中枢脑血管病专家讲座

CentralNervousSystem南京医科大学一附院放射科洪汛宁hongxunning@7/12/20241中枢脑血管病第1页TheFiveMostCommonStrokeSymptomsSuddennumbnessorweaknessofface,armorleg,especiallyononesideofthebody.Suddenconfusion,troublespeakingorunderstanding.Suddentroubleseeinginoneorbotheyes.Suddentroublewalking,dizziness,lossofbalanceorcoordination.Suddensevereheadachewithnoknowncause.(Source:NationalStrokeAssociation)7/12/20242中枢脑血管病第2页OtherImportantbutLessCommonStrokeSymptomsSuddennausea,feverandvomitingdistinguishedfromaviralillnessbythespeedofonset(minutesorhoursvs.severaldays).Brieflossofconsciousnessorperiodofdecreasedconsciousness(fainting,confusion,convulsionsorcoma).Source:NationalStrokeAssociation7/12/20243中枢脑血管病第3页ClinicalFeaturesDependsonvascularterritoryinvolvedUsuallyabruptonsetMostprecise:levelsofconsciousness(LOC),grossmotorlevelLeastprecise:sensoryexam,history(includingTIA)Clinicalexamperformanceimproveswithtraining7/12/20244中枢脑血管病第4页脑血管疾病

（cerebrovasculardisease）脑梗死（cerebralinfarction）脑出血（intracranialhemorrhage）动静脉畸形（aterio-venousmalformation）蛛网膜下腔出血（subarachnoidhemorrhage）和颅内动脉瘤（intracranialaneurysm）7/12/20245中枢脑血管病第5页

TheconsequencesofcerebralischemiadependonthedegreeanddurationofreducedCBF.Neuronscantolerateischemiafor30-60minutes.Perfusionmustbereestablishedbefore3-6hoursofischemiahaveelapsedorbeforetheCBFdropsto10.脑梗死cerebralinfarction7/12/20246中枢脑血管病第6页cerebralinfarctionPathologicchangeswithintheneuropilfollowthemetabolicabnormalities.OneofthefirsteffectsiscytotoxicedemathatresultsfromfailureoftheNa/Kionpump.Earlyon,thisstageisstillreversible.Prolongedischemialeadstocelldeathandcoagulationnecrosis.After3-6hoursofischemia,irreversibledamageoccurstothecapillaryendothelium.7/12/20247中枢脑血管病第7页CTandMRscansinpatientswithasymptomaticbruitsorTIA'sareusuallynegative.Theearliestsignmaybeabnormalvasculardensity/signal.ThefirstparenchymalchangesobservedonCTandMRreflectthecytotoxicedemaaffectingprimarilythegraymatter.ischemiccerebralinfarction7/12/20248中枢脑血管病第8页ItisimportanttorememberthattheCTscanmaybenegativeforthefirst24-48hours.Massiveinfarctionsmaybevisibleasearlyas6hours.TheMRscanisusuallypositivewithinthreetofourhoursfollowingastroke.OneoftheearliersignsonCTislossofthenormalgray-whitecontrastastheedematouscortexbecomesisodensetotheunderlyingwhitematter.After6-8hourstheaccompanyingvasogenicedemahighlightstheareasofbraininfarction.ischemiccerebralinfarction7/12/20249中枢脑血管病第9页CTCT扫描见低密度灶。常呈扇形，基底贴近颅内板，尖指向颅脑中心。早期（1~2天）边界较含糊，中后期（2~7天）边界较清，无占位征或略有占位征。病灶部位和范围与闭塞血管所属供血区域一致1~3周时可出现含糊效应（侧支循环建立）增强扫描可呈轻度脑回状强化（血脑屏破坏及侧循建立）1~2月后可出现低密度脑软化或伴脑萎缩。注：24小时内检出率低，24~48小时后检出率高，2天~2周水肿较显著。7/12/202410中枢脑血管病第10页TopographicVascularSupply

(Http://www.C/nm-Mediabook/figures/brainfigs.Html)7/12/202411中枢脑血管病第11页ACATerritoryStroke7/12/202412中枢脑血管病第12页PCATerritoryInfarct7/12/202413中枢脑血管病第13页RightPICAStroke

(/~c064s01/nr251.htm)7/12/202414中枢脑血管病第14页

male56yearsold,

150minaftersymptom常规CTTimetoPeakCBF随访颅内动脉栓塞随访CT显示液化灶7/12/202415中枢脑血管病第15页Cerebralinfarction7/12/202416中枢脑血管病第16页7/12/202417中枢脑血管病第17页7/12/202418中枢脑血管病第18页7/12/202419中枢脑血管病第19页HyperacuteStroke:CT

(Koeller,AFIPStrokeLecture)HyperdensearteryBasalgangliaobscuredInsularribbonlostEdema:sulcalorventriculareffacement7/12/202420中枢脑血管病第20页HyperdenseMCASignPrognosticValueoftheHyperdenseMiddleCerebralArterySignandStrokeScaleScorebeforeUltraearlyThrombolyticTherapyAJNRAmJNeuroradiol17:79–85,January19967/12/202421中枢脑血管病第21页HyperdenseRightMCA7/12/202422中枢脑血管病第22页AxialunenhancedCTimageobtainedina53-year-oldmanshowshypoattenuationandobscurationoftheleftlentiformnucleus(arrows),which,becauseofacuteischemiainthelenticulostriatedistribution,appearsabnormalincomparisonwiththerightlentiformnucleus.7/12/202423中枢脑血管病第23页ObscurationoftheRightBasalGangliainAcuteStroke

(AJNRAmJNeuroradiol17:1743–1748)7/12/202424中枢脑血管病第24页AxialunenhancedCTimages,obtainedina45-year-oldman2hoursaftertheonsetoflefthemiparesis,showobscurationoftherightlentiformnucleus(arrowinb).Thisfeatureislessvisiblewiththeroutinebrainimagingwindowusedfora(windowwidth,80HU;center,35HU)thanwiththenarrowerwindowusedforb(windowwidth,10HU;center,28HU).7/12/202425中枢脑血管病第25页MRI检出脑梗塞较CT敏感。梗塞6小时内，细胞毒性水肿，梗塞区含水量高，T1、T2时间延长。6小时后渐出现血管源性脑水肿，血脑屏障破坏。较高档MR应用MRI弥散成像和灌注成像，能更早期发觉病灶，有利于早期治疗。7/12/202426中枢脑血管病第26页DIFFUSION&PERFUSIONIMAGING

ConventionalCTandMRimagingarenotsufficientlysensitivetoevaluateacutestroke.Theultimategoalforimagingistodefinetheareaofbraininfarctionandperfusiondeficit,andtoidentifyanyischemictissuethatcanbesalvagedbymedicalorsurgicaltherapy.DWIcandetectacutebraininfarctionwithin1to2hours.Perfusionimagingispositiveimmediatelyfollowinganacutestroke.7/12/202427中枢脑血管病第27页AcuteRightMCAStroke7/12/202428中枢脑血管病第28页AcuteMCAStrokewithDiffusion

7/12/202429中枢脑血管病第29页4P’sofAcuteStrokeImaging•Parenchyma–Assesearlysigns,excludehemorrhagePipes–Assessextra&intracranialcirculationPerfusion–AssessCBV,CBF,&MTT

Penumbra–Assesstissueatriskofdying7/12/202430中枢脑血管病第30页HemorrhagicInfarct

(Koeller,AFIPStrokeLecture)

10%ofacutestroke.

HigherincidenceinAsianpopulation.

<24hours.

Anticoagulationcontraindicated.7/12/202431中枢脑血管病第31页HemorrhagicCerebralInfarction7/12/202432中枢脑血管病第32页HemorrhagicStroke

AJNRAmJNeuroradiol18:1011–1020,June19977/12/202433中枢脑血管病第33页HemorrhagicTransformation

(Koeller,AFIPStrokeLecture)

>24hoursafterinfarctbydefinition

Peak:1-2weeks

Diapedesis血细胞渗出Occursafterreperfusion:thefullpressureofarterialbloodintohypoxiccapillariesresultsinadiapedesisorredcellsmovingthroughthevesselhypoxicwalls

Occursinupto50%ofstrokes

Confirmsischemicnatureofinfarct7/12/202434中枢脑血管病第34页HemorrhagicTransformation

/AANLIB/cases/case42/mr1/012.html7/12/202435中枢脑血管病第35页腔隙性脑梗死lacunarinfarction丘脑基底节区或深部脑髓质小血管(A)闭塞所致CT征象：于好发部位见小低密度灶，普通为1~1.5cm大小，早期边界较含糊，中晚期边界较清MRI检验腔梗灶较CT敏感高，早期更易发觉7/12/202436中枢脑血管病第36页lacunarinfarction7/12/202437中枢脑血管病第37页MRIT2WI,T1WI,flairlacunarinfarction7/12/202438中枢脑血管病第38页存在问题致死率及致残率7/12/202439中枢脑血管病第39页影像学研究策略脑梗死前期脑缺血影像学研究Hypo-PbeforeIS7/12/202440中枢脑血管病第40页IntracranialHemorrhageVerycommonTrauma,Hypertension;Aneurysm;VascularMalformationOthers:Embolicstrokewithreperfusion;Amyloidangiopathy;Coagulopathies;Drugabuse;Tumor7/12/202441中枢脑血管病第41页CTofIntracranialHemorrhage

Allcerebralhematomas,whateverthecause,haveasimilarresolutionpatternonCT.Therateofresolutiondependsonthesizeofthehematoma,usuallywithinonetosixweeks,andtheyresorbfromtheoutsidetowardthecenter.Perihematomalowdensityappearsin24-48hours.Rimenhancementappearsinoneweekandpersistsforsixweeks.Theendresultofahematomaisdecreasedparenchymaldensity,focalatrophyandlocalventriculardilatation.7/12/202442中枢脑血管病第42页7/12/202443中枢脑血管病第43页7/12/202444中枢脑血管病第44页7/12/202445中枢脑血管病第45页脑内血肿（T1，T2，turbo-T2)其内有陈旧性出血7/12/202446中枢脑血管病第46页脑干出血7/12/202447中枢脑血管病第47页发病当初CT发病两年后MRI复查7/12/202448中枢脑血管病第48页脑血管畸形(AVM)影像能够明确诊疗，还能够观察大小及血供情况，常有脑萎缩当前主要是血管成像(DSA、CTA、MRA等)可直接显示畸形血管7/12/202449中枢脑血管病第49页CTCTfeaturesofanAVmalformationonplainscanincludeahigh-absorptionirregularmasswithlargefeedingarteriesanddrainingveins,focalareasofcalcificationandnosurroundingedemaormasseffect.Thecontrastscanshowsserpiginousenhancementwithprominentarteriesandveins.7/12/202450中枢脑血管病第50页MRIThebestMRAsequencesfordepictingtheanatomyofAVmalformationsare3DTOFandPCmethods.SEimagingisprobablymoresensitivethanMRAfordetectingAVM.7/12/202451中枢脑血管病第51页7/12/202452中枢脑血管病第52页7/1