（VA）①V1（骨外）段：向上进C6横突孔。②V2（椎间孔段③V3（脊椎外）段：④V4（硬膜内段）：过枕骨大孔，在脑桥及延髓交界处合成基底动脉。近侧椎动脉段解剖（A侧位；B前后位；C颏顶位）：骨外段（V1）横突孔段（V2）椎外段（V3）4.硬膜内段（V4）5.枕骨髁的大概位置椎动脉行程图A：斜侧位观；图B：前后位观；图C：俯观。5/9/202424《脑梗死的血管定位》课件1.左椎动脉2.脑膜后动脉3.小脑后下动脉（PICA）4.基底动脉5.小脑前下动脉(AICA)6.脑桥外侧支7.小脑上动脉（SCA）8.大脑后动脉9.小脑半球支大水平裂10.SCA的小脑半球分支11.小脑蚓上动脉椎基底动脉系统及其分支解剖（侧位）：5/9/202425《脑梗死的血管定位》课件椎基底动脉系统及其分支解剖（正位）：1.右椎动脉2.左椎动脉3.脊髓前动脉4.小脑后下动脉（PICA）5.基底动脉6.小脑前下动脉（AICA）7.脑桥外侧支8.小脑上动脉（SCA）9.大脑后动脉10.后交通动脉11.颈内动脉5/9/202426《脑梗死的血管定位》课件5/9/202427《脑梗死的血管定位》课件大脑后动脉（PCA）血液供应中央支：丘脑、下丘脑、底丘脑、膝状体以及大部分中脑。此外，分支到侧脑室及第三脑室脉络丛。变异大。主要来自PCA（72.5-88.3%）；来自ICA（6.8-20.2%）；两部分平均参加（4.3-11%）。5/9/202428《脑梗死的血管定位》课件PCA供血区模式图皮质支：半球底面和内侧面一部分（包括：海马回、梭状回、颞下回、舌回、窟窿回峡、楔叶、楔前叶后1/3及顶上小叶后部）5/9/202429《脑梗死的血管定位》课件Bloodsupplyofthethreesubdivisionsofthebrainstem.Diagramofmajorsupply.Sectionsthroughdifferentlevelsofthebrainstemindicatingtheterritorysuppliedbyeachofthemajorbrainstemarteries.5/9/202430《脑梗死的血管定位》课件脑桥的血液供应特点桥脑的血供源自椎—基底动脉，桥脑基底外侧和被盖部由短旋动脉供应；桥脑基底部内侧由基底动脉中央支供应，旁正中支供应桥脑被盖部正中部分—脑室底部、外展神经核、内侧纵束和网状结构；桥脑基底部和被盖部最外侧为长旋动脉供应。由于外侧区侧支循环丰富，发生梗塞概率较低。而桥脑旁正中动脉、短旋动脉呈直角起自基底动脉，易受高血压的影响而出现动脉粥样硬化，易出现梗塞。5/9/202431《脑梗死的血管定位》课件脑桥梗死的临床特点貌似大脑半球病变的纯运动性偏瘫占桥脑梗塞的60.9%。这是因为锥体束位于桥脑基底部，基底部由基底动脉的旁正中深穿支供应血流，该部位动脉易有动脉硬化性改变和透明变性，其近端闭塞时导致基底部正中梗塞，使未交叉的锥体束受损。PICA和SCA引起的梗塞通常仅累及小脑；而AICA（供应脑桥外侧被盖部和小脑中脚）不同，它引起的梗塞灶多累及脑干和小脑中脚。5/9/202432《脑梗死的血管定位》课件桥脑梗塞时交叉性瘫及颅神经麻痹并不常见，因桥脑的颅神经核多分部于被盖部，由较丰富的长旋动脉及小脑上动脉供应血流，后交通动脉、大脑后动脉和小脑上动脉有侧枝循环，所以颅神经可不受影响。脑桥梗死的临床特点5/9/202433《脑梗死的血管定位》课件脑桥上/中部旁中线综合征由基底动脉旁中央支血供障碍引起；病变对侧中枢性舌瘫＋对侧中枢性上下肢瘫痪＋同侧小脑性共济失调Patientswithunilateralparamedianinfarctionstypicallypresentedapuremotorhemiparesisthatprogressedoverthefirst3daysandwasaccompaniedbydysarthriaandhomolateralataxia.5/9/202434《脑梗死的血管定位》课件桥脑上外侧综合征小脑上动脉闭塞引起；①眩晕、恶心、呕吐、眼球震颤（前庭核损害）②两眼向病灶侧水平凝视不能（脑桥侧视中枢损害）③同侧肢体共济失调（脑桥臂、结合臂、小脑齿状核损害）；④同侧Horner综合征（下行交感神经损害）⑤同侧面部感觉障碍（三叉神经感觉束损害）和对侧痛觉、温度觉障碍（脊髓丘脑束损害）；⑥对侧下肢深感觉障碍（内侧丘系外侧部分损害）⑦双侧听力障碍，对侧较重。5/9/202435《脑梗死的血管定位》课件少见SCA综合征出现病变对侧感音性耳聋5/9/202436《脑梗死的血管定位》课件5/9/202437《脑梗死的血管定位》课件脑桥腹下部综合征

（Millard-GublerSyndrome)同侧外展N麻痹＋同侧周围性面瘫对侧中枢性舌瘫一；对侧肢体瘫。也其它位置不同的突出症状可能出现小脑前下动脉阻塞引起。5/9/202438《脑梗死的血管定位》课件5/9/202439《脑梗死的血管定位》课件脑桥基底内侧综合征

（FovilleSyndrome)

病灶侧周围性面瘫；两眼向病灶侧同向注视麻痹；病灶对侧偏瘫；基底动脉旁正中支闭塞引起。5/9/202440《脑梗死的血管定位》课件小脑后下动脉综合征

（Wallenbergsyndrome)现证实10％由PICA引起，75％由一侧椎动脉闭塞引起。余下由基底动脉闭塞引起。5/9/202441《脑梗死的血管定位》课件5/9/202442《脑梗死的血管定位》课件延髓内侧综合征

（Dejerine综合征）

椎动脉及其分支或基底动脉后部血管阻塞，引起延髓锥体发生梗死时产生同侧舌肌麻痹（XII脑神经损害）和萎缩，对侧上下肢中枢性瘫痪以及触觉、位置觉、振动觉减退或丧失。5/9/202443《脑梗死的血管定位》课件Magneticresonanceimageofthefluidattenuatedinversionrecoverysequencefortheaxial(left)andT2weightedcoronal(right)sections.Thereisawelldemarcatedunilateralmedialmedullaryinfarctjustbelowthepontomedullaryjunction.Therightsideofeachimagecorrespondstotheleftsideofthebrain.5/9/202444《脑梗死的血管定位》课件大脑动脉血管供血分区CT解剖(图文)5/9/202445《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支5/9/202446《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支脉胳膜前动脉5/9/202447《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支脉胳膜前动脉ACA穿支PCA穿支及PCoA5/9/202448《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支脉胳膜前动脉ACA穿支PCA穿支及PCoAMCA穿支5/9/202449《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支脉胳膜前动脉ACA穿支PCA穿支及PCoAMCA穿支5/9/202450《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支脉胳膜前动脉ACA穿支PCA穿支及PCoAMCA穿支5/9/202451《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支5/9/202452《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支5/9/202453《脑梗死的血管定位》课件MCA终末支ACA终末支PCA终末支5/9/202454《脑梗死的血管定位》课件MCA终末支ACA终末支5/9/202455《脑梗死的血管定位》课件ACA终末支5/9/202456《脑梗死的血管定位》课件5/9/202457《脑梗死的血管定位》课件5/9/202458《脑梗死的血管定位》课件5/9/202459《脑梗死的血管定位》课件脑的供血模式图5/9/202460《脑梗死的血管定位》课件5/9/202461《脑梗死的血管定位》课件5/9/202462《脑梗死的血管定位》课件5/9/202463《脑梗死的血管定位》课件5/9/202464《脑梗死的血管定位》课件左枕叶梗死。（PCA终末支）5/9/202465《脑梗死的血管定位》课件Figure1:(a)NormalinitialCTofthepatient;(b)ThecranialCTtwodaysaftertheincidentshowssignalchangesconsistentwithsimultaneousinfarctsintherightMCAandPCAareas;(c)InthedigitalsubtractionangiographyoftherightICA,PCAisseentooriginatefromtherightICAthroughPCoAi.e.fetaltypePCA5/9/202466《脑梗死的血管定位》课件PICAOntheleftCT-imagesofaleft-sidedPICA-infarction.Noticetheposteriorextention.Theinfarctionwastheresultofadissection(bluearrow).5/9/202467《脑梗死的血管定位》课件OntheleftCT-imagesofaleft-sidedPICA-infarction.Inunilateralinfarctsthereisalwaysasharpdelineationinthemidlinebecausethesuperiorvermianbranchesdonotcrossthemidline,buthaveasagittalcourse.Thissharpdelineationmaynotbeevidentuntilthelatephaseofinfarction.Intheearlyphase,edemamaycrossthemidlineandcreatediagnosticdifficulties.Infarctionsatpontinelevelareusuallyparamedianandsharplydefinedbecausethebranchesofthebasilarareryhaveasagittalcourseanddonotcrossthemidline.Bilateralinfarctsarerarelyobservedbecausethesepatientsdonotsurvivelongenoughtobestudied,butsometimessmallbilateralinfarctscanbeseen.5/9/202468《脑梗死的血管定位》课件SCAOntheleftCT-imagesofacerebellarinfarctionintheregionofthesuperiorcerebellararteryandalsointhebrainstemintheterritoryofthePCA.Noticethelimitationtothemidline.5/9/202469《脑梗死的血管定位》课件ACA：•A1segment:fromorigintoanteriorcommunicatingarteryandgivesrisetomediallenticulostriatearteries(inferiorpartsoftheheadofthecaudateandtheanteriorlimboftheinternalcapsule).•A2segment:fromanteriorcommunicatingarterytobifurcationofpericallosalandcallosomarginalarteries.•A3segment:majorbranches(medialportionsoffrontallobes,superiormedialpartofparietallobes,anteriorpartofthecorpuscallosum).5/9/202470《脑梗死的血管定位》课件AnteriorchoroidalarteryTheterritoryoftheanteriorchoroidalarteryencompassespartofthehippocampus,theposteriorlimboftheinternalcapsuleandextendsupwardstoanarealateraltotheposteriorpartofthecellamedia.ThewholeareaisrarelyinvolvedinAChAinfarcts.Ontheleftanuncommoninfarctioninthehippocampalregion.PartoftheterritoryoftheanteriorchoroidalarteryandthePCAareinvolved.5/9/202471《脑梗死的血管定位》课件MiddlecerebralarteryTheMCAhascorticalbranchesanddeeppenetratingbranches,whicharecalledthelaterallenticulo-striatearteries.Theterritoryofthelaterallenticulo-striateperforatingarteriesoftheMCAisindicatedwithadifferentcolorfromtherestoftheterritoryoftheMCAbecauseitisawell-definedareasuppliedbypenetratingbranches,whichmaybeinvolvedorsparedininfarctsseparatelyfromthemaincorticalterritoryoftheMCA.OntheleftaT2W-imageofapatientwithaninfarctionintheterritoryofthemiddlecerebralartery(MCA).

Noticethatthelaterallenticulo-striateperforatingarteriesoftheMCAarealsoinvolved(orangearrow).5/9/202472《脑梗死的血管定位》课件OntheleftimagesofahemorrhagicinfarctionintheareaofthedeepperforatinglenticulostriatebranchesoftheMCA.5/9/202473《脑梗死的血管定位》课件OntheleftenhancedCT-imagesofapatientwithaninfarctionintheterritoryofthemiddlecerebralartery(MCA).Thereisextensivegyralenhancement(luxuryperfusion).Sometimesthisluxuryperfusionmayleadtoconfusionwithtumoralenhancement.5/9/202474《脑梗死的血管定位》课件Posteriorcerebralartery(PCA)DeeporproximalPCAstrokescauseischemiainthethalamusand/ormidbrain,aswellasinthecortex.SuperficialordistalPCAinfarctionsinvolveonlycorticalstructures(4).Ontheleftapatientwithacutevisionlossintherighthalfofthevisualfield.TheCTdemonstratesaninfarctioninthecontralateralvisualcortex,i.eleftoccipitallobe.5/9/202475《脑梗死的血管定位》课件Therearetwopatternsofborderzoneinfarcts:1.CorticalborderzoneinfarctionsInfarctionsofthecortexandadjacentsubcorticalwhitematterlocatedattheborderzoneofACA/MCAandMCA/PCA2.InternalborderzoneinfarctionsInfarctionsofthedeepwhitematterofthecentrumsemiovaleandcoronaradiataattheborderzonebetweenlenticulostriateperforatorsandthedeeppenetratingcorticalbranchesoftheMCAorattheborderzoneofdeepwhitematterbranchesoftheMCAandtheACA.5/9/202476《脑梗死的血管定位》课件OntheleftthreeconsecutiveCT-imagesofapatientwithanocclusionoftherightinternalcarotidartery.Thehypoperfusionintherighthemisphereresultedinmultipleinternalborderzoneinfarctions.Thispatternofdeepwatershedinfarctionisquitecommonandshouldurgeyoutoexaminethecarotids.5/9/202477《脑梗死的血管定位》课件Ontheleftimagesofapatientwhohassmallinfarctionsintherighthemisphereinthedeepborderzone(bluearrowheads)andalsointhecorticalborderzonebetweentheMCA-andPCA-territory(yellowarrows).Thereisabnormalsignalintherightcarotid(redarrow)asaresultofocclusion.Inpatientswithabnormalitiesthatmayindicateborderzoneinfarcts,alwaysstudytheimagesofthecarotidarterytolookforabnormalsignal.5/9/202478《脑梗死的血管定位》课件OntheleftanotherexampleofsmallinfarctionsinthedeepborderzoneandinthecorticalborderzonebetweentheMCA-andPCA-territoryinthelefthemisphere.5/9/202479《脑梗死的血管定位》课件OntheleftanexampleofinfarctionsinthedeepborderzoneandinthecorticalborderzonebetweentheACA-andMCA-territory.Theabnormalsignalintensityintherightcarotidistheresultofanocclusion.Thiscombinationoffindingsissocommon,thatonceyouknowthepattern,youwillseeitmanytimes.5/9/202480《脑梗死的血管定位》课件脉络膜前动脉供血区梗死5/9/202481《脑梗死的血管定位》课件A9-year-oldpreviouslyhealthygirlwasadmittedtotheEmergencyRoomwithaneight-hourhistoryofsuddenonsetofsevereheadache.Thepainwaspulsatileandbilateralandnotaccompaniedbyothersymptoms.Thereisnohistoryofmigraine,epilepsyorstroke.Parentsreportedthatsoonaftertheonsetoftheheadachethepatientbecamedrowsyforaboutonehour.Notriggerfactorwasidentified.Ontheneurologicalexamination,thepatientwasalertandwellorientedwithnootherabnormalitiesbutmildnuchalrigidity.Computedtomographyofthebrainrevealedhemorrhageintherightlateralventricle(Fig1)andgadolinium-enhancedmagneticresonanceimagingstudyofthebraindisclosedaheterogeneouslesioninthemesialportionoftherighttemporallobe,aboveandinsidethetemporalhornofthelateralventricle.Thelesionextendeduntilthesubependimaryareaofthetrigonooftherightventricle.ThelesionwashypointenseonT1andT2-weightedimagesandenhancedwiththecontrast.OtherhyperintenseT1andT2-weightedimageslesionswereseenintherightlateralventriclesuggestingbleeding.Magneticresonanceangiographyandcerebralangiographydisclosedanarteriovenousmalformationinpartofthechoroidplexus,suppliedbytheanteriorchoroidalartery(Figs2and3).TheAVMwasclassifiedaccordingtoSpetzlergradingsystemasgrade3(deepvenousdrainage:1;eloquencearea:0andsize:2).5/9/202482《脑梗死的血管定位》课件Lacunesmaybeconfusedwithotheremptyspaces,suchasenlargedperivascularVirchow-Robinspaces(VRS).TheVRSareextensionsofthesubarachnoidspacethataccompanyvesselsenteringthebrainparenchyma.WideningofVRSoftenfirstoccursaroundpenetratingarteriesinthesubstantiaperforataandcanbeseenontransverseMRIslicesaroundtheanteriorcommisure,eveninyoungsubjects(5).OntheleftCT-andMR-imagesatthelevelof